Meaningful Use and E-Prescribing Workflow

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Meaningful Use and E-Prescribing Workflow

• Douglas S. Bell, MD, PhD
• Associate Professor, Dept. of Medicine, UCLA
• Research Scientist, RAND Corporation

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E-Prescribing A Model System?
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Benefits for Everyone

• Physicians
• Decrease pharmacy calls
• Automate renewal handling
• Pharmacies
• Decrease calls
• Automation
• Payors
• Drug, other spending
• Patients
• Safety
• OOP costs

• Valid, complete Rx
• Safety alerts
• Generics identified
• Insurance coverage
• Work delegation

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E-Prescribing Policy

• Medicare Modernization Act of 2003 (MMA)
• Authority to mandate transaction standards
• NCPDP SCRIPT
• New Rx
• Refill request
• Medication history
• 270/271 Eligibility
• Formulary and Benefit

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If You Install It, Will They Use?

• New Jersey E-Prescribe Program, Jan June 2006
• 293 prescribers who installed in CY 2005
• Incentive for use up to 500/qtr

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Does Use Change Over Time?

• Users with at least 1 quarter at gt50 use (41)

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Does Use Change Over Time?

• Users without any quarter of gt50 use (59)

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Medicare Improvements for Patients and Providers
Act (MIPPA)

• Payment incentive for meaningful use
• bonus then penalty if not
• 2009 2
• 2010 2
• 2011 1
• 2012 1 - 1.0
• 2013 0.5 - 1.5
• 2014 - 2.0
• Qualified systems must be able to 
• Communicate with the patients pharmacy
• Help the physician identify appropriate drugs and
  provide information on lower cost alternatives
  for the patient
• Provide information on formulary and tiered
  formulary medications
• Generate alerts about possible adverse events,
  such as improper dosing, drug-to-drug
  interactions, or allergy concerns

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Mechanism of E-Prescribing Effects

• Information available in the system
• Information display / capture at prescriber
• Changes in work processes
• Changes in drug use
• Appropriateness
• Costs
• Patient adherence

• Other effects
• Labor and other costs
• Health service use
• Patient satisfaction

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Macro Process Model
JAMIA, 2004 1160-70
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Rework Pathways

• Basic prescribing Reality

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E-Prescribing Attenuate the Rework

• E- prescribing

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Sample Modeling Results New Rx
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Lessons from Successful Practices

• Messages for buy-in, expectations
• eRx empowers you as a professional
• Benefits may be intangible (e.g. more accurate
  info)
• Setup
• Keep lists of favorites and default Sigs short to
  minimize search
• Reach out to pharmacies RE common problems
• Workflow
• Protocols for renewal authorization vs. tasking
  to prescriber
• Centralize renewals for medical group
• Confirm pts pharmacy at check-in
• Handout Rx pad patient reminder pharmacy
  instructions

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E-Prescribing Implementation Toolset

• Toolset chapters
• Understanding the building blocks
• Setting goals and achieving buy-in
• Assessing readiness preparing for change
• Selecting a system
• Scheduling monitoring the implementation
  process
• Setting up the technology
• Planning work process changes
• Training staff
• Launch
• Monitoring and remediating shortfalls
• Pilot testing toolset set to begin Sept., 2009

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Conclusions

• Achieving meaningful use of eRx may be
  challenging
• MIPPA incentives may be low
• Workflow, implementation innovations hold promise
• Future work
• Improving technical standards
• Validating workflow models
• EHR integration
• Implementation processes carried out by RECs

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Thank YouQuestions?

• dbell_at_ucla.edu or dbell_at_rand.org

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Reasons for Continuing to Use Paper
  Strongly disagree Disagree Neutral Agree Strongly agree
Patients were not in the PDA 5 8 5 47 36
I can't use the PDA because of technical problems 3 3 6 37 51
I get too busy 10 17 7 35 31
Pharmacies don't reliably receive and process the electronic prescriptions 8 13 33 36 10
System interfered with established office workflow 16 34 22 22 7
System takes too much of my time 15 24 19 30 13
System takes too much of my staff's time 24 32 30 9 6
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E-Prescribing is Growingbut underused

• 2006 2007 2008
• Prescriptions 13M 29M 68M
• 4.5 of 1.5B prescriptions/yr in U.S.
• Prescribers 15k 36k 74k
• 12 of 610k physicians, NPs PAs
• Pharmacies 35k 41k 46k
• 76 of 61k community pharmacies
• 46 of independents
• 6 of the largest mail-order pharmacies