The Logical First Step for EHR: E-Prescribing
While the variability of technology and solutions for overall electronic health record (EHR) may intimidate physicians and cause reluctance to adopt this approach to better healthcare, e-prescribing provides a safe introduction into the process for the ambulatory arena. A properly deployed e-prescribing system creates a win/win solution for all stakeholders and a pathway for future deployment of EHR and related applications. With a fully connected e-prescribing solution, payers and providers can begin to communicate in real time and in a relevant and efficient manner. It can establish the electronic highway that enables a more robust and relevant dialogue between payers and providers as well as establish an infrastructure on which to build.
By connecting to the payer environment, physicians enjoy immediate operational efficiencies and can comply with pharmacy and pay-for-performance programs. The operational efficiencies can be significant for a physician office. A majority of patients leave a physician visit with at least one prescription, and in todays manual paper environment, that translates to a large number of pharmacy calls for prescription verification, modifications and renewals.With each of those calls, a physicians office encounters a series of manual steps to address the question or correct the prescription, which in turn wastes valuable physician, nurse and office staff time.
For payers, the benefits of electronic prescribing come through improvements in formulary compliance, generic utilization and in establishing relevant and timely connectivity with physicians that can be leveraged to the benefit of both parties.
The benefit to the patient should also not be overlooked. Beyond the apparent patient safety benefits, there is ability for physicians to actually assess patient medication compliance. In todays manual environment, physicians may only know what prescription they wrote for a patient but they do not have a way to view if that prescription was ever dispensed. E-prescribing provides physicians with dispensed medication history, thereby giving physicians a view of what was actually dispensed which can lead to patient-physician discussions around compliance issues where they exist. The hassle factor is also removed for the patient, no longer needing to wait at the pharmacy counter as the pharmacist calls the physician office to verify or modify a prescription.
We would also be remiss if we did not address the value to the retail pharmacies. Studies have shown that the paper-based process adds a significant amount of administrative manual work to pharmacists jobs, impacting productivity and taking them away from their primary clinical role.
Everyone especially the patient derives benefits from enhanced information access and greater safety. E-Prescribing creates an infrastructure that benefits all stakeholders and provides a platform from which to expand into future applications.
Incentives for Implementation
Over the last year a number of forces have come together to make e-prescribing adoption more probable. One significant force is the current political environment that encourages and supports e-prescribing and EHR. The Medicare Modernization Act (MMA) solidly promotes the use of e-prescribing technology and the development of standards.While MMA does not mandate the use of e-prescribing, it does encourage differential payments for physicians who participate in Medicare Advantage Prescription Drug plans and who e-prescribe.
The federal government has also expedited the development of standards around e-prescribing, issued the foundational standards in 2005 and is expediting the development and testing of additional standard elements. All providers using e-prescribing will need to adhere to these standards, so, logically, payers must be able to accept and operate with them as well. The federal government encourages payers to create incentives that drive e-prescribing forward in the provider environment. As a primary payer, the federal government will probably follow suit with its own incentives as MMA implementation progresses.
Standard-setting organizations have also come together to help propel the movement forward. Organizations like NCPDP and HL7 for the first time have collaborated on mapping their standards to enable the sharing of information between inpatient and ambulatory environments. They have been joined by organizations such as RxHub, SureScripts and a number of private vendors to make this a reality.
Numerous foundations and private companies have also provided funding and leadership to move adoption of technology forward in healthcare. Health plans and employers are structuring incentives to encourage the use of technology by providers in their network. The incentives can and have taken several forms. One approach is pay-for-performance incentives that reward physicians for using an e-prescribing or an EHR application.
While this provides the carrot for adoption, it may not be enough to get some physicians over the hurdle of the initial investment. This is particularly true for physicians in small- to medium-sized practices. As such, some employers and health plans are considering sharing the cost of the initial investment; an approach that helps reduce the initial cost barrier to entry.
The Centers for Medicare & Medicaid Services is also exploring pay-for-performance demonstration projects and the federal government has targeted $50 million in funding in 2006 for e-prescribing programs for ambulatory physician practices. These practices serve as the keystone for regional and national health infrastructures, and e-prescribing starts the process by creating infrastructure building blocks. The government has taken the approach of funding demonstration projects and allowing final models to evolve as various infrastructures prove their viability.
E-Prescribing Captures Information
Full e-prescribing encompasses a broad spectrum of information and capabilities, including:
Eligibility status at the patient level for pharmacy coverage. Eligibility information reflects current status, provided the primary systems adjudicating claims remain current, which they tend to do since their business depends on real-time processing and payment of pharmacy claims.
Details about patient-level pharmacy benefit coverage. The information reflects individual details instead of aggregate grouplevel data, and integrates benefit coverage with formulary and preferred medication lists.
Formulary and preferred medication lists. This interactive listing of medications, coupled with the specifics of a patients benefit plan, transcends static listings of medications.
An ambulatory history of dispensed medications. Each physician or prescriber can access this electronic record of prescriptions (this information can be shared across physicians if the patient has provided consent). This history, which crosses prescribers and payer plans, includes active and past medications.
An ambulatory history of written medications. Each physician or prescriber can access this electronic record of prescriptions. (This information can be shared across physicians in the same practice if the patient has provided consent.)
The ability to assess written versus dispensed medications for a patient and identify medication therapy noncompliance.
The ability to integrate clinical messaging and rules. This capability integrates tools such as prior authorization, quantitylevel limits, step therapy rules, disease management triggers, care management messages and evidence-based care guidelines.
When integrated with an EHR, e-prescribing information can be coupled with a patient problem list, tests (lab, radiology) and results.
Implementation Today
Todays technological environment enables a relatively smooth implementation of e-prescribing. Existing technology can accommodate a variety of physician office and workflow requirements and support different business models that can make adoption more feasible for the smaller practices.
In addition, vendors and strategic alliances can provide turnkey solutions today that make it possible to migrate tomorrow to EHR. A group of companies, for example, each with vast experience in strategically applying technology to the needs of the healthcare industry, has come together to create an e-prescribing solution for the ambulatory market. They have combined best-in-class software, hardware, consulting and support services to connect physicians and clinicians directly with pharmacies for instant e-prescribing capabilities. This solution incorporates all components of the e-prescribing process, including interfaces to major practice management systems and the ability to load patient demographic and scheduling information directly into the application.
The single largest challenge to adoption of e-prescribing clearly is not technological reluctance to adopt in the ambulatory market presents the most significant obstacle. Fragmentation of the ambulatory market in small and single practices further complicates the situation. These practices face considerable financial and other challenges if they wish to adopt and integrate new approaches and maintain them for the long term.
To encourage ambulatory providers to adopt e-prescribing, sponsors, payers and vendors must deploy a hands-on, high-touch model and work with providers to educate, train and navigate through the learning curve. Behavior modification in a busy environment takes time for office staff and physicians.
As e-prescribing becomes more mainstream the standard for payers and providers to do business adoption rates will increase. Payers (including the federal government and large commercial health plans) can encourage this evolution by incorporating incentives into their contracts, such as reimbursement strategies tailored to e-prescribing or pay-for-performance rewards. Economics often serves as the major driver for behavior change. Because payers tend to benefit from e-prescribing more quickly and to a larger degree, accruing about 75 to 80 percent of the initial benefits, they need to share these benefits through co-funding strategies to lower the initial barrier to entry for ambulatory physicians.
With the federal government standing solidly behind e-prescribing and EHR, the ambulatory market enjoys an incredible opportunity for making these changes. Realizing improvements through reduced medical errors and fewer deaths from adverse drug events will fuel further action.
The Risks and Benefits
One of the major risks facing implementation of e-prescribing is that not enough health plans or payers will get behind the effort and encourage standardization of technology and business processes. If the federal government, as the single largest payer in the U.S., does not provide meaningful funding incentives, the effort will lose steam.Walking the talk is critical.
In addition, if enough of the large-group-practice e-prescribing/ EHR systems remain isolated from payer systems, we may see one model for large providers and another for the ambulatory segment. How will large payers react to this market? At this stage, some large e-prescribing/EHR vendors have moved forward to gain access to ambulatory information, but the risk remains that this effort will not move forward quickly enough to gain momentum.
An additional risk is with standalone e-prescribing vendors that do not have an EHR platform/application. These vendors need to position their offering to allow integration with EHR systems. Physicians may take e-prescribing as a single application but they will eventually want and need to move to a full EHR application that includes e-prescribing. The challenges may include both the ability of the e-prescribing vendor and the willingness of the EHR vendor
By and large, the benefits of implementing e-prescribing far outweigh the risks. The e-prescribing component of EHR is the easiest to implement and serves as a leading- practice model for all other pieces of the care continuum. The process can build on well-established pharmacy and interim technology standards, making it much more likely that the industry will reach MMA goals for full e-prescribing by 2009.
Where Is Deployment Today?
In the past couple of years, studies have indicated that somewhere between 5 to 15 percent of physicians use some version of e-prescribing applications. However, in the past year, with the alignment of various forces, e-prescribing seems to be taking off. According to RxHub, the last six months have seen double-digit growth in eligibility transaction volume (a core transaction for e-prescribing) month over month. This indicates large deployments and use of e-prescribing technology.
Some large payers, such as WellPoint, have made efforts to move their physician network forward in the use of technology in the ambulatory setting.WellPoints initiative focused on reducing the cost barrier of entry for physicians, and illustrates a payers understanding of the value that they as well as physicians derive when technology such as e-prescribing is deployed and used in the ambulatory setting. Other examples of large-scale efforts include RxConnect, a collaborative effort between Blue Cross Blue Shield Massachusetts and Tufts University, and a Blue Cross Blue Shield project in Michigan with employers such as GM, Ford and DaimlerChrysler.
In addition, standards development organizations have stepped up efforts to promote e-prescribing standards. This includes the key project between the National Council for Prescription Drug Programs (NCPDP) and HL7 to map their respective standards to allow pharmacy transactions across the inpatient and outpatient/ ambulatory settings. This begins to break down the silos of information that exist between inpatient and outpatient environments with pharmacy leading the way for a more patient-centric view of information. It also includes recommendations for e-prescribing standards by the National Committee on Vital and Health Statistics (NCVHS) Subcommittee on Standards and Security. NCVHS has already recommended a subset of transactions to be foundational standards for e-prescribing based on the fact that these transactions are already widely used in the market. Additional transactions related to e-prescribing such as the medication history transaction are in the process of certification via ANSI-accredited organizations such as NCPDP.
E-prescribing applications have existed for more than 10 years and the maturation of technology and applications makes it truly deployable in the ambulatory market. Likewise, maturation of associated business models has made e-prescribing more affordable, especially as payers serve as catalysts for deployment and enter into collaboration with physicians/providers where they share in some of the cost as well as the benefits. As payers continue to look for new ways to collaborate with providers, the likelihood of success increases. Ambulatory physicians hesitate to invest in vendor-dependent systems that may lose relevancy and remain confused by the offerings of the many vendors currently in the market. They need true partners to help them cut through the crowd to the solutions that fit their practice needs.
Integration of ambulatory practice systems with inpatient systems will further encourage deployment of e-prescribing. Inpatient systems are much more developed and implemented (even though the level of use and deployment remains suboptimal). Ambulatory systems remain fragmented between large-group practice systems and small- to medium-sized practice systems. The large group practices can more ably interface with inpatient environments, provided they operate on the same systems, while small to medium practices typically have no connection with inpatient environments and run on completely different systems.
By creating specific capabilities that provide value for both, eprescribing systems can overcome this fragmentation and link inpatient information with ambulatory care. For example, the HL7- NCPDP mapping project has created the ability to access a patients ambulatory medication history in an inpatient setting (such as in the emergency department). It has also provided the capability for discharging physicians to access patient ambulatory benefit coverage, write a prescription per that coverage and route it to a retail pharmacy.
The Time Has Arrived
Today, e-prescribing continues to grow rapidly because of increased pressure on the healthcare industry to improve quality, safety and efficiency. The MMA and its requirements for reasonably short-term deployment fuel this acceleration, as does increased payer emphasis on collaborating with providers and members to promote this beneficial tool.
A significant percentage of large group practices already have some level of EHR/e-prescribing (although not usually connected to ambulatory prescription data) in place and the rate of adoption is expected to increase over the next few years. Smaller groups and solo practices must keep pace to remain viable and competitive. E-prescribing a relatively low-cost, easy-to-implement solution is the logical starting point toward full-scale EHR implementation for all ambulatory practices.
