Getting the eRx Plumbing Right Is Hard Work

GUEST OPINION: Last week a troubling report from HSC about ePrescribing concluded that it wasn’t working as advertised. Practices were having trouble sending prescriptions electronically to pharmacies and weren’t receiving medication and formulary information about their patients. Similar reports from their pilot projects are expected this month from government agencies AHRQ and CMS.

Since the first wave of venture-backed ePrescribing companies failed, the big PBMs created RxHub in order to get formulary information and medication history into ePrescribing applications, and the pharmacies created Surescripts to enable prescriptions to be sent directly into pharmacies’ order systems. But apparently we haven’t made that much progress. As Surescripts’ president Kevin Hutchinson put it: “We agree with the vast majority of the report’s conclusions and appreciate them highlighting what was going on then (late 2005 to mid 2006), because it gives us a chance to highlight the progress since!”

That progress requires two main technical steps. Pharmacy system vendors need to be able to accept an electronic script from the Surescripts network, and EMR and stand-alone eRx vendors’ applications need to deliver an electronic prescription using the NCPDP standard. These have largely been achieved. Most stores belonging to the big chains are now certified, as are a growing minority of the independent pharmacies (18% vs. less than 3% a year ago). 65% of pharmacies are accepting eRx. Similarly, now all the major standalone eRx vendors and EMR vendors are Surescripts certified.

But that’s hardly all that’s needed. Workflow changes are required in physician practices and pharmacies. Given that a tiny proportion of the 3 billion scripts each year is electronic (versus paper, phone or fax), it’s hard for pharmacists to get in the habit of looking in their system for new, incoming eRx.

The same is true for providing patient drug information to the physician. RxHub’s COO J.P. Little says that it supplies eligibility, formulary, and medication history for 150 million Americans not just from the big three PBMs. For example, the entire Wellpoint system is currently being brought on to RxHub.

But Little concedes not all eRx applications are accessing that information. In part, this is because many EMR vendors are just now adding eRx connectivity and only about 20% of customers upgrade to the latest release each year. Little is realistic: “The good news is that the light is at the end of the tunnel. We were overly optimistic that if we landed the big guys we'd have transactions coming out of our ears -- it's just a long process. We're about 10 years into a 20-year process.” He cites the Southeast Michigan eRx pilot where RxHub can answer 8 out of 10 eligibility requests as a model for the future.

Despite these problems ePrescribing volume is growing fast. Both RxHub and Surescripts claim that their volume transaction was up tenfold from 2005 to 2006 and will grow as much again this year. Both are encouraged by the physicians in the HSC report who, despite all the problems, won’t go back to paper. They’re both convinced that the complete end-to-end connectivity required for eRx is much closer than it was a year ago.

That of course leaves the even bigger step --   there are still more than 80% of American physicians yet to migrate from the prescription pad. Hopefully when they come the infrastructure will be ready.

Matthew Holt is a health care consultant, occasional contributor to DHP and author, The Health Care Blog. He can be reached at

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