New Hampshire’s ePrescribing Initiative
Patrick Miller, M.P.H.
10/7/2008

Slide: 1
My name is Patrick Miller. I am with the University of New Hampshire. We are the state just 50 miles north of here yet we were pretty different than Massachusetts in a lot of ways. Our license plates says “live free or die” which is our state motto and sort of in that vain, I think our ePrescribing program could be described as sort of a free market program with an nudge. And I will talk about the nudge and a couple of nudges along the way.

Slide: 2
Structure of health reform in New Hampshire

Just a little bit of background to give you a sense of where ePrescribing fits in New Hampshire. We have a healthcare reformed program, not focused on coverage but more on focused on the pillars of the healthcare system that we feel are eroding and need help. A health promotion, quality and efficiency, finance transparency, and technology are three groups. And ePrescribing, was one of the first efforts coming out of this group two years ago and the core message here was that the focus for us is on quality and quality improvement. It is not technology project. If you look at the IOMs Crossing the Quality Chasm report, if you look at the number of people that are killed, the number of adverse drug events, etc. We feel that this fundamentally is really a quality issue that we are trying to address. Excuse me? Did not fit in? I do not know what to do about that. Okay. They are in the hand-outs.

Slide: 3
So, the presentation itself was about the how to's? And you know the healthcare were pretty good. We have typically about a 12 step programs. My four step programs for ePrescribing is set goals and find partners. There are three implementation focus areas, which are pharmacy readiness, payer readiness, provider adoption, and then finally assessment and I will talk through a bit of these.

Slide: 4
Pot of gold

When we first started our program two years ago, we were hopeful that there will be a pot of gold. We did an analysis and figured we needed $1.5 to $2.0 million and with that we could go out and provide an upfront incentive payment to practitioners that did not have a standalone solution or if they have EMR solution we could help them with their licensing cost. We have about 1500 PCPs in the state, another 1500 primary care support and then which is cut-off from the bottom is about 2500 specialists.

Slide: 5
Reality is there were no dollars

What we ended up with was this, and so we got creative; it is a New Hampshire way and then started to focus on our partnerships and what we found pretty quickly was that we had very interested providers, very interested payers, and very interested employers and so, we’ve tried to build upon those partners in the process. We had had some part-time project management and we are building upon a very solid EMR installation based. New Hampshire is pretty unique in the sense that more than half of our clinicians have some form of electronic medical records which if you look at the national statistics it is typically in a 5% or 10%, and so a lot of what we were doing is building upon that.

Slide: 6
We had excellent executive support from our governor. In October 2006, he issued a challenge to the market place saying “this is important, we would like to see by the fall of 2008 every prescriber in the state have some form of access to this technology.” You noticed I said access and not all up and running and using the technology, but nonetheless, it got a conversation in motion and start to allow us to pull people together. As I mentioned we have providing project management and education support, and developing a variety of partners.

Slide: 7
One of the key partners that we developed early on was with the Anthem web point, who is our largest payer and they were able to pull together with their efforts, a deal with NEPSI, Allscripts, and Sprint and launched that late last fall. And what they are offering is that a free phone with discounted rates, it has got a web interphase. They are pre-populating their membership and they are connected to SureScripts and RxHub. They have since added a member history functionality with claims data, etc. It was almost like a mini-EMR for their membership. The goal was that 300 prescribers by the end of this fall. We are about a third of way through that goal and the core market again is primarily the non-EMR practitioners in the state.

Slide: 8
Similar to that we have a large employer, our municipals association who also does PBM benefits for the state and the New Hampshire employees it is about 50,000 covered lives and what they have done is they have partnered with CareMark, whose their PBM to target their top 40 prescribers. We understand nationally that about 80% of the prescriptions written are written by the 30% of the prescribers, so hence, the goal to attack the top 40 and that we had about the quarter of that goal met in June of this year.

Slide: 9
I think most of our efforts right now and in the past few months; I have really been focused on our EMR vendors. GE Centricity is the largest platform in the state. All of our health centers, federally qualified health centers except for two are on it, as well as about half a dozen of our larger provider groups. And right now we have 200 licenses that are in the implantation queue for the end of this year beginning of next. There is about another 150 that were told are about you know, have their orders place. So that should bring about another 350 or so online. In addition to that, we got NextGen and EPIC, and Moccasin and other EMRs. And we estimated probably another 400 to 600 licenses they again targeting queue one of next year. So we are seeing significant movement. I will talk in a minute why it has been a kind of slow. We have a purchasers group on health. There are also starting to help us put pressure on the provider community to start to move forward, Medicaid has been a great partner. There is only about 10% of our payer mixed but they are starting to build requirements into the RFP and they are getting data as of July 1 through SureScripts-RxHub.

Slide: 10
In terms of our progress, I mentioned before the high percentage of folks of EMR. These folks are doing what I called ePrescribing like they are keying in the prescription and then they are using their fax server to push it to the pharmacy. The good news is they are used to entering prescription. The bad news is they are not getting the full functionality because they do not get the medication history information or the end and pharmacy communications, but again the move is on there. Almost 80% of our pharmacies are ready to receive electronic prescriptions. We are moving forward with providers.

Slide: 11
And on the payer side, we really only have five primary payers in the state. We have three large commercial payers representing about 550,000 to 600,000 lives. We’ve got the Part D plans and Medicaid, and with the exception of one our payers, all of them are connected to the RxHub network. So, we’ve made good progress there. We had about half this amount when we started the plan.

Slide: 12
New Hampshire is 14th in the country in terms of e-prescribing

We are ranked 14th in the country in terms of RxHub ranking. We are now as good as Mass or Rhode Islands as we heard this morning, but we are trying.

Slide: 13
Chart of active e-prescribers

And just to give you a sense of this, our numbers are small. If you look at 2005, 2006 through 2008, we jumped from 23 to 126 subscribers on the SureScripts network.

Slide: 14
We have made a good progress this year. We started the year with about 126, and as of September 30, 2008 we had 338. So the move is certainly on. And this also represents about 19 different EMR or ePrescribing platforms where there is no dictation must be not missed through that system unlike some of the other plans that are being modeled around the country, it is truly a free market. I think the market is clearly driving people towards those solutions. There are C-checks certified and SureScripts and RxHub certified. But we operate with a lot of different platforms.

Slide: 15
So my last two slides, Barriers to Adoption. Really the big one we’ve had is getting people to move from ePrescribing-lite in the fax solution, the full ePrescribing and convincing clinicians and their office staff that there is value there. Not just from a quality perspective but from a cost perspective. We have also found our EMR vendors have not all been ready with solutions and that slowed the number of providers down or promised releases or releases that exist but the migration path has not taken place within the providers. The free is not cheap enough pops up again here, I think as we have a connection. The former medical director of Tufts in New Hampshire are helping us with our program, that is record, he is a physician. But his point was really you just cannot go out and offer solution. You need to put somebody, a project manager on the ground like Tony talked about to help the officers choose the product and move forward. With the other thing, we hear a lot from our CIOs in our larger organizations says “it is a priority” but it is down to my IT queue somewhere. I got to get a pumped up but executive management is not telling me to push it far enough up. I think with the medicare incentives, with the fax piece going away 1-1, it is bumping up in the IT queues pretty quickly. But over the last 24 months that has been a big issue, and we heard a lot this morning about the DEA.

Slide: 16
For us, we're going to continue to market the program, we're going to continue to push the medicare incentives, we are also trying to push every payer in the state has a P4P incentive with a technology component. I would love if they flip that to match the medicare incentive so that there would uniformity across all the payers; we will see if the happens. We are continuing to monitor and badger the folks on EMR like to try to push them to full blown ePrescribing. And one of the thing it is not on her is we have just done an initial study of adverse drug events using an AHR queue methodology. And what we have found in 2006 was that there was more than $100 million worth of in-patient admissions with the ADE procedure and diagnosis codes on them for a state of 1.3 million people, so even if 10% or 20% of that number could have been avoided through ePrescribing. You know the return on investment is 10-fold right there. So we hope to have that study released jointly with the State of Maine in queue #1 of this coming year and use that to also further the conversation around other HIE adoption and HIT adoption such as EMR.

Slide: 17
So, that is a little bit about the folks to the north of where we are today. And I am happy to answer questions later. Thank you.