ePrescribing for eIdiots

ePrescribing is the stupidest thing to come to pharmacy to date.  It serves no point, it causes MORE errors, plus it costs pharmacies upward of $0.30/rx to receive each prescription.
Lets take a realistic look at this.  Next time you are at work, tally up how many refill requests you send to doctors a day.  Now multiply that by $0.30 and figure out how much a month that surcharge will cost you.  You think that the doctors are paying thousands of dollars a month for this “service?” No! The brunt of the cost is placed firmly on the backs of the pharmacies who get forced into this service by the doctors.  Wait, it gets better.  You know that idiot in the doctors office who points-and-clicks their way to that eRx? Well if they screw up and make any changes (and resubmit it to you), its another $0.30!  Oh, but this time you’ve already filled the Rx and now have to RTS and redo everything.

Despite what SureScripts (and the pharmacies who suck their dick, mostly Good Neighbor Pharmacy and the infamous AmerisorceBergen) claim;  eRx provides absolutely no cost or time savings for pharmacies or pharmacists.  This is because:

1. We have to retype /everything/ due to a lack of a standard sig code table between the 1000’s of pharmacy software vendors out there.  Not to mention that every pharmacy system has the drugs entered in differently as well.
2. It costs us $0.30 for the “privilege” of receiving an eRx, $0.25 for the NCPDP transmission, another $0.50 for the vial and label, another $2 for the labor, and when you’re dealing with horrible PBM’s (mostly MedImpact, MedImpact, MedImpact again, MedImpact and BlueShield), you only make $drugcost + $2.  You lose money with every eRx you get!
3. If the person typing in the eRx makes a mistake, its another $0.30.  If you fax it back for something that’s not covered and they respond via eRx, another $0.30.

If you can get your hands on the Good Neighbor Pharmacy bulletin, you’ll see how much GNP and AmerisorceBergen sucks the sweaty cock of SureScript.  Pharmacists just like you and I voiced their concerns in the GNP newsletter; and ABC and GNP pretty much said “well, deal with it.  You’ll make money we promise”.  Yeah… “Hi! I’m you’re wholesaler, bleed out money because I want to make sure SureScripts looks good”.  I hope GNP pharmacies are getting a huge cut on their wholesaler bill since now ABC is making business desisions for them.

Bruce Roberts, RPh, executive vice president and CEO of the National Community Pharmacists Association (NCPA), today hailed the move by AmerisourceBergen Corporation to enroll its Good Neighbor Pharmacy® network of independent community pharmacies as Founding Members of SureScripts, the nation’s largest network provider of electronic prescribing services.  The move will add more than 2,400 pharmacies to the SureScripts network.  NCPA co-founded SureScripts in 2001 to improve the quality, safety, and efficiency of the overall prescribing process.

Don’t say that your pharmacy associations don’t do anything for you! Now GNP pharmacies get ass-raped by their own for the low-low cost of only $0.30/eRx.  Here’s something about “quality, safety, and efficiency”: I have seen more errors, decimal point, and unit fuckups via SureScript eRx in one week than YEARS OF PAPER PRESCRIPTIONS.  In fact, I keep a file of all of the eRx fuckups that I get (it gets about 2-3 a day, that’s 15 a week) so when doctors say how WONDERFUL it is, I show them how many lives I have saved.  I’ve seen injection dose written instead of an oral dose, blatant overdoses, everything you can imagine.  I’ve even had controlled substances faxed to 2 different pharmacies 1 min apart for a cash paying patient MULTIPLE TIMES.  Hows that for safety and quality!

Now here’s the dirty secret of eRx’s, and why doctors have their panties moistened by its computer goodness.  You see, the “old fashioned way”, doctors had to sign each Rx they gave out to the patient.  However those days are long gone thanks to ePrescribing.  Now all some idiot has to know is the doctors password and ANYONE IN THE OFFICE CAN SEND OFF PRESCRIPTIONS.  That’s right, this bullshit doesn’t save the pharmacies any time, but it saves the doctor a bunch because its pretty much giving anyone who works in the office the power to sign and give patients legit prescriptions (even for controlled substances!)  Before, you had to steal the doctors pad and write out phonies, now anyone in the office with access to the eRx terminal can splatter out narcotics to every pharmacy that takes eRx’s and nobody would be the wiser.  Oh wait, SureScripts is all about safety and quality.

Did you also know that our omnipotent legislatures are trying to make ePrescribing mandatory for MediCare?  Boy, doesn’t that look really good for SureScript.  I wonder who’s hand is in who’s pants now.  Oh wait, remember Bruce Roberts of NCPA and co-founder of SureScripts?  He’s sucking the big O cock.  I wonder what sort of kickback he’s going to get if SureScripts becomes the ONLY ePrescribing outfit that is raping the backsides of pharmacies.  TRUST YOUR PHARMACY ASSOCIATIONS BECAUSE THEY ARE LOOKING OUT FOR YOUR OWN BEST INTERESTS.

An astute reader sent in the following (Thanks Angry Tech!):

You didn’t even go into how the government is MANDATING doctors to use E-Prescribing to avoid getting a reduction in Medicare reimbursement. (Best link I’ve been able to find is here)

Oh great, so now we’re FORCING the doctors to prescribe in a less-safe and unproven manner to prevent them getting a reimbursement cut.  Looks like the SureScript screwing is all around!  Lets see what Bruce Roberts says about all of this:

“I urge all independent pharmacists to get on board,” Roberts said. “Adoption of electronic prescribing is a critical step in moving the pharmacy profession forward.”

Wait, let me fix the quote so it reflects the writing on the wall:

“I urge all independent pharmacies to get on board.  Adoption of electronic prescribing will make NCPA and myself NOTHING BUT LOTS OF MONEY HAHAHAHAHA! ahem This is a good step forward for patient safety and moving the profession (retail is still around?) forward!”

SureScripts and ePrescribing is a solution in search of a problem.  This is how I would fix it:

1. Flat fee.  Make it $50/month for unlimited transmissions.  If you can’t do this then stop lobbying congress, you’ll save a bunch of money by doing that.  Pharmacies are not going to shell out an extra $3-4k/month (unless you’re forced to by AmerisourceBergen) for the “privilege” of receiving what they got for free.
   
2. Publish standard drug/sig codes and influence software vendors to work that into their software.  If we have to retype ANYTHING coming from and eRx, then its not worth a damn thing to us.  This includes typos from the doctors office.
3. Don’t be such a douchebag money-grubbing company that is making up a problem to fix with its own expensive solution.
   

Pharmacy has existed for hundreds of years with sloppy handwriting. Why try to reinvent something better than will just end up being more expensive and more costly than an Rx pad and a fax machine.  I wonder what the legal fallout will be when we get mistakes injected directly into our pharmacy software vs putting them in ourselves.

Update: Dr Grumpy gives what this is like from his side of the fence.

Comments #

Comment by UrbanRxTech on 2009-05-31 09:16:35 -0700 #

Our doctors just started with the eScribe and we absolutely hate it. No brand names – only generics, which is fine unless it’s an OTC(which all the freeloaders on Public Aid want for FREE) for Eucerin. Then we have to spend a good 15 minutes trying to find out what the doctor wants and then make a trip down the hall several times waiting for him to come out of a room. I cannot imagine what the chain stores do when they get one of these dumb-ass Rx’s….no wonder it takes 2+ hours to get a script filled there. Sigs are all messed up, and then we have a “Note” section that the doctor changes the sig in anyway (some do, others just leave what’s in there and it’s WAY wrong, prompting a call and/or visit down the hall again…..). Not to mention, the doctors sending the Rx to the wrong pharmacy.

Comment by The Angry Tech on 2009-05-31 09:38:47 -0700 #

Hi, long time reader here.

I’ve been waiting for either you or TAngriestPharm to tackle ePrescribing, because it’s a crock of shit. I wish I had the time/energy to keep track of the multiple eScript errors we’re forced to fix on a daily basis; just the other day we received an Rx for a blood pressure medication with directions of (I shit you not): “Take APPLY twice a day QD”. Now the quantity was for #180, but the patient had been on #90 QD previously. Tried calling the doctor’s office.. busy.. after 10 minutes of it being busy I faxed the stupid thing to the office with a note saying they will have to resubmit it or call in a new Rx as I was throwing it out. 30 minutes later they called in on our voicemail saying it’s supposed to be BID. I had to dig the script out of the trash.

Let’s also not forget how people expect eScripts to be done FASTER because it’s all ‘computerized’.. the above script I had to call on, the doctor’s office is a block down the road, and they had sent the patient right over. (of course!) And they had to come back because some community college reject of a receptionist typed in the Rx wrong.

Don’t get me wrong, I’d rather get typewritten Rxs than have to decipher bad handwriting, but just force the doctors to use a friggin typewriter. E-Prescribing is a joke, like you said it doesn’t save time. Most of the time (or so it seems) the ‘script needs Prior Authorization anyway. Or the patient has an allergy on file.

You didn’t even go into how the government is MANDATING doctors to use E-Prescribing to avoid getting a reduction in Medicare reimbursement. (Best link I’ve been able to find is here: http://www.acpinternist.org/archives/2008/09/erx.htm )

Like you I’ve also had to deal with the call ‘oh we sent it to the wrong store, it was supposed to go down the road’.. (I work for a national chain and there are two of us within 500 feet of each other) SURE, I don’t mind wasting my time inputing, another tech’s time counting, the pharmacist’s time verifying and the clerk’s time of filing it away. NO PROBLEM AT ALL.

Unfortunately it seems we’re in a minority in our opinions, I don’t expect it to change.

Comment by Dr. Grumpy on 2009-05-31 10:21:56 -0700 #

TAP, I agree with you. I’m on the other side of the prescribing aisle from you, but agree this is a crock of shit. I hate it.

I will post on my site about it now, giving my pissy opinion. Which will be ignored by the government, anyway. Come on over.

Comment by Jake on 2009-05-31 10:46:22 -0700 #

At our pharmacy we don’t accept e-scripts . . . so we just receive the prescriptions as faxes. It costs us nothing.

I keep hearing about how much time it will save us to actually receive the prescriptions electronically, and I’ve been wondering if it really might make financial sense to pay the transaction fees to do so. After reading this, though, it reinforces our current stance.

One thing, though: I’ve heard that the $0.30 fee also applies when you send a refill request to a doctor . . . so you get charged double. Is this true?

Comment by TXPharmGuy on 2009-05-31 11:26:38 -0700 #

TAP, my big issue is who is actually putting in the erxs. My guess is that it’s the nurses most of the time. Yes, I see jacked up scripts all day long. I bet we get about 50 true erxs per day (not to mention the numerous “faxed” erxs per day). Do you software have a unit qualifier for quantities? Case in point: Amoxicillin 400mg/5ml tk 1 tea po bid qty 1 refills 0. WTF? Atleast tell me how many days and I could figure out how many mls to dispense. Or Vigamox 1 gtt in ou tid qty 30 refills 0. Did you intend for 30 DROPS to be dispensed. That would be reasonable. So instead, I have to tell my tech to retype the rx because they put in 10 bottles (10 x 3 ml) of Vigamox. And don’t get me started on the whole controlled substance thingy. I know they passed proposed legislation back in the Federal Register in June of 2008 and the gubmint was seeking 90 days on public input. Ok that was September. Here we are nearly a year after proposed legislation was enacted and we don’t have jackshit.

Comment by Dr. Grumpy on 2009-05-31 11:41:08 -0700 #

Okay, here’s my commentary from my side of the fence

http://drgrumpyinthehouse.blogspot.com/2009/05/e-prescribing-crap.html

Comment by Frantic Pharmacist on 2009-05-31 15:05:12 -0700 #

NOTHING makes me madder than having to screw around trying to translate these nonsensical things. Oh, and I also love getting ones with a doctor’s name on it who I KNOW is not in the clinic that day. As you mentioned, someone else is helpfully putting in the Rx’s for him.
You gotta love it.

Comment by Rx Intern on 2009-05-31 16:06:54 -0700 #

This is about as stupid as these things get. If I were the owner of an independent or some other pharmacy, I would outright say no to it. If it’s gonna cost me $0.30 per script, return, on hold, sent or not, there’s no way in hell I would even go near e-prescribing. It’s a GIANT waste of time for the physician (and the clinic), the pharmacist (and the pharmacy), and for the patient.

Regular scripts keep our eyes keen and gives us the ability to read unreadable handwriting. Screw e-prescribing.

Just like JP said on his blog, there’s not one organization that will represent pharmacy, not even you, NCPA.

Comment by Katy on 2009-05-31 17:37:09 -0700 #

Seriously, what a load of crap.

I feel sorry for you guys in the USA, I don’t think you’d know what to do with yourselves if you came and worked in Australian pharmacy. All you’d have to deal with is expired concession cards. Not even health insurance, you just print a receipt and they make the claim themselves!

Comment by 20SomethingTech on 2009-05-31 17:54:08 -0700 #

I swear, you must be my boss. Word for word.

Rx Intern said: “This is about as stupid as these things get. If I were the owner of an independent or some other pharmacy, I would outright say no to it.”

A doctor’s office in town told us that we HAD to accept e-scripts, or they would send their patients elsewhere. Didn’t have much choice in the matter.

Comment by AnotherRxTech on 2009-05-31 20:14:27 -0700 #

My recent favorite eRx was for Synthroid 0.137 mg, take 1.0984837319289403 tablet qd. I shit you not, that’s what it said.

Comment by Kevin on 2009-05-31 21:03:59 -0700 #

OMG…The idea was ok…execution was DISASTER!!! It’s unbelievable!!! The error rate is phenomenal. And who are the numbskulls who wrote these programs in the first place? NOT Pharmacists or MD’s that’s for sure! The drug name will list verapamil er caps and the sig will say “Take one tab every day” (caps are 24hr and tabs are 12hr). Same for Prilosec OTC, Dyazide/Maxzide and on and on and on…It drives me crazy…and that’s just the beginning. I’ve had several hydralazine/hydroxyzine’s. And these systems are supposed to save our health care system $$…good luck with that!

Comment by NancyCHPT on 2009-05-31 21:22:05 -0700 #

Or my favorite was a prescription for lisinopril 1 tablet qd, quantity of 0 with 3 refills? Or a e-script for a post mastectomy bra, okayy we can’t fill it, but if you don’t type something in it keeps popping up so you have to enter a fake script for cash and be sure and delete it. Which I’m sure isn’t technically legal, but whatcha gonna do?? Not to mention that if you don’t print it out and give it back to the patient or call the doctor with the number for a medical supply facility they’re not going to get it filled at all.

Comment by Carolyn J. on 2009-05-31 21:59:11 -0700 #

I am not a pharmacist but I am in a time-sensitive, detailed business where we fill customer’s requests. Our bosses have been trying to replace our written work order forms with e-versions for years and it never works. Some things just need to be done with a pen and paper, I say.

Comment by sickofstupidpeople on 2009-06-01 06:41:47 -0700 #

eScripts aren’t legal for controlled substances, according to the DEA. Sure, some state laws allow it, but when federal and state laws don’t match, usually the more stringent of the two trumps the other. That said, the thing I hate most about eScripts is that I have to send multiple faxes out every day saying “Please sign and fax back – federal law prohibits electronic signatures for controlled substances” A lot of offices refuse to sign – when that happens, I call the DEA and report them…

Comment by The Angry Tech on 2009-06-01 06:50:21 -0700 #

I’ve seen a similar Rx for amoxicillin.. must be that the doctor can put in the patient’s weight and the software calculates (to the hundredth of a milliliter) exactly what the dose is.. I’m sure the High School drop-out receptionists love that, no math needed! (Also love when they just put in for a quantity ‘QS’..)

Comment by RxDawg on 2009-06-01 08:15:51 -0700 #

Um, actualy that’s the patient’s choice, not the dr office. Of course they could reccomend their patients elsewhere.

Comment by RxDawg on 2009-06-01 08:17:17 -0700 #

I know the grass always seems greener……but DAMN thats some nice grass you got over there!

Comment by Shaay on 2009-06-01 15:55:01 -0700 #

Thanks for this. As a patient, I now know to ask for a handwritten script to take to the pharmacy. The MD always asks if I’d like the pharmacy notified directly, but if I can help keep costs down by hand delivering the script then I will.

I’ve also noticed that my wait at the pharmacy is *shorter* when I bring the Rx in. When the script comes in my eScripts it appears to go directly to the back of a long, long line of scripts waiting to be filled. When I come in with a Rx slip, the pharmacist fills it as quickly as possible.

As a voter, I appreciate hearing from people on the inside of the medical industry, rather than from politicians.

Thanks for your good work.

Comment by Perez on 2009-06-01 15:57:04 -0700 #

How exactly do you receive an eRx? Does the patient give you a slip of paper with a code and you punch it in to access the prescription? Does the doctor send the prescription to your pharmacy much like a fax, which you pay to receive?

Comment by theangrypharmacist on 2009-06-01 18:17:02 -0700 #

Automatically sent to the pharmacy computer. Notification then pops up on the screen that you have a NEWRX waiting.

Comment by AnotherRxTech on 2009-06-01 19:39:09 -0700 #

You’re right, that is lovely. I actually see scripts on a regular basis from an NP that takes the time to write out “quantity sufficient” in cursive, rather than to take the 2.99823498239 seconds she would need to figure 1 tea bid x 10 days = 100 mL.

Comment by AnotherRxTech on 2009-06-01 19:42:08 -0700 #

It shows up directly in our software, somewhat like an e-mail, but it is supposed to be formatted to fill in all of the fields for necessary information about the prescription. Supposed to, that is.

Comment by UrbanRxTech on 2009-06-01 20:17:54 -0700 #

We receive them on our computers, most likey thru the internet. I say this because whenever our internet goes down, so does eScripts. How do we know we have some to be filled? At our pharmacy, we have little tiny blue numbers at the bottom of out screen. Teeny tiny. So you have to keep checking to see if those numbers change. Then you swear up a storm when it goes from 0 to 10 in 30 seconds. The doctors send the scripts thru our wonderful new electonic medical records system.

Comment by tpharm on 2009-06-01 20:30:33 -0700 #

My favorite e-rx of late was for a QVar inhaler. Inhale 16000 puffs. SIXTEEN THOUSAND! So of course I call and the nurse asks me “Well, what should it be?”

Comment by intern on 2009-06-01 20:48:57 -0700 #

Perez,

In my pharmacy (CVS), we receive e-Rx’s completely through our computer software. It’ll show up as *NEW* in our doctor callback list, and we generate a paper rx from the *NEW* rx in the doctor callback queue, which is then entered into the computer as a new script.

I had no idea that it cost $0.30 per eRx. Talk about your BS.

Comment by Another mad rph on 2009-06-01 22:31:31 -0700 #

The thing I hate most about escripts is that my lazy techs (not the 2 good ones) never read the damn things. They just assume they are right and send them to me. The sigs are almost never right and even if they are technically right they are almost never in proper understandable english. I am at my wits end trying to get the lazy techs to read the damn things and type them like they normally would rather then just hit fill when they pop up.

Comment by Grumpy RPh on 2009-06-01 22:33:36 -0700 #

Yes there is a charge both ways. So a refill request and auth/denial costs 60 cents. But if you receive faxed rx’s thru sure script there is a 20 charge for receiving the fax.

Comment by Grumpy RPh on 2009-06-01 22:48:17 -0700 #

I’m sure the chains get a better deal. It is a method of getting the independents to fall in line. They want us to be their high profit customer. The groups that are representing us are the same as those trying to extort more fees from us.

Comment by Grumpy RPh on 2009-06-01 23:02:03 -0700 #

Correction TAP if the DR/PA/High School dropout makes an error in entering the Rx, it cost 60 cents more – 30 cents to point out the error and another 30 cents to correct it and of course the original rx for a total of 90 cents. I have talked to Kaiser RPh who has the same problem with prescribing errors. They don’t like it and it’s free. It is just too easy to mis-click on a drop down menu.

Comment by toddq on 2009-06-01 23:22:25 -0700 #

$0.30 is a drop in the bucket for walmart who figures you are going to be buying a bunch of other stuff while picking up your RX but this is going to add up fast for independents if the insurance companies do not increase reimbursement.

I also think this is not good for patients because I have had several come in and say “I think my doctor efaxed something over to you guys but I am not sure what it is”. At least if the doctor wrote out and gave the script to the patient they would know what it is before coming to the pharmacy.

Comment by Prescirber on 2009-06-02 01:57:42 -0700 #

I find that as a prescriber eRx saves time and provides greater accuracy. I am not sure which systems generated the crap output you are all receiving, but it is not coming from our CCHIT-certified system. Irrespective of the costs you incur, it does do a wonderful job checking interactions not only among other meds on the list, but also med vs. diagnoses. Much of the problem Rxs have been eliminated as they were caught on the prescirbers’ end.

For what it’s worth, I am the only one with ability to send eRx, including ALL refill requests. I think the propensity for abuse is too great to simply leave it for some medical assistant or nurse to manage.

Always interesting to read your posts. After reading all your rants, I now try to take very good care of my local pharmacists. I feel for you guys.

Comment by Shalom (R.Ph.) on 2009-06-02 07:11:09 -0700 #

In other words, 0.150 mg…

(Probably picked the wrong tablet size off the dropdown list, so the genius software helpfully recalculated the dose.)

Sometimes the answer to the question “WTF were they thinking when they wrote this?” is “They weren’t.” (Edit: I meant the programmers, but it applies equally to the lusers who use the program…)

Comment by Peon on 2009-06-02 08:36:35 -0700 #

e-Rx’s are riddled with errors. eRx’s for controlled substances are ILLEGAL. That is, it is illegal for a pharmacist to fill it, not for a doc to transmit it. Of course, pharmacists always get the shaft by having the laws and rules applied to them…not the docs. The problem with e-Rx’s still lie at the docs office with the dipsy, teenager, just hired off the street by the doc, that is sending the e-Rx. If the government really wants to improve the system, the first thing they need to do is have requirements for the people that send these e-rx’s. Well….really…only the doc should should be able to send them, or examine them for accuracy before they are sent. Isn’t that the way it is in the pharmacy? A pharmacist always verifies the work of a tech.

Comment by Jeff on 2009-06-02 13:53:29 -0700 #

“Irrespective of the costs you incur, it does do a wonderful job checking interactions.”

Costs… $0.30 does not sound like much, but my pharmacy does around 5000 new Rx’s each month. That comes out to $1500/month or $18000/year. And that’s just new Rx’s, add in the refill requests and now we’re looking at $25000-$30000/year. All the while, the Dr. gets the service for free (after an initial investment in computer hardware, unless he/she already had a compatable system) and Medi-Care gives him/her a 2% bonus for using it. It is not right. Unfortunately, every pharmacy that accepts E-Scripts is another nail in the coffin of pharmacy.

As far as catching drug interactions is concerned… Isn’t that the pharmacist’s job? Next thing you know, someone will invent a “minute-clinic” and stick it in the corner at Wally-world, saving patients time and money, and making trips to the doctor’s office, like handwritten Rx’s, a thing of the past.

Comment by rph3664 on 2009-06-02 14:25:22 -0700 #

I wonder how many of those botched prescriptions are going to wind up on Jay Leno’s Headlines? You know, stuff like “Insert 1 suppository rectally by mouth…….”

The hospital I work at is phasing in CPOE (computerized physician order entry). We are all opposed to it, but do you think the powers that be are listening? Heck no!

Comment by intern on 2009-06-02 20:15:23 -0700 #

Wouldn’t that just put more independents out of business?

Comment by Elizabeth on 2009-06-03 05:33:46 -0700 #

This is completely random, but I read the most false article ever today:

http://today.msnbc.msn.com/id/30627962/

They clearly don’t even know what therapeutic substitution means! We call the prescriber for anything that’s not AB-rated, let alone bioequivalent. The whole “Your pharmacy cheats” thing is baloney. I don’t know of any pharmacy that would falsely tell any patient that a drug isn’t covered when it is.

Can we make them retract this? It’s driving me crazy!

Comment by family MD on 2009-06-03 07:49:56 -0700 #

Great post. Most physicians DO NOT like e-prescribing; they are being forced into it. It is so obviously the retarded love child of the insurance companies and the PBMs.

A couple experiences, before we ripped the system out:

1. asked a double Ph.D. holder which pharmacy he wanted his rx sent to: “the one next to the dry-cleaner, across the street from the Texaco.” That took about 15 minutes to clarify.

2. Wouldn’t let me prescribe Proctofoam for patient on Prozac: drug interaction.

Comment by jeepfreak2002 on 2009-06-03 09:24:41 -0700 #

I could not have said it better myself. It is now 12:22PM – already had 2 eRx errors from the offices. Proventil Nebulizer Amps beamed in as an MDI and the other one beamed in double the strength of Lasix, luckily the pt had a hand written Rx for the correct dose…

Comment by rph3664 on 2009-06-03 09:37:31 -0700 #

Knowing what I do about the “W” monsters (Walgreens and Wal-mart), that’s probably the idea.

Comment by Perez on 2009-06-03 12:59:20 -0700 #

Won’t that put independent pharmacists in a bad position? Especially if they are starting out? Think about it, a doctor’s office could send the request automatically to an arbitrary pharmacy, most likely a well known one like CVS or Walgreens.

Comment by pharmacy chick on 2009-06-03 17:42:13 -0700 #

I am still working on getting everybody on board to make sure everything interfaces properly. We get scripts for birth control and inhalers, insulin etc. They put a ‘1’ in the quantity field. they obviously intend it to mean one packet, one inhaler, one bottle. when we interface it into our own system the ‘1’ comes on over. A less than observant staff member fills it for ‘1’. We get seriously underpaid because nobody bothered to look at the prompt that said “package size incorrect!”
I did a copy for Androgel recently. they come 30 in a box but the package size was 150gm. They had filled it for 30 for 4 months, as it was escripted to them that way and nobody found it, til I did it.
they originating pharmacy was not amused, and neither was the customer. His copay was a percentage of the total. He was used to paying less than $20 for quantity of “30”. It jumped significantly when it was billed correctly for ‘150’.

Comment by Alan in AZ on 2009-06-03 20:19:57 -0700 #

I’m happy to say that our pharmacy has yet to begin accepting e-scripts directly into the computer system. For the moment, they come in as an image file just like any other faxed prescription, and it’s entered by a tech and verified by a pharmacist just like a paper script. I do agree that some of the errors and typos are inexcusable (is it THAT hard to pop up an error window for the person who is sending the eRx alerting them that prescribing an albuterol inhaler with directions “take 1 daily” doesn’t make any sense??).

If it worked the way it should, then I think it would be great, because we could utilize more of our techs for purposes other than menial data entry (which, for a high-volume pharmacy, is where an awful lot of our tech hours are clocked). But until some of these problems are fixed (to say nothing of the upside down-logic of billing a pharmacy to receive an eRx that was initiated by a physician), then it’s just going to create more work for all of us.

Comment by angie on 2009-06-03 21:59:46 -0700 #

hi, i didnt really read all of your blogs, but i read a couple…i was considering being a pharmacist..but im still young, 14 yrs old. anyway, you kinda changed my mind about being one. i have a few questions. if you could answer them, i’ll be really thankful :D. (sorry this is random)

if this career pisses you off so bad, why don’t you quit?
why did you choose to be a pharmacist?
does it EVER make you happy?
if you could go back, what career would you choose instead & why?
did it take lots of math and science knowledge to get where you’re at right now?

Comment by rph3664 on 2009-06-03 22:05:54 -0700 #

Angie, the way to find out if you want to be a pharmacist is to get a job in a pharmacy. Yes, you need lots of math and science to do this. Most pharmacies will not hire anyone under 18 but some will hire at 16. You also have to practice strict confidentiality, which means that you can’t talk about the patients or customers to other people.

Really, The Angry Pharmacist loves his job but not some of the things about it. When you get older, you will find out that all workplaces are pretty much the same on many levels.

Comment by 2BAPharmD on 2009-06-04 12:35:00 -0700 #

Angie,

After you spend years practicing and studying something, giving up and quitting just isn’t really an option! That, and how TAP expresses himself via his blog helps in what is known as catharsis- that is, his blog is an outlet that he can utilize to get out his frustration. I am sure TAP doesn’t hate being a Pharmacist, but working in any position in healthcarecan be an exercise in bureaucracy and annoyance.

Rph3364 hit it pretty well – you will need at the very least, a strong background in Algebra, Calculus, Physics, Biology/Microbiology and most importantly, Chemistry. Organic Chemistryand Algebra are the lynchpins for most Pharmacists, Angie, and you’ll really want to master those. I recommend poking around SDN’s Pre-Pharmacy forum(Student Doc Network).

Our profession is experiencing saturation in many markets and by the time you get through college the field may have tightened up substantially, so don’t letstories of people with 2.8 GPAs getting into UCSF and Purdue distract you – STUDY HARD. you can play later (with drugs!).

Cheers!

And TAP, you of all people should know that the end game of all this stuff ($4 scripts, eRx) is intended to close up the Indy pharmacies and put the corporations in charge of the entire operation.

I wouldn’t be surprised if in the not too distant future the idea of a modular “minute clinic” like we had in the Army comes to pass- a single facility which houses a dentist, a PCP, a pharmacist, and maybe even some specialists… and they’ll be in Walmart and Walgreens. Our society for better and worse is obsessed with speed and convenience, so it’s a likely possibility.

Comment by Prescirber on 2009-06-04 21:30:32 -0700 #

Unfortunately for physicians, in just a few short years, those who see Medicare pts and who does not use eRx will be PUNISHED (payment docked).

Time for physicians to jump on board to prevent further cuts in payments!

Comment by Pharmintern2010 on 2009-06-04 21:54:43 -0700 #

I had one a couple of days ago. Ammoxicillin Chew Tabs 250mg #150. 1 PO BID, the kid was maybe a year and a half. Called the MD and find its suppose to be Ammoxicillin suspension 250/5 #150cc, 7.5ml BID. It came up right on his end but came out as that on our end, they still can’t seem to figure out how the heck that was coming through as it was showing the suspension on the doc’s side but we were getting tabs on the e-script.

Comment by scriptgal on 2009-06-04 22:18:34 -0700 #

i agree…it’s a waste of time. the other day we had a dr testing it out and sending a shitload of scripts for “mickey mouse” “minnie mouse” and “donald duck”. so we wasted time, $$, and energy so he could dick around to see if the system was working. UGH!

Comment by angie on 2009-06-04 22:43:54 -0700 #

okay thanks for answering!

Comment by angie on 2009-06-04 22:48:34 -0700 #

oh man. sounds like lots of hard work

Comment by John on 2009-06-05 01:17:11 -0700 #

On paper, e-prescribing seemed like a revolutionary way to prevent errors and expedite the whole process. From reading this post and Dr. grumpy’s post, I am getting a clearer idea of the reality behind this whole system.

Angry pharmacist, what are your opinions on Priority Review Vouchers for pharmaceutical companies?

Comment by The.Dauphine on 2009-06-05 07:24:30 -0700 #

Let’s not forget the other problems e-scribe causes. We can’t send faxes for refill requests, so we have to call. Then the receptionist won’t take down a message because you have to send a fax!!! Well, I can’t send a fax because the doctor wants to use a PDA to prescribe drugs!!! Then, when we receive refill requests from an e-scribe, it takes all the ins and outs just view how many refills have been approved. Why can’t fax machines and phone be enough?? Why do I have to waste MY time trying to figure this shit out!!!

We received an e-scribe yesterday that said to dispense 282 birth control pills. Directions were standard, but the refills said 12! Yeah, that e-scribe crap is fool-proof, huh?

Comment by The.Dauphine on 2009-06-05 07:31:15 -0700 #

Got an e-scribe yesterday that wanted us to dispense 75 mls of penicillin at 2.5 mls per day. Like I said before: e-scribe must be fool-proof. I had to waste time calling the doctor to “verify” the directions because he couldn’t proofread before hitting send. I had more important things to do than call the doc.

Comment by PharmerMat on 2009-06-05 09:22:45 -0700 #

Hi TAP, I am a 2nd Year Pharm Student down in FL, and I hate eScribing SO MUCH!! I am working over the summer, for a large retail chain (begins with C ends with VS/pharmacy) and while our error rates are fairly low (about the same as our handwritten ones) our bigest problem is the same one we have with fax overs and call-ins. office sends rx, and tells patient “it’ll be ready when you get there” meanwhile it is inevitably, something we have to order, or for a patient we have never filled for… and the mistakes we do get, are AWESOME… warfarin 3mg tab #30, sig: 3mg on monday, 1.5mg (1.5 tabs) all other days…. wow, can’t wait to see that little old lady’s INR…

PS, that TODAY article…. GRRR!! doctors are angels and pharmacists are assholes… Really!?

Keep ranting TAP you keep me sane, because of you and the other commenters, i know i am not alone

Comment by rph3664 on 2009-06-05 20:43:34 -0700 #

I once filled a prescription for a duck, but IIRC, her name was not Donald.

Really.

Comment by rph3664 on 2009-06-05 20:48:16 -0700 #

When I saw what a pharmacist’s salary is, I knew immediately that it was going to be tough. And it was – a lot tougher than I ever imagined, but I have never regretted becoming a pharmacist.

Regretted taking some of the jobs I did, sure.

Read “Dilbert” for a very accurate portrayal of the working world.

Comment by OUT FOR LIFE on 2009-06-06 06:28:02 -0700 #

Actually they can’t. As a professional office, it is unlawful for them to make such recommendations. However, catching them on it, would be difficult. They cannot use their professional position in a prejudicial manner against another business. I don’t know the exact law, but when I worked for a big chain, a doctor’s office tried pulling that: corpo pharmacies lawyers shut his mouth quick.

Comment by FillMaster-5000 on 2009-06-10 03:26:24 -0700 #

In my opinion… All NEW prescriptions should be handwritten or typewritten and physically be brought in by the patient (since, technically, you’re supposed to actually go to a doctors office and be examined by a doctor in order to get a new prescription)
Phone-ins, faxes, and e-scripts should really only be acceptable for refills.

I cannot even begin to count the number of times someone has come in to my pharmacy to pick up a new prescription (often for pain) that their doctor supposedly “sent” over. But is nowhere to be found.
So I have to call to the doctor’s office to try to get the New script, only to find out that the office is closed between 12:00 and 2:00 PM for lunch and closes for the day at 2:30.
Whish I had those hours!

Comment by Irishwolf on 2009-06-10 09:57:37 -0700 #

In certain settings electronic ordering is a real godsend though. I have used 2 systems, one was a modified version of the VA system that I, basically, completely set up the pharmacy side from scratch. Set it up so it was easy for the providers to use, and easy on my end to fill the orders properly. Now I am using a web-based system with another government agency which, though not as powerful as the VA system, still speeds up my processing and intervention documentation. I find the biggest time saver here is that docs can no longer order things that are not on the formulary, they don’t show up on their list. Plus I have complete access to the chart, encounter notes, labs, radiology, etc. I can truly be a clinical pharmacist and protect my patients from crazy PA and NP orders. They still try to order OTC items, but I have the power to not fill them (or just fill a few days worth to get them by) and send the patients to the commissary to buy them. When they try to order doses that don’t exist or screwy doses, non FDA-approved treatments, etc, I just send it back to them. It then can take a bit longer for the patient to get their med, but my patients have nothing but time, if you catch my drift.

Comment by Jeff on 2009-06-16 16:47:01 -0700 #

Fortunately for Sure Scipts, most physicians and pharmacies are big fucking pussies who can’t wait to get the E-prescibing wood put to them. Grow a pair and stop letting everyone else tell you how to practice.

Comment by XXXXX on 2009-06-21 12:45:33 -0700 #

Mr. Roberts of NCPA fame has a daughter who graduated in our class. Surprisingly, she and her friends in our class just happened to be awarded NCPA scholarships for academic excellence and contributions to independent pharmacy, despite the fact she was failing a core class in our curriculum. I’m sure that nepotism played no part in the awarding of the scholarships. Glad to know that the contributions of independent pharmacies is being used wisely and that there is no personal gain by the board members.

Comment by Tim on 2009-06-25 16:06:57 -0700 #

You’d think we’d learn. The Government once thought it knew how to make software development better. They invented a programming language called Ada and required that all defense contractors to use it. Sure it was an okay language for some things but not everything it was being required for. The Government was meddling in an industry they didn’t understand but were pushed along by the lobbyist of one or two Ada compilers vendors. It all crumbled under its own weight after costing tax payers a ton of money, Now Ada is just a funny story kids learn in computer history class, and our political leadership have turned their attention to pharmacy (and banking and automotive) hey! maybe the government is secretly trying to compete with WalMart!

Comment by junkie on 2009-06-25 17:07:28 -0700 #

It seems like all of the doctors in my area enjoy pressing that “send eRx” botton. I think they had a meeting or something and decided they like it a lot, b/c I usually get double or tripple eRxs for the same pt from EVERY SINLGE ERX PRECRIBING MD IN THE AREA, and you can’t delete out, you have to process it as TPR, just like TAP said. When we call MD’s offices and ask them politely to please stop pushing that botton, nurses get upset for some reason. Hmm.., I guess it is not thier problem we pay $0.30 per erx.
P.S. Thankfully, I do not think you can send controls on eRx just yet. But,no, no, don’t get too happy, everybody, it might be coming soon in our bright future. So, this way you are not only dealing with junkies every 10 minutes. Now, junkies may have some help in the doctor’s office, exciting…

Comment by J Walter on 2009-08-28 16:58:19 -0700 #

I think eprescribing is horrible. Our local office uses the Next Gen software. I thought they had operator errors til I came across another office with same problems and the faxed script format is the same, so I asked and they use Next Gen too. Rx came as “amitiza 24mcg” sig: give 8 mcg bid #30. When I called to ask what in the world did they want us to dispense they said….the Dr. couldn’t find the 8mcg in the computer, so he just used the one he found.

Or how about this script: Risperdal 0.5mg take 2 tablet (1mg) by oral route 2 times every day, Qty 30 1 rf. Pt has never had Risperdal before. I call office, tell them I’m not comfortable with this sig and need to verify…. answer is: that was the default sig for that drug. What the doctor really wanted was ONE HS. What a load of crap.. we are supposed to be mind readers. No wonder I’m so crabby- I can’t believe any information I’m given and have to question everything and everybody.

Comment by njyoder on 2009-09-01 23:09:20 -0700 #

I love how you think the old fashioned method is more secure. You should probably leave this to security professionals to assess. It is VERY easy to falsify prescriptions, even without the doctor’s prescription pad, which is very easy to steal regardless (or washing used prescription papers). Most pharmacies will accept prescriptions, printed out on plain white paper, even for controlled substances. It’s also easy to just order a prescription pad with their information on it, or with a little more skill, print legitimate looking ones yourself.

Additionally, if we’re talking about people in the office, it is a million times easier to just take prescription pads or even just a few sheets at a time, to avoid detection.

So it seems that, as is the case with most of your posts, you are just pissed off because you were inconvenienced, not because you actually calmly thought the entire scope of the issue through. The old fashioned method is fraught with colossal security problems.

On the other hand, what makes you think it’s so easy for people to get the doctor’s password? And what if they start requiring 2- or 3-factor authentication? What good will a password alone do, then? (Did I just go over your head? That’s ok, you didn’t know what you were talking about anyway, having not only the inability to sit down and think through all aspects of this, but inability to realize you know nothing about computer security…NOTHING).

Lets not throw the baby out with the bathwater, shall we? You are conflating what is allegedly a bad implementation with the general idea being bad. Can we please, for a moment, try not to resist progress and the flow of technology just because you’re not comfortable with the first stage of a change to something to new (OMG change is bad OMG OMG)?

Don’t blame the system because doctors can’t use it properly. Double check what you write. Of course, a good implementation will try its best to catch any errors, and make sure the prescription is properly verified, such as suspect prescriptions with abnormal doses bringing up an error message to the doctor. It will detect any potentially dangerous or nonsensical prescriptions on the spot, so it can be corrected before it gets sent out.

To a doctor who knows how to use the system, it is easy to quickly write one and it also lets them easily track all of their own prescriptions for all their patients electronically. Having this all tied in with a software suite they use to manage their entire practice and all of their patients makes taking care of the patient a lot easier and more reliable than having to repeatedly write down, update and reread the patient’s records (which often aren’t read prior to new appointments). Everything just pops up on a screen about your current patient.

The doctor can also get instant feedback regarding things such as availability of the drug at local pharmacies, so they can correct it before sending out the prescription.

The company can track fraud, doctor shopping or any foul play across all pharmacies that the person uses, because it’s a centralized e-prescription system. They can track larger, overall trends based on all patients, not just one, to detect any sort of well organized criminal schemes.

It also can find interactions across all pharmacies a patient uses. Saying “isn’t that the pharmacists job” suggests some kind of arrogant idea that pharmacists are perfect and have an encyclopedic knowledge of all drugs (which computers actually do have). Plus you don’t necessarily know what they filled elsewhere, nor does the current pharmacist necessarily know what is still in their system/they’re still taking but aren’t filling at the moment.

Eventually, computer based drug interaction systems will completely surpass all humans (computers are great at large database processing and expert systems improve all the time), whether you like it or not. Expert systems can further detect drug combinations that may not be dangerous, but don’t make sense and even recommend better ones.

I don’t know how good the current implementations are, but it can help many people behind the scenes and you wouldn’t see any statistics on it, so you wouldn’t know. As a pharmacist, if you aren’t catching bad prescriptions, you are incompetent, so congratulations at doing your job.

I know some people hate the idea of progress and computers beating them out, much like the people who threw shoes into the new industrial age textile technology because it can easily outpace them (and thus put them out of their jobs), but it’s inevitable.

As for complaints about costs, you’re just abusing statistics in front of a naive audience. You need to compare percentages, not absolute values. 30 cents per prescription and “thousands of dollars” aren’t percentages. If that surcharge cuts into 1% of your profit, it’s still 1% no matter how much you sell.

At a 1% reduction in costs, $1,000 in charges would mean you’re still profiting by $99,000 out of $100,000 prior to payment. So yeah, in perspective, treating statistics PROPERLY, rather than just doing some naive manipulation and misrepresentation, shows that it’s nothing. That’s honesty in representation and it’s just how I roll.

I love it when upper class people whose businesses are doing well complain over pennies.

Notice how Jeff and everyone else completely and utterly left out how much profit was made by comparison. Durh. Saying it costs you thousands per nothing is TOTALLY MEANINGLESS without knowing how much you made.

Comment by njyoder on 2009-09-01 23:21:18 -0700 #

Ada is actually a pretty good language and is still being improved to this day. The reason they wanted defense contractors to use it is because it’s well designed for “safety critical” applications (i.e. things that, if they fail, people die e.g. airplanes, space ships, medical equipment, etc). A major part of this is targeting embedded systems as well. It’s still updated and used for embedded and safety critical systems today. It’s not really dead like Fortran is, it just has a very small niche compared to giants like C++.

It forces the programmer to do more work, which is annoying for regular programs, but has the benefit of making it easier to catch erroneous conditions. This annoyance deters it from general use. Because of this and just general, semi-random trends in programming languages, it ended up becoming an unpopular language. Unfortunately, regardless of how good a language is for something, the most popular languages will shoehorn their way into a certain type of application with some new additions which aren’t as good as the competing language.

Developing standards for software is always a tricky process. You get all these competing companies who all want the standard designed their way, so then you get a standards committee with all kinds of crazy internal politics. The government can’t really force a standard well, because a good standard will go through several phases of production (in-the-field) testing and alterations before it reaches a state of being “good.”

The government is better off organizing and heading the standards committee, but ultimately letting the private industry within the committee design it. The purpose of the government officials is to put pressure on them to make progress and not engage in ridiculous politics. They would also be there to make key decisions if they can’t vote or agree on a certain aspect of the standard–a tie breaker vote of sorts. The government could additionally make sure that actual usage studies are done on the different standards to analyze their benefits and drawbacks.

So they wouldn’t design a standard, but they’d act as a sort of “coach” or “mother,” pressuring their asses to get shit done, do fair testing, and not try anything shady. I think that standards like this are important enough that the government does need to intervene, rather than waiting for natural evolution, which takes forever and is a pain in the neck to everyone involved. HOWEVER, I think the focus should be on a single, standardized insurance processing standard, rather than e-prescriptions, which are a lesser priority at the moment.

Comment by shilpi on 2009-09-02 00:23:18 -0700 #

contact me [email protected]

Comment by whoaitsthatdude on 2010-01-07 11:19:02 -0800 #

Anyone else having problems with having to have a doctor’s office RESEND a prescription over electronically several times only to never get it? Or a huge delay between the time that the doctors office sent it and the time that we actually receive it? Keep up the posts TAP this is the first good laugh i’ve had in a while as I can related to it being a tech.

Comment by Sydney on 2010-02-01 16:54:27 -0800 #

The e-scripts can be sent from other sites when doctors are away from the office, especially if they have an electronic medical record. Those doctors may be responding to refill requests from home or from the hospital. All that is needed is an internet connection.

Comment by Prof K on 2010-02-13 01:03:28 -0800 #

Dear Readers of The Angry Pharmacist,

My research focuses on the barriers to adoption of e-prescribing so I’m looking for data (not just my hunch) that something is amiss. Many of the above replies are helpful. The more the better – statistics are even more helpful.

Where has e-prescribing caused you (or the physicians you work with) more work than before? What are you doing differently with e-scripts? Has the relationship with the physicians and medical staff changed? Are you changing fewer prescriptions because physicians are using e-prescribing systems to check the formulary and drug-drug interactions before they are sent to you? I’m also interested in e-iatrogenesis where the e-script sent to you has obvious errors “perfectly legible but suspect”.

I brought up some of these issues in my report “Overcoming Ambulatory E-prescribing Adoption Challenges: Governments Shaping Innovation on Behalf of Individual Stakeholders” for the IBM Center for Business of Government but there wasn’t any interest from government healthcare policy makers so the report was never published (see link on my website http://sites.google.com/site/hcinfosys/literature/e-prescribing). I’m now trying to publish a journal article to raise these concerns.

Please feel free to contact me directly if you wish to rant or pontificate in private (or share data) to nk50 [at] aub [dot] edu [dot] lb

Professor K

PS Sharing your pricing experience would be helpful to your community – maybe you can get a better deal. Back in 2006 Zix Corp had a press release that mentioned one dollar per transaction.

Comment by Rose on 2010-09-16 11:57:42 -0700 #

In the UK (NHS) the GP fills in the prescription on the computer using a drop-down menu and search etc. Any interactions, warnings etc are flagged up automatically for the doctor to review before finalising the prescription.

Then the doctor prints it, checks it, signs it, and gives it to the patient to take to the pharmacy.

I have been prescribed a great variety of drugs over the last several years, and pick up 9 prescriptions every month. I have never had a single error in my prescriptions.

Seems to work quite a bit better than this system, but without so many problems of illegible handwriting, interactions not being caught etc. However, I’m only on the patient side of it, so there may be problems I don’t know about.

Comment by YonnYoungJo on 2010-09-20 11:37:04 -0700 #

Angry Pharmicist? More like wanna be doctors. The problem with pharmacists is they think there doctors. You go to school to learn to check pill interaction and how to count pills. So STFU and count my f*\*ing pills. Don’t stand there and try and tell me you know better than my 2 doctors. Even after calling both doctors and getting clearance some of your wanna-be doctor pharmacists still try and stand there telling me my doctors don’t know what there talking about. Just STFU and do what you went to school for and count my f***ing pills, take my credit card and save the f**\*ing BS consultation. I have already spent a DR appointment discussing it with my doctor and I can read the drug info paper you provide with my meds. I don’t need you to stand there reading it aloud for me. Than try and tell me the drug info on the piece of paper and my Dr are wrong. Just STFU already and count my f***ing pills out.

Comment by micah smith on 2011-04-29 21:33:14 -0700 #

I am a nurse and have been using EHR and e-scripts for the past decade as part of beta testing.

WHAT YOU ARE ALL GRIPING ABOUT is the lack of A NURSE VERIFYING THE ORDERS, before they get to you… it is one less filter if the doctor enters it himself and one less filter of a written M.D. order then nurse entry who catches a lot by that verification….

I have a solution to all of this, and a mandated eRX system should be not for profit and standardized with registered numbers and barecards for each SPECIFIC drug/form/dose…

Comment by micah smith on 2011-04-29 21:41:43 -0700 #

this guy… your attitude is not fit for healthcare. ITS CHECKS AND FUCKING BALANCES TO SAVE YOUR ASS… sorry it wastes a bit of your time, but nurses and pharms have save your fucking medical liscense and avoided more lawsuits than you could possibly imagine you ingorant fucking prick… you would not be allowed to “practice” medicine on anyone I know…. your little student doctors and understudies are more likely than not, actually fucking dumbasses more than brilliant err free gods we should all worship. Most nurse practicioners I know are better at practicing “medicine” because they respect those they work around, appreciate the system, because they worked IN the system, and listen to the patient signs and symptoms more than dilusional warped godsyndrome bastards like yourself…. now surgeons they are awsome and a very special breed…. your one of “those doctors” not smart enough or skilled enough to be one, and neither are your “play” doctor students…. which is why you thump your chest at pharms, who infact HAVE RECIEVED MORE SCHOOLING ON MEDICATIONS, than YOU EVER FUCKING DID… and, infact, do know more … and actually look at the possible interactions with the fucking PATIENT’S HEALTH AS THEIR PRIMARY FUCKING CONCERN!!! – i hate fuckers like you, patients would be better off wiping their ass with the money you charge them to “take care” of them with your attitude.

Comment by micah smith on 2011-04-29 21:50:59 -0700 #

there = they are… I am sure your great at writing Rx’s though…