Presentation on theme: "Patricia L. Hale, MD, PhD, FACP"— Presentation transcript:
1Patricia L. Hale, MD, PhD, FACP Deputy DirectorOffice of Health Information Technology TransformationNew York State Department of HealthE-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 & QualitySaturday, April 4, 3:00 PM - 4:00 PM
2E-Prescribing Overview Objectives:Review the positive and negative points of e-PrescribingDiscuss implementation of e-PrescribingExamine the challenges of implementation
3A Public Health Crisis More than7,000 Americans Die Annually From Preventable Medication ErrorsKey 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 Annuallyby Preventable Medication ErrorsSource: The Institute of Medicine of the National Academies of Science (IOM).Slide used by permission from SureScripts
4The Challenge On Paper! Physicians write as many as The Challenge of “Prescription Hand-offs”Illegible HandwritingUnclear Abbreviations and DosesVerbal Communication AmongPhysicians, Patients and PharmacistsPhysicians write as many as4 billion prescriptionseach yearOn Paper!Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, National Center for Health StatisticsThe chain pharmacy industry profile. National Association of Chain Drug StoresAgency 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 prescription65% of the US population use a prescription medication each year
5The Technology is Available Today…But Not Used Less than 1 in 5 of Physicians Use ePrescribingOnly 20% of prescriptions are electronically prescribed with 80% still handwrittenMost electronic prescriptions are still sent by FAXKey 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 prescribingWhile 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 ofelectronic prescribing systemscould be more than $27 billionSources: eHealth Initiative, and: Center for Information Technology Leadership, “The Value of Computerized Provider Order Entry in Ambulatory Settings,” 2003.
6Current Challenges Rx Patient safety Between 1.5%-4.0% prescriptions are in error with serious patient riskAdverse drug events occur in 5%-18% of ambulatory patientsCost of errors: >$2 billion / yearQuality of care - Compliance20% of scripts are never filledPatient satisfaction is decliningImpact on productivity:Physician practice: 3 hours per dayPharmacy: 4 hours per day (up to 1 call per Rx)Inefficient delivery with paper, fax and phoneRxIllegible handwritingPhone tag and fax tagPatient waiting in the pharmacy
7Potential Impact of E-Prescribing on Preventable Adverse Drug Events (ADEs) PenPrint 6%Fax 37%EDI+DecisionSupport61%Source: CITLSlide used by permission from SureScripts
8What is e-Prescribing ?Ability to create a prescription electronicallyAbility to receive automated decision support during script creationMedication lists and informationEligibility determinationFormulary coverage from insurer including co-pay informationPrior authorizationclinical 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 electronicallyAbility to determine “fill status” as a measure of compliance (medication history)Ability for pharmacy to process electronic script in their systemSlide used by permission from SureScripts
9Intermediaries for Data Transfer New Rx, refills, renewals, authorizations, change Rx, Prescription history from pharmaciesPrescribereRxSoftwarePharmacy and PBMeRx SoftwareEligibility, Formularies, medication claims histories
10>150,000 Certified EMR Users Electronic prescribing is under-utilized: Purchasing software does not equal adoption or effective usePractice SizeBest estimates for ePrescibing or EMR adoption based on high quality surveys (%)All24Small7-16Large*39RxInterOp>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 awayExtremely low awareness among install baseSources: 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, 200610
11The Technology is Available Today… But Not Used Less than 1 in 5 of Physicians Use ePrescribingOnly 20% of prescriptions are electronically prescribed with 80% still handwrittenMost “electronic” prescriptions are still sent by FAXNational savings from universal adoption of e-prescribing systems could be more than $27 billion
12Market where incentives are most effective Where are we?TippingPoint??We remain at the tipping point of adoption of clinical systems at the point of careEarly adopters are now on board and EMRs are becoming mainstream in large practicesMandates to reach non-adoptersEnthusiastsAnd Early AdopteesMainstreamMarket where incentives are most effectiveeHIT2.5%13.5%34%34%16%
14Everyone 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 complianceLower 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
15Benefits 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:
17But… Providers are concerned about… Cost of buying, installing and supporting a systemand Return on Investment (ROI)Financial Cost Change Management and WorkflowLack of reimbursement for costs and resourcesIncreased time to use the system = reduced productivity (initially) while struggling to create efficient workflowsChallenges of creating a complete, accurate patient medication history from multiple sourcesTime required to review medications, warnings, alerts and recommendations
18But… 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 regulationsHardware and Software Selection and supportLimitations on E-Prescribing System Remote AccessPharmacy, Payer/PBM and Mail Order ConnectivityMedication History and Medication ReconciliationSystem Functionality GapsPrescribing from Multiple Office Sites or remotely…..Still not considered a routine standard of practice
19What are the key elements influencing the business case for clinicians? Business case varies according to:Size of practiceType of practice (primary care vs specialty, mostly new patients, mostly recurrent complex patients, etc)Participation of health plansParticipation of local pharmaciesPractice setting (large/small, urban/rural)Availability of IT infrastructure and supportStand alone e-prescribing vs EHRAvailability of incentives and ability to take advantage of them
20Cost:Initial costs include software licensing fees, hardware, network and Internet access and training and technical supportComplete cost will also includeTemporary decreases in productivity resulting from training and workflow redesign (averaging 2-6months)Practice management, lab and other interfacesCustomization for practice specialty and other factorsMaintenance of systemUpgradesData conversation (from different PMS or from stand alone e-prescribing system to EHR)
21Cost:Stand alone e-Prescribing start up and ongoing cost estimated at $ $3500 per physician per year for software plus hardware etcEMR costs estimated at $20-25,000 initial and $3000 per year per physician for software plus hardware etcCosts are less in urban areas where Internet and IT services are more readily availableLarge practices can save significantly through cost sharing and increased efficiency of implementation and support by being able to afford dedicated staff
22Potential Savings Both stand alone e-prescribing systems and EHRs Increased practice efficiency handling med renewal requestsIncreased prescriber accuracy resulting in fewer call-backs from pharmacies for legibility issues, drug incompatibility or ineligibilityEHRsDecreased chart pulls resulting in less staff timeDecreased transcription costs
23So – “bottom line”….What is the business case for a large urban practice? Advantages:Financial investment capabilityDedicated staff opportunityLeverage with health plans and pharmacies, etc for connectivityOften 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 implementationsMajor changes in workflow can be disruptive decreasing productivity making clinician payment strategies etc in need of temporary modificationsSignificant Initial cost
24So – “bottom line”….What is the business case for a small rural practice? Advantages:Organizational “buy in” less of an issueLess total initial investmentDisadvantagesDifficult to absorb cost including system cost and decreased productivityCan have connectivity issues and difficulty obtaining skilled IT supportNo leverage with health plans or pharmacies resulting in decreased opportunity for optimum data flowNo 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 SettingPractice typePrescriptions and Refills/day/ prescriberStand Alonee-Prescribing* length of time to achieve +ROI***EMR** approximate length of time to achieve +ROI****RuralSmall1-5 DocsPrimary Care40/603-5+years“Specialty20/402-5+ yearsRural Large 10+2-3+ years2-4+ years1-3+ yearsUrban Small 1-5Primary careUrban Large 10+1-2+ yearsMultispecialtyyears*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 costsReferences: 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
26Incentives and Implementation Support Services Where do they fit in?
27Overview of Current and Potential Programs to Promote e-Prescribing Economic IncentivesReimbursement for Utilization Incentive programs disincentive programsMIPPAARRAOther programs sponsored by Medicaid, private health plans, employers and othersGrants, Loans and other funding programsPay for PerformanceMalpractice Insurance Premium ReductionsHealthcare IT Suppliers discounts, group buying programs, etcPolicy Incentives and Programs for Implementation SupportAccreditation (JCAHO 2005 Hospitals’ National Patient Safety Goals, others in development)Relaxed STARK regulationsCMS DOQ-ITCCHIT 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.
28Medicare 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
29E-Prescribing and ARRA The stimulus package includes $36B in health IT funding from the federal government through Appropriations and IncentivesAppropriations for Health IT & HIENew Incentives for AdoptionNew 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 GrantsEHR State Loan FundNational Health IT Research Center & Regional Extension CentersWorkforce TrainingNew Technology R&DBroadband and Telehealth$4.3 billion for broadband & $2.5 billion for distance learning/ telehealth grantsDirects ONC to invest in telehealth infrastructure and toolsDirects the new FACA Policy Committee to consider telehealth recommendationsComparative Effectiveness$1.1 billion to HHS for CEREstablishes Federal Coordinating Council to assist offices and agencies of the federal government to coordinate the conduct or support of CER and related health services
30MIPPA 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 09/10Medicare and Medicaid ARRA incentive payments begin, presuming HIEs have come onlineMedicare and Medicaid ARRA incentive payments give way to penalties on providers for failing to adopt HITMIPPA e-prescribing incentives begins20092010201120122013201420152016MIPPA e-Prescribing incentive payments give away to penaltiesHHS to establish interoperability standardsby the end of 2009 to guide HIE developmentSetting 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
31Existing Statutory Definition of “Meaningful Use” of EHRs Three ComponentsUses EHR in a meaningful manner, which includes electronic prescribing as determined to be appropriate by the HHS SecretaryUses 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
32Medicare Health IT Physician Payment Incentives 2011 is first year2012 is first year2013 is first year2014 is first year2015 is first year2011$18,0002012$12,0002013$8,000$15,0002014$4,0002015$2,0002016$0TOTAL$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 ProviderPercent Match/ LimitMedicaid ShareLimit AmountIndependent physician85% net average allowable costs>30%$25,000 for purchase$10,000 for operations/maintenanceMax of $64,000 in 5 yearsPediatrician>20%$16,667 for purchase, $6,667 for operations/maintenanceMax of $51,200 in 5 yearsNurse mid-wifePhysician Assistant if is lead clinician at RQHC or FQHC>30% of patient population are “needy individuals”By determination of the SecretaryNurse practitionerHospital owned clinician practice>10%FQHC or RQHC-based practicing physicianThird-party sponsoring entity supporting EHR implementation85% of net allowable costs; third-party entity can keep 5% of funds as pass-through
34Predictions and Expectations for ARRA Will nearly double e-Prescribing adoption over MIPPA levels by 2014 and four fold over current levelsSaving of over $22 billion in federal costs will offset $19 billion investmentSavings of over $56 billion for all payorsWill help prevent more than 3.5 million serious medication errors (ADEs)Visante Report 2009
35E-prescribing Increases Use of Generics and More Affordable Brands 1-4% reduction in drug spendingPharmacy 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
36Increased Medication Adherence Decreased Errors and Hospitalizations Increased adherence, disease management and coordination of carePrevention of ADE related hospitalization, ER and physician visits0.25% reduction in ER and hospital costs1% increase use of target drugs for chronic disease andDM 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 costs30-50% 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
37What You Should DoConsider 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 forEvaluate your practice setting for decision on what type of product to implement and potential resources for supportBe 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.
39Resources for Implementation Support Medical Informatics OrganizationsHIMSS, eHI, AMIA etcVendor and vendor user groupsSurescripts/RxHubMedical SocietiesState or regional medical societiesMedical specialty society chaptersIPA or other regional physician groupsHospital or Medical CenterState Department of Health or other state agenciesHealth Plans or Employer groups sponsoring projectsPharmacies and Pharmacist organizationsConsultants
41References 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 2008E-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, 2008Free 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 2008HIMSS e-Prescribing Wiki:
42HIMSS 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 practiceHIMSS E-Prescribing interactive WikiComments 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!
43Web site with further information and links: www.pathalemd.com “We tried dedicating this computer to deciphering our doctors' handwriting."Cartoon by Dave HarbaughQUESTIONS?Web site with further information and links: