(click for larger image)
Figure 1. Each red mark represents the address of a different pharmacy in New York City.
PHOTO: NAYAN PATEL, MD
Many emergency physicians may be aware that electronic prescribing, where a prescription is sent via the Internet directly to a designated pharmacy, is an alternative to the traditional hard-copy prescriptions used in one form or another by almost all emergency departments. What may come as a surprise, however, is that mandatory electronic prescribing for all patients, including ED patients, is now the law in the state of New York and may well be adopted in other jurisdictions.
As of March 27, 2016, emergency physicians in New York are required to use only electronic prescriptions; paper, fax, and telephone prescriptions are all banned, with both civil penalties and imprisonment specified for noncompliance. Although the law apparently isn’t being enforced yet, it’s evident that the many pernicious effects, on emergency patients in particular, have received little consideration.
A Prescription for Confusion
Many ED patients may not know the specific pharmacy where they will get their prescription filled. For example, there are 140 pharmacies with the Duane Reade brand alone in Manhattan (which is just one of five boroughs in New York City) and another 47 with the CVS name. As Figure 1 indicates, there are multiple branches of each chain, often in proximity to one another—there are 24 Duane Reade pharmacies on Broadway alone! Moreover, there are 80 Duane Reade pharmacies on a street or avenue with at least one other pharmacy of the same chain. In all, there are a total of 33.6 pharmacies of all types for each square mile of Manhattan.
It’s estimated that there are 1.63 million nonresidents in Manhattan every day, including 848,000 visiting vacationers, day-trippers, and students from other countries and states. More than 500 languages are spoken in the city; the potential for confusion with our patients is evident.
Remarkably, the law doesn’t allow for the electronic prescription to be filled by any pharmacy except the geographic entity to which it was originally sent. For example, the CVS nearest Mount Sinai Beth Israel on First Avenue and 15th Street couldn’t send a patient to the Duane Reade right next door or even reroute a patient or prescription to another CVS a few blocks away. If the particular pharmacy is closed, doesn’t stock the formulation, or is simply out of the precise medicine prescribed, the only alternative for the patient is to return to the emergency department for another prescription.
Ironically, the law makes it impossible for the patient to comparison-shop for price or anything else such as availability, formulation, or store hours. Electronic prescribing will likely work well when patients have a long-standing relationship with a particular pharmacy. Unfortunately, this description doesn’t apply to many of the ED patients we treat.
There clearly are potential advantages to electronic prescribing, as anyone who’s had a prescription forged or a pad stolen can attest to. However, the potential harm to our ED patients, who often don’t have an ongoing relationship with a nearby pharmacy and are likely to receive a one-time prescription that needs to be filled quickly for an acute condition, seems to have been ignored.
Electronic prescribing is a reasonable option for both patients and clinicians, particularly in the office or clinic setting. But mandating it for ED providers and patients isn’t reasonable; it’s a (nonelectronic) prescription for inefficiency and confusion—a textbook example of misguided health policy.
Dr. Heller, Dr. Patel (resident), and Dr. Rose are all at Mount Sinai Beth Israel Department of Emergency Medicine and are affiliated with the Icahn School of Medicine at Mount Sinai in New York City.
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