1. Meaningful Use and E-Prescribing Workflow Douglas S. Bell, MD, PhD Associate Professor, Dept. of Medicine, UCLA Research Scientist, RAND Corporation

2. E-Prescribing: A Model System? ??

3. Benefits for Everyone Physicians –Decrease pharmacy calls –Automate renewal handling Pharmacies –Decrease calls –Automation Payors –Drug, other spending Patients –Safety –OOP costs Valid, complete Rx Safety alerts Generics identified Insurance coverage Work delegation

4. E-Prescribing Policy Medicare Modernization Act of 2003 (MMA) –Authority to mandate transaction standards NCPDP SCRIPT: –New Rx –Refill request –Medication history 270/271 Eligibility Formulary and Benefit 4.New Prescription 1.Eligibility check 2.Formulary&Benefit data 3.Medication History PrescriberPharmacy 5.Claim “adjudication” Health Plan 6.Refill requests

5. If You Install It, Will They Use? New Jersey E-Prescribe Program, Jan – June 2006 –293 prescribers who installed in CY 2005 –Incentive for use up to $500/qtr 21%26%53%

6. Does Use Change Over Time? Users with at least 1 quarter at >50% use (41%)

7. Does Use Change Over Time? Users without any quarter of >50% use (59%) 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 Q1Q2Q3Q4Q5Q6 Peak use.25-.5 (n=62) Peak use <.25 (n=90) Quit (n=22)

8. Medicare Improvements for Patients and Providers Act (MIPPA) Payment incentive for “meaningful use” bonus…then penalty if not 20092% 20102% 20111% 20121%- 1.0% 20130.5%- 1.5% 2014+- 2.0% Qualified systems must be able to: –Communicate with the patient’s pharmacy –Help the physician identify appropriate drugs and provide information on lower cost alternatives for the patient –Provide information on formulary and tiered formulary medications –Generate alerts about possible adverse events, such as improper dosing, drug-to-drug interactions, or allergy concerns

9. Mechanism of E-Prescribing Effects Information available in the system Information display / capture at prescriber Changes in work processes Changes in drug use –Appropriateness –Costs –Patient adherence Other effects –Labor and other costs –Health service use –Patient satisfaction

10. Macro Process Model JAMIA, 2004; 11:60-70

11. Rework Pathways Basic prescribing: Reality

12. E-Prescribing: Attenuate the Rework E- prescribing

13. Sample Modeling Results: New Rx Prescriber Time, 1000 New Rx 0.00 2.00 4.00 6.00 8.00 10.00 12.00 PrescribeTransmitDispenseDeliver/MonitorExceptionsTotal Hours Paper basic eRx eRx w/ Med Hx eRx w/ F&B Staff time, 1000 New Rx 0.00 1.00 2.00 3.00 4.00 5.00 6.00 PrescribeTransmitDispenseDeliver/MonitorExceptionsTotal Hours Paper basic eRx eRx w/ Med Hx eRx w/ F&B

14. Lessons from Successful Practices Messages for buy-in, expectations: –eRx empowers you as a professional –Benefits may be intangible (e.g. more accurate info) Setup –Keep lists of favorites and default Sigs short to minimize search –Reach out to pharmacies RE: common problems Workflow –Protocols for renewal authorization vs. tasking to prescriber –Centralize renewals for medical group –Confirm pt’s pharmacy at check-in –Handout “Rx pad” patient reminder & pharmacy instructions

15. E-Prescribing Implementation Toolset Toolset chapters 1.Understanding the building blocks 2.Setting goals and achieving buy-in 3.Assessing readiness & preparing for change 4.Selecting a system 5.Scheduling & monitoring the implementation process 6.Setting up the technology 7.Planning work process changes 8.Training staff 9.Launch 10.Monitoring and remediating shortfalls Pilot testing toolset set to begin Sept., 2009

16. Conclusions Achieving meaningful use of eRx may be challenging –MIPPA incentives may be low Workflow, implementation innovations hold promise Future work –Improving technical standards –Validating workflow models –EHR integration –Implementation processes carried out by RECs

17. Thank You Questions? dbell@ucla.edu or dbell@rand.org

18. Reasons for Continuing to Use Paper Strongly disagree DisagreeNeutralAgree Strongly agree Patients were not in the PDA 5854736 I can't use the PDA because of technical problems 3363751 I get too busy 101773531 Pharmacies don't reliably receive and process the electronic prescriptions 813333610 System interfered with established office workflow 163422 7 System takes too much of my time 1524193013 System takes too much of my staff's time 24323096

19. E-Prescribing is Growing… but underused 200620072008 Prescriptions13M29M68M – 4.5% of 1.5B prescriptions/yr in U.S. Prescribers15k36k74k – 12% of 610k physicians, NPs & PAs Pharmacies35k41k46k – 76% of 61k community pharmacies – 46% of independents – 6 of the largest mail-order pharmacies