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					Electronic Prescribing
 Tuesday, February 27, 1:00 PM - 2:00 PM
 Patricia Hale, MD, PhD, FACP
 HIMSS 07 Education Session 81

 www.pathalemd.com
Objectives:
   Describe how the electronic prescribing process specifically works
    to transmit medication information from the physician office to the
    pharmacy and within a regional health information network.
   List specific opportunities electronic prescribing provides to
    improve patient safety, office efficiency and control of health care
    costs.
   Specify challenges and barriers to implementation of electronic
    prescribing and how to address these issues.
   Evaluate resources available to assist in evaluation of electronic
    prescribing options and successful implementation.
   Discuss national electronic prescribing initiatives and how they
    may affect implementation.
   7,000 Americans Die Annually
From Preventable Medication Errors




                              1.5 Million Americans Injured Annually
                                by Preventable Medication Errors
                                                 Source: The Institute of Medicine of the
                                                 National Academies of Science (IOM).
                                                 Slide used by permission from SureScripts
                               The Challenge of “Prescription Hand-offs”
                               •     Illegible Handwriting
Physicians write               •     Unclear Abbreviations and Doses
4.5 billion prescriptions      •     Verbal Communication Among
                                     Physicians, Patients and Pharmacists
each year. . . .
                   On Paper!
   3.2 Billion Prescriptions Written Annually…
   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
            electronic prescribing systems
             could be as high as $27 billion
                  Sources: eHealth Initiative, 2004 and: Center for Information Technology Leadership, “The Value of
                  Computerized Provider Order Entry in Ambulatory Settings,” 2003.
         Rx
                                         Rx

Patient safety
   Between 1.5%-4.0% prescriptions                                 Rx
    are in error with serious patient
    risk
   Adverse drug events occur in 5%-
    18% of ambulatory patients
Quality of care - Compliance                     Illegible
   20% of scripts are never filled               handwriting
   Patient satisfaction is declining            Phone tag and
Cost of errors: $2 billion / year                 fax tag
                                                 Patient waiting
Impact on productivity*                           in the pharmacy
 Physician practice: 3 hours per day
   Pharmacy: 4 hours per day (up to 1
    call per Rx)
   Inefficient delivery
                                                                                                              Unfilled

    823 million visits to                                                             Renewals
                                                                                                                 0.4 B


     physician offices in 20001                                                                    0.5 B                                1.5 B

                                                                                                                                      Refills
    4 out of 5 patients who visit
     a physician leave with at
     least one prescription2                                                                                  1.4 B

                                                                                                      New Scripts
    65% of the US population
     (91% of Medicare) use a
                                                                                                      3.5 Billion Total Filled Prescription
     prescription medication                                                                                  Transactions in 2003
     each year3
1)   Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, 2002. National Center for Health Statistics. 2002.
2)   The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001.
3)   Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.
                                                                                      Best estimates for EMR
                                                                    Practice
                                                                                      adoption based on high
                                    Rx                                Size
                                                                                        quality surveys (%)
                                 InterOp
                                                                        All                         24
                                                                       Solo                         16
                                                                     Large*                         39
    150,000 Certified EMR Users                                       *”Large” is defined as > 20 physician FTEs in one
                                                                      study with 39% adoption and >50 in two another
        Certified version typically a                                studies with 47% and 57% adoption respectively.
         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. Slide used by permission from SureScripts
   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
                                                                Pharmacy
Prescriber                          ProxyMed and others          and PBM
   eRx
                                                               eRx Software
Software                   SureScripts Provides:
                          New Rx, refills, renewals,
                           authorizations, change
                           Rx, Prescription history
                              from pharmacies


                                     Medimedia
                                     and others


     RxHub Provides: Eligibility, Formularies, medication claims histories
      Minutes per day




                        Prescribers   Office staff
(2006 Study: Brown University)                   Slide used by permission from SureScripts
               Pen
                     Print
                     6%


                              Fax
                             37%
                                      EDI
                                       +
                                    Decision
                                    Support
                                    61%




Source: CITL                                   Slide used by permission from SureScripts
                                                                                                           “Evidence-
                                                           <5%                           National            Based”
                                  16-40%                                 National                           Medicine
                                                                          Health         Disease
                                                     Regional                           Databases
                 7-20%            Electronic          Health           Information
 40-80%                            Medical         Information        Infrastructure
                                   Records          Networks
 Patient &      Electronic         Systems
Physicians     Prescribing
  Access
 Medical
 Websites
                                        Increased Decision Support


                                                                                                       Algorithm-driven
                                                                                                        medicine and
                                                                                                        decision making
                                                                                 Population-
                                                              Streamlined
                                                                                  based outcomes
                                         Integrated                              and cost
                      Gains in
                                                                 information
                                          database allow                          information
                       accuracy and                              retrieval:
                                          decision                                readily available
  Better informed     connectivity       support tools          valuable for
                                                                 epidemiology     to consumers,
   consumers           enhance safety                                             physicians,
                       and efficiency                                             payers
   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)
   Cost of buying, installing and supporting a system
   Lack of reimbursement for costs and resources
   Increased time to use the system = reduced
    productivity (initially)
   Time required to review warnings, alerts and
    recommendations
   Still not considered a routine standard of practice
            In the past…                                           But now…
Very few pharmacies were directly connected to      Over 95% of US pharmacies are connected into
physician practices                                 a single network and growing

                                                    Computer applications can communicate directly
Electronic communications meant faxes
                                                    with each other

Only half the problem was being addressed…          Renewals can be automated in addition to new
writing new scripts                                 scripts

Software didn’t support the workflows in the        Software integrates with existing practice
practice                                            systems and smoothes office workflow

                                                    Most practices will save physician and staff time
There were few real benefits for most practices
                                                    as well as improve patient safety

                                                    Collaborate with pharmacies and payors on
There wasn’t a future path to additional benefits
                                                    patient compliance and other future functions

Automation was being driven by a few Health         State and nation-wide initiatives involving all
Plans and small software vendors                    major stakeholders
   Economic Incentives
       Grant and Loan Programs
       Reimbursement for Utilization
       Pay for Performance
       Malpractice Insurance Premium Reductions
       Healthcare IT Suppliers 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 ???
   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
     Eliminates anti-kickback regulation for hospital, physician groups and plan
      administrators 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
   Preempts State Laws contrary to the national standards or
    those that restrict the ability to carry out the new law.
   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    Launch 1-yr                                          All Medicare
    Secretary to      voluntary                         Deadline for    providers using
                                       Evaluation       Secretary to
      develop       ePrescribing                                       ePrescribing must
                                     results of pilot   finalize and
    ePrescribing   pilot program;                                       adopt finalized
                                     program due to        release
     Standards     plans can offer                                         standards
                                        Congress         standards
                         P4P



Sept 1, 2005       Jan 1, 2006        Apr 1, 2007       Apr 1, 2008       April 2009
   Bridges to Excellence
     “Physician Office Link”
     NCQA’s Physician Practice Connections
       Points for registry < eRx < EMR
   Integrated HealthCare Assoc (California)
     “technology is so critical to (program) success” (Williams)
     20% of bonus tied to (data collection) tech investment
   CMS
     Five pilots (includes tracking technology)
     “could account for 20-30% of what CMS pays providers”
       McClellan, WSJ, 9/17/04
The National ePrescribing Patient Safety Initiative
                    (NEPSI)

  A Coalition of the Nation’s Most Prominent Technology Companies,
       Healthcare Benefit And Medical Provider Organizations




   Dedicated to improving patient safety by providing free
    electronic prescribing for every physician in America



                                               Slide used by permission from NEPSI
National Sponsors   Technology Sponsors




                    Health Benefit Sponsors



                    Search Sponsor



                    Connectivity Sponsors
               The “ATM of Healthcare”
   eRx NOW™ from Allscripts
     Simple: Web-based E-prescribing Software
        Easy To Install and update
        Easy Interoperability
        Custom search engine from Google
     Safe
        Comprehensive Drug Interaction Checking
        Allscripts used by 20,000 MDs Nationwide
     Secure
        Secure anytime, anywhere access
        State-of-the-Art Privacy and Security
        Rigorous credentialing and authentication

                   www.nationaleRx.com

                                              Slide used by permission from NEPSI
                                         Rx         Hospital Payer LTC Others
                                Lab             Rad
Example Vendors                                              /PBM




                                  NHIN and RHIOs


                              Application Services
                               (ERx, EMR, HIS, PBHR, PHR, etc.)

                                                                                   Member
                  Physician
                                      Nurse            Patient
                                                                        Employee
                          Lab Tech        Pharmacist
                                                            Family
                                                                     Slide used by permission from SureScripts
Slide used by permission from SureScripts
Slide used by permission from SureScripts
Pharmacy Health Information Exchange™,
       operated by SureScripts®




E-Prescribing E-Refills   Rx History   Eligibility       Formulary


                                        Slide used by permission from SureScripts
                                             Inpatient
Pharmacy     In-store              HIS
                                             Pharmacy                                                Practice
Rx History    Clinics                                                                       EMR
                                                                                                    Management
                                             Emergency
 MTM &
                                             Department                                             Electronic
Care Mgmt
                                                                                                    Prescribing
                                           Hospitals
Pharmacies
                                                                   $                                Physicians

                                                                                                         Patients
                                                                                                          Home Care
                                                                                                          Monitoring

                                                                                                          Intelligent
                                                                                              PHR
                                                                                                            Dosing




                                                          $                                  Payers / PBMs
                                                                                            Payer-based
                                                                                                              P4P
                                                                                            Health Rec.


                                         $
                                                                             Prescription    Formulary     Predictive
                                                                RHIOs          History       & Guides      Modeling

                                                              Integration
                              Government                       Platform

                                                    Patient   Information
                        CDC       DEA
                                                   Locators     Policies
                                                                            Slide used by permission from SureScripts
                                                 System
       Company                      Product               E-Prescrib.   E-Refills   Rx History* Formulary* Eligibility
                                                  Type

A4 Health Systems      Healthmatics® EMR          EMR


Allscripts             TouchWorks/ TouchScript   EP/EMR


Allscripts/NEPSI       eRx NOW™                  EP/EMR


ASP.MD                 ASP.MD                     EMR


athenahealth           athenahealth               EMR


Axolotl                Axolotl                   EP/EMR


BCBS/AL                InfoSolutions              EP


BMA Enterprises        Chart Management System    EMR


Bond Medical           BondMedical, Inc           EMR


Cerner                 Community Health Record    EP


ChartConnect           MedManager                EP/EMR


DAW Systems            ScriptSure                 EP


DrFirst                DrFirst Rcopia             EP

eClinicalWorks, Inc.   eClinicalWorks             EMR

                                                  Slide used by permission from SureScripts
                                                      System
         Company                   Product                      E-Prescrib.   E-Refills   Rx History* Formulary* Eligibility
                                                       Type

eHealthSolutions      eHealthSolutions                 EP

e-MDs                 e-MDs Solution Series           EMR

Epic                  Epicare Ambulatory EMR          EMR

Gold Standard         eMPOWERx                         EP

Health Sys Research   Clinipath                       EMR

iSALUS                OfficeEMR™                      EMR

InstantDx             OnCallData                       EP

                      Providing connectivity for GE
Kryptiq               Centricity®EMR
                                                      EMR

LighthouseMD          CareTracker                      EP

McKesson              Horizon Ambulatory Care™        EMR

M.D. Web Solutions    AMCIS EMR                       EMR

Medent                MEDENT                          EMR

MedCommSys            mMD.net EMR                     EMR

MedicWare             MedicWare EMR                   EMR




                                                            Slide used by permission from SureScripts
                                            System
       Company                    Product               E-Prescrib.   E-Refills   Rx History* Formulary* Eligibility
                                             Type

MedNet System       emr4MD                   EMR

MedPlexus           MedPlexus                EMR

MedPlus             Care360                   EP

NaviMedix           NaviNet                 e-refills

Netsmart –          InfoScriber               EP
InfoScriber
NewCrop             NewCrop                   EP

NextGen®            NextGen EMR              EMR

OA Systems          Rx Cure                   EP

Polaris –Epichart   EpiChart                 EMR

Practice Partner    Practice Partner         EMR

RelayHealth         eScript™                  EP

RxNT                RxNT                      EP

SOAPware            SOAPware                 EMR

SSIMED              EMRge™                   EMR



                                             Slide used by permission from SureScripts
                                            System
       Company                    Product            E-Prescrib.   E-Refills   Rx History* Formulary* Eligibility
                                             Type

SynaMed                SynaMed              EMR

VipaHealth Solutions   SmartEMR             EMR

Wellogic               Consult              EMR

ZixCorp                PocketScript          EP




                                            Slide used by permission from SureScripts
   GoldRx certification status
      Certification based on standards alone no longer
       adequate
      Which vendors are not just testing and marketing
       interoperability
      Which vendors 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
   The first products to achieve
    GoldRx certification:
        TouchWorks EHR(Allscripts)
        ChartConnect EMR
        Rcopia (DrFirst)
        NextGen EMR
        eScript (RelayHealth)
        Pocketscript (Zix)




        Slide used by permission from SureScripts
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
Certification Commission for Health Information
Technology (CCHIT)
CCHIT Certification EMR ePrescribing Criteria            2007   2008   2009
                                                         l
Send an electronic prescription to pharmacy
Send a query for formulary information                          l

Send a query for medication history to PBM or pharmacy          l
and import medication list into EHR
Respond to a request for a refill sent from a pharmacy   l

Receive medication fulfillment history                          l

Respond to a request for a prescription change from a           l
pharmacy
                                                                l
Send a cancel prescription message to a pharmacy

Send electronic prescription to pharmacy including                     l
structured and coded SIG instructions
                    RxHub              SureScripts

Source of Data      Claims data from   Dispensed Drug Data
                    PBMs               from Pharmacies
Interoperability    Pass-through       Repository
Model
Details Included    No sig             Sig (unstructured)


Regional Coverage   Plan dependent     Pharmacy dependent


Pricing             $$$                $


          44
45
46
   A4 Health            InstantDx           OA Systems
   Achieve
   Allscripts           iScribe             Phytel
   Athena Health        MA Share            Purkinje
   Bond Medical
   Catalis Health       McKesson            Relay Health RxNT
   Cerner               MDAnywhere          SafeMed
   DrFirst
   eClinical Works      MdOffices           Script IQ
   eHealth Solutions    Medical Info Sys    ScriptRx
   EmDeon/WebMD
   EPIC                 MedicWare           Scriptsure
   Gold Standard        MedKeeper           Sequel Systems
   H2H Solutions
   Health Vision        MedPlus             SSIMED
                         Medport             STI Con
                         NewCrop             Synamed
                         NextGen             Zix Corporation

Bold = in production
          47
   SureScripts Certified EMR solution providers represent approximately 65%
    of all physicians that use an EMR system

   SureScripts Certified e-prescribing solution providers represent
    approximately 90% of total market of stand-alone solutions

   SureScripts contracted, but not yet certified EMR solution providers
    represent close to 20% of all Physician EMR users




SureScripts Certified and contracted solution providers
          represent over 150,000 prescribers
                                             Slide used by permission from SureScripts
As of February 2nd, 2004 - 25 States         As of February 2nd, 2007 - 48 States and
 cleared for electronic prescribing      Washington, D.C. cleared for electronic prescribing




                                       Slide used by permission from SureScripts
     Not shown: HI: 42%; AL: 24%; As of November 9, 2006
51
   Access to more than 160 million patient prescription information
    records for consenting patients, via payers and PBMs, through the
    growing list of RxHub certified technology partners. Contracts with
    payers and PBMs were executed representing additional access to more
    than 50 million patients though RxHub.
   An increase in transaction volumes of 50% from 29 million
    transactions in 2005 to more than 43 million transactions in 2006. 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.
   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
   Educational material and resources
“We tried dedicating this computer to deciphering our
                doctors' handwriting."
                     Cartoon by Dave Harbaugh
Contact me at: pathale@pathalemd.com

Web site with further information and links:
www.pathalemd.com

				
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