1. Patricia L. Hale, MD, PhD, FACP
Deputy Director
Office of Health Information Technology Transformation
New York State Department of Health
E-Prescribing Overview: What Works; What Doesn't and How Do We Implement It?
HIMSS 09 Physicians' IT Symposium: Closing the Gap: From Implementation to Safety & Quality
Saturday, April 4, 3:00 PM - 4:00 PM

2. E-Prescribing Overview
Objectives:
Review the positive and negative points of e-Prescribing
Discuss implementation of e-Prescribing
Examine the challenges of implementation

3. A Public Health Crisis More than7,000 Americans Die Annually
From Preventable Medication Errors
Key Points:
Back in 2000, the Institute of Medicine came out with a report that astonished everyone. Nearly 100,000 people die each year from medical errors of all kinds, including medication errors.
Six years later, the IOM released a report specifically on medication errors and again astonished everyone: According to the IOM, 1.5 million Americans are injured each year and 7,000 die from medication errors. This is simply unacceptable.
More than 1.5 Million Americans are Injured Annually
by Preventable Medication Errors
Source: The Institute of Medicine of the National Academies of Science (IOM).
Slide used by permission from SureScripts

4. The Challenge On Paper! Physicians write as many as
The Challenge of “Prescription Hand-offs”
Illegible Handwriting
Unclear Abbreviations and Doses
Verbal Communication Among
Physicians, Patients and Pharmacists
Physicians write as many as
4 billion prescriptions
each year
On Paper!
Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, National Center for Health Statistics
The chain pharmacy industry profile. National Association of Chain Drug Stores
Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.
NACDS estimates.
4 out of 5 patients who visit a physician leave with at least one prescription
65% of the US population use a prescription medication each year

5. The Technology is Available Today…But Not Used
Less than 1 in 5 of Physicians Use ePrescribing
Only 20% of prescriptions are electronically prescribed with 80% still handwritten
Most electronic prescriptions are still sent by FAX
Key Points:
So it have been six years since the IOM’s first report and the question is have we made any progress?
Unfortunately, not enough.
With over 3 billion prescriptions written every year; even though we have the technology to make this problem go away, less than 1 in 5 of the nation’s practicing physicians regularly use electronic prescribing
While many of the large academic medical groups like our own group at Texas A&M have already adopted electronic prescribing via an electronic health record, 50% of physicians are in small groups with 1 to 10 physicians lack the resources and the time to adopt a standard e-prescribing solution.
National savings from universal adoption of
electronic prescribing systems
could be more than $27 billion
Sources: eHealth Initiative, and: Center for Information Technology Leadership, “The Value of Computerized Provider Order Entry in Ambulatory Settings,” 2003.

6. Current Challenges 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
Cost of errors: >$2 billion / year
Quality of care - Compliance
20% of scripts are never filled
Patient satisfaction is declining
Impact on productivity:
Physician practice: 3 hours per day
Pharmacy: 4 hours per day (up to 1 call per Rx)
Inefficient delivery with paper, fax and phone Rx
Illegible handwriting
Phone tag and fax tag
Patient waiting in the pharmacy

7. Potential 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

8. What is e-Prescribing ?
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

9. Intermediaries for Data Transfer
New Rx, refills, renewals, authorizations, change Rx, Prescription history from pharmacies
Prescriber
eRx
Software
Pharmacy and PBM
eRx Software
Eligibility, Formularies, medication claims histories

10. >150,000 Certified EMR Users
Electronic prescribing is under-utilized: Purchasing software does not equal adoption or effective use
Practice Size
Best estimates for ePrescibing or EMR adoption based on high quality surveys (%)
All 24
Small
7-16
Large* 39 Rx
InterOp
>150,000 Certified EMR Users
*”Large” is defined as > 20 physician FTEs in one study with 39% adoption and >50 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 Nat’l Ambulatory Medical Care Survey, 2005; HSC Community Tracking Study, 2006; Forrester, 2003; SureScripts estimates, 2006 10

11. The Technology is Available Today… But Not Used
Less than 1 in 5 of Physicians Use ePrescribing
Only 20% of prescriptions are electronically prescribed with 80% still handwritten
Most “electronic” prescriptions are still sent by FAX
National savings from universal adoption of e-prescribing systems could be more than $27 billion

12. Market where incentives are most effective
Where are we?
Tipping
Point??
We remain at the tipping point of adoption of clinical systems at the point of care
Early adopters are now on board and EMRs are becoming mainstream in large practices
Mandates to reach non-adopters
Enthusiasts
And Early Adoptees
Mainstream
Market where incentives are most effective
eHIT
2.5%
13.5%
34%
34%
16%

13. So Why Aren’t We All e-Prescribing?

14. Everyone Benefits – But Not Equally
>80%
Payors/PBMs:
Increased generic/formulary usage, efficiency, Rx compliance and prevention of ADEs (reduced costs)
Patients:
Increased safety, efficiency and compliance
Lower co-pays
>20%
Providers:
Increased efficiency, improved care, patient satisfaction and potential short and long term incentives (pay-for-performance)
Pharmacies:
Increased efficiency, improved care, improved patient satisfaction

15. Benefits Include:
Discovery of potentially significant drug-drug, drug-allergy or drug-lab interactions;
Reduced adverse drug events (ADE),
Reduced avoidable emergency department visits or hospital admissions;
Eliminated transcription or legibility errors;
Availability of a more complete, up-to-date medication list for each patient;
Increased practice efficiency (particularly med renewal requests);
Increased prescriber efficiency (e.g., fewer call-backs from pharmacies);
More effective medication reconciliation across multiple settings of care;
Increased patient satisfaction.
MGMA 2008 survey:

16. Proprietary and Confidential
E-Prescribing Pilots 16
© RxHub LLC, 2008
Proprietary and Confidential 16

17. But… Providers are concerned about…
Cost of buying, installing and supporting a systemand Return on Investment (ROI)
Financial Cost Change Management and Workflow
Lack of reimbursement for costs and resources
Increased time to use the system = reduced productivity (initially) while struggling to create efficient workflows
Challenges of creating a complete, accurate patient medication history from multiple sources
Time required to review medications, warnings, alerts and recommendations

18. But… Providers are concerned about…
Limitations preventing use for all prescriptions due DEA restriction from use for controlled medications and other Federal and State rules and regulations
Hardware and Software Selection and support
Limitations on E-Prescribing System Remote Access
Pharmacy, Payer/PBM and Mail Order Connectivity
Medication History and Medication Reconciliation
System Functionality Gaps
Prescribing from Multiple Office Sites or remotely
…..Still not considered a routine standard of practice

19. What are the key elements influencing the business case for clinicians?
Business case varies according to:
Size of practice
Type of practice (primary care vs specialty, mostly new patients, mostly recurrent complex patients, etc)
Participation of health plans
Participation of local pharmacies
Practice setting (large/small, urban/rural)
Availability of IT infrastructure and support
Stand alone e-prescribing vs EHR
Availability of incentives and ability to take advantage of them

20. Cost:
Initial costs include software licensing fees, hardware, network and Internet access and training and technical support
Complete cost will also include
Temporary decreases in productivity resulting from training and workflow redesign (averaging 2-6months)
Practice management, lab and other interfaces
Customization for practice specialty and other factors
Maintenance of system
Upgrades
Data conversation (from different PMS or from stand alone e-prescribing system to EHR)

21. Cost:
Stand alone e-Prescribing start up and ongoing cost estimated at $ $3500 per physician per year for software plus hardware etc
EMR costs estimated at $20-25,000 initial and $3000 per year per physician for software plus hardware etc
Costs are less in urban areas where Internet and IT services are more readily available
Large practices can save significantly through cost sharing and increased efficiency of implementation and support by being able to afford dedicated staff

22. Potential Savings Both stand alone e-prescribing systems and EHRs
Increased practice efficiency handling med renewal requests
Increased prescriber accuracy resulting in fewer call-backs from pharmacies for legibility issues, drug incompatibility or ineligibility
EHRs
Decreased chart pulls resulting in less staff time
Decreased transcription costs

23. So – “bottom line”….What is the business case for a large urban practice?
Advantages:
Financial investment capability
Dedicated staff opportunity
Leverage with health plans and pharmacies, etc for connectivity
Often can leverage other incentive opportunities with health plans, P4P, PQRI etc.
Disadvantages:
Organizational “buy in” with large potentially diverse physician staff often resulting in “hold outs” and partial implementations
Major changes in workflow can be disruptive decreasing productivity making clinician payment strategies etc in need of temporary modifications
Significant Initial cost

24. So – “bottom line”….What is the business case for a small rural practice?
Advantages:
Organizational “buy in” less of an issue
Less total initial investment
Disadvantages
Difficult to absorb cost including system cost and decreased productivity
Can have connectivity issues and difficulty obtaining skilled IT support
No leverage with health plans or pharmacies resulting in decreased opportunity for optimum data flow
No opportunity for dedicated staff to maximize success or take advantage of other incentives like P4P and PQRI

25. “Bottom Line” Rural Small 1-5 Docs Primary Care 40/60 3-5+years “
Practice Setting
Practice type
Prescriptions and Refills/day/ prescriber
Stand Alone
e-Prescribing* length of time to achieve +ROI***
EMR** approximate length of time to achieve +ROI****
Rural
Small
1-5 Docs
Primary Care
40/60
3-5+years “
Specialty
20/40
2-5+ years
Rural Large 10+
2-3+ years
2-4+ years
1-3+ years
Urban Small 1-5
Primary care
Urban Large 10+
1-2+ years
Multispecialty
years
*Stand alone e-Prescribing start up and ongoing cost estimated at $ $3500 per physician per year for software plus hardware etc
**EMR initial and ongoing yearly costs estimated at $20-25,000 initial and $3000 per year per physician for software plus hardware etc
*** Stand alone e-Prescribing ROI calculated using savings estimates for time savings due to automated refill requests and decreased phone calls resulting in decreased staff time
**** EHR ROI calculated using savings estimates from e-Prescribing plus decrease chart pulls (staff time) and decreased transcription costs
References: MGMA survey 2007, 2008; Medical Group Management Association, “The cost of administrative complexity,” MGMA Connexion,
November/December 2004; “Evidence on the Costs and Benefits of Health Information Technology”. May Congressional Budget Office

26. Incentives and Implementation Support Services
Where do they fit in?

27. Overview of Current and Potential Programs to Promote e-Prescribing
Economic Incentives
Reimbursement for Utilization Incentive programs  disincentive programs
MIPPA
ARRA
Other programs sponsored by Medicaid, private health plans, employers and others
Grants, Loans and other funding programs
Pay for Performance
Malpractice Insurance Premium Reductions
Healthcare IT Suppliers discounts, group buying programs, etc
Policy Incentives and Programs for Implementation Support
Accreditation (JCAHO 2005 Hospitals’ National Patient Safety Goals, others in development)
Relaxed STARK regulations
CMS DOQ-IT
CCHIT certification of “free standing” E-prescribing and ambulatory EHR products
…and eventually…Mandates??
CMS has provided over $100 million in funding to state Medicaid programs to help them encourage prescribers to adopt e-prescribing.
STARK - At the federal level, regulations released in 2006 now allow free donation of e-prescribing hardware, software, and related services to prescribers by hospitals (to members of their medical staff), by a group practice (to their physician members), and by Medicare Advantage and Medicare Part D Prescription Drug Plans.

28. Medicare e-Prescribing Incentive Program (MIPPA)
Beginning January 1, 2009, Medicare offers physician payment incentives of 2% for using e-prescribing in 2009 and 2010, with this amount declining slightly over the following three years.
Those physicians who do not adopt e-prescribing for Medicare by 2012 will start seeing their Medicare payments incrementally reduced, up to 2% annually beginning in 2014.
The Secretary of Health and Human Services may make an exemption on a case-by case basis if significant hardship can be demonstrated.
Health plans offering Medicare Part D drug programs must begin supporting e-prescribing by May, 2009.
The Secretary has the authority to update the codes of the electronic prescribing measure in the future. The legislation refers specifically to the electronic prescribing measure currently in the 2008 Physician Quality Reporting Initiative (PQRI) (measure #125)
CCHIT certification is required for both “free standing” e-prescribing and EHR products

29. E-Prescribing and ARRA
The stimulus package includes $36B in health IT funding from the federal government through Appropriations and Incentives
Appropriations for Health IT & HIE
New Incentives for Adoption
New Medicare and Medicaid payment incentives to providers for EHR adoption
$20 billion in expected payments through Medicare
$14 billion in expected payments through Medicaid
~$34 billion in gross expected outlays,
$2 billion for loans, grants & technical assistance:
HIE Planning & Implementation Grants
EHR State Loan Fund
National Health IT Research Center & Regional Extension Centers
Workforce Training
New Technology R&D
Broadband and Telehealth
$4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grants
Directs ONC to invest in telehealth infrastructure and tools
Directs the new FACA Policy Committee to consider telehealth recommendations
Comparative Effectiveness
$1.1 billion to HHS for CER
Establishes Federal Coordinating Council to assist offices and agencies of the federal government to coordinate the conduct or support of CER and related health services

30. MIPPA and ARRA Timeline
State grant monies begin flowing from HHS to develop technical, privacy, governance and financing frameworks necessary for HIE to take shape...likely 09/10
Medicare and Medicaid ARRA incentive payments begin, presuming HIEs have come online
Medicare and Medicaid ARRA incentive payments give way to penalties on providers for failing to adopt HIT
MIPPA e-prescribing incentives begins
2009
2010
2011
2012
2013
2014
2015
2016
MIPPA e-Prescribing incentive payments give away to penalties
HHS to establish interoperability standards
by the end of 2009 to guide HIE development
Setting of standards enables the building of HIE infrastructure to practically and usefully implement standards to achieve interoperability to comply with Medicare and Medicaid incentive payment requirements for HIE interoperability

31. Existing Statutory Definition of “Meaningful Use” of EHRs
Three Components
Uses EHR in a meaningful manner, which includes electronic prescribing as determined to be appropriate by the HHS Secretary
Uses EHR that is “connected in a manner” that provides for the electronic exchange of health information to improve the quality of health care, such as promoting care coordination (in accordance with law and standards applicable to the exchange of information)
Submits information on clinical quality measures and other measures as selected and in a form and manner specified by the Secretary

32. Medicare Health IT Physician Payment Incentives
2011 is first year
2012 is first year
2013 is first year
2014 is first year
2015 is first year
2011
$18,000
2012
$12,000
2013
$8,000
$15,000
2014
$4,000
2015
$2,000
2016 $0
TOTAL
$44,000
$42,000
$35,000

33. >30% of patient population are “needy individuals”
Physicians receiving Health IT incentive payments under Medicaid are eligible for up to approximately $64,000 over a five year period if they can demonstrate “meaningful use” of EHRs in their practice.
Eligible Provider
Percent Match/ Limit
Medicaid Share
Limit Amount
Independent physician
85% net average allowable costs
>30%
$25,000 for purchase
$10,000 for operations/maintenance
Max of $64,000 in 5 years
Pediatrician
>20%
$16,667 for purchase, $6,667 for operations/maintenance
Max of $51,200 in 5 years
Nurse mid-wife
Physician Assistant if is lead clinician at RQHC or FQHC
>30% of patient population are “needy individuals”
By determination of the Secretary
Nurse practitioner
Hospital owned clinician practice
>10%
FQHC or RQHC-based practicing physician
Third-party sponsoring entity supporting EHR implementation
85% of net allowable costs; third-party entity can keep 5% of funds as pass-through

34. Predictions and Expectations for ARRA
Will nearly double e-Prescribing adoption over MIPPA levels by 2014 and four fold over current levels
Saving of over $22 billion in federal costs will offset $19 billion investment
Savings of over $56 billion for all payors
Will help prevent more than 3.5 million serious medication errors (ADEs)
Visante Report 2009

35. E-prescribing Increases Use of Generics and More Affordable Brands
1-4% reduction in drug spending
Pharmacy costs decrease 3-3.5% (Mass eRx Collaborative 2006)
3.3% increase in tier 1 prescribing (Archives Internal Medicine 2008)
Generic use increased 4.8% (Sierra/SW Medical 2006)
5.3% reduction drug costs (JMCP 2005)
Increased generic use from (HAP/HFMG 2006)
3.7% increased generic prescribing and 10.1% decrease in cost (WellPoint/Wellinx 2005)
11% decrease drug costs and $4.99 decrease per prescription (Ann Fam Med 2004)
Increased use of mail in service pharmacy 10% (Drug Benefit Trends 2003)
Increased formulary compliance by more than 5% and increased generic use by 7% (Aetna 2008)
Visante Report 2009

36. Increased Medication Adherence Decreased Errors and Hospitalizations
Increased adherence, disease management and coordination of care
Prevention of ADE related hospitalization, ER and physician visits
0.25% reduction in ER and hospital costs
1% increase use of target drugs for chronic disease and
DM management saves 15% in costs (HealthPartners 2007)
Hyperlipidemia treatment compliance increased from 50%-90% of benchmark (Project ImPACT 2000)
Increased use of ACE-inhibitors for DM+HTN (CITL 2003)
35% decrease preventable ambulatory ADEs with 0.05% decrease hospital, ER and physician costs
30-50% decrease of 8 million ambulatory ADEs (RAND 2005)
9.5% of new prescriptions changed or cancelled due to drug/drug interaction warnings (HAP/HFMG 2006)
Visante Report 2009

37. What You Should Do
Consider starting e-prescribing this year to take best advantage of Medicare incentives as they will decrease starting in 2011 and Medicare reimbursement will decrease in 2012 if you are not e-prescribing.
Evaluate your patient population to see which of the programs you may qualify for
Evaluate your practice setting for decision on what type of product to implement and potential resources for support
Be sure any potential vendors for either e-prescribing stand alone products (Medicare MIPPA e-prescribing program only) or EHR products are current year CCHIT certified.
Carefully evaluate any potential vendor to be sure they meet other restrictions. For ARRA incentives it will be critical to be sure your vendor is prepared for potential further requirements by HHS and ONC for capabilities to meet the “meaningful use” criteria.
Be sure your billing system will be prepared to handle Medicare electronic prescribing specific codes and possible new codes required for ARRA incentives.

38. Resources for Implementation Support

39. Resources for Implementation Support
Medical Informatics Organizations
HIMSS, eHI, AMIA etc
Vendor and vendor user groups
Surescripts/RxHub
Medical Societies
State or regional medical societies
Medical specialty society chapters
IPA or other regional physician groups
Hospital or Medical Center
State Department of Health or other state agencies
Health Plans or Employer groups sponsoring projects
Pharmacies and Pharmacist organizations
Consultants

41. References and Resources:
Electronic Prescribing for the Medical Practice: Everything You Wanted to Know But Were Afraid to Ask, Patricia L. Hale, PhD, MD, FACP, Editor and also the e-Prescribing resource center on the HIMSS web site at:
E-Prescribing - A Clinicians Guide - e-Health Initiative
E-Prescribing and health information technology. Davis, Ronald, American Medical Association.
National Progress Report on E-Prescribing SureScripts.
For more information on the Medicare incentive program: PQRI Toolkit - and for MIPPA-
Evidence on the Costs and Benefits of Health Information Technology. May Congressional Budget Office, page 17.
Physicians' Experiences Using Commercial E-Prescribing Systems - Physicians are optimistic about e-prescribing systems but face barriers to their adoption. - by Joy M. Grossman, Anneliese Gerland, Marie C. Reed, and Cheryl Fahlman - Health Affairs April 6, 2008
Free e-prescribing readiness assessment online -
E-Prescribing: Why the Fuss? Kenneth G. Adler, MD, MMM FAMILY PRACTICE MANAGEMENT Preprint | -
Surescripts/RxHub -
Electronic Prescribing: Building, Deploying and Using E-prescribing to Save Lives and Save Money – Center for Health Transformation 2008
HIMSS e-Prescribing Wiki:

42. HIMSS Resources and Initiatives for e-Prescribing
The HIMSS E-Prescribing Task Force will continue to develop:
“tip sheets” for providers on how to incorporate E-Prescribing solutions into the medical practice
HIMSS E-Prescribing interactive Wiki
Comments and recommendations on e-Prescribing issues such as CCHIT certification, definition of “meaningful use” criteria, etc.
HIMSS will leverage Virtual Conference and Exhibition programs to highlight E-Prescribing and provide education updates.
Join us!

43. Web site with further information and links: www.pathalemd.com
“We tried dedicating this computer to deciphering our doctors' handwriting."
Cartoon by Dave Harbaugh
QUESTIONS?
Web site with further information and links: