Why are most physicians writing their prescriptions by hand?

Is the pen mightier than the PC?

When it comes to prescribing, it appears so. A new report from the Center for Studying Health System Change finds that most physicians write their RX scripts by hand, despite financial incentives for physicians to adopt electronic prescribing. Even those who have e-RX systems do not always use them, and when they do, they may not to use the features that were anticipated to have the biggest impact on improving prescribing practices.

HSC’s nationally representative Health Tracking Physician Survey finds that “two in five physicians in office-based ambulatory practice (41.9%) reported that information technology was available in their practice to write prescriptions in 2008 … Moreover, physicians who had access to e-prescribing did not necessarily use it routinely. About a quarter of the physicians reporting availability of IT to write prescriptions (23.1%) used the technology only occasionally or not at all. So in 2008, about one-third of all physicians in ambulatory settings (32.3%) routinely used e-prescribing.” Advanced features – drug information alerts and patient formulary information – were used even less frequently.

Primary care physicians were more likely than medical and surgical specialists to use e-prescribing, as were physicians in larger group practices.

The low adoption rates for e-RX suggests to me that financial “carrots and sticks” may not be enough to drive adoption of health information technology. Medicare will pay a 2% bonus of total allowed charge to physicians for use of e-RX systems through 2013, but penalties will go into effect in 2012 on those who do not. Even larger chunks of money are available for physicians who adopt “certified” electronic medical records for meaningful use (including e-prescribing).

I am not sure why more physicians aren’t using e-RX systems. Is it because of cost? Force of habit? Or do the systems themselves lack user-friendliness and functionality?

Whatever the reasons, it doesn’t bode well for the government’s goal of getting a certified electronic health record in every practice. The HSC authors note, “the challenges to implementation of EMRs as a whole are substantially more complex than e-prescribing. And, EMR technology is much less mature, suggesting that policy makers should expect a substantially longer time horizon to achieve meaningful use of health IT than the five- to six-year horizon of the Medicare and Medicaid incentive programs.”

Why do you think physicians are slow to adopt e-RX, even with the government”s “carrots and sticks”?

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.

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  • Donald Green MD

    Someone once noted that no one had to encourage people to switch to cell phones. Its immediate usefulness made it a day to day occurrence. The same must be done for electronic documentation in medical practice. We have not reached that threshold and with juicing up “meaningful use” rules may make it an even more distant reality for many.

  • The Nerdy Nurse

    To many it is most likely a hassle. They do not wanto invest the initial time to learn the software and accordingly never see the benefits. Technology has an will continue to improve health care and we should all embrace what can only serve to make oir lives easier and hopefully help us to be more healthy. As an aspiring nurse informacist, I’m passionate about teaching others the benefits we can gain through through the use of (and early adaptation of) available technologies.
    Old dogs can and should learn new tricks.

  • ninguem

    How about when the computer system goes down……..

    again

    • Ms. Beck

      Or, how about when hackers realize the availability of street-prescription drugs at their fingertips, thanks to all those doctors with their e-signatures at their disposal. I know hackers that can go into anything and mess up anything. They can destroy your programs or rewrite them. MAC computers are the safest.

      I’m just waiting for a black out, with all medical records lost while in the middle of taking care of several crisis, with no hx and pysical, labs, or test results available. Be ready to keep a hard copy available just in case.

  • Finn

    When my internist uses her practice’s e-prescribing software to renew my raloxifene prescription, the software pops up a warning about its being contraindicated in pregnancy–even though I’m taking the stuff for postmenopausal osteoporosis. Apparently the software ignores both the age and history fields (status post TAH & BSO) and launches annoying warning dialog boxes based solely on the sex field: I’m female, therefore I might be pregnant despite my age and lack of necessary organs. I’m sure having to mouse up and click to make the warning dialog disappear and continue writing the prescription can become a major time-suck for some practices.

  • http://www.oasite.com/blog Omar

    Based on my experience, most physicians that are eprescribing love it. But it really does depend on the product they are using, some of the products are very intuitive and easy to use while others are cumbersome and confusing.

    In my opinion, the main reason the majority is not eprescribing is because there is a big resistance to change. When I can scribble something down in a matter of seconds (even though it may not be readable!), then why spend a minute to do the same thing via electronic means? Of course, there is no comparison in terms of safety as far as drug utilization reviews and the like, but speed is probably main concern that physicians have when it comes to not eprescribing.

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen

    “Or do the systems themselves lack user-friendliness and functionality?”

    Yes. I have tried a number of e-prescribing options and they have all dramatically slowed me down. We still do refills electronically – and that is helpful – but even then it is a disjointed system. As with most software created for physicians, work-flow and intuitiveness are typically absent.

    Some problems I’ve encountered:

    (1) Due to prescribing laws, I cannot send schedule II drugs electronically to pharmacies – which means I’ll always be writing some prescriptions.

    (2) It is much easier to write exactly what I want than to try to fit it into pre-made ‘slots’. Want to write a tapering dose of Prednisone? Its not so easy with electronic prescribing. Sometimes I want 15mg of Topamax not 25mg. It can’t always be in my favorites list – I have to create it from scratch

    (3) Sending scripts directly to a patient’s pharmacy sounds wonderful – except: “Oh, did you send it this time to pharmacy A? I’m today closer to pharmacy B.” Or “I don’t know the address or phone number of my pharmacy – can’t you look that up? It’s on Duke street.”

    (4) I don’t think mail-order pharmacies (all the rage now) accept electronic scripts. They want everything faxed.

    (5) Once I had a totally wrong drug sent to a pharmacy. It was an error in the programming of my own software (that our office uses) but that’s a pretty big error.

    • J.T. Wenting

      yup. Noticed my doc when he used his PC to compose my latest prescription.
      He had to browse through a list of about a hundred variations of the same medication before he found what he was looking for, could have written that same thing down in under half the time.

      But then it wouldn’t have been entered into the automatic billing system of course.
      Which was rather pointless as the pharmacy substituted something else when they didn’t have the stuff the doc prescribed in stock (but did have an equivalent from another manufacturer, same dose of the same medication in a different package).

  • Bobby

    It’s just quicker to grab a pad and scribble!

  • http://thewiredpractice.blogspot.com Mike Koriwchak MD

    Prescriptions are one of the best example of cultural resistance to EMR. About a year ago, 4 years after we got EMR, I noticed our administrator ordering a large number of prescription pads. I asked why so many since we use them so rarely now. She sheepishly admitted that a couple of our docs had gone back to script pads but were still using the other EMR functions just fine. When I asked one of the docs about it his answer was telling: “Unless I use a script pad I don’t feel like a doctor.”

    When I got married in 1994 all but one of my groomsmen were fellow residents. What did I get them for gifts? Personalized prescription pad covers.

    Apparently there is a lot of “doctoring mojo” in that script pad.

  • Justin

    The main reason I prefer not to e-rx is that the software I’ve used takes longer than handwriting, and I have good handwriting because I write slowly so it is easily readable. And once I have it filled out properly, I have to print it, then go get it from the printer, then hand it to the patient. This easily wastes 1-2 minutes per patient, which adds up over a 30+ patient day.

    Also, for some reason our software only accepts brand names for certain drugs. For example, gabapentin cannot be searched, so you have to type neurontin. And if you misspell amitriptyline, the software does not prompt you with options, so you have to look up proper spelling for difficult drug names.

    I hope that my clinic’s software is on the user-UNfriendly end of the spectrum; I would be embarrassed for a company that produced a worse e-rx feature in its software. I think this is a useful example of why this behavior is not being rapidly adopted.

    • http://www.oasite.com/blog Omar

      Justin,

      This is not too true eprescribing if you are not able to send the script directly to the pharmacy and instead of have to print it. You should try out another product that would allow you to save those precious minutes of having to print!

    • Sage

      To be fair with e-rx softwares: we need to compare Apples to Apples. May be it will take 2- 3 minutes to prescribe on a pad per patient. e-rx softwares does more than just prescribing: e-rx alerts for the potential Drug-to-Drug interaction, drug to patient allergy, dosage check, duplicate drug alert and Formulary Status check. A single mistake by a prescriber , even in a year span,may cast more time and resources. There are always some trade-off: with e-rx you spend little more time, but you are surely reducing the Adverse Drug events. e-rx also save patient and staff’s precious time as prescriber at the point of care will know the drug being prescribed is covered under the insurance plan.

  • http://fertilityfile.com IVF-MD

    Would it make more sense to put the challenge to the software companies to design quality software that actually improves workflow and does so at such a reasonable cost that we doctors would eagerly or at least voluntarily CHOOSE to adopt EMR of our own free will? Or does it make more sense to force it upon us and to bribe us with money taken involuntarily from working taxpayers so that even though it’s not really any better for patient care, doctors would buy it for the sake of going along with the mandate and going after the bonus money? I personally like the first scenario and the moment that I see it as a way to make it easier for me to do my job better at an irresistible cost, I will be the first to want to make the switch. Voluntary solutions are better than attempted solutions which are founded on coercion and force. Wouldn’t you agree?

    • http://www.oasite.com/blog Omar

      Great points! If the tools you use to practice medicine do not help you practice it better, then what is the point of even using those tools?

  • Michael F. Mirochna, MD

    We have an EMR at our residency. It is slow and cumbersome in prescribing, there are too many options and it takes too long. If you want to set-up prescriptions for the future, like the schedule II drugs, you have to first “commit” the first month, then go back in and change the dates, “commit” again, etc… If I want, quantity, one month supply, I think the computer would implode. You would think refills would be a hit, but it takes so long to update each med if there are any changes (in quickly running practices, I’ves seen the nurses fill out the scripts for the doc). Another problem is that patients will say, well the pharmacy on this street. If it’s a major street, there are 20 pharmacies on it.

    Allscripts is the devil (if you didn’t catch on with the “commit” idea).

  • DKDMD

    Dr. Green got it right. If the technology was so great that it would make us more effecient and safer for the patient. We’d be tripping over each other to get to the store to buy it?? I don’t hear any heards of docs running to buy this stuff. I hear politicians, who have friends in the software industry, telling me and enticing me to get the software because it is so wonderful. Something is wrong with this picture.

  • gerridoc

    My experiences with electronic prescribing were very frustrating. It is not easy to use. Why is it that the EMR gurus keep on insisting that electronic prescriptions are so great? If the technology and formats were “user friendly”, don’t you think that professionals with a post graduate degree and extensive training would readily adopt it?
    The first reply pointed out that cell phones have been readily adopted by a wide range of people.
    What don’t the IT people understand? Electronic prescriptions are not ready to be considered as “state of the art.”

  • http://fastsurgeon.blogspot.com JF Sucher, MD FACS

    1. Poor software design.
    2. Lack of integration of eRx with EMR
    3. Poor software design (yes, it is horrible)
    4. Inability to prescribe pain medications like Vicodin (in Texas). I am a surgeon.. there’s little else that I need to prescribe.
    5. Did I mention the software is horribly designed?
    6. Many pharmacies lack the ability to receive ePrescriptions.
    FaST Surgeon

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    EMR systems not located in Pediatric centers often do not take into consideration Pediatric dosages – all kinds of warnings-that-do-not-apply pop up and are a HUGE hassle to get around.

    It is far easier for me to break out a pad and simply write out the prescription than jump through all of the ridiculous hoops offered up by the EMR’s the “safety” protocols – which actually don’t seem all that safe to me because trying to cope with them on a busy day might incite an overwhelmed physician/nurse to violence or the destruction of equipment.

    I am the daughter of a teacher. She taught me to write in perfect print that is easy to read (the signature maybe notsomuch). Writing a script is not a problem.

  • http://www.ptjess.com Jess

    As long as I can read the script I am ok with hand written. There have been times (as a Physical Therapist) that I had difficulty knowing the diagnosis (shoulder vs knee) because the instructions were written so poorly. Luckily I can call…but in the short term end up guessing what it says. At the pharmacy, this could be disastrous. I think it is just safer to have it typed (EMR or alike). Great Blog Doc Kevin!

  • Marc Gorayeb, MD

    “Medicare will pay a 2% bonus of total allowed charge to physicians for use of e-RX systems through 2013, but penalties will go into effect in 2012 on those who do not.”

    These bureaucrats have no clue, do they? Clearly, they think physicians are gullible, programmable automatons who will do the government’s bidding if subjected to insulting and annoying financial pressures. You think private insurers are ruining your work day? Wait a couple of years.

    • family practitioner

      The medicare bonus can only be billed if an e-scrip is generated during an appointment. What about all of the scrips that are generated outside a visit?

  • Dr. J

    Lets re-frame the question: Why does anyone actually use eRx software? It’s cumbersome, time consuming and adds no value for either the doctor or the patient.
    At times the software seems frankly obstructive, as if it were written by a software engineer with a Merck Manual and no input at all from doctors or patients. Instead of being helpful the software pops up millions of useless warnings, and has no functionality to help with trickier aspects of prescribing such as weight based and renal dosing.
    I always get a kick out of people who claim that doctors are just not dedicated to ‘learning the software’. With the exception of very technical software (like CAD systems) any software that takes excessive time to learn is garbage to begin with.
    I once used an EMR/ERx program that was a cost saver because the developer had avoided paying windows licensing fees, so the EMR booted off of your regular desk-top (no other search windows, no email just the EMR), and every keystroke and button was different than everyone was used to (control-k is copy, and control-r is paste, the purple button closes this window and the green swirl has to be triple clicked to move to the next screen). In short, it was useless (but VERY inexpensive).
    There are some good examples of user friendly and innovative EMR/ERx systems out there (LifeRecord for example, no affiliation) but most of this software is total junk.

  • Brian Dillon

    The behavioral change from paper to electronic is a tough one to deal with and even more difficult if in fact the “electronic” paper is slower and in many cases cumbersome to use re: “not prescriber friendly”. After being the CEO of a progressive EMR developer and having done a relatively careful review of the more common eRx’s in the US market (Standalone) it became very apparent that my observations were very correct. Even those prescribers that are using technology over paper do it more for the data capture features and in many cases live with the short comings of the system so as to make certain that they have good sound data to refer or reflect upon.
    The ultimate solution is an eRx system that learns from the prescriber, adopts to their particular habits and allows fast and easy flow through of the prescriber’s steps. In essence if a standard script can be written in 10 – 15 seconds with minimal key or touch strokes, it should go a long way to changing the perception and yes the behavior of the end users. For those interested stay tuned as there is about to be launched an extremely versatile system that accomplishes the above and has been used in the Canadian market for 3 years with only a scant <5% return or abandonment rate from over 3000 users.

  • Easton

    This is amazing to me. I think habit, resistance to change, and laziness are factors. I e-prescribe everything, everyday. The only exceptions are if the patient needs to mail off the script, or for controlled substances (when oh when will the DEA join the 21st century and let me e-prescribe CS meds, at least schedule III-V).

    Patients love e-prescribing. Once doctors get in the habit of doing it, they love it too. The med list is automatically updated, all at once. Any financial incentives from Medicare are just gravy. I’d do it anyway.

    There are many inefficiencies and frustrations introduced by EHRs. But if properly set up and trained, I don’t think e-prescribing is one of them.

  • Greg

    All good points above. If something, especially software, is difficult to use, it won’t get adopted, except by a few hobbyists looking to tinker around with something (pre-Ubuntu Linux, anyone?). I have a bachelors degree in computer engineering, but now that I’m a doctor I still write prescriptions the old fashioned way. For me, the whole “well, doctors are just so old they don’t know how to use technology” argument doesn’t apply. I designed and programmed software back in engineering school, and usually assemble my own computers from component parts as a hobby. But as a physician, eRx programs are so non-user-friendly, and have so many obnoxious redundancies, it is much faster, sanity-saving, and cheaper to just write with a pen.

    There is another psychological effect of a doctor handing a handwritten note to a patient that you don’t get when a Rx is automatically wired to a pharmacy. It’s a ritual, where you make eye contact with another human being, and this helps strengthen the doctor-patient relationship. This is clearly NOT something on the minds of software developers or government lobbyists. But for doctors and patients, the process and authenticity of a handwritten document (where else in American life are notes and letters still written by hand) speak to a human connection which often baffles cold algorithmic process analysis types. The psychological benefits of handing over something that you wrote and signed with your name, looking eye to eye with another human being in distress, with an implicit “I’m here to help you,” is something a mid-level government bureaucrat or manager of a software company is not going to understand.

  • family doc

    E-scribing poses a problem when the local pharmacy is literally adjacent to your office in the same building of a community hospital. Electronic scripts through our EMR take about 20-30min to be processed and received by the pharmacy. Okay if the patient is going to have to drive to the pharmacy, but not so helpful if they are frustrated by waiting around in the lobby raising cain at both our front office and the pharmacy when their drugs aren’t ready for pickup.

    Further, our EMR has some flukes that make prescribing certain meds more than a chore. Prednisone tapers, compounded medications, etc. Errors in the actual prescriptions occur frequently on our system due to errors on the tech side – incorrect # of tabs, completely changing the instructions we have just typed in, no ability to write for mL to be dispensed on insulin Rx, random things we don’t know about until after the pharmacy calls with complaints.

  • PAUL MD

    For me and my practice, e-prescribing conflicts with the nature of my practice and the “human condition” of travel and uncertainty.

    It’s another uncompensated !@#$% hassle.

    I spend alot of call time re-doing e-scripts for the other docs I cover and likewise I’m sure. “the pharmacy didn’t get it” says the patient….no, the pharmacy you had it sent to is not the one you are calling from. I’m sure the pharmacies are also loving all of the restocking they are doing and the lost business by not having the patient poke around the store while they wait for their rx. Not really my problem but it may certainly be theirs.

    We do a lot of “try this med. IF it relieves your symptom, THEN fill the Rx. ERX is not made for this scenario.

    Snow birders to the south that don’t know which pharmacy they will be near or will have the best price etc…some patients meander on their drive to Florida and stay a week visiting family in S. Carolina. The tangible, traceable note signed by the doctor in the patient’s possession is still King or else Schedule 2 meds would be MANDATED to be sent via electrons.

    For my money, a paper script in the hand is worth two in the cloud.

  • http://www.touchingsoulsintl.org Tahmina Sultan

    Force of habit is the main reason for physicians still wants to write hand prescriptions. Going paperless makes everybody’s life easier. Not to mention, how difficult it is on pharmacist’s part to read some of the doctors bad handwriting, sometimes even they have their own abbreviation for name of a medicine, can not get in touch with the physician to clarify the prescription on time. And who suffers after all that? Any change is not comfortable in the beginning. But we need to accept what is better for the majority.

  • Don Berry

    Carrots and sticks have no impact if technology makes work easier while improving local outcomes.

    Carrots and sticks have no impact if technology fails to make work easier or improves local outcomes.

    Carrots and sticks are tools developed by those who don’t understand the difference.

  • Dr.Rick

    Proponents for EMR/EHR/ePrescription adoption are academics with government grants and those who benefit most from either software development work incentivized by ONC stimulus dollars or the mega-payer CMS.

    PCPs are not inclined to wholesale adopt ePrescribing as all it does is (allegedly) improve something we aren’t paid for doing now… so measuring the impact depends on the individual practice.

    Carrots and sticks make no difference when the adoption carrot provides a lower reimbursement premium than the penalty of lost producitivity… or the adoption stick hurts less than the higher productivity gained from doing what is best for patient and practice.

  • Mister M

    As a patient who has had to deal with illegible prescriptions before when his pharmacy couldn’t read them, I’m crying nonsense on the idea that writing by hand is “best for patient and practice.” Not to mention those rarer cases when the wrong medicine or dosage could seriously hurt or kill somebody. In fact, if money won’t be a good enough carrot and stick, I’m going to pointedly ask about electronic prescriptions at every internist and specialist I see from here on out. Maybe enough consumer complaints will be more annoying than spending 15 seconds to type something in rather than scribble out hieroglyphics.

    • http://fertilityfile.com IVF-MD

      Those are not the only choices. You can have pre-printed prescriptions that are fast, safe, effective, legible and without any need for expensive software packages.