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June 22, 2009

Spring Into E-Action
By Alice Shepherd
For The Record
Vol. 21 No. 13 P. 20

Despite potential workflow issues and overbearing drug alerts, experts suggest that e-prescribing can save both money and lives.

For physician practices and hospitals that are not yet e-prescribing, 2009 is the year to get started. Beginning this year and continuing through 2013, Medicare will provide incentive payments to eligible professionals who are successful e-prescribers as defined by the Medicare Improvements for Patients and Providers Act (MIPPA). Successful e-prescribers will receive 2% incentive payments on their Part B billings in 2009 and 2010, 1% incentive payments in 2011 and 2012, and 0.5% in 2013. Beginning in 2012, sticks will be added to the carrots: Those who have not adopted e-prescribing by 2012 will pay a 1% penalty, a number that will rise to 1.5% in 2013 and 2% in 2014 and beyond.

Until recently, providers’ expenditures for e-prescribing software were so high that adoption offered little economic benefit. Now, however, with the Medicare incentives, along with pay-for-performance programs, investments in e-prescribing systems will begin showing a return on investment. Plus, more significant rewards are coming from the American Recovery and Reinvestment Act (ARRA) for those adopting a full electronic medical record (EMR).

Choosing a Program
That’s all good news for technology enthusiasts, but it does little to ease the stress associated with selecting an e-prescribing system. First, a facility must decide whether to purchase stand-alone e-prescribing software or a full EMR. While EMRs are more expensive and involve a significant change management challenge, every provider should be moving toward this goal, according to industry experts.

In the meantime, high-prescribing practices with small budgets can get significant benefits from a stand-alone program. “Stand-alone e-prescribing software should be just a stepping stone on the road to a full EMR,” says Paul Foley, MS, MBA, RPh, vice president and senior consultant at Visante, Inc. “The MIPPA incentives are small compared to ARRA’s allocation of $20 billion of incentives for the implementation of electronic health records. Providers can get $18,000 in 2011, $12,000 in 2012, and $8,000 in 2013.”

Foley’s advice for practices choosing to start with a standalone system is to purchase it from a vendor that also offers EMR technology or has a partnership with a vendor that does to smooth the path to the full capability.

Based on a Visante study, the Pharmaceutical Care Management Association expects that financial incentives for physicians to adopt HIT included in the recent economic stimulus bill will increase the number of e-prescribers to more than 75% over the next five years. The association also anticipates that e-prescribing will help prevent 3.5 million harmful medication errors and save the federal government $22 billion in drug and medical costs over the next 10 years.

E-prescribing is likely to make medication management safer and more efficient, but it could be even more powerful when used as part of a full EMR. “E-prescribing alone leaves information disconnected,” says Foley. “Physicians are still handling paper charts or dealing with lab values on a separate computer system. When it all comes together in an EMR, efficiency and safety increase exponentially. Electronic medical records amplify the value proposition.”

Regardless of which technology is chosen, the next step is to consider what type of prescription information the system should be able to manage. “Providers that intend to take advantage of the Medicare e-prescribing incentive need to be aware that MIPPA specifies very clearly what the e-prescribing program has to include,” says Kate Berry, senior vice president of business development at Surescripts and executive director of the Center for Improving Medication Management. “It has to provide access to prescription benefit and formulary information; access to patient medication history, if available, from pharmacies and claims data; drug interaction safety alerts; and the ability to transmit to pharmacies in a truly electronic format. Prescriptions sent to e-prescribing–capable pharmacies by computer-generated fax are not eligible for the Medicare incentive payments.”

Beginning this summer, the Certification Commission for Healthcare Information Technology (CCHIT) will start certifying e-prescribing vendors. “If you need a system right away and can’t wait until CCHIT begins certifying e-prescribing vendors, visit the Surescripts Web site [www.surescripts.com] or ask the vendor if it is Surescripts certified,” suggests Foley. “This certification means that the e-prescribing vendor is fully connected to the national e-prescribing hub and is able to deliver the full value of e-prescribing. It also means the vendor will be CCHIT certified this summer.”

Surescript’s Web site lists more than 130 certified physician technology vendors and their capabilities for e-prescribing and full EMRs. Currently, the network includes more than 100,000 active e-prescribers.     

Hardware and Connectivity
The next step is to decide what type of hardware works best for the practice. One option is wall-mounted PCs in exam rooms, a particularly wise choice if the office intends to adopt a full EMR. Less expensive alternatives include laptops and PDAs with wireless connectivity. “E-prescribing tends to work very well on PDAs if the office has Wi-Fi capability,” says Foley. “On the other hand, tablet PCs or laptops have the larger screens needed to view full EMR information.” Other hardware considerations are where to install printers and what types of devices nurses and office staff will need to access the system for prescription renewals.

“When it comes to choosing hardware, remember the old adage, ‘you get what you pay for,’” says Foley. “Don’t buy the cheapest laptop and Wi-Fi router from your local discount store. You need highly reliable, business-grade computer hardware, as well as business-quality encryption, privacy, and security technology.”

Most vendors will provide a road map for rolling out the system. The first two steps are assessing the environment to determine the optimum hardware configuration and installing the hardware. The third step is to load the software and download patient demographic information from the practice management system. Ideally, the vendor will then train the physicians and staff on the system. “In general, e-prescribing systems are simple and quick to learn,” says Foley. “You can start e-prescribing within an hour. After that, a vendor’s representative should remain on site for a day to answer any questions.”

Internet connectivity, ideally broadband, is essential because much of the value of e-prescribing comes from connecting the prescriber to external resources that can provide medication history and insurance and pharmacy data. “A key value driver for the utilization of e-prescribing is the automation of the prescription renewal process,” says Berry. “It saves much time and effort by eliminating phone calls and faxes to and from pharmacies.”

Also, physicians who have access to insurance information are less likely to prescribe a nonformulary drug.

“The ultimate goal is the right medication to the right person at the right time in the safest manner possible,” says Bob Mayes, MS, RN, senior advisor for HIT with the Agency for Healthcare Research and Quality. “Historically, the players in medication therapy have been separate. The physician writes the script and hands it to the patient, who takes it to the pharmacist. The patient takes the drug home … and who knows what happens after that. The newer world of e-prescribing envisions a process that more tightly links together all of the players.”

With e-prescribing, physicians can check how often a patient refilled the medication, which in turn sheds light on patient compliance, notes Foley.

Changing the Workflow
More challenging than installing hardware and software is redesigning workflow around the system. “Any new technology is a disruptive agent, and the socio-organizational dynamics of that are often underestimated,” says Mayes. “What causes implementations to be less than successful are usually not the technical problems but issues around organization and authority. The fact is, computers don’t make the work go away; they just shift where it happens.”

Questions to be answered in redesigning workflow include who will enter a new prescription into the system? How will requests for refills be handled? Should prescriptions be sent to the pharmacy together at the end of the day or individually as they are written? The answers may depend on the size of the office, whether it is part of a larger organization, and the  number of pharmacies with which it does business. “Hopefully, it will be possible to shift some tasks away from the more expensive players in the organization or at least make the process more efficient,” says Mayes.

Buy-in from all players is important to making the change management initiative successful. “Involve everyone in the selection of the program and in designing the new workflow,” recommends Foley. “Identify how each group—physicians, nurses, and administrative staff—will interact with the e-prescribing system. E-prescribing will make the workflow much easier but only if you figure out how you’re going to change your workflow to accommodate making it easier. Design the new processes before going live. On the go-live day, you can then test everything out and tweak it.”

The new organizational relationships that come with e-prescribing transcend the physician office or hospital. “Communicating through an electronic system amounts to establishing contractual relationships with completely independent entities, such as pharmacies,” says Mayes. “Suddenly, you’re linked at a fundamental business level. In addition, patients will be inserting themselves into the workflow as well.”

Safety Alerts: Necessity or Nuisance?
According to a study led by investigators from the Dana-Farber Cancer Institute and Beth Israel Deaconess Medical Center published in the February issue of the Archives of Internal Medicine, clinicians consider drug interaction safety alerts a nuisance and prefer to rely on their own judgment. The clinicians who were part of the study overrode more than 90% of drug interaction alerts and 77% of drug allergy alerts. “Electronic prescribing clearly will improve medication safety, but its full benefit will not be realized without the development and integration of high-quality decision support systems to help clinicians better manage medication safety alerts,” says the study’s senior author, Saul N. Weingart, MD, PhD, vice president for patient safety at Dana-Farber and an internist at Beth Israel Deaconess.

MIPPA requires the safety alert feature in e-prescribing technology, so why don’t physicians pay attention? “That’s a tricky path to walk,” says Mayes. “On the one hand, there are so many potential interactions that it’s unrealistic to expect physicians to keep them all in their head. On the other hand, if every time you try to e-prescribe, a message pops up, it becomes impossible to deal with.”

“The sheer volume of alerts generated by electronic prescribing systems stand to limit the safety benefits,” says Thomas Isaac, MD, MBA, MPH, of Dana-Farber and Beth Israel Deaconess. “Too many alerts are generated for unlikely events, which could lead to alert fatigue. Better decision-support programs will generate more pertinent alerts, making electronic prescribing more effective and safer.”

“Most e-prescribing safety alerts are system edits based on the clinical logic originally designed for pharmacy systems over 20 years ago,” explains Foley. “Pharmacists needed a finer filter that catches all the potential drug interactions. It’s not that drug interactions are inconsequential for physicians, but they already know about most of them and are taking steps to mitigate them. Something has to be done to make the systems smarter.”

The Agency for Healthcare Research and Quality is currently researching how information can be displayed in a way that brings it to the user’s attention and motivates action without stopping workflow. “Usability work began with fighter pilots during the Vietnam War,” explains Mayes. “When computerized systems were first being built into aircraft, pilots found the constant warnings and flashing lights distracting and turned them off. However, safety alerts remain an indispensable component of e-prescribing systems. If you’re just adopting e-prescribing as a way of making your paper electronic and not leveraging it to make prescribing safer, you’re missing the point.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.


Five Key Drivers of Successful E-prescribing
The Center for Improving Medication Management conducted a study (High-Low Connected EMR Practice Evaluation) to analyze why similar practices using similar electronic medical record systems experience different levels of success with e-prescribing adoption, utilization, workflow, and physician, staff, and patient satisfaction. Kate Berry, the center’s executive director, cites five predictors of success:

1. A clear vision and commitment to move toward a paperless prescribing process, driven by a strong belief that technology will increase safety and efficiency.

2. Designating an e-prescribing “expert” or go-to person. Whether a doctor, a nurse, or a staff member, that person is responsible for making sure the system works and is being used consistently by everyone. That person should also be the contact for troubleshooting problems and have the ability to help others become comfortable with the technology.

3. Sharing prescriber-specific utilization data within the practice (eg, how many prescriptions are transmitted electronically rather than printed and faxed). Talking about this utilization data makes everyone aware of what they are doing, creates peer pressure, and identifies problems.

4. Communicating the value of e-prescribing to everyone in the practice and making sure people understand the new workflow, roles, and responsibilities. Educate patients on the value of e-prescribing to make them understand how it applies to them. The vast majority of patients have responded enthusiastically.

5. Clearly articulating expectations about system requirements, documentation, training, and support to the technology provider.

— AS


Getting Help
The Agency for Healthcare Research and Quality (AHRQ) has contracted with Rand Corporation to develop a tool set for implementing e-prescribing systems across various provider settings. Currently being tested and fine-tuned, it will be available free of charge via the AHRQ’s National Resource Center for Health IT Web portal (www.healthit.ahrq.gov) by the end of 2010. The center also offers free Webinars on various topics, including e-prescribing.

Elsewhere, the American Medical Association has launched an online education center on e-prescribing (www.ama-assn.org/ama/pub/erx/home.shtml), where providers can find vendors and learn about qualifying for federal and state incentive programs. It also includes readiness and planning tools and a calculator to estimate the time savings providers can expect with e-prescribing.

The Center for Improving Medication Management (www.thecimm.org) provides a clinician’s guide to e-prescribing and other resources to educate clinicians and their staff on the best approaches to implementing prescribing technology and integrating it with the day-to-day workflow.

Surescripts, in partnership with technology vendors and medical societies, has launched the E-Prescribing Resource Center, where providers can download an e-prescribing guide and buyer’s worksheet, read up on Medicare incentives, check on the certification status of software, view e-prescribing statistics, see which pharmacies are connected to the Surescripts network, and sign up for an e-mail newsletter to receive updates and news about e-prescribing.

— AS