Doctors and the Web

Are online pharmacies good for your patients—and for you?

Rogue Viagra peddlers aside, Internet drugstores will have a place in your medical practice, and not just as amazon.coms for pills. They're one more sign that everything in health care is converging electronically.

By Robert Lowes
Midwest Editor

If you've just gotten used to having patients walk into your office brandishing printouts from health care Web sites about how you should treat their hypertension and allergies, brace yourself for the next phase of the Internet revolution. Now patients can get medicines for these and other conditions from online pharmacies—and save a few dollars in the process.

Should that make any difference to you?

In some respects, doctors are bystanders when it comes to online pharmacies. A patient can fill a prescription wherever he wants, and if he goes the dot-com route, that's his business. But physicians should be prepared to advise patients about such pharmacies, and which ones—if any—would serve them best.

Clearly, online sources of medications can be fraught with danger. Some no-questions-asked Web sites hawk medications such as Viagra, while others require patients only to complete a perfunctory questionnaire before an online doctor issues a prescription. And that doctor isn't likely to do even the most cursory follow-up. (See "Dubious Web prescription sites are feeling the heat").

Then there are legitimate entities, such as PlanetRx.com and drugstore.com, that require real prescriptions from real doctors, employ real pharmacists, and otherwise play by the rules. If you can live with mail-order pharmacies, you can live with the online versions, because they basically occupy the same niche—refilling maintenance prescriptions to treat chronic illnesses while charging less than the corner drugstore.

"Lots of people use mail-order pharmacies, and if Internet pharmacies offer similar discounts, they can be a good thing," says Powder Springs, GA, pediatric emergency physician Debi Dalton, a former pharmacist.

If bona fide online pharmacies have had little or no impact on your practice to date, though, don't be surprised. This cyber-industry emerged only last year, and rang up a mere two-tenths of 1 percent of all prescription drug sales in 1999, according to Cambridge, MA-based Forrester Research, which studies e-commerce.

"None of my patients has ever mentioned using online pharmacies," says family practitioner Stanley Savinese in Aston, PA, "and I have 5,600 patients, many of whom look up medical information on the Web." Likewise, FP and electronic medical record evangelist Allen Wenner in West Columbia, SC, can point to only one patient who patronizes an online pharmacy. "They're simply not relevant to me," says Wenner, vice president for applications design at PrimeTime Medical Software in Columbia, SC.

Online pharmacies might remain largely irrelevant if they stayed in their current form. However, in the world of e-commerce, count on rapid change. Bricks-and-mortar pharmacies are forming alliances with their Internet counterparts or launching their own Web sites, which will only increase the number of patients who get medications online. And Web drugstores are moving, along with other health care players, toward the day when doctors routinely transmit prescriptions electronically.

For now, online pharmacies appeal mostly to patients with no drug coverage. This includes traditional Medicare beneficiaries without secondary insurance, the uninsured, and patients seeking noncovered medications such as fertility drugs. But if a sizable number of health plans begin to offer lower copays to members who order maintenance medications via Internet pharmacies, the concept could grow in a hurry.

The advantages of online dispensing

Legitimate online pharmacies process new prescriptions much the same way traditional drugstores do: The patient mails the doctor's script to the Web drugstore or asks his doctor to phone it in or fax it.

Certain safeguards are in place: Online pharmacies re-quire patients to complete a form asking not only for billing information, but for a list of all prescription and over-the-counter medications taken, and any medical conditions. When the patient needs a refill, he can place the order with a few mouse clicks.

While Internet orders are lightning quick, deliveries are as slow as the US mail, because that's how online pharmacies usually get medications into patients' hands. Of course, overnight delivery service is an option—but the extra cost can counteract the price advantage a Web site offers. Same-day service is usually possible only when an online pharmacy is working in tandem with a bricks-and-mortar counterpart (more on that later). The need to rely on "snail mail" explains why online pharmacies, like mail-order pharmacies, deal chiefly with medications for chronic illnesses.

Online pharmacies may lack the convenience of local drugstores, but they benefit from not having to paint, clean, repair, and heat those retail outlets, which allows them to sell their products for less. Smart Money magazine recently shopped for Lipitor and found that, on average, online pharmacies charged $50 for 30 10-mg tablets. Full-price, bricks-and-mortar pharmacies charged $65 on average; discount pharmacies, $61. Online pharmacies also had the lowest prices for two other popular drugs, Claritin and amoxicillin. Considering that some sites ship for free, the bargains are truly tantalizing for those who pay for their own medications.

Other advantages of Web drugstores include:

• Round-the-clock ordering capacity in the privacy of one's home. "Who wants to be in line talking to a pharmacist about erectile dysfunction?" asks physician and medical informatics consultant Ross Martin in Brookline, MA.

• Automatic e-mail reminders for refills. "If you're elderly or ill, it may be hard to keep track of multiple medicines," says Debby Wilson, a spokesperson for Bellevue, WA-based drugstore.com.

• Increased autonomy for patients. Typically, patients can inspect their personal prescription records online, or research their disease or medication at the site, gleaning information that doctors may have been too busy to provide.

Will Web drugstores make more work for doctors?

These advantages notwithstanding, online pharmacies have to overcome significant obstacles if they want to broaden their appeal among patients, much less survive financially. Indeed, one Internet prognosticator estimates that online prescription sales won't even top 1 percent of the total market in the year 2003.

One glaring weakness is the inability to provide patients with acute care drugs as soon as they're needed. "If your kid is crying because he has an ear infection, you don't want to wait several days for a supply of amoxicillin," says Allen Wenner.

Web drugstores are trying to solve this speed problem. Rx.com has begun experimenting with free same-day deliveries in its headquarters city of Austin. "We may implement this in other cities, depending on patient demand," says the company's Rachel Lee.

A more radical solution is partnering with bricks-and-mortar competitors. A pioneer e-pharmacy called Soma.com sold out last year to drugstore-chain giant CVS, allowing patients to pick up Internet-initiated prescriptions at any of CVS' 4,200 stores. Three other online pharmacies—drugstore.com, familymeds.com, and HealthCentralRx.com (formerly ePills)—have aligned themselves with drugstore chains and networks so they can offer a pickup option.

These kinds of strategic moves also may help solve another problem limiting the growth of e-pharmacies: the reluctance of insurers to embrace the idea. Self-paying patients accounted for only 20 percent of all retail pharmacy prescription sales in the fourth quarter of 1999, according to pharmaceutical research firm IMS Health in Plymouth Meeting, PA. In contrast, third-party payers other than Medicaid accounted for 69 percent of sales. "Online pharmacies must have payer relationships if they want to thrive," says James Kumpel, vice president of health care research at brokerage firm Raymond James & Associates in St. Petersburg, FL.

Some of the traditional drugstores affiliating with e-pharmacies are married in various ways to pharmacy benefit management companies, the firms that administer prescription benefits for insurers and self-insured employers. E-pharmacies also are directly partnering with PBMs. So one way or the other, they stand to get a foot in the third-party-payment door.

A local presence for Web drugstores may quell doctors' fears that patients will be poorly served by invisible pharmacists at the other end of a modem connection. "When you buy your meds online, it's like booking a vacation without a travel agent," says FP Neal Mack in Newburgh, IN. "Patients usually don't know much about pharmacology, so a friendly neighborhood pharmacist can be a lifesaver. And local pharmacies don't hesitate to call physicians with questions about illegible scripts or borderline dosages. Online pharmacies are less likely to do so."

Those online pharmacies that do play by the rules might try so hard to get things right that they make nuisances of themselves. Ophthalmologist Charles Aronberg in Beverly Hills, CA, says he usually receives follow-up calls from Web drugstores when they process new prescriptions. "They pretty much review every element—dosage, the number of pills, the number of refills," says Aronberg. "I'm glad they're careful, but it takes a fair amount of office time to deal with them. Regular drugstores are different. Ninety percent of the time, they don't call me about new prescriptions."

Rx.com's policy is to call the doctor whenever the company receives a written prescription, faxed or original. But Rachel Lee promises that follow-up calls will lessen with the natural evolution of the company's customer base to patients who primarily need refills, as opposed to those presenting new prescriptions.

Other physician gripes about online pharmacies also center on time encroachments. Allen Wenner complains that a doctor who faxes a prescription directly to PlanetRx.com must attach a copy of his letterhead. "That's twice the trouble," he says. Gastroenterologist Joel Brill in Camarillo, CA, says that when he returns a phone call from drugstore.com about a refill, he'll often get an answering machine. "Why can't they do this via e-mail?" Brill asks.

Electronically transmitted prescriptions could boost e-pharmacies

Hassles involving telephone calls and pieces of paper point to a weakness of online pharmacies: By and large, they're not set up to receive prescriptions from doctors electronically. As Allen Wenner puts it, "They haven't given me tools to use their services."

But they're making a start. PlanetRx.com and CVS.com, for example, have teamed up with Hillsboro, OR-based MedicaLogic, which provides doctors with software for electronic medical records, including a Web-based version. The arrangement will allow doctors using MedicaLogic software to transmit prescriptions to the two Web drugstores via the Internet.

Similarly, online pharmacies are cultivating relationships with makers of wireless, handheld prescribing devices. Allscripts and ePhysician machines, for instance, can zap prescriptions straight to PlanetRx.com. PocketScript machines can digitally talk to Rx.com.

The number of states allowing electronically transmitted prescriptions has been increasing in recent years—a trend that's bound to continue, especially in light of the highly publicized Institute of Medicine report on medical errors. According to the IOM, the US health care system could save many lives by relying on computer technology that would eliminate such problems as hard-to-read handwritten medical records. Rx.com's Rachel Lee, for one, says the IOM report will spur greater regulatory acceptance of e-prescriptions. "It's widely known this is the way to cut down on medical errors," she notes.

Currently, 32 states explicitly sanction electronically transmitted prescriptions from a doctor to an in-state pharmacy, while 10 states and the District of Columbia forbid it. The rest take stands in between or don't address the issue. When a doctor wants to send a prescription to an out-of-state pharmacy, states are less accommodating—26 say Yea; 12, plus DC, say Nay.

Prescriptions coursing along the Internet may someday become commonplace, but doctors won't be sending them exclusively to the likes of Rx.com. Traditional drugstore chains such as Walgreens and Phar-Mor have opened their own Web sites, and any mom-and-pop competitor can do likewise. In addition, PBM giant Merck-Medco is converting much of its mail-order business to the Internet, providing Web start-ups with a formidable competitor.

In effect, traditional pharmacies and PBMs are copying e-pharmacies—while the e-pharmacies, in their efforts to rush drugs to customers, increasingly resemble their rivals. Meanwhile, analysts such as James Kumpel wonder whether "pure" online pharmacies—which have no physical retail presence—will ever evolve beyond a niche role of providing discount maintenance medications.

Most important to doctors, though, is that as electronic connectivity spreads in health care, expressions such as "online pharmacy" will be less and less relevant. When everybody's online—patients, doctors, drugstores—you simply do as the Romans do: You press the "send" button.

Dubious Web prescription sites are feeling the heat

Picture this: A 50-year-old male patient asks you to prescribe Viagra. But he's already taking a vasodilator to treat his angina, and combining that drug with Viagra is potentially deadly. So you decline.

Your patient is hot to trot, however. Ignoring your warning about the bad drug interaction, he visits a Web site that sells Viagra, lies about his heart condition on a questionnaire, and the next evening swallows the love pill.

This is just one scenario that can play out in the world of Internet prescription drug sales, where quick bucks often come before patient well-being. The federal government is beginning to crack down on unsafe practices, and the pharmacy industry is trying to help consumers distinguish legitimate cyber-drugstores from their rogue counterparts.

Web sites selling medications fall into three categories: Those that sell drugs to whoever asks, those that both prescribe and disperse the drugs on the basis of an online questionnaire, and those that fill prescriptions only from the patient's regular doctor. The first two categories worry government officials and medical authorities the most, of course, because they allow patients to sidestep the safeguards built into the prescribing process. Also, many of these sites are located outside the US. The National Association of Boards of Pharmacy, which represents state pharmacy boards, estimates that close to 200 sites sell to anyone; the number of sites that prescribe on the basis of a questionnaire is much higher.

Many of the prescribing sites don't resemble pharmacies as much as they do pit stops for aging men who want a chemical fix for impotence, baldness, flab, and arthritic knees. Invariably, these sites say a doctor will evaluate a user's completed online questionnaire—sometimes for a fee—and decide whether a prescription is warranted. But how can patients know a college student isn't rubber-stamping their request?

The uncertainties don't stop there. Are patients getting the correct dosage? Is the drug pure? Is it a counterfeit from a foreign company? And who's going to monitor the patient for possible side effects?

"There is no substitute for examining the patient," says Beverly Hills, CA, ophthalmologist Charles Aronberg, who testified last November in favor of California legislation that would more tightly regulate online pharmacies. Prescribing sites also have alarmed the AMA. Last year, it decreed that doctors who write scripts without examining patients are practicing substandard medicine.

AMA pronouncements may not clean up the Internet prescribing scene, but the heavy club of the federal government might. The Food and Drug Administration has been busy hauling illegal Web drugstores into court and firing off warning letters to dozens of others. The Clinton administration recently proposed giving the FDA more money and legal authority to step up these efforts. The proposal also would require e-pharmacies to prove to the FDA that they comply with state and federal law before they're allowed to operate. Anyone who sells a medication without a valid prescription would face a $500,000 fine.

Meanwhile, the National Association of Boards of Pharmacy has created a seal of approval for Web pharmacies. The so-called VIPPS—Verified Internet Pharmacy Practice Sites—seal is awarded to companies that are properly licensed, employ bona fide pharmacists, and satisfy other NABP requirements. As of May 2000, five online pharmacies—CVS.com, familymeds.com, merck-medco.com, drugstore.com, and PlanetRx.com—displayed the VIPPS seal.

Robert Lowes. Are online pharmacies good for your patients--and for you?. Medical Economics 2000;11:77.