Wednesday, December 07, 2011

Guest Blogger Dr. Jeff Soulen on the Pros of E-Prescribing

Over on our Clinical Psychiatry News website I'm writing about my struggles with electronic prescribing.  The post, "To E-Prescribe or Not? That is the Question" will be posted on December 7, 2011.  In order to write it, I bothered just about every shrink I know, or it least it felt that way.  One of the psychiatrists who was kind enough to respond with a great deal of useful information was Dr. Jeff Soulen, a psychiatrist in private practice, who has had a positive experience.  This is Dr. Soulen's first experience as a blogger. 

I've been using Allscripts for about 3 years now, and I must say I like it a lot. It's free (no need to sign up for the paid Deluxe version) with a browser-based interface, so I can access it anywhere -- helpful when I'm away from my charts.  I pretty much do 100% of my scripts electronically except controlled substances, for which it's still illegal to e-prescribe. What I like about it:

  • I see a list of every script my patient has filled, including those from other docs, though this information is sometimes spotty. It's led to some important discussions about controlled substances I didn't know the patient was taking, drugs that have interactions with the ones I'm prescribing, etc. Kind of wondrous to enter a patient's name, zip and birth date and 5 minutes later the whole list is on your computer screen.
  • Patients love it.  Once they are in the system-- which takes a couple minutes the first time-- it takes me no more time to send a script electronically than to hand-write it, and by the time they get to their pharmacy later that day, the script is ready for them - no need to bring a paper script and wait.
  • For repeat scripts, it's faster than hand-writing - select from the list of scripts you've sent previously for that patient and send.
  • No more transcription errors from a paper or phoned script.
  • It's been a huge time-saver in that I no longer get calls requesting refills of scripts where I wrote refills, but the pharmacy in their rush put 'no refills' in their computer. This used to happen a lot.
  • All the mail-order pharmacies seem to be tied-in at this point, so sending mail-order scripts electronically is as easy as sending to a local pharmacy. Way faster than filling out fax forms by hand, then faxing them. And patients seem to receive mail-order meds about 4 daysafter I send an electronic script - significantly faster than faxed or phoned scripts.

It is true that an occasional script fails to make it through the system to the destination pharmacy. So far that's been well less than 1% of the scripts I have sent, and re-sending a script a few times a
year takes much less time than calling patients/pharmacies several times a month to tell them that yes, the original script did have refills on it.

If you want to prescribe from a smartphone, you have to purchase the Deluxe version.  I don't know how much that costs.

Bottom line, for my solo private practice it's been terrific -- faster and more accurate for me, gives me information on drugs my patients are taking and have failed to mention, and patients love it. I e-prescribe for all those reasons, not because of Medicare penalties.


If you surfed over to the CPN article, you'll know that my experience with e-prescribing has not been as happy as Dr. Soulen's.  Of course you're invited to tell us about your experiences...


rob lindeman said...

Now, an article on the cons of e-prescribing, that would be something!

wv = stowee; carry-on item, etc., stuffed in an overhead bin.

Dinah said...

Surf over to Clinical Psychiatry News-- we tried to coordinate posting both pieces at the same time but they had a technical issue (free Blogger seems more controllable for whatever reason)...and they lagged by a few minutes, but it's up now.

Would love your insights on e-prescribing. I'm not a fan, obviously.

Samsara said...

I understand the point the poster is trying to make about the potential benefit of seeing all medications a patient has been prescribed, but I do have concerns. I am not entirely sure that it is necessary for a psychiatrist to be able to see that a patient filled a prescription for a yeast infection. If the patient wants to bring her yeast infection up, okay, but generally, that is not something a lot of people would want to discuss with anyone but the doc who prescribed it. On another level, it feels like Big Brother. And on yet another level, will it come to the point that a doctor would have to check this e file for any other meds a patient has been prescribed lest he or she be sued for some nasty interaction he or she did not know about ,but now that the technology exists, ought to have known about? It seems that what is possible quickly morphs into the standard of what has to happen. There are some sticky points for
both doctors and patients.

On another point, this is the first time that I realized how to add a name to my comment.

Jeff Soulen, MD said...

Hi Samsara,
Thanks for raising such good points. As a physician who values being thorough, I actually do want to know if someone is on a medication for a yeast infection - perhaps that medication has an interaction with a medication I'm prescribing, or perhaps the yeast infection was acquired via activity that's worthy of attention in therapy - I'm thinking of someone I know who acquired a yeast infection "swinging"...and until the technology is demonstrated to be reliable and accurate, it would be hard to make a legal "should have known" case, and these databases, Big-Brothery as they are, are woefully incomplete and inaccurate. They are the future though, so we'll all be seeing what the future brings.

As the awakened have always observed, we live in a world of Nirvana within Samsara, Samsara within Nirvana...

Anonymous said...

".. or perhaps the yeast infection was acquired via activity that's worthy of attention in therapy - I'm thinking of someone I know who acquired a yeast infection "swinging.."
That is where it becomes problematic for me since by this logic, the psychiatrist should also have access to the patient's credit card files to see if any spending binges worthy of attention in therapy have taken place. The drug interaction is one thing but then we do get into what rights to privacy does a patient have?


jesse said...

At times I see a patient who absolutely does not want anyone to know both that he is seeing me and what medication is prescribed. Privacy is very important. A particular medication may be short-term, a trial, whatever, but the patient does not want it known what he is taking and certainly not that is saw a psychiatrist.

My greatest problem with e-anything and mandatory electronic records is that privacy is lost in cases where it should be maintained.

Frenetic said...

My psych uses this method. In the last year, there has only been one time that a script didn't come through. Another time, the pharmacy kept filling my lithium script wrong. Took several tries and figured it was an M.D. error on the dosage, so it was finally corrected.

Overall, as a patient, no complaints.

Dinah said...

Isn't it a funny world in which we live, where if I need important past psychiatric history I need a signed release from the patient to speak with their former doc, where we have to peel off and hide names on sign in sheets in the dentist's office for fear that anyone might know we get our teeth cleaned, where doctors won't talk to family members of compromised patients because of the deep dread of violating HIPAA, where we hear so much about this HIPAA protected sanctity of medical information, yet we create systems where the patient has no right to have their gyn events kept private from their dermatologist or their psychiatric issues kept private from the doc who treats their sprained ankle.
I guess I would wish for some consistency and some logic to it all.

I'm siding with Samsara and Namaskar here. Patients should have the right to come to the dignity of deciding what is private, and which difficulties they would like to address in treatment. For the most part...there are certainly exceptions, which I think may inspire a post on The Secret Lives of Patients...sometime soon.

Jeff, you're doing a great job as Guest Blogger!

(disclaimer: I can not hold my own in this conversation, but I thought I'd nod in the direction)

Jeff Soulen, MD said...

Frenetic, thanks for your post. Glad you are having a good experience. Anonymous, Jesse, Dinah, very very important issues you raise about privacy. Which raises the bar - what should/can we do in the current environment, where scripts are in the database, whether prescribed electronically or not? I see many scripts listed as reported by the pharmacy or reported by the pharmacy benefits manager. So even a script we phone in or hand-write has a good chance of being visible to e-prescribers. Is this a call to action? How would you prevent a script you write from getting into the database? Looking forward to your thoughts on this one.

Anonymous said...

If a physician obtains info about me without my consent then I have a big problem with that. I am definitely going to look into this as I don't recall ever siging a consent giving permission to any physician I have ever seen to access my history of prescriptions received. If they have done so, they have obtained information about me without my consent.

If I don't want a physician to know I'm getting a medication for a yeast infection that's my own business and I'll decide if I want to share it or not. If I choose not to share something and there's a drug interaction then that was a risk I was willing to take. I don't like the paternalistic, big brother crap. I'm an adult and if I want to share something I will. If I don't share somethign that would have been helpful for the physician to know, well then I accept the consequences for protecting my privacy.

I like gynecology, dermatology, and psychiatric records separate. There is very little I feel dermatology needs to know about me to remove a mole. But, the bottom line is if any physician is obtaining information about me without my consent, then there's a problem.

Sideways Shrink said...

Despite concerns about confidentiality, which I understand and had as a patient in the far north of Manhattan where the pharmacist yells out the name of your medication at full volume in front of everyone behind you, psychiatric medications ARE medications and have systemic effects that the prescriber needs to be aware of and really does not care why you had a yeast infection. It is unfortunate that "swinging" was brought up, as this is something which evokes a practice of sexual transgression from 30 years ago or of "promiscuity" which is a concept that my generation finds offensive.

I was a paralegal in my 20's to make money to travel and I did some insurance work, though never malpractice work. I have seen medical records blown up on the wall of a court room. What if a patient says they told the shrink they were on a certain medication and it is available in the online pharmacy record IF the shrink had looked up that record? But if the shrink states the patient did not tell them they were on contraindicated medication X when they prescribed medication Y, the shrink would have been foolish not to double check any records available to them. I don't think we are at that point yet medico-legally where we have to double check behind our patients, because we can, but I wonder, with the rise of Medicare being tied to electronic health records if this will not become the case....
I know I sound paranoid, but let's just say it's been a borderline fall....

Sarebear said...

Last year my GP's office had a form for me to sign, to agree to them being able to see any prescriptions I have in prescription databases. There was also a spot on the form to opt out, but they wouldn't opt you in if you didn't sign. You wouldn't get to see your doc for your appt. then if you didn't sign or opt out tho, but you just simply had to choose. I opted in.

samsara said...

Agree that psych meds have systemic effec but so does alcohol, a drug which does not make its way into online databases, and one which many people use/abuse ,
often without the doctor's knowledge. The doctor is free to ask me about my alcohol intake but it is another thing to have that info sent to them by the bar or liquor store or the hostess of that dinner function I attended.
There is a limit to the amount of privacy that we should be required to give up in order to receive treatment. The doctor does not follow me to the bar, and any meds I take that could interact with alcohol or which should or should not be taken with food, those that must be stored in the fridge, have labels saying so , courtesy of the pharmacist. My shrink told me that one of my meds cannot be taken with certain antibiotics. Assuming that I need antibiotics, I can let the doctor know that. I am not sure how database access will help me out in that situation since it is unlikely that any doctor is going to check it daily or even weekly for each and every patient. In that period of time, I could have taken a drug that does not play nice with my other meds. WRT the yeast infection, the same is true. By the time the psychiatrist sees that it has been prescribed, it will be history unless there is some system set up to send instant message alerts to all MDs about all the meds that all their patients are being prescribed. I don't see that happening, and if my doc were actually to receive instant message alerts, s/he would have no time left to practice. This will all change when docs are replaced by robots.

rob lindeman said...


Sounds like your problems are only technical in nature; they will resolve with time. [Full Disclosure] Rainu Kaushal is a former residency-mate and personal friend.

wv = monat; single-payer

jesse said...

@Jeff Soulen, M.D., patients have sought out pharmacies that were family-owned at which the pharmacist has reassured them that their prescriptions are not sent to any database. They pay out of pocket and seek no insurance reimbursement. There are many situations in which true privacy is essential.

Sideways Shrink said...

Something is wrong with these patient-shrink relationships. I would not see a shrink who I did not trust to see all of my medical records including pharmacy records. I would continue to look until I found one I trusted with that information. In inverse is not true: I would not want primary care or any other specialist to see my psych records and am against the idea of merging all medical records into one giant data base which happened in a multi-specialty group I worked for. It was against state law, but....
There is something in the zeitgeist right now which furthers patients' distrust of their doctors. I think the financial strain which shortens visits in some psych practices and in all of primary care is part of the problem. However, if there is one health care provider I suggest everyone invest the time trying to either work at trusting or finding one you can trust, I think it should be your shrink. This is the health care provider whose judgement you might need to trust when you feel iffy about your own judgement. I know we live in this era filled a rhetoric of rabid self sufficiency, but I just don't think that is the reality of the human condition.

Sideways Shrink said...

But I do have patients who work for Homeland Security, etc. and do pay cash because they have to have confidentiality and this is not the circumstance that I am talking about.

Dinah said...

I'm going to point out that we now have 3 discussions here:

1) is e-prescribing time-efficient (for the doc/for the patient) in a way that makes like better

2) Does e-prescribing work in it's goal to decrease medical costs due to medication errors from handwritten scripts (this is from my article on Clinical psychiatry News)...via improved handwriting and automated drug interaction alerts.


3) does e-prescribing compromise patient confidentiality, and this is really a variant on the many discussions we've had about electronic medical records.

Roy was talking about these issues years ago:
Always ahead of his time, that guy.

Sean Paul said...

My residency program uses this and I recently started using this system. It is a huge time saver and generally a great way to keep records. I have problems when I make an error, then resending the script always equals a phone tag game with the pharmacy. Just pausing a min before clicking "send" helps. I think that was easier to do when it was physically in my hand.