Un-paving the cow path: Prescription refills

“Paving the cow path” is the act of automating a business process without regard for whether the process is effective or efficient in solving the problem at hand. When someone invokes “paving the cow path,” it usually means that the problem and its solution would have benefited from critical analysis to arrive at a better solution rather than just computerizing the status quo. In this post-HITECH Act era of ubiquitous electronic health record (EHR) systems, paved cow paths are an epidemic in health care.

A prominent example of a paved cow path is the handling of prescription refill requests. When physicians write prescriptions, one detail that they specify is fill instructions, which includes dispense quantity and units (e.g., 30 tablets) and number of refills. Before the e-prescribing era, patients would generally request refills for a medication during an in-person physician visit or via a telephone call, and the physician’s office would call or fax the pharmacy with a new prescription or refill authorization. In the current American e-prescribing system (at least as it’s designed to be used), patients request refills through their pharmacy, which enters electronic refill requests that get transmitted to physicians’ EHRs, where they and/or their staff process and respond electronically to the pharmacy. This is still a lot of work for the physician’s office.

Just because it has always been done this way, though, doesn't mean that it’s the most effective or efficient way because—and this is essential—physicians don’t actually care about being able to specify dispense amounts and number of refills, per se. Instead, what they care about is the control of patient access to medications that specifying dispense amounts and number of refills gives them. With a different e-prescribing paradigm, this control could be achieved in other ways.

Vis-a-vis controlling patient access to medications, the details of what physicians actually care about are that:

1. Physicians can prescribe how the patient is to take the medication (i.e., frequency and dosage). 
2. Patients can access a supply of the medication (i.e., from a pharmacy). Physicians do not generally care which pharmacy patients use.
3. Physicians can limit supply of the medication if needed. This means that patients can’t purchase an unlimited quantity of a medication at any given time. This is important when a prescribed medication has significant potential for abuse and/or diversion. 
4. Physicians can revoke access to the medication if needed. Why would a physician want to revoke access? The obvious answers include discontinuing the medication for medical reasons such as adverse reaction, ineffectiveness, or concern for abuse. The less obvious reason is that physicians sometimes revoke access to a medication to incentivize patients to return to the office for an appointment. In a fee-for-service reimbursement system, physicians do not get paid unless they can bill for appointments, and renewing medication prescriptions is one of the few carrots (or is it a stick?) that they have. This practice is cynical but also common.

While pharmacists and insurance companies care about dispense amounts and number of refills—they have to dispense and pay for medications, respectively—these are details that physicians would need not concern themselves if they had a more elegant alternative way of controlling access. Consider the similar act of ordering a medication in an inpatient setting. When a physician orders a medication in an inpatient setting, the patient will continue to receive that medication as ordered until a provider discontinues it unless otherwise specified to be administered for a fixed duration. Physicians safely assume that the pharmacy will send the medication to the patient’s nursing unit so that it can be administered as prescribed. The logistics of filling and dispensing medication in the inpatient setting are abstracted from the physician, details with which they need not be involved. Something similar could also be achieved in the outpatient setting but not with our current e-prescribing paradigm.

Our current e-prescribing paradigm comes at a high cost to the physician’s practice due primarily to the administrative burden of processing medication refill requests. It largely just paved the cow path of the old paper-based status quo by taking all of the components of a paper-based prescription process and computerizing them without further abstraction. The paradigm is “you can only have a specified amount until and unless you ask me for more and I grant you that request.” When the best technology available to communicate between doctor and pharmacy was paper, this paradigm was reasonable, yet computers and the internet were already ubiquitous when e-prescribing went mainstream. This would have enabled useful abstractions that were not possible with paper. Still, control of patient access to medications that e-prescribing implemented cleaved largely to its paper-based predecessor, a paved cow path.

An arguably better approach, which could be implemented with relatively simple digital technology, uses the paradigm of “you can have as much as you need, to take it according to my instructions until and unless I stop or change it.” The new paradigm would default to unlimited refills for chronic medications (i.e., with the ability of a physician to revoke access to refills). Changing to the new paradigm would eliminate much administrative work performed in physicians’ offices.

In future blog posts, I hope to explore additional paved cow paths in health care IT and how alternative solutions built on different models might be better suited to today’s health care challenges. If you have ideas or topics you’d like me to cover, please send me a comment.

Adam Rothschild is a clinical informaticist with 3M Health Information Systems.