Measuring EPrescribing to Sustain Adoption and Support P4P

1
Measuring E-Prescribing to Sustain Adoption and
Support P4P
AMGA October 1, 2009

• R. David Allard, MD - Henry Ford Health System

2
Disclosure

• Member - DrFirst Inc. Physician Advisory Board
• Unpaid
• Position taken over 1 year after vendor chosen

3
Medical IT

• Technology is not the destination,
• it is the transportation.

Dr. Safron American Medical Informatics
Association
4
Goals

• Describe experience
• Discuss steps for successful roll out of
  ePrescribing
• List obstacles to adoption
• Understand motivating factors to adoption
• Understand Metrics for tracking quality and
  success
• Look at methods of measurement
• Review PQRI ePrescribing incentive
• Discuss collection of PQRI data

5
The Industrial Revolution in Healthcare

• Medicine must push out its performance envelope
• Technology is a natural direction for an
  information industry
• ePrescribing is an achievable first step

6
Henry Ford Health System Key Facts

• Henry Ford Health System includes
• Henry Ford Hospital and six owned hospitals
• Henry Ford Medical Group with 800 employed
  physicians/scientists
• 24 ambulatory centers located in Southeastern
  Michigan
• Health Alliance Plan, a 530,000 member managed
  care organization serving 2,800 employers

7
Henry Ford Health System Key Facts

• Ambulatory Clinic Organization
• Each clinic has a Physician In Charge (PIC), an
  administrative manager, and a nursing supervisor
• Key roles impacted by ePrescribing included
  physician, nurse, medical assistant, and customer
  service representative
• Technology
• Electronic medical record (EMR, called CarePlus)
  used throughout HFMG (clinics and hospital)
• All primary care exam rooms have PCs with network
  access used to connect to the EMR

8
HFHS ePrescribing Initiative History

• September 2004 GM asked HAP HFMG to partner
  with auto companies to test ePrescribing via the
  Southeast Michigan ePrescribing Initiative
  (SEMI). HFMG agreed to be the incubator for
  testing ePrescribing and eight HFMG primary care
  clinics launch ePrescribing
• January 2005 HFMG/HAP launched first 4 HFMG
  primary care clinics on ePrescribing
• January 2006 HFMG completed implementation at
  all primary care clinics
• January 2007 HFMG completed implementation in
  all outpatient specialty care clinics
• February 2007 Michigan is recognized for moving
  from the 10th highest ePrescribing state to the
  6th for 2006
• April 2007 HFMG launches 3 Emergency
  departments on ePrescribing
• February 2008 Michigan is recognized for moving
  from the 6th highest ePrescribing state to the
  5th for 2007
• June 2009 Michigan is recognized for moving
  from the 5th highest ePrescribing state to the
  3rd for 2008

9
ePrescribing Solution Scope

• Users can write prescriptions on a PC using the
  web or on a wireless device (smart phone, tablet
  PC) and send them directly to the retail pharmacy
  or mail order pharmacy for filling
• Application has real time access to
• Patients eligibility
• Formulary
• Drug fill history
• Drug allergies

10
Fostering Change

• Creating Readiness
• Overcome resistance
• Articulate the vision
• Generate Commitment to the vision
• Institutionalize the change

11
Setting the Stage

• Vendor selection
• Get the equipment
• Data preload
• Articulate a vision and position the event

12
ePrescribing Value Proposition - Quality

• IOM Dimension of quality
• Safety
• Reduce the rate of drug/drug interactions
• Reduce errors due to allergy
• Reduce error due to legibility
• Patient centered
• Allows patients to select their preferred
  pharmacy
• Reduces process time for patients
• Provides patients with a printed list of meds
• Allow easy use of mail order pharmacies
• Efficient
• Reduce paper based processes
• Reduce Staff time for renewals
• Reduce Pharmacy call backs to offices

13
ePrescribing Value Proposition - Quality

• IOM Dimension of quality
• Effective
• Improve ability to track compliance
• Increase formulary adherance
• Increase generic use rate

14
Go Live Strategy

• Trainers on site
• Training in groups by function
• A given clinic was closed in the AM for training
  with go live in the afternoon
• Trainers stayed on site for 3-5 days
• During hands on training sessions, rapid adopters
  were called upon to help others

15
Five Stages of Medical Technology Acceptance

• Abject horror
• Swift denunciation
• Profound skepticism
• Clinical evaluation
• Acceptance as standard of care

Frederick Knoll, Medical Imaging in the Age of
Informatics Stanford University, 11/15/2005
16
Adoption Measures

• Currently over 39,000 prescriptions generated
  each week
• Over 6 Million sent as of June 2009

17
Results Safer Care

• Over 1.1 million total warnings have been
  delivered as of early 2008
• Over 400,000 prescriptions have been changed or
  cancelled due to warnings

18
Results

• For HFMG capitated membership
• HAP/HFMG initial capital investment of 1.6
  million plus annual operating costs averaging
  590,000 reaps total savings of more than 1.9
  million in total for 2005 and 2006
• Future estimated savings through 2009 will
  average 4 million per year
• Based on the 2005 and 2006 realized improvement
  in generic use rate, the five year Return On
  Investment is now estimated to be over 14M

19
Results

• Key sources of cost reduction benefit are
• GUR Improvement totaling 1.5 million for 2005
  2006 and estimated at 3 million/year for
  2007-2009
• Administrative savings totaling 700,000 for
  2005 2006 and estimated at 560,000/year for
  2007-2009
• Estimated impact of reduced adverse drug events
  (ADEs) totaling 540,000 for 2005 and 2006 and
  540,000/year for 2007-2009

20
Adoption Measures

• HFMG primary care physician feedback after 1 year
• 85 agree that ePrescribing has improved the
  practice of medicine at their clinic
• 77 agree that ePrescribing improves the safety
  of the care that patients received
• 75 agree that ePrescribing improves the quality
  of the care that patients receive
• 70 agree that ePrescribing improves patient
  satisfaction

21
Adoption Measures

• Strong patient preference for ePrescribing
• Saves time at pharmacy
• Simplifies process for mail order pharmacies
• Improves medication reconciliation procedures
  giving increased patient confidence

22
Adoption Measures

• Support staff love it
• Old process time/renewal 7 minutes, 12 seconds
• ePrescribing 3 minutes 50 seconds/renewal and got
  better with time
• Time savings did not result in headcount
  reduction but enables other activities by support
  staff

23
Measuring Use

• Need to assess continued use
• Look for pockets of resistance

24
Measuring Use

• Retrospective Study Comparing Insurance claims
  data to prescription
• Advantages
• Shows the percentage of scripts written
  electronically
• Ignores differences between specialties
• Difficult to dispute
• Disadvantages
• Very time consuming and labor intensive
• Requires claims data from insurance company (or
  possibly RxHub)

25
Measuring Use
Patients with Health Insurance Plan with
prescription drug riders Match patient, Doctor
and Medication
26
Prescription Distribution

• Prescription Distribution
• Based on insurance claim data 81 of all
  prescriptions during the 12 months study period
  were written by primary care. 13 were written
  by medical subspecialties and 6 by surgical
  specialties
• Approximately 2/3 of all prescriptions are
  filled. This does not change across specialty

27
Measuring Claims and ERx
28
Claim vs. ERx Data
29
RVU vs. ERx

• Advantages
• Does not require insurance information
• Fairly easy to count
• Disadvantages
• Does not reliably account for case acuity between
  providers
• Still requires data from more than one source

30
ERx vs. RVU generation
31
Measuring with Prescription Volume Only

• Easy data to collect
• Matches well with Other methods
• Non-users defined as creating less than 15
  prescriptions/week
• The other data collection methods were still
  worthwhile as they validated the volume method

32
Analysis

• In contrast to primary care, medical and surgical
  specialties were trained by specialty not
  location.
• This greatly decreased the on-site post go-live
  support
• Fewer opportunity for super users to help out
• Specialties write far fewer prescriptions
  essentially practicing less. This is
  particularly true regarding refills (the area of
  greatest efficiency)

33
Reported Problems

• Too much time logging in and out
• Answer, integrate with single sign-on
• It takes too long to write a script
• Answer, Use favorites, single sing-on, have
  support staff verify pharmacies
• I have to much to do
• Answer Nurse refill process for maintenance
  medications

34
Overcoming Resistance

• Data Collected from more than one source is
  harder to refute
• Sell the process
• Build on the Process
• Target ongoing training to areas of slowest
  adoption

35
ePrescribing from the Physician Prospective
Sources of Error

• Patient gives wrong information or doesnt have
  information (I,E,R)
• CSR incorrectly copies information (E,R)
• Written information is misplaced and not seen by
  doctor (R)
• Chart misplaced or slow to be located/retrieved
  (I,R)
• Review time in chart (I)
• Correct phone number for pharmacy needed (E,R)
• Time spent on phone with pharmacy (I)
• Transcription error at pharmacy (E,R)
• Transcription error in medical record or not
  recorded (E,R)
• Patient fails to get prescription (I,R)
• Patient fails to notice error (E)
• IInefficiency, RRework, EError

Patient calls for medication refill
Customer Service Rep (CSR) writes information for
nurse/doctor review and action
Doctor or doctors agent (nurse) reviews
prescription and makes decision for fill or not
Doctor or agent calls pharmacy with prescription
information, information documented in the
medical record
Pharmacy fills prescription and patient picks it
up
36
ePrescribing from the Physician Perspective
Sources of improved efficiency and decreased error
1
2
Pharmacy sends refill request electronically
Patient calls for medication refill

• Greatly reduced time and no transcription errors
• Information on patient available as prescription
  created
• Requests not lost
• Information available as decision made
• Enormous time savings
• No transcription error
• Reliable documentation

Electronic request sent to a clinic in box for
review by doctor or doctors agent and decision
on action
3 4
Prescription automatically sent to pharmacy and
documented
5 6 7
Pharmacy fills prescription and patient picks it
up
37
Overcoming Resistance Obstacles

• Learning curve
• Training needed to be ongoing
• Time study
• Resistance to change itself
• Congratulate past success and then change

38
Overcoming Resistance

• Depends heavily on setting the stage
• Listen to feedback
• Discuss and contrast with paper/phone process
• Share successes (data from adopters)
• GUR improvement,
• Changed scripts due to warnings
• Elicit testimonials
• Enlist participation in users group

39
Overcoming Resistance Users Group

• Users group with wide range of technical ability
• Ongoing review of bugs and enhancement requests
• Over 320 Software enhancements and fixes to date

40
Generate Commitment

• Celebrate Successes
• Foster involvement
• Users group
• Train the trainer
• Solicit ideas
• Communication!

41
Institutionalize the Process

• Users become trainers
• Process becomes the foundation of the next aspect
• Specify the metrics

42
Institutionalize the Process Building On the
Foundation

• Nurse medication renewal policy started with
  standing orders for nurse
• Uses ePrescribing process
• Medication Reconciliation with ePrescribing as
  source of truth
• A JCAHO compliant medication note can be created
  with one click provided the user has kept the
  medication list up to date. The best way to do
  this is to write the prescriptions in the
  software!
• PQRI makes ePrescribing a requirement

43
Adoption Measures
44
Next Steps

• Continue metrics
• Scripts by Volume (varies per specialty)
• warnings
• Offer retraining/refresher for low utilizers
• Continued integration into EMR
• Continued improvement and feedback

45
PQRI ePrescribing Incentive

• For those physicians using ePrescribing, payment
  will be made at a higher rate

46
CMS Electronic Prescribing Incentive
47
CMS Electronic Prescribing Incentive

• Current requirement is to submit G-code with each
  claim
• CMS has to date not accepted aggregate reporting
  from medical groups
• G8443 - All prescriptions generated during the
  office visit were created electronically
• G8445 - No prescriptions were generated during
  the encounter.
• G8446 - Some or all prescriptions generated
  during the encounter were handwritten, faxed, or
  called in.  (This does not include prescriptions
  created electronically and handed to patient or
  then faxed, which would be reported using G8443.)

48
Attaching G Codes

• Currently attaching G Code at the point of care
  based on provider reporting.
• Billing is captured from an optical scanning
  scheet
• G Codes were added as an optional field (at
  first)
• Clinicians bubble a choice of all e-Rx,
  Paper Rx, or no Rx this visit
• Looking at attaching code based on ePrescription
  generation but this only returns a numerator.
  This does not differentiate visits which had no
  prescriptions from those with paper prescriptions.

49
PQRI reporting success
In June, a hard stop was introduced in the
billing process, not allowing the billing sheet
to be processed unless a G Code was added.
50
Summary

• ePrescribing was not only financially sound but
  resulted in safer, more patient centered care
• Our ePrescribing success was due to several
  factors
• Goals consistent with mission and culture of
  organization
• Planning to make adoption easier
• Ongoing improvement
• Enthusiasm
• Training and monitoring becomes a continual
  process which will not end

51
Questions/Discussion