Thursday, October 8, 2009

The Mystery of the Denied Refill Requests

Voicemail: "Hello doctor. This is Mr. Smith. The pharmacist said you denied my refill for Suboxone."

That's odd. Mr. Smith never called to ask me to order a refill from the pharmacy. The pharmacy never contacted me to ask me to authorize a refill for Mr. Smith. Why would they think I denied it?

This mystery has haunted my practice for a year. Come to think of it, that pretty much coincides with how long I have been ordering most prescriptions (all but controlled substances) online. I signed up with both and about a year ago, hoping to gain enough experience to decide which I like better and maybe write an article comparing the two. But as I found myself preparing for a two-week absence from the office for vacation I realized I needed to simplify, so I quit using Allscripts and have been using Iscribe exclusively ever since. In a phone call to the customer service line at Iscribe yesterday I may have heard the solution to the mystery.

Generally when these mystery denials have taken place the pharmacists have offered no explanation, however a few months ago a pharmacist told me that a message had appeared either on the pharmacy computer or the pharmacy fax machine, and agreed to fax me a copy. Sure enough, there was a message indicating the request had been rejected. The patient's name, my name, and the drug were printed thereon, but there was no indication whatsoever of the source of the message.

I began to ask other pharmacists and to talk to my patients about the problem. One pharmacist suggested that an automated telephone prescription refill system might have generated the mystery messages, but some of my patients said they talked directly with pharmacists when they requested refills. Another pharmacist suggested the problem might be with an e-prescribing service. Regulations still prevent ordering controlled substances using Iscribe, and I understood that only renewal requests for non-controlled substances could be communicated to me using Iscribe.

A couple weeks ago, however, I was pleasantly surprised to receive some electronic requests for refills for Suboxone on Iscribe for the first time. This has become my favorite way to recieve refill requests. Typically an email message notifies me that a renewal request has arrived. I log in to my Iscribe account. A couple clicks, and it's done. Of course I was not able to authorize these Suboxone refills online. This is still not allowed. I could print a paper prescription, but since the patient is not present that does not help. Instead, I fax the prescription to the pharmacy as I would routinely. This brings me to the phone call to Iscribe. I asked the representative whether there might be a way to remove the renewal request from the inbox without printing it. In responding he mentioned that Iscribe had changed the system because of unwanted denials.

We may never know the truth, but it appears to me that, either through an automated phone system or initiated by a pharmacist, Iscribe generated the denials unbeknownst to me and with no indication of where the denials originated. It has been my understanding that e-prescribing services such as Iscribe and Allscripts use a clearinghouse, possibly, as an intermediary with pharmacies. My best guess now is that, after the patient asked the pharmacist for a refill, the pharmacist, rather than contacting me by fax, entered the request through the clearinghouse which identified me as participating with Iscribe. At that point either the clearinghouse or Iscribe rejected the request automatically because the drug is a control substance, without notifying me. The pharmacist thought I had generated the rejection.

E-prescribing promises many advantages over paper, phone and fax orders, but designers need to correct potential stumbling blocks quickly when identified. We will see whether the mystery denials stop.

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