The Road Less Traveled
Jim Morrow, M.D.
10/7/2008

Slide: 1
With that I will turn it over to Dr. Morrow. Thank you Ray. I have a little hitch in my get along this morning. I think I hurt my leg in celebration after the Red Sox game. We will persevere here and move on through this. I want to talk to you about obviously electronic prescribing

Slide: 2
and a little bit about our experience in North Fulton Family Medicine with doing this and I will preface this with the fact that our E-prescribing experience has been that in using E-prescribing within the context of a full electronic medical record. A little bit different from a freestanding system no doubt. We are going to address some of the good and bad about both and talk to you about why you might or might not want to make such a change. One of the first arguments is obviously I use paper charts and I am not certain that I want to make this huge process change to go to electronic prescribing. Doctors are very accustomed because they have done it since the stone tablet age I suppose in writing prescriptions, or right after the stone table, writing prescriptions on paper in the exam room. They feel like they do not have the time it would take to do electronic prescribing and understand the system whether it is in the exam room on a handheld system or outside of the exam room on a different sort of system. I do not know of a doctor who feels like when he writes a prescription the pharmacist cannot read it. I have never known a doctor who wrote a prescription thinking there is no way he is going to read that in sending it to the pharmacist. It is difficult to find the doctors that actually responsible for the one and half million medical errors that occur every year. But they are out there and one of them standing here at this podium prior to the time that he went with electronic prescribing. Doctors frequently think I know the interactions, I know that I am not going to give by accident to someone on Lipitor. I am not going to give ketoconazole to someone on Lipitor, I am not going to give ketoconazole to someone on Keppra, but the problem is a lot of times you do not know that the patient is taking some of these other drugs that you might not be the prescribing physician for. Having this system which allows you or can and even in our next version of the EMR hopefully being installed while I am up here, allow us to know what other medicines people are taking and to know these interactions might possible occur. Then physicians also will tell you that their patients do not like computers. I will tell you right now that is not true. Do not believe for a second that is true. Our 80 year old patients will get on the internet and check their labs on our online portal and they will send me 30 blood sugars a month and let me keep those in their chart and look those over and see what their average might be and it is a wonderful thing to get that kind of thing from even the oldest of my patients.

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So you need to reconsider this thought and we will give you a lot of reasons why you might do that. Obviously one of them is efficiency and efficiency equals money when you are talking about this. It is true that if you are using an E-prescribing system, especially a handheld system, the very first time you do that, it is going to take more time. If you have a Medicare patient and they are on seven different medications, the first time you do this; it is going to be a little bit of a cumbersome process to get those medications into the system. The next time you do this, those refills are the easiest one you will do. That patient who is taking those seven medications is for the most part, everybody knows this from experience, continuing to take those seven medications. So instead of having to handwrite those seven, three on one page, two on the next, two on the next like I used to do, it was a real nuisance. Although I did know patients names then, I will say that, I had to write their names, so I knew somebody’s name when I saw them at the mall and today I go high blood pressure, high cholesterol. How are you? Who are you more importantly? I have my wife trained to throw her name out there real quickly so they will say, oh, I am John Smith and I go of course you are. Because otherwise I do not write their name anymore. So the refill, and the second time and the third and fifth and the eighth time that you see these people, prescribing these medications is so much, so much easier. Clinical decision support. Having the ability to have a flag, an electronic flag about a possible interaction. Someone allergic to penicillin you are giving them Keflex. You can say I do not care; I am giving it any way. Someone who is on medication that might be a serious reaction, you can say, good to know, we will go another way. As Mike had mentioned earlier, access to patient’s prescriptions that they are getting from other doctors. A patient may call your office and say, I need a refill on my blood pressure medicine. You have had them on Benicar and they really want a refill on the Toprol because the cardiologist switched them from Benicar to Toprol. You do not know that because you have a faxed letter somewhere in your system, or in your paper chart and you have no idea they changed it. So you call in Benicar and the patient calls angry because you did not call in the right medication and then you get well don’t you guys talk. Well I know every provider in here spends their day talking to the referral specialist talking about each and every patient trying to keep track of exactly what happened. It is a problem and you can know that using the electronic system.

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Electronic refill requests are outside of quality, they are the best thing about electronic prescribing. With our system within the EMR I am sitting there at the desktop with a patient, pretty much finished with the visit. I look down at myDesktop and my work area, and here is an electronic refill request from a pharmacist for Allegra for a patient, I hit approved, and it is gone back to the pharmacy. My nurse is not involved. In the paper world, of course you have to receive a phone call or a fax, pull the chart, send the chart to the doctor, the doctor says what to do, send it back to the nurse, the nurse has to call the pharmacy or fax to the pharmacy, we never did that, but you do one of the two. The nurse’s time is taken up and my nurse is paid by the hour. When I have to pay her to get involved in this process, it costs money and every person that does prescribing of any kind can save money if they can take that nurse, that hourly employee out of the loop. So with electronic refills, you can take that person out the loop. It comes directly to you, you can say yes or no. You do not say yes, you can say no it accomplishes the same goal, you say no; you get a chance to say why. They need an office visit – bam. The pharmacist then is your own paid employee to tell the patient you have to go to the doctor. I am not picking on pharmacists, but that just is the way the process is. Reducing staff time is huge and our overtime has been tremendously decreased. In the past, in the paper world, even before the days of electronic prescribing, we had people in the office until six thirty in the evening. Now at 5:15 our office is a ghost town. People are gone; people are home with their loved ones where they need to be. Decreasing wait times. In many cases, and certainly not all, but in many cases by sending the prescription electronically to the store, the pharmacist has an opportunity to get ahead of the game. These prescriptions frequently can be filled when the patient arrives at the pharmacy. This is a huge thing and it increases the satisfaction of the patient with the pharmacy and review of the provider.

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No one but other physicians have prescribed, I mentioned this a minute ago and it is a huge thing not only looking at what medicine might have been changed, but also seeing that this person has been to this doctor and this doctor and this doctor and they have given them these pain medicines, whatever and being able to know that is a tremendous benefit. A tremendous benefit. Something you cannot know from the paperwork. This next one is interesting to me because I have no idea we are not doing this yet, we are on the verge, I have no idea right now how many times I will write a prescription for a 45 year old man for high blood pressure medicine and he goes home, his wife says what did he tell you and he said I am fine. He said to come back in three months and he will check it again. He did not go to the pharmacy. His blood pressures is 158/94, he ought to be taking some medication, he is not, he is thinking, maybe it will go away. The five most dangerous words in the English language, maybe it will go away. That’s what he tells her, I am fine, no problem, I am going back just to be sure and he is not filling his prescription. We are going to be able to know that. We are going to be able to know that he is or is not taking his medications. Legible, accurate transfer of information to the pharmacist. It is a huge benefit for the pharmacy to send this electronically because within the proper system, it prevents the pharmacist from having to sit and enter this data into their system. It automatically goes into their system. I am not sure how that works, I am not doing it from that end, but I have a good friend that is a pharmacist and he tells me in no uncertain terms that when he gets an electronic prescription, he prints the label, the tech fills the bottle and he is gone. Everybody is happy, everybody is finished.

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Now how do you pull this off? I think the most important thing about pulling this off is it has to be mandatory for all providers. It is very difficult to use a dual system where you have one person who is using paper, he is using electronics and he off on Wednesday afternoon, the person that sees the patient using paper, they do not even know how to access the system. Not a good idea, not likely to work and not going to be happy with that. It is something where somebody has to decide this is the way we are going to do it starting today. Training is mandatory. For all staff and providers because everybody involved with the system needs to understand how to use it. So training is absolutely mandatory. Getting the patients involved by giving them handouts and educating them on the entire process. The fact that we are going to be changing this, we are going to be doing everything we can to get prescriptions sent electronically and give them a good list of reasons why you are planning to do that.

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Decide on a vendor. I cannot help you with that. There are plenty of those out there, some are free, some are not, some are better then others. It is like buying a car. Buy one that works for you, but look at a handful, try some out and make a decision and move on with it. It is time to do this; there is no question about that. How are you going to do it with hardware, are you going to use a PDA, a handheld? Some people love that, I think it is an awfully small amount of real estate, some people do love it. Some people have the table PC, a little smaller then a laptop, some laptop, some a desktop PC. You figure out what you are going to do. Are you going to do wired or wireless? We installed our electronic record in 1998, wireless was not a good option so we still have not done much in the way of wireless, but that is a very good option today. It is one that most people can do if you have internet access in your office, and I would wager that a majority of you do, then throw in a wireless access point into that system as a $50 to $75 investment; you have a wireless system in your office. It is just not terribly difficult thing to pull off.

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Go to the pharmacist personally and tell them what you are planning to do. The majority of them, chain pharmacies are onboard with this, they are ready to go. The independent pharmacies might be a problem. We have three main independent pharmacies that serve our area, one is doing electronic prescribing, and two are not. They had a theme to benefit but I honestly believe they will loose business in the short run if they are not doing this. Gathering EDI numbers, the number that allows you to do data interchange is an important part of this. We were fortunate that our vendor downloaded those numbers into our system and thank heaven because that was huge. But if you think about it, it just cannot possibly take too terribly long for you to put in the 30 pharmacies in your area that are most commonly used. It is just not that difficult.

Slide: 9
Send test prescriptions. Call your pharmacy, say I am going to send you a prescription, this is a dummy patient and his name is in fact Dummy Patient so do not fill this, I just want to be sure you got it. Have them send you a refill back. Be sure that Dummy’s refill comes back to you. Again, if you can interface any system you have with your practice management system it is going to be a huge saver for you, but that will cost you money. It will cost you something. What is costs you is money well spent, but it will cost you something. But if you do this, you will not have to enter every single patient’s demographic information into the system when you first prescribe for them. It will save you an awful lot of time and in the long run money. So I urge you to consider doing this. If you are on paper charts, look for a system that works well with your process. If you are using an EMR, it almost, if it is CCHIT certified it has an electronic prescribing module period and you need to be using this in every possible situation, you will be very glad that you did. Thank you.