The End of Prescriptions as We Know Them in New York
nytimes.com/2016/03/15/nyregion/new-york-to-discard-prescription-pads-and-doctors-handwriting-in-digital-shift.html?_r=0
One morning this month, Silvia Cota, a nurse supervisor in the emergency room at Lenox Hill Hospital in Manhattan, gathered her nurses together in a huddle to prepare them for the future.
“It really is not a complicated thing,” Ms. Cota told them, speaking loudly over the bustle of patients and emergency room staff. “We just have to get used to it.”
Starting on March 27, the way prescriptions are written in New York State will change. Gone will be doctors’ prescription pads and famously bad handwriting. In their place: pointing and clicking, as prescriptions are created electronically and zapped straight to pharmacies in all but the most exceptional circumstances.
New York is the first state to require that all prescriptions be created electronically and to back up that mandate with penalties, including fines and imprisonment, for physicians who fail to comply. Minnesota has a law requiring electronic prescribing but does not penalize doctors who cling to pen and paper.
Just as doctors putting away their pads will face a culture change in New York, so, too, will patients, who will no longer be able to shop around for the shortest waiting time or the best price for their medications.
Lenox Hill was one of several New York hospitals owned by Northwell Health, formerly the North Shore-LIJ Health System, that on March 1 began to comply with the new mandate.
The shift is rooted in a 2012 state law known as I-Stop that was designed to curtail the growing problem of prescription opioid abuse. The scale of the problem is enormous. More controlled-substance prescriptions were written in the state from 2013 to 2014 (about 27 million) than there were residents (about 20 million), according to the State Health Department. In 2004, there were 341 opioid-related deaths in the state. In 2013, there were 1,227.
The first part of I-Stop, put into effect in 2013, is an online registry that a doctor must check before prescribing a controlled medication. The registry lists all controlled substances recently prescribed to a patient so doctors can spot a history of abuse.
But the registry can be gamed, even by a move as simple as a patient’s misspelling his name for the doctor.
“It’s certainly not foolproof,” said Dr. Douglas Schottenstein, a Manhattan pain management doctor whose office writes dozens of controlled-substance prescriptions daily.
The second major component of I-Stop legislation is the shift to electronic prescriptions, intended to reduce fraud, as well as mistakes caused by misinterpreted handwriting.
The transition was scheduled to take place a year ago, but state lawmakers pushed the start date back, largely because of software security issues. Those have been resolved.
“There should really be no reason that a doctor shouldn’t have had ample time to get it up and running,” said Dr. Joseph R. Maldonado, president of the Medical Society of the State of New York.
With the push to go digital over the past year, New York now leads the nation in the percentage of medical practitioners able to prescribe controlled substances electronically, according to Surescripts, the company that runs the network on which the prescriptions travel.
In the emergency room at Lenox Hill Hospital, nurses were given a briefing on the move to electronic prescriptions this month. Credit Christian Hansen for The New York Times
Still, many institutions are waiting until the last minute. As of January, only about 60 percent of the state’s roughly 100,000 prescribers were able to send prescriptions electronically, and about half as many were set up to prescribe controlled substances, which requires an extra security step.
Hospitals and nursing homes are among the late adopters, in part because of the complexity of rolling out technical systems in big institutions. Several of New York’s major health systems are applying for waivers to get more time for at least some of their facilities, including Montefiore Health System, NYU Langone Medical Center, Northwell Health and the Mount Sinai Health System.
Officials say that transmitting prescriptions to pharmacies will cut down on fraud, because people will no longer be able to modify a prescription by, for example, increasing the number of pain pills ordered.
“Paper prescriptions had become a form of criminal currency that could be traded even more easily than the drugs themselves,” said Eric T. Schneiderman, the state’s attorney general, who helped write the legislation. “By moving to a system of e-prescribing, we can curb the incidence of these criminal acts and also reduce errors resulting from misinterpretation of handwriting on good-faith prescriptions.”
Yet electronic prescribing will present its own set of challenges as patients and doctors get used to the idea.
Although I can understand the need to do something about prescription abuse, as someone who uses medication for chronic health issues…
Patients will have to come in knowing what pharmacy they want to use. At Lenox Hill, nurses will ask all incoming patients to indicate a preferred pharmacy, or have them pick one from a list presented by the software.
And if the medication at the pharmacy is either too expensive or not available, there will be no quick fix. To have a prescription sent to another pharmacy, the doctor will have to cancel it by phone and then prescribe it again.
The hospitals acknowledge the difficulties. When trying to convince doctors of the benefits of electronic prescriptions, “I don’t pitch it as, ‘It’s going to be faster for you,’” said Dr. Michael Oppenheim, the chief medical information officer for Northwell Health. Instead, Dr. Oppenheim said, he mentions things like improved legibility and better coordination of care.
Yet problems at Northwell’s pilot sites have been relatively few, he said. And at NYU Langone, where nearly three-quarters of prescriptions are now issued electronically, doctors report that most patients seem to like that the prescription is sent to the pharmacy ahead of them.
One unexpected impact has been that doctors tend to prescribe more common medications that are likely to be in stock, to avoid the headache of having to reissue a medication because the pharmacy does not have it.
“It’s probably driven us to prescribe more standardized regimens and more standardized dosing,” said Dr. Paul A. Testa, the chief medical information officer at NYU Langone. “And the reality is, there is always the phone. If I have a doubt, I can call the pharmacy.”
Doctors can still write prescriptions by hand in exceptional cases, such as when the medication will be filled out of state, when there are technical problems and when the prescription is for something other than a medicine, like crutches or a wheelchair.
Doctors who fail to follow the mandate “will be subject to a full range of disciplinary actions, including both civil and criminal penalties and fines,” according to the State Health Department.
Saying goodbye to the prescription pad is a relief for some doctors. After all, in most medical settings, pointing and clicking is already more prevalent than writing with a pen.
“My handwriting is really pathetic to the point where I think I have dysgraphia,” said Dr. Steven Lamm, the medical director of the Preston Robert Tisch Center for Men’s Health with NYU Langone, which has embraced electronic prescribing over the past year. Now, he said, “my prescriptions are actually legible.”
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There is already rumors of street dealers selling Naloxone along with Heroin or other opiates to those who have addictive personality disorder.
