March 19, 2007

Push Things Forward
By Kathryn Foxhall
For The Record
Vol. 19 No. 6 P. 24

That’s the aim of a coalition that has introduced an impressive plan to increase the use of e-prescribing technology among physicians.

All the news out of Washington isn’t bad: Recently, it was announced that all physicians should be able to prescribe electronically for free and with no new hardware and only a few minutes of training.

That’s according to the National ePrescribing Patient Safety Initiative (NEPSI), a coalition of several high-profile IT organizations, health insurance companies, and medical groups led by Allscripts and Dell Computer. NEPSI, which announced its program to allow doctors to register for the service at www.NationaleRX.com in January, was set to begin national deployment of free e-prescribing by the middle of February.

National sponsors also include household names such as Aetna, Cisco Systems, Fujitsu, Google, Microsoft, and Sprint Nextel. Designed to appeal to physicians in solo or small group practices, the free system is a new version of the most commonly used e-prescribing program in the country, according to an Allscripts spokesperson, with 20,000 physicians writing millions of prescriptions.

The coalition called the program “not unlike” many other Web-based applications. And with nearly all pharmacists already connected electronically, physicians are supposed to be able to identify a pharmacy and send the prescription directly to it.

Any state-licensed physicians authorized by the U.S. Drug Enforcement Administration to prescribe medications can use virtually any Internet-connected device, including their telephones and BlackBerrys, to access the program, according to Nancy Dickey, MD, president of the Texas A&M Health Science Center and 1999 president of the American Medical Association, who made the announcement at a press conference in Washington, D.C.

The coalition pledges to pour up to $100 million into the effort over five years. An Allscripts spokesperson said NEPSI is not releasing how much support each organization is supplying but that Dell is the most significant contributor, with support in technology and financial resources. Also involved is SureScripts, which provides connectivity to an estimated 55,000 pharmacies.

According to the sponsors, the system includes comprehensive drug interaction checking, a real-time complete medication database by Wolters Kluwer Health, and real-time notification of insurance formulary status from leading payers, plans, and pharmacy benefit managers. Large health insurance payers, including Wellpoint and Aetna, are providing incentives for physicians to use the system.

Allscripts CEO Glen Tullman noted that different payers have different sets of incentives for e-prescribing adoption and utilization. Although those incentives have been used before, they have often not been sufficient to offset the cost of installing a program, a barrier that is now eliminated, he said.

Dickey agreed, saying that up to this point, “the people who are being asked to take the time and spend the money to put this into their offices—physicians—generally are not necessarily the ones who are going to get the financial benefit.”

In addition, because “physicians like to learn from physicians,” said Tullman, more than one dozen regional medical sponsors, including large group practices and integrated delivery networks, have agreed to sponsor education sessions on the program.

Dickey called the group “the most significant coalition of stakeholders ever to address the issue of medication errors.” To underscore the public health importance, she cited an Institute of Medicine report that said 1.5 million Americans are injured each year, and more than 7,000 die from medication errors.

She also stressed that her medical center treated many Hurricane Katrina victims. “And I saw firsthand what happens when people are forced to flee in a very short time period and come with no information about their healthcare and, specifically, about their prescriptions.”

What’s in It for Private Companies?
Asked what the private companies will get from their participation, Tullman said no one will make money from the initiative itself. But, in terms of his own company’s interest, for example, e-prescribing is the first step onto an electronic healthcare highway, and the electronic health record is a product Allscripts does sell.

Scott Wells, vice president of marketing for Dell’s Public Business Group, said his company believes it has an opportunity as an infrastructure provider to the model: “We expect that the manageability and security of that network is going to be absolutely superior.”

Microsoft general manager Steve Shihadeh said, “Healthcare is a big and rapidly growing business for Microsoft. We view this as a solid investment in promoting technology. And we are just big supporters of empowering consumers from a technology standpoint.”

Getting the Word Out
Tullman said each participant is committed to getting the word out to physicians. Some of the larger medical organizations, he noted, have a vested interest in connecting with smaller providers who are a source of referrals. Those regional medical sponsors, ranging from George Washington University Faculty Associates in Washington, D.C., to the Sierra Health Services and Southwest Medical Associates in Las Vegas, are listed on the NEPSI Web page.

Dickey said she hoped patients will begin to demand e-prescribing now that physicians have fewer reasons for not using it.

Tullman also indicated that numerous patient safety organizations will be stepping up to provide support. He pointed to a statement from the Institute for Safe Medication Practices, saying that NEPSI was breaking down barriers and “handwritten prescriptions ought to be a thing of the past.”

Another prominent figure at the press conference, Mark McClellan, MD, PhD, who was head of the Centers for Medicare & Medicaid Services (CMS) until last fall, said, “I think every single major employer and every single health plan in this country is very concerned right now about finding ways to support the delivery of better quality of care at lower cost.

“How exactly each of these plans is going about it is a little bit different,” he continued. “But the fundamental pressure is high now and it is going to get higher on physicians as time goes on. So having an opportunity for physicians to respond to those pressures at a low cost makes it much easier to make these kinds of incentives work.”

Saying there is a new expectation about changing healthcare, McClellan asserted, “It is not going to be that far in the future where a typical patient will be asking, ‘Are you giving my prescription to my pharmacy electronically? Can I see those electronic records? Can I get that put in my personal health record that I am using to keep track of my own healthcare?’

“That change is coming this year,” he predicted.

Quick Fix for Adoption?
Since e-prescribing is now free, will it become a hit with physicians? Lawrence Kocot, senior advisor on pharmacy matters at the CMS, said that although the program is a “great thing,” he believes “it’s not a magic bullet that will make adoption happen quickly.” Kocot said it is also about changing behavior and habits, noting earlier efforts to give doctors incentives to e-prescribe have not worked as was hoped.

Praising the coalition’s focus on smaller practices, Kocot said, “The more granular that we get to identifying barriers to adoption,” the more likely efforts are to work.

Frank Opelka, MD, FACS, professor of surgery at Louisiana State University, said he believes one major motivating factor for physicians will be the possibility of decreasing the many calls to their offices that happen because pharmacists cannot read their handwriting or other problems with a prescription. His office gets approximately 15 of those calls per day, he said, and those will go away or diminish significantly with this system.

Opelka, a NEPSI program participant, also indicated that physicians are being judged more on the quality of care they give patients. He said he no longer looks at e-prescribing as a burden but considers it an avenue to bring value to patients.

Opelka likes the fact that when a patient calls him at home, he can check the background on the case and send the prescription to the pharmacy immediately, without having a patient go to the on-call physician at a nearby hospital.

Azar Korbey, MD, a New Hampshire family physician who has been using Allscripts e-prescribing systems for 10 years, said doctors will be more inclined to use such systems after they understand the time savings.

“Once you log on, you simply pick your patient, select your diagnosis, you put your medication in, you put the directions [one-a-day, two-a-day, three-a-day] in, you select their pharmacy, and you hit send. And that whole process can literally be done in under a minute,” said Korbey.

Although a paper prescription can also be written in that time, he said time savings occur when the blanks repopulate themselves as the physician is writing more than one prescription; when the most common diagnoses used by that doctor begin to show up on the screen immediately; and, for each specific diagnosis, the most common drugs the physician prescribes appear.

“So, very quickly after you have used this for a couple of weeks, it becomes very much point and click,” said Korbey.

Of course, if the training is complex and time-consuming, physicians won’t bother. However, Dickey says it should take only 15 or 20 minutes to train the office. “The staff here [in the office] has walked me through the process literally standing on the sidewalk,” she says. “So it is extraordinarily quick and easy.”

Privacy
NEPSI says it will offer the highest levels of security available with layers of firewall, deep-packet inspection, secure socket layer encryption, database encryption, intrusion detection, and virus, spyware, and malware protection for the program’s remote servers.

Because of the importance of privacy and security in moving any healthcare technology forward, Tullman said the coalition has tried to exceed established standards in designing the product. The group expects to continue to monitor those issues, she said.

McClellan said features that meet or exceed HIPAA standards are built into the program.

Real-time Drug Information
For drug interactions and other information, the drug databases will be taken from some of the major standard listings used throughout the country, Tullman said.

Dickey noted that new information on drugs will be communicated from the FDA to the program as well: “For example, if a new black box warning came out or if a drug was removed, that would automatically and immediately be communicated. So if I started to prescribe something tomorrow that I did not realize had been removed, I would be notified through e-prescribing.”

“Any drug recalls can be instituted almost instantaneously,” said Tullman, “so you know that everyone who has received that prescription can get a letter overnight, the next day, within 24 hours, if a drug is recalled or there is a black box notification.”

And in terms of the program’s own response to a recall, he said, “it’s not even a function of being able to write it. It is simply no longer available on the system.”

He noted reports that under the paper system, there were 5,000 new prescriptions written—and one half were filled—in the three weeks following one of the largest drug recalls in history.

Other Aspects
Tullman said the program will also include a custom-designed healthcare search engine from Google, with real-time information on best practices and other information. He said it will also have “real-time notification of patient information through their health plans.”

The program, he said, will be easy to update and fully interoperable: “The information contained in the product at any time can be moved, imported to any other product.”

On the other hand, Tullman admitted that connection to practice management systems “is probably the thorniest problem here.”

The company had built a number of interfaces with leading practice management systems to allow that data to be dumped into the system, he said, and it is working with large providers to prepopulate the devices with information that makes it easier for physicians to use. Third parties who offer those interfaces will be listed on the coalition’s Web site, he indicated.

Asked whether the project would supersede the programs some states are working on to encourage e-prescribing, Tullman said the coalition hopes to supplement and build on those efforts. He also indicated the hope that many of the programs now paying for e-prescribing software will be able to redeploy dollars into physician incentives, training, and other support.

On the complicated issue of e-prescribing of controlled substances, Tullman said that the laws surrounding that still vary from state to state, and physicians who are uncertain should talk to their pharmacy board or SureScripts.

— Kathryn Foxhall is a freelance writer in the Washington, D.C., area. She covers health informatics, public health, health policy, reimbursement, mental health, and other issues.