1. E-prescribing in community- based 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

2. 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

3. 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

4. Study setting Initiated by BCBSMA and Tufts Health Plan Partnered with ZixCorp, providing physicians with PocketScript system Program began in early 2004

5. Prior studies – erx adoption Fischer et al, JGIM, 2008

6. Prior studies – e-rx and costs Fischer et al, Arch Int Med, 2008, in press

7. 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

8. Study questions What is the experience of community- based 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?

9. 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

10. Findings E-prescribing positives Ongoing challenges/barriers

11. E-prescribing positives Prescription security Financial gain Office efficiency Medication safety Insurance issues Communication with pharmacy

12. E-prescribing positives Prescription security –Less people touch the actual prescription –Patients cannot lose the prescription –Patients cannot tamper with prescription

13. 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

14. 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

15. 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..”

16. 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

17. E-prescribing positives Communication with pharmacy –Timely flow of information –Ability to send specific messages e.g.: “no more refills until patient sees doctor”

18. Ongoing challenges/barriers Learning curve Usability Reliability Safety concerns Patient resistance Data security

19. 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

20. 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

21. 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 non- prescribers in the process of queuing

22. 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

23. 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

24. 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

25. 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