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E-prescribing: the next 'unfunded' mandate for doctors?

Why the College doesn't support legislation to force electronic prescribing technology on physicians

From the September ACP Observer, copyright © 2003 by the American College of Physicians.

The federal government has an unfortunate propensity to take the best of ideas and saddle them with unrealistic and unworkable regulatory constraints. The end result usually is legislation that keeps lawyers and government bureaucrats busy, but fails to achieve the good that was intended in the first place.

The Health Insurance Portability and Accountability Act (HIPAA) regulations regarding electronic health transactions are a recent case in point. The law started with a good idea: eliminate unnecessary paperwork by creating a system for sending and receiving health information electronically.

The federal government could have helped turn this good idea into a reality by providing funding and resources to encourage the private sector to move to a paperless world. But Congress instead chose to mandate that standards for electronic transactions take effect on Oct. 16, 2003, without considering whether or not this date was even realistic.

As a result, health plans and providers are now rushing to meet standards that have not been adequately tested—and might not even work. If these new standards fail, thousands of health insurance claims submitted on or after Oct. 16 might not be paid.

A new mandate

Now Congress may be on the verge of repeating that same pattern, this time with electronic prescribing (e-RX).

Almost everyone agrees that e-RX is a good idea. Done properly, e-RX can reduce prescription errors and adverse drug interactions. Many in the private sector are already working diligently to develop, test and encourage the timely adoption of e-RX technologies in clinical practice.

Congress, however, is unwilling to let electronic prescribing technology evolve at its own pace. Instead, both the House of Representatives and the Senate included provisions in their versions of the Medicare prescription drug legislation that would accelerate the shift from the centuries-old practice of handwritten paper prescriptions to electronically written ones.

While the Senate bill (S.1) would not force physicians or anyone else in health care to give up their prescription pad, organizations using e-RX systems would have to meet new federal standards regulating the content of e-prescriptions.

The legislation, for example, specifies that e-prescriptions must be able to transmit information like patient-specific medication histories, eligibility, benefits and cost-effective alternatives to the drug prescribed, between prescribers and dispensers of drugs. Health professionals—both those who prescribe and dispense drugs—would have until Jan. 1, 2008, to demonstrate that their e-RX systems can meet the new standards.

While the House bill (H.R. 1) also includes similar requirements on transaction and data requirements for electronic prescribing, it goes much farther.

The House bill requires that all prescriptions for Medicare-covered drugs be submitted electronically by Jan. 1, 2006. Because the legislation would also greatly expand the drugs that are covered under Medicare, physicians, pharmacists and health plans would have little choice but to use e-RX systems for all of their prescriptions, as it would not be feasible to use e-prescribing for Medicare-covered drugs and paper prescriptions for other medications.

Barriers to implementation

The problem with mandating electronic prescribing is that the technology isn't ready for prime time. In an Aug. 15 letter to House and Senate negotiators working on Medicare reform legislation, ACP President Munsey Wheby, FACP, put the issue simply:

Electronic prescribing remains an unproven and evolving technology that is still in its infancy. A federal mandate to require that all prescriptions be written and transmitted electronically within three years, as H.R. 1 proposes to do, attempts to "force feed" unproven systems and technologies on patients and clinicians. The inevitable result will be a mad rush to design and force compliance with systems and technologies that will not work in the real world of clinical practice.

The immature technology isn't the only barrier, however. Policy-makers need to consider and resolve a whole host of complex—and controversial—questions before e-RX technology can become a reality. Here is an overview of some of those issues:

  • Who should write the standards regulating e-prescribing? Should a federal agency write the standards? Or should the federal government encourage efforts by recognized private sector standard-setting organizations to develop appropriate standards in consultation with organizations representing physicians, pharmacists and patients?

  • Who will determine what information will be required and how it will be used? Both the House and Senate bills state that the intent of e-RX is to improve patient safety. But e-RX can also become a powerful tool for payers to drive physicians toward prescribing the cheapest therapeutic agent (in terms of unit cost to the payer), rather than the one that is best for the patient.

  • Will the standards be tested in the real world of clinical practice? Neither the House nor Senate bills require that e-RX standards be pilot-tested before they become operative. Without pilot-testing, we will likely see an unworkable set of standards that disrupt patient care as prescriptions can't be filled in a timely manner because of problems with the standards.

  • Who will pay for e-RX? One recent study suggested that switching to e-RX technology would cost clinicians up to $27,000 in the first year. Without financial help, it is unrealistic to think that physicians will be able to invest in e-RX technologies, especially since it is not clear that there would be any real dollar return on the investment in terms of increased revenue or reduced practice costs.

ACP speaks up

ACP was the first national physician organization to express strong opposition to the mandate in the bill passed by the House of Representatives. With input from the College's Medical Informatics Subcommittee, we were also the first to provide Congress with preliminary principles on e-prescribing. (These principles are online.)

We have also given House and Senate negotiators recommendations on improving the Senate's framework for voluntary standards by requiring pilot-testing of the standards and allowing enough time for those pilot tests to occur. (For more, see "Medicare bill must address physician pay, other issues.")

Despite our efforts, there are still too many influential members of Congress who believe that the only way to get physicians to accept e-RX technology is to force it upon them under the threat of law. ACP has developed a sample letter that members can send to lawmakers to urge them to oppose an unfunded e-RX mandate. The sample letter can be found online at our Legislative Action Center.

Legislators need to hear from you on why an unfunded, poorly designed and highly premature mandate to write prescriptions electronically will do more harm than good. Otherwise, e-prescribing will join the long list of good ideas gone bad because of unrealistic and unworkable legislative mandates.

Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.

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