1. Barriers to Provider Adoption of eRx Lessons Learned from the NEO CMS eRx Pilot AHRQ National Meeting, Bethesda September 8 th, 2008 Bob Elson, MD, MS (MetroHealth) John Kralewski, PhD (U MN) Dave Gans, MSHA, FACMPE (MGMA)

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3. 3 NEO eRx Project Participants  UH Medical Practices + Ohio KePRO  MGMA Center for Research  Univ. of Minnesota Division of HSR  InstantDx (OnCallData™)  RxHub, SureScripts, NDC  Aetna, Anthem, Medical Mutual of Ohio  Partners (Bates / Seger) … and CMS, AHRQ, and the other pilots

4. 4 NEO eRx Overview  eRx adoption, including “incumbent” transactions –Eligibility, Med Hx, NEWRX  Impact on workflow  Transaction interventions –Medication Hx, Fill Notification, Prior Auth  Impact on safety and utilization

5. 5 JanFebMarAprMayJunJulAugSeptOctNovDec NEO eRX PROJECT TIMELINE 2006 RxFILL Training Prior Auth Training Med Hx (new) Training 270/271 SCRIPT Formulary Med Hx Site Visits Planning, Tool Development Practice Recruitment, IRB Health Plan Data Acquisition / Analysis

6. 6 Provider Adoption of eRx  Practice vs. provider adoption  Workflow realities  Role of practice culture

7. 7 UH Medical Practices (UHMP) 285 physicians, 73 practices, 42 communities 46 primary care; 27 specialty 1.25 million office visits / yr

8. 8 Small Practice Adoption: Magic Mix  eRx offered free to all UHMP practices  Out-of-the-box integration w/ practice management system  Minimal equipment requirements  ASP delivery; robust remote training and support  Each practice allowed to determine optimal workflow  Malpractice subsidy if met threshold utilization criteria You can lead a horse to water…

9. 9 Pre-Project eRx Adoption (All of UHMP) Total e-Rx / mo, 1/05 -> 1/06 AND make it drink (voluntarily) … !

10. 10 Pre-Project eRx Adoption (by Practice) UHMP Primary Care, Jan -> August ‘05

11. 11 eRx (Study) and Control Practices Study (eRx) group (n=25 practices, 130 physicians)  Part of University Hospital Medical Practices (UHMP) –Community-based, primary care practices in Northeast Ohio  Access to OnCallData™ e-prescribing software  At least one doctor in the practice generated a minimum of 150 eRx in any month of 2006 prior to enrollment Control group (n=22 practices, 77 physicians)  Independent primary care practices in NEO –Not currently e-prescribing  Convenience sample –Practices w/ Ohio KePRO relationship under 8 th SOW

12. 12 eRx and Control Practices eRx and Control Groups:  25 UHMP practices with access to eRx (130 MDs)  22 non eRx practices (100 MDs)  Loosely matched by size and specialty (separately)

13. 13 e-Prescribing @ 25 Practices (2006) MonthAll UHMP eRxStudy Group eRx% of Total January32,15321,09565.6 February31,72321,30467.2 March40,07926,54966.2 April35,68023,40665.6 May42,64627,49764.5 June40,45126,58865.7 July37,79524,34964.4 August43,56027,97764.2 September42,22827,66065.5 October47,99831,40265.4 November46,44030,34365.3 December44,67429,13165.2 TOTAL485,427317,30165.4

14. 14 eRx / prescriber / mo (10/06 by practice) p p p p p p p = pediatric practice # at top of each bar = number of physicians in that practice 2 4 6 6 5 3 1 3 6 1 2 13 9 5 3 1 11 5 9 6 4 2 8 7 8 25 UHMP primary care practices 130 physicians

15. 15 Provider Adoption of eRx  Practice vs. provider adoption  Workflow realities  Role of practice culture

16. 16 Surrogate-Based e-Prescribing  48,013 eRx in October (all UHMP) –16,715 entered directly by MD 15,724 NewRx (~1000 Renew) –97 / 219 e-prescribers did at least some data entry themselves 122 did none

17. 17 Renewal Workflow Findings  eRx decreases dependence on phone / fax –Incoming Rx renewal requests from local pharmacies received by:  eRx practices still depend on paper for internal processing –For phoned-in requests, 81% communicated to MD by paper Only 7% entered into OnCallData™ on the front end –For faxed requests, fax itself used for internal communication 91%  73% sent back to pharmacy via eRx –only 33% come in by eRx, but most entered into OCD on back end –25% of authorizations called or faxed to pharmacy vs. 90% in control eRxControl Phone41%62% Fax25%36% eRx33%0%

18. 18 eRx Impact on Call Types  Inbound / outbound Ratio  Relative % of outbound calls going to pharmacy

19. 19 Practice Adoption Summary  eRx w/ advanced transactional capabilities can be rapidly adopted by small, community-based practices –PMS integration, no license fee + small incentive –Large (>2/3) dependence on surrogates Implications for decision support and safety benefits unclear Policy guidance? P4P? –Big impact on efficiency and communication channels, but… Paper-based internal communication still predominates Faxing is tough to beat re: overall resource requirements Opportunity for additional efficiency with more pharmacy participation plus true e-messaging within the practices –Conventional wisdom challenged: eRenewals drive adoption (?) Surrogates provide bridge to MD adoption (?) eRx is a stepping stone to a full EMR (?)

20. 20 Provider Adoption of eRx  Practice vs. provider adoption  Workflow realities  Role of practice culture (in provider adoption)

21. 21 In press…  “Factors influencing physician use of clinical electronic information technologies after adoption by their medical group practices” –Kralewski, JE et. al. –Health Care Management Review, October-December 2008  “Culture as a management tool in medical group practice” –Physician Executive Journal (http://www.acpe.org/Publications/PEJ/index.aspx?expand=pej )http://www.acpe.org/Publications/PEJ/index.aspx?expand=pej –Kralewski, JE et. al. Measuring the culture of medical group practices. Health Care Management Review; 2005; 30:184-193  krale001@umn.edu krale001@umn.edu

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24. 24 MGP Culture Survey: 8 Dimensions  Collegiality  Quality emphasis  Management style  Cohesiveness  Organizational trust  Adaptive  Autonomy  Business

25. 25 Related to eRx Adoption? Physician ageAge in years Physician gender1 = female, 2 = male Physician specialty1 = family practice, 2 = general pediatrics, 3 = general internist Practice sizeNumber of FTE physicians Patient work loadNumber of pt encounters for each physician per week Practice complexity 0 = single specialty, 1 = multispecialty Practice cultureMean score for practice on 1-4 scale, with 4 being more so (8 dimensions) Dependent variableProportion of total prescriptions written by each physician during a 2 month period that were sent electronically

26. 26 Hierarchical Model Individual-level characteristicsCoefficientSEz Age-.0010.003-0.25 Gender0.0090.0420.21 Internal medicine-0.1870.077-2.45* Family medicine-0.0950.106-0.9 Workload-.0000.000-0.84 Clinic-level characteristicsCoefficientSEz Practice size0.0700.0262.70* Multispecialty practice0.2180.0872.50* Collegiality0.2200.1721.28 Quality emphasis-0.5580.246-2.27* Management style0.1850.1481.25 Cohesiveness-0.3870.144-2.68* Organizational trust0.4170.0712.44* Adaptive1.4160.3873.66** Autonomy0.4220.1432.96** Business0.4130.1123.69** *Significant at the 0.05 level; **Significant at the 0.01 level

27. 27 Practice Culture and eRx Use  Driving practice adoption is just the beginning  Practice culture has major influence on eRx use patterns by providers within the practice  Personal characteristics of physicians do not –other than specialty  Good news: –Can predict physician cooperation by assessing practice culture –Gauge amount of passive or active resistance  Bad news: –Cultures are not easy to change! –Better to shape the innovation process to accommodate the culture