AHIP Coverage (July/August 2008)
Steady Progress in E-Prescribing
By Lisette Hilton
Spured by the goals of reductions in medication errors , increased patient and physician convenience, time savings for physicians, and cost reductions, health plans across the country are assisting providers to convert to e-prescribing. The technology allows prescribers to electronically send accurate, error-free, and understandable prescriptions directly to pharmacies from hand-held devices or from computers in prescribers’ exam rooms. E-prescribing replaces handwritten prescriptions, which are often difficult to read—and, in some instances, downright illegible.
Humana has begun deploying an e-prescribing capability to high-prescribing physicians in South Florida. The system is offered through Availity, a company created in 2001 as a collaboration between Humana and BlueCross BlueShield of Florida, says Marie Dieudonne, director of e-Health within Humana’s Clinical Guidance Organization.
In early 2007, Health Care Service Corporation (HCSC), which operates through its Blue Cross and Blue Shield divisions in Illinois, New Mexico, Oklahoma, and Texas, became a third owner-partner of Availity, she explains.
Availity offers an IT platform that provides physicians with numerous administrative services and clinical information through the Availity Care Profile, including an e-prescribing capability.
Dieudonne explains why the health plans collaborated to form Availity. “If you were to walk into [most] doctors’ offices today, they might have separate systems for [many] payers….You can see the impact on the workflow from the provider’s standpoint. Going with a multipayer solution does a lot of things to support that provider and allows for some tremendous innovations. You can envision that we would really be able to drive health information technology innovation around Care Profile, the e-prescribing solution.”
With e-prescribing, “right there, within the office, the physician can do an electronic transaction to members’ choices of pharmacies for their prescriptions, and all that data can be reported back into the Care Profile,” Dieudonne says.
Most of the transactions in the Availity.com platform are free to providers from Availity, she says. The Web-based platform is accessed from a computer in the provider’s office. The physician can write prescriptions from the computer or from a hand-held wireless tool, which Availity provides free of charge.
“In the state of Florida, Availity has achieved 98 percent adoption by hospitals and physician offices,” Dieudonne says.
“Within that platform, the Care Profile is accessed significantly and usage is growing. Over the last 18 months, we have seen major usage profiles increasing by double-digit percentages,” she says.
The rollout of the e-prescribing capability is next. “Just getting to the platform is the first step of adoption,” she says. “Our target for this year is to have slightly less than 500 physicians onboard [for e-prescribing]. So, we’re going through a careful deployment and rollout, to make sure we do it correctly and that we can take that practice and translate it.”
Dieudonne says that interest levels during the initial rollout of e-prescribing in South Florida “have been great” but that usage data won’t be available for a few months. The e-prescribing capability will continue to be expanded in Florida and next be rolled out in Texas, she says.
In New England, a collaborative among Blue Cross Blue Shield of Massachusetts (BCBSMA), Tufts Health Plan, and Neighborhood Health Plan is providing prescribers with handheld devices loaded with e-prescribing software. The electronic system checks for drug-drug and drug-allergy interactions, identifies generic alternatives to brand-name drugs, checks health plan formularies for coverage information, and offers a comprehensive prescription drug reference guide.
The collaborative is boosting the use of e-prescribing. According to Steven J. Fox, vice president, provider network management at BCBSMA, in 2007, collaborative prescribers added 471 new providers and sent 4.8 million e-prescriptions (eRxs), an 8.4 percent increase from 2006. “In the first quarter of 2008, we saw 1.1 million electronic prescriptions sent,” Fox says.
Funding the technology is the biggest obstacle for physicians, says Fox, so the eRx collaborative subsidizes the cost for one year to help physicians acquire it. In addition, BCBSMA has a financial incentive program, based on the percentage of electronic prescriptions that eligible providers write, to encourage them to obtain and use the technology. It’s worth the effort and cost, according to Fox.
“E-prescribing enhances practice efficiencies—many providers have reported it saves them between one to two hours per day,” Fox says. “Last year, BCBSMA providers who used an e-prescribing device reported they were able to choose more cost-effective drugs, saving them 5 percent more on their drug costs than prescribers who did not use the technology. It also saves money for our members. In 2006, BCBSMA members saved approximately $800,000 in prescription co-payments.”
These private sector plans are not alone. Government is doing its part to foster paperless prescribing. While it does not mandate electronic prescribing, the Medicare Modernization Act of 2003 (MMA) requires drug plans participating in the new prescription benefit to support electronic prescribing. The Centers for Medicare & Medicaid Services (CMS) has since issued standards for the technology’s use, and Sen. John Kerry introduced the bipartisan “Medicare Electronic Medication and Safety Protection (E-MEDS) Act of 2007,” legislation that would require e-prescribing in Medicare.
Standards Lay Foundation
CMS standards for the electronic sharing of information among health care providers, pharmacies, and health plans are helping to lay the foundation for mandatory e-prescribing. The first set of standards was issued several years ago and is in place; the new, next version of the standards, which add functionality, become effective April 1, 2009, according to Tom Wilder, senior regulatory counsel, America’s Health Insurance Plans (AHIP).
“The Medicare law [MMA] does not require physicians to use e-prescribing, but if they do, the law says they have to use these standards. A health plan is required to have a system in place so that it can receive this information electronically using the standards,” Wilder says.
Health plans need to make sure that they are prepared to meet the standards for their Medicare business next year. And while the law is intended to work for Medicare, the standards will also be used on the commercial side of the business, according to Wilder.
Reducing Errors
While the momentum toward e-prescribing began in 2003 with its inclusion in the MMA, a July 2006 Institute of Medicine report on the role of e-prescribing in reducing medication errors helped raise awareness of e-prescribing’s ability to improve patient safety. Recent research further defines the benefits of e-prescribing. According to a July 2007 report prepared by Gorman Health Group on behalf of the Pharmaceutical Care Management Association (PCMA), government options to increase e-prescribing could reduce federal health expenditures by up to $29 billion over the next decade.
E-prescribing would prevent nearly 1.9 million adverse drug events over the same time period by helping physicians avoid serious medication errors, which cause illness, hospitalization, and death, according to the Gorman report. “Approximately 70 percent of the safety and savings advantages of e-prescribing result from doctors being given immediate access to patient medication histories, safety alerts, preferred drug options, and pharmacy options so that they can better counsel patients on safe and affordable choices before prescriptions are transmitted to the pharmacy,” according to the report. Pharmacy benefit managers who have piloted e-prescribing in many markets have found it reduces medication errors and saves money for payers and patients because it improves formulary compliance, according to PCMA.
Health plans are finding the same results. Group Health Cooperative measured provider prescribing errors before the organization started using e-prescribing in 2005, says Ted Eytan, M.D., the plan’s medical director, health informatics and Web services. “When we were on paper, there was about a 3 percent chance that a patient leaving the doctor’s office would show up at the pharmacy window with a mistake,” Eytan says.
“When that three out of 100 patients came to the pharmacy, it was fixed because the pharmacist caught it. But it was inconvenient for patients… and there’s always the chance that stuff slips through. After [implementing] the electronic system, we recorded a 1.29 percent error rate, which is a cut by two-thirds,” Gorman says.
Blue Cross and Blue Shield of North Carolina’s (BCBSNC) e-prescribing program, launched in January 2006, is credited with significant reductions in prescribing errors, according to Ron Smith, Pharm.D., vice president–employer health and corporate pharmacy at BCBSNC.
“Currently, more than 850 prescribers are actively participating in e-prescribe,” Smith says. “Since the launch, over 4 million e-prescriptions were written for North Carolinians.
The program showed a 50 percent increase in the rate of eprescriptions in 2007.”
Smith notes that the company’s research has shown that 59 percent of e-prescriptions written receive a drug-drug interaction warning and 20 percent are changed or cancelled; 1 percent of e-prescriptions receive a drug-allergy interaction warning and 35 percent of those are changed or cancelled; and 32 percent of e-prescriptions receive a formulary warning and 15 percent are changed or cancelled. “Due to the success of the pilot, we are actively considering expanding the program in North Carolina,” Smith says.
Additional Benefits
The classic benefit of the technology is that pharmacists no longer have to decipher providers’ handwriting. In addition, e-prescribing has the power to put vital and helpful information at the prescriber’s fingertips.
Full e-prescribing systems provide physicians with realtime clinical and cost information on prescription options, so they can make better decisions and counsel patients. The technology gives physicians a real-time view of patient medication histories, including what they and other providers have prescribed, as well as safety alerts to avoid drug-drug interactions and drug allergies.
This information allows physicians to make the best possible prescribing decisions, according to Doug Van Zoeren, M.D., physician director for the Kaiser Permanente medical centers in the District of Columbia. Kaiser Permanente’s system, for example, lets a doctor know if a diabetic patient isn’t receiving commonly prescribed medications to lower blood pressure and cholesterol. The physician has the final say about whether to alter the patient’s medication use.
Different e-prescribing systems offer various features, according to Mark H. Snyder, M.D., associate medical director for information technology, Kaiser Permanente of the Mid- Atlantic States. Snyder says that the Kaiser Permanente system alerts providers when medications are considered high risk for certain population groups, such as the elderly or children. For example, there are medications that are considered high risk for the elderly because they might cause drowsiness and predispose them to falls. The e-prescribing system will note if a physician tries to prescribe one of those drugs to a patient in a high-risk category and sends an immediate prompt letting the prescriber know that the medication could cause problems for the patient.
As a result of e-prescribing, “we have seen a significant decline in the prescribing of those medications that are high risk for the elderly, such as Darvocet,” Snyder says.
Formulary information—especially when one provider sees patients from multiple plans—also is helpful, says Barbara Forster, Pharm.D., pharmacy content coordinator for KP HealthConnect, Kaiser Permanente’s electronic medical record. “E-prescribing systems offer the advantage that multiple formularies can generally be programmed in the system. . . so that the provider can also see that real-time.”
Also important: E-prescribing can save physicians and their staffs significant time with patients on the phone. A recent Medicare pilot of e-prescribing found that all this time spent obtaining prior approvals, responding to refill requests, and resolving pharmacy callbacks [was reduced]. . . with eprescribing— some physician practices reported a 50 percent reduction in time spent on the phone.”
Making Believers
In 2004, U.S. automakers approached Health Alliance Plan (HAP), owned by Detroit-based Henry Ford Health System, to pilot e-prescribing and determine if it would in fact cut costs and improve patient safety. HAP partnered with the 800-physician Henry Ford Medical Group and quickly found that e-prescribing improved generic use rate, reduced administrative time spent on the prescription processes at practices, and reduced adverse drug events, according to Matt Walsh, associate vice president of purchaser initiatives at HAP.
Henry Ford prescribers in Southeast Michigan have written more than 4 million scripts electronically, generating more than 34,000 a week. Health Alliance Plan has trained all 800 employed physicians and some 450 independent physicians in Southeast Michigan by partnering with independent physician associations (IPAs). The IPAs and practices outside the Henry Ford Medical Group network purchase the eprescribing equipment, while HAP provides resources to help with implementation.
“One of the key things that we’ve learned is that to make this successful and provide value as soon as possible requires close partnerships with physicians. We have a methodology we’ve developed, where we work directly with physicians, understand their processes in their clinics, and help them think through how processes need to change when they go to the electronic solutions. We help them with their IT requirements and data conversion and provide on-site training and support after they go live to ease through the transition,” Walsh says. “We have yet to come across a doctor who— once they’ve implemented e-prescribing and been on it for a couple of weeks—has ever wanted to go back.”
In Van Zoeren’s experience, the more challenging providers to convert were the late adopters, older physicians, those who didn’t see the value of e-prescribing or disagreed with having computers in patient rooms, as well as physicians who had difficulty typing. “There would be all sorts of resistance points [that we] successfully overcame,” Van Zoeren says. At Kaiser Permanente, the key to overcoming that resistance was a well-planned implementation, he says.
Taking the time to do the needed training is one of the biggest challenges to implementing e-prescribing, Forster explains. “It’s difficult for a lot of the providers to find the time to be able to look at materials. We’ve approached that by trying to provide a variety of different training materials. We usually have online links to both online documents as well as online video clips that usually run from two to three minutes. We also send out information in e-mails and hard copy newsletters. Everybody likes to learn and read their information in a different way; so, we’ve tried to approach it from multiple angles to try to reach everybody.”
Providing technical support is one potential way to spur adoption.
When BCBSNC launched its e-prescribing pilot, the health plan funded the technology and setup required for primary care physicians who routinely write a large volume of prescriptions.
“These select doctors were issued electronic prescribing software licenses, handheld personal digital assistants (PDAs), and wireless network hardware, free of charge,” Smith says.
“To encourage rapid adoption of the technology, physicians were also offered a one-time upload of their patients’ medical information, along with product training, implementation, and consulting.”
Overcoming Obstacles
There are problems to be solved before the system can go completely paperless. For example, the Drug Enforcement Agency is working on addressing legal issues around government requirements for prescribing controlled substances.
Currently, some substances require a handwritten, or “wet” provider’s signature, according to Wilder. “I would love to say that we’re 100 percent paperless, but Schedule II-IV prescriptions (controlled substances) still need to be printed out.
Prescribers put those into the system so that they have records of them, but they still print them out and sign them with ink,” HAP’s Walsh says.
Even the fragmentation that exists among providers, pharmacies, and health plans today can be overcome. “[An] important and often unrecognized opportunity is better adoption and training at the retail pharmacy level,” BCBSNC’s Smith says.
Collaborating is one solution to fragmentation, according to Fox, with the BCBSMA collaborative. “Collaboration between competitors sends a powerful message. It ensures that each health plan’s information is available to providers. Most providers deal with multiple insurers, and making information more accessible helps them to improve patient safety and practice efficiencies. Health plans don’t need to differentiate themselves on technology—we need to work together to accelerate adoption,” Fox says.
Despite the remaining hurdles, experts say there is a foreseeable end to the use of prescription pads. In fact, more e-prescribing transactions were transmitted in the first three quarters of 2007 than in 2004, 2005, and 2006 combined, according to a December 2007 SureScripts “National Progress Report on E-Prescribing.” In 2008, SureScripts estimates that the number of prescription transactions routed electronically will exceed 100 million—that’s compared to 35 million such transactions between prescribers and pharmacists in the United States in 2007.
But while many advantages can be cited for e-prescribing, industry leaders believe that patient safety issues alone will be enough to establish e-prescribing as the standard in the very near future.
Lisette Hilton is a freelance writer based in Florida who has been covering health care for 17 years.
