Electronic prescribing—often referred to as "e-prescribing," or even "eRxâ€â€”is one technology application that seems to enjoy virtually universal support, at least in theory. Many see e-prescribing as thepoint of the spear that will help move physicians into trueelectronic patient care—a long-awaited key advance forthe healthcare system.
Although e-prescribing appears beset by fewer complications than electronic medical record development or regional health information organizations, it has faced several fundamental issues, including connectivity, standards and financial investment.
Fortunately, progress is pushing forward. The Medicare Modernization Act of 2004 (MMA) includes the deployment of a nationwide e-prescribing pilot program, slated to begin in January 2008. The MMA also mandates e-prescribing based on national standards by 2009 for drug plans participating in the new Medicare Part D prescription drug benefit program, which went into effect on Jan. 1. In November, the Department of Health and Human Services (HHS) approved a final rule to adopt foundation standards for e-prescribing under the new Medicare Part D.
Says John Quinn, partner and chief technology officer in the health provider practice at Accenture, a NYC-based consulting firm: "As a key force for general change, it seems to be pretty important to Congress, and to employers, that we figure out how to improve patient safety and reduce the rate of growth in healthcare costs." Clearly, e-prescribing is one important piece of the federal push, Quinn notes.
Although a January 2008 deadline for nationwide e-prescribing sounds compelling, Quinn notes, "Where it goes from there gets a little fuzzy. HHS at the very least seems to be setting a goal for itself of 80 percent-plus adoption within three years, beginning in 2008." Among the challenges physicians face, he explains, "You won't be able to just substitute a PDA or tablet you're writing on. You'll actually have to have an application where you select drugs and have access to current lab tests and problem lists."
Payers offer big carrots
If the federal government's e-prescribing push sounds partly carrot and partly stick in nature, the willingness of a growing number of health plans to fund physicians' adoption of e-prescribing solutions sounds much more "carrot." A statewide e-prescribing initiative in Massachusetts and the establishment of a foundation to promote a combination of e-prescribing and electronic medical record (EMR) adoption in Pennsylvania are promising examples.
The Massachusetts e-prescribing initiative rolled out in the fourth quarter of 2003, with initial support from Boston's Blue Cross Blue Shield of Massachusetts (BCBSMA) and Tufts Health Plan, Waltham, Mass., two of the state's largest health insurers. In August 2004, Boston's Neighborhood Health Plan also joined in the initiative. The program has trained 3,300 physicians, with another 900 expected to join the fold within the next few months.
"The response has been overwhelming, and we're working with two different vendors to try to keep pace," says Vincent Plourde, vice president of the provider services division at BCBSMA. It's hard to estimate the number of physicians who might participate in the program statewide, Plourde says: "Some physicians already have some type of e-prescribing through some type of EMR application. This is really a standalone application we're talking about. But we're looking to add another 1,200 [users] next year."
BCBSMA is already documenting actual changes in prescribing based on information physicians receive electronically at the point of care. For example, because of safety alerts for drug-to-drug interactions or drug-allergy interactions, physicians participating in the program changed 3,400 of their prescriptions written in October, Plourde notes. Those kinds of physician actions, ones that presumably result in improved patient safety, are what BCBSMA is after, he says. He also concedes that enhanced formulary compliance and much more extensive use of generic drugs are appealing factors. Based on the initial results, he says the program has been "a tremendous success."
Meanwhile, in Pennsylvania, executives at the Pittsburgh-based Highmark Blue Cross and Blue Shield were so eager to launch wide-scale e-prescribing that in November the company contributed an initial $26.5 million to jumpstart an independent foundation to support e-prescribing and EMR technology investment among physicians in that state. The action made the Highmark-funded foundation effort the largest statewide initiative to date, notes Donald R. Fischer, M.D., Highmark's senior vice president and chief medical officer.
"Our first thought was that we would like to facilitate a higher rate of adoption of technology in the community, and if we were able to partner in some way, this would happen," Fischer says. "And we look at e-prescribing as an entry-level tool that would allow a significant entry into technology." The strategy is one where "quality drives efficiency," he says. "If we can somehow facilitate the right care for the right intervention happening to the right member at the right time, that will drive efficiency."
Perceptions and realities
Those involved in e-prescribing programs clearly understand how cost—or the preception of cost—can be a barrier in physician adoption of e-prescribing tools.
"The doctors do get real benefit from participating in e-prescribing, but not direct financial benefit," notes Daniel Z. Sands, M.D., vice president and chief medical officer at ZixCorp, Dallas. "There are savings in staffing resources, because of the more efficient renewal process and working with the pharmacy; but those savings don't become apparent for a year or more. In the short term, they're prescribing more effectively." One factor that will help push e-prescribing forward will be the increasing use of multi-tiered formularies, he adds. As consumers are given more of the prescription drug bill to pay, they will demand to know what the comparative costs are for different drug options before the physician has written the prescription, he explains.
Another adoption driver is the growing use of pay-forperformance systems in large medical groups, notes Betty Jo Bomentre, M.D., Ph.D., senior consultant for clinical transformation at ACS Healthcare Services, Dallas. Bomentre has been working on several e-prescribing projects, including one at the Carle Clinic in Champaign-Urbana, Ill. The combination of carrot and stick incentives, including providing physicians with tools they really need and can use, will encourage acceptance among practicing physicians in a relatively short time, she predicts.
Broader solutions are still needed in order for e-prescribing to work as a tool for physicians and as a facilitator of electronic healthcare, says Kevin Hutchinson, CEO of the Alexandria, Va.-based SureScripts, a national e-prescribing service provider network.
One emergent lesson, Hutchinson says, is that e-prescribing is about much more than electronic script transfers and drug dispensing. Part of the system-wide potential of e-prescribing, he says, will be facilitating physicians' ability to monitor patient compliance with medication orders through a national database. This spring, SureScripts will roll out a service that will provide physicians with pharmacy-based medication histories on patients.
With broad initiatives on multiple fronts, e-prescribing is set to pass a tipping point in the near term. BCBSMA's Plourde believes that numerous health plans will soon develop programs similar to the one in Massachusetts to fund e-prescribing adoption by physicians. He also sees health plans and providers coming together to co-fund EMR expansions, with success in e-prescribing acting as "a gateway to help introduce this new technology, and get providers used to it." On the commercial side, predicts Accenture's Quinn, data aggregators like the St. Paul, Minn. - based RxHub will continue to expand their networks and alliances to connect payers and providers through needed data links.
For many, e-prescribing will be a primary key to help unlock the electronically facilitated healthcare of the future.
Mark Hagland is a contributing writer in Chicago.
