EPrescribing Standards and Beyond OHIT Health IT Grantee Meeting

1
E-PrescribingStandards and BeyondOHIT Health
IT Grantee Meeting

• Prashila Dullabh MD
• NORC
• November 6th, 2007

2
Status Quo

• The current means for prescribing and dispensing
  medications in the United States is neither
  efficient nor safe.
• Over 7,000 deaths each year due to manual-process
  prescribing errors (IOM)
• A shift to interoperable e-prescribing systems
  could avoid more than 2 million ADEs annually,
  and has the potential to create significant cost
  savings to the US healthcare system. (Bates et
  al)
• Today e-prescribing systems do not consistently
  employ standards.

3
Todays Prescribing Process
3
Source RxHub
Chelle Woolley
4
Current Status of E-Prescribing

• Only 10-15 of physicians are using e-prescribing
  but that number is ramping
• 45 physicians said it improved compliance with
  formularies
• 36 of physicians said e-prescribing improved
  efficiency
• 33 physicians said it had a major impact on
  quality of care
• Source Harris Interactive and Boston Consulting
  Group Poll, 2003

5
E-Prescribing Real Time End-to-End Solution
5
Physicians/Prescribers
Patients
PBM/Payers
Pharmacy
Source RxHub
6
Federal Response to Current Prescribing Problems

• The 2003 Medicare Prescription Drug Improvement
  and Modernization Act (MMA) requires that
• All health plans and pharmacies participating in
  the new Medicare prescription drug benefit (Part
  D) support an e-prescription program,
• The Secretary of Health and Human Services (HHS)
  establish federal standards that all
  e-prescribers must follow for Part D patients.
• The six initial standards are pilot tested to
  investigate their interoperability with
  foundation standards as well as clinical and
  economic outcomes associated with e-prescribing.

7
CMS-funded E-Prescribing Pilots

• In 2006 CMS funded 5 Pilots to test the standards
  and assess the outcomes and impact of
  E-Prescribing
• Rand Health
• SureScripts Florida, Massachusetts, Nevada, New
  Jersey, Tennessee
• Achieve (Long Term Care) - Minneapolis
• Ohio KePRO
• Brigham and Womans hospital
• Pilots were in diverse healthcare settings
  including long-term care
• Included a wide range of participants including
  prescribers in ambulatory settings, pharmacies,
  PBMs, transaction networks (RxHub,
  SureScripts),payers and technology vendors

8
E-Prescribing Standards
Initial Standards
Foundation Standards
NCPDP Telecommunications Standard ASC X12N
270/271 NCPDP SCRIPT for Change, New, Renewal
and Cancellation Messages
NCPDP Formulary Benefits Standard NCPDP
SCRIPT Medication History NCPDP SCRIPT Fill
status Notification Structured and Codified
Sig Prior Authorization RxNORM
Interoperability
9
Description of Initial E-Prescribing Standards

• Medication History - provides a uniform means for
  prescribers, dispensers, and payers to
  communicate about the list of drugs that have
  been dispensed to a patient regardless of which
  physician seen or pharmacy visited.
• Formulary and Benefits - provides prescribers
  with information about a patients drug coverage
  at the point of care which includes whether
  drugs are considered to be "on formulary,"
  alternative medications for those drugs not on
  formulary, rules for prior authorization and step
  therapy, and the cost to the patient for one drug
  option versus another.
• Prescription Fill Status Notification - notifies
  the prescriber after a patient has picked up a
  prescribed medication at the pharmacy.
• Prior Authorization offers a streamlined,
  electronic process to communicate the need for
  prior authorization directly to the prescriber,
  and allow the prescriber to send the needed
  information along with the prescription.
• Structured and Codified SIG includes patient
  instructions for taking medications (such as by
  mouth, three times a day) at the end of a
  prescription.
• RxNorm provides a standardized vocabulary for
  name, dose, and form of available drugs.

10
Bell DS, Cretin S, Marken RS, and Landman AB, A
Conceptual Framework for Evaluating
Outpatient Electronic Prescribing Systems Based
on Th ear Functional Capabilities, Journal of
the American Medical Informatics Association,
Vol. 11, No. 1, January/February 2004,
11
Findings from the Pilot evaluation

• Standards that are ready for implementation
• Medication History
• Formulary and Benefits
• Prescription Fill Status Notification
• Implementation considerations
• Medication history
• Generally underutilized because of software
  usability issues
• Providers concerned that the list is not
  comprehensive and they still need to collate
  information from multiple sources
• Formulary and benefits
• Plan coverage
• Correct patient matching to ensure that
  eligibility information will be available
• Eligibility checking should support real-time
  changes in patient status
• Prescription Fill status
• Currently no good workflow to inform providers
  that script that was filled was picked up at
  pharmacy
• Limited perceived utility for providers

12
Results of the impact of E-Prescribing Use

• Workflow
• Prescriber workflow
• Prescribers staff (e.g., surrogate prescribers)
  played a much more important role in the
  e-prescribing process than anticipated
• E-prescribing almost never fully replaced the
  need for paper-based prescribing
• E-prescribing tools may decrease reliance on
  verbal orders and generate certain efficiencies
  for small physician offices.
• E-prescribing reduces the number of phone time
  for physician practices
• Pharmacy workflow
• E-prescribing creates dramatic paradigm shifts
  in pharmacy workflow, which requires that
  pharmacies allocate sufficient resources to deal
  with substantial workflow and change management.
  
• General
• True end-to-end prescribing is rare
• Critical need for training, education, and
  understanding of key value propositions for both
  prescribers and pharmacists

13
Results of the impact of E-Prescribing Use

• E-Prescribing Adoption and Satisfaction
• Providers
• Providers seemed generally optimistic about the
  use of e-Prescribing
• Effective use of requires a re-examination of
  workflow
• In order to facilitate prescriber adoption,
  institutions need to assess and the role of their
  organizational culture
• The use of surrogate prescribing is real and
  needs to be factored into the new workflow
• Patients
• Most patients are satisfied with e-prescribing
• Offers new opportunities for medication
  management
• Pharmacists
• Generally optimistic
• Significant workflow impact
• There are significant efficiencies that can be
  realized
• E-Prescribing will create new challenges still
  need to intervene due to issues with structured
  patient instructions (codified sig), lack of
  integration of systems require information to be
  re-entered, fax still more efficient

14
Other outcomes related to E-Prescribing Use

• Reductions in new prescription rates
• LTC facilities reported a reduction in new
  prescription rates, indicating the possibility
  that e-prescribing may reduce unnecessary
  accumulation of active medications.
• Call Backs
• Improved efficiency in practice setting
• May create additional burden at the pharmacy
• Increase in generic prescribing
• Early results indicate that the use of generic
  prescribing is increased but this may occur as
  part of any CPOE system that shows generic
  alternatives
• Too early for definitive results on
• ADEs
• Impact to inappropriate prescribing practices

15
Current Initiatives

• CCHIT certification for eRx software
• Vendors upgrading/updating software to support
  new standards
• Part D plans required to accept electronic Rx
• 2006 Pilot testing of initial eRx standards
• 2007 HHS reports to Congress on standards that
  are ready to be adopted
• 2008 Part D initial eRx standards implemented
• Ongoing work on standards that are currently not
  ready

16
Conclusions

• Standards are a critical component to promote
  end-to-end e-Prescribing
• Three of the six standards are deemed ready for
  implementation
• Standards may be ready but there are
  implementation considerations
• Work still need to be done on clinical drug
  terminologies (RxNorm), structured patient
  instructions (codified sig) and prior
  authorization messaging
• CCHIT certification of e-Prescribing vendors will
  motivate vendor industry to respond
• E-Prescribing has significant workflow impacts at
  both the prescriber and pharmacy end and will
  need to be addressed to promote adoption and use