E-Prescribe: Adopting Health Care Information Technology ADG associates presenting: Barbara Antuna Jessica Carpenter Patrick Esparza Brian Frazior

Need to reduce medication errors Project Problem Need to reduce medication errors Currently seeing about 62.5 errors per 1,000 medication orders American Recovery and Reinvestment Act CPOE needed for “Meaningful Use” Medicare Incentives CMS offering financial incentives Proposed Solution: Computerized Physician Order Entry Sources: The Leap Frog Group. Factsheet: computerized physician order entry. Accessed from: http://www.leapfroggroup.org/media/file/FactSheet_CPOE.pdf on October 1, 2009. Centers for Medicare and Medicaid Services. E-Prescribing Measure. Accessed from: http://www.cms.hhs.gov/ERxIncentive/06_E-Prescribing_Measure.asp on October 1, 2009. Dolan, PL., Prepare to meet "meaningful use" EMR requirement. American Medical News. June 15, 2009. Accessed from: http://www.ama-assn.org/amednews/2009/06/15/bica0615.htm on October 1, 2009.

CPOE Readiness Assessment Strategy How needed is this project and how committed to the project is the organization? Stakeholder involvement and expectations Structure/Culture Timeline, financials and staff expectations Technology Does the hospital have enough technology resources Electronic records already in place? Management Control Processes Does the organization have the proper management in place to implement a project of this size Clinical IT/Project Management Does the IT department have the expertise and tools needed Source: Health Care Excel. CPOE Readiness Assessment Version 1. Accessed from: http://www.hce.org/Education/ToolKits/CPOE_Toolkit/03_TOOLS/05-CPOE-ReadinessAssessment-DRAFT-Tool.pdf on October 1, 2009

Readiness Assessment Results and Strategic Fit

Qualify HIMSS(Healthcare Information and Management Systems Society) EMR Adoption Model

Justification - Financials American Recovery and Reinvestment Act (ARRA) Health Informatics Initiative Require a meaningful use system by 2011 Non-compliance results in financial penalties starting in 2015 Reduction in cost due to fewer medication errors Reduced risk of liability Reduced costs associated with Adverse Events Reduction in cost due to more efficient methods More accurate methods for cost tracking Time and efficiency savings in finding/recording information in charts Medicare incentives 2008 Medicare Improvements for Patients and Providers Act Bill provides economic incentives for physicians to e-prescribe

Justification - Regulatory ARRA Will have a system that functions under federal guidelines Better ability to provide Joint Commission requirements Increase efficiency for producing required reports More accountability Assist with compliance of policies at the point of prescribing Accurate record of all drugs administered Up to date information on drug availability at the point of prescribing Reporting Requirements National Health Quality Measures (NHQM) Reporting Hospital Quality Data for Annual Payment Updates (RHQDAPU) Physician Quality Reporting Initiative (PQR)

Patient Safety and Quality of Care Studies show a vast reduction in errors Hospitals that use CPOE have fewer complication and death rates Reduce transcription errors prescriptions No legibility issues Notes can be attached to record with clarifying decisions Allergy warnings always available and linked to drug selection Reduce missed doses Ability to track and audit changes in drug treatment during admission Identifies drug interactions at the point of prescribing Availability of up to date medication histories Source: Bobb, A., Gleason, K., Husch, M., et al. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med, 164., 2004.

Improved patient safety Patient Satisfaction Increased efficiency Quicker turnaround from time physician orders prescription to when patient receives Improved patient safety Fewer problems with unclear orders, dosage mistakes, and duplication of drug therapies Keeping up with technological advances Source: McCarthy, G., Deliver Tangible ROI: Three healthcare organizations see reduced costs, enhanced efficiency and increased compliance with CPOE systems. Health Management Technology., Accessed from: http://www.healthmgttech.com/features/2009_june/0609_deliver.aspx on October 5,2009.

Initial and Ongoing Costs Organization already has existing clinical information system , leads to reduction in up-front costs. Approximately $1.5 Million in initial costs for a 200 bed facility – best case scenario Approximately $4.2 Million in initial cost for a 200 bed facility – worst case scenario Source: Ohsfeldt., RL, Ward, MM., Schneider, JE., et al., Implementation of hospital computerized physician order entry systems in a rural state: feasibility and financial impact. JAMIA., 12 (1)., 2005.

ROI Case Studies Early Case Study: Brigham and Women’s Hospital Implemented in 1992 – saw profits 6 years later that are continually and steeply increasing. Source: Kaushal, R., Jha, AK., Franz, C., et al., Return on investment for a computerized physician order entry system. JAMIA., 13(3), 2006. State of Massachusetts Study CPOE systems could prevent 55,000 medication errors in Massachusetts and save $170 million statewide per year ($2.7 million per hospital). Expect to see payback within 26 months through reducing hospitalizations generated by errors. Source: Blue plan: EMRs don't offer good ROI, but CPOE does. Accessed from: http://www.fiercehealthfinance.com/story/blue-plan-emrs-don-t-offer-good-roi-but-cpoe-does/2008-03-12#ixzz0UPgd0E7s.,on October 5, 2009.

Stakeholders Direct Stakeholders Indirect Stakeholders Patients CEO Prescribing Providers CEO Pharmacy/ Pharmacist CFO HOSPITAL Payers/Pharmacy Benefits Managers (PBMs) CIO Government (Federal and State) Healthcare Facility

Prescribing Providers Pharmacy/Pharmacists Stakeholders Patients Prescribing Providers Pharmacy/Pharmacists Payers/Pharmacy Benefit Managers (PBMs) Government (Federal and State) Healthcare Facility

Stakeholders - Patients Power and Interest Reasonable level of power and minimal interest Goal is to keep the patients satisfied Responsibilities Financial asset to the healthcare system Paying for a portion of the hospital services including e-prescription Needs and Wants Accurate, timely, and authorized prescriptions Increased safety and quality of care Role in Driving System Architecture Reduce involvement in prescribing workflow Increase access to prescription history

Stakeholders - Prescribing Providers Power and Interest “Committed” with a great deal of power and interest They must find the system easy and efficient to use Responsibilities Primary users of the system Highly affected by changes in current workflows Needs and Wants Reduction in medical errors Increased efficiency in medical prescription Role in Driving System Architecture Design considerations to improve and not hinder current workflows

Stakeholders - Pharmacy/Pharmacists Power and Interest “Committed” with minimal power but high interest Must be willing and able to accept e-prescriptions Responsibilities Pharmacies must be willing to upgrade systems to support e-prescribing Needs and Wants Increased efficiency due to problems with current paper-based prescriptions Automated prescription renewals Patient safety and care Reduction in time spent mediating between payers and providers resulting in reduced costs Role in Driving System Architecture Partners in working through common concerns Ensure electronic prescription standards are met

Stakeholders - Payers/Pharmacy Benefit Managers (PBMs) Power and Interest “Committed” with high power and high interest They will need to be managed closely Responsibilities Will need to work with providers as well as pharmacies Possibly upgrade systems to accept electronic prescriptions Needs and Wants Reduction in prescription costs through the promotion of cheaper therapeutically equivalent drugs Reduction in medical errors resulting in lower medical costs Role in Driving System Architecture Must interact with the e-prescription system to act as an intermediary between the provider, patient, and pharmacy

Stakeholders - Government (Federal and State) Power and Interest “Committed” with high power and high interest Goal is to reduce health care costs Responsibilities Provide patients safe and high quality health care Promote electronic prescription through financial incentives, laws, and education Needs and Wants Increase quality of care Cost savings through the use of generics and formulary compliance Role in Driving System Architecture Defining e-prescription requirements and data standards

Stakeholders – Healthcare Facility Power and Interest “Authorized” with high power and high interest Goal is to maintain an efficient, cost effective prescription system Responsibilities Put forth financial backing to implement e-Prescription system Needs and Wants Return on investment Improved quality scorecard results Satisfied physicians and community Role in Driving System Architecture Provide budgetary approval

Workflow – Actors People System Providers Provider Office Staff Dispensers Dispenser Staff Payers Patients System EMR, both at provider locations and hospitals PIS Payer IS HIE

Workflow Current State – Patient/Provider

Current State – Dispenser/Payer

Future State – Patient/Provider, Dispenser/Payer

Staff Satisfaction and Productivity Satisfiers and Improved Productivity Eliminates provider office staff and transmission of prescription Improvement in dispenser workflow due to increased legibility of prescriptions Improvement in dispenser workflow due to less payer covered formulary checking Provider able to identify payer covered meds Provider given access to dosing at point of care Provider given drug-drug and allergy information at point of care Better security of provider license and DEA information Dissatisfiers Change in workflow for provider Will not entirely eliminate office staff involvement May not necessarily change anything for the patient

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