ePrescribing Current Issues and the road ahead

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e-PrescribingCurrent Issues and the road ahead

• Patricia L. Hale, MD, PhD, FACP
• CMIO, Glens Falls Hospital and CTO , Adirondack
  Regional Community Health Information Exchange
  pathale_at_pathalemd.com
• www.pathalemd.com

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E-Prescribing Current Issues and the Road Ahead

• Learning Objectives
• Impact of e-prescribing on patient safety and
  reduction of medication errors
• Whats new
• Explore the training requirements for physicians
• Explore the implementation differences between a
  small medical practice and an RHIN

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A Public Health Crisis
7,000 Americans Die Annually From Preventable
Medication Errors
1.5 Million Americans Injured Annually by
Preventable Medication Errors
Source The Institute of Medicine of the National
Academies of Science (IOM).2006 Slide used by
permission from SureScripts
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The Challenge

• The Challenge of Prescription Hand-offs
• Illegible Handwriting
• Unclear Abbreviations and Doses
• Verbal Communication Among
• Physicians, Patients and Pharmacists

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

• On Paper!

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The Technology is Available TodayBut Not Used

• Over 4.5 Billion Prescriptions Written Annually
• Less than 1 in 5 of Physicians Use e-Prescribing
• Only 20 of prescriptions are prescribed
  electronically with 80 still handwritten
• Most electronic prescriptions are still sent by
  FAX

National savings from universal adoption
of electronic prescribing systems could be as
high as 27 billion
Sources eHealth Initiative, 2004 and Center
for Information Technology Leadership, The Value
of Computerized Provider Order Entry in
Ambulatory Settings, 2003.
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The Current System Causes a Number 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
• 20 of 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

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The number of prescriptions in the US is rapidly
increasing
Unfilled

• 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

0.4 B
Renewals
0.5 B
1.5 B
Refills
1.4 B
New Scripts
3.5 Billion Total Filled Prescription
Transactions in 2003 increased to 4.5 in 2006
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.
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Electronic prescribing is under-utilized
Purchasing software does not equal adoption or
effective use
Rx InterOp
150,000 Certified EMR Users
Large is defined as gt 20 physician FTEs in one
study with 39 adoption and gt50 in two another
studies with 47 and 57 adoption respectively.

• Certified version typically a simple upgrade away
• Extremely low awareness among install base

Sources Jha et al, Health Affairs, 10/11/06
MGMA, 2005 CDC/NCHS Natl Ambulatory Medical
Care Survey, 2005 HSC Community Tracking Study,
2006 Forrester, 2003 SureScripts estimates,
2006. Slide used by permission from SureScripts
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Full e-Prescribing includes

• Ability to create a prescription electronically
• Ability to receive automated decision support
  during script creation
• Medication lists and information
• Eligibility determination
• Formulary coverage from insurer including co-pay
  information
• Prior authorization
• clinical decision support including Drug
  interactions, drug-allergy, etc.
• Ability to send script electronically to pharmacy
  using standard transmission messaging (NCPDP
  SCRIPT, ASC12)
• Ability to receive/authorize pharmacy
  initiated-renewals electronically
• Ability to determine fill status as a measure
  of compliance (medication history)
• Ability for pharmacy to process electronic script
  in their system

Slide used by permission from SureScripts
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Intermediaries for Data Transfer
Pharmacy and PBM eRx Software
Prescriber eRx Software
ProxyMed and others
SureScripts Provides New Rx, refills, renewals,
authorizations, change Rx, Prescription history
from pharmacies
Medimedia and others
RxHub Provides Eligibility, Formularies,
medication claims histories
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Impact of e-prescribing on time spent
(minutes/day) on refills/renewals
Minutes per day
Prescribers
Office staff
(2006 Study Brown University)
Slide used by permission from SureScripts
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Impact of E-Prescribing on Preventable Adverse
Drug Events (ADEs)
Pen
Print?6
Fax?37
EDI Decision Support ?61
Source CITL
Slide used by permission from SureScripts
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Connectivity Roadmap Using computer technology
to improve patient care
Evidence-Based Medicine
National Disease Databases
16-40
lt5
National Health Information Infrastructure
Regional Health Information Networks
Electronic Medical Records Systems
7-20
40-80
Electronic Prescribing
Patient Physicians Access Medical Websites
Increased Decision Support

• Algorithm-driven medicine and decision making

• Population-based outcomes and cost information
  readily available to consumers, physicians, payers

• Streamlined information retrieval valuable for
  epidemiology

• Integrated database allow decision support tools

• Gains in accuracy and connectivity enhance safety
  and efficiency

• Better informed consumers

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Who Benefits from eRx?
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Potential Benefits of eRx

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

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But Providers are concerned about

• Cost of buying, installing, implementing and
  supporting a system
• Lack of reimbursement for costs, time and
  resources
• Increased time to use the system reduced
  productivity (initially)
• Increased time required to review warnings,
  alerts and recommendations (long term)
• Still not considered a routine standard of
  practice

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Why now? The problems of past efforts have been
successfully addressed
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What Initiatives and Incentives Will Drive Future
Adoption of eRx?
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An Overview of Potential Incentives

• Economic Incentives
• Grant and Loan Programs
• Reimbursement for Utilization
• Pay for Performance
• Malpractice Insurance Premium Reductions
• Healthcare IT Suppliers group discounts, etc
• Pharmacies or Transaction Brokers Defray Costs
• Policy Incentives and Programs
• Accreditation (JCAHO 2005 Hospitals National
  Patient Safety Goals, others in development)
• Employer Programs (Leapfrog and others)
• Medicare support for economic incentives
• DOQ-IT
• CCHIT certification of inpatient and ambulatory
  EMRs
• Mandates ???

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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
• Modifies anti-kickback regulation for hospital,
  physician groups and plan administrators to allow
  them 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 (but must be
  budgeted)
• Preempts State Laws contrary to the national
  standards or those that restrict the ability to
  carry out the new law.

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Regulations (CMS/MMA) ePrescribing

• Progress-to-date
• Issued Notice of Proposed Rule-Making (10/05)
• Issued final rule naming foundation standards
  (11/05)
• Pilot programs competed and reports submitted
  (2/06)

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Whats New?
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Interim Results From CMS e-Prescribing Pilots
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e-Prescribing Pilot Participants

• RAND New Jersey BCBS NJ, Caremark mail order,
  Walgreen retail pharmacy
• Brigham Womens Hospital - CareGroup Health
  system in Boston use in EMR and e-prescribing
  Gateway utility
• Achieve tech vendor for long term care industry
  in Midwest with its own pharmacies
• Ohio University Hospital Health System and Ohio
  KePRO QIO - 300 hospital physician practices
• Surescripts - with practices in Florida, Mass,
  Nevada, New Jersey and Tennessee with a variety
  of software vendor systems and assortment of
  chain and independent pharmacies

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Interim Results

• Med History recommended to be included as ready
  for adoption. Main challenge is ensuring the
  data is collected and reconciled from a large
  number of sources to be sure history is complete.
• Formulary and Benefits recommended to be
  included as ready for adoption. Issues
• Systems must adequately match patient to health
  plan
• Payers vary in the level of information provided
  making data difficult to interpret
• Should support real-time changes in patient
  status as patient moves between benefit plans

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Interim Results

• Prescription Fill Status Notification
  recommended to be included as ready for adoption.
  However many pharmacies do not currently have
  the ability to track patient pick-up status
  accurately and questionable prescriber demand for
  this if the info is already available in the med
  history.
• Prior Authorization NOT recommended for
  implementation Limited experience at pilot
  sites to evaluate this function and there are
  work flow and other issues which suggest a need
  to have more work done to improve the standard.
• Structured and Codified Sig - NOT recommended
  for implementation needs additional work with
  reference to field definitions and examples as
  well as naming conventions and clarification of
  field use.

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Interim Results

• RxNorm (standard for name, dose and form of
  drugs) Not recommended for implementation
  Dictionary standard requires further evaluation
  and refinement.
• Recommended updates to SCRIPT v8.1 Need to
  further refine the standard to be able to
• update prescriptions without having to create a
  new order,
• send a refill from the facility to the pharmacy
  without physician intervention,
• update patient information outside the context of
  prescriptions

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Interim Results

• Prescriber staff (surrogate prescribers) played
  a much more important role in the process than
  anticipated.
• Never fully replaces need for paper-based
  prescribing
• Causes a shift in pharmacy work flow
• Poor adoption and use of medication history
• Long term care site reported a reduction in new
  prescription rate which may indicate reduction in
  accumulation of multiple medication
• Not enough data yet on effects on safety or
  change in use of generic medications.

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New and expanded Programs to promote electronic
prescribing
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New Efforts to Increase eRx Adoption
The National ePrescribing Patient Safety
Initiative (NEPSI) A Coalition of the Nations
Most Prominent Technology Companies, Healthcare
Benefit And Medical Provider Organizations
Dedicated to improving patient safety by
providing free electronic prescribing for every
physician in America
Slide used by permission from NEPSI
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NEPSI Coalition Sponsors
National Sponsors
Technology Sponsors
Health Benefit Sponsors
Search Sponsor
Connectivity Sponsors
Slide used by permission from NEPSI
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eRx NOW -Advertised as Simple, Safe, Secure and
Free ePrescribing
The ATM of Healthcare??

• eRx NOW from Allscripts described as
• Simple Web-based E-prescribing Software
• Easy To Install and update
• Easy Interoperability
• Custom search engine from Google
• Formulary information available
• Safe
• Comprehensive Allergy and Drug Interaction
  Checking
• Secure
• Secure anytime, anywhere access
• Rigorous credentialing and authentication

www.nationaleRx.com
Slide used by permission from NEPSI
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Surescripts network
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Over 95 of the nations community pharmacies
have systems certified to connect to the Pharmacy
Health Information Exchange
Slide used by permission from SureScripts
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All major physician technology vendors in the
United States are certified on the Pharmacy
Health Information Exchange
Slide used by permission from SureScripts
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SureScripts Network Services
Pharmacy Health Information Exchange, operated
by SureScripts
Formulary
E-Prescribing
Eligibility
Rx History
E-Refills
Slide used by permission from SureScripts
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SureScripts Certification is Not Universal
Vendors are Certified by Service/Message Type
Slide used by permission from SureScripts
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Granting physician software and service
providers a uniform certification for pharmacy
interoperability is no longer adequate

• GoldRx certification status
• No longer based on just compliance to standards
• Identifies which vendors are not just testing and
  marketing interoperability but are truly
  delivering and committed to
• Customer Education
• Proven Pharmacy Interoperability
• Advanced Medication Management
• Workflow Enhancements Demonstrable Expert
  Experience with Electronic Prescribing Process

Slide used by permission from SureScripts
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Granting physician software and service
providers a uniform certification for pharmacy
interoperability is no longer adequate

• The first products to achieve GoldRx
  certification announced in Feb 2007
• TouchWorks EHR(Allscripts)
• ChartConnect EMR
• Rcopia (DrFirst)
• NextGen EMR
• eScript (RelayHealth)
• Pocketscript (Zix)

Slide used by permission from SureScripts
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Nations Community Pharmacies Announce Key
Indicator For Patient Safety In The U.S. The Top
10 States For Electronic Prescribing
Created by the National Association of Chain Drug
Stores, the National Community Pharmacists
Association and SureScripts
Last Year RI was 1, MA was 3, MI was 10, WA
and NJ not on last years list and  FL and VA were
in last years Top 10
Slide used by permission from SureScripts
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Certification by CCHIT

• Certification Commission for Health Information
  Technology (CCHIT)

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Ambulatory EMR CCHIT ePrescibing Criteria
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Medication History
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Medication History Current Options
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Example of Rx Claims History via RxHub
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(No Transcript)
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RxHub-connected eRx/EMR Vendors

• OA Systems
• Phytel
• Purkinje
• Relay Health RxNT
• SafeMed
• Script IQ
• ScriptRx
• Scriptsure
• Sequel Systems
• SSIMED
• STI Con
• Synamed
• Zix Corporation

• A4 Health
• Achieve
• Allscripts
• Athena Health
• Bond Medical
• Catalis Health
• Cerner
• DrFirst
• eClinical Works
• eHealth Solutions
• EmDeon/WebMD
• EPIC
• Gold Standard
• H2H Solutions
• Health Vision

• InstantDx
• iScribe
• MA Share
• McKesson
• MDAnywhere
• MdOffices
• Medical Info Sys
• MedicWare
• MedKeeper
• MedPlus
• Medport
• NewCrop
• NextGen

Bold in production
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ICERx.org

• Health care professionals can register for an
  ICERx.org account at www.ICERx.org or call
  1.888.ICERX.50 (888-423-7950).

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ICERx.org

• During periods of emergency, licensed health care
  professionals who have registered on ICERx.org
  can login to the online prescription database,
  where they will have access to
• Evacuee prescription history information and the
  name of the provider who wrote the prescription
  and the pharmacy that filled it
• Available patient clinical alerts, including drug
  interaction, therapeutic duplication and elderly
  alerts
• Clinical pharmacology drug reference information,
  including drug monographs, interaction reports
  and the drug identifier tool

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Evidence of increased adoption
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Paving the way for pharmacy connectivity Overco
ming legal and regulatory barriers
As of February 2nd, 2007 - 48 States and
Washington, D.C. cleared for electronic
prescribing
As of February 2nd, 2004 - 25 States cleared for
electronic prescribing
Slide used by permission from SureScripts
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Pharmacy Activation By State
Not shown HI 42 AL 24 As of November 9,
2006
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RxHub Adoption Data

• Access to more than 160 million patient
  prescription information records via payers and
  PBMs, through the growing list of RxHub certified
  technology partners. Direct contracts with
  payers and PBMs represent additional access to
  more than 50 million patients.
• An increase in transaction volumes of 50 from 29
  million transactions in 2005 to more than 43
  million transactions in 2006. These transactions
  were real-time requests for patient eligibility
  and benefits, formulary, and medication history
  information, made at the point-of-care in the
  ambulatory and acute care settings from
  clinicians across the United States.
• A ten-fold increase in true electronic
  prescriptions, which includes the transmission of
  patient-specific clinical decision support
  information at the point of prescribing, to
  retail and mail order pharmacy locations of the
  patients choice.

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Training requirements for physicians
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(No Transcript)
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Training Requirements for Physicians

• No two medical practices are alike evaluation
  of current processes is critical in determining
  best product and implementation plan
• Physicians learn by apprentice model be sure
  there is a physician champion
• Evaluate requirements for physician training
  early and plan schedules to accommodate decreased
  productivity
• Workflow is a critical factor in success

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Training Requirements for Physicians

• Staff roll in the prescribing process is a major
  influence on potential success and usually
  underestimated
• Time for training and implementation should be
  maximized (consider vendor recommendations as a
  MINIMUM)

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Differences in Implementation in a Small Practice
or a RHIN -

• When implementation of electronic prescribing is
  through a regional health information network new
  issues arise which include
• Management of shared medication lists
• Management of shared problems lists
• Opportunity for aggregated medication history
  data
• Increased concerns about secondary use of
  prescriber data

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Why Is Now the Right Time to e-Prescribe?

• More options for stand alone, certified EMR and
  information network based electronic prescribing
  products
• Increased connectivity of pharmacies and PBMs
• Increased functionality to improve office
  efficiency (electronic refills)
• Support for implementation through programs like
  DOQ-IT and others
• Grant, P4P and other funding opportunities
• New educational material and resources are
  available

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We tried dedicating this computer to deciphering
our doctors' handwriting." Cartoon by Dave
Harbaugh
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Questions?

• Contact me at pathale_at_pathalemd.com
• Web site with further information and links
  www.pathalemd.com