Electronic Prescribing: Planning and Implementation to Achieve Success and Maximize Value Jonathan Teich Pat Hale Peter Basch Bob Elson Rick Ratliff

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Electronic Prescribing: Introduction - the Value - Stages of eRx Jonathan Teich, MD, PhD SVP and Chief Medical Officer Healthvision Chair, eHI Electronic Prescribing Project

4 What is electronic prescribing? “Electronic prescribing” or “Computerized prescribing” = all systems that use a computer to enter, modify, review, and communicate drug prescriptions.

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7 PDA’s Useful where space is limited, or for multi-room practice Wireless and stand-alone Security concerns – “the floor and the door” EHR/EMR connected systems usually desktop- based

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9 Formulary Checking

10 Rx in EHR Connectivity Med Profile Management Allergy, Formulary, Age Basic Rx Entry / Dose check Reference only Stages of eRx

11 eRx Value There are significant errors and ADE’s Gandhi: ADE’s in 5-18% of ambulatory pts/yr CITL: Nationwide adoption of “ACPOE” predicted to eliminate 2.1 million ADE’s/year (136,000 life- threatening) There are significant inefficiencies CGEY: Nurses save 2.87 minutes per faxed Rx Illinois study: 50% reduction in pharmacy callbacks

Electronic Prescribing: Planning and Implementation to Achieve Success and Maximize Value A Provider’s Perspective Peter Basch, MD Medical Director MedStar e-Health Initiative

13 MedStar’s e-Health Initiative MedStar Health – 7-hospital system in the Baltimore-Washington corridor MeHI started in 2000 to Provide guidance to physicians from physicians, on practical e-health technologies Syndicate selected e-health products and services e-Prescribing was an early target for syndication Far easier and cheaper than inpatient CPOE, a “near term doable” Goals – enhance patient safety while improving workflow within the physician’s practice (as well as wins for other stakeholders)

14 MeHI’s approach to eRx – 2001 Investigated market Used a consultant to do a preliminary vendor analysis Demos + “demo-lition derby” Selectively engaged with finalist vendors Far easier to do in an emerging market with startups Became part of process / political redesign Better product Align costs / benefits

15 MeHI’s approach to eRx – 2003-now Preferred pricing arrangements for any MD affiliated with our hospitals with 2 vendors Participation in the eHealth Initiative report on eRx 1-yr pilot with DrFirst and CAQH 4 of every 1000 prescriptions (~2/day) were deemed by the prescriber to be significant mistakes (and were changed before being sent to the pharmacy) 93% of meds were written as generic or allowed to be substituted 30% of meds were substituted for a formulary alternative Benefit for providers is less clear

16 Moving ahead with eRx… Getting clinicians’ attention Choosing a vendor A lingering question… standalone eRx vs. EHR? Incentives – aligning costs / benefits

17 Getting clinicians’ attention Creating the imperative Paper-based prescribing is fraught with error - sure there’s bad handwriting, missing decimal points, and just bad judgment… But if you want to be heard by doctors… Exponential increase in new drugsExponential increase in new drugs More patients with multiple conditions taking multiple medsMore patients with multiple conditions taking multiple meds Multi-tasking is efficient but can lead to errorsMulti-tasking is efficient but can lead to errors eRx is the right thing to do, and can be done todayeRx is the right thing to do, and can be done today eRx will be the standard of careeRx will be the standard of care The challenge – busy clinicians still have to slow down to listen to this message

18 Choosing a vendor Design and usability Web-based for PC, tablet, and PDA use PDA issues Pocket PC vs. PalmPocket PC vs. Palm Synchronous vs. asynchronousSynchronous vs. asynchronous Consider incremental adoption if office e- readiness is low (start with refills, progress to point-of-care prescribing) Usability is critical Workflow Physician and staff workflow Integration with practice management system Robust bidirectional connectivity Information gateway Transactional gateway

19 Standalone eRx vs. EHR Standalone eRx is cheaper and easier than an EHR But it doesn’t do the functions that makes embedded eRx desirable (Rx + med list + chart documentation) To make it fit clinician workflow Either keep medication database separate from the chartEither keep medication database separate from the chart Always print it for the chart, orAlways print it for the chart, or Always open the eRx application with the chart (for staff and doctors)Always open the eRx application with the chart (for staff and doctors) Point-of-care prescribing and renewals should never be done in a vacuum Embedded eRx in an EHR Clear advantages to workflow and staff efficiency May not require any additional incentives

20 Summary Without mandates and/or incentives, getting clinician attention / engagement takes work Even with mandates, incentives are necessary to align costs and benefits Choosing a good vendor should make the work of implementation much easier While standalone eRx may work for some clinicians, for others it may make more sense to start by adopting eRx as part of an EHR

Electronic Prescribing: Managing Implementation - Pointers and Pitfalls Patricia L. Hale, MD, PhD CMIO Glens Falls Hospital Chair of MISC - American College of Physicians

22 Implementing eRx Planning Gather key stakeholders Understand your needs and your feasibilities System Selection Features Price – pricing models Potential for upgrading to EHR Hardware and services Workflow issues DesktopPDA’sLists Training/startup period

23 Implementation Recommendations Access important resources including the vendor and similar organizations that have already deployed the same application. Ensure adequate infrastructure and devices. Pay attention to organizational culture and behavior change management from the start. Before selecting and implementing an electronic prescribing application, plan for migration towards a complete EMR.

24 Implementation Process Purchase and install system hardware Establish users and roles Load lists: patients, pharmacies, formularies, favorites, etc. (Possibly) load prior patient medical or medication data Identify and address major implementation issues before selecting a system.

25 Implementation Issues Address startup and interface issues early: Integration with a practice management system to gain access to registration and schedule information, Loading patients’ initial medication lists from the previous system or from paper records; and Selecting and loading the appropriate payer and formulary information. Communication with pharmacies, health plans, etc.

26 Implementation Issues Identify Hardware and Service Needs: In-office siting and connections Networking / Internet / wireless Communications services (e.g., to pharmacies) What are your pharmacies ready for? How will you access Health Plan information? Can you communicate with other providers?

27 Implementation Issues Prepare Lists: Users Patient load or PM connection FormulariesFavorites Initial medication load

28 Implementation Issues Keys to Success: Strong leadership & commitment Incremental approaches High support staff involvement Medication history preload The “basics” well planned in advance PMS interface, network, devices, training & support

29 Implementation Issues Challenges: Good application not sufficient Cultural issues/managing behavior change Startup issues and problem resolution. Rollout timing and sequencing. Higher relative cost for small practices

Electronic Prescribing: Managing Implementation – Clinical Decision Support, Formulary, Medication Lists Bob Elson, MD, MS VP Medical Affairs RxHub, LLC

31 Implementation: Decision Support List maintenance Active medications, allergies, problems Other key data: weight, lab results Warnings management / workflow User roles / privileges Override justification / documentation De-activation / disabling of warnings Knowledge base updating Custom warnings? Understand decision support “holes” Application safety “czar” Bell, DS. A conceptual framework for evaluating eRx systems. JAMIA, : Fernando, B. Prescribing safety features of GP computer systems. BMJ. 2004;328:1171

32 “Intelligent Intervening Provider” Application Safety: User vs. System Error

33 Implementation: Formulary Getting the data On vs. off-formulary, preferred, restrictions, copay Health plan coverage Data costs? Mapping a patient to the right formulary Workflow Pointers to preferred alternatives Overrides Prior authorization

34 Implementation: Medication Lists Building initial medication lists The “backfile conversion” problem Medication list maintenance “brown paper bag” intake Active vs. inactive meds Medications prescribed by other physicians Assessing compliance

35 Implementation: “Front-End” Connectivity Eligibility-driven formulary mapping Claims-based prescription history

36 Member ID Load Eligibility-driven Formulary Mapping PBM Multiple responses combined Clinic System (eRx, EMR) Master Person Index MPI Eligibility Request Unique patient identification Eligibility Request Eligibility Response eRx Utility

37 Claims-based Prescription History PBM Medication History Request Med History Response Medication History Response Clinic System (eRx, EMR) eRx Utility

38 Sample Rx Claims History “Report” Patient Filled Prescription Report: Patient ID:PATID1234 Name: JONES, WILLIAM A. Address:1200 N ELM STREET GREENSBORO, NC DOB:06/15/1961Gender: Male Filled Prescription Date Range:08/01/2002 – 08/01/2003 CAUTION: Certain information may not be available or accurate in this medication claims history, including over-the-counter prescriptions, prescriptions paid for by the patient or non- participating sources, or errors in insurance claims information. The provider should independently verify medication history with the patient FILLED PRESCRIPTION SUMMARY Summary: Drug Name:StrengthOldest Most Recent #of DosageFill Date Fill DateFills HYDROCHLOROTHIAZIDE50 MG07/01/ /01/20032 INSULIN100 U/ML08/01/ /01/ GLUCOVANCE2.5/50012/15/ /25/20038 GLUCOTROL XL10 MG8/01/ /20/ PREVACID30 MG10/23/ /30/ MG09/23/ /23/20021 SLOW K10 MG10/29/ /29/ FILLED PRESCRIPTION DETAIL HYDROCHLOROTHIAZIDE Drug: HYDROCHLOROTHIAZIDE 50 mgFilled: 08/01/2003 Form:50 mg TABLET Quant:30Days: 60 Pharm:JOES PHARMACY #02236Source: PBM A MD/DO:JEFFRIES,RHONDA

39 Impact of Rx Claims on Clinical Detection Bieszk. Detection of nonadherence through review of pharmacy claims data Am J Health-System Pharm. 60: , visits w/ or w/o 6 months Rx claims report Mean age 61 yrs; 5.5 drugs per patient Abstractor-detected non-adherence: 57 vs. 58% MD-detected non-adherence: 30.5% vs. 0%* Drug changes: 1.3 vs. 0.3* (*p < 0.001) Dose changes, drug additions, discontinuations (all p<0.05) 46% of MDs saved 1-3 min per encounter Henry Ford Health System Clinics

40 Implementation: A Few Key Areas Decision Support Formulary Medication Lists

Electronic Prescribing: Physician - Pharmacy Issues; Building Community Initiatives Rick Ratliff Chief Operating Officer SureScripts

42 Four Core Ideas 1. Electronic prescribing is a process 2. Quality and efficiency 3. The journey begins with a first step 4. Community and trust

43 The prescribing process is more than just writing a prescription and dispensing a medication Before Encounter Schedule patient Pull patient chart Review patient chart After Encounter Re-file chart Clarification calls Prescription benefits issues Renewal authorizations P H Y S I C I A N Acquire Prescription Drop Off, Phone, Fax, IVR Insurance ID card Data input into computer Communicate Review of DUR alerts Handling of payer issues Patient counseling Renewal requests P H A R M A C I S T Encounter Interview patient re: meds Decide medication therapy Write prescription Document Rx in note Process Prescription Pharmacy DUR Claims: Payer DUR Claims: Eligibility / benefits Order fulfillment / dispense

44 Errors and inefficiencies in the encounter Patient monitoring Unknown meds? Did pt fill the prescription? Clinical decisions Access to expert info Complex drug coverage rules Writing the script Handwritten scripts are error-prone Est. 2.1 million ADE’s could be prevented with eRx (CITL) Before Encounter Schedule patient Pull patient chart Review patient chart After Encounter Re-file chart Clarification calls Prescription benefits issues Renewal authorizations P H Y S I C I A N Encounter Interview patient re: meds Decide medication therapy Write prescription Document Rx in note

45 Productivity and satisfaction… key moment: after the encounter Callbacks for clarification Handwriting, abbreviations, unclear verbal orders, fax problems… Coordinating prescription benefit issues Payer formularies and prior authorization Managing the renewal authorization process Calls and faxes taking unnecessary hours of staff and physician time (>2 hrs/day in a 3-MD practice) Nurses burdened with admin tasks Before Encounter Schedule patient Pull patient chart Review patient chart After Encounter Re-file chart Clarification calls Prescription benefits issues Renewal authorizations P H Y S I C I A N Encounter Interview patient re: meds Decide medication therapy Write prescription Document Rx in note

46 Physicians and pharmacists collaborate for improvement Patient Safety & Care Quality Clinical Practice Efficiency & Before Encounter Schedule patient Pull patient chart Review patient chart After Encounter Re-file chart Clarification calls Prescription benefits issues Renewal authorizations P H Y S I C I A N Encounter Interview patient re: meds Decide medication therapy Write prescription Document Rx in note Acquire Prescription Drop Off, Phone, Fax, IVR Insurance ID card Data input into computer Communicate Review of DUR alerts Handling of payer issues Patient counseling Renewal requests P H A R M A C I S T Process Prescription Pharmacy DUR Claims: Payer DUR Claims: Eligibility / benefits Order fulfillment / dispense

47 Roadmap of prescribing services for physician and pharmacy collaboration Services Providing True Connectivity Renewals New scripts Foundation for future collaboration Fair and open network Services Impacting Patient Cost Payer formularies Prior authoriz’n Rx change message Switch in class Services Impacting Patient Safety Drug interaction checks + safety net Medication history Patient compliance Patient-focused care management Prescribing Plus: Collaborate in the Journey Billing and scheduling Lab results Payer communications Referrals Diagnostic reports Charge capture and coding Clinical notes BasicPrescribingAdvancedPrescribing Toward an Automated Practice 123

48 Elements of Community Adoption Program (CAP) Alignment of stakeholders Physician organizations, health plans, health systems, pharmacies, pharmacist organizations, government agencies, others Key outcomes Shared vision and public endorsement of initiative Physician outreach through educational seminars Incentive programs (best are pay-for-utilization) Tipping point model Start with key opinion leaders Develop proof points in local markets Develop physician to physician programs

49 Market Example: Rhode Island Electronic Prescribing Project Stakeholders engaged in the project by Rhode Island Quality Institute Physician involvement was driven by a core group of physicians who collaborated on the planning and implementation of the project Over 70% of the state’s retail pharmacies connected into the electronic prescribing network Approximately 300 physicians participating with an expectation of 50% of physicians within Rhode Island participating by end of Summer 2004