Improving Patient Safety and Practice Efficiency Through ... Presentation.pdf · (1) Institute for...

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Improving Patient Safety Improving Patient Safety and Practice Efficiency and Practice Efficiency

Through Electronic Through Electronic PrescribingPrescribing

Health Industry Council

September 7, 2004

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[ 1 ]

The number of prescriptions in the US is rapidly increasing

823 million visits to physician offices in 20001

4 out of 5 patients who visit a physician leave with at least one prescription2

65% of the US population use a prescription medication each year3

Over 3 billion prescriptions are dispensed each year4

The number is expected to rise to 4 billion by 20074

1) Pastor PN et. al. Chartbook on trends in the health of Americans. Health, United States, 2002. National Center for Health Statistics. 2002.2) The Chain Pharmacy Industry Profile. National Association of Chain Drug Stores. 2001.3) Agency for Healthcare Research and Quality. MEPS Highlights #11: distribution of health care expenses, 1999.4) Estimates - NACDS Economics Department

3.22 Billion Total Filled Prescription 3.22 Billion Total Filled Prescription Transactions in 2003Transactions in 20034

1.2 B

0.3 B

0.5 B

1.56 B

Refills

New Scripts

Renewals

Unfilled

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[ 2 ]

The efficiency of the total prescription system is challenged by hundreds of millions of phone calls and faxes

One study estimates that indecipherable or unclear prescriptions result in more than 150 million calls from pharmacists to physicians asking for clarification1

Others estimate the number of prescription-related telephone calls annually at 900 million, citing practices reporting almost 30% of prescriptions required pharmacy callbacks2,3

Requesting and receiving approval for refills alone, estimated at nearly 500 million per year, adds to the telephone and fax burdens4

(1) Institute for Safe Medicine Practices. A Call to Action: Eliminate Handwritten Prescriptions Within Three Years, 2000.(2) Forrester Research, 2002.(3) Medco Health, 1/29/03, via ePharmaceuticals(4) NACDS and SureScripts estimates

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[ 3 ]

Many resulting errors can be prevented

More than 8.8 million adverse drug events (ADEs) occur each year in ambulatory care, of which over 3 million are preventable1

1 out of 131 ambulatory patient deaths can be attributed to medication error2

According to the Institute for Safe Medication Practices, many errors result from:

• Miscommunication due to illegible handwriting

• Unclear abbreviations and dose designations

• Unclear telephone or verbal orders

• Ambiguous orders and fax-related problems

1 Center for Information Technology Leadership. The Value of Computerized Provider Order Entry in Ambulatory Settings, 2003Institute of Medicine, Committee on Quality in Healthcare in America. To Err is Human: Building a Safer Health System, Washington, DC, National Academy Press; 1999

2 Gurwitz JH et al. Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting, JAMA, 2003; 289: 1107-1116. 3 Gandhi TK et al. Adverse Drug Events in Ambulatory Care, N Engl J Med, 2003; 348: 1556-64.

Gurwitz, JAMA, 20033

25% of patients had ADEs

13% were serious

39% of total were either ameliorable or preventable

Gandhi, NEJM, 20034

28% of ADEs preventable

42% of the most serious

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[ 4 ]

The Overall Prescribing Process is Much More Complex Than Writing the Prescription and Dispensing

Document Prescription in Notes

Schedule Patient Drop Off, Phone, Fax, IVR

Pull Patient’s Chart Insurance ID Card

Review Chart Data Input Into Computer

BEFORE ENCOUNTER ACQUIRE PRESCRIPTION

Interview Patient Pharmacy DUR

Determine Therapy Claim Transmission

Write Prescription Order Fulfillment/Dispense

AT ENCOUNTER PROCESS PRESCRIPTION

Re-File Chart Review of Payor DUR

Clarification Calls Handling of Payor Issues

Handle Drug Coverage Issues Patient Counseling

AFTER ENCOUNTER COMMUNICATE

Renewal Authorizations Renewal Requests

PHYSICIANPHYSICIAN PHARMACISTPHARMACIST

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[ 5 ]

The Prescription Workflow in the Physician’s Practices is still Predominantly Paper Based Today

Pull Patient’s Chart

Review Chart

BEFORE ENCOUNTER

Interview Patient

Determine Therapy

Write Prescription

ENCOUNTER


Re-File Chart

Clarification Calls

Handle Drug Coverage Issues

AFTER ENCOUNTER

Renewal Authorizations

PHYSICIANPHYSICIAN

The majority of practice automation is around patient scheduling ( and billing ) activities

Schedule Patient

Write Prescription

According to eHI, current studies show between5% – 18% of physicians and other clinicians are using electronic prescribing

Schedule Patient

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[ 6 ]

The majority of “e-prescribing” still has NO connection to the pharmacy – strictly a one-way fax communication

Data used courtesy of

7% 11%

93% 89%

0%

25%

50%

75%

100%

All Physicians Essential Integrator

41% 33%

59% 67%

0%

25%

50%

75%

100%

All Physicians Essential Integrator

“Does Your Electronic Prescribing System Link Directly to the Pharmacy?”

“Do You Currently Use Any Type of Electronic Prescribing System?”

Among Those Using an eRx System:

No

Yes

No

Yes

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[ 7 ]

Future Drivers* of Electronic Prescribing are Largely Based on Increased Safety & Efficiency

Data used courtesy of

34%

36%

37%

38%

40%

42%

46%

47%Increased Accuracy

Reduced Pharmacy Callbacks

Commonly Used Rx in Lists

Better Order Entry Devices

Verified Formulary Coverage

Financial Incentives From Payers

Better Interface Between eRx and Other Office Systems

Ability to Charge Transaction Fee

Among Those Not Currently ePrescribing and Interested in Using eRx in the Future:

Decreasing Over Time

*4 or 5 on a 5-Point Scale

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[ 8 ]

In Contrast to Physician Practices, Much More Automation Exists in the Pharmacy Today

Pharmacies by law, all perform a Drug Utilization Review (DUR) that queries internal databases to assess the medication prior to dispensing

Pharmacies are connected to virtually 100% ofthe payers

• Check member eligibility and member-specific pharmacy benefits ( formulary management )

• Another DUR against payer medication history

Over 50% of the pharmacies, or pharmacy software vendors that serve them, have upgraded their systems to exchange prescription information electronically

Drop Off, Phone, Fax, IVR

Insurance ID Card

Data Input Into Computer

ACQUIRE PRESCRIPTION

Pharmacy DUR

Claim Transmission

Order Fulfillment/Dispense

PROCESS PRESCRIPTION

Review of Payor DUR

Handling of Payor Issues

Patient Counseling

COMMUNICATE

Renewal Requests

PHARMACISTPHARMACIST

Pharmacy DUR

Claim Transmission

Review of Payor DUR


Renewal Requests

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[ 9 ]

It’s at the Encounter when the Process is Most at Risk for Error and Inefficiencies


Review Chart

BEFORE ENCOUNTER

ENCOUNTER

Re-File Chart

Clarification Calls


AFTER ENCOUNTER


PHYSICIANPHYSICIAN

Schedule Patient

Write Prescription

Interview Patient

Determine Therapy


Misinterpreted handwriting

Incorrect medication choice

Incorrect dosing regimen

Failure to account for drug interactions

Failure to account for contraindications

Unappreciated allergy history

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[ 10 ]

It’s After the Encounter that Communication Hassles Cause Inefficiencies and Impact Prescriber and Staff Satisfaction


Review Chart

BEFORE ENCOUNTER

Interview Patient

Determine Therapy

Write Prescription

ENCOUNTER


PHYSICIANPHYSICIAN

Schedule Patient

Re-File Chart

Clarification Calls



Most prescribers and staff rank the renewal authorization process as the most time-consuming, sometimes taking hours of staff time in a small office to handle the phone calls and faxesChart pulls and re-filing are required for every pharmacy call concerning a prescriptionNurses report spending most of their time handling administrative issues when they would rather be in direct patient careMore than 80% of clarifications are attributed to:

• Directions unclear or missing• Refill quantity unclear or missing• Dosage unclear• Drug name/strength unclear

AFTER ENCOUNTER

Source: Mail-Order Prescriptions Requiring Clarification Contact With the Prescriber: Prevalence, Reasons, and Implications, Richard A. Feifer, Md; Linda M. Nevins, Rn, Mba; Kimberly A. Mcguigan, Phd; Les Paul, Md, Ms; And Jacob Lee, Mba, Rph

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[ 11 ]

Physicians and Pharmacists can Establish “True” Electronic Prescribing Connectivity & Improve the Prescribing Process

Schedule Patient


Review Chart

BEFORE ENCOUNTER

Interview Patient

Determine Therapy

Write Prescription

AT ENCOUNTER


Re-File Chart

Clarification Calls


AFTER ENCOUNTER


PHYSICIANPHYSICIAN


Insurance ID Card



Pharmacy DUR

Claim Transmission



Review of Payor DUR


Patient Counseling

COMMUNICATE

Renewal Requests

PHARMACISTPHARMACISTPHYSICIANPHYSICIAN PHARMACISTPHARMACIST

With a direct two-wayexchange of prescriptioninformation, physicians

and pharmacists can collaborate to improve

the prescribing process

“ePrescribing” becomes truly electronic - providing significant value to all

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[ 12 ]

Computer-to-Computer Connectivity between Physicians & Pharmacists Provide the Foundation for Process Improvements

Schedule Patient


Review Chart

BEFORE ENCOUNTER

Interview Patient

Determine Therapy

Write Prescription

AT ENCOUNTER


Re-File Chart

Clarification Calls


AFTER ENCOUNTER


PHYSICIANPHYSICIAN


Insurance ID Card



Pharmacy DUR

Claim Transmission



Review of Payor DUR


Patient Counseling

COMMUNICATE

Renewal Requests



Write Prescription

Eliminates:

• Illegible Prescriptions• Computer Entry at Pharmacy• Transcription Errors• Potential Sound-Alike Meds• Lost Fax Orders/Paper Jams• Undeliverable Prescriptions

Prescription Arrives at the Pharmacy Before Patient Leaves the Office

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[ 13 ]


Schedule Patient


Review Chart

BEFORE ENCOUNTER

Interview Patient

Determine Therapy

Write Prescription

AT ENCOUNTER


Re-File Chart

AFTER ENCOUNTER


PHYSICIANPHYSICIAN


Insurance ID Card



Claim Transmission



Patient Counseling

COMMUNICATE

Renewal Requests



Write Prescription

Clarification Calls


Pharmacy DUR

Review of Payor DUR


Eliminates phoning and faxing for:

• Change Requests• Prior Authorization• Drugs Not Covered• Formulary Issues

Pharmacy DUR

Review of Payor DUR

Handling of Payor IssuesClarification Calls


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[ 14 ]


Schedule Patient


Review Chart

BEFORE ENCOUNTER

Interview Patient

Determine Therapy

Write Prescription

AT ENCOUNTER


AFTER ENCOUNTER


PHYSICIANPHYSICIAN


Insurance ID Card



Claim Transmission



Patient Counseling

COMMUNICATE

Renewal Requests


Write Prescription

Clarification Calls


Pharmacy DUR

Review of Payor DUR


Pharmacy DUR

Review of Payor DUR



• Drastically Reduce Phone Calls and Faxes

• Complete Renewals in Seconds, Not Hours

• More Time for Patient Care and Counseling

Re-File Chart




Renewal Requests

Re-File Chart

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[ 15 ]

Computer-to-Computer Connectivity between Physicians & Pharmacists Provide the Foundation for Future Advancements

Schedule Patient


Review Chart

BEFORE ENCOUNTER

Interview Patient

Determine Therapy

Write Prescription

AT ENCOUNTER


AFTER ENCOUNTER



Insurance ID Card



Claim Transmission



Patient Counseling

COMMUNICATE

Renewal Requests

Write Prescription

Clarification Calls


Pharmacy DUR

Review of Payor DUR


Pharmacy DUR

Review of Payor DUR



PHARMACISTPHARMACISTPHYSICIANPHYSICIAN

• Lab Results

• Medication History

• Immunizations

Imagine the Two-Way Exchange of Additional Clinical Data Including:

PHYSICIANPHYSICIAN PHARMACISTPHARMACIST

The Possibilities for Continued Collaboration

Once Connected are Endless

Re-File Chart

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[ 16 ]

SureScripts does NOT develop, sell, or endorse electronic prescribing software, but works with existing technology vendor to certify and connect to the network

1. Electronic Prescribing Software that is certified by SureScripts

2. An Internet connection

1. Pharmacy management software has been certified by SureScripts

SureScripts provides the behind-the-

scenes network that makes the two-way electronic exchange of new prescription

and renewal information possible

Rx Rx

What the Physician Needs: What the Pharmacy Needs:

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[ 17 ]

Electronic Prescribing: Much has been accomplished

Pharmacies are connected• 75%+ connected for electronic prescribing, Pharmacies have been

activated in over 40 states on the SureScripts network and are actively exchanging electronic prescriptions in over 30 states today

• Near 100% of pharmacies are connected electronically to PBMs andPayers for the Drug Utilization Review (DUR) and electronic Claims Adjudication process

States are removing roadblocks to electronic prescribing• Few problem areas remaining (30+ states cleared to date)

Neutrality and Choice are critical to ensure the successful adoption and use of electronic prescribing• Physician choice of therapy and patient choice of pharmacy

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[ 18 ]

Rhode Island

“Once you add in physician and nurse and other staff time, e-prescribing is saving me at least 3 to 4 hours a day… easily.”

Dr. John Bossian, Main Street Family Practice

We save enormous amounts of time on renewals, not having to use nurses to decipher what a patient says on voice mail…”

Judith Bessoff, Practice Manager, Anchor Medical

(estimated savings: 10 minutes per renewal authorization)

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[ 19 ]

Why now? The problems of past prescribing automation efforts have been addressed…

State-wide initiatives involving all major stakeholders seek to improve the Rx process

Automation was being driven by a few small software vendors

Collaborate with pharmacies on patient compliance and other future functionsThere wasn’t a future path to additional benefits

Most practices will save physician and staff time as well as improve patient safetyThere were few real benefits for most practices

Software integrates with existing practice systems and smoothes office workflowSoftware didn’t support the workflows in the practice

Renewals can be automated in addition to new scripts

Only half the problem was being addressed…writing new scripts

Computer applications can communicate directly with each otherElectronic communications meant faxes

Over 75% of US pharmacies are connected into a single network and it’s still growing

Very few pharmacies were directly connected to physician practices

But nowBut now……In the pastIn the past……

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