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Patricia L. Hale, MD, PhD, FACP
CMIO, Glens Falls Hospital and CTO , Adirondack Regional
Community Health Information Exchange
pathale@pathalemd.com
www.pathalemd.com
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
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).2006
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!
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
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
prescription medication 3.5 Billion Total Filled Prescription
Transactions in 2003 increased to 4.5 in
each year3 2006
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, 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
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
Collaboration now available with 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 now occur
Plans and small software vendors involving all major stakeholders
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 ???
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.
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
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 - 300 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
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
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.
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
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.
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 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
www.nationaleRx.com
Slide used by permission from NEPSI
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
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
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
The first products to achieve
GoldRx certification
announced in Feb 2007:
TouchWorks EHR(Allscripts)
ChartConnect EMR
Rcopia (DrFirst)
NextGen EMR
eScript (RelayHealth)
Pocketscript (Zix)
Slide used by permission from SureScripts
Created by the National
Association of Chain Drug
Stores, the National
Community Pharmacists
Association and 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
Health care professionals can register for an
ICERx.org account at www.ICERx.org or call
1.888.ICERX.50 (888-423-7950).
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
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
52
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 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.
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
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)
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
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
“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
