And the Winner Is … Everyone

Identifying the e-prescribing software to be used was one of the first tasks. “Admittedly, we had a short timeframe,” says Walsh. “We performed the technology evaluation and assessments, and framed our strategy for roll out, in October and November 2004,” with the initial pilot roll out planned for January 2005. “We brought in three vendors for one day and asked them all to execute the exact same business scenarios,” so that HAP and physician representatives could compare the products on an apples-to-apples basis. “It was important that the physicians were satisfied with the software, but it was also important that the software selected would enable them to succeed with e-prescribing and would work for the project overall.”

The Henry Ford Medical Group was no stranger to healthcare IT. Part of the expansive Henry Ford Health System that also includes five hospitals, HFMG is one of the nation’s largest medical groups, with 800 physicians, 200 of whom are primary care physicians practicing in ambulatory centers. HFMG uses its own electronic medical record (EMR) called CarePlus, along with an integrated PACS (picture archiving and communications system) that offers clinicians real-time and simultaneous viewing of digital images. Additionally, the organization runs disease management programs for coronary artery disease, congestive heart failure, diabetes, depression and asthma, and has won numerous regional and national awards for clinical performance and dedication to quality outcomes.

But at the end of the day, workflow is everything for a practicing physician. Even the most tech-savvy physicians pay attention to newly chosen technology that alters their workflow or the workflow of office staff. “Writing prescriptions is a fundamental part of every physician’s day,” says David Allard, M.D., a family medicine practitioner at Henry Ford Medical Group—Royal Oak and also an e-prescribing champion. “Physician practices spend hours every day managing prescriptions,” long after the original prescription has been written. “This includes returning phone calls from patients, calling in refills, looking up past medications and determining if they are still appropriate and deciding which prescriptions must be reworked for insurance formularies.” It is an inherent part of every medical practice that affects physicians and office staff alike.

Factors Behind the Choice
There’s no doubt about it—electronic prescribing changes both the physician’s workflow and the office’s workflow. How well the deployment has been planned, and how prepared both physicians and staff are to embrace the new technology, can make or break its success.

Allard says that overall, even for early adopters and e-prescribing power-users, it is still faster for a physician to grab a prescription pad and write a prescription. Faster, yes—but not better for office efficiency and not safer for patients. Physicians, he says, are always aware of factors that influence office efficiency. “When information technology can make the physician’s day a little easier, that’s a benefit. One of the obvious broader benefits of e-prescribing is in terms of the time spent managing prescriptions each day throughout the practice. With e-prescribing, it’s all so easy. We already have data about the patient in the system, along with medications the patient is taking and insurance coverage information, so it’s easy to generate a prescription and transmit it to the pharmacy.”

Allard was one of two physicians who, in the early stages of the HAP/HFMG pilot, vetted vendor products and influenced development of the short list. After assessing the three vendors’ technologies from the on-site demonstrations, the HAP/HFMG group selected Rcopia from Rockville, Md.-based DrFirst, and Allard says the physicians have been very pleased with it. “We chose DrFirst because we want fast throughput. Right now, we are redesigning our EMR to be Web-based rather than client/server-based, so we wanted something that wasn’t graphically intense. What we want is data—fast.”

Fast data was what they got. HAP and HFMG launched the first e-prescribing pilot in January 2005, rolling out the technology to four primary care adult clinics, followed by roll out to another group of four clinics in March, for a total of eight practices and 60 doctors using and assessing the technology for a six-month period.

Training was a joint effort, according to Allard and Walsh, with trainers from both HAP and HFMG at the clinic sites. “We provided a couple of pre-meetings,” says Walsh, “to understand each clinic’s workflow issues and to identify configuration changes that might have to be made. Then we went right into training. We went to the clinic site, trained physicians and started them in writing prescriptions. After that, we provided a week of on-site support with an expert physically on the premises who could be pulled into exam rooms to answer physicians’ questions as necessary.”

According to Allard, Henry Ford physicians are accustomed to pilot programs being tested within the organization, “but this was one of the very few pilots where other clinics called us and asked how they could participate.”

Mastering the Technology
Allard says that at one level, e-prescribing is like any other software tool. “You might sit down at a computer with Microsoft Word, and even if you’re new to the application, within five minutes you can probably write a letter. But beyond that, it takes a little more time to learn the rest of the functionality, which functions you will use and how to customize those functions so they fit within your preferences.”

The same, he says, is true with e-prescribing. “As a physician gets better, he learns what can speed him up. With any application, until you learn what makes you more efficient, you have to sacrifice a little time.”

When the HAP/HFMG training team approached each roll-out site, one of their first objectives was to map the office workflow and map exactly where a prescription would enter into the office system. After that, the trainers could determine modifications necessary for the office process as well as configuration changes needed with the software.

It is important to physicians to develop a comfort level with e-prescribing in the exam room so that, over time, they can determine for themselves the factors that increase their efficiency with the technology. Walsh says that following a two- or three-week learning curve, “physicians really liked it and saw value in having information at their fingertips. They spread the word throughout the other 24 clinics, and the Henry Ford medical director supported it, so we spent most of 2005 rolling it out to all adult primary care clinics in the medical group.”

Some of the Henry Ford clinics already had computers in exam rooms to accommodate doctors using the organization’s EMR, so physicians in these clinics learned to generate their prescriptions on a desktop computer. But for Allard at the Royal Oak location, a wireless network and tablet PCs support e-prescribing. He says the office went wireless because both the building and exam rooms are small; instead of having to build custom cabinetry to hold desktop computers, the office chose a cost-neutral wireless alternative. Allard says the “choice of device makes a big difference. Having a desktop computer in the exam room does require the doctor to turn away from the patient, while inputting into a tablet represents much less of an obstacle.”

Meritorious Metrics
Health Alliance Plan and Henry Ford Medical Group used DrFirst’s customized Rcopia Insight reporting tool to analyze physician performance and prescribing behavior. In February 2006, one year after the pilot program had started, they had commendable results to report. By that point, HFMG doctors were generating about 20,000 electronic prescriptions each week, having written about 500,000 e-prescriptions during the project’s first year. More than 80,000 prescriptions had been changed or canceled during the pilot year due to drug-drug interaction alerts, and more than 50,000 were changed or canceled based on formulary alerts. Through e-prescribing and a combination of other initiatives, HFMG increased its use of generic drugs by more than 7 percent during that first year, translating to a projected savings in pharmacy costs of about $3 million.

When HAP and HFMG issued this first set of data, about 300 physicians were e-prescribing. By the summer, that number rose to 600, and Allard says that by year end, all 800 HFMG physicians will use the technology.

Meanwhile, in July the Southeast Michigan e-Prescribing Initiative announced continuation of the patient safety initiative in Michigan for another year, indicating broad level support for the effort. This follows on the heels of attention from the federal government and the Centers for Medicare and Medicaid Services which, in conjunction with Medco, is formally studying the impact of e-prescribing on medication error reduction, with a fall 2006 report due.

Also by summer, the HFMG had seen 98,000 total prescriptions changed or canceled for drug-drug interaction reasons, and 63,000 total prescriptions changed for formulary reasons, proving that the technology never seems to peak or quit in terms of generating results. Henry Ford projects that e-prescribing will save $1 million per year beginning in 2006 through its increased use of generic drugs, reduced adverse drug events and improved administrative processes.

Payer Perspective
Health Alliance Plan is a nonprofit corporation that serves about 524,000 members from approximately 2,800 employers, ranging from small local employers to large national groups. The organization offers HMO, PPO, POS and EPA products in addition to consumer-directed health plan products and a Medicare Advantage product.

While 2005 was dedicated to introducing primary care physicians to e-prescribing, the initiative for 2006 is focused on bringing e-prescribing into the specialty practices, and Walsh says neurology, nephrology, rheumatology, cardiology, gastroenterology, OBGYN and pediatrics were among the first specialties of focus. Specialty practices all operate differently, he says, and most specialists work in multiple locations. “The training focused first on bringing them all together and training them, then sending them back out to their locations and providing additional on-site support during their first live week.”

Henry Ford treats about half of HAP’s total membership. Another 250,000 patients are treated by other providers and provider groups; the largest is United Physicians with about 1,700 doctors and a different organizational model than HFMG. Walsh says that HAP is also piloting e-prescribing at several United Physicians locations this year.

Walsh says that many employers favor e-prescribing because it supports use of cost-effective generic drugs and also because it can reduce adverse drug events.

What Makes It Work?
Is there an end-user organization alive that doesn’t genuinely want a partnership—not just a buyer/seller relationship—with its vendors? From the outset, one of the factors that made this e-prescribing project succeed is the relationship among Henry Ford Medical Group, HAP and the staff and product of DrFirst.

DrFirst Senior Vice President G. Cameron (Cam) Deemer says, “Henry Ford and Health Alliance Plan really opened themselves up to us as a collaborator from the start. Their attitude was that they expected collaboration from a vendor. Too often a healthcare organization views a vendor primarily in terms of how to extract the best price. But, the point of care for a doctor is, by no means, a commoditized space. Henry Ford said, ‘Here is our situation; here is our internally developed EMR. Our workflows are independent and different, and we have a high volume of prescriptions filled with in-house pharmacies.’ That attitude gave us the opportunity to demonstrate what we as the supplier could bring to the initiative.”

According to Deemer, DrFirst cut its teeth with tough clients: MedStar and Kaiser Permanente were among its first customers. “Early on, they showed us how flexible our product must be to fit varying workflows, how the product must perform in a variety of ways with functions that can be switched on and off based on clinician preference. From the beginning, we started with demanding customers; we were up for this challenge.”

Rcopia works well for the physicians at HFMG because it fulfills their need for fast data without a lot of annoying glitz. “Virtually everything is on one page,” says Deemer. “There’s not a lot of mousing around or opening and closing multiple windows. The application is built for speed.” Plus, the staff of DrFirst interfaced the application with the HFMG’s EMR, so information from the prescription process goes into the organization’s EMR.

“Every physician practice wants, first, to keep its patients safe,” says Deemer. “Beyond that, big practices want efficiency. Workflow, that’s where all the efficiency benefits are from e-prescribing. In a manual environment, it may take three or four people, even five, including nurses and doctors, to manage one prescription. Automation routes the prescription efficiently,” eliminating the unnecessary hands-on efforts.

If It’s So Hot, Why Isn’t It Everywhere?
Many stakeholders in successful e-prescribing initiatives ask themselves exactly that. Everyone wins with e-prescribing: health plans, employers, patients, physicians, office staff and pharmacists.

Allard has a take on the answer. He is as much of a champion as IT could hope for, yet even he admits that “it’s slower than writing paper prescriptions, but it saves time for the support staff” and that it requires embracing technology, which hasn’t been part of most physicians’ training, except for the newest doctors. Much of a doctor’s exam is hands-on and highly interactive with the patient, and having to write a prescription on a computer “chops up” the flow of a physician’s work style. But Allard is quick to add, “Even the few physicians at Henry Ford who find it slow or irritating openly say, ‘I know it’s safer for the patient and more efficient for the office.’”

He also thinks that many physicians do not look at information technology the same way they view other medical technologies. “With IT, there is a perception that it should be so intuitive, you can just start using it” with no training, and he says that is a deterrent. “A physician would never expect himself to master a new medical device in a day. Neither would a practice manager expect an employee who had never used PowerPoint to produce a PowerPoint presentation in a morning. Learning a new technology requires mental readiness, along with time and practice. No physician would expect himself to be able to use it fully right off the bat.”

Allard says that IT should be viewed as part of the medical care environment, a piece of the ever-evolving process, “like continuing education that doctors are accustomed to participating in. Learning how to use these tools is part of having a successful medical practice.” By the end of this year, there will be 800 Henry Ford Medical Group doctors who can attest to that.

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