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ePrescribing and its Impact on Care Management

Marybeth Regan, PhD, for HealthLeaders Media, January 28, 2008
New technology is being introduced every day in the healthcare industry, which impacts the manner in which providers deliver care. Impacts may be positive or negative, depending on the technology and the way in which it is implemented and supported. The goal is to implement the right technology at the right time, in the right way, so patients are receiving higher quality care, delivered in a safer environment and in a more efficient manner.

In the ideal scenario, prescriptions would be checked against a patient's current medications, allergies, diagnoses, body weight, and age for possible interactions, appropriateness, and dosage. Prescriptions would be legible and patient information about their medications, including indications, properties, side effects and instructions for administration, would be dispensed with the medication. A permanent record would be created that included all of the patient's medication history over time. Not only would prescription data be available on orders, but also that the prescription was refilled. Patient adherence to medication regimens can be improved through a closed-loop communication of refill data to both payers and physicians.

ePrescribing is an interactive data transaction that allows the prescriber to see a complete profile of the patient's medication with software inputs allowing the physician to check formulary status, any administrative limits (Rx limits per month, days supply limits, etc) and clinical edits (drug/drug interactions, disease drug interactions, dose checks, etc.)

ePrescribing is greater than just process improvement. ePrescribing has the possibility of impacting clinical outcomes for the positive. Prescribing medication is the physician's most frequently used, efficacious, and potentially dangerous therapeutic tool, outside of surgical interventions. The proper or improper use of prescription drugs has a profound effect on patient outcomes. And, because prescription drugs are expensive, the physician's selection of drugs has a major impact on the cost for payers and employers. The management of prescription medications directly or indirectly affects every stakeholder in healthcare.

The bulk of the over 3.27 billion prescriptions issued in United States last year were still written manually, generating the need for an estimated 150 million phone calls from pharmacists to physicians' offices for clarification of handwriting, dosing, and other issues. Up to 40 percent of prescriptions require reworking at the retail pharmacy before they are dispensed to the patient. Medication errors are currently responsible for an estimated 7,000 deaths per year, and approximately $77 billion is spent annually on treatment of adverse drug events.

ePrescribing can benefit patients, physicians and pharmacists by significantly decreasing medication errors, reducing the incidence of adverse drug reactions, saving physicians and pharmacists valuable time now spent on non-clinical administrative tasks, and enabling payers to improve formulary program compliance--collectively saving millions of dollars while potentially increasing patient and physician satisfaction.

Doctors' hieroglyphic handwriting and prescription pads could soon be a thing of the past. Electronic drug prescriptions can now be delivered to pharmacies in all 50 states.

It is no longer appropriate to manage pharmaceutical therapies and costs independent of overall medical care, as prescription drugs have become an indispensable part of modern treatment regimens. By 2010, prescription drugs will account for about 16 percent of overall healthcare costs, according to Hewitt Associates, but this underestimates their impact on costliness, because pharmaceutical care also influences the use of inpatient, outpatient and emergency room services.

ePrescribing takes a process laden with numerous workaround steps and streamlines it to offer significant clinical improvements. Experience teaches us that the greatest problems do not involve technology, but rather are due to organizational issues and human factors. At the end of the day, it is human will--political, professional, and personal--that must drive the technology if it is to serve the users.

Collaboration
Health plans are joining forces with technology vendors, pharmacies and other organizations in a collaborative effort toward the successful adoption of ePrescribing in order to improve patient safety, healthcare affordability, quality and delivery.

In a report issued last year by the Institute of Medicine, researchers set a goal for the use of ePrescribing: "By 2010, all pharmacies should be able to receive prescriptions electronically. By 2008, all prescribers should have plans in place to implement electronic prescribing."

While the Institute of Medicine has called for a complete switch to ePrescribing by 2010, implementation of ePrescribing in the marketplace has been slow. Currently less than one in five of practicing physicians process prescriptions electronically. And studies indicate that most physicians have been reluctant to adopt electronic prescribing, largely because of the cost of the systems and a perception that the technology requires too much time to learn and install.

Technology Adoption
Even though physicians are resisting, adoption of ePrescribing is inevitable. Health plans are now looking at various strategies around quality and pay-for-performance to persuade physicians to adopt ePrescribing. The collaborative efforts that are happening now make adoption much easier. Better data availability and clinical decision support for ePrescribing depend on the functionality of the particular e-Prescribing application in use. Databases that account for the majority of managed care formularies in the United States are available and widely used.

Physician behavior change could be described as the carrot vs. the stick (sadly the stick is usually more effective), but this behavior change will create healthcare savings opportunities and potential P4P endeavors. States should mandate this activity tied to reimbursement and create P4P incentives based on the newly created data stream. Current systems from Pharmacy Benefit Managers (PBMs) and pharmacies allow for a retrospective analysis of the claim with safety and quality rules applied at the pharmacy at point-of-service (POS). This could move those rules into the physician space which would obviate the need for PBMs and other Rx transactional interventionists to apply prior authorization rules/step therapy edits etc.

All of the stakeholders benefit from ePrescribing; listed below are the stakeholder benefits;

Patients

  • Improved patient safety and accuracy
  • Better formulary adherence
  • Streamlined communication of prescriptions to pharmacies
  • Improved patient satisfaction, through rapid prescription fulfillment, less visits to the pharmacy and fewer errors

Physicians

  • Increased safety and accuracy
  • Improved access to data--Rx History
  • Improved decision support
  • Increased patient satisfaction and peace of mind
  • Potential decreased premiums for malpractice insurance.
  • Enhanced efficiencies through decreased callbacks to pharmacies through illegible prescriptions, non-formulary medications, potential drug interactions, incorrect dosages, renewal requests and others

Pharmacies

  • Reduced errors due to misinterpretations or data entry mistakes
  • Avoided unnecessary phone calls
  • Increased processing efficiencies
  • Improved customer relationships

Health Plan/Employers

  • Control increasing pharmacy cost
  • Improved formulary adherence and generic drug utilization
  • Future opportunities for disease management and patient compliance
  • Reduction in costs associated with adverse drug events
  • Improved access to data on physicians prescribing patterns and patient medication profiles
  • Improved patient adherence to therapeutic regimens
  • Reduced healthcare costs
  • Healthier, more satisfied workers
  • Potential reduced claim losses

The Care Management Partnership

Care management--a strategy for patient care across the entire healthcare delivery system and throughout the life cycle of a condition or a disease--is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.

About 10 percent of patients, primarily those with chronic conditions, account for 70 percent of healthcare spending, according to published studies. There were 129 million people with chronic conditions in 2005, expected to grow 32 percent to 171 million in 2030, according to Partnership for Solutions, a research cooperative led by Johns Hopkins University.

If providers and payers were able to combine the use of ePrescribing with their Care Management programs, care delivery could be improved and costs could be lowered. ePrescribing and Care Management are complimentary in many ways:

  • ePrescribing supports the physician- or practitioner-patient relationship and plan of care. The basis for care and disease management is the exchange of information between practitioner and patient. With ePrescribing, information is exchanged and discussed, since time can be spent on discussion and not just verbal updating. Visual information allows the discussion to be more valuable. In addition, the issue of compliance and cost can be addressed.

    In addition, when patients pay more for prescription medicine, they use it less. When prescriptions are not refilled on schedule, the overall medical costs increase with more hospitalizations and use of emergency departments.

  • Care Management emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies. The comprehensive medical information (including patient input) allows the full picture of the patient and helps prevent exacerbations and complications. With the exchange and consolidation of information, the patient is empowered to be a partner in his or her care.
  • ePrescribing helps evaluate clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving overall health. The collection of all data is important to all aspects of DM and this data can be used on a patient-specific basis and also be accumulated in aggregate.
  • ePrescribing benefits all stakeholders in the continuum of care. Step by step, we are getting closer to a solution that can have a big impact on our healthcare system.

Conclusion
The current system of healthcare delivery suffers from severe fragmentation that puts the patient and the patient's physicians at a disadvantage particularly when care is complex. In the long term, there is potential for greater patient and provider satisfaction, better care delivery, greater workplace productivity, improved patient safety, less waste and overall improved provider performance.


Marybeth Regan, PhD, is an expert in disease and care management. She recently completed her dissertation titled, Disruptive Innovation: The Acceptance of Technology by Physicians focused on EMR, PHR, ePrescribing and Telemedicine. She may be reached at Marybeth.regan@reden-anders.com.
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