Home Forums Discussions General Discussion ePrescribe is starting to suck

OK, when I first began ePrescribing, I thought it was the greatest thing since...well, the prescription pad...then the fax. But, now it is driving me crazy. We only ePrescribe 30 to 50 scripts a day, but we are now averaging 5 to 10 patient calls saying they aren't there. Some make it in five minutes, some in more than an hour.

It's hideous, because I used to tell my patients, "Well, you saw me email your script directly to your pharmacy. So they can't tell you it isn't there." But, that's exactly what they tell them 25% of the time. We don't hear that as often, but I think the pharmacies tell them it is on the way.

Faxing had an issue of not making it about 8% of the time, but it was a hell of a lot faster. A local pharmacy told me yesterday that they got 45 ePrescribes in the morning which were sent the evening before.

I guess, from what a pharacist told me, the script doesn't go directly to the pharmacy PC which would make sense. Just like an email, it would be there in seconds. No, it goes up to SureScripts which does something like validate it or something, which takes time, BUT if the pharmacy you send to has a different vendor, it must check it on the way down.

Maybe it will improve. I hope so. I was thinking of something today, but it will never happen. It would be helpful if when you send the ePrescribe, the actual script did its thing possibly arriving in 30 minutes, but an actual small packet or email got sent directly to the pharmacy saying so and so practice sent Zithromax on an D. B. It wouldn't need to have all the particulars or even a name. This way when the patient arrives, the pharmacy wouldn't say, "We never got that." They could tell him or her that they received notification that a script is on its way. It should be here soon.

Have you ever noticed that a pharmacy never tells the patient, "We don't have that yet, but it may have been sent and not gotten here yet or maybe we have lost it or whatever." No the patient always thinks we didn't send it even if they watched us fax it.

Lastly, while I certainly understand a patient wondering why he or she is leaving without a script, I always laugh. I mean in the days when I wrote a script, I NEVER asked them their pharmacy. Now, I am starting at a computer, and I ask them their pharmacy. I then basically in front of them, run through the ePrescribe database or fax addresses and send it. When they ask at the front desk, "Isn't Dr. whatever supposed to give me a script," I can't help but think do they ever wonder why I asked them what their pharmacy was.

Previously, I used PocketScript through ZixCorp for my eprescribing and it was a far superior product to NewCrops. Unfortunately, they got out of the e-prescribing business last year. When I changed to AC, the number of dropped scripts was astounding. We finally identified part of the problem as my internet provider (Comcast). Due to a feedback problem from the public school across the street, we were getting frequent drops in service. It was not enough to notice while working on the internet, however it would interrupt the eprescribing sufficiently to drop the rx. Often, if I sent multiple rx, only 1 or 2 would get through. NewCrops did not pick it up as a failed rx because they never received it from the AC connection. I guess with the prior pocketscript, there was no emr as a middle man so they could always tell me immediately if the rx did not go through. Once Comcast did their repairs, the complaints decreased dramatically. I do find that if you check the admin section of the NewCrops page, you can confirm if the rx was successful. The final hurdle is the pharmacy staff that does not identify the incoming rx. We have addressed those problems by targeting the specific pharmacy that does not receive a rx and speaking to their staff. Often, they are having connection problems on their end. On the positive side, the mail order plans (Medco, Express, Cigna, Aetna, Caremark) are fairly consistent. I just wish they would send electronic refill requests instead of faxes. I have been e-prescribing for about 8 yrs and the patients, overall, really appreciate it. I do miss my PocketScript, though.

I am new to e-rx, and thought that I was doing something wrong. Patients are calling saying the pharmacy never received the scipt just as described above.
OK, so... is there a fix for this, short of just printing the scripts out until the bugs in the system are worked out

Having the same problem at the FP office I work at using Allscripts EMR.

http://www.newcroprx.com/companycontact.html

Well, first, it is quite obvious that someone ePrescribed some heavy duty drugs to the guy who made New Crop's website. Or maybe, it should win an award in simplicity. I don't get the strawberries.

But, as I wrote in another thread, there apear to be several vendors such as New Crop that are the intermediaries or software for the EMRs, and then there are several SureScripts type companies which are the network that transfers all of the scripts. I think I recall from the SureScripts site that they advised calling your software company, NewCrop, first. Maybe I have this all wrong.

It would be interesting to email the CEO on the site. From what I can gather, there are a lot of players, and they don't all play well together. I think the script has to go from AC through NewCrop to Surescripts where it is processed in some manner before going to "OtherScripts" and down to the software for Rite Aid before making it to their computer. A longer road to travel than I thought. I don't think the system is broken as much as it 1) needs to be ironed out, and 2) needs a Sirius Satellite Radio and XM Satellite Radio merger. If we could get at least one network, it may help things a lot.

Here we are with email, which arrives in seconds, and we now have this new technology which should be rather zippy as well, but it doesn't seem to be.

I prefer using ePrescribe for a multitude of reasons. But, I now have to tell all my patients it may be 30 minutes. So, there are two big issues it has to work out:

1. Speed and consistency first. Should be on the pharmacists screen in less than a minute
2. One should be able to send ANY controlled substance without the ridiculous Something You Know, Something You Are, Something You Owm bullsh..... I thought that was for weddings.

I am not having any of this problem. For us the eRx do not generate nearly the number of call backs that the faxed Rx did.

As I having been using AC now since 04-2009 in general I would say that most of the time that I was having a problem that wasn't been by lots of users it was a "local" problem in my system and not AC.

If some of the Rx go through and not others I think an unreliable internet access sounds pretty plausible.

Thanks Deborah,

Here the pharmacies have issues with all practices.we had more failures with fax, but they were much faster.

As you know, we're not on board with an EHR yet, but our billing software has a bare bones SureScripts ePrescribing interface, so we're trying to use that to avoid the penalty for not doing so that hangs over our heads beginning Jul '11 (withhold on Medicare reimbursement for second half '11 claims beginning 1/01/12).

Our experience has been like yours. We'll submit an eRx, and the patient will call us and tell us the pharmacy never received it. We've had a local pharmacy dispense the wrong dose of an antihypertensive (of course, we're told that eRx is supposed to make such errors impossible).

(disclaimer: I'm a liberal - Bert already knows that) Still, my sense is that the Feds just cannot turn off their bureaucracy genes and just nurture the development of medial IT that works; they just cannot get beyond the notion of loading up "protection" on data exchange interfaces to the point that they don't work.

On the other hand, there is truth in the "anything that can go wrong, will" canard. Last year, I started Prednisone/Cytoxan on a patient with ANCA-related RPGN (rapidly progressive glomerulonephritis). I did the intitial presciptions over the phone with a pharmacist on the other end. I specified 3 50 mg cyclophosphamide tablets each morning. A month later, I received a fax refill request for 6 25 mg cyclosporine capsules each morning! The pharmacist "explained" that his computer interface had an automatching algorithm, so that as he typed "c...y...c...l...o..." the first match that "caught his eye" was for "cyclosporine." Seems not to have mattered that there are no cyclosporine tablets, nor is cyclosporine available in a 25 mg size.

There was a study (I think from Boston Childrens Hospital) reported in NEJM, I think, that stuck a pin in the "notion balloon" that electronic data interchange was guaranteed to reduce errors. Does anyone else see the humor in the website "captcha" logins that attempt to verify the presence of a real human trying to log in by having the user decipher some almost illegible script?

Jim Robertson

This is deja vu all over again from the early days of computer accounting programs, where your bank's program would accept a key slip that allowed it to be three or four decimal places off, and not blink an eye. Contrast that with mature programs like the software that tracks your visa card and that will put a lock on the card 10 seconds after it is used for a $20.00 purchase that does not fit your profile. It is possible for the EHR to make good on all of its promises, but between the "bureaucracy genes", fantastical privacy worries, and the lack of common standards we are just not going to be getting close anytime soon.

First - I think the original concept of our sending a codified med and it being auto typed by the receiving pharmacist's computer was completely disregarded as one of my friends who is a local pharmacist demonstrated to me the prescription is indeed on their computer but they have to 'match' it which defeats the original purpose of erx......

Second - I have been using ERX for almost 2 years and it rarely ever does not get there. Most of the time if I go back and check I forgot to hit the final send and I never sent it. It does take up to 10 or 15 minutes at times, but I think about how our state's workmen's comp office takes 2 days to receive a fax - I send it and they cannot receive it before it goes through a dept. in charge of processing faxes. I think that pt's need to have a realistic expectation and cannot call from the pharmacy for refills and expect it to be there in 10 seconds, it may take a few minutes to get there by erx too.

I will say that most of 'it never came' have come from 1 or 2 chain types - one is Bert's favorite and starts with a W - I think they might even have clinics in their stores......

I have no doubts that it can work just fine. I spend some time at Kaiser. Of course, they not only do everything paperless, but they also own their own pharmacies. I can finish chatting with a patient, have the patient tell me which Kaiser pharmcacy in the medical center he'd like to pick up his Rx at, and by the time he gets there it's ready.

I have been working with a multiple-provider practice, and they have encountered instances of pharmacy stating that they don't have the script even after it has been sent and shows a status of verified.

They are also implementing their patient portal, and so the current plan (esp in the case of trouble pharmacies) is to drop the patient a secure message telling them the prescription was sent, and verified at such-and-such a date and time.

That gives the patient specifics if the pharmacy is difficult, and it sets expectations with the patient as when the practice did the prescription. We'll see how that works out.

This is likely a function of busy pharamcy practice in general. I am finding that call ins are taking up to 48 hours to be filled. This is likely a function of the pharamcy taking care of "birds in hand" (pts present in pharmacy) while getting those "in the bush" later (those on fax machine).

I made the mistake of sending the e-rx to the wrong pharmacy. I sent it again to the correct pharmacy and called the 1st to tell them of my error. Before my patient was out of the parking lot, the 1st pharmacy had my e-rx. Another pharmacist told me it takes a couple of hours to show up? A big problem I run into is that each new rx gets a new number. So when my patient calls in to the machine and reads the numbers off the old bottle they hear that there are no new refills We spend a lot of time educating them about this. It is ubiquitous with all pharmacies.

My experience is that of Jim and David. While the patients may have unrealistic expectations, I think that they can A) expect the script to be there within 15 minutes or less and B) expect the script.

This is neither the fault of the pharmacy or the practitioner. This is the fault of eRx and its not being thought out properly. When we handed out paper scripts printed from the EMR (especially when I was allowed to give them to Medicaid patients -- another ridiculous piece of government bureaucracy), the patient's expectation was 0 seconds when they get to the pharmacy. Faxes made it in under 10 minutes almost every time (albeit they had a higher failure rate).

While it is true that virtually 100% of my eRx arrive at the pharmacy (if I hit the send button like Steven), what good is it if they vary in time from five minutes to overnight? Yes, overnight.

If you were a patient and drove 15 minutes with two sick kids to the pharmacy even if you believe the pharmacies who tells you it was likely sent but hadn't arrived, "what would your expectation be?" If they were told it WOULD DEFINITELY be one hour, and it was one hour, I think expectations come into play.

There are basically four ways a script makes it to the pharmacy:

1. Paper delivered by patient
2. Called in by the office
3. eRx
4. Fax

In the first two, the patient is told I got your script you just handed me or I got the phone call from your office (yes some times they didn't check their answering machine), but in both scenarios, the patient is told we will have your script ready in a few minutes or maybe even 20 minutes. If the patient expects it sooner than that, I think they are being unreasonable.

However, on the other two, what is the patient supposed to EXPECT. If the pharmacist tells them "If it has been eRx, it hasn't made it, but it will be here some time between now and who knows. So, the patient just stands there watch five other people get their meds ahead of them. Same with fax.

I pretty much love ePrescribe. And, I use it almost exclusively. But, a month ago, I thought it was really cool to say as I did it, "And your script is......AT your pharmacy). Now, I tell them it could be up to 20 minutes.

The problem is, unlike eMail, it does not go straight to the pharmacy. In fact, I ePrescribed a script last night at 8:40 PM. Given they close at 9 pm and the medicine was mission critical (Nystatin for thrush, lol), I called. The pharmacist was my next door neighbor. He told me it would probably be over an hour as it has to go to Bum.....Egypt. This is true. It's up to Surescripts and down to Allscripts up in the cloud.

Ironically as I think I posted before, Indy's idea is a good idea. But, I can't do a two step process. If it is going to be this slow, there should be a one line email that goes to the pharmacy stating a drug and practice has just been sent. I wouldn't want to get into any patient data if it weren't HIPAA compliant, but if I sent a Z-pack on Bill Smith at 6:00 pm, my guess is they figure out that the Z-pack send from my office at 6 pm was probably intended for Bill Smith when he arrives.

That's a great point. I always wonder what to do when I send to R/A Union Street, and the patient then changes to Wal-Mart. Do I just figure the pharmacy will figure it out when no one shows up. I think a lot of pharmacies wait until the pt shows up anyway depending on the type of med.

If I do tell them, I send another eRx, which I am sure they hate as it is 10 cents a script.

Bert:

is it certain pharmacies? I found it was one particular walgreens having an issue.

Hi all, I have complained about AC speed. I have whined about problems with the internet down. But (at the risk of jinxing us) erxing has done VERY VERY well. We are not using it for mail order pharmacies, but all others have been near flawless. I have only gotten 2 or 3 calls in the last 6 mo about rxs not received. And this is running peer-to peer without a server!!!! Gene

Not sure. Miller Drug here has difficulties, but they literally get thousands of scripts per day. Six full time pharmacies standing behind a wall fill scripts.

Interesting. I was having problems wihto nly one out of the gazillion walgreens which was wierd...and i would call them and they would be like nope we don't have it...not sure what the issue was, but it magically fixed it self.

I am a trial "newbie" (without e-prescribing via AC). Currently using RxNT for e-prescribing. I have sent an electronic script while in the room with a patient, and by the time I have gone to talk with the front desk the pharmacy is on the phone with a question (eg that dose is not available). Hesitant to drop RxNT after reading the prior threads. Have these delay issues been worked out with the new version of AC?

I have been using the E-prescribing through Amazing Charts since about November last year. It's not perfect (that's a whole other topic), but at least it documents things in AC. I've had a few calls from patients stating the pharmacy never got it, but not many. If a patient calls stating the pharmacy never got it, my office staff instructs them to have the pharmacy call us. Must motivate them to look for it because I don't get many calls from pharmacy's anymore since we went to E-pre. No more wasted time on phone calls with the pharmacy.

In Version 6 you can pull up the prescription status and see where a script was sent to. You can also see if it "failed" or was "verified".


Of course there is always a pharmacy who seems to have problems. I just tell the patients to go elsewhere. If that pharmacy calls, I advise them that their competitors don't seem to have problems with it.

Lastly, there is always the patient who tells you what pharmacy they want, but they go to a different one. Some things just can't be helped.

I agree with Marty. I am not on V6 yet but have been using e prescribing for about a year now and very rarely do I get a call saying it is not there. When it does happen, I am never sure where the error occurred. I send probably 50-100 Rxs per day and I might get one call back every week or two.

I have few issues.

I am sure others are doing this, but here are some thoughts.
My patients NEVER go to another pharmacy. I ask them if they want the same pharmacy as last, e.g. Do you wrong Wrong Aid on 5th Street. I always tell them, 1) I just sent your prescription electronically to Wrong Aid. 2) Make SURE you tell them, that your doctor electronically sent the script via eRx. 3) It usually takes five to ten minutes, but it can take longer. If you tell them it was ePrescribed, they will look and likely ask you to wait. If you tell them you are there to pick up a script, they do not know if it were sent then or two days ago, and they will tell you, "I don't know, it isn't here. Your office must have not called it in." 4) Finally, as Marty states, they should demand their pharmacy call us. I know that they must get 50 customers a day claiming there is a script there, but then they need to call 50 times per day. If not, you get this:

Pt told no script.
Pt calls us upset either from the pharmacy or after they go home.
We then have to look up phone number of pharmacy.
We then must hold waiting for pharmacist.
Instead, of one call, does all.

I am sorry, but tht is their job. They have techs. If I get a call like that, I ePrescribe it ten times for a $1.00.

Finally, what annoys me the most is that the patient calls from the store on their cell phone. But, the pharmacist won't take the cell phone from the patient. I somewhat understand. But, why not have a phone just outside the pharmacy, which has a connection to inside the pharmacy. Pt calls us, puts us on hold. Pharmacist picks up the phone.

I personally think that a patient should just tell them, they are walking away and never coming back. That is the only way to fix things. Talk to the manager of the store and the manager of the company who owns the pharmacy, but that will never happen.

I agree with Bert.

For goodness sakes! Just call the offending pharmacies and straighten out the connections. When we started e-prescribing years ago, it was new to NJ so I did have to call CVS central and they addressed the issues and corrected them. We have so many chains in this area that if the competition cannot handle e-prescribing, they will lose the business.

Finally, remind the patients to not go directly to their pharmacies because it does take time to process, just like a paper rx would. This is meant to save them the wait time, so do not rush to the pharmacy or you will still wait!

With all due respect, Catherine, and this is not a power struggle of us against them, it is purely a time issue. If the patient takes the time to go to the pharmacy or even call, then it is highly likely a script was sent my email, mail, fax or ePrescribe.

Having the patient call us who was likely told that we didn't send the script is just not efficient.

The pharmacist who has a tech right there, should call the office.

So is ePrescribe starting to suck, as Bert asked? It seems like there really are not too many issues. Some people have a significant problem where the pharmacy doesn't get the prescription and blames the doctor's office; others haven't seen this. Perhaps this is partly a function of specialty (peds patients-or actually, their parents-may run right to the pharmacy in search of the medication; adults may be less likely to do so) and also geography (proximity and number of pharmacies).

Either way, I would suggest that eRx doesn't suck, but the response of a few pharmacists at the other end may. We can control this aspect of their business. My suggestion would be that the next time the issue arises, have a brief conversation with the pharmacy manager. Explain that you expect a response along the lines of "I am sure the doctor sent it, but I just can't find it; I will call and request it again for you". Tell them that the next time the tech blames the provider and tells a patient to call you will be the LAST time you send a prescription to that pharmacy; in the future, you will tell the patient they need to pick a pharmacy that provides better service.

I have been e-prescribing with one program or another for about 5+ years. It took a while for the local pharmacies to figure out I was doing that. Once they knew to expect it, when a patient showed up asking for a prescription, they would automatically look in the computer. Prior to that, they would look on the fax machine. It took a while for them to know where to look, and not assume we had not sent it.

That is an advantage of a smaller community, where all the pharmacies know who I am. But, as above, mostly the issues seem to lie with the pharmacies, not the e-prescribing system.

I cannot say that AC is my favorite e-prescribing program... I liked the Allscripts web-based system a lot better... but having it integrated with the rest of the record is vital.

Jon, this is a great idea, but it simply is not reality. First, it is just as likely that the pharmacy manager is the one who said it. I have always wished that pharmacists would say, "We don't have it. It is possible that either your doctor didn't send it, or that it didn't make it or we misplaced it. Let me call your doctor. Most times, though, they or the tech just say, "We don't have it." The patient just assumes we didn't send it. Many times we get a call from the patient, we then HAVE to call the pharmacy, and they tell us it just arrived. Whether it just arrived or not, we will never know. But, the patient could have been patient and probably would have had the pharmacist simply educate them on the process whether it is fax or eRx. I have a saying I made up called "The power of last authority." I don't know how many times I tell a patient to wait at radiology until I call them with the result, but they leave because the tech tells them, "It is normal, you can go home and your doctor will call you." This is simply one more phone call IF they are home, instead of the tech telling me and handing the phone to the patient. Yes, radiology will hand a phone to a patient. I am willing to bet that I could literally walk over with the patient, show the patient the script for Zantac, hand it to the pharmacist in front of the patient, and if the pharmacist told him or her they hadn't received it, one out of 100 would call the office. Sure, a bit of an exaggeration.

The other problem is you and I can decide to boycott a certain restaurant, but we cannot force a patient to. Sure, a subtle reminder that Wrong Aid and Wal-Mart don't even stock amoxicillin, may persuade them to change. But, most patients like their pharmacies for other reasons, and are not going to change.

I think this would all get much better if 1) we worked together to educate the patients as to how and/or why a script got there or not and the possibilities of why it did not as well as telling them about the system. "I know your doctor ePrescribes most of his or her scripts, so it will probably be here soon. Walgreens texts my patients. And, 2) the pharmacist should call the office.

I agree with Bert

Me too.

It is frustrating that there is so much in medical practice that we cannot control. I find it liberating to exercise influence when we can (even in small ways). Sure, the patient usually picks the pharmacy, but we have a say if we choose to. If a pharmacist provides lousy service, I have had no problem telling the patient "I would rather you pick a different one; we have had problems getting good service [or reasonable prices] from that one". I have done this (only after giving the pharmacy a chance to improve their service) and the patient is fine with it.

I am in an area where there are literally hundreds of pharmacies, so the patient can pick a different one with little inconvenience. That may not be true in a smaller town. On the other hand, if there are only a few pharmacies in town, I would think that each would be more sensitive to the requests of individual docs.


I am all for educating patients about the workings of eRx. This is the fallback position when the problem persists.

I am relatively new the e-prescribe with AC, but it works pretty well. I tell the patient that I just transmitted the script and that it takes awhile for the pharmacy to get it. I explaine that this is travelling on bandwidth and it helps to consider it going up to and orbitting the Space Station and then comes back to the Pharmacy. Some patients have taken this literally, some use as a reminder that it is not instanteous and some just get confused! But all of them know I transmitted it and that it will take awhile for it to be filled.

I only have two things to say. OK, I know. That's a record.

Jon, I wish it were that easy. I do agree with you that I would ban the pharmacy if possible. I guess it all depends on your patient mix and where you live.

The other: Like the song, all I am saying is, give peace a chance. All I am saying is, "The pharmacies should call us, not the other way around."

Which, to be fair Jon, brings us back to your point. If they don't call and work with us, we should send our patients to a different pharmacy. Don't get me wrong, I completely agree with you, and I do bring it up and maybe some of them do. We always try to stop them from Wal-Mart.

I KNEW you couldn't break the record! On the other hand, item #3 was for a really good cause.

I agree with Bert. The pharmacies should call us. I started that about 22 years ago, and there was resistance at first. It used to be that patients would call the office and tell the receptionist they needed "refills" -- and I would get a note to "call in refills." Often, it was unclear what was supposed to be refilled, and especially with elderly and chronically ill people, it wasn't clear that our records and what the pharmacy was dispensing were the same at all. Often required several more phone call to get that straight.

So I changed, and said, if you want a refill, call the pharmacy -- don't call my office. It took a while, but finally everyone came into formation.

I said, if the pharmacy initiates the request, then I know exactly what they are filling, and I know it is a refill, and I can chart it as such.

On the other hand, if I initiate the request, it is a new prescription, I can't really be sure what your pharmacy fills the prescription with (maybe there is an error), and in any case, if I call to pharmacy, it is a NEW prescription and requires you to make an office call (and pay me). If the pharmacy requests it, it can be a REFILL, which we authorize without charge.

So, there are fewer errors and less cost to the patient if the pharmacy initiates the refill request.

Over time, the patients, the pharmacies and my office worked together to make a more workable system -- I tried to avoid power struggles and adversarial relationships. To a large degree it worked, and now most offices around here do it that way.

We are starting to work with pharmacies on e-prescribing, which except for the Long Beach Peninsula -- an out of the way place with a pharmacist who is way ahead of the curve -- the idea is new, and doesn't sink in very fast.

I usually give patients a printed or written Rx even if I send the eRx. I really don't trust the system yet, and if the patient has a piece of paper, they feel more secure. It wastes paper, but avoids phone calls.

Maybe some day everyone will get on board. The increasing complexity of it all, and the increasing number of fingers in the pie make me doubt it. I'm guessing the whole thing will collapse within 5 years, and we will be back to 5x8 index cards for recording office calls and accounts in the same place.

As most of us suspected, this recent journal article showed no reduction in prescribing errors with eRx.

So the government's widely acclaimed eRx initiative to improve patient safety has feet of clay .

So here is an article by a good peer-reviewed journal that wants to help patient care, but they want us to pay $30.00 to buy it. Oh, that's for one day unless you print it.

Compare this to iTunes where teenagers (and others) can purchase the latest song by Creed for $1.29. (It did go up right from 99 cents) and keep it as long as they want.

I may need to monitor my prescribing habits, but I don't think I make an error in one out of ten scripts, but it's possible.

Thanks John for the article. It is eye opening.