E-prescription for IT disaster

The federal paperless prescription mandate is a model for pathetic planning that will leave users and IT blamed for failures

Researchers just finished mapping a patient's leukemia tumor genome, finding only eight differences between her tumor cells and normal ones taken from her skin. This breakthrough in medical technology was somehow accomplished while the American Medical Association and U.S. government health agencies are doing a rip and replace of the nation's medication distribution system. Taking the prescription system paperless has been on the national road map since timeshared mainframes were the rage, but up to now, those delivering, managing, regulating, and receiving health care always found wiser uses for the time and money required for a prescription system overhaul.

Now, in the final seconds before an administration sworn to reform health care takes office, e-prescribing is being lofted as a Hail Mary pass by interests with a mix of honorable and questionable intentions. It has not remotely begun to gel, but now it is poor planning made law, and it falls to practitioners, pharmacies, and IT to make it work. Make it work now, or the government will dock already inadequate reimbursement for treatment under Medicare and Medicaid. Company-paid insurance can't be handled any other way.

It probably seems that I'm casting too jaundiced an eye on the issue. Who could oppose the modernization of a paper system whose flaws exact tolls in lives and taxpayer dollars lost to fraud? Trouble is, e-prescribing is loaded with agendas, with conduits for control and work-arounds for potential future regulation and reformation (whatever those may be). It is being executed under the rubric of urgent social necessity, but the health care system has far more pressing issues to deal with. Doctors have less time to see patients, new reasons to refuse to treat patients on government assistance, and new levels of complication that tacitly discourage certain types of prescriptions.

Ain't broke

E-prescribing is sold as an essential modernization of a creaky, error-prone, inefficient, and costly paper system that cannot keep pace with the explosive growth of prescriptions. If you didn't know better, you might say they're right. This archaic system has its roots in simpler times when small-town pharmacists knew small-town doctors and their office staff personally. Pharmacists' experience and face-to-face dealings with patients red-flagged erroneous or suspicious prescriptions.

That human element is still pharmacists' most important role, and the many eyes under which prescriptions pass keep the system remarkably safe and efficient. Tens of thousands of tragic deaths and injuries are rightly blamed on improperly filled prescriptions. One such injury is too many; I won't argue that. But put the incidence of error in context: 3.5 billion prescriptions were filled by U.S. retail pharmacies in 2007, and most of these came into the system on hand-carried paper, faxes, and phone calls between doctor's offices and pharmacy staff. This system looks really ugly from 30,000 feet, but it works.

Of all the massive problems facing U.S. health care, that paper-free prescriptions rises to the top of the list shows that priorities are messed up. When a rip and replace is ordered for a process that's working, it stinks of politics. I'm not referring to partisan politics, but the politics that IT encounters in sick organizations in which management uses IT as an instrument to define new channels of control. If you control data and the means by which it is exchanged, you control the organization. You insert people and interests into the loop, and remove them from the loop by defining their access rights and their roles and priorities in the workflow. IT is a great tool for the indirect restructuring and consolidation of power.

E-prescribing endeavors to reduce human involvement in the provision of health care. In the ideal scenario (as I understand it), doctors enter prescription requests directly into computers on their desks. The request is transmitted to somewhere. I'm not sure where, but the first stops are a national prescription tracking system and an insurance provider. The pharmacist is reduced to dispensing as instructed by the insurer and collecting payment. Interaction between pharmacists and practitioners' office staff is limited. Ideally, the patient never sees the prescription. In the ideal ideal, the patient never consults a pharmacist. The prescription is filled by mail.

Trouble ticket

I was unaware of the patient-hostile aspects of e-prescribing until I got caught up in it. On my most recent visit to my doctor, in lieu of a paper prescription, he gave me a business card with the number of a toll-free call center. I was to call this number, not my pharmacy and not his office, for my prescription and subsequent refills. The rule is that I have to call exactly two days before my medication runs out. Any sooner than that and I'll be told to call back, and I'll be marked as having requested an early refill (a serious no-no). Any later and I'll just run out. If I run out on a weekend, I have to call on Wednesday or wait to call on Monday and get my prescription on Wednesday. Got that? Calling a day late for your heart or diabetes medication must be a real drag.

My first call to the call center was an eye-opener. Someone I'll never meet asked only for my name, my birth date, and my doctor's name. After that cursory authentication, I found that I was able to freely query the agent on my entire prescription status and history, along with office visit dates and diagnostic codes. It took a solid five minutes for the agent to key in my refill request. I was told that a selected (by whom?) mail-order pharmacy would deliver my medication. Only when I protested was I told that I could choose a pharmacy. The refill was transmitted to my doctor for his direct approval; his staff cannot approve refills. He came back from rounds on Thursday night to approve and transmit my refill. The call center being closed Friday, I followed the rules and yet risked three days without prescribed medication. I'm glad I don't have heart disease, AIDS, or diabetes.

Redirecting the fill to my familiar pharmacy saved my bacon. My call center received my request, promptly printed it, but didn't send it to the pharmacy because two years ago I was prescribed the same drug at a different dosage. This flipped on the database "doctor shopping" alert. When you change doctors or dosages, you are suspect of using multiple doctors to fill the same prescription. Insurance flags this no-no. The process halted; the call center sandbagged calls from me and my pharmacist. Finally, in exasperation, my pharmacist paged my doctor late Saturday. He issued a new script that couldn't be filled until Monday.

I asked my MD what this was about and I got an unexpected answer. He said that apart from all insurance companies and government agencies, the data could be used long term to flag physicians writing a high number of mental health scripts. Being in a database of mentally ill patients may affect job prospects, access to credit, provision of a license, and stigmatize broad categories of mental illnesses as undeserving of coverage.

Bad medicine

The law was put in place without standards or the means to make it work. I'll tell you how doctors handle it where I live. An initial prescription is entered into a computer by the doctor. His staff prints the prescription and faxes or e-mails it to the pharmacy, which then fills it. Patients' refill requests must be phoned into a call center by the patient; pharmacies cannot call your doctor's office for a refill. Interaction with the call center takes much longer than a phone call to a doctor's office, and ironically, requires virtually no proof of the caller's identity.

Further fallout, including access to the database by private detectives, law enforcement, and plaintiffs in civil suit, is unthinkable. As unthinkable as broadband users having their content and behavior examined at wire speed by a nongovernment entity with no need of a warrant? Or as unthinkable as the identities of mentally ill being "leaked" by low-level staff to end a political campaign or promising career?