Testimony for NCVHS

Outcomes of e-Prescribing Pilots
May 2, 2007

Thank you for inviting me to testify today and to share some of the insights on how the e-prescribing pilots’ efforts will help understand and overcome some of the key challenges in moving us towards an environment where adoption is accelerated and patients, providers, payers and all stakeholders in the prescribing industry achieve indisputable benefit and value.

Each of the 5 grantees participating in the eprescribing pilots were expected to test the six initial standards as you’ve heard summarized previously, but were given vast flexibility and latitude in testing various outcomes of eprescribing including prescriber uptake and satisfaction, workflow changes, impact on callbacks between physicians, pharmacies and PBMs/payers, use of eprescribing functions including medication history, change in fill status, use of on-formulary/generic medications and impact on medication errors.

The grantees had mostly completed their reporting of the standards portion of the pilot tests, however at the writing of our interim report many of the grantees were still compiling and analyzing results of the “other outcomes” section of their report. The “other outcome” results and understanding the impact eprescribing has on areas outside of the standards themselves are critical to truly focusing on a culture of acceptance and adoption by all stakeholders in this process. Like the lessons learned in other demonstrations of electronic health information exchange, in order to have a sustainable environment for exchanging health information; putting the right information in the hands of the right individuals at the right time is dependent on both the technological architecture and adherence to use of common standards, as well as the policies, business rules, and culture of trust and collaboration that need to drive those technological design decisions. Merely achieving success in the agreement of which standards to use for eprescribing will not move the information to where it needs to be that enables better care for the patient and improved efficiency for the physician and pharmacy.

Without addressing the challenges that face the various stakeholders in this process in terms of workflow changes, additional requisite investments, establishment of trust and collaboration amongst the various players—we’ve only solved half of the equation.

Medication History

A key example of this is related to the utilization of the features and functions enabled by standards for eprescribing like medication history. Overall the pilots’ findings demonstrated poor adoption of this functionality, even though this transaction has been implemented by a vast majority of the eprescribing technology vendors participating in these demonstrations for several years. The availability of a patient’s medication history can enable prescribers and pharmacists to prevent medication errors by checking for duplication of an existing drug or therapeutic class and potential drug-drug interactions. Three of the pilot sites specifically tracked how frequently prescribers access medication history information via the eprescribing system or asked for feedback on how useful this information was to the prescribing process. In assessing the overall data quality, usability and completeness of the standard, there was agreement that errors in Medication History data are rare, but given the flexibility of the standard in naming important data elements as “optional”, some key information may be missing including the prescriber’s identity, the SIG, the quantity dispensed, and the name of the dispensing pharmacy. Another contributor to the low adoption rate is that each application uses different references to identify this feature in their software. Without adequate training and education, physicians may not be aware this capability exists. But for those physicians using the eprescribing medication history function prior to and during the pilot testing, found this information very useful. Some of the positive comments from physicians surveyed during the pilot testing related to accessibility of information, ability to view medications across multiple prescribers, ability to detect potential drug abuse and doctor shopping, assistance in medical decision making and ability to review a more comprehensive list with their patients. Traditional inpatient CPOE systems have shown that when prescribers have a unified view of all active prescriptions, there is a decrease in the overall number of prescribed medications.[1] Overall, this is considered an improvement in the quality of care, as medications become more coordinated and drug-drug interactions are less likely to occur.

Prescriber & Pharmacy Workflow Impacts

One hope for eprescribing is that it will improve workflow for both prescribers and pharmacists. Widespread adoption of eprescribing will require that prescribers realize these improvements in workflow, or that other perceived benefits of eprescribing are large enough to counteract any negative impact on workflow.

In the LTC setting, it was realized early on that physician adoption would be minimal, that in fact a majority (94% or more) of prescriptions were managed by RNs and LPNs on site, who drafted orders for physicians to sign. With the implementation of CPOE, there was no noticeable change in prescriber workflow.

Pharmacy workflow was impacted negatively in several pharmacy chains studied. Despite current thinking, the vast majority of pharmacy chains stores in one of the pilot areas did not carry out true eprescribing. In this case the pharmacies had the capability but in reality reported that they generally printed out the prescriptions they received electronically and subsequently re-entered the data in their pharmacy system, introducing another potential opportunity for error.

One of the most important findings of the pilots was the high rate of surrogate-based eprescribing. Engaging surrogates around eprescribing appeared to be a remarkably winning strategy for driving practice adoption. If the surrogate-based workflow made sense for a practice at the beginning of an implementation, then it worked for a specific reason and tended to persist, exhibiting a long term sustainable change.

Implementation of eprescribing has the potential to dramatically change prescriber and pharmacy workflow, often with positive impacts, but some negative consequences may occur as well. Additional long term successful adoption and acceptance of eprescribing will require a commitment to upfront training and education of all key stakeholders in this prescribing process. The traditional prescribing process includes a number of data transactions both manual and automated among a number of entities. Striving for a streamlined, end-to-end interoperable flow of information in real-time requires careful coordination, collaboration, and ongoing education amongst these stakeholders. We’re at a turning point, yet not quite all the way were we need to be. CMS continues to have a critical role to play to ensure we reach our final destination. The result will be better patient care, improved efficiencies in both prescriber and pharmacy workflow and reduced cost of health care delivery and healthier Americans. A set of goals worthy of pursuing.

[1] Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme JF, Lloyd JF, Burke JP. A computer-assisted management program for antibiotics and other antiinfective agents. New England Journal of Medicine. 1998; 338(4):232-238.