Barriers to Provider Adoption of eRx
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Transcript of Barriers to Provider Adoption of eRx
Barriers to Provider Adoption of eRxBarriers to Provider Adoption of eRxLessons Learned from the NEO CMS eRx Pilot
AHRQ National Meeting, BethesdaSeptember 8th, 2008
Bob Elson, MD, MS (MetroHealth)John Kralewski, PhD (U MN)Dave Gans, MSHA, FACMPE (MGMA)
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NEO eRx Project ParticipantsNEO eRx Project Participants
UH Medical Practices + Ohio KePRO
MGMA Center for Research
Univ. of Minnesota Division of HSR
InstantDx (OnCallData™)
RxHub, SureScripts, NDC
Aetna, Anthem, Medical Mutual of Ohio
Partners (Bates / Seger)
… and CMS, AHRQ, and the other pilots
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NEO eRx OverviewNEO eRx Overview
eRx adoption, including “incumbent” transactions– Eligibility, Med Hx, NEWRX
Impact on workflow
Transaction interventions– Medication Hx, Fill Notification, Prior Auth
Impact on safety and utilization
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Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
NEO eRX PROJECT TIMELINE 2006
RxFILL
Training
Prior Auth
Training
Med Hx (new)
Training
270/271SCRIPT
FormularyMed Hx
SiteVisits
Planning, Tool DevelopmentPractice Recruitment, IRB
Health Plan Data Acquisition / Analysis
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Provider Adoption of eRxProvider Adoption of eRx
Practice vs. provider adoption
Workflow realities
Role of practice culture
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UH Medical Practices (UHMP)
285 physicians, 73 practices, 42 communities46 primary care; 27 specialty1.25 million office visits / yr
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Small Practice Adoption: Magic MixSmall Practice Adoption: Magic Mix
eRx offered free to all UHMP practices
Out-of-the-box integration w/ practice management system
Minimal equipment requirements
ASP delivery; robust remote training and support
Each practice allowed to determine optimal workflow
Malpractice subsidy if met threshold utilization criteria
You can lead a horse to water…
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Pre-Project eRx Adoption (All of UHMP)Pre-Project eRx Adoption (All of UHMP)
Total e-Rx / mo, 1/05 -> 1/06
AND make it drink (voluntarily) … !
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Pre-Project eRx Adoption (by Practice)Pre-Project eRx Adoption (by Practice)
UHMP Primary Care, Jan -> August ‘05
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eRx (Study) and Control PracticeseRx (Study) and Control Practices
Study (eRx) group (n=25 practices, 130 physicians)
Part of University Hospital Medical Practices (UHMP)– Community-based, primary care practices in Northeast Ohio
Access to OnCallData™ e-prescribing software
At least one doctor in the practice generated a minimum of 150 eRx in any month of 2006 prior to enrollment
Control group (n=22 practices, 77 physicians)
Independent primary care practices in NEO– Not currently e-prescribing
Convenience sample – Practices w/ Ohio KePRO relationship under 8th SOW
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eRx and Control PracticeseRx and Control Practices
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eRx Control
Small (1-3 docs)
Med (4-8 docs)
Large (9+ docs)
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eRx Control
Fam Med
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eRx and Control Groups:
25 UHMP practices with access to eRx (130 MDs)
22 non eRx practices (100 MDs)
Loosely matched by size and specialty (separately)
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e-Prescribing @ 25 Practices (2006)e-Prescribing @ 25 Practices (2006)
MonthAll UHMP
eRxStudy Group
eRx % of Total
January 32,153 21,095 65.6
February 31,723 21,304 67.2
March 40,079 26,549 66.2
April 35,680 23,406 65.6
May 42,646 27,497 64.5
June 40,451 26,588 65.7
July 37,795 24,349 64.4
August 43,560 27,977 64.2
September 42,228 27,660 65.5
October 47,998 31,402 65.4
November 46,440 30,343 65.3
December 44,674 29,131 65.2
TOTAL 485,427 317,301 65.4
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eRx / prescriber / mo (10/06 by practice)eRx / prescriber / mo (10/06 by practice)
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p = pediatric practice# at top of each bar = number of physicians in that practice
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25 UHMP primary care practices130 physicians
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Provider Adoption of eRxProvider Adoption of eRx
Practice vs. provider adoption
Workflow realities
Role of practice culture
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Surrogate-Based e-PrescribingSurrogate-Based e-Prescribing
48,013 eRx in October (all UHMP)– 16,715 entered directly by MD
• 15,724 NewRx (~1000 Renew)
– 97 / 219 e-prescribers did at least some data entry themselves • 122 did none
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Fam Med Int Med Peds
Physician Other
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Renewal Workflow FindingsRenewal Workflow Findings eRx decreases dependence on phone / fax
– Incoming Rx renewal requests from local pharmaciesreceived by:
eRx practices still depend on paper for internal processing– For phoned-in requests, 81% communicated to MD by paper
• Only 7% entered into OnCallData™ on the front end
– For faxed requests, fax itself used for internal communication 91%
73% sent back to pharmacy via eRx – only 33% come in by eRx, but most entered into OCD on back end
– 25% of authorizations called or faxed to pharmacy vs. 90% in control
eRx Control
Phone 41% 62%
Fax 25% 36%
eRx 33% 0%
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eRx Impact on Call TypeseRx Impact on Call Types
Inbound / outbound Ratio
Relative % of outbound callsgoing to pharmacy
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Inbound Outbound
eRx Control
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% Outgoing Calls to Pharmacy
eRx Control
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Practice Adoption SummaryPractice Adoption Summary
eRx w/ advanced transactional capabilities can be rapidly adopted by small, community-based practices– PMS integration, no license fee + small incentive– Large (>2/3) dependence on surrogates
• Implications for decision support and safety benefits unclear• Policy guidance? P4P?
– Big impact on efficiency and communication channels, but…• Paper-based internal communication still predominates• Faxing is tough to beat re: overall resource requirements• Opportunity for additional efficiency with more pharmacy participation plus
true e-messaging within the practices
– Conventional wisdom challenged:• eRenewals drive adoption (?)• Surrogates provide bridge to MD adoption (?)• eRx is a stepping stone to a full EMR (?)
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Provider Adoption of eRxProvider Adoption of eRx
Practice vs. provider adoption
Workflow realities
Role of practice culture (in provider adoption)
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In press…In press…
“Factors influencing physician use of clinical electronic information technologies after adoption by their medical group practices”– Kralewski, JE et. al.– Health Care Management Review, October-December 2008
“Culture as a management tool in medical group practice”– Physician Executive Journal
• (http://www.acpe.org/Publications/PEJ/index.aspx?expand=pej )
– Kralewski, JE et. al. Measuring the culture of medical group practices. Health Care Management Review; 2005; 30:184-193
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MGP Culture Survey: 8 DimensionsMGP Culture Survey: 8 Dimensions
Collegiality
Quality emphasis
Management style
Cohesiveness
Organizational trust
Adaptive
Autonomy
Business
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Related to eRx Adoption?Related to eRx Adoption?
Physician age Age in years
Physician gender 1 = female, 2 = male
Physician specialty 1 = family practice, 2 = general pediatrics, 3 = general internist
Practice size Number of FTE physicians
Patient work load Number of pt encounters for each physician per week
Practice complexity 0 = single specialty, 1 = multispecialty
Practice culture Mean score for practice on 1-4 scale, with 4 being more so (8 dimensions)
Dependent variable Proportion of total prescriptions written by each physician during a 2 month period that were sent electronically
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Hierarchical ModelHierarchical ModelIndividual-level characteristics Coefficient SE z
Age -.001 0.003 -0.25
Gender 0.009 0.042 0.21
Internal medicine -0.187 0.077 -2.45*
Family medicine -0.095 0.106 -0.9
Workload -.000 0.000 -0.84
Clinic-level characteristics Coefficient SE z
Practice size 0.070 0.026 2.70*
Multispecialty practice 0.218 0.087 2.50*
Collegiality 0.220 0.172 1.28
Quality emphasis -0.558 0.246 -2.27*
Management style 0.185 0.148 1.25
Cohesiveness -0.387 0.144 -2.68*
Organizational trust 0.417 0.071 2.44*
Adaptive 1.416 0.387 3.66**
Autonomy 0.422 0.143 2.96**
Business 0.413 0.112 3.69**
*Significant at the 0.05 level; **Significant at the 0.01 level
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Practice Culture and eRx UsePractice Culture and eRx Use
Driving practice adoption is just the beginning
Practice culture has major influence on eRx use patterns by providers within the practice
Personal characteristics of physicians do not– other than specialty
Good news:– Can predict physician cooperation by assessing practice culture– Gauge amount of passive or active resistance
Bad news:– Cultures are not easy to change!– Better to shape the innovation process to accommodate the culture