E-prescribing value for patients: promises, proof, pitfalls
Michael Fischer, M.D., M.S.
10/7/2008

Slide: 1
Okay thanks very much. What I am going to talk about today is giving an overview of some of the topics that have been touched both by Paul and Devin here and also did have come up in some of the general sessions. The way I organized this in terms of promises, prove, and pitfalls, they all sound alike, but we could think about it as much as what we think and what we know and what we still need to do. A lot has been said especially in the general session about e-prescribing will save lives, e-prescribing will improve safety, and there is some conflicting era of what we think it can do and what we have evidence about so far. So….

Slide: 2
What I am going to start with a little bit is the promise specifically focusing on the benefit for patients, although I touch a little bit on benefits for physicians, for pharmacists, and for others in the system what we think the systems can do and then try to bring us back to the ground in terms what is the evidence today, what do we know of both quantitatively in terms of measurable outcomes and qualitatively from experiences with using the system. Then talk about the remaining barriers that the pitfalls. What are some of the problems with the current systems to get in the way of them being as effective as they might be of being as adopted as widely as they might be and make some suggestions that I have started addressing that. Some of those elements were covered in the earlier times.

Slide: 3
So, I am going to focus on the safety of drugs, the efficiency of prescribing processes and the cost of medications in terms of the pharmacist to proving the pitfalls and then talk a bit more about the barriers to adoption and use of e-prescribing.

Slide: 4
I will start by giving away the punch line in case for any recent attention wonders over the next few minutes. You will know where I am going to be leading you. So, hopefully we all by virtue of being at this conference agree on some level that e-prescribing has the potential to improve patient’s safety, to increase the quality and efficiency of prescribing. What I am going to spend some time on is going over the evidence whether these gains can be achieved in the outpatient setting and with current systems, we are really still developing that and that still a lot of that still remains to be shown or is in the process of being shown. I do conclude the barriers to full adoption are going to need to be addressed aggressively to really deliver on the promise that we all think is there.

Slide: 5
So let's start with increasing safety which I am going to spend the most time on. So, I think that is really where patients in the general public seeking the largest value and the first one and I was open with the legibility problems. Could you count on any sort of general audience setting like the opening one this morning that someone is going to talk about doctor handwriting and lot of people made some comments and jokes about doctor handwriting this morning and I am going to think that the joke like that is funny because it is true, I mean it is a problem and it is addressed by having the prescription names to be typewritten or chosen, but that only takes us so far. On a more detailed level, Kat Hutchinson mentioned the idea that e-prescribing can reduce adverse drug events by 25%. What he was referring to there is the study from the Center for Information Technology and Leadership and that was really focused on better information at the point of prescribing. How do you get that 25% reduction. You get up by not having allergic reactions because the data on the patients’ allergies are there and they are not accurate. You get it because you know what other drugs the patient is on so you can avoid drug interaction when you are choosing a new drug. In general, that point of prescribing in spoken lead to more safe medication use whether by guiding doctors to the right dose, the right frequency of the drug, adjusting the dose for a patient’s age or other medical conditions. All of those are potential benefits.

Slide: 6
What is the proof in terms of increasing safety? There is a lot of proof but it is mostly enclosed inpatient settings. So with computerized drug interaction with e-prescribing in for hospitalized patients which is in summary if you will more like a laboratory than the real world without patient community-based medicine. But the evidence there is really terrific in compelling and I think that the proof of concept is that all I am excited about this, so David Bates was speaking in another session today, has done really important work over the Brigham about the ability of electronic prescribing for inpatients to reduce the kinds of various drug and drug interactions, allergy problems, and so on. And then when you have that all the information and you have an enclosed system, you can provide some of that detailed point of prescribing information, so for example, there have been studies using electronic prescribing for inpatients to improve antibiotic management, to make doses of drug safer for elderly patients. We have got some work at our hospital guiding doctors through the use of drugs for patients with severe septic shot, very ill patient population high risk of adverse events and these are, as I say, very encouraging but in the inpatient setting. In the outpatient setting, we are relying mostly on qualitative data and it touches on a lot of the points that have been brought up both in the general sessions and touched down a little bit in this session as well. We have heard qualitatively a lot of clinicians to feel there is a lot of benefit from being able to review the medication history, to know what other drugs the patient has tried in the past, what drugs they are on at the present time. Also we have heard about safety gains from identifying patients on high risk drugs, for example, I was doing a focus group earlier this spring with clinicians here in Massachusetts and we are taking with the practice manager who referred to the warnings that came out from the FDA about the Avandia as people may remember the diabetes drug where there were concerns about cardiovascular toxicity. They talked about the ability in their practice to rapidly identify all the patients who are on Avandia and get information out to them but you may want it and the drug was still in the market but you may want to talk about how you are using it whether you are having problems. Something they could have done with the paper system would have been just too cumbersome in terms of person time. And, obviously, the ability to avoid tampering with the prescriptions.

Slide: 7
But, there are some pitfalls to this as I implied in the earlier slide, we don’t have quantitative outpatient data yet. In fact, some people have tried to quantify this effect in the outpatient setting. It has been hard to document. ... and colleagues looked at e-prescribing that was done by a group of outpatient practices affiliated with a large hospital and found that although e-prescribing was being done, they could measure an actual reduction in actual medication errors. Why do we see something like that or it may be that the alerts that are been given, the safety warnings that are being given to doctors at this point in the outpatient setting are not exactly what they need and another study found that over 90% of the alerts that appear to prescribers were overwritten or dismissed, prescribers just moved on to write the prescription. There is a real kind of signal to know each problem and there that many warnings being dismissed and in addition to that limitation of the safety systems we have, there have been concerns raised by users of some other systems that new errors that may come as people are trying to use different kinds of interfaces. The ability to select a wrong patients, some of the common name, John Smith and to get to a drop down among John Smith, so you are picking the right one. As opposed to sound alike drug which is often a problem with verbal orders from calling things and a problem with us or spell alike drugs, if first three letters are the same, you get to your drop down menu or your fill in text, it is easy to choose the wrong drug and fire that off to the pharmacy not realize what you have done. Pediatricians have struggled with the problem that they write a lot of weight based doses use different formulation of drugs that may not be in the e-prescribing systems that creates frustration for them and either merely to an unclear prescription or on the other hand may lead to number from e-prescribing for some of their use.

Slide: 8
So the really important challenge is if we are going to deliver on the safety promise of e-prescribing for outpatient. As a first step, I think we need to may be a little biased and the researcher may think that defining and measuring is the most critical thing but I would say that we need to define what the real safety gains are, so that everybody knows what they are getting with these systems. As opposed to efficiency, you know, with the legibility problems before, what you might see instead when a patient showed up at a pharmacy with an eligible prescription, the pharmacist would not necessarily pick a drug at random, they would probably call back to the doctors’ office, which means now you have a patient standing around wasting their time. You have a pharmacist distracted and taking up their time if the doctor’s staff and the doctor all interrupting what they are doing, usually we do not know this quantitatively probably the right prescription was dispensed in yet. It is an incredibly inefficient way to do things. Will e-prescribing get around a lot of that mess, that terrific that a real gain but is there a real safety gain. We need to define what is there so people know what they are getting. One of the ways you can do that is by making the alert more targeted to what the information that doctors need, so there has been some initial research trying to do things to calm down the alert to eliminate some of the very common alerts that may not actually be clinically relevant and just a little bit of messaging that the doctors need at that moment and when that happens, the except rates starts to go up. Doctors do not dismiss so many of the alerts. To make all of that work though, we need as a Paul was getting a very important in terms of standards, there needs to be a data infrastructure they are the support safety. You need to connect other systems so that the information on things like allergies, medication history is accurate and up-to-date, linking that EMR, hospitals records, and so on because for a lot of small practices if that data infrastructure is not there, the system only works, for example in great drug allergy alert, in an e-prescribing system only works if all the patient allergies are in there and if you do not have that good connectivity someone in the office has to sit and enter all those allergies and most busy primary care practices do not have that kind of person time sitting around with nothing to do ready to enter thousands of patients’ allergies in to a system.

Slide: 9
Efficiency, I am going to spend a little bit less time on the promise that it is clear from the anecdote, I was just giving about the eligible prescription in the call backs. But the thing is that is not an isolated event. There is a study by A. J. Jess in 2004 that estimated that there are 1 billion such calls per year that is a tremendous amount of wasted time for all of the people I mentioned there but there are also secondary problems you get with that. With patients beside they are wasting time if there is a problem, they are standing there. It is unclear if they are going to get a reply and what the prescription is that day, they may walk away. They may not end up taking the drug if their doctor would like them to take. Pharmacist obviously says that they are wasting their time. They are distracted from doing the dispensing and more importantly the counseling that would like them to be doing with patients and prescribers of course are being pulled out if rooms are interrupted. Their interaction with other patients are not going be as productive and narrow gauge is going to be less efficient and it has been shown in time motion studies that there are inefficient processes throughout the system in the way the most factors do things down. From the patient and the doctor when they are writing the prescription to getting in to pharmacy to filling it and then coming back for refills of those. But, there is a lot of promise to make things better to address those inefficiencies with e-prescribing.

Slide: 10
Well the proof today this is still mostly qualitative, although it is very striking what you hear a lot of practices in patients talk about the ability to ... lost prescriptions and the patients not relied on to keep track of that peace of paper. If for some reasons something is not transmitted, the patient decide to switch pharmacies, you can be just be transmitted. The reduced call back to the office is in pharmacies are real game for all of those practitioners but also for patients and their doctors on an as distracted during visits, they can get the drugs they need right away with the pharmacy. The ability to prove prescribing tabs also allows offices to do things like refills, renewals, seasonal medications that patients may need calling for once a year. If that all those up and get those addressed very quickly so the patients can get the drugs they need more rapidly and they are no waiting a long time for what they want.

Slide: 11
But there are definitely challenges. We do not have quantitative data yet and so for provider because we really need practices to adopt e-prescribing and make this happen, it is not clear to them there is a return on investment that they are really saving time and therefore money or able to see more patient and that is a big hurdle. Connectivity and reliability problems are a really big problem, both from the patient and from the provider point of view. We have heard qualitatively a lot of stories especially among early adopters, although problem with prescriptions getting through. One example I have heard in couple of different settings is a smaller community based settings, worse likely that the medical office building in a small community is right near the pharmacy in that small community, so the doctor sends the e-prescription and the patients at the pharmacy 5 minutes later and if there is high traffic in the system if the pharmacist is busy and may be things haven’t come down yet. There is nothing there and as opposed to a paper prescription where the patient has something in their hand, nobody knows anything. The patient is walking back to the doctor’s office. The power of the negative anecdote is really striking that these kinds of episodes even if there are other efficiency gains happening the people don’t appreciate, it has really been a barrier to getting the people to be fully accepting of e-prescribing as it is. Similarly the problem with reliability, a lot of doctor says consistently that when they are seeing patients on weekends or late in the evening, they are about to close the office, don’t give the patient a paper prescription instead of sending in electronically but are still worried that it won’t go thorough and then if the patient at the pharmacy calls back, the office will be closed and someone else might be covering and that I think speaks volumes to what we expect in terms of the reliability, in terms of it really being a 100% and where that reliability is right now which certainly falls short of that. I will see people at working hard to address that but that is a big barrier for providers of patients. Paul mentioned some of the problem with the inability to prescribe scheduled two medications because of controlled substances, the need to print some or write some and it can e-prescribe others that creates the sort of inefficiency in the parallel system which isn’t optimal. That in fact is also the case with some mail-away prescriptions that the patients wanted to sent to their PBMs, some PBMs since and e-prescription systems can interact but a lot of them can’t and so, physicians need to print some prescriptions for them to mail-away, some for them to take to the pharmacy, some to send to the pharmacy that creates a fragmentation that really diminishes the efficiency of the systems.

Slide: 12
Now in terms of controlling cost, the lasted three areas I want to cover for promises-proven pitfalls. The promise of using medications causes a thing that has been widely counted. We spent the lot of drugs that could be avoided from simple things like using generic versions of medication that you gone on path, so a chemically identical substitute. As well as things like therapeutic substitution for example for patient with hypertension using a drug like a thiazide diuretic and an expensive generically available drug instead of some of the more expensive alternatives. In addition to that though there are gains beyond the simple cost of that first prescription, we could patient who get medications of lower co-payment have they demonstrated to be more likely to come back and refill that medications. I pay less the first time, there is less of a barrier than coming back and paying for the second and third time and if you want patients to stay on their medications which has speak as a primary care doctor, I usually do when I put some on medication for some like hypertension or diabetes. I like that idea that they are more likely to come back and refill their meds and they will keep realizing those savings each time they refill it and pay a lower co-payment.

Slide: 13
The proof to that is starting to emerge, we have done some more of a study in the ERX collaborative here in Massachusetts where couple of large insurance companies and colleagues in the back of the room helped me get these data. Some of the large insurance companies are worked with e-prescribing vendors to put accurate formulary information they are right at the point of prescribing. It is important to keep in mind this is a study that was in Massachusetts where there is already a very high rate of generic drug use. A mandatory generic substitution by the pharmacist even so there was a 3.3% increase in generic drugs bill when doctors were using e-prescribing and that represents a real game for patients in terms of reduced co-payments also again obviously for insurers in this case and for the system generally for whosoever is paying for the prescription drugs. Beyond those quantitative gains, doctors also appreciate the ability to discuss cost with patients when there is accurate formulary information there that if the patient says I really want drug A and you can see that that comes up in your system with a little red flag you can say to them that you know it is going to have a high co-payment when you get to the pharmacy and if they ask what else could I take, you can look and see here is a couple of options and if you feel they are clinically equivalent, you can suggest that to the patient and that ability to discuss cost, the doctor’s perception is certainly is more satisfactory encounter and we would like to think it that way for the patients as well and similarly the safety example I gave with Avandia, there is again the ability to identify patients on costly meds, for example practices and talked about generic Simvastatin, generic Zocor one of the more widely used cholesterol lowering medication that became available. Some of the practices have been sent in for generic prescribing but we are able to quickly identify all the patients who might be eligible to switch to a generic at that point and identify them not the doctors who are doing that for their reasons but there is a real gain to the patient as well there in terms of potential savings if they choose to make that switch.

Slide: 14
There are definitely challenges here though and again it goes back the formulary standard which is targeted for 2012, so that is still away it is on. The data needed to be current and accurate to affect decisions. Doctors won’t have faith in the system if they give some what they think is an affordable drug and patient gets there and finds out he has got a high co-payment. One of the important things in our study is when there is variable use of e-prescribing, doctors will e-prescribe some of the time and then stop those affect that we found the increased generics went away, almost right away which is not that surprising really as positive, no doctor can memorize all the formularies of all the different insurers, so the information needs to be in front of the doctors at the moment who is prescribing and accurate in order for having an impact and their connectivity and the standards are not quite there yet, so that is a remaining challenge for us.

Slide: 15
In addition to the barriers that I mentioned in the pitfalls, there are a couple of other structural barriers that we have heard some things about today. We know that the doctor remains slow when you get outside places like Massachusetts and Rhode Island. One of the big barriers is cost. We heard a couple of questions from physicians. I had the first session this morning asking secretary Levin about some of the cost concerns that they have not clearly a barrier as well as the learning curve for practices that are facing challenges in terms of maintaining their productivities so that they can stay on business. As well as the learning curve for the practices that are facing challenges in terms of maintaining the productivities so that can stay in business, they can hit the productivity while learning about the technology is a big issue. Usability and reliability are major challenges even when practices are dart to getting them to be active users of e-prescribing and to use it for all of their prescriptions. If the systems are not going to work as we talked about, they need to be interoperable, they need to communicate with the other systems and that connectivity needs to be reliable and always there. There is also interestingly an inspection in light of the data that Paul presented, there is a perception from doctors and nurses that older patients are much more comfortable leaving the office with a PC paper in their hand and so a perceived from the physicians resistance of patients e-prescribing their contact which is likely somewhat Paul’s presented so important and I hope that gets out there more and can help convince physicians that there is a desire out there from patients to have e-prescribing and the data security concerns are clearly there but I think ... those in wonderful detail.

Slide: 16
So how do we overcome the barriers and enter to realize the case to get the gains to the patient or the thing is that there may be gains along the gains I have talked about for patients, e-prescribing is taken up at the practice level as the practice is they doing, so it needs to be made positive for practices and that is especially the case for smaller practices for whom the cost concerns doing large but also concerns about technical support if you are a small practice 45 miles away from your major metropolitan area, what is going to happen when you are e-prescribing system goes down, are you just out of luck for a day or two until someone can get out there, that is a big risk for practices to take on, so they need to know that the support is there that the system will be interoperable. If we can use studies like Paul’s in his groups to get to straight as patient preference, that something they can really move prescribers to feel that there is something in for them if they know their patient wanted as opposed to some day government banned it with all the respect to CMS, that is really what physicians are going to feel motivated about in their day-to-day interactions with patients if we can ensure the reliability and security of these systems, that will be a long way for patients in practices feel comfortable in taking it up.

Slide: 17
So the key points that I warned you were we are going to wrap up with before, I think that we agree about the potential of e-prescribing to improve patient safety and increase the quality and efficiency of e-prescribing. There is preliminary evidence that some of these aims can be achieved in the outpatient setting but with current system, I have to say lot of that evidences still being developed and would not all the way there yet and if we are going to be able to deliver on the promise of e-prescribing, we need to aggressively address these barriers so that we can have systems to deliver on that promise and that everyone try to fully ready to adopt, and then we can really see some value for patients out of these systems. So I think that we will stop there and open it up to some questions. Thank you very much. If you have a question we'd ask that you raise your hand because the session is being recorded for playback on the conference website. So my colleague, Rick Hoover, is going to walk around with the mic, so please just raise your hand if you have questions.Hi, Steve Redhead from Congressional Research Service in Washington, a comment on the question, the congressional budget of this I think is scoring the new medicare payment centers set up to a billion dollars over the five years. The question I have is just I have been interested in getting some more specific comments on the concerns you have with the proposed rule from DEA that would provide for electronic prescribing of controlled substances because everybody seems to be have nothing good to say about that.First and foremost, e-prescribing new things provides a huge opportunity to better track who is getting a prescription, so you would be able to use these electronic databases for basically determining again to see where somebody has been having unusual amounts of a prescription or any usual patterns, you would be able to see where somebody has gone doctor shopping to look for different and repeated prescriptions for something like oxycodone. They do not seem to have taken advantage of that potential to use e-prescribing to prevented use. At the same time, they have created a number of hurdles that are going to discourage providers from doing as for example, they require a physician to register either at their local hospital or somewhere and physician has to go and do something and register in person face-to-face. There does not seem to be any benefit from that, then we could see that any other stack holders could see, they ask people to check at database that has been kept up-to-date regularly. There are number of things I think, there was a list of five or more different major problems with regulation. I would be happy to forward you the comment letter that we sent to the DEA, you might want to check some of the other comment letters that went into much greater detail than the consumer. We just went it from the consumer’s prospective as the consumers want this, there is huge benefits you are not helping and we did not go into the weeds a lot as the pharmacy folks, the physician folks, I talked all of the people who are writing their comment letter, they had substantial major concerns with the barriers that are really going to discourage providers from using e-prescribing in ways that just do not help. These initiatives of e-prescribing relate to other initiatives to help and power and help patients such as Microsoft Health Vault or Google health.For the personal health record products, I know Microsoft design is not here, Microsoft does not like to be pigeonholed into the PHR box but nevertheless, we are talking about tools that are consumer facing and designs to allow consumers to have more information at their fingertips on their own healthcare that they can manage their care better, participate in their care more, etc. I think one of the dose tools are made much more effective when information that is electronic at the provider setting can be downloaded directly into those products as supposed to having to be manually entered by the patient or scanned in through scanning technology. It is just you know where you do not have those interfaces, the products I think their value does not yet resonate with the public, no places in the country where the systems are more advanced with respect to EHR adoption, I think our head of the curve and the places for where lot of these major PHR vendors have formed partnerships like I know is the case in Mayo Clinic, Cleveland Clinic where they are actively working to create those interfaces, I think the interest among consumers and the uptake will likely be much greater. To the extent that e-prescribing is yet another tool for getting the information more in electronic format at the providers setting where there might be a capability to link it into PHR more easily as a post to again continuing the paper based system which does not facilitate that, it is just one more step I think in a series of steps that we are going to have to take to you know to make that happen but you know, to the extent that e-prescribing is you know, I think Paul mentioned in his presentation that so the gateway to it may be adoption of other types of electronic health technologies where moving towards back digital environment where that the PHR are willing to interface with.Yes, e-prescribing is the easy first step to a lot of other things that are out there.Judith from Blue Cross Blue Shield of Illinois, how do we make the case with consumers when cost is not necessarily a factor, for instance in Illinois, we have a lot of pharmacies and supermarkets that are coming up with the four-dollar prescriptions, therefore, you know the consumer does not matter whether they get a paper script or electronic script, they are more concerned about that four-dollar drugs they are going to get, so how do we make that case with them.If they are going to get that script electronically sent to their Wal-Mart or four-dollar prescription place so that it is there when they go as a post to having to deliver it and then wait for it to be sold, I mean that is the, you know, the other cost issue, you know I think these prescriptions are being marketed as being cheap but I doubt that they are all that cheap, so to the extent of the decision support tools become available where the patient and the physician can make the choice of prescription that will be more likely to get them to the four-dollar prescription that they can get at the pharmacy that offers the cheap drug, again the idea is the efficient transmission of the prescription and gain, I think the knowledge of what is either covered by their insurance if they have got it what provides the lowest co-pay or in the case of these pharmaceutical deals that are out there, again I doubt that it is everything on the formulary too.On the safety side, we are saving it over 95% what medication history check before they have the prescription written, that is a huge benefit and people really understand that they are dangerous interactions among drugs, so if you tell them that e-prescribing can help prevent those interactions, they can start.The right script from the cheap place, right.I think one of the challenges is as I was getting out, would be having the accurate information there so the formulation where the comes from the PVM is going more often identify the same drugs, most of the drugs that are in the four-dollar generics are tier one and just about every major insurer, but you know, no one is going to be confident enough to put that and I do not know if the Wal-Mart or any of those folks are working with the e-prescribing vendor as the certificate that information as the point of prescribing as well. This probably would be smart to do that but doubt would be the kind of thing that is useful to the patient for example, when they are pharmacies there, you know, it can then be sent directly there and I think the idea goes back to the idea, you know physicians I think are happy to be able to offer that to the patients if they think alike, should take the drugs usage here and spend the time quitting the drug yet if they want the patient to take it slowly. I think it would be for it if there was an easy way to getting information there that is a challenge getting the information there.Thank you for sharing some of the, I guess, objective outside perspective on the potential or on the data itself there, I think there has been a lot of optimism and only sessions and I think it is almost at a point where I would believe that my hair would filled in, I would loss weight, and I am going to rescue kidneys with e-prescribing, yes, we are all very supportive of it and I think there is a lot of potential there. Stepping back and looking at drug safety, adverse drug events and a lot of work showing that most of the avoidable really serious adverse drug events are not due to misreading prescription writing, they are not due to dispensing errors, they are due to non-evidence based prescribing, failure to monitor, failure to respond, failure to followup with patients and I know that e-prescribing is a small part of helping through this electronic health record but from a data mining pharmacal epidemiology perspective from a quality improvement perspective, I know the measures being developed by CMS and other groups, you can tell now from the claims data available whether the drugs have been monitored in a timely manner or not, whether visits have been made and adherence is happened with the existing data bodies of the determines happening, are we missing an opportunity here spend the billion dollars in a way that focuses on high risk diseases, high risk drugs, and high risk practices or is this a simple step we have to take first before we can actually make the improvement that are going to see this 25% reductions. I am not confident myself that just changing how we speed up the existing systems is going to cause the healthcare improvement that we needed. Please if you could please comment on that briefly.Sure, I think it should only take 5 or 6 hours to address the things you got. They have some left over chicken from myself, bring it up. You raised very important points and I think that the first order arrow is the really striking one. You know, the legibility upon the wrong drugs, you know, it is equivalent of the inpatient hospitalization operating on the wrong side of the patient, I think they are really striking and they are sensible events but they are really not that common and you write that the more difficult point is the judgment or are we doing operations that are more likely to harm in health in sort of more of a judgment way, are we using medications that carry more risks than harm with patients and those are very-very and those are much more difficult questions to tease out. I think a lot of what has been talked about can start to address that because you know he mentioned a lot of good work that is going on in terms of how do you address those kind of things, for example, failure to monitor or what you need for that is the interoperability between for example, laboratory systems and prescribing systems. I think you would also need a lot of clinical knowledge to make sure that the decision support is accurate, so there are lot of moving parts that need to get in the prescribing decision, you have made the information to utilize, for example about monitoring laboratories and then as I said, you need to make sure that the logic for using is right, so you are not giving someone sort of useless alert, you know all patients on this drug should be monitored for something or other, sort of rare one in 10 million event but people start just missing all the warnings. You need to really get them a relevant one. That is a heck of a lot of work to do which is why we have to take a long time talk about but I think the basic foundation for that is going to come from starting to get better interoperability of these kinds of systems and so, I think there is a long-long way to go and I think, you know, eventually may be we will get to the saving kitten stage but before we get to that, it is true that a lot of the estimates about the certain morbidity and mortality for prescription drug problems, is not from those really shocking events, I think that is a logic from people, you know, your typical story about this will start with what are two really shocking drug errors and then say the IOM report about how many preventable tests there are per year and we will say, my god, these are 100,000 people being given a completely wrong drug every year. If we just fix that, that will go away, and as you eluded to and as you clearly understand, that is now how it is. But if we can start figuring out how to fix the simple one which may only be a small proportion, we can start try to prove that we can at the heart enough to grab, but is going to take a lot of work to get there.I am Mark Stevens from Pennsylvania Health and Issue. Given all the statistics and I preferred actually in other forms today that e-prescribing price higher utilization of these generic drugs, I am pleasantly surprised that both Wyeth and Pharma were sponsors of today’s event but that we have seen the pharmaceutical industries to slow to support the prescribing with sort of case can be made for the Pharma industry that get behind e-prescribing.The other one would be where this is not database, this is just my opinion about where there was a gain for them or areas where we have more use of drug for sort of win-win, so for example, adherence to chronic medications for things like hypertension, high cholesterol, diabetes, various drugs for cardiac and heart failure drugs, there is a lot of generic drugs can be used for that but frankly a lot of patients with for example, diabetes or hypertension are given the two, three, or four drugs to control especially to get patient living longer and longer they get, hypertension continues to worsen. As a lot of these companies, I would guess again this is my guess, they may see a game because if e-prescribing systems can made to better adherence, you know what the patient is on, you are getting the information, you are getting daily reminders that hey, their cholesterol is still too high and their blood sugar still too high, so you are looking to add it on the drug because you are trying to take better care of them and so there may be a game for them in that as you are getting patients on to drugs and getting them adhere to drugs but in those cases, it may well be a game for the system because if you really get off treatments that we think are efficacious, then obviously I am sort of cherry picking the examples that you know fits what I like in terms of preventive care, and things that are really going to pay off down the road but that is my guess that where they see an incentive but more cynical view would say were going there anyway and you can either be, you know, the power faced and all political expressions that are outside the tent spitting in or inside the tent spitting out, you know you decide where you want to be in that process.One additional question if there are any. Okay, we thank you all so much of being here and I hope this is a great session for you. I want to thank Michael, Devan, and Paul for such a fantastic session.