Implementing ePrescribing: Infrastructure
Ken Majkowski, Pharm.D.
10/7/2008

Slide: 1
It is really a pleasure to be here today. I feel very honored to have been asked as a speaker. You’ve heard earlier from Kerry Weems how CMS put this whole thing together in six weeks. I got called about two weeks ago. David and I had the opportunity to get on a phone call last Monday and David Bates was out of the country and we didn’t talk about what we are all going to do here today until about 15 minutes ago. So we hope we are going to put together an enjoyable opportunity for you today. I actually have a relatively short message and then I am going to get out of the way for the people who are here to really tell you what happens in the community and on the mainstream. And I’m going to talk to you, the key message that you wanted to get out from me is there is an infrastructure in place and because of that infrastructure in place e-prescribing and connectivity between payers and physicians, between physicians and pharmacies can take place because of the infrastructure, and I am going to explain that a little bit to you and show you a little bit what that looks like.

Slide: 2
I think the first thing I wanted to do though is make sure I define electronic prescribing because the easy thought of our electronic prescribing is that transmission of the prescription from the physician to the pharmacies electronically. I will touch on that in a second, but what I want to do is expand on that definition that it meets the CMS Guidelines after the CMS e-prescribing pilots, that e-prescribing is actually getting physicians support information to the physician in the point of care. Getting formulary and benefit information and medication history at the point of care seamlessly in their work flow through the very vendors. You see if the vendor show here today that allows the physician during the prescribing process, during the interface with the patient to hopefully write the most medically appropriate and economically appropriate prescription the first time. If you were in the last session, this is what Don Hunter would have called a clean prescription. Okay, one that does not require rework, and now that that has taken place at the point of care, now the patient can decide where they want that prescription sent. They can send that to the pharmacy of their choice whether that will be a retail pharmacy, a chain store pharmacy, they are local independent or they are mail order pharmacy because that is what they have in their benefit. And then the transmission of that prescription is electronic and what I mean by electronic is that if ETI back end the physician technology system to back end over the pharmacy technology system, so that data does not have to be re-entered by anyone. It is not electronic faxed, it is not electronic to a printer; so it is printed and has to be re-entered into that pharmacy system. It is end to end, last mile transmission of a prescription through the whole system. I think that is important because that is what we are talking about when we are talking about electronic prescribing. Most of you know that about a hundred days ago, SureScripts and RxHub merged. I think it’s important for you to understand what that means. What I have; I have been with the RxHub legacy side of the business. It is going to be seven years this January and I have the opportunity to work with the SureScripts people over the years and a number of initiatives around the country, and we work well together. And now that we are merged, what is very interesting is that philosophically we are really the same in many many cases.

Slide: 3
Our core principles, these core principles both came; this took about the first three minutes of the merger to put together because we truly believe this. We are both based on industry standards and we implement to and hold fast to industry standards. We do not charge physicians or software vendors for the transactions. The payers pay the cost of getting the decision support transactions to the physician technology vendors at no cost and the pharmacies pay for the cost of resending electronic prescriptions. So for physicians and software vendors, there is no charge. We preserve the patient’s choice of pharmacies whether it is mail or retail. Both of us have from the beginning and we will continue in the future. We preserve the physician choice of therapy. Yes, we are going to recommend formulary, we are going to show co-pay information, benefit information but at the end of the day that physician can prescribe whatever they want to prescribe on all of the applications that we have certified. We do not allow advertising or commercial influence. We do not do data mining, in fact the legacy at RxHub the only database we have is a master person index and all the information we get about a patient is federated. It goes back to the source once we find were the patient has the benefits. We require patient consent to access their medication history. If in the NCPDP transaction, there is the consent flag, there are medication reconciliation basis. We require an ADT, which mean for the patient has been admitted to a hospital with both consent, as well as HIPAA notification or their security privacy rights. And we won’t do anything without patient consent. And we continue to operate it as a low cost utility. We were wearing LLC, both of us are. We are chartered to be in cost recovery, and so where we are with our prices to our prayers and for pharmacies today. Our goal overtime as we start to reach break even and both of us are closed and as an entity we are closed. Overtime, we will be continuing to become utility that lowers the cost of our services to the industry as time goes on.

Slide: 4
The merger speeds the transition to paperless e-prescribing. We were going to be working on a more comprehensive medication information that provides information from both pharmacies as well as from claim to databases. We are going to expand access to benefit information to save the patient’s money and ensure the clean prescriptions that are sent to pharmacy for the first time with little re-work and streamline the process for all of our technology partners to integrate with us. Our SureScripts RxHub work group that starting in St. Paul this afternoon and going to Thursday were introducing a single draft script 10.5 implementation manual for one implementation for both entities RxHub and SureScripts.

Slide: 5
Infrastructure of e-prescribing includes logos of all those involved

And when I talk about infrastructure, I do not want to be so presumptuous and think that SureScripts-RxHub infrastructure for e-prescribing is much, much, much more. The players are enormous, the moving parts are huge. There are all the stakeholders and include the patient’s, the payers, the physicians, and the pharmacist and more importantly all the technology systems that each of those stakeholders use to connect to us so that we can connect to payers to get information at the point of care. It includes the certification organizations like CCHIT and EHNAC or both EHNAC certified. It includes the standards organizations whether BMCPDPH07X12, we participate in all. And it also includes all those industry leaders who create opportunities like CMS and this particular session like the CMS initiatives like the payers who like North Carolina, Rhode Island, Horizon e-prescribe Florida. Blue Cross and Blue Shield of North Carolina and Illinois all who are providing additional incentives for physicians, Southeast Michigan, Ford, Chrysler, GM. If those are that is what the ePrescribing infrastructure really looks like and I’m here to tell you it is in place and it works.

Slide: 6
Surescripts/RxHub’s flow of information – how it works

Let me tell you how it works from a workflow point of view first. When a patient sees a physician, the technology vendor in the physician’s office transacts with us maybe the morning before middle of the night, we collect basic demographic information and we look up that patient in our master person index with about 200 million people in it. If we find the patient we send that transaction to the payer and the payer creates an eligibility response and then forwards that back through the RxHub SureScripts infrastructure back to the technology vendor. The technology vendor can now create a medication history request that goes back to the payer and medication history could be delivered back to the technology vendor and when that technology vendor in that position want to generate a prescription, that prescription is generated in the technology application and forward it through RxHub SureScripts network to the pharmacy of the patient’s choice, so all these takes place in work flow and through the infrastructure that exist today.

Slide: 7
What does this mean for the stakeholders? The government report, the government group did a report for the PCMA last summer, looking at the impact of e-prescribing and cost and efficiency and basically found that 70% of the cost and efficiency in e-prescribing is seen on the front end when we can get clean information and patient specific information in the hands of the physicians at the point of care and when we can do that and then they can send that electronically then the efficiency is multiplied.

Slide: 8
August 2008 Map of the US regarding penetration of Surescripts/RxHub

It gives you an idea of what our Master Person Index Coverage across the United States looks. I am going to tell you in the next six to eight weeks it is going to get darker because we have as many pairs in implementation right now as we have technology vendors, as things are getting close for the April 1, 2009 implementation of the standards for Medicare part D. You can see that in 39 states, we have a critical mass of greater than 50% of the individuals who lived in that state throughout United States. And where we have critical masses where you see a lot of the e-prescribing initiatives.

Slide: 9
Workflow of information of Surescripts

How does this look from a transaction workflow? The payers have formulary. It is in a lot of formulary files. We are connected to about 20 payers and we distribute those formulary files to the applications so that they have the resident under applications when they want to access them.

Slide: 10
Transaction workflow – how it works

Again, when the patient comes in backup, the PBMs then send us a membership load of all their members and every night send us any changes that we adds. Our master person index looks like our payers membership files almost exactly, and we’ve done a lot to look at that. So now we know where the patient has their benefit. When they come in, they send us an eligibility transaction an X12 270, that has a demographic information that allows us to locate a patient in our Master Person Index, when we find that patient, we forward that eligibility transaction to the payer. In 12% to 15% of the time, patients have multiple coverages, so we send more than one PBM. They get us an X12 271 response, if it is more from more than one payer. We aggregate that and then send that back to the clinician and their technology vendors so it is resident to point of care. If they want a medication history, they can make those medication history requests. They have to set a consent flag in order to do that. If they have patient consent or following local state federal laws as it relates to where they are practicing, and then we pass through that medication history to the payer. We query the claims databases at the payers and get up for one year’s medication history from the claims databases, and then send those back to the technology vendors, so that information again is a resident at the point of care.

Slide: 11
Map of US - Penetration of e-prescribing

Now we’ve got the physician who has formulary medication history and all the information to make sure they need to write a prescription and now it is time to write a prescription. And this gives you the status of the top 10 states across the United States where the states end up being for e-prescribing. As we heard from the governor’s this morning Massachusetts is number one, Rhode Island is number two, Rhode Island was number one a couple of years ago and is striving to do that again. Not far behind our places like Michigan, Nevada, and Arizona. All places were e-prescribing initiatives are taking place.

Slide: 12
E-Prescribing routing – the SureScripts/RxHub transaction workflow

The transaction workflow for pharmacy is very similar. The physician writes the prescription but before prescriptions are written by the physician, we have to know who is connected. So pharmacies tell us what pharmacies are connected, physicians tell us or physician application companies tell us which physicians are connected, and we trade that information so that Walgreens knows who they can send or refill renewal to and all scripts know who they can send an electronic prescription to. So they have those provider updates as to who is electronically connected. Now when they write the prescription, they use the script standard, they send it through the infrastructure, and we send it on to the pharmacy. The pharmacy creates a status that they’ve received the prescription and we send a status back to the application. This is a second or so second, second and a half transaction. This happen real time. When the pharmacy wants to have a renewal request, they send the renewal request. It is received in the clinician’s office and they all handle it under different workflow. If you heard David talk earlier in the other session, sometimes they get them as quick as 20 minutes, sometimes physicians wait till the end of the day or the next day, it all depends on the physician workflow. And when they fill that out, they send a renewal response back to the pharmacy electronically.

Slide: 13
E-prescribing routing – workflow description

Again, if you have heard Gary talking the last, there is also other transactions that are taking place like the cancel transaction and response but more importantly, some transactions that fit into long term care. Like the census transaction and the refill and long term care re-supply transaction, these are all going to be part of the 10.5 scripts. There are a number of transactions in that electronic transaction step.

Slide: 14
Just to finish up here, I will give you a little progress report. At the end of 2008, we will have 200 million plus names in our Master Person Index. Mainly commercial names, okay, but we are starting to get additional Medicaid to sign up and additional Medicaid, initiatives, New Hampshire’s signed up, we’ve got some lives in New Mexico, in California, in Missouri, working with Delaware, Arkansas, Indiana, and others to get Medicaid involved. We will receive about 70 million eligibility requests this year that relates to a 70 million patient visits across the United States that should be 7%. There are about a billion patient visits in the United States who is about 7% there. We will have about 85,000 physicians connected to e-prescribe. In the last two months, 8,000 physicians have been enrolled into the SureScript’s network for e-prescribing. We will have 45,000 pharmacies connected. More than that certified but connected. Most of these are receiving electronic prescriptions but in some cases, it is relatively low. You have heard about workflow issues, as this gets more into workflow, it is going to increase the ability of the pharmacies to handle this. Remember when a physician’s office decides to go electronic, the whole office goes electronic, a pharmacy never goes all electronic. They are always going to have electronic prescriptions, fax prescriptions, e-faxes, walk-ins, and printed prescriptions whatever. They will never go over in 24-hour period like physicians’ office. So pharmacies are saddled with having those multiple workflows because of how they have received prescriptions. We will have six of the top 10 mail order pharmacies connected and we are going to approach 100 million e-prescriptions, again, about 6% or 7% of the prescriptions that can be transmitted electronically by the end of the year and these are large growth numbers for both of our enterprises over the last year.

Slide: 15
A couple of things we need to do. We need the DEA to allow e-prescribing, you have heard about that. The NTRM came out. We have commented and now we’ve got a way to see what happens. Technology vendors need to convert users from fax to e-prescribing as a standard part of e-prescribing and health plans see to follow CMS as leading and creating incentives and we are starting to see that as well.

Slide: 16
You can go to our website for additional resources that can help you again a point to the electronic health initiative and the center for medication managements. A white paper that came out this morning, released this morning specifically on a clinician’s guide to e-prescribing and what steps they need to take to implement it. It has been my pleasure to talk to you today. I appreciate, we are going to take questions at the end of our discussion and I am looking forward to any questions you might have. At this point, I would like to turn this over to David Feeney. Thank you.