Electronic Prescribing

1
Electronic Prescribing

• What the Doctor Ordered
• Patricia L. Hale, MD, PhD, FACP
• CMIO, Glens Falls Hospital
• phale_at_glensfallshosp.org

2
e-Prescribing -What the Doctor Ordered

• Current state
• Improvements in patient safety
• Drivers and barriers
• National initiatives

3
What problems do eRx address?
4
(No Transcript)
5
The Challenge

• Physicians write
• 4.5 billion prescriptions
• each year. . . .

• On Paper

6
Increased Need for Access to Constantly Changing
Information

• 40,000 Medline citations added monthly
• 1-2 new drugs approved on average each week
• Rapidly increasing number of diagnostic tests

• A physician who reads all day long for 6 weeks
• will already be a century behind.
• (Criswell, JAIA 2002)

7
The Current System Causes aNumber of Serious
Problems
Rx

• Patient safety
• Between 1.5-4.0 prescriptions are in error with
  serious patient risk
• Adverse drug events occur in 5-18 of ambulatory
  patients
• Quality of care - Compliance
• 1.1 billion scripts are never filled
• Patient satisfaction is declining
• Cost of errors 2 billion / year
• Impact on productivity
• Physician practice 3 hours per day
• Pharmacy 4 hours per day (up to 1 call per Rx)
• Inefficient delivery

Rx

• Illegible handwriting
• Phone tag and fax tag
• Patient waiting in the pharmacy

8
Many resulting errors can be prevented

• More than 8.8 million adverse drug events (ADEs)
  occur each year in ambulatory care, of which over
  3 million are preventable1
• 1 out of 131 ambulatory patient deaths can be
  attributed to medication error2
• Many errors result from
• Miscommunication due to illegible handwriting
• Unclear abbreviations and dose designations
• Unclear telephone or verbal orders
• Ambiguous orders and fax-related problems

• Gurwitz, JAMA, 20033
• 25 of patients had ADEs
• 13 were serious
• 39 of total were either ameliorable or
  preventable
• Gandhi, NEJM, 20034
• 28 of ADEs preventable
• 42 of the most serious

1 Center for Information Technology Leadership.
The Value of Computerized Provider Order Entry in
Ambulatory Settings, 2003Institute of Medicine,
Committee on Quality in Healthcare in America. To
Err is Human Building a Safer Health System,
Washington, DC, National Academy Press
1999 2 Gurwitz JH et al. Incidence and
Preventability of Adverse Drug Events Among Older
Persons in the Ambulatory Setting, JAMA, 2003
289 1107-1116. 3 Gandhi TK et al. Adverse Drug
Events in Ambulatory Care, N Engl J Med, 2003
348 1556-64.
9
The number of prescriptions in the US is rapidly
increasing

• 823 million visits to physician offices in 20001
• 4 out of 5 patients who visit a physician leave
  with at least one prescription2
• 65 of the US population (91 of Medicare) use a
  prescription medication each year3
• Over 3 billion prescriptions are dispensed each
  year4
• The number is expected to rise to 4 billion by
  20064

Unfilled
Refills
0.4 B
Renewals
0.5 B
1.5 B
1.4 B
New Scripts
3.5 Billion Total Filled Prescription
Transactions in 2003
1) Pastor PN et. al. Chartbook on trends in the
health of Americans. Health, United States, 2002.
National Center for Health Statistics.
2002. 2) The chain pharmacy industry profile.
National Association of Chain Drug Stores.
2001. 3) Agency for Healthcare Research and
Quality. MEPS Highlights 11 distribution of
health care expenses, 1999. 4) NACDS estimates
10
Rx-Related Call Volume at 20 MD Clinic

• 370 calls / day
• 206 (56) related to Rx
• Chart retrievals
• 50 of Rx calls
• add 9-33 min
• Rx messaging FTEs
• Phone - nurse 28 hr/d MD 6 hr/d

Data courtesy of McKesson (Abaton) and Medco
11
The efficiency of the total prescription system
is challenged by hundreds of millions of phone
calls and faxes

• One study estimates that indecipherable or
  unclear prescriptions result in more than 150
  million calls from pharmacists to physicians
  asking for clarification1
• Others estimate the number of prescription-related
  telephone calls annually at 900 million, citing
  practices reporting almost 30 of prescriptions
  required pharmacy callbacks2,3
• Requesting and receiving approval for refills
  alone, estimated at nearly 500 million per year,
  adds to the telephone and fax burdons4

(1) Institute for Safe Medicine Practices. A Call
to Action Eliminate Handwritten Prescriptions
Within Three Years, 2000. (2) Forrester Research,
2002. (3) Medco Health, 1/29/03, via
ePharmaceuticals (4) NACDS and SureScripts
estimates
12
Frequency of Incomplete Medication Histories

• 304 patients admitted to general internal
  medicine
• Mean age 71 yrs
• Compare meds in chart with pharmacy records
• Resolve discrepancies via patient interview
• Admission records included 1196 drugs
• Additional 518 in pharmacy records (410 in active
  use)
• 61 of patients with at least one drug missing
• 33 with two or more

Lau, H.S., et al., The completeness of medication
histories in hospital medical records of patients
admitted to general internal medicine wards. Br J
Clin Pharmacol, 2000. 49 597-603.
13
What is the Process of eRx?
14
Electronic Prescribing (eRx) Definition

• All systems that use a computer to enter, modify,
  review, and communicate drug prescriptions.

www.ehealthinitiative.org/initiatives/erx
15
Stages of e-Prescribing
16
PRESCRIBING EQUIPMENT OPTIONS
ASPPDA or any Internet browser
Client/server PDA
OUTPUT
Local printing
Fax/electronic to brick or mail-order pharmacy
17
60 eRx Function Recommendations (RAND)
Number of Recommendations
Category

• Patient identification 4
• Access to patient historical data 8
• Medication selection 14
• Alerts and other messages 12
• Patient education 2
• Data transmission and storage 7
• Monitoring and renewals 5
• Transparency and accountability 2
• Prescriber-level feedback 2
• Security and confidentiality 4

Bell, DS. A conceptual framework for evaluating
eRx systems. JAMIA, 2004.1160-70.
http//www.rand.org/health/healthpubs/bell_supp_ex
.pdf
18
Role of Surescripts and RxHub
19
How electronic connectivity to the Payors and
PBMs works
Medco Health Express Scripts AdvancePCS

• As the physician writes the prescription, the
  e-Prescribing application connects with RxHub to
  determine whether the patient is eligible for a
  particular payor
• At that time, the patients up-to-date formulary
  and medication history is brought to the provider
  at the point-of-care
• The physician has the choice to prescribe the
  same drug or choose a drug on the patients
  formulary
• Ability to send scripts to the mail order
  pharmacies operated by the PBMs

20
How electronic connectivity to the retail
pharmacies works

• Once the prescription is finalized, the physician
  can route it to the patients pharmacy of choice
• If the pharmacy is online, the SureScripts
  Messenger Services is the network through which
  the prescriptions are routed
• The prescription is sent to the pharmacys
  computers, and renewal requests are sent from the
  pharmacys computer to the provider
• SureScripts provides two-way electronic
  connectivity to 75 (online or in process) of
  pharmacies for the transmission of new
  prescriptions, refill authorizations and denials
  and change requests

21
RxHub Partners
eRx / EMR Vendors/ Hospitals

• Allscripts
• A4
• Barnes
• Bond Medical
• Cardtronic
• Cerner
• DrFirst.com
• HealthRamp
• HEALTHvision
• InstantDX
• iScribe
• McKesson
• MDanywhere

• MedPlus
• MedPort
• MobiHealth
• NextGen
• Phytel
• Quest
• ReCare
• Relay Health
• RxNT
• RxRite
• SafeMed
• ScriptRx
• WebMD
• Wellinx
• ZixCorp

PBMs / Health Plans

• Caremark/APCS
• Express Scripts
• Medco Health Solutions
• PCN
• CAQH

In production
22
SureScripts Partners

• Electronic Medical Record (EMR) Solutions
• A4 Health Systems
• Allscripts -
• Bond Medical
• ChartConnect
• iMedica
• MediNotes
• McKesson
• MedicWare
• Medplexus -
• NewCrop
• Physician Micro Systems
• Spring Medical
• Synamed

• Electronic Prescribing Solutions
• DrFirst
• Gold Standard Multimedia -
• HealthRamp -
• InstantDx
• MDanywhere Technologies
• Zix Corporation
• Other Services
• Axolotl
• Cleveland Clinic -
• HEALTHvision
• Lighthouse
• Medplus
• ScriptRx
• UNC Health System -

23
The SureScripts Regulatory Assessment
Intervention Process has cleared the way for
SureScripts and its partners in 35 states
As of November 10, 2004
24
SureScripts is engaged with many organizations
across the country on electronic prescribing
initiatives
25
What does eRx Software Look Like?
26
Optimal eRx Design
27
Workflow

• Improve current workflowAddress convenience
  factors
• Support multiple models of prescribing (e.g. some
  written by staff)
• Improve processes such as refills, remote access,
  reduction in pharmacy call-backs
• Provide better information including simple and
  advanced clinical decision support
• Easy to install, learn and use
• Limit start-up time and decrease in productivity

28
Safety

• Support safe and optimal care
• Compliance with quality criteria
• Support drug treatment protocols
• Ability to load past medications
• Allow shared medication lists
• Include standard and advanced clinical decision
  support
• Enhance chronic disease management

29
Connectivity

• Unfettered patient/doctor choice of pharmacy
• Accessible wherever Rx writing is needed
• Improved and more reliable transmission to
  pharmacies (brick or mail-order)
• Enhance workflow
• Filler can send request for renewal order
• Reduced transcription errors
• Reduced callbacks
• Improve admission and discharge process by
  communication with inpatient CPOE systems

30
Where are we Today?

• Current Adoption

31
Increased Physician Use of Mobile Technology

• Approximately 40 of U.S. doctors use PDAs
• (Forrester Research 2003)
• -- An increase of 50 since 2001
• This is projected to have grown to gt50 by
  end of 2004
• and gt75 by 2007 (Gartner Research 2002)
• Physicians reported that use of PDA-based
  applications prevented an average of 2
  adverse drug events
• (Bates, JAMIA 2001)

32
How Physicians Are Using PDAs
MDs Using the Function

• Source Health Information and Management Systems
  Society, 2002

33
Physician Adoption of eRx Has Remained Low

• Adoption of electronic prescribing remains low
  year-to-year with only 9 of physicians using
  the systems and only 2-3 of prescriptions
  transferred electronically to pharmacies
• Among adopters, less than 20 are writing more
  than 15 electronic prescriptions per month
• 50 of early adopters stopped using eRx systems
• 64 of physicians say financial incentives from
  payers could act as a driver of future use

34
Benefits of eRx
35
National Cost Savings to Providers and Other
Healthcare Stakeholders
In US Millions
Source CITL
36
Potential Benefits of eRx

• Patients
• Increased safety, efficiency and compliance
• Lower co-pays
• Pharmacies
• Increased efficiency
• Payors/PBMs
• Increased generic/formulary usage, efficiency, Rx
  compliance and prevention of ADEs (reduced costs)
• Providers
• Increased efficiency, improved care, and
  incentives (pay-for-performance)
• Pharma?
• improved compliance balanced by more generic usage

37
Potential Savings from eRx
Savings from Preventable ADEs
906.8 Million Ambulatory Visits per Year
(includes emergency, urgent care, etc.)
823.5 Million Visits to Physicians Offices 2
Million ADEs could be prevented using IT
4.00 per member per year savings generated from
preventable ADEs Savings from Over/Underuse
of Medications 10 average rate of overused
medications which are medically unnecessary
35-70 per member per year Net Savings Generated
from Overuse and Underuse of
Medications Net Total Estimated Savings from
Electronic Prescribing 39-74
per member per year
38
Challenges and Barriers of eRx Adoption
39
ePrescribing Challenges

• Formularies
• Regional insurance formularies may make up much
  of practice but may not be available in eRx
  system
• Pharmacies
• Pharmacy connectivity is variable and training is
  required
• Integration
• Practice Management Systems may not provide
  interfaces
• Cost
• 1 Year costs of 600-1000/MD for software plus
  hardware costs and cost of work flow change

40
Providers are concerned about

• Cost of buying and installing a system
• Lack of reimbursement for costs and resources
• Increased time to use the system reduced
  productivity (initially)
• Time/RVU to review a warning
• Not considered standard of practice

41
Standards and Regulatory concerns

• Varied standards make system development
  difficult and expensive
• State prescription requirements
• Formulary conventions
• Drug dictionaries
• DEA restrictions
• Drug specification at the doctor-friendly level
  is lacking (RxNorm)
• Prescription specifications are not standardized
  (example sig)

42
Concerns About Increased Errors from Use of
Electronic Prescribing

• Study of more than 235,000 error reports
  submitted in 2003 by 570 health care facilities
• Computer entry" was the fourth-leading cause of
  errors, accounting for 13 (27,711) of the
  medication errors reported in 2003.
• Illegible or unclear handwriting was the
  15th-leading cause, and accounted for 2.9
  (6,134) of reported errors.
• Less than 13 of the participating facilities
  were outpatient centers
• Errors related to electronic prescribing are less
  likely to lead to patient harm
• only 0.1 led to patient harm while the
  percentage of patient harm associated with all
  errors was 1.51.

• U.S. Pharmacopeial Convention's fifth annual
  report on medication errors

43
Why are Things Better Now?
44
Why now? The problems of past prescribing
automation efforts have been addressed
45
Success Stories
46
Mass eRx Collaborative

• Launched in October 2003 by Blue Cross Blue
  Shield of Massachusetts (BCBSMA),Tufts Health
  Plan (THP), Zix Corporation(R) (ZixCorp) and
  Neighborhood Health Plan (NHP)
• initial goal of deploying e-prescribing in the
  offices of 3,400 Massachusetts physicians. As of
  Dec. 31, 2004, nearly 2,700 physicians plus their
  clinical staff have signed up to participate and
  more than 1,500 physicians had the technology
  incorporated into their practices.
• The average weekly e-prescriptions written during
  the last month of Q4 were more than 27,000, a 77
  percent increase during the same time frame of
  the previous quarter
• 35 percent of prescribers reported
• Patient care benefits due to the ability to check
  drug interactions and improved prescription
  accuracy
• Improvement in the efficiency of prescribing,
  saving physician's practices up to two hours a
  day.

47
CAQH and DrFirst 12 month eRx Initiative with
MedStar

• 34.4 of non-formulary prescriptions were
  modified to formulary products after a formulary
  warning (4th quarter)
• 4 of prescriptions were modified after drug
  interaction warnings
• 8.3 of prescriptions were modified after
  allergic reaction warnings
• 96 of prescriptions allowed generic substitution
• Providers were given the software and training
  free of charge, but no additional incentives were
  offered
• CAQH the Council for Affordable Quality
  Healthcare. MedStar Health is a not-for-profit,
  community-based healthcare organization in the
  Baltimore/Washington area.

48
CAQH and DrFirst 12 month eRx Initiative with
MedStar

• 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

49
CAQH and DrFirst 12 month eRx Initiative with
MedStar

• 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
• 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
50
CAQH and DrFirst 12 month ePrescribing
Initiative with MedStar

• Financial
• Direct
• Members - Reduction in co-pays due to change of
  drug because of adherence to formulary warnings
  estimated 2,500 saved
• Health plans - Reduction in hospitalizations/ER
  visits for potential adverse drug reactions
  estimated 100,000 saved
• Health plans Evaluated impact on health plan
  drug costs due to formulary switches, however,
  numbers are very small given size of pilot and
  use of formulary. One plan noted a 35 net
  savings in health plan drug costs when a
  formulary warning is given and then acted upon.
• Indirect
• Reduced call volume between provider offices and
  pharmacies to resolve issues
• Improved access to medication lists for provider
  office staff

51
What Initiatives and Incentives Will Drive Future
Adoption of eRx?
52
An Overview of Incentives

• Economic Incentives
• Grant and Loan Programs
• Reimbursement for Utilization
• Pay for Performance
• Malpractice Insurance Premium Reductions
• Healthcare IT Suppliers
• Pharmacies or Transaction Brokers Defray Costs
• Policy Incentives
• Accreditation
• Employer Programs Leapfrog and others
• Medicare support for economic incentives
• Mandates ???

53
2003 Medicare Bill - eRx Provisions

• Voluntary program
• Mandatory National eRx Standards for Medicare
• Initial standards 2005 Pilot program 2006, Final
  Standards 2009
• Recommendations delivered by NCVHS
• Information Requirements include
• Lower cost, therapeutically appropriate
  alternatives
• Interactive, real-time to the extent feasible
• Encourages Physician Adoption
• Permits use of appropriate messaging
• Eliminates anti-kickback regulation for hospital,
  physician groups and plan administrators to give
  out eRx hardware and training
• Allows plans to pay-for-technology and
  pay-for-cost effective performance in Medicare
  Advantage Plans
• 50MM of federal grant money in 2007
• Preempts State Laws contrary to the national
  standards or those that restrict the ability to
  carry out the new law.

54
NCVHS Goals for eRx

• Improve patient safety
• Improve quality of care
• Improve efficiency (including cost savings)
• Not present an undue administrative burden on
  prescribers and dispensers
• Be compatible with other standards
• Permit electronic exchange of drug labeling and
  drug listing information maintained by the Food
  and Drug Administration (FDA) and the National
  Library of Medicine (NLM)
• Include quality assurance measures and systems
• Permit patient designation of dispensing pharmacy
  
• Comply with HIPAA Privacy regulations
• Support interactive and real-time transactions

55
Pay for Performance

• Bridges to Excellence
• Physician Office Link
• NCQAs Physician Practice Connections
• Points for registry lt eRx lt EMR
• Integrated HealthCare Assoc (California)
• technology is so critical to (program) success
  (Williams)
• 20 of bonus tied to (data collection) tech
  investment
• CMS
• Five pilots (includes tracking technology)
• could account for 20-30 of what CMS pays
  providers
• McClellan, WSJ, 9/17/04

56
JCAHO 2005 Hospitals National Patient Safety
Goals
Goal Accurately and completely reconcile
medications across the continuum of
care

• During 2005, for full implementation by January
  2006, develop a process for obtaining and
  documenting a complete list of the patient's
  current medications upon the patient's admission

http//www.jcaho.org/accreditedorganizations/hosp
itals/npsg/05_npsg_hap.htm
57
The Future

• Increased Patient Involvement

58
Patient Participation

• Patient access to drug reference info
• Patient's personal medication record
• Review current medications
• Refill drugs on the Web or through other
  electronic means
• Receive alerts for renewals
• Connectivity to physician
• Renewal request form to doctor's office
• Home monitoring of drug levels
• Home reporting of side effects
• Controlled sharing of med list

59
Questions?
60
Key eRx References

• Center for Information Technology Leadership. The
  Value of Computerized Provider Order Entry in
  Ambulatory Settings, 2003Institute of Medicine,
  Committee on Quality in Healthcare in America. To
  Err is Human Building a Safer Health System,
  Washington, DC, National Academy Press 1999
• Gurwitz JH et al. Incidence and Preventability of
  Adverse Drug Events Among Older Persons in the
  Ambulatory Setting, JAMA, 2003 289 1107-1116.
• Gandhi TK et al. Adverse Drug Events in
  Ambulatory Care, N Engl J Med, 2003 348
  1556-64.
• Lau, H.S., et al., The completeness of medication
  histories in hospital medical records of patients
  admitted to general internal medicine wards. Br J
  Clin Pharmacol, 2000. 49 597-603.
• Bell, DS. A conceptual framework for evaluating
  eRx systems. JAMIA, 2004.1160-70.
  http//www.rand.org/health/healthpubs/bell_supp_ex
  .pdf
• Pub L No. 108-173. Social Security Act
  A71860D-4(e), MMA A7101(a)(2). Social Security
  Act A71852(j)(7), MMA A7102(b). MMA A7108.
• CMS Feb. 4, 2005 published proposed eRx rule
  http//www.gpoaccess.gov/fr/index.html (do search
  on e-prescribing)
• The Decade of Health Information Technology
  report.Available at www.hhs.gov/onchit/framewo
  rk .
• Hearing on Electronic Prescribing. Available at
  http//waysandmeans. house.gov/hearings.asp?f
  ormmodedetailhearing167com1
• Electronic Prescribing vendor survey at
  PhysiciansEHR.com http//www.physiciansehr.com/
  cms/content/view/97/43/
• Electronic Prescribing Toward Maximum Value and
  Rapid Adoption - http//www.ehealthinitiative.org/
  initiatives/erx /
• Center for IT Leadership (CITL)
  http//www.citl.org/research/ACPOE.htm
• Sarah Corley MD - Electronic Prescribing A
  Review of Costs and Benefits Top Health Inform
  Manage Vol.24, No.1, pp. 29-38