E-prescribing: Preparing and Selecting
Steve Waldren, M.D., M.S.
10/7/2008

Slide: 1
Our first speaker is Dr. Steven Waldren. Dr. Waldren is the Director of the American Academy of Family Physicians, Center for Health Information Technology. He joined the American Academy of Family Physicians in 2004 and he is a co-founder of Open Health Data whose mission is to promote healthcare data reuse through the development and utilization of open source products and services. He co-chairs a host of communities including serving as Board Chair of the Center for Improving Medication Management as co-chair of the Ambulatory Functionality Working Group of CCHIT and co-chair of AQA Alliances Data Aggregation and HIT subcommittee. He is a board certified family physician and I would like to introduce Dr. Waldren. Good afternoon. We are going to keep the room a little cold because we are all talking about the potential of the postprandial sugar cutoff after the brownie.

Slide: 2
But, what I wanted to do is talk a little bit about the kind of preparation in the selection phase and then Dr. Allard will talk a little bit more about implementation and the real world experience at Henry Ford and then Dr. Teich will talk a little bit more about once you have actually getting the value out of it. So, again in the preparation thing, we will talk about some of the predictors of success. I will talk about some of the needs to assessment work that needs to be done, what ground work you start today when you go back to your practice or your organization tomorrow. What things you can start doing that day. I will talk a little bit about the selection; talk some about EHR versus stand alone e-Prescribing, talk about selection criteria and how to go through that process. And then wrap up, my section talking a little bit about some of the key points that we’ve learned working with our members, AAP as a membership organization of Family Physicians. We are also working through the Center for Improvement Medication Management doing studies on high prescribers and low prescribers relative to e-Prescribing and what were the success factors from that.

Slide: 3
But, I think one of this is very important in regards to change management in e-Prescribing is this is a cycle. This is something that you are not going to start and say “Okay, we are going to implement; we implemented; yeah, we are done.” This is something that we have to continue to maintain and keep going through the rest of the time at you delivering healthcare.

Slide: 4
When you look at preparation, there are some things that you can you do upfront that have shown to be leading to more successful implementations and utilization than not. I think one of the key things is a vision of being paperless. If you are thinking about having parallel systems and saying “we are going to implement this in one part of our clinic” or “we are going to only do this to doctors of high prescribers” or “we are going to do this for our chronic disease patients because they are on multiple meds and we can save some time there.” It really needs to be a blanket adoption across the practice and we have to go towards that vision of being paperless. We are hopeful that the DEA will get us a rule that allow us this structure to do with controlled substances as well. There has to be a commitment to the technology. What we found is that there are a lot of our physicians would sign up for the free e-Prescribing applications through the web by Allscripts called NEPSI.org and what we’ve find is that once they have come to one particular barrier, so it did not quite work right or the internet was down for a second while we return to see this patient, they gave up completely on it. So, there has to be a commitment and ability to go through the troubleshooting and that is as you move forward. Good office clinic communication is critical because this is going to be a team approach. It is not about automating the physician or automating the nurse, it is about automating the practice to do e-Prescribing. Just like any big project, you have to have a check and have to be clinician or business person in a practice that is the champion that needs kind of to go to person relative to the whole process. It is never too early, start doing some outreach to your pharmacies and your patients. Go to your pharmacies especially if you are in the rural area or urban area that has a lot of independence; try to figure out who are the top pharmacies that your patients are going to. Asking about e-Prescribing, so you guys are doing and watch your volume, we are going to move forward and what you have heard from the community with e-Prescribing and same thing with patients. Let them understand the value of e-Prescribing both from the convenience standpoint but also from the quality and safety standpoint.

Slide: 5
When we are talking about needs assessment, these are some of high level kind of questions that we talked to our members about all the time relative to HIT in general. So, what is the goal? Why are you adapting e-Prescribing? Is it to get the 2% incentive? Is it to increase your efficiency? Is it to increase the quality of care you deliver to your patients? Is it to save an FTE in regards to front office staff managing your frills? Is to decrease the load of the telephone calls that are coming to your office? So your patient can actually call when they need to make an appointment or have a real problem? What are those goals? You need have those and make sure the technology can fulfill those and make sure that you have some measure of were we successful or not? What are your technical constraints? So, do you have a place to store servers? Do you have places in the exam room that could put the computer in? Do you have internet connectivity in the exam rooms? Do you have some technical support locally, if you do need to put that in? What are your business constraints? How much can we spend? How much can we decrease our productivity to do training? Or as well on wrapping up to really get to utilize the system fully. What are the clinical constraints? Are the physicians in those prescribers on board? Some of those types of things you have to make sure that you ask those questions and become explicit and have that conversation. Just by going through those conversations, your ability to start setting up a team and really start thinking about from the practice, what you will find is people have certain expectations that are not the same. So, for an office staff who says, we just do not want to keep being on hold but the pharmacy to send the information and we do not want to keep calling back the patient. And the physicians are like it is going to be quick, it is going to be fast, it is going to be easy.

Slide: 6
So what are some of the things that you can do as part of the ground work? I think one of the important things you can do is start mapping what your current processes are for prescribing and renewals. Who gets the ball first? Who hands off the ball to whom? Who collects the data? Who documents in the chart? What is that entire process? Is that what you want in to be able to do is start looking at this e-Prescribing applications and see where they match, where they do not, how can you improve your current process? And without mapping those you have no idea how does it going to work? And how you are going to fed that because you are gonna find that at least in lot of our practices that even in small practices of five to ten doctors, part of the practice did it one way, and part of the practice did it other way, but with an EMR or with the e-Prescribing application you are going to need do it pretty much in one way. Discover what your processes, I mean you see your metrics are. So how many prescriptions are you writing? How many in a week? How many renewals are you coming? Renewals, how many are coming in by phone, how many are coming in by fax. You have to understand those that you know what your loads going to be and you can talk to your vendor about those and make sure that they can fulfill those, but also you want to know, alright how are we going be able to decrease certain things. So, beginning down telephone calls for example is one of your many goals of e-Prescribing getting the how many, you have coming in and know what you are actually get to once you put in the system. We talked about the documentation and the needs of assessment. We go those questions really need to write these things down. We are going to need to actually go through the process of saying alright, what are our goals? What do we need to write down? What does this system have to actually do? You need to write that down. Not only to get right buying, but also to get the vendor a listing of things that you need to get accomplished with the technology.

Slide: 7
When you are looking at the selection process, the first question a lot of our physicians talk about, should I go with the EMR or shall I do a stand alone? There is no right or wrong answer. It really depends where you at, it is just the pros and cons to each. When you are looking at electronic health records some of the pros and the fact that you have the patient record embedded in the EMR. So you if you are doing just a stand alone e-Prescribing application for many things you still going to pull the charts. You have the ability to automate you entire process; you get the either process gains or efficiencies from implementing the e-Prescribing first to the EMR. You also have the ability to participate in the quality incentives so there is a PQRI of 1.5% bonuses as well from CMS that do some of the quality initiative works. You can actually put those two together and get 3.5%. Some of the downsides of course cost the biggest one. A cost for an EMR somewhere around $30,000 to $50,000 per physician, you can get a lot cheaper than that, you get a lot more expensive than that. Complexity of implementation is gonna be a lot more complex implemented in the EMR than e-Prescribing stand-alone product and you have a lot more process change in your practice that you would by just doing the e-Prescribing.

Slide: 8
When we look at the standalone e-Prescribing applications some of the pros of course are going to be the opposite of the EMR cons. It is a lower cost than the EMR. It is less complex to implement, and there is a less impact of change in your practice. Some of the cons you are still going to have to pull the paper chart from many things. You really need to understand how much data you can put in e-Prescribing application. Some will let you put in problem list, some would even let you put in some lab data, so the more data you in the e-Prescribing application the less like you going to have pull the chart. It is like an automated one process so you are still going to figure out how can you make advances in other parts of your practice. It has the potential of delaying an implementation of the EHR. We found that some of our practice will use up their intellectual or financial capital to put in e-Prescribing application and they would delay there from actually going forward to a fully EMR. So you have to understand what your short term or long term goals are relative to the technology.

Slide: 9
When we are looking at the actual selection process. We talked a lot about the need to assessment. It is a hard work, it is going to be a boring work but it is something it has to be done to be successful. There is a lot of information out there, web searching. I would look to your medical societies and the AAFP has a lot of information. The AMA has a lot of information, ACP and AAP. We are also been working with several organizations on a get connected program. If you get to www.getrxconnected.com, they will actually walk you to the process of figuring out where at and what are your step for moving forward. So if you have EMR but you are even prescribing want to EMR’s supported, does your version supported if not who do you contact. Arc alpha is a national resource for HIT is a great resource. There is a lot of information from multiple resources all pulled together in integrated search. You want to find practices that are alike e-Prescribing. Search around though your state, medical society is your city states, city societies relative who is doing e-Prescribing in your neck in the woods. You want to get their experience and also see what vendors their using. Site visits are critical as part of the selection process. You need to come up with some type of matrix relative to ranking some of these vendors and we will talk about some of the functionality criteria. If you are a smaller practice, you may not want to go through the full rigors of an RFP process, but if you are a larger one, I would recommend that you go to that. There is a lot of resources and how to go through it, full RFP process. I think what your real goal is in the beginning is to narrow your list down to two to three vendors and then actually work with those vendors to make sure which out is the best one for you and also negotiate on price just because the retail price is not what you almost and like used cars salesman when here you can get the price down from many of these products and services.

Slide: 10
So when you are looking at creating that functionality matrix, functionality is important. How does it do new prescriptions? Does it do renewals? What is the work flow in my office? Can I have a nurse, for example write a script, and forward it to me, so I can sign off on it? Can I set up protocols that there is a person that can co-sign and order for me? Interoperability to make sure the SureScripts or RxHub are compatible, usability does it take 50 clicks or 20 clicks throughout or 10 clicks or 5 clicks or 2 clicks to do a new prescription or a renewal? Again, work flow is critical there. What is there track record? Support is a big one, ask them for a listing of about 20 or so practices that are using their product, call random number of those or random set of those, figure out saying what is your track record or support? Did you ever have an issue? If you did, how fast did they come back and actually solve your problem? Or did they ever?

Slide: 12
Some of the kind of key selling points I think are preparations, selection; the whole process is critical. We find a lot of our physicians would just jump forward into the selection. Dr. Smith down the road, he picked e-clinical works. Alright, I want go with e-clinical works and find out but it is not the right product and also find out that we did not do any either prep work. We did not think about, do we have all this demographic data? How do we get it in? Or we should ask for an interphase? So you got to see the products in the real world. Just a simple demo is not enough. The contract that you have with the vendors are the only thing that you are going to buy in them. So, relative to support, anything like that if they said, “Oh, the salesperson does a great thing and like that.” Only if it is in the contract, the only thing that you have to in a legal recourse. You have to make sure the solution meets the requirements for Medicare. Make sure it is the qualified system that has the safety checks. The decision support, it has formula. It has the connectivity and then check with local pharmacies to make sure they are accepting new scripts. You do not want to spend the money, energy, and time to go through this process and find out that 70% of your independence in your neighborhood do not do e-Prescribing. So all with that, go back to Julie.