Q and A With Lee Ann Stember and Phillip Scott

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NCPDP

Leaders of the NCPDP explain why adoption of e-prescribing will be morerapid than EHRs.

Healthcare Technology: Can you provide some background on the NCPDP?

Phillip Scott: The National Council for Prescription Drug Programs (NCPDP) is a not-for-profit ANSI-accredited standards development organization consisting of over 1,300 members representing virtually every sector of the pharmacy services industry. NCPDP creates and promotes standards for the transfer of data to and from the pharmacy services sector of the healthcare industry. The organization provides a forum and support wherein our diverse membership can efficiently and effectively develop and maintain these standards through a consensusbuilding process. NCPDP also offers its members resources, including educational opportunities and database services, to better manage their businesses.

HCT: What are the goals and objectives of EHRs?

PS: Well the goals and objectives are those that everyone has been touting for a number of years, which would be the obvious things: patient safety, and portability of the information. For me, I guess there are two issues: electronic health records (EHRs) and electronic medical records (EMRs). The terms get used interchangeably, but I think they’re actually two different things.

EHRs are the overall affirmation relating to a patient’s health, and the other is very specific information related to medical adventures in their life. I think that the overall goals are that we’re really looking at the opportunity to take a patient’s medical experience or history out of individual silos. As it exists today, what happens in the community stays in the community. What happens in the hospital tends to stay in the hospital. And if a patient has an event or long-term care, or any of the assisted living care, what happens there stays there. It’s truly three individual silos. And patient medication information, drug history and medical history all travel in a big brown envelope or in a little brown sack. For the first time, we’re really looking at the opportunity to get rid of that. So that when a patient has a change in medication or has a medical adventure, it is taken from the community environment into a hospital.

Up until very recently, when it comes to drug history, it’s whatever your daughter- in-law remembered to throw in the brown sack. And that is no way to run an army. So at a grassroots level, that’s really what the goals and objectives of EHRs and EMRs are. A community pharmacy will tell you that when a patient is put on a new medication, when they’re discharged, the pharmacy where they normally do business does not get that new information. So there’s a lot of confusion. If you’ve got histories, or you’re taking a product that is contraindicated for a new circumstance that you’re being treated for in the hospital, there’s no way for the pharmacist to know that. And that’s a terrible set of circumstances for a patient. And now you move the patient out of the hospital straight into long-term care or to assisted living for a period of time, and something changes there — the attending doctor is not the same doctor that they saw in the hospital, because the patient went in and was treated by a cardiologist, but the patient is being treated by an internist in the nursing home. So the goal is to get that whole environment out of manual transmissions of big brown envelopes and little brown bags.

Let’s say you’ve got an emergency circumstance at home. The EMT (emergency medical technician) comes, they do what they can to stabilize the patient, and as they head out the door they shout and say, be sure and grab all his medications that he’s taking.Well, you know, folks don’t always keep them all in the same place. This morning he picked up one of them and went to the phone and took it to get it refilled and left it sitting on the desk. So you only get three of the four, or whatever. Or it’s not even somebody that’s normally in your house and you just kind of go rummaging in and you pick up stuff, and half of it belongs to the spouse.

So there’s the advantage of EMRs, if a patient is within the system and we know that it’s United or Kaiser, then we are able to go in and plug in the patient’s ID and, in the best of circumstances, be able to call that up and know immediately what the patient’s drug history is and what their medical history is. And it’s not at all unusual for someone to be going in for a circumstance where the medicine to be utilized is contraindicated for another chronic ailment that they are on. If we don’t have access to this information, we can’t know it.

HCT: What do you think are some of the implementation challenges for EMRs and EHRs?

PS: I’m not so sure that the public really is aware right now. I mean, they hear all the right stuff, so, say you’re in the San Francisco Bay Area; well, when they find out that they’re starting to have all of that health record information, whether they care if anybody knows or not, you know they’re going to raise a big stink, right?

Lee Ann Stember: I think one of the main concerns is how all this information is going to get disseminated, and is the right information going to be given? Also where is this big database going to reside and how are we going to make sure that everything is correct? I want to make sure that Lee Ann Stember is Lee Ann Stember, with all the correct data.

PS: I think the challenges tick off like this. One, it is a standards issue. There are three standards bodies: X12N, HL7 (Health Level 7) and NCPDP.We have to continue with our initiatives around interoperability in mapping the standards so that we can talk to each other across what have been existing barriers in the past. Just as we talked about the three silos earlier, with institutions, community and extended care, there are three existing silos, and that’s X12, which is financial; HL7, which tends to be medical, and the hospital stuff; and then NCPDP, which is the pharmacy services sector of healthcare.

We’ve been fine operating within our own environment, for the most part, for the last number of years.We can’t do that effectively in the future.We have to be mapping our standards so that we can speak to each other across these invisible barriers.What happens today is that the physician thinks he’s doing an electronic prescription because he has the handheld system that he can do all of his stuff with inside his office, and then he hits send and it goes over to his office system, and because his office system is written potentially in HL7 language, it can only send a fax to the store that he wants the prescription to go to. So it leaves an electronic world, goes into a paper world, and then when it goes into a paper world, it goes to the exact same level of performance as a handwritten prescription does. So that’s a barrier. It’s got to go to, as one of our members says, all electrons all the time.Well that’s maybe a little grandiose, but it’s certainly more akin to what we expect to get to than it is today.

Another concern is the uptake of technology by the physician. But let me tell you, there’s a level of physicians out there today that is what I would refer to as the second generation or the third generation in practice, and those are in that 40-, say 50-year-old level and lower. A pharmacist told me about an environment where there were 10 physicians that he was dealing with in a practice and they were all less than 10 years in practice, and they didn’t use paper. So the ones that are leaving school right now, they’re ready. So the challenge for them is the technology being available to them as soon as they’re ready for it. Then there’s those that have been in practice that are 35, 40 years old, so they’ve been in practice 15 or 20 years and they’re not as technically savvy but they’re certainly willing. Then there’s the ones that have been in practice who are looking to retire, and they want no part of it. The downside of that is that if it’s a group practice, they’re probably the managing partner. So if there’s cash outlay, they’re not looking to spend $100,000 or $200,000, because they’re looking at that as reserves for them to divvy up when they retire in two years.

PS: So to say that physicians are technophobes, I think that that’s not exactly true. But what I do suspect, and we’ve heard it from doctors who are in that kind of middle ground of practice, is that they found that if their life gets a lot easier in an electronic prescribing world than they would prescribe electronically, but it is the guy who is controlling the purse strings that won’t make the investment. So that’s a major hurdle, if you will, to implementation.

How do you start to figure out who to ask and what the questions are to ask, and to pursue this as a serious goal to get yourself up and running in an electronic world? It’s a whole lot of trouble. And the handheld products, over the last three to five years have left a lot of doctors unsatisfied, because they’d get one, they’d get fully implemented and the company goes away.

Then they’d go off to another device, because they like it, and that company goes away after a year and a half, so some of these physicians, not only are they seeking knowledge, it also becomes a matter of, can I trust the technology, is this a solid company, what am I going to be left with if, three years from now, this device goes belly up? And those aren’t issues of technology, those are the issues of business and the negative impact that happens to early adopters, you know, those pioneers out there that really move ahead early and have the idea to make it happen, but they can’t get the funding to survive. I had a friend who was one of the early folks in a customer relations management system, and he tromped all over New England selling this thing and trying to get it up, and trying to get it funded. He said the first guy over the hill is the first one to get shot, but those that come after him can get over that hill really easy by crawling over him.

And so a lot of that happens: You have great ideas and great folks, insufficiently funded, and you end up leaving a bad taste in a practitioner’s mouth because they’ve tried three times. Now why are they going to waste their time and money on that again?

HCT: Do you think there will be widespread adoption in the next five years?

PS: I think that in medical records,maybe not, but I think that in electronic prescribing, we are going to have widespread adoption in the next five years.

LS: I would agree with that.

PS: Part of that is that 86 percent of the pharmacies in the U.S. are ready to receive electronic prescriptions today.

So in this EHR world, electronic prescribing is just one element, but the NCPDP standard was adopted and accredited in 1997, so the script standard for electronic prescribing has been in existence since 1997. The pharmacies have been prepared to do that and have pretty widespread implementation now for at least two years.

So it’s a matter of getting the physicians ready to use that. And the federal government has encouraged that. They’ve named the NCPDP script standard as the base standard to use, and they’ve encouraged that because it’s one of those early successes for them in the bigger picture. Any time you take a grandiose initiative to do something as needed and as incredible as EHRs and EMRs, it takes a long time. So I think that a five-year outlook for that is …

LS: That is very optimistic.

PS: Very optimistic around that element of it, for sure. And I think that the other elements of medical records are going to start to move a lot faster as well. For example, the task of mapping from HL7 to NCPDP has been going on since September 2004, and while that initiative is not completed, there is a significant amount of work that is happening. In March 2005 there was a demonstration both at HEMS and NCPDP annual in which the prescription left the patient’s bedside in the hospital and through the hospital system was transmitted in a communitybased pharmacy. So now it’s the back half of that that we’re working on, which is the communication, the ticket from the pharmacy back to the hospital and then all of the information that has to occur in between. So I think there’s a bright outlook for this, really a bright outlook.