Electronic Prescribing:
Planning and Implementation to Achieve
Success and Maximize Value
Jonathan Teich
Pat Hale
Peter Basch
Bob Elson
Rick Ratliff
www.ehealthinitiative.org/initiatives/erx
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Electronic Prescribing:
Introduction - the Value - Stages of eRx
Jonathan Teich, MD, PhD
SVP and Chief Medical Officer
Healthvision
Chair, eHI Electronic Prescribing Project
What is electronic prescribing?
“Electronic prescribing” or “Computerized
prescribing” = all systems that use a
computer to enter, modify, review, and
communicate drug prescriptions.
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PDA’s
•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 desktopbased
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Formulary Checking
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Stages of eRx
Rx
in EHR
Connectivity
Med Profile
Management
Allergy, Formulary, Age
Basic Rx Entry / Dose check
Reference only
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eRx Value
There are significant errors and ADE’s
Gandhi: ADE’s in 5-18% of ambulatory pts/yr
CITL: Nationwide adoption of “ACPOE” predicted to
eliminate 2.1 million ADE’s/year (136,000 lifethreatening)
There are significant inefficiencies
CGEY: Nurses save 2.87 minutes per faxed Rx
Illinois study: 50% reduction in pharmacy callbacks
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Electronic Prescribing:
Planning and Implementation to Achieve Success
and Maximize Value
A Provider’s Perspective
Peter Basch, MD
Medical Director
MedStar e-Health Initiative
MedStar’s 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 physician’s practice (as well as wins
for other stakeholders)
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MeHI’s 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
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MeHI’s 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
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Moving ahead with eRx…
Getting clinicians’ attention
Choosing a vendor
A lingering question… standalone eRx vs.
EHR?
Incentives – aligning costs / benefits
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Getting clinicians’ attention
Creating the imperative
Paper-based prescribing is fraught with error - sure
there’s 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
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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 ereadiness 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
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Standalone eRx vs. EHR
Standalone eRx is cheaper and easier than an EHR
But it doesn’t 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
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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
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Electronic Prescribing:
Managing Implementation Pointers and Pitfalls
Patricia L. Hale, MD, PhD
CMIO Glens Falls Hospital
Chair of MISC - American College of
Physicians
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
PDA’s
Lists
Training/startup period
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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.
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Implementation Process
Purchase and
install system
hardware
Establish
users and
roles
Load lists:
patients,
pharmacies,
formularies,
favorites, etc.
(Possibly) load prior
patient
medical or
medication data
Identify and address major implementation issues before selecting a system.
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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.
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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?
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Implementation Issues
Prepare Lists:
Users
Patient load or PM connection
Formularies
Favorites
Initial medication load
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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
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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
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Electronic Prescribing:
Managing Implementation –
Clinical Decision Support, Formulary,
Medication Lists
Bob Elson, MD, MS
VP Medical Affairs
RxHub, LLC
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, 2004.11:60-70.
Fernando, B. Prescribing safety features of GP computer systems. BMJ. 2004;328:1171
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Application Safety: User vs. System Error
“Intelligent Intervening Provider”
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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
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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
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Implementation: “Front-End” Connectivity
Eligibility-driven formulary mapping
Claims-based prescription history
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Eligibility-driven Formulary Mapping
Clinic System
(eRx, EMR)
Member ID Load
Eligibility Request
eRx
Utility
Master
Person
Unique
patient
Index
identification
MPI
Eligibility Request
Eligibility Response
Member ID Load
Multiple responses
combined
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PBM
Eligibility Request
Eligibility Response
Member ID Load
Eligibility
Response
PBM
PBM
Claims-based Prescription History
Medication History
Request
Clinic System
(eRx, EMR)
Medication
History
Request
eRx
Utility
PBM
Medication History
Response
PBM
Med History
Response
PBM
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Sample Rx Claims History “Report”
Patient Filled Prescription Report:
Patient ID:
Name:
Address:
DOB:
PATID1234
JONES, WILLIAM A.
1200 N ELM STREET
GREENSBORO, NC 27401-1020
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 nonparticipating sources, or errors in insurance claims information. The provider should
independently verify medication history with the patient.
----------------------- FILLED PRESCRIPTION SUMMARY ------------------Summary:
Drug Name:
Strength
Oldest
Most Recent
Dosage
Fill Date
Fill Date
HYDROCHLOROTHIAZIDE
50 MG
07/01/2002
08/01/2003
INSULIN
100 U/ML
08/01/2002
08/01/2003
GLUCOVANCE
2.5/500
12/15/2002
07/25/2003
GLUCOTROL XL
10 MG
8/01/2002
07/20/2003
PREVACID
30 MG
10/23/2002
06/30/2003
15 MG
09/23/2002
09/23/2002
SLOW K
10 MG
10/29/2002
06/29/2003
----------------------- FILLED PRESCRIPTION DETAIL -------------------HYDROCHLOROTHIAZIDE
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,RHONDA
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#of
Fills
2
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8
12
7
1
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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 < 0.001)
Dose changes, drug additions, discontinuations (all p<0.05)
46% of MDs saved 1-3 min per encounter
Bieszk. Detection of nonadherence through review of pharmacy claims data Am J
Health-System Pharm. 60:360-366, 2003.
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Implementation: A Few Key Areas
Decision Support
Formulary
Medication Lists
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Electronic Prescribing:
Physician - Pharmacy Issues; Building
Community Initiatives
Rick Ratliff
Chief Operating Officer
SureScripts
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
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The prescribing process is more than just writing a
prescription and dispensing a medication
PHYSICIAN
PHARMACIST
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
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Errors and inefficiencies in the encounter
PHYSICIAN
Before Encounter
Schedule patient
Pull patient chart
Patient monitoring
Unknown meds?
Did pt fill the prescription?
Review patient chart
Encounter
Interview patient re: meds
Decide medication therapy
Write prescription
Clinical decisions
Access to expert info
Complex drug coverage rules
Document Rx in note
After Encounter
Re-file chart
Clarification calls
Prescription benefits issues
Renewal authorizations
Writing the script
Handwritten scripts are error-prone
Est. 2.1 million ADE’s could be
prevented with eRx (CITL)
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Productivity and satisfaction…
key moment: after the encounter
PHYSICIAN
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
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
(>2 hrs/day in a 3-MD practice)
Nurses burdened with admin tasks
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Physicians and pharmacists
collaborate for improvement
PHYSICIAN
PHARMACIST
Before Encounter
Acquire Prescription
Schedule patient
Pull patient chart
Review patient chart
Encounter
Drop Off, Phone, Fax, IVR
Patient Safety
&
Care Quality
Insurance ID card
Data input into computer
Process Prescription
Interview patient re: meds
Pharmacy DUR
Decide medication therapy
Claims: Payer DUR
Write prescription
Document Rx in note
&
After Encounter
Re-file chart
Clarification calls
Claims: Eligibility / benefits
Order fulfillment / dispense
Communicate
Clinical Practice
Efficiency
Review of DUR alerts
Handling of payer issues
Prescription benefits issues
Patient counseling
Renewal authorizations
Renewal requests
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Roadmap of prescribing services for physician and
pharmacy collaboration
1
Basic
Prescribing
Services Providing
True Connectivity
Renewals
New scripts
Foundation for
future
collaboration
Fair and open
network
2
Advanced
Prescribing
Services Impacting
Patient Cost
Payer formularies
Prior authoriz’n
Rx change message
Switch in class
Services Impacting
Patient Safety
Drug interaction
checks + safety net
Medication history
Patient compliance
Patient-focused care
management
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Toward an
3 Automated
Practice
Prescribing Plus:
Collaborate in the
Journey
Billing and
scheduling
Lab results
Payer
communications
Referrals
Diagnostic reports
Charge capture
and coding
Clinical notes
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
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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 state’s 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
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