E-prescribing in community-based practices: successes and barriers

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E-prescribing in community-based practices
successes and barriers

• Michael A Fischer, M.D., M.S.
• Division of Pharmacoepidemiology and
  Pharmacoeconomics
• Department of Medicine
• Brigham and Womens Hospital
• Harvard Medical School

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Research team

• Co-authors
• Ritu Agarwal, PhD
• U Maryland
• Corey Angst, PhD
• Notre Dame
• Cate Desroches, PhD
• MGH

• BCBSMA
• Megan Bell
• Adrienne Cyrulik, MPH
• Tufts Health Plan
• Julie Newton
• Zix Corporation
• Angus MacDonald
• Scott Plunkett

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Background

• Promise of e-prescribing
• Improved safety
• Value
• Efficiency
• Slow spread to community-based practices
• Uncertain what drives successful e-prescribing
  uptake in community setting

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Study setting

• Initiated by BCBSMA and Tufts Health Plan
• Partnered with ZixCorp, providing physicians with
  PocketScript system
• Program began in early 2004

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Prior studies erx adoption
Fischer et al, JGIM, 2008
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Prior studies e-rx and costs
Fischer et al, Arch Int Med, 2008, in press
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Prior studies e-rx and safety

• Most alerts over-ridden by prescribers
• Weingart et al. Arch Int Med, 2003
• Reviews suggest reduced ADEs, but inadequate
  studies in outpatient setting
• Ammenwerth et al. JAMIA, 2008

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Study questions

• What is the experience of community-based
  practices that adopt electronic prescribing
  systems?
• What barriers remain to successful adoption and
  use of e-prescribing?
• Where has e-prescribing succeeded has it created
  new problems?

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Study design

• Focus groups
• Conducted spring 2008
• Prescribers and office staff
• Internal medicine, pediatrics, FP, cardiology,
  nephrology
• Both current and former users
• High/low volume, abandoned, transitioned to EMR
• Interviews
• Detailed discussions with prescribers

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Findings

• E-prescribing positives
• Ongoing challenges/barriers

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E-prescribing positives

• Prescription security
• Financial gain
• Office efficiency
• Medication safety
• Insurance issues
• Communication with pharmacy

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E-prescribing positives

• Prescription security
• Less people touch the actual prescription
• Patients cannot lose the prescription
• Patients cannot tamper with prescription

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E-prescribing positives

• Financial gain
• Direct incentives a major factor
• Initial adoption subsidized
• Later incentives for ongoing use
• Potential gains in patient satisfaction
• if we can reduce wait times, weve succeeded
• Unclear of RoI in terms of practice billing

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E-prescribing positives

• Office efficiency
• Major changes in practice workflow
• Less calls for front-end staff
• Refills and other non-critical medication issues
  can be batched for MD review
• Frees staff time and attention
• Less interruption of work
• Pharmacy information is updated and accurate
• Perceived ROI, but hard to quantify

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E-prescribing positives

• Medication safety
• Quick review of patient medication history
• Available round the clock, out of office
• Alerts about drug-drug interactions
• Office staff appreciated reminders
• Physicians less certain, many alerts dismissed
• Ability to identify patients on a specific drug
• Especially useful for recalls
• I can identify all the patients on..

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E-prescribing positives

• Insurance issues
• Can see if a drug is not covered
• Avoids callbacks, increased patient satisfaction
• Ability to identify patients on a specific drug
• Also useful for prescribing incentive programs

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E-prescribing positives

• Communication with pharmacy
• Timely flow of information
• Ability to send specific messages
• e.g. no more refills until patient sees doctor

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Ongoing challenges/barriers

• Learning curve
• Usability
• Reliability
• Safety concerns
• Patient resistance
• Data security

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Ongoing challenges/barriers

• Learning curve
• New skill not covered in medical school
• Difficult for older prescribers
• High burden on champions/superusers
• New tasks for some personnel source of
  resistance
• Lack of support
• Locked in with initial vendor choice

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Ongoing challenges/barriers

• Usability
• Types of devices/interfaces
• Problems with some pharmacies
• Inability to transmit to PBMs
• Reliability
• Connectivity/network problems, loss of
  productivity
• Resistance for sick patients or weekends

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Ongoing challenges/barriers

• Safety concerns
• Selecting wrong patient
• Selecting wrong drug (Cipro/Cialis)
• Some doses/formulations not in system
• Drug alerts not perceived as helpful ignore
  almost all
• Some alerts may be handled by non-prescribers in
  the process of queuing

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Ongoing challenges/barriers

• Patient resistance
• Wanting something in hand (older pts)
• Bad experiences with failed transmissions
• Inability to transmit to PBMs
• Data security
• Concern about whether transmitting patient data
  creates liability exposure
• Concern about prescribing data and
  tracking/profiling
• Who owns the data cost of changing

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Summary observations

• Overall positive experience almost none would
  turn back the clock
• Successes office efficiency, pharmacy
  communication, formulary information,
  prescription security
• Barriers/challenges Learning curve, reliability,
  questionable safety impact

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Summary observations

• Benefits more apparent in larger practices with
  high volume of chronic mediations
• More opportunities to streamline workflow
• Prescription volume/management is seen as a major
  issue at baseline
• Possible financial gains easier to perceive

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Next steps

• On-site visits to observe system use, validate
  focus group observations
• Large-sample survey to test generalizability of
  initial findings
• Quantitative studies of e-rx impact on cost,
  safety, adherence, clinical outcomes