Effect of e-prescribing in ambulatory settings: Evaluation of the Formulary and Benefit standard Douglas S. Bell, Jesse C. Crosson, Nicole Isaacson, Debra Lancaster, Barbara DiCicco-Bloom, Emily A. McDonald, Anthony Schueth My co-authors are from RAND health, Rutgers University and Point of Care Partners. North American Primary Care Research Group Annual Meeting, October 22, 2007 Funded by the US Agency for Healthcare Research and Quality 1 U18 HS016391-01 PI: Bell

Background Medicare Modernization Act  Part D drug benefit required participating health plans to support electronically transmitted prescriptions Required HHS to evaluate e-prescribing transaction standards: Formulary and Benefit Medication History Fill Status Notification Structured and Codified SIG Prior Authorization RxNorm Health plans and pharmacies participating in the new Medicare Part D prescription drug benefit must support the use of electronic prescribing. To support this requirement the secretary of the Department of Health and Human Services established six initial standards for e-prescribing.

Formulary and Benefit standard Purpose: Help in selecting affordable medications by informing prescribers about the patient’s drug coverage at the point of care The formulary and benefit standard is designed to provide prescribers with information about drug coverage at the point of care. Specifically, prescribers could receive information about what is “on formulary” for a particular patient, alternative medications, notification of the need for prior authorization, and information on costs to the patient of various treatment options. Since medication costs are a significant barrier to medication adherence, especially among patients with chronic diseases this information could be particularly useful in improving the quality of care for these patients. One of the key potential benefits of having accurate formulary and benefit information at the point of care is that it could offer prescribers an opportunity to select clinically equivalent medications at a lower cost to patients.

F & B Information Flow Mail-order pharmacy Mail-order pharmacy RxHub Coverage Plan Eligibility RxHub Health Plans Retail pharmacy Retail pharmacy Retail pharmacy Health Plans SureScripts & others

Study Objectives To evaluate the effect of the formulary and benefit (F&B) electronic prescribing standard in ambulatory care settings vs. currently-available sources of F&B information

Setting Existing “E-prescribe” initiative sponsored by Horizon Blue Cross Blue Shield of New Jersey Recruited and enrolled individual physicians Paid for e-prescribing system, installation, training Caremark - iScribe Allscripts - TouchWorks Both implemented the F&B standard Target: 1000 MDs (of ~10,000 MDs in Network) Our study uses data from a previously existing e-prescribing program sponsored by Horizon BCBSNJ Horizon offered the iScribe e-prescribing system, including hardware, software They targeted individual physicians as opposed to physician offices, and they focused on physicians who originate more than 500 prescriptions per year for Horizon patients. That threshold includes almost 2/3 of all physicians in Horizon’s physician network.

Methods: Sampling and Data Collection Comparative case study Purposive sample of ambulatory practices scheduled to install iScribe or Allscripts Site visits before and 3 mo. after eRx Observation of physical environment, organizational culture, clinical and prescription workflow. In-depth interviews of physicians, office managers, and office staff involved in prescription workflow. (70 interviews total) We conducted a comparative case study of 12 ambulatory medical practices before and after the scheduled installation of the Caremark’s iScribe™ system and half Allscripts’ TouchScript™ system. Practices were purposively sampled to ensure a mix of practice size and physician specialty with half of the practices implementing system. Prior to implementation, in March and April 2006, a field researcher visited each practice for three days and used a template to guide observation of the physical environment and organizational culture along with clinical and prescription workflow. In each practice, between 3 and 6 in-depth interviews exploring existing prescription workflow and expectations relating to implementation were conducted with members of each of the following groups; physicians, office managers, and staff members involved in prescription workflow. Questions focused on expectations of how e-prescribing would affect work in the practice and how the practice handled work relating to prescriptions – such as formulary and benefit issues, prior authorization and maintaining accurate medication history data. Approximately three months after installation, field researchers returned to practices for a two-day visit to document usage patterns. A total of 70 interviews were conducted in the two periods.

Methods: Analysis Used a template organizing style to identify common themes. Coding reports were used to generate data summaries and representative text segments were identified. Interview transcripts and observational fieldnotes were entered into ATLAS.ti for coding and analysis. A diverse team of investigators, including health services researchers, physicians, nurses, social scientists and industry experts, coded and analyzed text data using a template organizing style to identify common themes relating to e-prescribing implementation. Coding reports were analyzed by two investigators to generate data summaries and representative text segments were identified. The resulting analyses were checked with other members of the team to ensure validity.

Results Electronic prescribing systems were installed and being used in 8 practices at follow-up Practice sizes: 1 to 6 physicians Types: family medicine, general internal medicine, pediatrics and obstetrics/gynecology

F & B Information - Baseline Periodically we get those, but I … throw them out because they change so frequently, and we have so many insurance plans … I glance through them … just to see what the flavor of the month is, and then (it) goes in the wastebasket. We just rely on the patient saying, “Hey, it wasn’t covered.” But, do we look at the lists? No…. But, I know, those computer things will help a lot … Before implementation few physicians reported using paper-based F&B information to assist in making medication choices. When an interviewer asked one doctor: Do you have any resources that help you keep track of what medications are covered by different plans? The doctor gave an answer typical of these prescribers … Another doctor said …

Formulary and Benefit – Follow Up The computer will tell me … which ones are preferred…. So that does make a difference. If a patient is going to be paying 200 bucks for a prescription when I can give them something for 20 bucks, I’d rather do that if they are bio-equivalents. That part of it I don’t use at all … ‘cause I try not to… I try not to let that cloud how I’m prescribing the medication. Following implementation, physicians in some practices reported using F&B information to adjust medication choices taking into account patient costs. As one doctor reported … Other physicians were unsure of the reliability of the information and reported mismatches between F&B information available in the practice and that available to pharmacists. As another prescriber put it … Nonetheless, some reported prescribing generic drugs more frequently since the programs consistently suggested generic alternatives.

Formulary and Benefit – Follow Up They’re not all in here. So I’m just letting it default to Horizon. And once it gets to the pharmacy, the pharmacies will sort it out. They do have a little system with the smiley faces. Ours is not, I guess, sophisticated enough yet where it actually says it was Aetna versus United versus whatever to tell me. It’s funny, because it really hasn’t changed much of my prescribing habits, because I notice that, like nasal steroid sprays… I look under Nasonex, they all have the same yellow face. Following implementation, physicians in some practices reported using F&B information to adjust medication choices taking into account patient costs. As one doctor reported … Other physicians were unsure of the reliability of the information and reported mismatches between F&B information available in the practice and that available to pharmacists. As another prescriber put it … Nonetheless, some reported prescribing generic drugs more frequently since the programs consistently suggested generic alternatives.

Conclusions Many prescribers want more accurate formulary and benefit information at the point of care. Drug coverage information currently being provided via the Formulary and Benefit standard does not seem to provide helpful information consistently. While some prescribers reported that they used F&B information to adjust medication choices thus potentially decreasing patient and health plan costs and reducing calls from pharmacists regarding coverage problems, prescribers had widely varying understandings of the completeness, accuracy and usefulness of this information.

Discussion Why is F&B information incomplete and inaccurate? Many insurers don’t publish F&B information especially Medicid plans The F&B information made available doesn’t reflect the actual complexity of drug coverage Future Implications F&B standard was recommended by HHS Unlikely to have the intended effects on Rx costs Address the technical limitations