Measuring E-Prescribing to Sustain Adoption and Support P4P

1. Measuring E-Prescribing to Sustain Adoption and Support P4P R. David Allard, MD - Henry Ford Health System AMGA October 1, 2009

2. Disclosure • Member - DrFirst Inc. Physician Advisory Board • Unpaid • Position taken over 1 year after vendor chosen

3. Medical IT “Technology is not the destination, it is the transportation.” Dr. Safron – American Medical Informatics Association

4. Goals • Describe experience • Discuss steps for successful roll out of ePrescribing • List obstacles to adoption • Understand motivating factors to adoption • Understand Metrics for tracking quality and success • Look at methods of measurement • Review PQRI ePrescribing incentive • Discuss collection of PQRI data

5. The Industrial Revolution in Healthcare • Medicine must push out its performance envelope • Technology is a natural direction for an information industry • ePrescribing is an achievable first step

6. Henry Ford Health System –Key Facts • Henry Ford Health System includes: • Henry Ford Hospital and six owned hospitals • Henry Ford Medical Group with 800 employed physicians/scientists • 24 ambulatory centers located in Southeastern Michigan • Health Alliance Plan, a 530,000 member managed care organization serving 2,800 employers

7. Henry Ford Health System –Key Facts • Ambulatory Clinic Organization • Each clinic has a Physician In Charge (PIC), an administrative manager, and a nursing supervisor • Key roles impacted by ePrescribing included physician, nurse, medical assistant, and customer service representative • Technology • Electronic medical record (EMR, called CarePlus) used throughout HFMG (clinics and hospital) • All primary care exam rooms have PCs with network access used to connect to the EMR

8. HFHS ePrescribing Initiative – History • September 2004 – GM asked HAP & HFMG to partner with auto companies to test ePrescribing via the Southeast Michigan ePrescribing Initiative (SEMI). HFMG agreed to be the incubator for testing ePrescribing and eight HFMG primary care clinics launch ePrescribing • January 2005 – HFMG/HAP launched first 4 HFMG primary care clinics on ePrescribing • January 2006 – HFMG completed implementation at all primary care clinics • January 2007 – HFMG completed implementation in all outpatient specialty care clinics • February 2007 – Michigan is recognized for moving from the 10th highest ePrescribing state to the 6th for 2006 • April 2007 – HFMG launches 3 Emergency departments on ePrescribing • February 2008 – Michigan is recognized for moving from the 6th highest ePrescribing state to the 5th for 2007 • June 2009 – Michigan is recognized for moving from the 5th highest ePrescribing state to the 3rd for 2008

9. ePrescribing – Solution Scope • Users can write prescriptions on a PC using the web or on a wireless device (smart phone, tablet PC) and send them directly to the retail pharmacy or mail order pharmacy for filling • Application has real time access to: • Patient’s eligibility • Formulary • Drug fill history • Drug allergies

10. Fostering Change • Creating Readiness • Overcome resistance • Articulate the vision • Generate Commitment to the vision • Institutionalize the change

11. Setting the Stage • Vendor selection • Get the equipment • Data preload • Articulate a vision and position the event

12. ePrescribing – Value Proposition - Quality • IOM Dimension of quality • Safety • Reduce the rate of drug/drug interactions • Reduce errors due to allergy • Reduce error due to legibility • Patient centered • Allows patients to select their preferred pharmacy • Reduces process time for patients • Provides patients with a printed list of meds • Allow easy use of mail order pharmacies • Efficient • Reduce paper based processes • Reduce Staff time for renewals • Reduce Pharmacy call backs to offices

13. ePrescribing – Value Proposition - Quality • IOM Dimension of quality • Effective • Improve ability to track compliance • Increase formulary adherance • Increase generic use rate

14. Go Live Strategy • Trainers on site • Training in groups by function • A given clinic was closed in the AM for training with go live in the afternoon • Trainers stayed on site for 3-5 days • During hands on training sessions, rapid adopters were called upon to help others

15. Five Stages of Medical Technology Acceptance: • Abject horror • Swift denunciation • Profound skepticism • Clinical evaluation • Acceptance as standard of care Frederick Knoll, “Medical Imaging in the Age of Informatics” – Stanford University, 11/15/2005

16. Adoption Measures • Currently over 39,000 prescriptions generated each week – • Over 6 Million sent as of June 2009

17. Results – Safer Care • Over 1.1 million total warnings have been delivered as of early 2008 • Over 400,000 prescriptions have been changed or cancelled due to warnings

18. Results • For HFMG capitated membership • HAP/HFMG initial capital investment of $1.6 million plus annual operating costs averaging $590,000 reaps total savings of more than $1.9 million in total for 2005 and 2006 • Future estimated savings through 2009 will average $4 million per year • Based on the 2005 and 2006 realized improvement in generic use rate, the five year Return On Investment is now estimated to be over $14M

19. Results • Key sources of cost reduction benefit are: • GUR Improvement – totaling $1.5 million for 2005 & 2006 and estimated at $3 million/year for 2007-2009 • Administrative savings – totaling $700,000 for 2005 & 2006 and estimated at $560,000/year for 2007-2009 • Estimated impact of reduced adverse drug events (ADEs) – totaling $540,000 for 2005 and 2006 and $540,000/year for 2007-2009

20. Adoption Measures • HFMG primary care physician feedback after 1 year • 85% agree that ePrescribing has improved the practice of medicine at their clinic • 77% agree that ePrescribing improves the safety of the care that patients received • 75% agree that ePrescribing improves the quality of the care that patients receive • 70% agree that ePrescribing improves patient satisfaction

21. Adoption Measures • Strong patient preference for ePrescribing • Saves time at pharmacy • Simplifies process for mail order pharmacies • Improves medication reconciliation procedures giving increased patient confidence

22. Adoption Measures • Support staff love it • Old process time/renewal 7 minutes, 12 seconds • ePrescribing 3 minutes 50 seconds/renewal and got better with time • Time savings did not result in headcount reduction but enables other activities by support staff

23. Measuring Use • Need to assess continued use • Look for pockets of resistance

24. Measuring Use • Retrospective Study Comparing Insurance claims data to prescription • Advantages • Shows the percentage of scripts written electronically • Ignores differences between specialties • Difficult to dispute • Disadvantages • Very time consuming and labor intensive • Requires claims data from insurance company (or possibly RxHub)

25. Measuring Use Patients with Health Insurance Plan with prescription drug riders Match patient, Doctor and Medication

26. Prescription Distribution • Prescription Distribution • Based on insurance claim data: 81% of all prescriptions during the 12 months study period were written by primary care. 13% were written by medical subspecialties and 6% by surgical specialties • Approximately 2/3 of all prescriptions are filled. This does not change across specialty

27. Measuring Claims and ERx

28. Claim vs. ERx Data

29. RVU vs. ERx • Advantages • Does not require insurance information • Fairly easy to count • Disadvantages • Does not reliably account for case acuity between providers • Still requires data from more than one source

30. ERx vs. RVU generation

31. Measuring with Prescription Volume Only • Easy data to collect • Matches well with Other methods • Non-users defined as creating less than 15 prescriptions/week • The other data collection methods were still worthwhile as they validated the volume method

32. Analysis • In contrast to primary care, medical and surgical specialties were trained by specialty – not location. • This greatly decreased the on-site post go-live support • Fewer opportunity for super users to help out • Specialties write far fewer prescriptions – essentially practicing less. This is particularly true regarding refills (the area of greatest efficiency)

33. Reported Problems • Too much time logging in and out • Answer, integrate with single sign-on • It takes too long to write a script • Answer, Use favorites, single sing-on, have support staff verify pharmacies • I have to much to do • Answer – Nurse refill process for maintenance medications

34. Overcoming Resistance • Data Collected from more than one source is harder to refute • Sell the process • Build on the Process • Target ongoing training to areas of slowest adoption

35. ePrescribing from the Physician Prospective –Sources of Error Patient gives wrong information or doesn’t have information (I,E,R) CSR incorrectly copies information (E,R) Written information is misplaced and not seen by doctor (R) Chart misplaced or slow to be located/retrieved (I,R) Review time in chart (I) Correct phone number for pharmacy needed (E,R) Time spent on phone with pharmacy (I) Transcription error at pharmacy (E,R) Transcription error in medical record or not recorded (E,R) Patient fails to get prescription (I,R) Patient fails to notice error (E) I=Inefficiency, R=Rework,E=Error Patient calls for medication refill Customer Service Rep (CSR) writes information for nurse/doctor review and action Doctor or doctor’s agent (nurse) reviews prescription and makes decision for fill or not Doctor or agent calls pharmacy with prescription information, information documented in the medical record Pharmacy fills prescription and patient picks it up

36. ePrescribing from the Physician Perspective Sources of improved efficiency and decreased error 1 2 Pharmacy sends refill request electronically Patient calls for medication refill Greatly reduced time and no transcription errors Information on patient available as prescription created Requests not lost Information available as decision made Enormous time savings No transcription error Reliable documentation Electronic request sent to a clinic “in box” for review by doctor or doctor’s agent and decision on action 3 4 Prescription automatically sent to pharmacy and documented 5 6 7 Pharmacy fills prescription and patient picks it up

37. Overcoming Resistance –Obstacles • Learning curve • Training needed to be ongoing • Time study • Resistance to change itself • Congratulate past success and then change

38. Overcoming Resistance • Depends heavily on setting the stage • Listen to feedback • Discuss and contrast with paper/phone process • Share successes (data from adopters) • GUR improvement, • Changed scripts due to warnings • Elicit testimonials • Enlist participation in users group

39. Overcoming Resistance –Users Group • Users group with wide range of technical ability • Ongoing review of bugs and enhancement requests • Over 320 Software enhancements and fixes to date

40. Generate Commitment • Celebrate Successes • Foster involvement • Users group • Train the trainer • Solicit ideas • Communication!

41. Institutionalize the Process • Users become trainers • Process becomes the foundation of the next aspect • Specify the metrics

42. Institutionalize the Process –Building On the Foundation • Nurse medication renewal policy started with standing orders for nurse • Uses ePrescribing process • Medication Reconciliation with ePrescribing as source of truth • A JCAHO compliant medication note can be created with one “click” provided the user has kept the medication list up to date. The best way to do this is to write the prescriptions in the software! • PQRI makes ePrescribing a requirement

43. Adoption Measures

44. Next Steps • Continue metrics • Scripts by Volume (varies per specialty) • # warnings • Offer retraining/refresher for low utilizers • Continued integration into EMR • Continued improvement and feedback

45. PQRI ePrescribing Incentive • For those physicians using ePrescribing, payment will be made at a higher rate

46. CMS Electronic Prescribing Incentive

47. CMS Electronic Prescribing Incentive • Current requirement is to submit G-code with each claim • CMS has to date not accepted aggregate reporting from medical groups • G8443 - All prescriptions generated during the office visit were created electronically • G8445 - No prescriptions were generated during the encounter. • G8446 - Some or all prescriptions generated during the encounter were handwritten, faxed, or called in.  (This does not include prescriptions created electronically and handed to patient or then faxed, which would be reported using G8443.)

48. Attaching G Codes • Currently attaching G Code at the point of care based on provider reporting. • Billing is captured from an optical scanning scheet • G Codes were added as an optional field (at first) • Clinicians “bubble” a choice of “all e-Rx”, “Paper Rx”, or “no Rx this visit” • Looking at attaching code based on ePrescription generation but this only returns a numerator. This does not differentiate visits which had no prescriptions from those with paper prescriptions.

49. PQRI reporting success In June, a “hard stop” was introduced in the billing process, not allowing the billing sheet to be processed unless a G Code was added.

50. Summary • ePrescribing was not only financially sound but resulted in safer, more patient centered care • Our ePrescribing success was due to several factors: • Goals consistent with mission and culture of organization • Planning to make adoption easier • Ongoing improvement • Enthusiasm • Training and monitoring becomes a continual process which will not end