E-prescribing in community-based practices: successes and barriers

1. E-prescribing in community-based practices: successes and barriers Michael A Fischer, M.D., M.S. Division of Pharmacoepidemiology and Pharmacoeconomics Department of Medicine Brigham and Women’s Hospital Harvard Medical School

2. Research team • BCBSMA • Megan Bell • Adrienne Cyrulik, MPH • Tufts Health Plan • Julie Newton • Zix Corporation • Angus MacDonald • Scott Plunkett • Co-authors Ritu Agarwal, PhD U Maryland Corey Angst, PhD Notre Dame Cate Desroches, PhD MGH

3. Background • Promise of e-prescribing • Improved safety • Value • Efficiency • Slow spread to community-based practices • Uncertain what drives successful e-prescribing uptake in community setting

4. Study setting • Initiated by BCBSMA and Tufts Health Plan • Partnered with ZixCorp, providing physicians with PocketScript system • Program began in early 2004

5. Prior studies – erx adoption Fischer et al, JGIM, 2008

6. Prior studies – e-rx and costs Fischer et al, Arch Int Med, 2008, in press

7. Prior studies – e-rx and safety • Most alerts over-ridden by prescribers • Weingart et al. Arch Int Med, 2003 • Reviews suggest reduced ADEs, but inadequate studies in outpatient setting • Ammenwerth et al. JAMIA, 2008

8. Study questions • What is the experience of community-based practices that adopt electronic prescribing systems? • What barriers remain to successful adoption and use of e-prescribing? • Where has e-prescribing succeeded; has it created new problems?

9. Study design • Focus groups • Conducted spring 2008 • Prescribers and office staff • Internal medicine, pediatrics, FP, cardiology, nephrology • Both current and former users • High/low volume, abandoned, transitioned to EMR • Interviews • Detailed discussions with prescribers

10. Findings • E-prescribing positives • Ongoing challenges/barriers

11. E-prescribing positives • Prescription security • Financial gain • Office efficiency • Medication safety • Insurance issues • Communication with pharmacy

12. E-prescribing positives • Prescription security • Less people touch the actual prescription • Patients cannot lose the prescription • Patients cannot tamper with prescription

13. E-prescribing positives • Financial gain • Direct incentives a major factor • Initial adoption subsidized • Later incentives for ongoing use • Potential gains in patient satisfaction • “if we can reduce wait times, we’ve succeeded” • Unclear of RoI in terms of practice billing

14. E-prescribing positives • Office efficiency • Major changes in practice workflow • Less calls for front-end staff • Refills and other non-critical medication issues can be batched for MD review • Frees staff time and attention • Less interruption of work • Pharmacy information is updated and accurate • Perceived ROI, but hard to quantify

15. E-prescribing positives • Medication safety • Quick review of patient medication history • Available round the clock, out of office • Alerts about drug-drug interactions • Office staff appreciated reminders • Physicians less certain, many alerts dismissed • Ability to identify patients on a specific drug • Especially useful for recalls • “I can identify all the patients on..”

16. E-prescribing positives • Insurance issues • Can see if a drug is not covered • Avoids callbacks, increased patient satisfaction • Ability to identify patients on a specific drug • Also useful for prescribing incentive programs

17. E-prescribing positives • Communication with pharmacy • Timely flow of information • Ability to send specific messages • e.g.: “no more refills until patient sees doctor”

18. Ongoing challenges/barriers • Learning curve • Usability • Reliability • Safety concerns • Patient resistance • Data security

19. Ongoing challenges/barriers • Learning curve • New skill: “not covered in medical school” • Difficult for older prescribers • High burden on champions/superusers • New tasks for some personnel – source of resistance • Lack of support • “Locked in” with initial vendor choice

20. Ongoing challenges/barriers • Usability • Types of devices/interfaces • Problems with some pharmacies • Inability to transmit to PBMs • Reliability • Connectivity/network problems, loss of productivity • Resistance for sick patients or weekends

21. Ongoing challenges/barriers • Safety concerns • Selecting wrong patient • Selecting wrong drug (Cipro/Cialis) • Some doses/formulations not in system • Drug alerts not perceived as helpful: “ignore almost all” • Some alerts may be handled by non-prescribers in the process of queuing

22. Ongoing challenges/barriers • Patient resistance • Wanting something in hand (older pts) • Bad experiences with failed transmissions • Inability to transmit to PBMs • Data security • Concern about whether transmitting patient data creates liability exposure • Concern about prescribing data and tracking/profiling • Who owns the data: cost of changing

23. Summary observations • Overall positive experience – almost none would “turn back the clock” • Successes: office efficiency, pharmacy communication, formulary information, prescription security • Barriers/challenges: Learning curve, reliability, questionable safety impact

24. Summary observations • Benefits more apparent in larger practices with high volume of chronic mediations • More opportunities to streamline workflow • Prescription volume/management is seen as a major issue at baseline • Possible financial gains easier to perceive

25. Next steps • On-site visits to observe system use, validate focus group observations • Large-sample survey to test generalizability of initial findings • Quantitative studies of e-rx impact on cost, safety, adherence, clinical outcomes