Implementing electronic prescribing in primary care practices

Primary care physicians provide essential health services to patients of all ages and while a family physician's office is a warm, comfortable environment, a physician's practice also is a business. Ensuring the success of that business, in part, requires keeping up with modern-day technology, a sometimes difficult task for a small practice. Research led by Jesse Crosson, PhD, at UMDNJ-Robert Wood Johnson Medical School has identified key techniques in the implementation and use of electronic prescribing that help to make a physician's practice efficient in the digital age and more effective at patient care.

Electronic prescribing (e-prescribing) is commonly a first step for physicians in establishing electronic health records and has been a central focus of primary care transformation efforts, as prescription drugs are among the most commonly used treatments in primary care. According to the study, there has been an even greater focus on implementing e-prescribing since the American Recovery and Reinvestment Act of 2009 (ARRA) was passed, establishing incentive payments for physicians who make "meaningful use" of electronic health record systems.

"ARRA gives physicians an incentive to move toward electronic health records. More important, successful e-prescribing can increase medication safety for patients," said Dr. Crosson, an assistant professor in the department of Family Medicine and Community Health's research division and principal investigator of the study. "E-prescribing also allows physicians to discuss medication options and the costs of drugs with patients at the point-of-care, having the potential to reduce healthcare costs and increase a patient's compliance with the recommended treatment."

Dr. Crosson's research team looked at five practices of different sizes and organizational structures that were considered successful at overcoming the challenges many physician practices face in adopting e-prescribing. The study determined that the common thread among these "exemplary" practices was that each one had carefully moved through three phrases: planning, implementing and use of the systems.

The planning phase provided a review of workflow within the practice, established standard operating procedures and was inclusive to all team members, including those outside of the office such as local pharmacists. Implementing e-prescribing required ongoing, easily accessible technical support that provided real-time solutions, training of all staff members in both hardware and software systems, and the training of "super users" who could provide support following the implementation, when information technology (IT) personnel may not always be readily available.

"Creation of super users within the physician practices was an essential component for successful e-prescribing," said Dr. Crosson. "They bridged the role between the staff and IT, preventing frustration and possible interruptions to workflow."

Use of the systems presented challenges that successful practices needed to continually address. Some challenges were within the systems, such as the need to create shortcuts or templates to establish a more efficient process. But for many practices the biggest obstacle to overcome was the need to redesign procedures when exchange of information with patients' electronic health records, pharmacies or databases containing drug information wasn't possible.

The lessons learned from the study resulted in key recommendations that practices wishing to implement - and successfully maintain - e-prescribing should consider: 1 - a practice should have a leader who will advocate the benefits of e-prescribing within the process of delivering clinical care to patients; 2 - develop strategies to communicate with and include patients and pharmacies in the process; 3 - have readily accessible technical support, particularly during implementation, to reduce user frustration; and 4 - be flexible and willing to transform traditional work processes of all staff members to effectively incorporate e-prescribing.

In one of two editorials that accompanied the published study, Carlos Roberto Jaen, MD, PhD, FAAFP, of the University of Texas Health Science Center at San Antonio, wrote "The article by Crosson et al provides us with lessons learned from the successful implementation of electronic prescribing (e-prescribing) in 5 diverse exemplary practices. These lessons share a common pathway for success: (1) extensive efforts to redesign workflow with a deep understanding of the function that they are trying to deliver, (2) willingness and sufficient trust to design protocols to allow non-clinician members of the team to safely deliver prescription-related work, (3) physician champions, (4) ongoing training for team members, (5) readily available technical support, (6) targeted communication to stakeholders outside the practice (patients and pharmacists), and (7) a commitment to continuing improvement. Each of these steps requires substantial transformation of the mental models and processes that are often present in primary care practices."