Statement of the National Community Pharmacists Association to the HIT Policy Committee Information Exchange Workgroup Hearing on Successes and Challenges Related to E-Prescribing Room 505A, Humphrey Building, HHS, Washington, DC January 25, 2010 Co-chairmen McGraw and Tripathi, Ms. Sparrow, and members of the Information Exchange Workgroup, the National Community Pharmacists Association (NCPA) is pleased to provide for the record the following comments on behalf of community pharmacies regarding the successes and challenges seen to date with regard to E-Prescribing. NCPA represents the interests of over 60,000 community pharmacists and 260,000 employees of nearly 23,000 community pharmacies across the United States. Community pharmacists provide prescription drug and related health care services to millions of patients, many of them in underserved areas. We hope that our comments will shed light on the successes and challenges that independent pharmacies have experienced to date, and that the Workgroup will consider promoting our recommendations to make further implementation and growth of E-Prescribing more successful. I. Pharmacists Support Accurate and Cost-Effective E-health Technologies Pharmacists consider themselves to be health care providers and patient advocates, and in those roles we support the adoption and use of accurate and cost-effective e-health technologies, including E-Prescribing. NCPA has always been a strong advocate for E-Prescribing and we have spearheaded its growth by forming, along with NACDS, Surescripts, which is the nation s largest electronic prescribing network. Surescripts reports that E-Prescribing message volume doubled from 120 million in 2007 to over 240 million in 2008, with the volume increasing to 800 million in 2009. In addition, the number of prescribers routing electronic prescriptions more than doubled from 37,000 in 2007 to 78,000 in 2008 or 12 percent of all office-based prescribers. Surescripts reports that by the end of 2009 there were over 150,000 active prescribers. While this is a positive development, there is much room to build on this growth. For example, Surescripts reported that 76 percent of all community pharmacies were connected for prescription routing (having the systems capability to E-Prescribe, but not necessarily engaging in E-Prescribing) by the end of 2008. That figure, however, included only 10,000 independent community pharmacies, or about 44 percent of independents. The numbers by December 2009 increased to 85 percent of community pharmacies and 13,700 (approximately 60 percent) of all independents. E-Prescribing capabilities vary tremendously among independent pharmacies, with the lowest capabilities generally found in rural areas.
Successes include generally positive patient acceptance and improvement in work flow for pharmacists though calling back prescribers to verify or correct incomplete information on electronic prescriptions can sometimes be time intensive and negate the original intent of E- Prescribing. We believe that the independent pharmacy community stands ready to work with HHS, DEA, physician groups and others to address the successes and challenges outlined in this statement so that we can all accelerate the development of a robust system of E-Prescribing. Additional challenges include installation and transactions costs, the costs associated with training staff and having to call back physicians regarding incomplete information on prescriptions, the compatibility of technology systems, and the need to have 2-way communications with prescribers. The reality is that some pharmacists and pharmacies particularly independent ones -- are facing significant cost challenges in implementing E- Prescribing. Actions taken by federal and state authorities should reflect those requirements and incentives that will firmly encourage the implementation of an effective, robust system of E- Prescribing. While independent community pharmacists support the growth and development of E-Prescribing, the critical challenge and key to its improved success -- is to grow it responsibly. II. Patient Safety is a Primary Focus of E-Prescribing Of paramount importance in implementing E-Prescribing is promoting the safety of prescription drug use by patients through reducing prescription errors. For this reason, it should be noted that there is still a significant learning curve for physicians, as they adapt to moving away from paper and pen prescriptions and to E-Prescribing. The Workgroup should know that we have heard that as a result of this adaptation process, at times physicians are providing incorrect or incomplete information, which unfortunately takes longer to resolve through E- Prescribing than through traditional methods. We have heard of instances when incorrect prescriptions are sent multiple times from the same physician; when incorrect inputs by physicians and nurses are harder to correct than by traditional means; and when refill requests are sent to the provider, yet come back to the pharmacy as a new request. We are also aware of cultural errors, such as when physicians tell pharmacists that physicians can E-Prescribe controlled substances because it is an option field in software/hardware (which was inserted in anticipation of the DEA allowing E-Prescribing of controlled substances), that can create difficulties. These and other types of errors discussed in the Appendix 1 (such as listing the wrong patient, medication, dose or route) reduce the benefits of E-Prescribing. Most significantly, nearly 4 times more respondents in a recent Michigan Pharmacists Association 1 The Appendix lists some highlights of two recent surveys of pharmacists regarding E-Prescribing conducted by the Michigan Pharmacists and Iowa Pharmacy Associations. 2
survey found more prescribing errors resulting from E-Prescribing than found fewer errors (see Appendix). III. Ways to Encourage Independent Pharmacy Participation in E-Prescribing In order to promote an effective, robust system of E-Prescribing, significant cost issues need to be addressed. A. E-Prescribing Fees Pose Challenges for Independent Pharmacists Confirming what is commonly known, in the Michigan Pharmacists Association survey, in response to the question, What does it cost your pharmacy to receive a new prescription or to send renewal requests electronically? (question 23), 67.7% of respondents said 25 cents or more per script. Those fees are a result of what Surescripts charges pharmacy system vendors. The fees Surescripts charges vendors have recently decreased, which in turn should lower the transaction costs for pharmacies. Nevertheless, this is a very significant expense, as serving patients can often involve very small reimbursement amounts, such as only one dollar. Combined with the software/hardware implementation and training costs, the total expenses can make E-Prescribing cost prohibitive for some pharmacies. The cost burden is particularly difficult to overcome in areas where few physicians E-Prescribe the limited volume of prescriptions translates to high marginal costs. E-Prescribing is intended to foster better, quicker, safer, more efficient and less costly communications between providers and pharmacies/pharmacists regarding patient prescriptions. We hope the workgroup can therefore understand that pharmacists particularly independent pharmacists were disappointed that MIPPA provided incentives in 2009 2013 for physician providers to E-Prescribe (and penalties in 2012-2014 for failure to do so), yet did nothing to encourage or facilitate E-Prescribing on the pharmacist side of the relationship. The imbalance is of concern not only on the basis of equity and fairness, but also in light of effectively encouraging a robust system of E-Prescribing. This lack of a parallel incentive for pharmacists in effect may create disincentives to them working with prescribers to promote E-Prescribing. - B. Grants are Needed to Address Initial and Continuing Implementation Costs Securing the ability for pharmacies to be able to E-Prescribe can be very costly. In some cases, pharmacies will have to install completely new information technology systems to be able to do so at costs that can easily reach thousands of dollars per pharmacy. This cost can especially be a problem in rural areas, where independent community pharmacies are often the only pharmacy presence in a wide geographic region. In many rural states, for example, there 3
are areas where there is no broadband capability, thus impacting connectivity and interoperability issues and related costs. Targeted grants are needed to address these implementation costs. The Tennessee Pharmacists Association, through the Tennessee Pharmacists Research and Education Foundation, is working with the State of Tennessee to provide up to $3,500 per store in grants to independent community pharmacies in Tennessee. Qualifying independent pharmacies will in essence be reimbursed the cost of necessary updates to pharmacy systems. Whether a Tennessee model reimbursement system is used, or advance grants are offered, requirements should be tailored to truly address the concrete need for independent pharmacies to obtain assistance to be able to participate in E-Prescribing. In addition, time and money resources must be spent training staff on not only how to use the hardware and software to process e-prescriptions, but also to proactively look for errors that might occur because of incorrect and incomplete inputs from the prescriber. C. It Takes Time to Responsibly Correct E-Prescribing Errors E-Prescribing is supposed to prevent or at least greatly limit the need for pharmacists to call physicians to clarify prescriptions. However, imprecise physician E-Prescribing practices can create extra burdens on pharmacists because pharmacists must take the time to spot and correct potential E-Prescribing errors. This extra time expenditure not only causes extra pressures on the delivery of safe and effective care to patients, it also runs counter to key attributes of E-Prescribing convenience and cost-effectiveness. Significantly, three times as many pharmacists in a recent Iowa Pharmacy Association survey found that E-Prescribing and/or erx-to-fax prescription errors were more difficult to resolve than non-e-prescribing prescription errors. (see Appendix). IV. Two-Way Communications are Essential E-Prescribing would be of further use in efficiently increasing the quality of health care if it encompassed two-way communication between the physician and the pharmacist regarding the patient s needs. A two-way exchange of information would increase the utility of medication therapy management systems and would help to dispel confusion over diagnosis codes, as one example. Patient care would be advanced if pharmacies could receive a diagnosis for each prescription to make sure the medication prescribed matches the diagnosis. V. Other Systematic Challenges Other systematic issues include: 1) not enough physicians engage in E-Prescribing, which makes it difficult for pharmacists to help make E-Prescribing a more robust system of health 4
information exchange; 2) getting the system up and running is not the end of the process, and it would help tremendously if pharmacists can write into the data, such as adding additional information to reflect the patient s complete medication list and not just be able to read it; 3) E- Prescribing utilization systems such as physician hand-held devices and pharmacy management systems -- are not standardized and are not compatible, thus the need for a more common format; 4) to date, there is no real ability to transmit E-Prescriptions for controlled substances, thus impacting patient care and ensuring the continued existence of a significant disincentive for physicians to E-Prescribe; and 5) making sure that pharmacies are in compliance with confidentiality and information sharing restrictions (HIPAA). VI. CMS Should Strengthen E-Prescribing Requirements There is a related equity and effectiveness concern regarding standards that providers have to meet in CMS Physician Fee Schedule and Part B Rule for CY 2010 to be considered successful E-Prescribers, and thus eligible to receive incentives/avoid penalties. CMS now requires that a prescriber only has to E-Prescribe 25 times during the 2010 reporting period to be eligible for the incentive of 2% of all total estimated allowed charges covering all professional services furnished during the 2010 reporting period. As NCPA pointed out in its comments to the proposed rule, there are many reasons why the level of E-Prescribing CMS is requiring for providers to be eligible to receive incentives is undesirably low: 1) it is not balanced to reward providers with a generous E-Prescribing bonus for conducting minimal levels of E-Prescribing, while pharmacies and pharmacists receive no federal bonus for doing so; 2) it is an unsound use of taxpayer funds to provide such large sums of money for what might be an overall very small driving force to promote E-Prescribing; 3) the physician E-prescribing eligibility level is so low that it might actually discourage an increase in E-Prescribing by some providers, as some physicians might have been prepared to conduct much higher levels of E-Prescribing, but would now be glad to be able to continue with their traditional paper and fax prescribing methods (except for in a very limited number of cases); and 4) the physician E-prescribing eligibility low level will likewise discourage both more participating pharmacists, and also greater participation by those pharmacists, as they will be discouraged from spending the funds and taking the time necessary to e- prescribe, when they believe perhaps correctly that physicians will not significantly increase their level of E-Prescribing, and thus the pharmacy s efforts will not be worthwhile and will provide no real benefit to the patient. 5
NCPA therefore reiterates its support for the advancement of standards that it and Surecripts recommended in response to the proposed (now final) rule on the Physician Fee Schedule and other revisions to Part B for CY 2010 2 -- i.e., the recommendation to increase the 25 times/year successful prescriber threshold to 250 500 prescriptions a year per eligible professional, and 25,000 50,000 per year, per group practice of at least 200 eligible professionals. The current low threshold limits the incentive for physicians to E-Prescribe, thus lowering the utility (and raising the marginal costs) for pharmacists to invest the time and monetary resources necessary to accept relatively low amounts of physician-prescribed E- Prescriptions. NCPA thanks the Workgroup for this opportunity to provide our statement and we would be pleased to further engage in dialogue with the Workgroup. Encl: Appendix of highlights of two recent surveys of pharmacists regarding E-Prescribing conducted by the Michigan Pharmacists and Iowa Pharmacy Associations 2 In the proposed rule, CMS extrapolated that a group practice would have to report that at least 1 prescription during an encounter was generated using a qualified E-Prescribing system in at least 2,500 instances during the reporting period. 6
Appendix to Statement of the National Community Pharmacists Association to the HIT Policy Committee IE Workgroup Hearing on Successes and Challenges Related to e- Prescribing Room 505A, Humphrey Building, HHS, Washington DC, January 25, 2010 Patient Safety A recent small survey (73 respondents) by the Michigan Pharmacists Association on e- Prescribing asked What is/are the biggest challenge(s) regarding e-prescribing for your pharmacy today (if applicable, select more than one) (question 18). The option Prescribing errors was chosen by 81.6% of respondents. In addition, in response to the question, Clinically, has e-prescribing led to any types of errors, (question 19), 76.9% answered yes. For the follow up question Please specify if you have seen these types of errors on e- prescriptions (please elaborate), the percentage of respondents that responded sometimes or frequently (as opposed to never or rarely ) (question 21), was as follows: Wrong patient 19% Wrong medication 62% Wrong dose 69% Wrong route 42% Most significantly, 4 times more respondents found more physician prescribing errors from e-prescribing than found fewer errors. Here is the breakdown to the responses to the question: Have you seen any change in physicians prescribing behavior for those who are prescribing electronically? (question 27) Yes, more errors: 40.3% Yes, fewer errors: 10.4% A somewhat larger survey of all types of pharmacies (177 respondents) by the Iowa Pharmacists Association found similar results: Q. 7. Of the prescriptions received by your pharmacy as e-prescriptions and/or erx-to-fax over the past week, what percentage required contacting the prescriber due to an error or mistake? 0-20% 110 (64%) 21-40% 44 (25%) 41-60% 17 (10%) 61-80% 3 (2%) 81-100% -0- Q. 8. For the e-prescriptions and/or erx-to-fax found to have errors or mistakes over the past week in your pharmacy, what components of these prescriptions contained errors? Check all that apply. Patient information 15 (9%) Prescriber information 10 (6%) Drug product 109 (63%) Dosage form 107 (62%) Strength 102 (59%) Quantity 102 (59%) Instructions 136 (79%) Refills 27 (16%) Other 23 (13%) E-Prescribing Creates Additional Burdens 7
In response to the previously-cited Michigan Pharmacists Association survey question What is/are the biggest challenge(s) regarding e-prescribing for your pharmacy today (if applicable, select more than one), 61.1% chose Increased calls to prescribers (due to signature issues, controlled substances, etc.) (question 18). Similarly, in response to a later question, What types of operational problems have you experienced with e-prescribing?, 77.9% chose More calls to prescribers (due to signature issues, controlled substances, etc.). Significantly, three times as many Iowa pharmacists found e-prescribing and/or erx-tofax prescription errors more difficult to resolve than non-e-prescribing prescription errors: Q. 14. For which type of prescriptions were errors or mistakes more easily resolved on the last day you worked? E-prescribed and/or erx-to-fax 23 (13%) Non-e-prescribed 60 (35%) Equal 90 (52%) The Iowa Pharmacists Association survey yielded the following responses regarding the relatively large amount of pharmacist time spent resolving e-prescribing errors in relation to all errors. This degree of time was needed to address e-prescribing errors even though 65% of Iowa pharmacist respondents said that 20% or less of prescription filled at their pharmacy over the past week were received as e-prescriptions and/or e-rx-to-fax. Q. 12. How much time per day does your pharmacy staff spend resolving errors associated with e-prescriptions and/or erx-to-fax? < 15 minutes 33 (19%) 16-30 minutes 66 (38%) 31-45 minutes 31 (18%) 46 minutes - 1 hour 32 (18%) > 1 hour - 2 hours 13 (8%) > 2 hours 2 (1%) Q. 13. How much time per day does your pharmacy staff spend resolving errors associated with all prescriptions? < 15 minutes 10 (6%) 16-30 minutes 27 (16%) 31-45 minutes 33 (19%) 46 minutes - 1 hour 49 (28%) > 1 hour - 2 hours 40 (23%) > 2 hours 14 (8%) 8