Patricia L. Hale, MD, PhD, FACP CMIO, Glens Falls Hospital and CTO, Adirondack Regional Community...

Patricia L. Hale, MD, PhD, FACPCMIO, Glens Falls Hospital and CTO , Adirondack Regional Community Health Information Exchange [email protected] www.pathalemd.com

Learning Objectives Impact of e-prescribing on patient safety

and reduction of medication errors What’s new Explore the training requirements for

physicians Explore the implementation differences

between a small medical practice and an RHIN

Source: The Institute of Medicine of the National Academies of Science (IOM).2006 Slide used by permission from SureScripts

7,000 Americans Die Annually From Preventable Medication Errors

1.5 Million Americans Injured Annually by Preventable Medication Errors

Physicians write

4.5 billion prescriptions

each year. . . .On Paper!

The Challenge of “Prescription Hand-offs”

• Illegible Handwriting

• Unclear Abbreviations and Doses

• Verbal Communication Among Physicians, Patients and Pharmacists

Over 4.5 Billion Prescriptions Written Annually… Less than 1 in 5 of Physicians Use e-Prescribing Only 20% of prescriptions are prescribed

electronically with 80% still handwritten Most electronic prescriptions are still sent by

FAX

Sources: eHealth Initiative, 2004 and: Center for Information Technology Leadership, “The Value of Computerized Provider Order Entry in Ambulatory Settings,” 2003.

National savings from universal adoption ofelectronic prescribing systems could be as high as $27 billion

Patient safety Between 1.5%-4.0%

prescriptions are in error with serious patient risk

Adverse drug events occur in 5%-18% of ambulatory patients

Quality of care - Compliance 20% of scripts are never filled Patient satisfaction is

decliningCost of errors: $2 billion / yearImpact on productivity* Physician practice: 3 hours

per day Pharmacy: 4 hours per day

(up to 1 call per Rx) Inefficient delivery

Illegible handwriting

Phone tag and fax tag

Patient waiting in the pharmacy

Illegible handwriting

Phone tag and fax tag

Patient waiting in the pharmacy

RxRx

Rx

823 million visits to physician offices in 20001

4 out of 5 patients who visit a physician leave with at least one prescription2

65% of the US population (91% of Medicare) use a prescription medication each year3

1) Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, 2002. National Center for Health Statistics. 2002.2) The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001.3) Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.

3.5 Billion Total Filled Prescription Transactions in 2003 increased to 4.5 in

2006

1.4 B

0.4 B

0.5 B 1.5 B

Refills

New Scripts

Renewals

Unfilled

Certified version typically a simple upgrade away

Extremely low awareness among install base

RxInterOp

150,000 Certified EMR Users

Practice Size

Best estimates for EMR adoption based on high

quality surveys (%)

All 24

Solo 16

Large* 39

*”Large” is defined as > 20 physician FTEs in one study with 39% adoption and >50 in two another studies with 47% and 57% adoption respectively.

Sources: Jha et al, Health Affairs, 10/11/06; MGMA, 2005; CDC/NCHS Nat’l Ambulatory Medical Care Survey, 2005; HSC Community Tracking Study, 2006; Forrester, 2003; SureScripts estimates, 2006. Slide used by permission from SureScripts

Ability to create a prescription electronically Ability to receive automated decision support during script

creation Medication lists and information Eligibility determination Formulary coverage from insurer including co-pay

information Prior authorization clinical decision support including Drug interactions, drug-

allergy, etc. Ability to send script electronically to pharmacy using standard

transmission messaging (NCPDP SCRIPT, ASC12) Ability to receive/authorize pharmacy initiated-renewals

electronically Ability to determine “fill status” as a measure of compliance

(medication history) Ability for pharmacy to process electronic script in their system

Slide used by permission from SureScripts

Prescriber eRx

Software

Pharmacy and PBM

eRx SoftwareSureScripts

Provides:New Rx, refills,

renewals, authorizations,

change Rx, Prescription history from pharmacies

ProxyMed and others

Medimedia and others

RxHub Provides: Eligibility, Formularies, medication claims histories

Prescribers Office staff

Min

ute

s p

er

da

y

(2006 Study: Brown University) Slide used by permission from SureScripts

PenPrint6%

Fax37%

EDI+

Decision Support

61%

Source: CITL Slide used by permission from SureScripts

Patient & Physicians

AccessMedical

Websites

Electronic Prescribing

Electronic Medical Records Systems

Better informed consumers

Gains in accuracy and connectivity enhance safety and efficiency

Integrated database allow decision support tools

Streamlined information retrieval: valuable for epidemiology

Population-based outcomes and cost information readily available to consumers, physicians, payers

Algorithm-driven medicine and decision making

Regional Health

Information Networks

National Health

Information Infrastructure

National Disease

Databases

“Evidence-Based”

Medicine

Increased Decision Support

40-80%7-20%

16-40% <5%

Patients:Patients: Increased safety, efficiency and compliance Lower co-pays

Pharmacies:Pharmacies: Increased efficiency, improved care, improved

patient satisfaction Payors/PBMs:Payors/PBMs:

Increased generic/formulary usage, efficiency, Rx compliance and prevention of ADEs (reduced costs)

Providers:Providers: Increased efficiency, improved care, patient

satisfaction and potential incentives (pay-for-performance)

Cost of buying, installing, implementing and supporting a system

Lack of reimbursement for costs, time and resources

Increased time to use the system = reduced productivity (initially)

Increased time required to review warnings, alerts and recommendations (long term)

Still not considered a routine standard of practice

In the past… But now…

Very few pharmacies were directly connected to physician practices

Over 95% of US pharmacies are connected into a single network and growing

Electronic communications meant faxesComputer applications can communicate directly with each other

Only half the problem was being addressed… writing new scripts

Renewals can be automated in addition to new scripts

Software didn’t support the workflows in the practice

Software integrates with existing practice systems and smoothes office workflow

There were few real benefits for most practicesMost practices will save physician and staff time as well as improve patient safety

There wasn’t a future path to additional benefitsCollaboration now available with payors on patient compliance and other future functions

Automation was being driven by a few Health Plans and small software vendors

State and nation-wide initiatives now occur involving all major stakeholders

Economic Incentives Grant and Loan Programs Reimbursement for Utilization Pay for Performance Malpractice Insurance Premium Reductions Healthcare IT Suppliers group discounts, etc Pharmacies or Transaction Brokers Defray Costs

Policy Incentives and Programs Accreditation (JCAHO 2005 Hospitals’ National Patient

Safety Goals, others in development) Employer Programs (Leapfrog and others) Medicare support for economic incentives DOQ-IT CCHIT certification of inpatient and ambulatory

EMRs Mandates ???

Voluntary program Mandatory National eRx Standards for Medicare

Initial standards 2005; Pilot program 2006, Final Standards 2009 Recommendations delivered by NCVHS

Information Requirements include Lower cost, therapeutically appropriate alternatives Interactive, real-time to the extent feasible

Encourages Physician Adoption: Permits use of appropriate messaging Modifies anti-kickback regulation for hospital, physician groups

and plan administrators to allow them to give out eRx hardware and training

Allows plans to pay-for-technology and pay-for-cost effective performance in Medicare Advantage Plans

$50MM of federal grant money in 2007 (but must be budgeted) Preempts State Laws contrary to the national

standards or those that restrict the ability to carry out the new law.

Progress-to-date Issued Notice of Proposed Rule-Making (10/05) Issued final rule naming foundation standards

(11/05) Pilot programs competed and reports submitted

(2/06)Deadline for Secretary to

develop ePrescribing Standards

Sept 1, 2005

Jan 1, 2006

Apr 1, 2007

Apr 1, 2008

April 2009

Launch 1-yr voluntary

ePrescribing pilot

program; plans can offer P4P

Evaluation results of

pilot program due to

Congress

Deadline for Secretary to finalize and

release standards

All Medicare providers

using ePrescribing must adopt

finalized standards

RAND – New Jersey BCBS NJ, Caremark mail order, Walgreen retail pharmacy

Brigham & Women’s Hospital - CareGroup Health system in Boston use in EMR and e-prescribing “Gateway” utility

Achieve – tech vendor for long term care industry in Midwest with it’s own pharmacies

Ohio University Hospital Health System and Ohio KePRO QIO - 300 hospital physician practices

Surescripts - with practices in Florida, Mass, Nevada, New Jersey and Tennessee with a variety of software vendor systems and assortment of chain and independent pharmacies

Med History – recommended to be included as ready for adoption. Main challenge is ensuring the data is collected and reconciled from a large number of sources to be sure history is complete.

Formulary and Benefits – recommended to be included as ready for adoption. Issues: Systems must adequately match patient to

health plan Payers vary in the level of information provided

making data difficult to interpret Should support real-time changes in patient

status as patient moves between benefit plans

Prescription Fill Status Notification – recommended to be included as ready for adoption. However many pharmacies do not currently have the ability to track patient pick-up status accurately and questionable prescriber demand for this if the info is already available in the med history.

Prior Authorization – NOT recommended for implementation – Limited experience at pilot sites to evaluate this function and there are work flow and other issues which suggest a need to have more work done to improve the standard.

Structured and Codified Sig - NOT recommended for implementation – needs additional work with reference to field definitions and examples as well as naming conventions and clarification of field use.

RxNorm – (standard for name, dose and form of drugs) – Not recommended for implementation – Dictionary standard requires further evaluation and refinement.

Recommended updates to SCRIPT v8.1 – Need to further refine the standard to be able to: update prescriptions without having to create a

new order, send a refill from the facility to the pharmacy

without physician intervention, update patient information outside the context of

prescriptions

Prescriber staff (“surrogate prescribers”) played a much more important role in the process than anticipated.

Never fully replaces need for paper-based prescribing

Causes a shift in pharmacy work flow Poor adoption and use of medication history Long term care site reported a reduction in new

prescription rate which may indicate reduction in accumulation of multiple medication

Not enough data yet on effects on safety or change in use of generic medications.

“Dedicated to improving patient safety by providing free electronic prescribing for every physician in America”

The National ePrescribing Patient Safety Initiative (NEPSI)

A Coalition of the Nation’s Most Prominent Technology Companies, Healthcare Benefit And Medical Provider Organizations

Slide used by permission from NEPSI

National Sponsors Technology Sponsors

Connectivity Sponsors

Search Sponsor

Health Benefit Sponsors


eRx NOW™ from Allscripts described as: Simple: Web-based E-prescribing Software

Easy To Install and update Easy Interoperability Custom search engine from Google Formulary information available

Safe Comprehensive Allergy and Drug Interaction

Checking Secure

Secure anytime, anywhere access Rigorous credentialing and authentication

The “ATM of Healthcare??”

www.nationaleRx.com


FormularyE-Prescribing Rx HistoryE-Refills Eligibility

Pharmacy Health Information Exchange™, operated by SureScripts®


EMReClinicalWorkseClinicalWorks, Inc.

EPDrFirst RcopiaDrFirst

EPScriptSureDAW Systems

EP/EMRMedManagerChartConnect

EPCommunity Health RecordCerner

EMRBondMedical, IncBond Medical

EMRChart Management SystemBMA Enterprises

EPInfoSolutionsBCBS/AL

EP/EMRAxolotlAxolotl

EMRathenahealthathenahealth

EMRASP.MDASP.MD

EP/EMReRx NOW™Allscripts/NEPSI

EP/EMRTouchWorks/ TouchScriptAllscripts

EMRHealthmatics® EMRA4 Health Systems

EligibilityFormulary*Rx History* E-RefillsE-Prescrib.System

TypeProductCompany


GoldRx certification status No longer based on just compliance to

standards Identifies which vendors are not just

testing and marketing interoperability but are truly delivering and committed to: Customer Education Proven Pharmacy Interoperability Advanced Medication Management Workflow Enhancements &

Demonstrable Expert Experience with Electronic Prescribing Process


The first products to achieve GoldRx certification announced in Feb 2007: TouchWorks

EHR(Allscripts) ChartConnect EMR Rcopia (DrFirst) NextGen EMR eScript (RelayHealth) Pocketscript (Zix)


Last Year: RI was #1, MA was #3, MI was #10, WA and NJ not on last years list and FL and VA were in last year’s Top 10


Created by the National Association of Chain Drug Stores, the National Community Pharmacists Association and SureScripts

Certification Commission for Health Information Technology (CCHIT)

CCHIT Certification EMR ePrescribing Criteria 2007 2008 2009Send an electronic prescription to pharmacy

l

Send a query for formulary information l

Send a query for medication history to PBM or pharmacy and import medication list into EHR

l

Respond to a request for a refill sent from a pharmacy

l

Receive medication fulfillment history l

Respond to a request for a prescription change from a pharmacy

l

Send a cancel prescription message to a pharmacy

l

Send electronic prescription to pharmacy including structured and coded SIG instructions

l

44

RxHub SureScripts

Source of Data Claims data from PBMs

Dispensed Drug Data from Pharmacies

Interoperability Model

Pass-through Repository

Details Included No sig Sig (unstructured)

Regional Coverage Plan dependent Pharmacy dependent

Pricing $$$ $

47

A4 Health Achieve Allscripts Athena Health Bond Medical Catalis Health Cerner DrFirst eClinical

Works eHealth

Solutions EmDeon/

WebMD EPIC Gold Standard H2H Solutions Health Vision

InstantDx

iScribe

MA Share

McKesson

MDAnywhere

MdOffices

Medical Info Sys

MedicWare

MedKeeper

MedPlus

Medport

NewCrop

NextGen

OA Systems

Phytel

Purkinje

Relay Health RxNT

SafeMed

Script IQ

ScriptRx

Scriptsure

Sequel Systems

SSIMED

STI Con

Synamed

Zix Corporation

Bold = in production

Health care professionals can register for an ICERx.org account at www.ICERx.org or call 1.888.ICERX.50 (888-423-7950).

During periods of emergency, licensed health care professionals who have registered on ICERx.org can login to the online prescription database, where they will have access to: Evacuee prescription history information and the

name of the provider who wrote the prescription and the pharmacy that filled it

Available patient clinical alerts, including drug interaction, therapeutic duplication and elderly alerts

Clinical pharmacology drug reference information, including drug monographs, interaction reports and the drug identifier tool

As of February 2nd, 2007 - 48 States and Washington, D.C. cleared for electronic prescribing

As of February 2nd, 2004 - 25 States cleared for electronic prescribing


52Not shown: HI: 42%; AL: 24%; As of November 9, 2006

Access to more than 160 million patient prescription information records via payers and PBMs, through the growing list of RxHub certified technology partners. Direct contracts with payers and PBMs represent additional access to more than 50 million patients.

An increase in transaction volumes of 50% from 29 million transactions in 2005 to more than 43 million transactions in 2006. These transactions were real-time requests for patient eligibility and benefits, formulary, and medication history information, made at the point-of-care in the ambulatory and acute care settings from clinicians across the United States.

A ten-fold increase in true electronic prescriptions, which includes the transmission of patient-specific clinical decision support information at the point of prescribing, to retail and mail order pharmacy locations of the patient’s choice.

No two medical practices are alike – evaluation of current processes is critical in determining best product and implementation plan

Physicians learn by apprentice model – be sure there is a physician champion

Evaluate requirements for physician training early and plan schedules to accommodate decreased productivity

Workflow is a critical factor in success

Staff roll in the prescribing process is a major influence on potential success and usually underestimated

Time for training and implementation should be maximized (consider vendor recommendations as a MINIMUM)

When implementation of electronic prescribing is through a regional health information network new issues arise which include:

Management of shared medication lists Management of shared problems lists Opportunity for aggregated medication

history data Increased concerns about secondary use of

prescriber data

More options for stand alone, certified EMR and information network based electronic prescribing products

Increased connectivity of pharmacies and PBMs Increased functionality to improve office efficiency

(electronic refills) Support for implementation through programs like

DOQ-IT and others Grant, P4P and other funding opportunities New educational material and resources are

available

“We tried dedicating this computer to deciphering our doctors' handwriting."

Cartoon by Dave Harbaugh

Contact me at: [email protected]

Web site with further information and links: www.pathalemd.com

Patricia L. Hale, MD, PhD, FACP CMIO, Glens Falls Hospital and CTO, Adirondack Regional Community...

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Transcript of Patricia L. Hale, MD, PhD, FACP CMIO, Glens Falls Hospital and CTO, Adirondack Regional Community...