Archive for category Low Value

E-Prescribing — if not why not?

e-prescribing 2011

The above map comes from Internal Medicine News.  State by state it shows where doctors are using electronic prescribing.   A simple question for those doctors in the white states:  why live in the past?  Huge numbers of pharmacies accept electronic prescriptions, patients like electronic prescriptions better than paper prescriptions, prescribing errors are much lower, patients get better care, drug interaction checks can be done BEFORE the prescription is sent (so the pharmacist does not have to call),  and a record of the prescription is available as part of the medical record.

The doctor perspective:  “Just more computer work for me”

The patient perspective:  “I like the idea of fewer errors”

How does it work?
The prescriber needs to have several things in place:

  • An electronic medical record
    (without this much of the advantage is lost)
  • An electronic list of the patient’s active prescriptions
  • An electronic list of the patient’s allergies and intolerances
  • A diagnosis associated with the prescription
  • A record entry to document the thought process for the prescription
  • An internal link to the insurance drug formulary

A very good process is to have the computer screen for prescribing where the patient can see the actions of the prescriber.  That way the patient can see what  is being prescribed, whether it is covered by insurance, where the prescription will be sent, the instructions, the amount and the refills.  If there are problems the patient can comment — it is much better to have feedback at the time of prescribing rather than the patient not take the medication or get phone calls later with questions from the patient or pharmacist.  Physicians who use e-prescribing don’t ever want to go back to the old way!  Pharmacists never liked physician handwriting anyway.

So, if your physician is not using e-prescribing give them a copy of this post!

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Low Value Health Care — The Equation

The “Sick in America Poll” shows 33% of people who were sick in the past year believe they don’t get a good value for health care.  One way to look at “value” is the following equation:

V = B / P

Value = Benefit divided by Price

If a person wishes to cross a river there might be 2 ways to get across.  $5 to go across a bridge or $2 to go across a tightrope.  If the benefit (getting across the river) is the same then the best value would be to use the tightrope.  But, low risk,  no need for training and convenience are actually part of the benefit for the bridge — which is indeed the best value.

In health care the “value equation” runs into problems.  What if a person only has $2 (the unemployed).   What if a person does not know about the bridge (poor health literacy).  What if a person does not need to cross the river but pays a fee just in case (insurance).  What if a person pays tax for the bridge (taxation).  What if the bridge is in disrepair so a person falls (cost of poor quality).  What if a person will not live long enough to get across the river (quality adjusted life years).  Health care economics is indeed complicated.

There is also a “funnel theory” of health care which says that despite theoretical complexity there are only a few solutions to come out.

  1. Deliver evidence based healthcare
  2. Stay within a budget
  3. Eliminate waste
  4. Maximize quality
  5. Minimize cost
  6. Be fair
  7. Know the value of life


Finally, the “Marcus Welby” theory of health care is dead.  That is to say, the doctor who knows everything, treats a few patients (with lots of drama) and bills enough to have a great lifestyle is now off the air.  Cost is now the king, and Americans must work within a system to meet budget requirements.  Corporations live under the same constraints, so must health care.

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