Electronic Prescribing (erx): The Pros and Cons. Richard Kalish, MD, MPH Medical Director Boston HealthNet August 13, 2009

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1 Electronic Prescribing (erx): The Pros and Cons Richard Kalish, MD, MPH Medical Director Boston HealthNet August 13, 2009

2 Established in 1995 Boston HealthNet Partnership between Boston Medical Center, Boston University School of Medicine and 15 Community Health Centers (CHCs) The network s CHCs account for 1.2 million patient visits annually Over 206,000 patients FTE Physicians 14 of the 15 CHCs have EMRs, beginning in 2002

3 e Prescribing Defined The two way [electronic] communication between physicians and pharmacies involving new prescriptions, refill authorizations, change requests, cancel prescriptions and prescription fill messages to track patient compliance. Electronic Prescribing is not Faxing or printing paper prescriptions. National Council for Prescription Drug Program, Inc. (NCPDP)

4 With or Without erx With erx Reduces Cost Increasing speed and ease of issuing new prescriptions Reducing paper prescriptions Reduces back and forth communication with the pharmacy Improves in safety and quality of care Reduce errors due to illegible paper based prescriptions. Clinical decision support Becomes part of the electronic patient record Improves patient satisfaction Reduces wait time Improves compliance Without erx Difficulty reading handwritten prescriptions Phone call needed for 30% of all prescriptions Inefficient prescribing process Prescriptions lost by patient Little potential for Clinical Decision Support Medication errors harm over 1.5 million people each year (IOM 2006) Treating drug related injuries in hospitals cost about $3.5 billion annually (IOM 2006) Incentives from payors, feds 4

5 Prescriptions Today 5

6 Electronic transmission MD to Pharmacy (e.g. fax) 6

7 Electronic Eligibility Check 7

8 erx: Complete Prescription Cycle 8

9 E Prescribing Growth by State 9

10 Kryptiq s esm Solution: Minor Workflow Change Proposed workflow is almost identical to current workflow erx enabled pharmacies appear with an (*) asterisk next to the name Users will select Electronic as the Prescribing Method

11 Kryptiq s erx Workflow Sending a new prescription with esm fits seamlessly into current prescription workflow New prescriptions get sent securely from Centricity on the prescriber s desktop through esm Central and SureScripts to the pharmacy Minimal Training

12 Challenges Issue Some CHCs pharmacy s not on SureScripts network Multiple locations of care at BMC Prescriber Phone number NPI number wasn t associated erx latency Collaborating provider not on script BMC pharmacy workflow issues Refill Requests from Pharmacy Oct 1, 2008 TRP mandate April 1, 2009 e Prescribing Standards Solution Contacted pharmacy and had them added Used a consolidated location of care (home location). This does pose a prescription origin and contact info issue. Phone number of general service was used. esm upgrade manual process to register residents currently esm backend query issue, Obs Table issue; resolved with new query. Kryptiq will add a field on the back end to send this information in the electronic transmission. Upcoming release will correct this. Inpatient discharge issue; prioritization issue; volume change. We decided to start with New Rx only. Process for refill requests need to be fixed with Pharmacies first. Microprint on script Currently we are on Logician 5.6 and there is no solution 12

13 BHN User Feedback MD s have not felt too much of a difference (that s a good thing) NP s perceive their productivity has increased No need to wait for physician to manually sign Can submit Rx immediately and move on Believe the call backs from pharmacies have decreased 80% Do not need to re fax Rxs Would like DEA to allow erx of controlled substances

14 BHN Feedback (cont d) April 1, 2009 erx standards not possible with Logician 5.6. These include: Formulary & Eligibility Fill status Medication History

15 E Prescribing So, what s the bottom line? has not changed provider work flow very much has tremendous benefits to support staff, CHC and patients.

16 Thank You! Richard Kalish, MD, MPH

17 Implementing e Prescribing Lessons Learned Debbie Bonnell CHAN Systems Administrator/Security Officer Community Health Access Network a Health Center Controlled Network (HCCN)

18 Environment 5.6 escriptmessenger (esm) 2.0

19 Dedicated Team CHAN put together a team of staff from different disciplines to lead the project. Business Systems Analyst Systems Administrator EMR Coordinator Hardware Administrator Physician Advocate The team also utilized the e Rx vendor to work thru implementation and to address questions and issues pre and post implementation

20 Pre Implementation & Setup Clean up the Pharmacies as close to the implementation date as possible (remove dup s, make sure phone & fax are listed with area code). Gather all information; prescribers, delegates, etc. Determine who will manage the esm console to resolve error flags etc. Review existing workflows and modify if necessary Identify super users who can assist with ongoing support, workflow adjustments etc. Set up a test E Rx workstation and connect to a training database. Gave us the opportunity to set up real physicians for training and workflow development. Also keeps the live database clean. Communicate with staff. Develop a marketing plan for your internal clients (staff) as well as your external clients (patients and pharmacies)

21 Implementation Piloted with 2 members (two sites) Opportunity to work out discovered issues, training requirements etc, prior to all members going live. Some issues experienced were directly related to doing a pilot instead of going live with all sites with at least new rx s.

22 What We Thought What We Discovered Once we matched up the pharmacies with Sure Scripts we THOUGHT if the user was not given the privilege within the EMR to send electronic the option would not be available. We DISCOVERED that this was not the case

23 The default prescribing method set up by the user is correct even if the patients preferred Pharmacy has been matched.however

24 If a new Pharmacy is selected and it has been matched the default method switches to Electronic. Providers that are NOT e prescribing need to manually change their prescribing method. This created numerous errors at the esm console. Most staff assumed script was sent via direct fax.

25 Geographic proximity of members had an impact on which Pharmacies we ended up matching and some sites are inter dependent on others for go live.

26 Additional Discoveries Delegate needs to have sign refill and sign append Delegates can be changed real time. Can stop/start refill requests coming in by provider at any time. SureScripts & Kryptiq monitor refill requests and will stop a provider receiving refill requests if their response takes longer than 2 days, 50% of the time. If provider prefers not have DEA number in Logician it can be removed once registration process is complete. Takes 24 to 48 hours after software installation.

27 Additional Discoveries If scheduled drug is sent with other refills, only scheduled drug will fail. Sure Scripts handles each request individually. Provider will NOT receive advanced warning if they refill scheduled medications. Electronic prescriptions sent for patients that are listed as inactive or obsolete in the EMR will fail. When refilling prescriptions enter 0 or leave it blank. If you type none or PRN hit or miss if the script will be accepted or fail. Pharmacies do not except QS in quantity Providers need to send five (5) prescriptions first, before they can receive refill requests from the pharmacy.

28 Training Sending New RX Required minimal training to start using. Refills require a bit more. Pilot showed we needed to primarily focus the training on how to deal with failure flags and resend the script. Common Failures No instructions included on script Scheduled Drug was sent Script sent for patient who is inactive in the system Quantity entered incorrectly

29 Marketing SureScripts allows you to use their marketing tools and modify with your own logo (go to CHAN provided each member site with marketing material templates; flyers, postcards, FAQ s etc. to help get them started. Remember to market internally and externally.