E-prescribing in Community-Based Practices: Successes and Barriers (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 8, 2008, Michael A. Fischer, M.D., M.S., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (540 KB).

Slide 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

Slide 2

Research team

Co-authors:

• Ritu Agarwal, PhD, University of Maryland
• Corey Angst, PhD, Notre Dame
• Cate Desroches, PhD, Massachusetts General Hospital (MGH)

BCBSMA [Blue Cross Blue Shield of Massachusetts]:

• Megan Bell
• Adrienne Cyrulik, MPH

Tufts Health Plan:

• Julie Newton

Zix Corporation:

• Angus MacDonald
• Scott Plunkett

Slide 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.

Slide 4

Study setting

eRx Collaborative: Blue Cross Blue Shield of Massachusetts; Neighborhood Health Plan; Tufts Health Plan; DrFirst; Zix Corporation

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

Slide 5

Prior studies—erx adoption

Figure 2: E-prescribing rate by month

Source: Fischer et al, JGIM 2008.

Slide 6

Prior studies—e-rx and costs

This graph shows the percent tier 1 by month relative to first e-prescription for Control prescribers; Intervention prescribers, non-e-prescriptions; and Intervention prescribers, e-prescriptions.

Source: Fischer et al, Arch Int Med 2008, in press.

Slide 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)

Slide 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?

Slide 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 electronic medical record (EMR).

Interviews:

• Detailed discussions with prescribers.

Slide 10

Findings

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

Slide 11

E-prescribing positives

• Prescription security.
• Financial gain.
• Office efficiency.
• Medication safety.
• Insurance issues.
• Communication with pharmacy.

Slide 12

E-prescribing positives (continued)

Prescription security:

• Less people touch the actual prescription.
• Patients cannot lose the prescription.
• Patients cannot tamper with prescription.

Slide 13

E-prescribing positives (continued)

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.

Slide 14

E-prescribing positives (continued)

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.

Slide 15

E-prescribing positives (continued)

Medication:

• 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..."

Slide 16

E-prescribing positives (continued)

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.

Slide 17

E-prescribing positives (continued)

Communication with pharmacy:

• Timely flow of information.
• Ability to send specific messages.
  • E.g.: "No more refills until patient sees doctor."

Slide 18

Ongoing challenges/barriers:

• Learning curve.
• Usability.
• Reliability.
• Safety concerns.
• Patient resistance.
• Data security.

Slide 19

Ongoing challenges/barriers (continued)

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.

Slide 20

Ongoing challenges/barriers (continued)

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.

Slide 21

Ongoing challenges/barriers (continued)

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.

Slide 22

Ongoing challenges/barriers (continued)

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.

Slide 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.

Slide 24

Summary observations (continued)

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.

Slide 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.