Electronic Prescribing: Planning and Implementation to Achieve Success and Maximize Value

1
Electronic Prescribing Planning and
Implementation to Achieve Success and Maximize
Value

• Jonathan TeichPat HalePeter BaschBob Elson
• Rick Ratliff

2
www.ehealthinitiative.org/initiatives/erx
3
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.

5
(No Transcript)
6
(No Transcript)
7
PDAs

• 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

8
(No Transcript)
9
Formulary Checking
10
Stages of eRx
11
eRx Value

• There are significant errors and ADEs
• Gandhi ADEs in 5-18 of ambulatory pts/yr
• CITL Nationwide adoption of ACPOE predicted to
  eliminate 2.1 million ADEs/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

12
Electronic Prescribing Planning and
Implementation to Achieve Success and Maximize
Value A Providers Perspective

• Peter Basch, MD
• Medical Director
• MedStar e-Health Initiative

13
MedStars 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 physicians practice (as well
  as wins for other stakeholders)

14
MeHIs 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
MeHIs 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 theres bad handwriting, missing decimal
  points, and just bad judgment
• But if you want to be heard by doctors
• Exponential increase in new drugs
• More patients with multiple conditions taking
  multiple meds
• Multi-tasking is efficient but can lead to errors
• eRx is the right thing to do, and can be done
  today
• eRx 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. Palm
• Synchronous 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 doesnt 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
  chart
• Always print it for the chart, or
• 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

21
Electronic PrescribingManaging 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
• Desktop
• PDAs
• Lists
• 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
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
• Formularies
• Favorites
• 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

30
Electronic PrescribingManaging 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, 2004.1160-70.
Fernando, B. Prescribing safety features of GP
computer systems. BMJ. 20043281171
32
Application Safety User vs. System Error
Intelligent Intervening Provider
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
Eligibility-driven Formulary Mapping
eRx Utility
PBM
Clinic System(eRx, EMR)
PBM
PBM
Multiple responses combined
37
Claims-based Prescription History
PBM
eRx Utility
Clinic System(eRx, EMR)
PBM
PBM
38
Sample Rx Claims History Report
Patient Filled Prescription Report Patient
ID PATID1234 Name JONES, WILLIAM
A. Address 1200 N ELM STREET GREENSBORO, NC
27401-1020 DOB 06/15/1961 Gender 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 ------------------- Su
mmary Drug Name Strength Oldest Most Recent
of Dosage Fill Date Fill
Date Fills HYDROCHLOROTHIAZIDE 50 MG 07/01/2002
08/01/2003 2 INSULIN 100 U/ML 08/01/2002
08/01/2003 13 GLUCOVANCE 2.5/500 12/15/2002
07/25/2003 8 GLUCOTROL XL 10 MG 8/01/2002
07/20/2003 12 PREVACID 30 MG 10/23/2002
06/30/2003 7 15 MG 09/23/2002
09/23/2002 1 SLOW K 10 MG 10/29/2002
06/29/2003 6 ----------------------- FILLED
PRESCRIPTION DETAIL -------------------- HYDROCHLO
ROTHIAZIDE Drug HYDROCHLOROTHIAZIDE 50
mg Filled 08/01/2003 Form 50 mg
TABLET Quant 30 Days 60 Pharm JOES
PHARMACY 02236 Source PBM A MD/DO JEFFRIES,R
HONDA
39
Impact of Rx Claims on Clinical Detection
Henry Ford Health System Clinics

• 231 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 lt 0.001)
• Dose changes, drug additions, discontinuations
  (all plt0.05)
• 46 of MDs saved 1-3 min per encounter

Bieszk. Detection of nonadherence through review
of pharmacy claims data Am J Health-System Pharm.
60360-366, 2003.
40
Implementation A Few Key Areas

• Decision Support
• Formulary
• Medication Lists

41
Electronic PrescribingPhysician - 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
P H Y S I C I A N
P H A R M A C I S T
Before Encounter
Acquire Prescription
Schedule patient
Drop Off, Phone, Fax, IVR
Pull patient chart
Insurance ID card
Review patient chart
Data input into computer
Encounter
Process Prescription
Interview patient re meds
Pharmacy DUR
Decide medication therapy
Claims Payer DUR
Write prescription
Claims Eligibility / benefits
Document Rx in note
Order fulfillment / dispense
After Encounter
Communicate
Re-file chart
Review of DUR alerts
Clarification calls
Handling of payer issues
Prescription benefits issues
Patient counseling
Renewal authorizations
Renewal requests
44
Errors and inefficiencies in the encounter
P H Y S I C I A N

• 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 ADEs could be prevented with
  eRx (CITL)

Before Encounter
Schedule patient
Pull patient chart
Review patient chart
Encounter
Interview patient re meds
Decide medication therapy
Write prescription
Document Rx in note
After Encounter
Re-file chart
Clarification calls
Prescription benefits issues
Renewal authorizations
45
Productivity and satisfactionkey 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 (gt2 hrs/day in a 3-MD
  practice)
• Nurses burdened with admin tasks

P H Y S I C I A N
Before Encounter
Schedule patient
Pull patient chart
Review patient chart
Encounter
Interview patient re meds
Decide medication therapy
Write prescription
Document Rx in note
After Encounter
Re-file chart
Clarification calls
Prescription benefits issues
Renewal authorizations
46
Physicians and pharmacists collaborate for
improvement
P H Y S I C I A N
P H A R M A C I S T
Before Encounter
Acquire Prescription
Patient Safety Care Quality
Schedule patient
Drop Off, Phone, Fax, IVR
Pull patient chart
Insurance ID card
Review patient chart
Data input into computer
Encounter
Process Prescription
Interview patient re meds
Pharmacy DUR

Decide medication therapy
Claims Payer DUR
Write prescription
Claims Eligibility / benefits
Document Rx in note
Order fulfillment / dispense
Clinical Practice Efficiency
After Encounter
Communicate
Re-file chart
Review of DUR alerts
Clarification calls
Handling of payer issues
Prescription benefits issues
Patient counseling
Renewal authorizations
Renewal requests
47
Roadmap of prescribing services for physician and
pharmacy collaboration
Basic Prescribing
Advanced Prescribing
Toward an Automated Practice
1
2
3

• Services Providing True Connectivity
• Renewals
• New scripts
• Foundation for future collaboration
• Fair and open network

• Services Impacting Patient Cost
• Payer formularies
• Prior authorizn
• 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

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 states 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