Pharmacies ... offices and pharmacies to resolve issues ..

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• Highlights of CAQH-MedStar-DrFirst-Safeway
• Electronic Prescribing Pilot
• November 2004

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Sponsors

• CAQH
• Not-for-profit alliance of health plans and
  networks that promotes collaborative initiatives
  to
• Share knowledge to improve quality of care
• Make administration easier for physicians and
  their patients
• Participating companies include 22 of Americas
  largest health plans and trade associations
  chairman is John W. Rowe, MD, who is Chairman and
  CEO of Aetna
• MedStar Health
• Not-for-profit, community-based healthcare
  organization that owns and operates seven major
  hospitals and other healthcare services in the
  Baltimore/Washington area the hospitals include
  both teaching and community facilities

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Sponsors

• DrFirst
• DrFirsts Rcopia system is a leading electronic
  prescription management solution that was awarded
  Top Honors by the Medical Records Institute at
  TEPR 2004
• DrFirsts clients include health plans, health
  systems, hospitals, IPAs, EMR/POMIS vendors, and
  individual physician practice groups
• Safeway
• Operates 1,815 stores with over 1,300 pharmacies
  across the United States and in Western Canada
  eastern division operates 178 stores, including
  124 pharmacies, in the metropolitan areas of
  Washington, Baltimore and Philadelphia

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Pilot Parameters

• Offered a 12-month free Rcopia subscription to
  MedStar providers
• Participants provided their own hardware, with
  the software being available for either desk-top,
  web-based or hand-held technology
• In addition to a free subscription, participants
  received free on-site training and on-going
  assistance additional incentives were not
  offered
• Key functionality of Rcopia e-prescribing
  technology included
• Clinical data (e.g., drug-to-drug interactions)
  sourced by First Data Bank
• Option of entering patients allergies and
  receiving warnings
• Option of checking patients formulary coverage
  (where available)
• Ability to send prescriptions electronically or
  via Fax to the pharmacy, and ability to print or
  save prescriptions (could go to any chain or
  independent pharmacy)
• Sponsors agreed to jointly review outcomes data
  and agree on key findings (data was analyzed in
  Summer 2004)
• Outcomes data was generated from Rcopia system as
  well as through pre and post pilot participant
  surveys, phone interviews with providers/office
  managers and anecdotal feedback Rcopia staff
  received during participant training/assistance
  
• All provider and patient-specific data was
  blinded

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Provider Interest

• Provider interest
• 200 free, one-year subscriptions to e-prescribing
  tools were offered to 1,000 MedStar affiliated
  providers with no required renewal
• 60 of available subscriptions were utilized by
  registered participants of these registered
  participants, 75 were active participants,
  who were defined as participants who sent at
  least 100 scripts
• Registered participants gave the following
  reasons for low provider participation
• Time constraints
• Conflicting priorities
• Non-reimbursable/lack of incentive for a time
  consuming activity
• Existing ability to use the already tested,
  traditional handwritten system

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Volumes and Interactions

• Volume of prescriptions
• Participants generated 126,758 prescriptions
• Active participants generated an average of
  1,424 prescriptions over the 12 month period
  number of scripts sent were not more than in
  traditional system
• The active participants became comfortable with
  the system over time, reverting to the
  handwritten method less frequently average
  number of prescriptions written per active
  participant increased by 30 between the 1st
  quarter and the 4th quarter of the pilot (no
  increase in overall of scripts)
• Internal Medicine participants, who represented
  27 of the total registered participants,
  generated 54 of the total pilot prescriptions
• Clinical interactions
• 2 of the pilot prescriptions had an allergy
  warning 6 of these warnings were acted
  upon/cancelled
• 8 of the pilot prescriptions had a drug
  interaction warning 3 were acted upon/cancelled
• The pilot potentially avoided over 400 adverse
  reactions
• The high percentage of warnings ignored is common
  and can be attributed to several explanations
  such as lack of clinical significance as
  determined by the prescriber

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Formulary Use

• Provider interest and use of formulary
• 75 of the registered participants opted to have
  formulary enabled. The key reasons participants
  gave for not wanting formulary enabled were
• Formulary is not the responsibility of the
  provider
• Did not want the extra responsibility/activity
• Did not want to have to do any manual entry
  (manual data entry of patient drug histories was
  required in some cases)
• 22 of enabled users actually referenced
  formulary. The key reasons for the low usage rate
  were
• Time needed for manual entry
• Gaps in payer coverage, e.g. MAMSI did not
  participate
• Time constraints /other priorities
• Lack of know-how
• Lack of interest

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Formulary Impact

• Impact of non-formulary warnings
• 22 of the formulary references generated a
  non-formulary warning (507 warnings in total)
  participants acted upon 25 of these warnings
• 15 of warnings resulted in a change of drug
• 9 of warnings resulted in a cancellation of a
  drug
• Between 1st and 4th quarters there was a 20
  increase in providers changing a drug vs.
  ignoring or canceling it after receiving a
  non-formulary warning

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Pharmacy Connection

• Pharmacy connection
• 62 of the prescriptions were sent to the
  pharmacy (9 of these were also printed), 27
  were only printed and 11 were only saved
• Saved prescriptions were a way in which
  prescribers could add to a patients medication
  history
• Of the 62 of the prescriptions sent to the
  pharmacy, 40 were sent electronically and 60
  were sent by fax
• There was a 270 increase in electronic
  prescriptions when comparing 1st to 4th quarter
  data. This was largely attributable to increased
  market activity by SureScripts and others
  responsible for developing electronic connections
  to pharmacies however, pharmacies reported that
  the existence of the pilot provided incentive for
  them to adopt the technology
• Two national chains represented the majority of
  pharmacies receiving electronic prescriptions
  while a mix of independent and national chains
  received the faxes

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Work Flow Impact

• Impact on work flow
• Provider offices
• Reduced calls from pharmacies for clarification
  of prescriptions
• Increase in number of legible prescriptions
• Fewer benefit coverage issues
• Reduced staff requests for provider assistance in
  locating medication lists
• DrFirsts Rcopia system can save and print out
  patient medication lists that are legible and
  easy to find
• Pharmacies
• Significantly reduced time needed to read
  prescriptions due to legibility of
  computer-generated faxes or electronic
  prescriptions
• Minimally reduced calls to resolve benefit
  coverage issues because of the availability of
  formulary information

Based upon qualitative survey of pilot
participants Based upon interviews of Safeway
pharmacists
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Benefits

• Clinical
• Pilot supports concept that e-prescribing
  positively impacts patient safety by reducing
• Drug errors that occur due to illegible
  handwriting
• Potential adverse reactions
• Administrative burdens, so providers can focus on
  patient care
• Financial Indirect
• Reduced call volume between provider offices and
  pharmacies to resolve issues
• Pilot providers reluctant to quantify this into
  actual savings given size of pilot
• Improved access to medication lists for provider
  office staff
• Pilot providers reluctant to quantify this into
  actual savings given size of pilot

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Benefits (contd)

• Financial Direct
• Members Copays
• Reduced co-pays occurred because of adherence to
  formulary warnings
• Savings increase as adherence increases
• Reduction in initial prescription co-pays
  estimated at 2,500
• Potential of 30,400 saved annually if
  on-formulary drug continued to be used monthly
• Health plans Reduced hospitalization and
  increased formulary adherence
• Reduction in hospitalizations/ER visits estimated
  at 100,000 saved identified savings occurred
  through reduction in hospitalizations/ER visits
  as a result of Rcopia communicating potential
  adverse drug reactions
• Evaluated impact on health plan drug costs due to
  formulary switches, however, numbers are very
  small given size of pilot and low use of
  formulary
• One plan noted a 35 net savings in health plan
  drug costs when a formulary warning is given,
  with an average savings of 29.21 per
  prescription for the initial prescription
• Providers (see indirect benefits)
• Applying the estimated benefits from the pilot to
  industry-wide adoption would correlate into
  enormous clinical and financial benefits for the
  US heath system

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Industry-wide Implications

• Comparison to other pilots
• When compared to other recently published pilot
  findings, the total direct savings from this
  pilot were lower, however, the pilot sponsors
  believe this pilot is more representative of
  actual market challenges than previously
  conducted studies as it represents a real-world
  setting
• Sponsors consisted of organizations with no
  history of working together on information
  technology and were located in a region not known
  for market interest in adopting new healthcare
  technology
• Participants had no level of association
  to/vested interest in working with a specific
  health plan(s) and/or Pharmacy Benefit Manager
  (PBM)
• Providers were given the software and training
  free of charge, but no additional incentives were
  offered

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Industry-wide Implications (contd)

• Requirements to achieve industry-wide adoption
• Gain a multi-stakeholder focus on the same set of
  goals
• Different participants are at different points in
  the e-prescribing life cycle for success, each
  stakeholder needs to agree on the goals upfront,
  understand their unique role and the activities
  they will need to undertake to achieve those
  goals
• Resolve the technical barriers
• Develop the required infrastructure, e.g.
  pharmacy connection, automated coverage
  information
• Pre-populate medical and drug histories into
  e-prescribing tools
• Agree and adopt basic standards for technical and
  outcome measures
• Conduct large scale, multi-stakeholder studies to
  analyze, test and review outcomes, focusing on
  gaining agreement on
• Financial and clinical benefits
• Provider incentive models

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Contacts

• For detailed pilot findings, please contact any
  of the sponsors
• CAQH
• Gwendolyn Lohse (glohse_at_caqh.org or 202-778-1142)
  
• MedStar Health
• Peter Basch, MD (peter.basch_at_medstar.net or
  202-546-4504 x316)
• DrFirst
• John Bartos (jbartos_at_drfirst.com or 301-231-9510
  x109)
• Safeway
• David King (david.king_at_safeway.com or
  713-268-3440)