American College of Physicians Internal Medicine 2008 Washington, DC May 15-17, 2008 E-Prescribing: What Is It? Why Should I Do It? What's in the Future? Daniel Z. Sands, MD, MPH, FACP Posted Date:May 6, 2008 2008 American College of Physicians. All rights reserved. Reproduction of Internal Medicine 2008 presentations, or print or electronic material associated with presentations, is prohibited without written permission from the ACP.
Disclosure of Financial Relationships Daniel Z. Sands, MD, MPH, FACP E-Prescribing: What Is It? Why Should I Do It? What's in the Future? Daniel Z. Sands, MD, MPH, FACP Assistant Clinical Professor of Medicine, Harvard Medical School Senior Medical Informatics Director, Cisco Has relationships with the following proprietary entities producing health care goods or services. Employee Cisco Systems Consultant/Advisory Board Blue Cross Blue Shield of MA epocrates Manhattan Research Medscape Thomson Healthcare Script Agenda Introduction Paper-based prescribing and its problems E-Prescribing explained Potential benefits The future of e-prescribing Practical issues Prescription Safety 8.8 million outpatient adverse drug events per year Medication errors cause 1 of every 131 outpatient deaths 60% safety improvement from legibility, formatting, and completeness e-rx can prevent: ¼ of adverse drug events 190,000 hospitalizations 1.3 million office visits Prescription Drug Costs 3.5 billion scripts written/year ½ U.S. adults take at least one prescription each year $231 billion per year or 11% of healthcare costs Rising at 10-12% per year Payor response: Restricted formularies Step therapy Prior authorization requirements Sources: CITL, IOM Sources: IMS Health, AHRQ, CMS dsands@cisco.com 1
Administrative Costs Barriers to Adoption More than 150 million clarification calls regarding prescriptions made per year, most requiring chart pull At $5 per chart, that s $750 million in chart pulls alone e-prescribing is underutilized Only 5-18% of physicians What are the barriers? Application/hardware costs Physicians don t understand ROI Poor technology/products Workflow change Source: ehealth Initiative Free isn t cheap enough Harvey V. Fineberg, MD Institute of Medicine Paper-based Prescribing Refilling & Renewing Prescription Administration Transmission Dispensing Prescribing Safety Prescribing Efficiency Failure to refill or renew Refilling & Renewing Prescription Illegibility Interactions Dosage errors Contraindications Drug N/A Wrong route Wrong frequency Communication: Patient-Pharmacy Pharmacy-doctor Refilling & Renewing Prescription Time to write Rx Rework due to payor/ rules Non-adherence Administration errors Administration Transmission Loss Alteration Administration Transmission Delay Dispensing Dispensing errors Dispensing Time to fill dsands@cisco.com 2
HELLO HELLO D. Z. Sands E-Prescribing April 2008 e-prescribing Online patient reminders Online patient requests requests to physician or staff queue Patient education Patient/physician nonadherence alerts Electronic patient queries Refilling & Renewing Administration Dispensing Prescription Transmission Computergenerated Interactions checked Dose verification Decision support available Formulary checks Automatic routing Eliminate transcription! %#@!! Current Rx Process Pick Here! %#@! Drop Off Here Rx Data Info Info Doctor Office Pharmacist Patient Doctor Nurse sends Manager reviews also looks gives writes learns takes calls refers fills calls up signed approval Doctor sends prescription fills renewals Pharmacist from the Pharmacy renewed puts clinical Doctor Prescription prescription renewal fax Pharmacist printed Medical information to because prescription and Benefit Doctor s the formulary History, request give hands end Nurse that the a in of Manager drug the pharmacy and journals day local for requires current to she hands renewal processing on before drug Office it pharmacy obtain Doctor s is and via medication the reference out Prior it Manager leaving EDI medical approval Prior patient of Patient the and desk transaction for refills Authorization Patient the filling filing book texts listoffice Drop Off Here Rx Data! Used with Permission from Pfizer True erx All Electrons, All the Time Clinical Alerts Formulary Reference Rx History Eligibility Patient and Doctor review history Prior from Auth. EMR and discuss current issue Fill Notify Fill Notify Fill Notify Rx Doctor sends renewal Pick Up approval Here before the patient Fill Notifyarrives for next refill Approval Fill Notify Pharmacist sends Doctor Pharmacist renewal uses request on-line receives tools erx from Pharmacist and multiple Prior fills script and sends fill doctor at time Auth. of last sources information refill to write electronically erx notification to Doctor Technology Components The application The knowledge-base The local network The networks and connectivity The destination Used with Permission from Pfizer e-prescribing Devices dsands@cisco.com 3
e-rx Terminology e-rx Terminology Pharmacy Benefit Manager: manages prescription benefits for payors. Pharmacy Benefit Manager: manages prescription benefits for payors. RxHub Network and hub that provides patient eligibility, formulary, dispensed history that PocketScript displays to the prescriber at the point of care. Founded by three major s. e-rx Terminology PocketScript Information Flow RxHub SureScripts Pharmacy Benefit Manager: manages prescription benefits for payors. Network and hub that provides patient eligibility, formulary, dispensed history that PocketScript displays to the prescriber at the point of care. Founded by three major s. Network that connects e-prescribing applications to > 85% of retail pharmacies for sending and receiving prescription information. Beginning to include medication history. Formed by National Association of Chain Drug Stores and National Community Pharmacists Association. Status of the e-prescription is logged and monitored in PocketScript 9 PocketScript checks for drug-to-drug and drug-to-allergy interactions and alerts 6 doctor to potential interactions Doctor completes the script details, selects a pharmacy, and clicks Send 7 Doctor selects a drug from 2 5 drug list colorcoded for or RIM Triple DES Secure session via SSL formulary 1 Doctor logs into PocketScript through handheld or browser creating a secure session 8 Pharmacy Rx sent via SureScripts SSL & IPSEC VPN or Fax direct RxHub or other data source request via SSL 3 4 Data source returns patient eligibility status and formulary ID Courtesy of Zix Corporation e-prescribing: a 3 Step Process 1. Select Drug 2. Confirm Details 3. Send to Pharmacy Impact - Patient Safety Automatic interaction checks: Drug-to-drug Drug-to-allergy Pregnancy warnings Courtesy of Zix Corporation Courtesy of Zix Corporation dsands@cisco.com 4
Impact Cost-effectiveness Automatic formulary checks Specific recommendations for Rx substitutions Courtesy of Zix Corporation Benefits: Patient Safety Drug-to-drug and drug-toallergy checks at the point of care Medication history available at the point of care Prevents illegible prescriptions Prevents use of stolen prescriptions Additional Patients Benefits Lower costs due to formulary and generic drug information at the point of care average of $4 per prescription (source BCBSMA) Reduced wait time at the pharmacy Prevents lost prescriptions More productive time spent between patient and physician Patient retention due to improved satisfaction dsands@cisco.com 5
Benefits: Office Efficiency Newton-Wellesley Internists Case Study Reduced pharmacy calls Physicians can prescribe from anywhere, anytime Fewer chart pulls Faster prescription renewal process Fewer administrative resources needed Percent Time Reduction 70 60 50 40 30 20 10 0 Labor Hours Pharmacy Calls Time for Rx s Benefits: Security and Legal Why the Excitement and Momentum? HIPAA-compliant systems Payor Doctor Pharmacy Strong adherence to data security regulations Helps reduce liability in malpractice suits Keeps better patient records Controls theft and misuse of prescriptions Payors, s, Medicaid, Medicare, malpractice insurers, retail pharmacy, specialty pharmacy, pharmaceutical companies, claims processing companies, other point-of-care vendors e-prescribing at the Tipping Point Increased stability Applications Networks Companies Recognition of benefits Successful large-scale deployments Integration with EHR Federal initiatives Evolving sponsorship and incentive models Role of Federal Government Medicare Drug Improvement and Modernization Act of 2003 Increased awareness Increased need to prescribe to formulary Pilot projects Stark and anti-kickback exemptions Will e-rx be mandated? dsands@cisco.com 6
Who Will Pay for e-prescribing? Are incentives aligned? More Players e-rx Application Companies EHR vendors enhancing e-rx offerings EHR vendors integrating with e-rx applications Vertical application vendors integrating with e-rx: Charge capture Dictation Results reporting Reference Involvement of: Payors Communities Patients Broader Connectivity / Higher Utilization The National eprescribing Patient Safety Initiative (NEPSI) is a joint project of dedicated organizations that each play a unique role in resolving the current crisis in preventable medication errors. Electronic prescribing (erx) is a viable solution to counter shortcomings of the current paper-based prescribing processes that are in large part responsible for these errors. However, accessibility and cost barriers have slowed adoption of erx by providers. The goal of NEPSI is to increase patient safety by making erx accessible and desirable to all physicians and medication prescribers by providing it free of charge. The erx software provided by NEPSI is Simple Online prescribing is easier than a script pad Safe Instant checks on drug interactions, dosage levels and patient-specific factors including prior adverse reactions Secure Patient information protected by privacy and security measures including prescriber authentication e-rx standards maturing Pharmacy connectivity will overcome barriers: Not yet all pharmacies Bi-directionality still nascent Pharmacy workflow still problematic Currently an open loop system and payor connectivity evolving Patchwork of state regulations will slowly resolve Free Provided without cost by Allscripts and the members of NEPSI Presentation_ID 2006 Cisco Systems, Inc. All rights reserved. Cisco Confidential 42 dsands@cisco.com 7
Deeper Functionality Deeper clinical decision support Additional functionality will include: Charge capture Results reporting e-communication Documentation Expanded use of e-rx, including: Physician education Recruiting for clinical trials Recruiting for disease management Alerting patients and physicians about drug adherence e-rx Becoming Strategic Payors and s See value in reduced drug spending Physicians and medical groups When responsible for drug spending As a competitive advantage Improve efficiency Malpractice carriers Premium reduction to influence adoption Regional health data exchanges e-rx as important data source Practical Issues The Digital Journey Is e-prescribing right for you? Finding sponsorship, if needed Selecting system Contracting Preparing Implementing Assessing impact Dictation Results Reporting e-rx e-communication EHR Advanced CDS e-billing Clinical Refs Questions? dsands@cisco.com "The doctor's going to try e-prescribing. Alert all the pharmacists." Please submit your evaluations! dsands@cisco.com 8