Is it time to rethink electronic prescribing in the US?

It is a fact of life that most – if not all – patients will require some form of prescription medication during their lifetime. Generally, accessing their assigned medication is relatively straightforward, as non-specialty drugs can be dispensed through various channels, including national retail chains, community retail pharmacies, and mail-order pharmacies.

But, for the select few patients that need specialty drugs, accessing a filled prescription is not quite as simple. While these medications account for a relatively small percentage of overall prescription volume, they tend to be more complex and, in many cases, far more expensive.

Over the past two decades, payers, technology experts, pharmacy benefit managers, and pharmacies have developed solutions to help improve the prescription landscape in the US, with electronic prescribing achieving almost universal adoption across the country. However, this was largely dominated by one company and, as such, practitioners had limited avenues to explore when it came to adopting new methods and processes.

With an increasing number of specialty drugs being approved by the US Food and Drug Administration, demand for a greater variety of options in the space has become louder. And both start-ups and historied companies have begun to answer the call.

One such company is First DataBank (FDB). With more than 40 years’ experience providing drug knowledge, medicines optimisation and clinical decision support, in 2022, the company announced that it was entering the ePrescription market with a non-exclusive cloud-based network.

For FDB president Bob Katter and vice president of clinical network services at FDB, and general manager of FDB Vela, Lathe Bigler, the decision to expand into new territory has been a long time in the making.

“For specialty drugs, there are additional needs and a lot of that is still done very manually,” explains Katter. “I think the increased demand for more sophisticated services for specialty drugs, as well as just general unease in the marketplace about not having a choice of networks are the things that made an impression on us.

“Nearly all standard prescriptions for basic eligibility, basic formulary checking, and Rx routing are digital at this point. People are almost frustrated that they still have to do manual workflows for other things, such as around specialty drugs. I think those end users are saying, ‘Why doesn’t this work as easily for enrolling a specialty drug for instance, as it does for just dispensing a standard medication?’,”

Controversy creates market opportunities

In an industry famed for feats of lifesaving innovation mixed with significant risk, the electronic prescription space may not seem like a likely hotbed of controversy. And yet, over the past few years, progress in the market has been clouded by a high-profile anti-competitiveness lawsuit brought against one of the leading figures in e-prescriptions.

ePrescribing has been in the works for over a decade, with precursors to today’s systems appearing in the late 90s. But it wasn’t until 2008, one year after electronic prescribing became legal nationwide, that the industry reached the critical crossroads to advance healthcare technology adoption in pharmacy services.

Surescripts has long been an influential feature of the ePrescribing market, having developed an established national network connecting doctors, hospitals, pharmacies, and health plans since its founding in 2001. However, while the company played a fundamental role in shaping the current landscape of prescriptions in the US, it has also been the subject of significant criticism.

Perhaps the most notable controversy began in 2019 when the US Federal Trade Commission sued the company for alleged anti-competitive practices in the electronic prescribing market. The agency’s complaint accuses Surescripts of engaging in a “long-running anticompetitive scheme to maintain its monopolies over two separate, complementary markets: electronic prescription routing (“routing”) and eligibility”.

While the company denies any wrongdoing, both sides continue to clash over what relief might be appropriate to resolve the lawsuit. And, with one of the biggest names in electronic prescribing now the target of high-profile criticism, a new wave of competitors is entering the field.

Navigating the red tape of specialty prescribing

According to IQVIA, specialty medicines will account for nearly two-thirds of launches over the next between 2019 and 2023, up from 61% in the five years prior. As a result, the specialty share of spending is forecast to rise to nearly 50% by 2023 in most developed markets.

Unlike traditional prescription medications, specialty drugs are typically higher-cost therapies that require large amounts of clinical information that must be transferred from provider to pharmacy before it comes close to reaching the patient. Consequently, the unique demands and resource-intensive processes of dispensing these medications have fuelled the rise of dedicated specialty pharmacies across the US.

While these pharmacies may provide unique training or expertise, many still rely on telephone and fax communication to relay vital information between prescriber and pharmacy. Moreover, the prescriber may not know where to send a prescription electronically, as a given drug may only be available through a limited distribution network. As a result, it takes an average of 24 days for a medication to be dispensed, leaving vulnerable patients waiting for vital treatments.

To improve efficiency and reduce the risk of human error, many specialty pharmacies have adopted online enrolment forms that providers can fill out and fax over for pharmacy staff to review. However, this approach is not infallible, as there are still multiple opportunities for mistakes to be made during manual data entry.

“Fundamentally, when we’re talking about specialty drugs, we’re talking about more red tape,” explains Bigler. “Right now, I can go to my provider, get a prescription written if it’s a standard drug, and go pick it up at the pharmacy an hour later.”

“But for specialty drugs, because of the authorisation requirements prior to the patient actually receiving that prescription and the significant amount of work that goes on behind the scenes, we saw a real true pain point where applying technology, innovation, and automation could make a difference very quickly.”

How electronic prescriptions can improve market access

As the healthcare industry looks to eliminate administrative burdens and curb unnecessary spending, reducing human error in prescribing is a particular area of interest. According to the US Government, the total cost of caring for patients with medication-associated errors exceeds $40 billion each year. Add to this the initial high price tag associated with specialty drugs and the psychological and physical experience for patients, and the overall monetary and human cost is even greater.

For patients, accessing these expensive medications is also a costly endeavour. However, whereas healthcare professionals have an insight into the wider prescribing environment, patients are often left in the dark regarding the limitations of distribution networks.

“In the US, a lot of patients go to the pharmacy and find they have a significant out-of-pocket liability and maybe the drug that the provider thought they would be filling and taking, they’re not going to take because of cost considerations,” explains Katter. “Bringing that transparency up right at the point for the doctor and the patient to be able to see that is critically important. That’s transparency. That’s part of this equation.”

In a market landscape built upon sharing large amounts of complex data, interconnectivity has become a notable trend in the space. This is particularly evident in specialty medicine, as each different network can require three or four unique processes, which ultimately place a higher administrative burden on pharmacists.

“There should be more of a unified approach,” says Bigler. “If you’re a provider and you’re just essentially doing what you do in your EHR workflow, all of the administrative requirements that flow from that: the specialty enrolment, eligibility, the formulary check, the authorisation, all that should happen in one unified step. You shouldn’t have to go to three different places or a different portal to do that step, which should just really flow out of the natural workflow process.”

Leveraging data to drive developments in US pharmacies

Disrupting the standard practice in any market is a challenging prospect. However, the emergence of new competitors after a period of stagnation is a positive sign that a fire has been lit underneath the ePrescribing market. With multiple innovators working to develop solutions to approach this new workflow and support different business models, the industry appears to be set to witness an influx of innovative solutions to help specialty pharmacies decrease costs, increase efficiencies, and, ultimately, improve outcomes.

For Katter, connecting multiple stakeholders across the market will be an important feature in future developments. With the insight garnered from notable industry figures, as well as the patients and practitioners set to be impacted by any changes to standard processes, companies can create a system that serves both patients and industry,

“For the network to be successful, pharmacies, pharmacy benefit managers, specialty pharmacies, not to mention the providers who use electronic health record systems – all of those different parties need to participate.”

The unification is not limited to healthcare professionals. Instead, Katter foresees a central role for patients in the prescription process in a future landscape that harkens back to more patient-controlled paper-script methods.

“We think at some point in the industry, consumers will once again control their own prescriptions, most likely through a secure connection on their cell phone,” he explains. “It’ll be much more unified, a lot of the side workflows will be eliminated, and everybody, including the patient, will be involved.”

*Surescripts did not respond to multiple requests for comment

Eloise McLennan is the editor for pharmaphorum’s Deep Dive magazine. She has been a journalist and editor in the healthcare field for more than five years and has worked at several leading publications in the UK.

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