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February 20, 2006
E-prescribing:
The Write Move Paper prescription pads are so “yesterday.” There’s nothing like the ePrescribing Rule to shred your love affair with the printer that supplies those prehistoric pads. With ePrescribing Rules going into effect under Medicare Part D, physicians and pharmacies can obtain information about the patient’s eligibility and medication history from drug plans. One of the biggest payoffs from this system is better quality of care for the patients. While sitting with the patient, the doctor and patient can see a complete medication history at a glance. They can also determine how the medication assists in disease management and check for adverse interactions and allergies. The result is that the correct medication can be given without the fear of it being the incorrect dosage or being in conflict with another drug. Plus, in real time, the prescription will be sent to the pharmacy and the amount of the copay will be determined. Funding Those physician groups still considering electronic health records (EHRs) can build a strong case for payors to fund their e-prescribing software if they understand how both provider and payor can benefit from the system. In a January release, Blue Cross Blue Shield of North Carolina (BCBSNC) announced that it would fund the technology and setup required for 1,000 primary care physicians who routinely write a large volume of prescriptions. Doctors will be issued e-prescribing software licenses, handheld PDAs, and wireless network hardware at no charge. Physicians will also be offered a one-time upload of their patients’ medical information, along with product training, implementation, and consulting. This represents a “good corporate citizen” seal of approval on BCBSNC’s part, especially since the e-prescribing software can be used to transmit prescriptions to other health plans. “We believe so strongly that it will improve prescription accuracy and lower prescription drug costs for North Carolinians that we are investing in its adoption among the medical practices most likely to benefit from it,” says BCBSNC President and CEO Bob Greczyn. E-prescribing will generate drug cost savings of approximately $250 per doctor per month due to the increased use of generics, avoidance of unnecessary or inappropriate prescriptions, and other efficiencies. BCBSNC and its members could save millions of dollars in medical costs when the technology is fully deployed across the state. DrFirst, an e-prescribing technology company, is helping put together the e-prescribing program. North Carolina isn’t the first state to invest in prescription technology. E-prescribing is a big part of the $50 million grant that BCBS of Massachusetts donated to the state’s eHealth Initiative. And in Florida, after piloting an e-prescribing service in 2004, Gov Jeb Bush and the legislature were so impressed with the results that they allocated more than $7 million over the next two years to fund e-prescribing. The
Bloated Administrative Paper System • The Institute for Safe Medication Practices estimates that pharmacists will place more than 150 million calls to physicians asking for clarification. • Forrester Research estimates the number of prescription-related telephone calls at 900 million because one in three prescriptions required pharmacy call backs. • Pharmacies take nearly 500 million calls annually to request and receive approval for refills alone. • In 2000, patients made 823 million visits to physician offices.1 In that year, four in five patients left with at least one prescription.2 • When patients pick up the medication, they seldom ask, “Did you have any difficulty reading the doctor’s handwriting?” • More than 3 million of the 8.8 million adverse drug events that occur each year in ambulatory care are preventable. The Institute for Safe Medicine Practices says these errors result from illegible handwriting, unclear abbreviations and doses, unclear telephone or verbal orders, and ambiguous orders. “The future drivers are safety and efficiency,” says Bob Beckley, senior vice president, partner relations and product strategy at SureScripts. “Pharmacies are connected electronically to 100% of payors and nearly 90% of the pharmacies are certified and ready to flip the switch to e-prescribing. Vendors are connecting tens of thousands of physicians to pharmacy access and patient plan data.” Six
Steps to Implementing e-Prescribing Step
1: Evaluate Your Workflow In the “Before” model, the average practice identified 14 administrative steps and six places where paper files could be lost. They unanimously advocated the workflow exercise claiming it to be the most critical step in moving to a digital practice. “Before” Workflow: Paper-Based Prescription
Renewal • Patient calls office, asks for medication renewal, and leaves message for nurse. • Nurse asks medical records clerk to pull patient file. • Clerk pulls file and puts it on nurse’s desk. • Nurse evaluates patient chart, returns patient call, and leaves message. The chart is stored at nurse’s station. • Patient chart gets moved. • Patient returns call. Nurse searches for record. • Nurse asks medical records clerk to pull patient file. • Doctor reviews file, checks for allergies and adverse reactions, and approves renewal. • Patient calls back, talks to nurse. • Nurse says she’ll call in prescription; nurse looks up number, calls pharmacy. • Patient goes to pharmacy; prescription isn’t there. • Pharmacist calls doctor’s office. • Nurse confirms renewal. • Patient goes to pharmacy, gets medicine. “Most physicians don’t hire their nurses to be clerks,” says John Bartos, president and CEO of DrFirst. The annual subscription fee for DrFirst’s Rcopia is approximately $600 per year, per physician. “Most physicians don’t realize they are paying 20 times that amount to clinical staff to track renewals” he says. “This nonautomated prescription process is highly inefficient and susceptible to errors.” “After” Workflow: E-prescription Renewal • Patient calls pharmacy for refill. No refills remain. • Message sent through e-prescribing vendor into physician’s system. • Physician or nurse opens message. System automatically checks for allergies, drug-drug interaction, and formulary coverage. • Physician considers adverse reaction and patient history and selects number of renewals. May ask nurse to request that the patient come in for a visit before next renewal. • Asks patient to come in for visit. • Sends message to pharmacy. • Patient goes to pharmacy to get medicine. Step
2: Select a Vendor Both save time and money, and improve patient safety. A full-blown EHR is a bigger initial investment in culture change management, practicewide technology adoption, budgeting, and implementation. But once physicians experience the benefits of technology in one area, they want to move deeper to experience the savings systemwide. Not sure which is right for you? Step
3: Identify Your Priority Data Elements With some e-prescribing programs, physicians can access their e-prescribing tools securely via the Internet to quickly prescribe, check for drug interactions, access medication histories, review drug reference information, and send prescriptions directly to a pharmacy safely and securely from virtually anywhere. When the practice chooses, it can use desktop computers wired to the Internet to send prescriptions, allowing it to e-prescribe without setting up wireless devices. If the software chosen by the practice isn’t set up to handle true electronic transactions, it can send prescriptions through the software’s faxing capabilities to the pharmacy. However, that is a one-way transaction—unless the practice is also using a company such as ProviderLink that tracks faxes through barcoding technology. For e-prescribing to work in either model, there are a few steps the vendor and physician need to put in place. Step
5: Make E-prescribing Software Work for You • Improve workflow processes (reduce time spent in renewing prescriptions, clarifying prescriptions to the pharmacist, exchanging voice mails with patients). • Provide both e-fax and electronic data transfer capabilities. • Provide patient-specific information from pharmacy benefit plans, including eligibility, patient-specific formulary, and medication history. • Provide immediate information on drug recalls, complications, or drug-drug interactions. • Test prescriptions for drug-allergy and drug-drug interactions. • Integrate drug information into the patient’s EHR (demographics, allergies, formulary, payor information). • Store favorite prescriptions and dosages. • Improve the reimbursement cycle from payors. • Interface data seamlessly within the practice’s software and hardware: Practice management/scheduling, PDAs, laptops, desktops, and tablet PCs. • Be affordable. • Get 24-hour technical support. Step
6: Test Data Exchanges Part
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5 Involve your patients in the e-prescribing process. Undoubtedly, you’ll uncover that 12%. Clear and compassionate conversation will help them come clean about their extra Rx activities, allowing you to enhance your patient-physician relationship. — Carolyn P. Hartley is president and CEO of Physicians EHR, LLC in Raleigh, N.C. She is also coauthor of the forthcoming book Technical and Financial Guide to EHR Implementation (AMA Press, 2006). References: 2. The Chain Pharmacy Industry Profile. National Association of Chain Drug Stores, 2001. Pharmacy
Chains Certified for E-prescribing
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