Barriers to Provider Adoption of eRx: Lessons Learned from the NEO CMS eRx Pilot

Slide Presentation from the AHRQ 2008 Annual Conference

On September 8, 2008, Bob Elson, M.D., M.S.; John Kralewski, Ph.D.; and Dave Gans, M.S.H.A., F.A.C.M.P.E., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (7.4 MB; Plugin Software Help).

Slide 1

Barriers to Provider Adoption of eRx: Lessons Learned from the NEO CMS eRx Pilot

AHRQ National Meeting, Bethesda
September 8th, 2008

Bob Elson, MD, MS (MetroHealth)
John Kralewski, PhD (Universisty of Minnesota)
Dave Gans, MSHA, FACMPE (Medical Group Management Association [MGMA])

Slide 2

Photograph of a young lady out on the water with a view of the city in the background.

Slide 3

NEO eRx Project Participants

• University Hospitals (UH) Medical Practices + Ohio KePRO
• MGMA Center for Research
• Univ. of Minnesota Division of Health Services Research (HSR)
• InstantDx (OnCallData™)
• RxHub, SureScripts, NDC
• Aetna, Anthem, Medical Mutual of Ohio
• Partners (Bates/Seger)

...and the Centers for Medicare & Medicaid Services (CMS), AHRQ, and the other pilots.

Slide 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.

Slide 5

NEO eRX Project Timeline 2006

• Middle of February: 270/271 SCRIPT Formulary Med Hx.
• Middle of February to August: Planning, Tool Development, Practice Recruitment, and institutional review board (IRB).
• August through October: Site Visits.
• October through December: Health Plan Data Acquisition/Analysis; Med Hx (new), with training beginning in mid-September; and RxFill, with training beginning in mid-September.
• November through December: Prior Auth with training beginning in mid-October.

Slide 6

Provider Adoption of eRx

• Practice vs. provider adoption.
• Workflow realities.
• Role of practice culture.

Slide 7

University Hospitals Medical Practices (UHMP)

Screen shot of a colored map which shows counties in Ohio with UH Medical Practices.

Text below map:

• 285 physicians, 73 practices, 42 communities within Erie, Lorain, Cuyahoga, Medina, Summit, Lake, Geauga, Portage, Ashtabula, and Trumbull Counties.
• 46 primary care; 27 specialty
• 1.25 million office visits per year.

Slide 8

Small Practice Adoption: Magic Mix

You can lead a horse to water...

• 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.

Slide 9

Pre-Project eRx Adoption (All of UHMP)

"And make it drink (voluntarily) ...!"

Screen shot of a bar graph showing the total number of e-Rx per month from January 2005 to January 2006.

Data shown is:

January 2005: approximately 7,500
February: approximately 7,500
March: approximately 8,500
April: 10,000
May: approximately 14,500
June: approximately 14,500
July: approximately 14,500
August: approximately 17,500
September: approximately 19,000
October: approximately 24,000
November: 25,000
December: approximately 28,500
January 2006: approximately 32,000

Slide 10

Pre-Project eRx Adoption (By Practice)

Screen shot of a bar graph showing eRx numbers at UHMP Primary Care from January to August of 2005. The data is also displayed in tabular form.

Slide 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 8th Statement of Work (SOW).

Slide 12

eRx and Control Practices

Screen shot of bar graphs showing:

• Of 25 UHMP practices with access to eRx (130 MDs), 12 were small practices (1-3 doctors), 10 were medium practices (4-8 doctors), and 3 were large practices (9 or more doctors).
• Of 22 non eRx practices (100 MDs-Control Group), 14 were small practices (1-3 doctors), 6 were medium practices (4-8 doctors), and 2 were large practices (9 or more doctors).
• Of the 25 UHMP practices, loosely matched by size and specialty (separately), with access to eRx, 5 were family medicine, 14 were internal medicine, and 6 were pediatricians.
• Of the 22 non eRx practices (100 MDs-Control Group), loosely matched by size and specialty (separately), 10 were family medicine, 8 were internal medicine, and 4 were pediatricians.

Slide 13

e-Prescribing @ 25 Practices (2006)

Slide 14

eRx/Prescriber/Month (10/06 by practice)

Screen shot of a bar graph which shows that in October of 2006, 25 UHMP primary care practices, consisting of 130 physicians, used eRx as follows:

• Practice 1 (2 doctors) used eRx approximately 750 times.
• Practice 2 (4 doctors) used eRx approximately 525 times.
• Practice 3 (6 doctors) used eRx approximately 510 times.
• Practice 4 (6 doctors) used eRx approximately 510 times.
• Practice 5 (5 doctors) used eRx approximately 430 times.
• Practice 6 (3 doctors) used eRx approximately 390 times.
• Practice 7 (1 doctor) used eRx approximately 370 times.
• Practice 8 (3 doctors) used eRx approximately 280 times.
• Practice 9 (6 doctors) used eRx approximately 270 times.
• Practice 10 (1 doctor) used eRx approximately 230 times.
• Practice 11 (2 doctors) used eRx approximately 220 times.
• Practice 12 (13 doctors) used eRx approximately 210 times.
• Practice 13 (9 doctors) used eRx approximately 210 times.
• Practice 14 (5 doctors) used eRx approximately 200 times.
• Practice 15 (3 doctors/pediatric practice) used eRx approximately 200 times.
• Practice 16 (1 doctor) used eRx approximately 195 times.
• Practice 17 (11 doctors/pediatric practice) used eRx approximately 190 times.
• Practice 18 (5 doctors) used eRx approximately 180 times.
• Practice 19 (9 doctors/pediatric practice) used eRx approximately 180 times.
• Practice 20 (6 doctors) used eRx approximately 170 times.
• Practice 21 (4 doctors/pediatric practice) used eRx approximately 130 times.
• Practice 22 (2 doctors) used eRx approximately 110 times.
• Practice 23 (8 doctors/pediatric practice) used eRx approximately 95 times.
• Practice 24 (7 doctors) used eRx approximately 90 times.
• Practice 25 (8 doctors/pediatric practice) used eRx approximately 70 times.

Slide 15

Provider Adoption of eRx

• Practice vs. provider adoption.
• Workflow realities.
• Role of practice culture.

Slide 16

Surrogate-Based e-Prescribing

48,013 eRx in October (all UHMP).

• 16,715 entered directly by the doctors:
  • 15,724 NewRx (approximately 1000 Renew).
• 97 out of 219 e-prescribers did at least some data entry themselves:
  • 122 did none.

The bar graph shows that e-prescribing was used:

• 38% by physicians and 62% by others in family medicine.
• 18% by physicians and 82% by others in internal medicine.
• 43% by physicians and 57% by others in pediatrics.

Slide 17

Renewal Workflow Findings

• eRx decreases dependence on phone/fax:
  • Incoming Rx renewal requests from local pharmacies received by:
    
    

    Renewal Type	eRx	Control
    Phone	41%	62%
    Fax	25%	36%
    eRx	33%	0%

    
    
• 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.

Slide 18

eRx Impact on Call Types

Screen shot of two bar graphs measuring:

• Inbound/outbound ratio:
  • Inbound: 5.5 eRx; 4.1 Control
  • Outbound: 1.5 eRx; 3.6 Control
• Relative % of outbound calls going to the pharmacy:
  • 59.7% eRx; 75.7% Control

Slide 19

Practice Adoption Summary

eRx w/ advanced transactional capabilities can be rapidly adopted by small, community-based practices

• Payment Management System (PMS) integration, no license fee + small incentive.
• Large (>2/3) dependence on surrogates:
  • Implications for decision support and safety benefits unclear.
  • Policy guidance? Pay-for-Performance (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 electronic medical record (EMR) (?).

Slide 20

Provider Adoption of eRx

• Practice vs. provider adoption.
• Workflow realities.
• Role of practice culture (in provider adoption).

Slide 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)
  • Kralewski, JE et. al. Measuring the culture of medical group practices. Health Care Management Review 2005; 30:184-193.
• krale001@umn.edu

Slide 22

Medical Group Practice Culture Survey

The sample medical survey asks for opinions on a number of questions concerning the group practice. The responses are rated from 1 (Not at all) to 4 (To a great extent). Respondents are to circle the appropriate number for each question.

In our group practice:

1. There is a great deal of sharing of clinical information.
2. Our administrative decision-making process can be best described as top down when compared to bottom up consensus building approaches.
3. We are a data drive practice.
4. We can count on being treated fairly.
5. We easily adapt to changes in the field.
6. We value information technologies.
7. There is a close collegial relationship among the physicians.
8. There is an emphasis on physician individuality; each physician has the right to practice according to his/her own style.

Slide 23

Medical Group Practice Culture Survey (continued)

9. We are quick to adopt new techniques and practices.
10. We encourage internal discussion of patient care adverse events.
11. Our administrators are considered to be a very important part of our patient care team.
12. We view ourselves more as a business than as a community health center.
13. There is a strong sense of belonging to the group.
14. There is a high degree of organizational trust.
15. Bottom line considerations influence most of our decisions regarding what services to offer and how to provide them.
16. There is an identifiable practice style that we all try to adhere to.
17. There is a feeling that we are autonomous clinicians, but practicing in the same organization for support services.
18. There is an open discussion of clinical failures.

Slide 24

MGP Culture Survey: 8 Dimensions

• Collegiality.
• Quality emphasis.
• Management style.
• Cohesiveness.
• Organizational trust.
• Adaptive.
• Autonomy.
• Business.

Slide 25

Related to eRx Adoption?

• Physician age: Age in years.
• Physician gender: 1 = female, 2 = male.
• Physician specialty: 1 = family practice, 2 = general pediatrics, 3 = general internist.
• Practice size: Number of full-time-equivalent (FTE) physicians.
• Patient work load: Number of pt encounters for each physician per week.
• Practice complexity: 0 = single specialty, 1 = multispecialty.
• Practice culture: Mean score for practice on 1-4 scale, with 4 being more so (8 dimensions).
• Dependent variable: Proportion of total prescriptions written by each physician during a 2 month period that were sent electronically.

Slide 26

Hierarchical Model

*Significant at the 0.05 level;
** Significant at the 0.01 level

Slide 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