# Presentation: 822203

## Materials Developed in Consultation With:

- Jonathan Teich, M.D., Ph.D., Harvard University
- Kelly Cronin, M.P.H., Centers for Medicare & Medicaid Services, HHS
- James Bradley, M.S., M.B.A., Independent Consultant
- David Bates, M.D., M.Sc., Partners Healthcare
- Dana Haza, Office of the National Coordinator for Health Information Technology, HHS* *

- This briefing has been developed under the auspices of **Health Systems Research, Inc.** under a contract with the Office of the National Coordinator for Health IT, HHS

- November 29, 2005

## Scope and Boundaries – Problems with Paper

- Paper world: quick to write, BUT:
***Safety:*** Illegible, not checked for errors, not optimized for condition, needs multiple transcriptions, poor recordkeeping, poor transfer to other settings
***Costs  ***from callbacks for clarification, lost prescriptions, reprints, insurance problems
***Quality ***: “short list” of meds due to complexity; caregiver not aware of other drugs/conditions; non-compliance due to costs

## Scope and Boundaries – What is electronic prescribing (eRx)?

- “Electronic prescribing” or “Computerized prescribing” = all systems that use a computer to assist in creating a prescription
- Spectrum also includes:
- Clinical decision support
- 1-way and multi-way communication
- Integration with EHR and practice mgmt. systems

## Clinical Decision Support

- Safety-based
- Error checks, condition-based recommendations, disease management, compliance
- Reimbursement-based
- Formulary, alternatives
- Just-in-time information
- Relevant info for providers and patients

## Key Benefits: Quality and Cost

- Adverse drug events (ADE’s) in 5-18% of ambulatory pts/yr
- 77% of potential ADE’s preventable by eRx
- Nationwide “Ambulatory CPOE*” predicted to eliminate 2.1 million ADE’s/year (136,000 life-threatening), save $29B
- Comprehensive clinical decision support needed to realize full benefits

- *computerized provider order entry

**Notes:**
CGEY - Cap Gemini Ernst & Young 
BWH - Brigham and Women's Hospital
CITL – Center for Information Technology Leadership

## Environmental Scan 

- Only 10%-16% of US physicians use electronic Rx
- Increasing usage of and buzz about EHR’s providing context
- Complexity of Medicare Part D turning eyes to eRx
- Growing recognition of the impact of errors
- Katrina project focused attention on med history
- Costs of technology continuing downward
- Stark and anti-kickback relief proposals hopeful
- Pilots in several states: MI, FL, RI, MA...

## Environmental Scan (cont.)

- Lack of credible ROI for system purchase
- Caregivers skeptical of benefit claims due to mixed messages
- Successes not well publicized
- Some, but not all, eRx combined or combinable with EHR
- Continued competition between Pharmacies and PBM’s

## Major Barriers 

- Physician resistance to change
- Financial – inadequate business model! Misalignment of incentives
- Most eRx communications still fax; some pharmacies unwilling/unready for eRx
- Some systems complex and slow
- Cost of buying and installing
- Not standard of care
- Controversy over security requirements for prescribing controlled substances

## Barriers: Lack of Standards

- “Doctor-friendly” drug dictionary (RxNorm)
- Its lack hampers basic interoperability among systems, medication reconciliation, and clinical decision support
- Formulary conventions and plan identifier
- Without these, MD’s cannot easily stick to formularies using eRx
- Common Rx spec for states
- Its lack raises cost of systems and hampers electronic communication

**Notes:**
Although Script is good...

## Potential Implementation and Acceleration Opportunities

**1. Complete development of certification   criteria and process specifically for eRx **
- Specific attention to: decision support/clinical value, EHR migration and interoperability, usability, connectivity
- Possible approach: Expert panel including key stakeholders present recommendations to Certification Commission

## Potential Implementation and Acceleration Opportunities

**2. Develop a national resource repository for executable medication-related decision support for use by vendors/providers**
- Possible approach: public/private collaborative initiate a pilot project in 2006
- Initial discussions Oct. 2005 could provide basis

## Potential Implementation and Acceleration Opportunities

**3. Finish and enforce key standards, and include in certification **
- Specific attention to: RxNorm; Formulary information; Payer/plan ID; Differing state board of pharmacy regulations
- Possible approach: Expert group including key stakeholders to resolve

## Potential Implementation and Acceleration Opportunities

**4. Tie financial support to certified systems**
- Stark exceptions and pay-for-performance requirements for certified eRx/EHR systems
- Possible approaches:
- Finalize Stark and anti-kickback regulations with certified eRx and EHR exception
- Payers accept data on performance from certified EHR’s for pay for performance initiatives