Patricia L. Hale, MD, PhD, FACP Deputy Director Office of Health Information Technology Transformation New York State De

1. Patricia L. Hale, MD, PhD, FACP Deputy Director Office of Health Information Technology Transformation New York State Department of Health

2. Current state Benefits of e-Prescribing Challenges and barriers Cost vs benefits for various medical practice settings “Bottom line”? Roll of Incentives

3. A Public Health Crisis Key Points: Back in 2000, the Institute of Medicine came out with a report that astonished everyone. Nearly 100,000 people die each year from medical errors of all kinds, including medication errors. Six years later, the IOM released a report specifically on medication errors and again astonished everyone: According to the IOM, 1.5 million Americans are injured each year and 7,000 die from medication errors. This is simply unacceptable. Key Points: Back in 2000, the Institute of Medicine came out with a report that astonished everyone. Nearly 100,000 people die each year from medical errors of all kinds, including medication errors. Six years later, the IOM released a report specifically on medication errors and again astonished everyone: According to the IOM, 1.5 million Americans are injured each year and 7,000 die from medication errors. This is simply unacceptable.

4. The Challenge Physicians write as many as 4 billion prescriptions each year. . . . On Paper! Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, 2002. National Center for Health Statistics. 2002. The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001. Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999. NACDS estimates. Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, 2002. National Center for Health Statistics. 2002. The chain pharmacy industry profile. National Association of Chain Drug Stores. 2001. Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999. NACDS estimates.

5. The Technology is Available Today…But Not Used Less than 1 in 5 of Physicians Use ePrescribing Only 20% of prescriptions are electronically prescribed with 80% still handwritten Most electronic prescriptions are still sent by FAX Key Points: So it have been six years since the IOM’s first report and the question is have we made any progress? Unfortunately, not enough. With over 3 billion prescriptions written every year; even though we have the technology to make this problem go away, less than 1 in 5 of the nation’s practicing physicians regularly use electronic prescribing While many of the large academic medical groups like our own group at Texas A&M have already adopted electronic prescribing via an electronic health record, 50% of physicians are in small groups with 1 to 10 physicians lack the resources and the time to adopt a standard e-prescribing solution. Key Points: So it have been six years since the IOM’s first report and the question is have we made any progress? Unfortunately, not enough. With over 3 billion prescriptions written every year; even though we have the technology to make this problem go away, less than 1 in 5 of the nation’s practicing physicians regularly use electronic prescribing While many of the large academic medical groups like our own group at Texas A&M have already adopted electronic prescribing via an electronic health record, 50% of physicians are in small groups with 1 to 10 physicians lack the resources and the time to adopt a standard e-prescribing solution.

6. The Current System Causes a Number of Serious Problems ! 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 Cost of errors: >$2 billion / year Quality of care - Compliance 20% of scripts are never filled Patient satisfaction is declining Impact on productivity: Physician practice: 3 hours per day Pharmacy: 4 hours per day (up to 1 call per Rx) Inefficient delivery with paper, fax and phone Illegible handwriting Phone tag and fax tag Patient waiting in the pharmacy

7. Impact of E-Prescribing on Preventable Adverse Drug Events (ADEs)

8. Full e-Prescribing includes: 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

9. Intermediaries for Data Transfer

10. Electronic prescribing is under-utilized: Purchasing software does not equal adoption or effective use Certified version typically a simple upgrade away Extremely low awareness among install base

11. Where are we? We remain at the tipping point of adoption of clinical systems at the point of care Early adopters are on board and EMRs are now mainstream in large practices

12. So Why Aren’t We All e-Prescribing?

13. Who Benefits from eRx?

14. Everyone Benefits – But Not Equally > 80% Payors/PBMs: Increased generic/formulary usage, efficiency, Rx compliance and prevention of ADEs (reduced costs) Patients: Increased safety, efficiency and compliance Lower co-pays >20% Providers: Increased efficiency, improved care, patient satisfaction and potential short and long term incentives (pay-for-performance) Pharmacies: Increased efficiency, improved care, improved patient satisfaction

15. Benefits Include: Discovery of potentially significant drug-drug, drug-allergy or drug-lab interactions; Reduced adverse drug events (ADE), Reduced avoidable emergency department visits or hospital admissions; Eliminated transcription or legibility errors; Availability of a more complete, up-to-date medication list for each patient; Increased practice efficiency (particularly med renewal requests); Increased prescriber efficiency (e.g., fewer call-backs from pharmacies); More effective medication reconciliation across multiple settings of care; Increased patient satisfaction.

16. E-Prescribing Pilots

17. But… Providers are concerned about… Cost of buying, installing and supporting a system Lack of reimbursement for costs and resources Increased time to use the system = reduced productivity (initially) while struggling to create efficient workflows Challenges of creating a complete, accurate patient medication history from multiple sources Time required to review medications, warnings, alerts and recommendations Limitations preventing use for all prescriptions due DEA restriction from use for controlled medications …..Still not considered a routine standard of practice

18. What are the key elements influencing the business case for clinicians? Business case varies according to: Size of practice Type of practice (primary care vs specialty, mostly new patients, mostly recurrent complex patients, etc) Participation of health plans Participation of local pharmacies Practice setting (large/small, urban/rural) Availability of IT infrastructure and support Stand alone e-prescribing vs EHR Availability of incentives and ability to take advantage of them

19. Cost: Initial costs include software licensing fees, hardware, network and Internet access and training and technical support Complete cost will also include Temporary decreases in productivity resulting from training and workflow redesign (averaging 2-6months) Practice management, lab and other interfaces Customization for practice specialty and other factors Maintenance of system Upgrades Data conversation (from different PMS or from stand alone e-prescribing system to EHR)

20. Cost: Stand alone e-Prescribing start up and ongoing cost estimated at $1000 - $3500 per physician per year for software plus hardware etc EMR costs estimated at $20-25,000 initial and $3000 per year per physician for software plus hardware etc Costs are less in urban areas where Internet and IT services are more readily available Large practices can save significantly through cost sharing and increased efficiency of implementation and support by being able to afford dedicated staff

21. Potential Savings Both stand alone e-prescribing systems and EHRs Increased practice efficiency handling med renewal requests Increased prescriber accuracy resulting in fewer call-backs from pharmacies for legibility issues, drug incompatibility or ineligibility EHRs Decreased chart pulls resulting in less staff time Decreased transcription costs

22. Impact of e-prescribing on time spent (minutes/day) on refills/renewals NOTES: Participants of the e-prescribing standards study (participants in six states using 1 of 6 different physician software applications) Average time spent per day among clinicians decreased in half – from 35 minutes per day to 17 minutes per day. Staff time spent on refills and Renewals also was cut in half – from 87 minutes per day to 43 minutes per day.NOTES: Participants of the e-prescribing standards study (participants in six states using 1 of 6 different physician software applications) Average time spent per day among clinicians decreased in half – from 35 minutes per day to 17 minutes per day. Staff time spent on refills and Renewals also was cut in half – from 87 minutes per day to 43 minutes per day.

23. So – “bottom line”….What is the business case for a large urban practice? Advantages: Financial investment capability Dedicated staff opportunity Leverage with health plans and pharmacies, etc for connectivity Often can leverage other incentive opportunities with health plans, P4P, PQRI etc. Disadvantages: Organizational “buy in” with large potentially diverse physician staff often resulting in “hold outs” and partial implementations Major changes in workflow can be disruptive decreasing productivity making clinician payment strategies etc in need of temporary modifications Significant Initial cost

24. So – “bottom line”….What is the business case for a small rural practice? Advantages: Organizational “buy in” less of an issue Less total initial investment Disadvantages Difficult to absorb cost including system cost and decreased productivity Can have connectivity issues and difficulty obtaining skilled IT support No leverage with health plans or pharmacies resulting in decreased opportunity for optimum data flow No opportunity for dedicated staff to maximize success or take advantage of other incentives like P4P and PQRI

25. “Bottom Line”

26. Incentives Where do they fit in?

27. An Overview of Potential Incentives Economic Incentives Grant and Loan Programs Reimbursement for Utilization Pay for Performance Malpractice Insurance Premium Reductions Healthcare IT Suppliers discounts, etc Policy Incentives and Programs Accreditation (JCAHO 2005 Hospitals’ National Patient Safety Goals, others in development) Employer Programs (Leapfrog and others) DOQ-IT CCHIT certification of inpatient and ambulatory EMRs Mandates ???

28. Medicare e-Prescribing Incentive Beginning January 1, 2009, Medicare will offer physician payment incentives of 2% for using e-prescribing in 2009 and 2010, with this amount declining slightly over the next three years. E-Prescribing can also be used to help meet one of the three requirements to receive PQRI incentives which can raise the incentive payment to a total of 4%

29. Relaxed STARK regulations At the federal level, regulations released in 2006 now allow free donation of e-prescribing hardware, software, and related services to prescribers by hospitals (to members of their medical staff), by a group practice (to their physician members), and by Medicare Advantage and Medicare Part D Prescription Drug Plans.

30. Other incentive programs CMS has provided over $100 million in funding to state Medicaid programs to help them encourage prescribers to adopt e-prescribing. NYS Medicaid is considering a 80%/20% Physician/Pharmacy split of $1/e-Prescription incentive program There are a number of national and state level incentive programs (by health plans and others) providing everything from software and/or hardware to direct incentive payments and P4P programs

31. Barriers and Challenges Financial Cost and Return on Investment (ROI) Change Management and Workflow Controlled Substances and other Federal and State rules and regulations Hardware and Software Selection and support Limitations on E-Prescribing System Remote Access Pharmacy, Payer/PBM and Mail Order Connectivity Medication History and Medication Reconciliation System Functionality Gaps Prescribing from Multiple Office Sites or remotely Small/Rural Practice Challenges

32. KEY QUESTIONS TO ASK WHEN BUYING AN E-PRESCRIBING SYSTEM About stand-alone systems 1. Can it be interfaced with my practice management system (PMS)? What does the interface cost? 2. Is it compatible with any EMR? In other words, if I move to an EMR later, can I easily transfer my already populated medication, allergy and problem lists to the new EMR? 3. How often has the system gone down? What is my recourse if it goes down and I can’t access my patient’s medication information? 4. How financially stable is the vendor? What would I do if the vendor went out of business? Could I obtain all my patient information easily and transfer it to another vendor’s program? 5. How fast an internet connection do I need for optimal use? 6. If there is a cost to the program, will the efficiencies I gain from using it (or any insurance company incentives) offset the cost?

33. About any system – stand-alone or EMR-based 7. Is it SureScripts-RxHub compatible? Which functions? 8. Is it a “qualified eRx program” under Medicare? 9. Does the program create personal favorites lists and/or memorize ‘sigs’ as I prescribe? Is it generated automatically or do I need to select the drugs Iwant as favorites? 10. Does the program allow me to see prescriptions from other physicians? How about prescription fill information? 11. Can I create “split prescriptions” – send a prescription to a local retail pharmacy and a mail order pharmacy at the same time? 12. Where does the pharmacy information come from and how accurate is it? 13. Where does the formulary information come from and how accurate is it? 14. How often is the database updated with new information – new medications, removed medications, updated formulary information, drug interaction information, new pharmacy information etc.? 15. How does the program compare to other e-prescribing programs in ease of use? (Some programs require more clicks – and more time – to perform the same functions.) KEY QUESTIONS TO ASK WHEN BUYING AN E-PRESCRIBING SYSTEM

34. Resources

36. HIMSS intends to continue providing education to our members and industry colleagues using a number of vehicles Social Networking: HIMSS intends to post information on the outcomes of the Conference and Technology Showcase on the HIMSS LinkedIn Community, Facebook, and Twitter. We will be developing an E-Prescribing Wiki. Content Development: The HIMSS E-Prescribing Task Force will continue to produce a series of “tipsheets” for providers on how to incorporate E-Prescribing solutions into the medical practice Conferences: HIMSS will leverage our Virtual Conference and Exhibition in November 2008 and HIMSS09 April 2009, to highlight E-Prescribing and provide education updates.

37. References and Resources: E-Prescribing and health information technology. Davis, Ronald, 2008. American Medical Association. http://www.ama-assn.org/ama/pub/category/18579.html. National Progress Report on E-Prescribing. 2007. SureScripts. http://www.surescripts.com/pdf/National-Progress-Report-on-EPrescribing-1.pdf. For more information on the Medicare incentive program: PQRI Toolkit - http://www.cms.hhs.gov/PQRI/31_PQRIToolKit.asp and for MIPPA- http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3200 Electronic Prescribing for the Medical Practice: Everything You Wanted to Know But Were Afraid to Ask, Patricia L. Hale, PhD, MD, FACP, Editor www.himss.org/bookstore and also the e-Prescribing resource center on the HIMSS web site at: http://www.himss.org/ASP/topics_eprescribing.asp Evidence on the Costs and Benefits of Health Information Technology. May 2008. Congressional Budget Office, page 17. http://cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf Physicians' Experiences Using Commercial E-Prescribing Systems - Physicians are optimistic about e-prescribing systems but face barriers to their adoption. - by Joy M. Grossman, Anneliese Gerland, Marie C. Reed, and Cheryl Fahlman - Health Affairs April 6, 1008 Free e-prescribing readiness assessment online - http://www.getrxconnected.com/ E-Prescribing: Why the Fuss? Kenneth G. Adler, MD, MMM FAMILY PRACTICE MANAGEMENT Preprint | www.aafp.org/fpm - Surescripts/RxHub - http://www.surescripts.com/get-connected.aspx?ptype=physician Electronic Prescribing: Building, Deploying and Using E-prescribing to Save Lives and Save Money – Center for Health Transformation 2008

39. Questions? Contact me at: pathale@pathalemd.com Web site with further information and links: www.pathalemd.com