E-prescribing is now a reality for pharmacies and physicians alike, and attention has shifted to evaluating the impact of this innovation on practice and practitioners. Like their physician counterparts, many community pharmacy owners and managers are wondering, "what is the value proposition for implementing e-prescribing in my practice?"

In recent years, many claims have been made about the potential benefits of e-prescribing in community pharmacy. Advocates assert that e-prescribing can improve staff productivity when compared to other methods of transmitting, receiving, and processing prescription orders. If true, e-prescribing could substantially reduce dispensing-related costs, since labor typically represents the lion's share of dispensing costs in the community practice setting. Besides reducing costs, increased staff productivity could also lead to enhanced customer service. That should improve customer satisfaction and loyalty, while also allowing staff to participate in new services that help diversify the pharmacy's revenue base. Importantly, improvements in staff productivity and workflow could also improve the quality of staff work life in the hectic and often stressful environment of community pharmacy practice.

The results of a recent study show strong support for the claim that e-prescriptions improve pharmacy staff productivity when compared to other methods of transmitting and receiving prescriptions in the community practice setting.

Study Methods
Data collection was conducted at 10 outlets of a single chain pharmacy organization in New England during September, October, and November of 2004. Participating pharmacies had been successfully processing e-prescriptions via their proprietary computer system for approximately three months prior to the beginning of data collection.

At each of the 10 study pharmacies, observers were instructed to track and record the time required by pharmacy staff to complete each of five key dispensing activities for a sample of prescriptions:

1. Receive the Rx Order — including greeting the patient and obtaining all necessary prescription and insurance information.
2. Process the Rx Order — including entering required prescription and third-party data into the computer.
3. Resolve 3rd Party Conflicts — including online DUR alerts and edits, formulary enforcement activities, eligibility problems, and prior authorizations.
4. Resolve Clinical Conflicts — including in-store DUR alerts and all pharmacist-initiated interventions related to the prescription being dispensed.
5. Prepare the Prescription — including retrieving the drug from storage, counting or pouring the quantity desired, filling the container, preparing and affixing the label, returning the bulk container to stock, final check, and bagging the prescription and placing it in the will-call area.

At each study pharmacy, observers tracked a total of 80 prescriptions, 10 from each of eight categories: New and renewed e-prescriptions; new and renewed walk-ins; new and renewed phone-ins; and new and renewed fax-ins. At the conclusion of data collection, staff at each of the study pharmacies was asked to complete and return a survey to assess their attitudes toward e-prescriptions. Observers were instructed to only record the time that pharmacy personnel were actively engaged in performing one of the above activities on the prescription order being tracked. Time that elapsed during which no staff member was actively engaged in one of the above activities on that prescription (e.g., waiting for a call-back from a physician's office) was not recorded.

Results
The results of the study provide a strong endorsement for e-prescribing in the community setting. The average time (in seconds) that pharmacy staff took to complete the five dispensing activities for each class of prescriptions is illustrated in Table 1. E-prescriptions required the least staff time among new prescriptions, followed by fax-in, phone-in, and walk-in prescriptions. When compared to all other new prescriptions processed during the study, e-prescriptions required 26.6 percent less staff time. Renewal e-prescriptions required 10.2 percent less staff time than all other renewal prescriptions. And that's excluding time spent waiting for a call-back from a physician's office.

Comparative improvements in staff productivity for both new and renewal e-prescriptions were primarily due to increased efficiencies in receiving and processing the prescription order. Although prescriptions that were phoned in for renewal (via the chain's fully automated IVR system) were found to require the least total staff time of all renewal prescriptions, this result should be interpreted with caution, since this study did not include staff time required to request refill authorizations from physicians' offices.

A more detailed examination of staff time for each of the five categories of prescription dispensing activity appears in Figures 1 and 2, for new and renewal prescriptions, respectively.

Receiving the Rx: New phone-in prescription orders required more total staff time to receive than any other prescription type. New phone-in prescriptions were particularly conspicuous users of pharmacist time, accounting for over 36 percent of the total time that pharmacists devoted to prescriptions in this class. Walk-in prescriptions also used a relatively high amount of staff time in this activity class. In contrast, new and renewed e-prescriptions, new and renewed fax-in prescriptions, and renewed phone-in prescriptions required relatively little staff time to receive at participating pharmacies.

Processing the Rx: As expected, new prescriptions far outpaced renewals in the time required of staff to process the prescription order. New walk-in prescriptions were particularly heavy users of staff time, followed by fax-in, phone-in, and e-prescriptions. For renewal prescriptions, fax-ins consumed the most staff time. The differences among the other three renewal prescription types were negligible.

Resolving 3rd Party Conflicts: Resolving third party conflicts at pharmacies in the study accounted for 3.9 percent of staff time on new prescriptions, and 1.6 percent for renewals. Although new e-prescriptions required the most staff time in this activity classification, the relevance of this finding is unclear considering the comparatively small amount of total staff time that was devoted to this activity.

Resolving Clinical Conflicts: Activities involved in resolving clinical conflicts at pharmacies in the study accounted for a mere 0.3 percent of staff time for new prescriptions, and only slightly higher— 0.7 percent— for renewals. For two prescription types, new e-prescriptions and new fax-ins, no staff time was recorded for this activity across the 100 prescriptions that were observed (10 from each store). Once again, however, these results must be interpreted with caution given the very small amount of time involved.

Preparing the Rx: Preparation of the finished prescription accounted for 47.2 percent of staff time for new prescriptions, and 68.5 percent for renewals. Despite this apparent difference, the absolute time consumed by this activity was relatively similar for new and renewal prescriptions.

Staff Attitudes Toward E-Rxs
A total of 24 staff members returned completed satisfaction surveys (Figure 3). Respondents were equally split between pharmacists and technicians.

Pharmacy staff judged e-prescriptions to be much better in speed of processing/dispensing and in overall general comparison with other prescription types. Staff viewed e-prescriptions as slightly better for causing disruptions in workflow and for DUR issues. Pharmacists and technicians were remarkably similar in their attitudes toward e-prescriptions. Differences were small and none were statistically significant.

Economic Impact
A 1999 study sponsored by the National Association of Chain Drug Stores (NACDS) found the activities associated with receiving and processing the prescription order and preparing the finished prescription, together accounted for 59.3 percent ($2.53 in 1999 dollars) of the total pharmacy labor cost to dispense a prescription . If applied to the results obtained in this study, new e-prescriptions reduced total labor costs by 15.8 percent when compared to all other new prescriptions, and 6.1% when compared to all other renewal prescriptions.

When adjusted for an annual inflation rate of 8.7 percent in pharmacy staff salaries since 1999 the average per-prescription reduction in pharmacy labor costs from e-prescriptions in this study was $0.97 for new prescriptions, and $0.37 for renewed prescriptions. Most pharmacy owners and managers recognize this can mean the difference between profit and loss in some third party prescription benefit plans that community pharmacies routinely accept. Furthermore, the savings demonstrated for renewal prescriptions in this study do not include pharmacy staff time required to make refill requests to physician offices, nor does it consider the inconvenience of lengthy delays often faced by pharmacy staff and patients alike while awaiting refill authorizations from the physician's office.

Conclusions
One of the study's most important findings was the per-prescription savings in pharmacy labor costs created by e-prescribing, which was $0.97 for new prescriptions and $0.37 for renewed prescriptions. Regarding demands on staff time, e-prescriptions compared favorably with all other modes of receiving and processing prescription orders. New e-prescriptions required significantly less staff time - 26.6 percent—to receive and process than all other prescription types, and renewal e-prescriptions required significantly less time—10.2 percent—than either fax-in prescriptions or the combination of all other types (i.e., all non e-prescriptions).

The study also showed that e-prescriptions demanded significantly less time from selected pharmacy staff. New e-prescriptions required less pharmacist time than phone-in prescriptions, and less technician time than walk-ins. A similar theme was evidenced among renewed prescriptions, where e-prescriptions required less pharmacist time than walk-ins, and less technician time than either walk-ins or the combined all-other types. For both new and renewed prescriptions, improvements in staff productivity were due primarily to increased efficiencies in receiving and processing e-prescription orders.

Although e-prescribing is still in the introductory phase of its diffusion into community pharmacy practice, the results of this analysis suggest that the innovation maintains some significant advantages in its effect on staff productivity and labor cost when compared with other methods of receiving and processing prescriptions. Additional studies to define other components of the value that e-prescribing represents to community pharmacy practice are clearly warranted as soon as they can be conducted.

Acknowledgments: This study was made possible by funding from SureScripts LLC.

Michael T. Rupp, Ph.D., R.Ph., is a member of the NIPCO advisory board and managing partner for Desert Mentors LLC, a research and consulting firm in Glendale, Arizona, specializing in community pharmacy practice. He may be contacted at estaffa@advancepharmacy.org