Download ePrescribing in community

E-prescribing in communitybased 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-authors
Ritu 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
64%
Start of
e-prescribing
62%
Percent Tier 1
60%
58%
56%
Control prescribers
54%
Intervention prescribers, eprescriptions
Intervention prescribers, non-eprescriptions
52%
50%
-6
-5
-4
-3
-2
-1
1
2
3
4
5
6
7
8
9
10
Month relative to 1st e-prescription
Fischer et al, Arch Int Med, 2008, in press
11
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 communitybased 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
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•
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•
•
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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
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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 nonprescribers 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