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

Research team• Co-authorsRitu Agarwal, PhD

U Maryland

Corey Angst, PhD

Notre Dame

Cate Desroches, PhD

MGH

• BCBSMA– Megan Bell– Adrienne Cyrulik, MPH

• Tufts Health Plan– Julie Newton

• Zix Corporation– Angus MacDonald– Scott Plunkett

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

Study setting

• Initiated by BCBSMA and Tufts Health Plan

• Partnered with ZixCorp, providing physicians with PocketScript system

• Program began in early 2004

Prior studies – erx adoption

Fischer et al, JGIM, 2008

Prior studies – e-rx and costs

50%

52%

54%

56%

58%

60%

62%

64%

-6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11

Month relative to 1st e-prescription

Per

cen

t T

ier

1

Control prescribers

Intervention prescribers, e-prescriptionsIntervention prescribers, non-e-prescriptions

Start of e-prescribing

Fischer et al, Arch Int Med, 2008, in press

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

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?

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

Findings

• E-prescribing positives

• Ongoing challenges/barriers

E-prescribing positives

• Prescription security

• Financial gain

• Office efficiency

• Medication safety

• Insurance issues

• Communication with pharmacy

E-prescribing positives

• Prescription security– Less people touch the actual prescription– Patients cannot lose the prescription– Patients cannot tamper with prescription

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

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

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..”

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

E-prescribing positives

• Communication with pharmacy– Timely flow of information

– Ability to send specific messages• e.g.: “no more refills until patient sees doctor”

Ongoing challenges/barriers

• Learning curve

• Usability

• Reliability

• Safety concerns

• Patient resistance

• Data security

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

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

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

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

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

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

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