Research and applications

Transmitting and processing electronic prescriptions:

experiences of physician practices and pharmacies
Joy M Grossman, Dori A Cross, Ellyn R Boukus, Genna R Cohen

< An additional appendix is ABSTRACT Although research on the effects of electronic

published online only. To view Objective A core feature of e-prescribing is the transmission is limited, physicians appear to save
this file please visit the journal electronic exchange of prescription data between time, primarily from electronic renewals.2 3 More-
online (www.jamia.bmj.com/
content/19/3.toc). physician practices and pharmacies, which can over, electronic transmission of both new prescrip-
potentially improve the efficiency of the prescribing tions and renewals has the potential to streamline
Center for Studying Health
System Change, Washington, process and reduce medication errors. Barriers to workflow for other practice and pharmacy staff and
implementing this feature exist, but they are not well minimize interruptions from phone and fax

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DC, USA
understood. This study’s objectives were to explore communications.2e7 Pharmacy staff also may save
Correspondence to recent physician practice and pharmacy experiences time processing prescriptions that do not have to be
Joy M Grossman, Center for with electronic transmission of new prescriptions and entered manually.7e9 Reducing manual entry has
Studying Health System
Change, 1100 1st Street, renewals, and identify facilitators of and barriers to the potential to lower the rate of prescription errors
NE, 12th Floor, Washington, effective electronic transmission and pharmacy as well.7 10e12
DC 20002-4221, USA; e-prescription processing. Despite these and other potential e-prescribing
jgrossman@hschange.org Design Qualitative analysis of 114 telephone interviews benefits, e-prescription volume has been low,
Received 29 July 2011
conducted with representatives from 97 organizations although it is growing as physicians respond to
Accepted 15 October 2011 between February and September 2010, including 24 Federal financial incentive programs.13 14 Medicare
Published Online First physician practices, 48 community pharmacies, and began paying bonuses to qualifying physicians
18 November 2011 three mail-order pharmacies actively transmitting or using electronic health record (EHR) or stand-alone
receiving e-prescriptions via Surescripts. e-prescribing systems under the Medicare Elec-
Results Practices and pharmacies generally were tronic Prescribing Incentive Program in 2009.
satisfied with electronic transmission of new Physicians can qualify for substantially larger
prescriptions but reported that the electronic renewal payments through the Medicare and Medicaid
process was used inconsistently, resulting in inefficient Electronic Health Records Incentive Programs
workarounds for both parties. Practice communications (EHR Incentive Programs), starting in 2011. To
with mail-order pharmacies were less likely to be receive incentives, physicians must fulfill require-
electronic than with community pharmacies because of ments to demonstrate that they are meaningful
underlying transmission network and computer system users of certified EHRs, including generating and
limitations. While e-prescribing reduced manual transmitting more than 40% of all prescriptions to
prescription entry, pharmacy staff frequently had to pharmacies electronically, excluding prescriptions
complete or edit certain fields, particularly drug name for controlled substances. This threshold is
and patient instructions. expected to rise as program requirements become
Conclusions Electronic transmission of new more stringent.15 E-prescribing volume likely will
prescriptions has matured. Changes in technical grow further as new standards are implemented to
standards and system design and more targeted support e-prescribing of controlled substances.
physician and pharmacy training may be needed to To maximize the benefits of electronic prescrip-
address barriers to e-renewals, mail-order pharmacy tion transmission, including improved efficiency and
connectivity, and pharmacy processing of reduced medication errors, both physician practice
e-prescriptions. and pharmacy staff must use the feature routinely.
However, not all physicians who use health infor-
mation technology (IT) applications to generate
prescriptions have systems that support electronic
transmission of new prescriptions or renewals, and
INTRODUCTION even when these features are available, physicians
Physician use of electronic prescribing (e-prescribing) do not always use them.6 13 16e21 Similarly, not all
systems to generate legible and complete prescrip- community and mail-order pharmacies have the
tions could potentially reduce medication errors and ability to receive new prescriptions electronically or
improve physician practice and pharmacy efficiency to send electronic renewal requests, and even if they
by mitigating pharmacists’ need for clarification.1 do, staff may not use these features routinely.8 13
Another important e-prescribing feature is the two- Pharmacies have faced additional challenges,
way electronic exchange of prescription data including delays in receiving or being alerted to new
between physicians and pharmacies. Physicians can e-prescriptions, continued need to manually enter or
transmit new prescriptions directly from their edit prescription data, and the need to follow-up
This paper is freely available e-prescribing systems into pharmacy information with physicians to resolve gaps, errors, or lack of
online under the BMJ Journals systems as well as respond to pharmacies’ electronic clarity in e-prescriptions.7 8 10 22
unlocked scheme, see http:// renewal authorization requests once medication Most studies that identify e-prescribing barriers
jamia.bmj.com/site/about/
unlocked.xhtml
refills are exhausted (see box 1 and figure 1). are based on data from 2007 or earlier and do not

J Am Med Inform Assoc 2012;19:353e359. doi:10.1136/amiajnl-2011-000515 353

 Research and applications

and the effects on pharmacies’ prescription processing. The

Box 1 Electronic prescription transmission study also explores strategies to support more effective use of
these features. The data were collected as part of a broader
When physician practices and pharmacies use the e-prescribing qualitative research project to better understand recent experi-
routing features of their computer systems, the prescription data ences of physician practices and pharmacies using advanced
are transmitted as follows (see figure 1): e-prescribing features.23

New prescriptions
METHODS
Once a physician completes a new prescription and selects the
Participants
option to send it electronically, it is transmitted through the
Sampling frames of physician practices and community phar-
e-prescribing vendor to the electronic prescription routing inter-
macies actively using e-prescribing in 12 Community Tracking
mediary’s network. From there, the prescription is typically
Study (CTS) sites were developed from lists of physicians and
routed through the pharmacy system vendor or the pharmacy’s
pharmacies registered with Surescriptsdthe dominant elec-
central corporate server to the chosen pharmacy location. Staff
tronic prescription transmission network in the USAdwhich

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are alerted to the e-prescription arrival on the pharmacy system’s
were obtained from the company’s website. Since 1996, the CTS
display screen, for example, with an icon or new work log entry,
has monitored healthcare market changes in 12 communities
and the prescription is opened in the work queue for processing.
through periodic site visit interviews with leaders of local
If the pharmacy does not accept e-prescriptions, the intermediary
healthcare organizations, including physician practices.24 CTS
converts the prescription to a fax.
sites were selected to be nationally representative of metropol-
Renewals itan areas with populations over 200 000 (see table 1 for sites).
Once refills are exhausted, at the request of the patient, the Stratifying the sampling frame by CTS sites allowed compari-
pharmacy sends an electronic renewal authorization requestd sons of practice and pharmacy e-prescribing experiences within
also known to users as a ‘refill’ requestdto physicians for and across markets that vary by factors that may be related to
approval. The renewal authorization request is logged into the e-prescribing experiences, including relative market shares of
pharmacy and practice system message queues pending approval. local and national pharmacies, e-prescription volume, and state
The physician reviews the request and has three options: (1) to e-prescribing regulations.25 26
approve it as transmitted; (2) to make changes to a limited number Physician practices that participated in the CTS previously or
of fields, such as number of refills; or (3) to deny it. Authorization is were suggested by CTS respondents were selected purposefully
sent back to the pharmacy as a new prescription that is linked to from the sampling frame to vary in size, specialty, and type of
the old prescription by a unique identifying code. This linkage e-prescribing system (EHR vs stand-alone). In each practice, the
allows the pharmacy system to auto-populate the necessary data CTS contact was asked to identify an experienced physician
from the existing prescription. If the physician denies the request, user, and an additional respondent such as an IT manager or
the physician typically selects a reason, such as ‘following with nurse if needed, to capture both clinical and operational
a new prescription’ for a change in dosage or to make other perspectives on the practice’s e-prescribing experiences.
substantial prescription modifications. The new prescription Because less research exists on pharmacy e-prescribing expe-
references the prescription number of the denied request to allow riences, pharmacies were oversampled relative to physician
the pharmacy staff to delete the initial renewal request. Alterna- practices to support more in-depth study. The pharmacy
tively, the physician can initiate an e-renewal, in which case the sampling frame was stratified by local and national ownership
pharmacist handles the renewal as a new prescription. (see table 2 for more detail). While a few national companies
account for a substantial proportion of pharmacy locations in
the USA, the same information system is typically used across
locations, so locally owned pharmacies were oversampled to
explore electronic transmission in detail. This study focuses on capture more variation in e-prescribing experiences. The
how electronic transmission features are being used for new corporate headquarters of some national companies were
prescriptions and renewals, the facilitators of and barriers to use, contacted to select pharmacy locations to participate. Other

Figure 1 E-prescribing information

exchange. Source: adapted from Bell
DS, Straus SG, Belson D, et al. A toolset
for e-prescribing implementation in
physician offices; figure 2.1 (prepared
by RAND Corporation under contract
no. HHSA 290-2006-00017, TO #4,
AHRQ publication no. 11-0102-EF).
Rockville, MD: Agency for Healthcare
Research and Quality, 2011 (in press).

354 J Am Med Inform Assoc 2012;19:353e359. doi:10.1136/amiajnl-2011-000515

 Research and applications

Table 1 Characteristics of participating physician Table 2 Characteristics of participating community pharmacies

practices Number of community
Number of Characteristic pharmacies (N[48)*
Characteristic practices (N[24)*
Ownership
Specialty Local (within state)
Primary care 16 Independentdthree or fewer locations 16
Medical or surgical specialty 5 Independentdregional/local chain drug store, 8
Multispecialty 3 supermarket, provider-owned, and other
Number of physicians Total 24
1e9 12 National (multi-state)
10e49 7 Chain drug store 15
50e500 5 Supermarket 3
Practice ownership Mass merchant 6
Physician 17 Total 24
Estimated average prescriptions per week

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Hospital 6
Faculty practice 1 200e750 11
Type of e-prescribing systemy 751e1750 16
Part of electronic health record system 17 >1750 16
Stand-alone system 7 Unknown 5
Number of years prescriptions sent electronically Pharmacy information system
<2 12 Home-grown 19
2+ 12 Commercial vendory 29
Estimated percentage of prescriptions sent electronically Number of years prescriptions received electronically
<70 6 <2 32
70+ 17 2+ 13
Unknown 1 Unknown 3
Estimated percentage of prescriptions received electronically
*Two practices were interviewed in each of the 12 Community Tracking
Study (CTS) sites: Boston; Cleveland; Greenville, South Carolina; #5% 15
Indianapolis; Lansing, Michigan; Little Rock, Arkansas; Miami; northern 6%e14% 11
New Jersey; Orange County, California; Phoenix; Seattle; and Syracuse, 15%e24% 8
New York.
yTwelve different commercial e-prescribing vendors were represented. 25%+ 11
Among the 17 practices using electronic health record systems, vendors Unknown 3
included: Allscripts (4), eClinicalWorks (2), Epic (3), GE Centricity (2),
GEMMS, McKesson, MedENT, NextGen (2), and one homegrown *Four pharmacies were interviewed in each of the 12 Community Tracking Study (CTS)
system. Stand-alone e-prescribing system vendors used in the remaining sites: Boston; Cleveland; Greenville, South Carolina; Indianapolis; Lansing, Michigan; Little
seven practices included: Allscripts (2), InstantDX, Prematic, RelayHealth Rock, Arkansas; Miami; northern New Jersey; Orange County, California; Phoenix; Seattle;
(2) and DrFirst, which was integrated into a Greenway Medical and Syracuse, New York.
Technologies electronic health record system. yThirteen different pharmacy information system vendors were represented among the 29
participating pharmacies using commercial systems, including: McKesson (including
Enterprise, PharmaServ, and Condor products) (11), QS/1 (4), PDX (3), Transaction Data
Systems Rx30 (2), as well as nine other vendors.
pharmacies were selected through recommendations from
professional associations and physician respondents or recruited
directly. In each pharmacy location, the pharmacist-in-charge used along with the transcripts to systematically confirm and
was asked to participate. Other experts, including representa- further refine themes, and weigh the evidence supporting each
tives of vendors, e-prescribing intermediaries, and state phar- finding.28 The principal investigator and another researcher first
macy associations, were identified to provide context for the summarized a small sample of transcripts in preliminary table
user interviews. shells developed using project themes and codes, then met to
resolve discrepancies and modify the shells as needed. The two
Data collection and analysis other researchers completed summaries of the remaining prac-
Six researchers formed two-person teams, consisting of a lead tice and pharmacy transcripts, respectively; all transcripts and
interviewer and a note-taker, to conduct 30e60 min tele- summaries were also reviewed by the principal investigator. The
phone interviews between February and September 2010. Semi- authors met regularly to resolve conflicts and reach consensus on
structured protocols were tailored to each respondent type and the data tables and study findings.27
included questions on IT systems; implementation and use of
e-prescribing features, including electronic routing of new RESULTS
prescriptions and renewals; and pharmacy processing of A total of 114 telephone interviews were conducted with
e-prescriptions. (See supplementary online appendix 1 for representatives of 97 organizations. Twenty-four physician
selected protocols.) Interview team members jointly reviewed practices participated, two in each CTS site. Forty-eight
the interview transcriptions for accuracy. community pharmacies also participated, divided between local
The six-person research team used an iterative process to and national companies, with four pharmacies per site. For each
develop and refine emerging themes and to ensure data satura- participating national chain drug store, pharmacists were
tion based on a rolling review of the transcripts. Codes were interviewed at a minimum of three different locations. National
developed using the ‘integrated’ approach described by Bradley respondents included representatives of three mail-order phar-
and colleagues in which a ‘start list’ is developed from the macies and three chain pharmacy headquarters and 21 other
literature and then refined based on the data.27e29 The interview experts.
transcripts were coded and further analyzed by the four study Tables 1 and 2 provide more descriptive information on
authors using Atlas.ti qualitative software. Data tables were participating physician practices and community pharmacies,

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 Research and applications

respectively. About 70% of practices used EHRs, while the one-quarter of the participating community pharmacies,
remainder used stand-alone e-prescribing systems, closely including 11 of the 24 local pharmacies and three national
representative of the national distribution of physicians regis- pharmacies, did not send electronic renewal authorization
tered on Surescripts in 2009.13 Practices and pharmacies used requests. Eight of these pharmacies lacked the functionality, and
a variety of system vendors and the sample included both early the rest chose not to use the feature, mainly to avoid Surescripts
and later adopters. transaction fees. Similarly, one-third of physician practices were
More than two-thirds of practices estimated they sent at least not set up to receive e-renewal requests or received them infre-
70% of prescriptions electronically. Physicians selected other quently.
transmission modesdsuch as print, fax, or phonedwhen Among practices that did receive e-renewal requests, respon-
necessary, for example, when prescribing controlled substances, dents identified ways in which the renewal process broke
when a patient did not need a prescription filled immediately or down, resulting in inefficiencies. For example, they reported that
expressed a preference for a printed prescription, or when local and national pharmacies able to receive e-prescriptions
a pharmacy was unable to receive e-prescriptions. from the practice did not consistently request renewal authori-
In contrast, more than half of community pharmacists esti- zations electronically and sometimes sent multiple requests for

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mated their pharmacy received <15% of prescriptions electron- the same prescription using different means, even after the
ically, with national pharmacies more likely to receive a higher physician had responded electronically. As one physician
proportion. This rate was low, in part, because many physicians explained, ‘Sometimes the patient will call, the pharmacy will
did not transmit any prescriptions electronically. Moreover, fax, and [send something via] Surescripts, all for the same
community pharmacies noted receiving numerous computer- patient, the same prescription, on the same day. That is
generated prescriptions that were faxed or printed, sometimes cumbersome.’
outnumbering e-prescriptions. Pharmacists explained that follow-up is necessary if physi-
Physician and pharmacy respondents generally noted overall cians do not respond in a timely way, for example, within 24 h
satisfaction with e-prescribing and perceived improvements in as Surescripts recommends. A pharmacist from a national
efficiency and patient safety. However, respondents identified pharmacy chain explained, ‘Our system automatically generates
some substantial challenges to fully realizing the anticipated the request. If they [don’t] respond, that’s where we run into
benefits from the transmission and processing of e-prescriptions. problems. We fax the next day because we can’t send a duplicate
request electronically.’ Another pharmacist noted that his
Electronic transmission system is set up to automatically resend an e-fill request every
New prescriptions 72 h until the initial request is marked as complete.
Most respondents expressed satisfaction with the electronic Inconsistent pharmacy renewal request methods reinforced
transmission of new prescriptions. Despite the complexity of inconsistent modes of response from physician offices, making it
prescription routing through multiple parties, respondents more difficult for both parties to ensure that the prescription is
reported true transmission failures were rare. However, about filled and that their systems are updated. Pharmacists reported
one-third each of physician practices and community pharma- that physicians often approve electronic requests by fax or
cies noted that, on a daily basis, patients arrived to pick up phone. They also noted that physicians often mistakenly deny
orders before the pharmacy had received the e-prescription. the request and then send the same prescription as a new order.
Practice respondents were more likely to attribute the problem In contrast, multiple physician respondents noted that they
to pharmacy staff being inadequately trained to identify new typically try to respond to all renewal requests electronically,
e-prescriptions, with problems reportedly diminishing as phar- regardless of delivery mode, to capture the prescription in their
macy staff gained e-prescribing experience. Pharmacists, e-prescribing system and to convey to the pharmacy that they
however, believed that incoming e-prescriptions were easily are enabled for electronic renewals.
identified and were more likely to point to physician delays When physicians transmitted prescription renewals without
in transmitting the prescriptions or, less commonly, trans- responding to a pharmacy request, pharmacists typically had to
mission to the wrong pharmacy. Pharmacies typically resolved enter the prescriptions as if they were new, losing efficiencies
transmission problems by calling physicians for verbal orders. from auto-population. Both pharmacies and physician practices
also had to manually update their systems’ message queues, for
Prescription renewals example, by deleting any pending requests.
Physicians and community pharmacists found that the elec-
tronic renewal process was not as consistently successful as new Mail-order pharmacy connectivity
prescription routing and was more difficult to integrate into Electronic routing for new prescriptions and renewals with mail-
organization workflows. Respondents, nonetheless, highlighted order pharmacies posed additional challenges, with about three-
the time-saving advantages of the electronic renewal process quarters of the physician practices experiencing difficulties.
when working properly. A physician respondent from a small Many practices were not sure which mail-order pharmacies
family-medicine practice noted, ‘Previously, someone had to get accepted e-prescriptions and believed that, even when a mail-
the fax, distribute it, get the approval and call or fax it in.. order company did accept them, the process was unreliable.
Now the physician gets. a refill request to their inbox right According to a nurse in one practice, ‘We are nervous about
away and can deny or accept it in seconds. It eliminates hand- sending electronically to mail orders. The success rate isn’t
offs. So instead of 24 h, the turnaround time is an hour.’ On the high.. If it doesn’t go through, I will fax it. We can lose four or
pharmacy side, according to a manager of a mass-merchant five days though. finding out that it never went through.’
pharmacy, ‘The physician sends me back the exact same Respondents also largely noted that renewal authorization
everything.. The e-prescription is married to something in my requests from mail-order pharmacies were received only by fax.
system, so five keystrokes and it’s ready to go.’ In response to these challenges, some practices first tried elec-
While both physicians and pharmacies stand to benefit from tronic routing for new prescriptions or renewal responses,
the increased efficiency of electronic renewals, more than followed by faxing or printing the prescription if unsuccessful.

356 J Am Med Inform Assoc 2012;19:353e359. doi:10.1136/amiajnl-2011-000515

 Research and applications

Others simply avoided electronic communication altogether by Moreover, both physician and pharmacist respondents
routinely faxing or printing all mail-order prescriptions. explained that physicians must select medications with more
Practice respondents were surprised by these challenges, specificity when e-prescribing, making decisions about pack-
expecting electronic routing to function identically for aging, drug form, or other features that commonly are made by
community and mail-order pharmacies. However, as mail-order pharmacists for hand-written prescriptions, sometimes leading
pharmacy respondents explained, few e-prescribing vendors that to more pharmacy follow-up. In an example provided by an
were Surescripts-certified to e-prescribe with community phar- independent pharmacist, ‘A doctor might pick ‘minocycline
macies were also certified for new prescriptions with mail-order tablet, 100 mg.’ He wouldn’t intentionally select this because
pharmacies, and even fewer were certified for mail-order it’s seven times more expensive than capsules.. In the past, the
renewals. As a result, while some practice respondents believed doctor would have called in simply ‘minocycline.’ I would pick
they were sending prescriptions electronically when they ‘capsules’ in the system because I know the cost difference.
selected mail-order pharmacies from the e-prescribing directory, When the doctor puts in ‘minocycline tablets,’ I, as a pharma-
the mail-order pharmacies noted most e-prescriptions from cist, can’t change that. I have to give what they said.’ Physician
Surescripts were delivered by fax. For the same reason, most respondents confirmed this problem, as one physician in a small

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mail-order renewal requests also were sent by fax. These practice noted, ‘No longer now can I just say ‘potassium,’ I have
connectivity barriers arose because the new Surescripts organi- to pick if it’s a tablet, capsule, or liquiddyou used to just let the
zation, formed from a merger of SureScripts and RxHub in 2008, pharmacist and patient deal with that.’
continued to maintain two legacy transmission networks. Physicians elaborated on the challenges in selecting the
Some mail-order pharmacies addressed these barriers by intended medication given the overwhelming number of different
converting all e-prescriptions to images and processing them forms and strengths of medications available in a search query. A
with fax and paper prescriptions in a single workflow, while physician respondent observed, ‘On my preference list, there are
others maintained dual workflows, processing e-prescriptions 19 adult and pediatric dosings for amoxicillin. If you don’t have
separately. Since the time of the interviews, transmission a preference list, you’re searching in the general database, which
network changes have been implemented to enable more is an absolute nightmare. There are two full screens with 60
e-prescribing vendors to route new prescriptions electronically to entries for variations on the theme of amoxicillin. and that’s
mail-order pharmacies, but changes to support e-renewals lag. a good situation.’ As another example of ‘over-specification,’
physicians may have to choose from among different generic
Pharmacy processing of e-prescriptions drug manufacturers. Pharmacists noted that stores stock only
Most pharmacies received new e-prescriptions directly into their a limited number of manufacturers of any particular generic,
pharmacy systems for processing. However, two mail-order making it difficult for the pharmacy system to match to the
pharmacies and six community pharmaciesdincluding local and manufacturer specified in the e-prescription. Physicians and
national retailersdcontinued to manually enter all e-prescriptions. pharmacists also noted the serious problem of ‘fat fingers,’ or
Most of these pharmacies, though, were implementing new inadvertently selecting a drug with a similar spelling but
systems with automated processing. a different clinical purpose than the intended medication.
The majority of the remaining pharmacies processed
e-prescriptions similarly. Once the pharmacy staff were alerted to Quantity
a new e-prescription and opened it, the system attempted Pharmacists and physicians both noted that physicians face
to match the patient and physician. Staff sometimes had to challenges accurately specifying quantities for prepackaged or
manually select the correct individual from a computer-generated multi-use medicationsdsuch as pill packs, syringes, inhalers, or
list of options or create a new profile. creamsdin e-prescriptions. E-prescribing systems typically list
Staff then processed each prescription element, either clicking such medications by the container or package, rather than the
on the information in the view screen to import it into the individual dosing units, which can cause physician confusion in
corresponding pharmacy system field or visually verifying the selecting the appropriate quantity. Pharmacists commented that
information if the field was auto-populated. Pharmacists callbacks were typically unnecessary, but staff must be trained
reported that the necessary fields were typically complete in to recognize and correct this type of problem, especially since
e-prescriptions, unlike paper prescriptions. When needed, phar- pharmacists must specify the quantity of the active ingredient
macy staff typed in or edited text in a field or selected an entry on insurance claims. Observed a pharmacist in a national chain
from computer-generated options. Three prescription fields location, ‘With inhalers, prescribers usually enter the quantity
commonly required manual manipulationdmedication name, ‘1,’ if you don’t change that, you’ll be billing (the insurer) for 1 g
quantity, and patient instructions (also known as the Signatura but it weighs 17 g so you’ll be shorting yourself. It’s the same
or ‘Sig’). with Enbrel, an injection medication that is 3.92 g. You have the
potential to lose $3000 if someone is not paying attention.’
Medication name
When physicians select a medication, the data field typically Patient instructions
contains a single string with the drug name, strength, and dosage Nearly half of pharmacists noted that patient instructions
form, which is transmitted to the pharmacy along with the Food typically had to be rewritten for patients to understand. As an
and Drug Administration National Drug Code (NDC). Although independent pharmacist explained, ‘A lot of times we can’t copy
NDCs are used to standardize medication identification across the directions word for word because the patient doesn’t
systems using different drug-database vendors, there is no understand them, just like with paper prescriptions. We have to
central, up-to-date source for a unique NDC for each clinically go in and erase ‘t.i.d.’ and put in, ‘One tablet three times a day’.’
distinct drug.7 If the NDCs in the e-prescription and the phar- While some e-prescribing systems may facilitate writing
macy system do not match, the data cannot be auto-populated instructions in English, pharmacists indicated that, even when
and the pharmacist must rely on the transmitted information to not in Latin, Sigs often were written for the pharmacist and
manually select a medication from the pharmacy database. needed editing to be more patient-friendly.30

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 Research and applications

About a third of pharmacists noted another challenge: the Practices may benefit from direct communication about these
potential for physicians to provide additional instructions in changes and education on how to most efficiently process mail-
another field, such as the extended instruction or comment box, order prescriptions and renewals in the interim and after changes
that contradict what is stored in the Sig field. This sometimes are implemented.
prompts callbacks, as a respondent at one local chain explained,
‘We’ll see ‘Take one tablet.’ Then it will say below in the notes Reducing the need for pharmacy editing of e-prescriptions
field, ‘Take two tablets in the morning.’ It’s like the first part is Study findings on challenges to reconciling prescription data
automatically filled in for the doctor.. We normally look in fields between practice and pharmacy systems are consistent
patient history.. If we see one tablet used in the past, then we with other recent research.7 34 To address challenges related to
keep it at one tablet; otherwise we call the physician.’ While drug identifiers, experts have recommended that NCPDP
some physicians confirmed that this problem could arise in their consider using a new technical standard, RxNorm, a standard-
e-prescribing system, it is unclear how dependent this problem is ized nomenclature for clinical drugs, in place of NDC codes as
on specific system designs. the main identifier.7 RxNorm could help reduce drug selection
inefficiencies and potential errors by better conveying physi-

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DISCUSSION cians’ clinical intent without requiring them to over-specify
Study findings suggest that use of electronic transmission their choice and allowing pharmacists to use that information to
features has matured relative to earlier research, with practices select the most appropriate medication. E-prescribing vendors
and community pharmacies reporting few barriers to electronic and drug database vendors also could explore ways to enhance
routing and receipt of new prescriptions. However, respondent system interfaces and drug selection tools and promote best
reports suggest that challenges related to e-renewals, mail-order practices so that physicians could more easily choose among
pharmacy connectivity, and pharmacy processing of select clinically appropriate options and convey the correct quantity
e-prescription fields remain. These challenges likely will become information regardless of dosage form.
more salient for physician practices and pharmacies as To improve the quality of patient instructions in e-prescrip-
e-prescription volume accelerates in response to Federal incen- tions, the Structured and Codified Sig Format is being incorpo-
tives. In addition, some physicians may be penalized inadver- rated into the NCPDP SCRIPT e-prescribing transaction
tently if they are unable to meet increasing threshold standards.34 Moving from free text to a structured format may
requirements under the EHR Incentive Programs for the allow physicians to write more complete, clinically accurate, and
proportion of prescriptions sent electronically because of chal- unambiguous Sigs. Experts recently recommended that the
lenges associated with mail-order prescriptions. While some Format be strengthened before it is made mandatory, and
challenges may be mitigated as physicians and pharmacies gain suggest a solution to address the potential for conflicting Sig
more experience, structural issues underlying these challenges information under the new standard.34 Meanwhile, e-prescribing
likely will need to be addressed directly. A broad group of public vendors could explore ways to improve system design to miti-
and private stakeholders, including the Federal government, the gate the existing problems with conflicting Sigs. Other expert
National Council for Prescription Drug Programs (NCPDP) recommendations include providing additional physician
standards setting organization, vendors, and medical informatics training and developing best practices to encourage physicians to
researchers would need to work together to help support these send amended prescriptions to the pharmacy to avoid repeating
efforts. mistakes.35e37

Supporting e-prescribing expansion

Increasing e-renewal reliability and efficiency
Additional research on the barriers to and facilitators of two-
The e-renewal process may become more predictable if phar-
way electronic communication will be increasingly important as
macies and practices with e-prescribing that are still faxing
pharmacies and physician practices not only expand use of
renewals discontinue this practice when the Federal exemption
existing e-prescribing features but also seek more electronic
for computer-generated fax transmissions under the Medicare
communication tools. Technical standards to support additional
Part D program expires on January 1, 2012.31 Study findings
two-way electronic communication between practices and
suggest that pharmacies and practices also may benefit from
pharmacies, for example, to change or cancel a prescription and
explicit guidance on incorporating the e-renewal process into
for clinical queries, have been incorporated into the
workflows, for example, through implementation guides, best-
NCPDP SCRIPT standard or are being developed; none are yet in
practice tools, and targeted education, training, and support,
widespread use.38
particularly once users have gained some e-prescribing experi-
ence.32 33 There also may be opportunities to modify or enhance
underlying technical standards and physician and pharmacy Study limitations
system design to better support electronic communication Because this is a qualitative study based on a small and
during the renewal process, for example, providing alerts if purposeful sample, findings cannot be statistically generalized to
e-prescribers do not respond to renewal responses within all physicians and pharmacies using electronic prescription
a specific time period or supporting standardized approaches for routing. Moreover, because respondent identification was
pharmacy follow-up requests. purposeful and participation was voluntary, the sample may
have been systematically biased about e-prescribing in a positive
Improving mail-order pharmacy connectivity or negative way. However, respondents typically identified both
Surescripts, mail-order pharmacies, and e-prescribing vendors are facilitators of and barriers to effective electronic routing.
working on network and system changes to increase the
Acknowledgments We are grateful to the respondents for their willingness to
proportion of practices that can communicate electronically share their time and insights. We would also like to thank Teresa Zayas Cabán,
with mail-order pharmacies, and this transition could possibly Jonathan White, and Terri Warholak for valuable input into the study design and
accelerate with the expiration of the Federal fax exemption. earlier drafts of the paper.

358 J Am Med Inform Assoc 2012;19:353e359. doi:10.1136/amiajnl-2011-000515

 Research and applications

Funding This research was funded under contract number HHSA 290-05-0007 (03) 18. Grossman JM, Gerland A, Reed MC, et al. Physicians’ experiences using
from the Agency for Healthcare Research and Quality (AHRQ), US Department of commercial e-prescribing systems. Health Aff (Millwood) 2007;26:w393e404.
Health and Human Services. The opinions expressed in this document are those of the 19. National Opinion Research Center (NORC) at the University Of Chicago. Findings from
authors and do not reflect the official position of AHRQ or the US Department of the Evaluation of E-Prescribing Pilot Sites. (Publication No. 07-0047-EF). Rockville,
Health and Human Services. MD: Agency for Healthcare Research and Quality (AHRQ), 2007.
20. Crosson JC, Isaacson N, Lancaster D, et al. Variation in electronic prescribing
Competing interests None. implementation among twelve ambulatory practices. J Gen Intern Med 2008;23:364e71.
21. Wang CJ, Patel MH, Schueth AJ, et al. Perceptions of standards- based electronic
Provenance and peer review Not commissioned; externally peer reviewed. prescribing systems as implemented in outpatient primary care: a physician survey. J
Am Med Inform Assoc 2009;16:493e502.
22. National Community Pharmacists Association (NCPA). Statement of the
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