PDAs for Doctors

Electronic prescribing: What does your state allow?

In most of the US, it’s now legal to beam PDA-generated scripts to pharmacies by computer fax. But the preferred method–electronic data interchange–is another story.

By Neil Chesanow
Northeast Editor

The swiftness of technological change has outpaced the ability of many state pharmacy boards and legislatures to keep up. In November 1999, the Institute of Medicine shocked the nation with a report detailing the unacceptably high number of errors made by doctors who write scripts and by pharmacists who fill them incorrectly (often because the script is illegible). By May 2000, companies such as Allscripts, ePhysician, iScribe, ParkStone, and PocketScript were offering personal digital assistants (PDAs)–devices that, when loaded with prescribing system software, can generate scripts electronically to greatly reduce errors (see "Your ticket to fast, flawless prescribing"). Among the advantages:

• Since system software lets you choose from standard dosages for thousands of commonly prescribed drugs, the likelihood that you’ll select the wrong dosage–a major source of errors, according to the IOM report–is greatly reduced.

• You’re alerted if the drug you want to prescribe reacts adversely with other medications the patient is taking–another major source of errors.

• The systems check the drug for formulary compliance. If the drug isn’t approved by the patient’s health plan, the software suggests an on-formulary alternative.

In some cases, the systems also automate script delivery, making it possible for a doctor to beam a prescription from his exam room or office to a desktop computer in another room. Special software on the desktop PC then sends the script to a designated pharmacy by electronic fax (which is more convenient than using a fax machine) or EDI (electronic data interchange). The latter is a form of computer-to-computer communication that’s more secure than ordinary e-mail.

When manufacturers demonstrate these automated script generation and delivery systems for state pharmacy boards, the board members "typically get very excited about the technology," says Clifford E. Berman, general counsel for Allscripts.

Their enthusiasm isn’t hard to understand: Technology that promises to slash prescribing errors is compelling, especially during a time of public outcry. On the other hand, explains John Cronin, general counsel for ePhysician, "pharmacy boards have three concerns–the confidentiality of script information, the accuracy of the information, and the ability of a pharmacy to verify that a script came from a bona fide physician and not someone using a home computer with a floppy disc containing a stolen signature."

To allay the last concern, PocketScript’s software, for example, asks a doctor to use his PDA stylus to sign in every morning on the device display and enter a password. For the rest of the day, he can choose his handwritten signature as an item on a pick list, instead of having to rewrite it. The next day, he must repeat the process.

Because some states also insist that doctors handwrite "DAW" or "dispense as written" on a script, and may have other stipulations for Medicaid patients, PocketScript’s system permits a user to write the necessary information at the start of the day, then choose it as a pick-list item to automatically add to scripts. The rationale: "Most states want a physician to indicate that he’s made a conscious decision in generating each script," says Jack Cummins, general counsel for PocketScript.

To prevent an unauthorized person from using a doctor’s PDA to issue prescriptions, PocketScript’s software has a time-out function in which the time can be adjusted by the physician. If the script isn’t completed within the preset time, the doctor must re-enter a password.

Are such measures enough to satisfy pharmacy boards? Only up to a point. With the exception of Alabama, Vermont, and Washington, DC, the electronic faxing of scripts is accepted nationwide. But faxing–with its busy signals and occasional garbled scripts due to line static–isn’t the preferred delivery method. Ideally, a script should be sent by EDI.

"In states that anticipated electronic prescribing technology, regulatory language has been drafted allowing for EDI," says Cronin. "But some states say that until their pharmacy boards change the rules, a doctor must transmit an image of an actual signature, as in a fax. An electronic image of a signature isn’t good enough."

That’s because when authorities seek to arrest and prosecute someone who writes prescriptions in a doctor’s name, they traditionally require paper evidence (i.e., a stolen prescription pad) and an actual forged signature. Twenty states remain uncertain about whether electronic evidence will stand up in court. Still, it’s reasonable to assume that the holdouts will ultimately come around, especially after the Justice Department’s recent victory over Microsoft, which was based largely on incriminating e-mail.

Another impediment to the nationwide acceptance of EDI script transmission is that local pharmacies often aren’t up to speed. Many still use ancient DOS-based software that’s incompatible with the advanced Windows systems used by PDA prescribing software manufacturers. Upgrading pharmacy software systems is expensive and will take time. For this reason, even in states where EDI is permissible, electronic prescriptions are usually sent to pharmacies via electronic fax–assuming that the pharmacy has a fax machine. Cincinnati family practitioner Daniel H. Sway discovered two local pharmacies without them. When Sway expressed astonishment, one pharmacist responded, "You mean other pharmacies use fax machines?"

Horse-and-buggy stories aside, within the next year, doctors in most states probably will be permitted to send scripts to pharmacies by telephone fax, electronic fax, or EDI. The benefits are clear, and pharmacists, pharmacy boards, and state legislatures don’t want to incur the ire of inconvenienced doctors and patients, who are also customers and voters.

Sending electronic scripts to pharmacies:
How the states compare

. PDAs for Doctors: Electronic prescribing: What does your state allow?.

Medical Economics

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