1. e-Prescribing Current Issues and the road ahead
Patricia L. Hale, MD, PhD, FACP
CMIO, Glens Falls Hospital and CTO , Adirondack Regional Community Health Information Exchange
e-Prescribing Current Issues and the road ahead

2. E-Prescribing – Current Issues and the Road Ahead
Learning Objectives
Impact of e-prescribing on patient safety and reduction of medication errors
What’s new
Explore the training requirements for physicians
Explore the implementation differences between a small medical practice and an RHIN

3. A Public Health Crisis 7,000 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.
1.5 Million Americans Injured Annually
by Preventable Medication Errors
Source: The Institute of Medicine of the National Academies of Science (IOM).2006
Slide used by permission from SureScripts

4. The Challenge On Paper! Physicians write 4.5 billion prescriptions
The Challenge of “Prescription Hand-offs”
Illegible Handwriting
Unclear Abbreviations and Doses
Verbal Communication Among
Physicians, Patients and Pharmacists
Physicians write
4.5 billion prescriptions
each year
On Paper!
Major problem is COMMUNICATION… either on paper, verbal or FAX
Usually 2-3 people (physician, office staff, pharmacy staff) are involved in communicating the prescription
Multiple people involved in the process increase the risk of errors (the “telephone game”)

5. The Technology is Available Today…But Not Used
Over 4.5 Billion Prescriptions Written Annually…
Less than 1 in 5 of Physicians Use e-Prescribing
Only 20% of prescriptions are prescribed electronically with 80% still handwritten
Most electronic prescriptions are still sent by FAX
Key Points:
So it has been six years since the IOM’s first report and the question is have we made any progress?
Unfortunately, not enough.
With over 4.5 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 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 as high as $27 billion
Sources: eHealth Initiative, and: Center for Information Technology Leadership, “The Value of Computerized Provider Order Entry in Ambulatory Settings,” 2003.

6. The Current System Causes a Number of Serious Problems !Rx 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
Quality of care - Compliance
20% of scripts are never filled
Patient satisfaction is declining
Cost of errors: $2 billion / year
Impact on productivity*
Physician practice: 3 hours per day
Pharmacy: 4 hours per day (up to 1 call per Rx)
Inefficient delivery Rx
Illegible handwriting
Phone tag and fax tag
Patient waiting in the pharmacy

7. The number of prescriptions in the US is rapidly increasing
Unfilled
823 million visits to physician offices in 20001
4 out of 5 patients who visit a physician leave with at least one prescription2
65% of the US population (91% of Medicare) use a prescription medication each year3
0.4 B
Renewals
0.5 B
1.5 B
Refills
1.4 B
New Scripts
The older, more complex and vulnerable patients are the ones with the most prescriptions and are at the highest risk for error.
3.5 Billion Total Filled Prescription Transactions in 2003 increased to 4.5 in 2006
1) Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, National Center for Health Statistics
2) The chain pharmacy industry profile. National Association of Chain Drug Stores
3) Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.

8. Best estimates for EMR adoption based on high quality surveys (%)
Electronic prescribing is under-utilized: Purchasing software does not equal adoption or effective use
Practice Size
Best estimates for EMR adoption based on high quality surveys (%)
All 24
Solo 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, Slide used by permission from SureScripts

9. Full e-Prescribing includes:
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

10. Intermediaries for Data Transfer
Pharmacy and PBM
eRx Software
Prescriber
eRx
Software
ProxyMed and others
SureScripts Provides:
New Rx, refills, renewals, authorizations, change Rx, Prescription history from pharmacies
Examples of intermediaries in the transfer of prescription information from the physician office to the pharmacy.
Medimedia and others
RxHub Provides: Eligibility, Formularies, medication claims histories

11. Impact of e-prescribing on time spent (minutes/day) on refills/renewals
Minutes per day
NOTES: Participants of the e-prescribing standards study = located in six states using 1 of 6 different physician software applications)
Average time spent per day among clinicians decreased in half – from 35 minutes per day to 17 minutes per day. Staff time spent on refills and
Renewals also was cut in half – from 87 minutes per day to 43 minutes per day.
Prescribers
Office staff
(2006 Study: Brown University)
Slide used by permission from SureScripts

12. Impact of E-Prescribing on Preventable Adverse Drug Events (ADEs)
Pen
Print 6%
Fax 37%
The major impact occurs when clinical decision support is available at the time of prescribing. Unfortunately many clinician offices have office staff performing much of the prescribing process limiting access to this information by clinicians at the time of decision making. Physician practices that can integrate electronic prescribing directly in to physician work flow will result in the greatest safety benefit.
EDI +
Decision
Support
61%
Source: CITL
Slide used by permission from SureScripts

13. Connectivity Roadmap – Using computer technology to improve patient care
“Evidence-Based” Medicine
16-40%
<5%
National
Disease Databases
National Health Information Infrastructure
Regional Health Information Networks
7-20%
Electronic Medical Records Systems
40-80%
Electronic Prescribing
Patient & Physicians Access
Medical Websites
Increased Decision Support
Algorithm-driven medicine and decision making
Population-based outcomes and cost information readily available to consumers, physicians, payers
Streamlined information retrieval: valuable for epidemiology
Integrated database allow decision support tools
Gains in accuracy and connectivity enhance safety and efficiency
Better informed consumers

14. Who Benefits from eRx?

15. Potential Benefits of eRx
Patients:
Increased safety, efficiency and compliance
Lower co-pays
Pharmacies:
Increased efficiency, improved care, improved patient satisfaction
Payors/PBMs:
Increased generic/formulary usage, efficiency, Rx compliance and prevention of ADEs (reduced costs)
Providers:
Increased efficiency, improved care, patient satisfaction and potential incentives (pay-for-performance)

16. But… Providers are concerned about…
Cost of buying, installing, implementing and supporting a system
Lack of reimbursement for costs, time and resources
Increased time to use the system = reduced productivity (initially)
Increased time required to review warnings, alerts and recommendations (long term)
Still not considered a routine standard of practice

17. Why now? The problems of past efforts have been successfully addressed…
In the past…
But now…
Very few pharmacies were directly connected to physician practices
Over 95% of US pharmacies are connected into a single network and growing
Electronic communications meant faxes
Computer applications can communicate directly with each other
Only half the problem was being addressed… writing new scripts
Renewals can be automated in addition to new scripts
Software didn’t support the workflows in the practice
Software integrates with existing practice systems and smoothes office workflow
There were few real benefits for most practices
Most practices will save physician and staff time as well as improve patient safety
There wasn’t a future path to additional benefits
Collaboration now available with payors on patient compliance and other future functions
Automation was being driven by a few Health Plans and small software vendors
State and nation-wide initiatives now occur involving all major stakeholders

18. What Initiatives and Incentives Will Drive Future Adoption of eRx?

19. An Overview of Potential Incentives
Economic Incentives
Grant and Loan Programs
Reimbursement for Utilization
Pay for Performance
Malpractice Insurance Premium Reductions
Healthcare IT Suppliers group discounts, etc
Pharmacies or Transaction Brokers Defray Costs
Policy Incentives and Programs
Accreditation (JCAHO 2005 Hospitals’ National Patient Safety Goals, others in development)
Employer Programs (Leapfrog and others)
Medicare support for economic incentives
DOQ-IT
CCHIT certification of inpatient and ambulatory EMRs
Mandates ???

20. 2003 Medicare Bill - eRx Provisions
Voluntary program
Mandatory National eRx Standards for Medicare
Initial standards 2005; Pilot program 2006, Final Standards 2009
Recommendations delivered by NCVHS
Information Requirements include
Lower cost, therapeutically appropriate alternatives
Interactive, real-time to the extent feasible
Encourages Physician Adoption:
Permits use of appropriate messaging
Modifies anti-kickback regulation for hospital, physician groups and plan administrators to allow them to give out eRx hardware and training
Allows plans to pay-for-technology and pay-for-cost effective performance in Medicare Advantage Plans
$50MM of federal grant money in 2007 (but must be budgeted)
Preempts State Laws contrary to the national standards or those that restrict the ability to carry out the new law.

21. Regulations (CMS/MMA) & ePrescribing
Progress-to-date
Issued Notice of Proposed Rule-Making (10/05)
Issued final rule naming foundation standards (11/05)
Pilot programs competed and reports submitted (2/06)
Deadline for Secretary to develop ePrescribing Standards
Sept 1, 2005
Jan 1, 2006
Apr 1, 2007
Apr 1, 2008
April 2009
Launch 1-yr voluntary ePrescribing pilot program; plans can offer P4P
Evaluation results of pilot program due to Congress
Deadline for Secretary to finalize and release standards
All Medicare providers using ePrescribing must adopt finalized standards
Lawmakers seem to be well aware of where we are. Besides standards, they built in other incentives to increase adoption of electronic prescribing.
For one, discretionary grants may be made available to prescribers. The 2004 budget set aside $100 million.
They also defined exceptions to the Stark Laws, which limited hospitals, plans and group practices from purchasing hardware for physicians.
Finally, they allowed plans to pay additional fees for reduced medication errors, formulary compliance and fewer adverse drug events. Plans are still working out how to implement this component of the MMA.
While NCVHS has already begun evaluating standards, the timeline stretches into 2009.

22. What’s New?

23. Interim Results From CMS e-Prescribing Pilots

24. e-Prescribing Pilot Participants
RAND – New Jersey BCBS NJ, Caremark mail order, Walgreen retail pharmacy
Brigham & Women’s Hospital - CareGroup Health system in Boston use in EMR and e-prescribing “Gateway” utility
Achieve – tech vendor for long term care industry in Midwest with it’s own pharmacies
Ohio University Hospital Health System and Ohio KePRO QIO hospital physician practices
Surescripts - with practices in Florida, Mass, Nevada, New Jersey and Tennessee with a variety of software vendor systems and assortment of chain and independent pharmacies

25. Interim Results
Med History – recommended to be included as ready for adoption. Main challenge is ensuring the data is collected and reconciled from a large number of sources to be sure history is complete.
Formulary and Benefits – recommended to be included as ready for adoption. Issues:
Systems must adequately match patient to health plan
Payers vary in the level of information provided making data difficult to interpret
Should support real-time changes in patient status as patient moves between benefit plans

26. Interim Results
Prescription Fill Status Notification – recommended to be included as ready for adoption. However many pharmacies do not currently have the ability to track patient pick-up status accurately and questionable prescriber demand for this if the info is already available in the med history.
Prior Authorization – NOT recommended for implementation – Limited experience at pilot sites to evaluate this function and there are work flow and other issues which suggest a need to have more work done to improve the standard.
Structured and Codified Sig - NOT recommended for implementation – needs additional work with reference to field definitions and examples as well as naming conventions and clarification of field use.

27. Interim Results
RxNorm – (standard for name, dose and form of drugs) – Not recommended for implementation – Dictionary standard requires further evaluation and refinement.
Recommended updates to SCRIPT v8.1 – Need to further refine the standard to be able to:
update prescriptions without having to create a new order,
send a refill from the facility to the pharmacy without physician intervention,
update patient information outside the context of prescriptions

28. Interim Results
Prescriber staff (“surrogate prescribers”) played a much more important role in the process than anticipated.
Never fully replaces need for paper-based prescribing
Causes a shift in pharmacy work flow
Poor adoption and use of medication history
Long term care site reported a reduction in new prescription rate which may indicate reduction in accumulation of multiple medication
Not enough data yet on effects on safety or change in use of generic medications.

29. New and expanded Programs to promote electronic prescribing

30. New Efforts to Increase eRx Adoption
The National ePrescribing Patient Safety Initiative
(NEPSI)
A Coalition of the Nation’s Most Prominent Technology Companies,
Healthcare Benefit And Medical Provider Organizations
Key Points:
a group of leading technology companies, health insurers and provider organizations that have “the will, the resources, and the technology to address this serious problems of medication errors in this country.”
The members of NEPSI believe “the current status quo is unacceptable, that we can do better”
NEPSI will make free Electronic Prescribing available to Every Physician in America, especially those practicing in underserved areas, where the cost of implementing this technology has been a significant barrier to adoption.
By providing every physician in America e-prescribing, “we also provide them an on-ramp to the healthcare information superhighway – and that highway is being supported by a number of the largest companies in the country…”
“Dedicated to improving patient safety by providing free electronic prescribing for every physician in America”
Slide used by permission from NEPSI

31. NEPSI Coalition Sponsors
National Sponsors
Technology Sponsors
Health Benefit Sponsors
Key Points:
The coalition includes leading organizations and key stakeholders in healthcare and technology
Our national sponsor is Dell, which has taken a leadership role in the Coalition.
Also have a “who’s who” of technology companies– including, Cisco, Fujitsu Microsoft
Google is a partner and has developed a Custom Search Engine for this initiative
Information and content partner is Wolters Kluwer Health
Telecom partner is Sprint who, in addition to their financial commitment will also be donating e-prescribing enabled phones to the first physicians that sign up.
Importantly, the coalition also includes Wellpoint and Aetna, two of the largest healthcare payers in the nation, as well as regional payers such as Horizon Blue Cross Blue Shield of New Jersey.
Search Sponsor
Connectivity Sponsors
Slide used by permission from NEPSI

32. eRx NOW™ -Advertised as “Simple, Safe, Secure and Free ePrescribing”
The “ATM of Healthcare??”
eRx NOW™ from Allscripts described as:
Simple: Web-based E-prescribing Software
Easy To Install and update
Easy Interoperability
Custom search engine from Google
Formulary information available
Safe
Comprehensive Allergy and Drug Interaction Checking
Secure
Secure anytime, anywhere access
Rigorous credentialing and authentication
Highlight key points about the product:
The solution NEPSI will provide is designed to be safe, simple and smart. It is also interoperable Web-based e-prescribing software program complete with hosting, support, clinical content, insurance formulary information and connectivity to 55,000 US pharmacies from our partner surescripts
eRx NOW™ is a stand-alone, web-based version of Allscripts existing electronic prescribing solution that is already used by 20,000 physicians Nationwide to write millions of electronic prescriptions today.
Importantly, eRx State-of-the-Art Privacy and Security
In the same way that the ATM provide a simple, secure and safe standard for banking that could be accessed anywhere at anytime, eRx NOW will provide a similar approach for prescription writing.
Slide used by permission from NEPSI

33. Surescripts network

34. Over 95% of the nation’s community pharmacies have systems certified to connect to the Pharmacy Health Information Exchange™
Slide used by permission from SureScripts

35. All major physician technology vendors in the United States are certified on the Pharmacy Health Information Exchange™
Slide used by permission from SureScripts

36. SureScripts Network Services
Pharmacy Health Information Exchange™,
operated by SureScripts®
E-Prescribing
E-Refills
Rx History
Eligibility
Formulary
Slide used by permission from SureScripts

37. SureScripts Certification is Not Universal – Vendors are Certified by Service/Message Type
EMR
eClinicalWorks
eClinicalWorks, Inc. EP
DrFirst Rcopia
DrFirst
ScriptSure
DAW Systems
EP/EMR
MedManager
ChartConnect
Community Health Record
Cerner
BondMedical, Inc
Bond Medical
Chart Management System
BMA Enterprises
InfoSolutions
BCBS/AL
Axolotl
athenahealth
ASP.MD
eRx NOW™
Allscripts/NEPSI
TouchWorks/ TouchScript
Allscripts
Healthmatics® EMR
A4 Health Systems
Eligibility
Formulary*
Rx History*
E-Refills
E-Prescrib.
System Type
Product
Company
Slide used by permission from SureScripts

38. “Granting physician software and service providers a uniform certification for pharmacy interoperability is no longer adequate”
GoldRx certification status
No longer based on just compliance to standards
Identifies which vendors are not just testing and marketing interoperability but are truly delivering and committed to:
Customer Education
Proven Pharmacy Interoperability
Advanced Medication Management
Workflow Enhancements & Demonstrable Expert Experience with Electronic Prescribing Process
Slide used by permission from SureScripts

39. “Granting physician software and service providers a uniform certification for pharmacy interoperability is no longer adequate”
The first products to achieve GoldRx certification announced in Feb 2007:
TouchWorks EHR(Allscripts)
ChartConnect EMR
Rcopia (DrFirst)
NextGen EMR
eScript (RelayHealth)
Pocketscript (Zix)
“These six technology vendors have not only made the commitment, but also have demonstrated their ability to provide their customers with clinical solutions that go above and beyond the “technical” requirements of electronic prescribing. “
These vendors are delivering and committed to:
Customer Education
Proven Pharmacy Interoperability
Advanced Medication Management
Workflow Enhancements & Demonstrable Expert Experience with Electronic Prescribing Process
Slide used by permission from SureScripts

40. Nation’s Community Pharmacies Announce Key Indicator For Patient Safety In The U.S.: The Top 10 States For Electronic Prescribing
Created by the National Association of Chain Drug Stores, the National Community Pharmacists Association and SureScripts
The Safe-Rx Awards was created to: “Raise awareness of e-prescribing as a more secure, accurate and informed means of prescribing patients medication.”
Honors the Top 10 states that are leading the nation in electronic prescribing. (Not fax transmissions – true EDI)
States are ranked by the number of prescriptions routed electronically in 2006 as a percentage of the total number of prescriptions eligible for electronic routing. (i.e., Controlled substances are excluded).
Created by the National Association of Chain Drug Stores, the National Community Pharmacists Association and SureScripts, operator of the Pharmacy Health Information Exchange. (This is the second annual awards. Last year RI was #1, MA was #3, MI was #10 and WA and NJ were not in the top 10 – FL and VA were in last year but not this year.)
Last Year: RI was #1, MA was #3, MI was #10, WA and NJ not on last years list and  FL and VA were in last year’s Top 10
Slide used by permission from SureScripts

41. Certification by CCHIT
Certification Commission for Health Information Technology (CCHIT)
Certification by CCHIT

42. Ambulatory EMR CCHIT ePrescibing Criteria
CCHIT Certification EMR ePrescribing Criteria
2007
2008
2009
Send an electronic prescription to pharmacy l
Send a query for formulary information
Send a query for medication history to PBM or pharmacy and import medication list into EHR
Respond to a request for a refill sent from a pharmacy
Receive medication fulfillment history
Respond to a request for a prescription change from a pharmacy
Send a cancel prescription message to a pharmacy
Send electronic prescription to pharmacy including structured and coded SIG instructions

43. Medication History

44. Medication History – Current Options
RxHub
SureScripts
Source of Data
Claims data from PBMs
Dispensed Drug Data from Pharmacies
Interoperability Model
Pass-through
Repository
Details Included
No sig
Sig (unstructured)
Regional Coverage
Plan dependent
Pharmacy dependent
Pricing
$$$ $

45. Example of Rx Claims History via RxHub

47. RxHub-connected eRx/EMR Vendors
A4 Health
Achieve
Allscripts
Athena Health
Bond Medical
Catalis Health
Cerner
DrFirst
eClinical Works
eHealth Solutions
EmDeon/WebMD
EPIC
Gold Standard
H2H Solutions
Health Vision
InstantDx
iScribe
MA Share
McKesson
MDAnywhere
MdOffices
Medical Info Sys
MedicWare
MedKeeper
MedPlus
Medport
NewCrop
NextGen
OA Systems
Phytel
Purkinje
Relay Health RxNT
SafeMed
Script IQ
ScriptRx
Scriptsure
Sequel Systems
SSIMED
STI Con
Synamed
Zix Corporation
Bold = in production

48. Health care professionals can register for an ICERx.org account at or call ICERX.50 ( ).
ICERx.org

49. ICERx.org
During periods of emergency, licensed health care professionals who have registered on ICERx.org can login to the online prescription database, where they will have access to:
Evacuee prescription history information and the name of the provider who wrote the prescription and the pharmacy that filled it
Available patient clinical alerts, including drug interaction, therapeutic duplication and elderly alerts
Clinical pharmacology drug reference information, including drug monographs, interaction reports and the drug identifier tool

50. Evidence of increased adoption

51. Paving the way for pharmacy connectivity…
Paving the way for pharmacy connectivity… …Overcoming legal and regulatory barriers
As of February 2nd, States cleared for electronic prescribing
As of February 2nd, States and Washington, D.C. cleared for electronic prescribing
Slide used by permission from SureScripts

52. Pharmacy Activation By State
Not shown: HI: 42%; AL: 24%; As of November 9, 2006

53. RxHub Adoption Data
Access to more than 160 million patient prescription information records via payers and PBMs, through the growing list of RxHub certified technology partners. Direct contracts with payers and PBMs represent additional access to more than 50 million patients.
An increase in transaction volumes of 50% from 29 million transactions in 2005 to more than 43 million transactions in These transactions were real-time requests for patient eligibility and benefits, formulary, and medication history information, made at the point-of-care in the ambulatory and acute care settings from clinicians across the United States.
A ten-fold increase in true electronic prescriptions, which includes the transmission of patient-specific clinical decision support information at the point of prescribing, to retail and mail order pharmacy locations of the patient’s choice.

54. Training requirements for physicians

56. Training Requirements for Physicians
No two medical practices are alike – evaluation of current processes is critical in determining best product and implementation plan
Physicians learn by apprentice model – be sure there is a physician champion
Evaluate requirements for physician training early and plan schedules to accommodate decreased productivity
Workflow is a critical factor in success

57. Training Requirements for Physicians
Staff roll in the prescribing process is a major influence on potential success and usually underestimated
Time for training and implementation should be maximized (consider vendor recommendations as a MINIMUM)

58. Differences in Implementation in a Small Practice or a RHIN -
When implementation of electronic prescribing is through a regional health information network new issues arise which include:
Management of shared medication lists
Management of shared problems lists
Opportunity for aggregated medication history data
Increased concerns about secondary use of prescriber data

59. Why Is Now the Right Time to e-Prescribe?
More options for stand alone, certified EMR and information network based electronic prescribing products
Increased connectivity of pharmacies and PBMs
Increased functionality to improve office efficiency (electronic refills)
Support for implementation through programs like DOQ-IT and others
Grant, P4P and other funding opportunities
New educational material and resources are available

60. Cartoon by Dave Harbaugh
“We tried dedicating this computer to deciphering our doctors' handwriting."
Cartoon by Dave Harbaugh

61. Questions? Contact me at: pathale@pathalemd.com
Web site with further information and links: