Introduction
Electronic prescribing or e-prescribing has been identified as an important technology and stepping stone for improving the safety, quality, and efficiency of healthcare ( ). E-prescribing was initially touted as the “killer app” that would lead to wider adoption of e-health and telehealth by physicians, especially in small practices. The difference between what most would have envisaged and what is the current reality in most states and nations, points at design and operational failure. One feature touted over a decade ago was the ability to maintain a complete medication list, and a recent medication history for each patient; complete with decision support tools which would alert and remind prescribers and those dispensing of any relevant information such as contraindications, interactions, and dosing issues. If one were completing a checklist, each of these items could be said to have been provided. However a patient attending one healthcare provider doesn’t necessarily have access to the same records or even the full record of dispensed drugs that another provider, in another health system has. It is also the case that different provider locations, within the same health systems, but that utilizes different electronic health records (EHR), sometimes do not have a common, unified and complete record of prescribed and dispensed drugs. Similarly, outside of some states enacting legislation covering the need to maintain a centralized record of dispensation of controlled substances, most pharmacies cannot be certain that they have a complete record of all the drugs a given patient has been dispensed, as patients may use any number of competing chain, independent, online, or specialty pharmacies, and there is no centralized record of care.
In retrospect, while e-prescribing adoption did increase in the past decade, most of the credit for its uptake should be attributed to Medicare and Medicaid EHR incentive programs, which began circa 2010 in the United States ( Fig. 11.1 ). The promises that e-prescribing systems would increase patient safety and reduce costs through improved legibility and improved practice efficiency were not fully realized. While practice administrators may no longer have to direct calls from pharmacies unable to decipher a handwritten prescription, and healthcare providers may not have to have their work interrupted over their handwriting, they still need to confirm the intended drug, its dose or route of administration, are correct. While less interruptions to work may have occurred, the promise of improved patient safety should really have been the only priority. E-prescriptions in many respects reduced the barrier to access to medicines, including controlled and addictive medicines. However, e-prescribing systems have and continue to experience many issues hampering realization of their potential ( ).
Reducing barriers to access to prescription drugs is very clearly a two-edged sword. Legislation in the United States has been introduced by states to attempt to improve patient safety, reduce error rates in prescribing, and reduce the occurrence of prescription fraud. For example, while overall opioid prescribing rates decline in the United States of America following the opioid epidemic, e-prescriptions for opioids increased by more than a third ( ). New York State, for example, passed a law in March 2016 mandating healthcare providers to issue e-prescriptions for controlled substances in Schedules II through V, with only some exceptions. Yet there is no evidence to suggest that these initiatives have done anything to reduce abuse of controlled substances other than to track legitimately prescribed opioids. Ultimately, the gatekeeper to the legal access of controlled and addictive substances such as these, is the prescribing physician. While technology may promise improved legibility and a digital prompt to remind the prescriber of spelling and dose, it may also facilitate the abuse of an already overworked and underresourced healthcare staff. There is concern that the ease of e-prescription may be a tempting short-term solution, but not necessarily be the optimal mode of care.
E-prescribing—a tool to address the large burden of urological disease and the limited workforce?
The burden of urological disease in America is immense, both financially and individually ( ). Societies such as the American Urological Association have done much to highlight the need for greater access to care, and also advocated to increase the number of specialists to treat patients and address disparities in access. Despite such efforts, poor access to care and an overburdened system among other factors, has resulted in many patients receiving shorter visits with caregivers ( ).
Many urological symptoms and conditions are responsive to medical therapy, such as lower urinary tract symptoms resulting from bladder outlet obstruction, overactive bladder and urinary incontinence, as well as erectile dysfunction. While not all of these conditions are universally cured by such interventions, many do obtain symptom relief and practice guidelines from various specialty interest groups, do include pharmacotherapies as a first-line care for some of these conditions. Some patients could be managed remotely, and at least for a period of time, without the need for in-person care.
The healthcare industry has traditionally relied on face-to-face consultations, where doctors hear and examine the patient, and can get a sense of what ills the patient. One of the most widely used interventions used to prevent and treat disease are pharmaceuticals. As a result, medicines are now one of the largest health expenditures, accounting for an average of 16% of total health expenditure in the Organisation for Economic Co-operation and Development (OECD) countries in 2015.
This is nowhere better demonstrated than by the growth of “digital health”/“direct-to-consumer” providers such as those discussed elsewhere in this book, and discussed in a case example later in this chapter. Some of such providers consider medical conditions as “verticals” and have in many respects, “productified” ICD-10 codes. Profitable conditions where limited physician interaction can result in a prescription for an otherwise young and most often medication-free individual, now have multiple online companies, vying to on-board them, to a subscription service, which offers repeat prescriptions with minimal clinical review and oversight. It is an important distinction to make that these are businesses and not medical practices. While they often have the oversight of a medical director and employ (most often as contractors), physician assistants/physician associates or nurse specialists, many are public companies, and all that the author is aware of are for profit entities. In one respect, these businesses improve access to “care.” However, it could be argued that such businesses only provide access to the sort of care that is a monetizable model of recurrent prescriptions, often fulfilled by the company themselves, using their own branded generic medication, and charging a healthy markup above generic costs, which would be available to patients accessing care through a conventional healthcare setting such as their urologist. It has been said these businesses are competing to medicate young and healthy individuals for conditions, which often are complex and that would benefit most from multidisciplinary care. There is no doubt though that making healthcare a consumer product, infinite and on-demand, diminishes the importance of the patient–physician relationship, and disempowers healthcare providers as health advocates. Without that central relationship, providers can no longer fully advocate for their patients and indeed really don’t have patients any longer, so much as tasks to complete in a work queue.
Opportunities for e-prescribing
The third largest category of healthcare spending across the OECD is for medical goods. On average (see Fig. 11.2 ), the proportion of spending by category including medical goods (under which pharmaceuticals and other prescription goods are included) has remained stable over this time period. Price differences for international goods such as medicines tend to vary less across countries than for locally produced services (such as care provision). As a result, in low-income countries, spending on medical goods (including prescribed medicines) often accounts for a higher share of health spending than spending on services. Consequently, expenditure on medical goods accounted for almost a third of all healthcare expenditure in Hungary and the Slovak Republic in 2019. In Denmark, Norway, and the Netherlands, on the other hand, the shares were much lower with about 10% of total health expenditure (see Fig.11.3 ).
Drug misuse and diversion in urology is not a new problem
Prescription drug diversion is defined as the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace. This includes transferring drugs to people they were not prescribed for. There are a number of scheduled and controlled substances commonly prescribed by urologists (see Table 11.1 ).
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