Slide Presentation from the AHRQ 2008 Annual Conference
On September 8, 2008, Michael A. Fischer, M.D., M.S., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (540 KB).
Slide 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
Slide 2
Research team
Co-authors:
- Ritu Agarwal, PhD, University of Maryland
- Corey Angst, PhD, Notre Dame
- Cate Desroches, PhD, Massachusetts General Hospital (MGH)
BCBSMA [Blue Cross Blue Shield of Massachusetts]:
- Megan Bell
- Adrienne Cyrulik, MPH
Tufts Health Plan:
Zix Corporation:
- Angus MacDonald
- Scott Plunkett
Slide 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.
Slide 4
Study setting
eRx Collaborative: Blue Cross Blue Shield of Massachusetts; Neighborhood Health Plan; Tufts Health Plan; DrFirst; Zix Corporation
- Initiated by BCBSMA and Tufts Health Plan.
- Partnered with ZixCorp, providing physicians with PocketScript system.
- Program began in early 2004.
Slide 5
Prior studies—erx adoption
Figure 2: E-prescribing rate by month
| Month |
Acute Medications |
All Medications |
| Month 1 |
25% |
15% |
| Month 2 |
26% |
15% |
| Month 3 |
27% |
16% |
| Month 4 |
30% |
18% |
| Month 5 |
32% |
19% |
| Month 6 |
34% |
20% |
| Month 7 |
35% |
21% |
| Month 8 |
35% |
20% |
| Month 9 |
36% |
22% |
| Month 10 |
39% |
24% |
| Month 11 |
40% |
25% |
| Month 12 |
42% |
26% |
Source: Fischer et al, JGIM 2008.
Slide 6
Prior studies—e-rx and costs
This graph shows the percent tier 1 by month relative to first e-prescription for Control prescribers; Intervention prescribers, non-e-prescriptions; and Intervention prescribers, e-prescriptions.
| Month |
Control prescribers |
Intervention prescribers,
e-prescriptions |
Intervention prescribers,
non-e-prescribers |
| Month -6 |
53.8% |
|
55% |
| Month -5 |
54% |
|
55.2% |
| Month -4 |
54.1% |
|
55.8% |
| Month -3 |
54.8% |
|
55.9% |
| Month -2 |
55% |
|
56.5% |
| Month -1 |
55.6% |
|
56.7% |
| Month 1 |
55.8% |
57.6% (began this month) |
61.8% |
| Month 2 |
56% |
58% |
61% |
| Month 3 |
56.5% |
59% |
61.8% |
| Month 4 |
56.7% |
58.9% |
61% |
| Month 5 |
57% |
58.9% |
61% |
| Month 6 |
57.2% |
58.9% |
60.2% |
| Month 7 |
57.3% |
59.2% |
61.4% |
| Month 8 |
57.5% |
59.6% |
62.5% |
| Month 9 |
57.7% |
60% |
62.3% |
| Month 10 |
57.8% |
60% |
61.9% |
| Month 11 |
57.8% |
61% |
63% |
Source: Fischer et al, Arch Int Med 2008, in press.
Slide 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)
Slide 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?
Slide 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 electronic medical record (EMR).
Interviews:
- Detailed discussions with prescribers.
Slide 10
Findings
- E-prescribing positives.
- Ongoing challenges/barriers.
Slide 11
E-prescribing positives
- Prescription security.
- Financial gain.
- Office efficiency.
- Medication safety.
- Insurance issues.
- Communication with pharmacy.
Slide 12
E-prescribing positives (continued)
Prescription security:
- Less people touch the actual prescription.
- Patients cannot lose the prescription.
- Patients cannot tamper with prescription.
Slide 13
E-prescribing positives (continued)
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.
Slide 14
E-prescribing positives (continued)
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.
Slide 15
E-prescribing positives (continued)
Medication:
- 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..."
Slide 16
E-prescribing positives (continued)
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.
Slide 17
E-prescribing positives (continued)
Communication with pharmacy:
- Timely flow of information.
- Ability to send specific messages.
- E.g.: "No more refills until patient sees doctor."
Slide 18
Ongoing challenges/barriers:
- Learning curve.
- Usability.
- Reliability.
- Safety concerns.
- Patient resistance.
- Data security.
Slide 19
Ongoing challenges/barriers (continued)
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.
Slide 20
Ongoing challenges/barriers (continued)
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.
Slide 21
Ongoing challenges/barriers (continued)
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.
Slide 22
Ongoing challenges/barriers (continued)
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.
Slide 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.
Slide 24
Summary observations (continued)
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.
Slide 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.
Current as of January 2009
Internet Citation:
E-prescribing in Community-Based Practices: Successes and Barriers. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090808slides/Fischer.htm
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