How can e-prescribing improve the workflow between veterinarians and pharmacists?
This article was originally published by Drug Topics, a sister publication to dvm360.
When it comes to prescription medications for our pets, veterinarians are in a unique position. Unlike most of their counterparts in human health care, veterinarians are both prescribers and dispensers. In the past, veterinarians were the only source for medications for pet patients, with one exception: Veterinarians could write a prescription to be filled at a local pharmacy for expensive or less frequently prescribed medications that were primarily pharmaceuticals for humans.
Over the past few decades, veterinarians’ dual role has changed dramatically as the internet took off, creating more options for pet owners to fill their pet’s prescriptions. In 1996, one of the first online pet pharmacies entered the fray. Soon after, big-box retail stores also started to offer veterinary medications. In many ways, filling prescriptions has become the Wild West with the $36 billion veterinary industry1 filling medications in veterinary hospitals, local drug stores, compound pharmacies, online, and in a plethora of other ways.
Before these options, it was easy for veterinarians to hand a prescribed medication to the client and be the sole source for refills. Today, it is becoming more common for pet owners to request a paper or electronic prescription to be filled elsewhere, often for less money.
“In some states, it is legally required that if a client wants to get a prescription to take to an outside pharmacy, vs getting it filled by the vet, [the practice] has to honor those requests,” said Lauren Forsythe, PharmD, DICVP, FSVHP, a clinical assistant professor of pharmacy in the Department of Veterinary Clinical Medicine at the University of Illinois at Urbana-Champaign College of Veterinary Medicine. “In those states where it’s not necessarily legally required, it’s an American Veterinary Medical Association standard of ethics…for a vet to honor that [request].”
Between writing prescriptions, addressing refill requests from online pharmacies, interacting with local pharmacists, and managing their own in-house inventory, prescription management is a huge drain on veterinarians, taking time away from patient care. For pharmacists—especially those unfamiliar with requirements and licensure for veterinarians—the back-and-forthcommunication between the pharmacy and the clinic about a prescription can consume an equally significant amount of time. Equally confounding is the financial pressure competitive forces are putting on in-house veterinary pharmacies, pushing margins down. Are there simple solutions to help streamline this process while allowing veterinarians to stay in control of both the patient and client experience?
Pet parenthood on the rise
The COVID-19 pandemic disrupted the norm for every sector of the health care profession—including pharmacists and veterinarians. An increasing demand for pharmacy options from pet owners led to changes in almost every aspect of small business delivery models. According to data from the American Society for the Prevention of Cruelty to Animals (ASPCA), more than 23 million households—approximately 1 in 5 across the United States—adopted a pet during the pandemic.2 With more pets came a greater need for providers and processes to deliver a greatclient experience. The number of veterinary telehealth and mobile veterinary practices increased, along with a significant shift from brick-and-mortar pharmacies to an online pharmacy modelwith more requests for prescription fills and refills from online pharmacies outside the veterinary practice. This new virtual model requires electronic prescribing to function optimally and support their patients and pet parents.
Consider the following:
As the largest population of pet owners, millennials are a key driving force behind trends in veterinary prescribing. This group—adults between the ages of 27 and 42—generally prefers online shopping, with 55% of millennials expressing a preference towards online retailers6 and 87% prioritizing convenience over all else.7 In the face of these statistics, what can pharmacists and veterinarians do to pave the way for pet parents to fill their prescriptions in brick-and-mortar independent pharmacies?
Rules and Regulations Drive Everything
It’s important for both veterinarians and pharmacists to understand the regulatory and licensure rules that govern each group. Veterinary hospitals and veterinarians are overseen by numerous regulatory agencies—local, state, and federal—that govern the practice of veterinary medicine, the veterinary client-patient relationship, and the prescribing and dispensing of medications. Because veterinarians can both prescribe and dispense, state boards of pharmacy—and in some cases, state-level controlled substance regulations, in combination with federal agencies like the FDA and Drug Enforcement Administration (DEA)—are all part of the alphabet soup that set the guidelines under which veterinarians operate. Even when veterinarians are dispensers, they must follow pharmacy law as dispensers of drugs, including controlled substances.
Because most physicians and other mid-level providers of human health care are only able to prescribe, regulatory agencies have worked diligently to create oversight around prescribing medications, such as assigning National Provider Identifier (NPI) numbers. These 10-digit numbers are mandatory for any health care provider working in a HIPAA-covered entity, including those who bill Medicare for services.8 Neither HIPAA nor Medicare apply to veterinarians which is why veterinarians do not require an NPI to prescribe.
“I explain [to vets] that [NPI numbers are] designed to indicate providers who can prescribe for Medicare and Medicaid patients,” Forsythe said, “and our animals are not eligible for either program. Therefore, [legally,] vets cannot have NPI numbers.” Forsythe encourages her veterinarian colleagues to help educate pharmacists about the NPI issue. “I’ve had some [veterinarians] tell me that they get so much pushback… ‘Why won’t the pharmacist just believe I don’t have one?’”
These issues are exacerbated when it comes to controlled substances: DEA numbers can be expensive, and not all veterinarians have one. “If it’s a practice setting where they don’t really need to prescribe or dispense controlled substances, such as a dermatologist, [then] they don’t necessarily have a DEA number. Requiring one to fill a prescription for an antibiotic doesn’t really work,” she explained.
For Forsythe, much of the issue comes down to technology. “I understand that state license numbers are hard to look up in systems,” she said. Not only is there variability, but NPI numbers aren’t the typical identifier that pharmacy software systems are looking for, making it difficult for pharmacists to fill veterinarian scripts and requiring extra attention.
The Importance of E-Prescribing
E-prescribing technology might be state of the art for human health care, but most veterinarian practice information management systems (PIMS) don’t meet National Council for Prescription Drug Program (NCPDP) standards that are fundamental to the process. These standards include syntaxes used in the exchange of pharmacy information—such as the SCRIPT standard—to transmit prescriptions electronically from a prescribing health care provider to the pharmacy. For controlled substances, some, but not all, states have an electronic prescribing mandate. Of the states with mandates, most include veterinarians in their requirements. However, many also offer veterinary exemptions since e-prescribing technology has not been available to them.
“There’s a disconnect of language,” Forsythe said. “E-prescribing is literally your system securely sending the prescription [to the pharmacy].” However, she explained, “a lot of vets think of it as, ‘I’m going to put my prescription in electronically, and print out this electronic prescription.’ Or they’re going to fax it, or email it, and in their heads, that’s e-prescribing.”
To be able to use e-prescribing, PIMS will have to be updated to meet NCPDP and electronic prescribing for controlled substances (EPCS) guidelines. The best reasons to do so are for convenience and to make it easier to communicate with human pharmacies accurately, in the same language that other health care providers use. In other words, veterinary e-prescribing needs to get up to speed with human e-prescribing.
Despite the current disconnects, e-prescribing provides numerous benefits to veterinarians, their clients, and their patients. Perhaps the most significant advantages are faster and easier processing of prescriptions and renewals.
An electronic system can, and should, track all prescription information—including renewals and refills—for all pets to keep our furry friends safe. When a complete list of a pet’s medications is not readily available in one system, the pet is at a higher risk of a drug-drug interaction or of experiencing an avoidable adverse drug event. With e-prescribing, veterinarians can manage their patients’ prescriptions directly from the PIMS or a standalone e-prescribing application, reducing prescription delays and paperwork.
E-prescribing also enhances accuracy. The NCPDP SCRIPT standard makes it easier to process and complete prescriptions, minimizing the risk of errors that can occur with manual prescribing methods. Moreover, e-prescribing expands access to retail pharmacies, making it more convenient for pet owners to obtain the medications their pets need.
Perhaps one of the most valuable benefits of e-prescribing for veterinarians is the additional time it makes available to focus on treating pet patients, satisfying clients, and expanding their practice. By reducing administrative tasks, such as extra phone calls, associated with prescription processing, e-prescribing can free up valuable time for veterinarians to concentrate on growing their practice and expanding services
High Tech, High Touch
E-prescribing may seem like just another way that prescription medications are being extricated from the control of the veterinarian. With the way things are currently progressing, and with the continued federal efforts to give pet owners the freedom to choose where they buy prescriptions medications through the Fairness to Pet Owners Act,9 the need to simplify the pharmaceutical prescribing process is crucial.
“Adding e-prescribing options to veterinarian practices is really all about flexibility, patient safety, and customer satisfaction,” said Lathe Bigler, vice president, clinical network services and general manager at FDB Vela. “Veterinarians can now meet the expectations that pet parentshave, to pick up a prescription either in-house or from a retail pharmacy, while spending more time with their patients as well.”
“We need education and we need better technology,” Forsythe said. “There’s a [history], to some extent…where pharmacists and veterinarians don’t particularly like working together. I think we’re past the financial aspect [of that]; it’s more the logistics of prescribing. It’s challenging for veterinarians, and I’m sure it’s frustrating on the pharmacy side as well.”
“We need a system that recognizes our veterinarians better,” she added, such as an NPI number equivalent for veterinarians, or a standardized number for veterinarians across the country. “[We also need] e-prescribing software that talks between veterinarians and pharmacists—that would be big.”
Peter Weinstein, DVM, MBA, is a husband, father, pet parent, veterinarian, and leader. He is a published author, most notably of The E-Myth Veterinarian: Why Most Veterinarians Practices Don’t Work and What to Do About It. Weinstein teaches business and finance at the Western University College of Veterinary Medicine in Pomona, California.
Kelley Detweiler is a DEA and regulatory compliance expert who provides controlled substance and DEA-listed chemical solutions to the veterinary, health care, supply chain, and pharmaceutical industries operating in the public and private sectors. She is a partner at Simple Solutions 4 Vets, Inc, and the coauthor of Safeguarding Controlled Substances. Detweilier has spoken at the United Nations, and continues to speak and write for industry associations, organizations, and publications.