How To's of E-Prescribing
Kim A. Caldwell, R.Ph .
10/7/2008

Howdy, I am not from around here like esteemed colleagues and since I talk a little slower, they have given me the next 45 minutes to do my 15 minute presentation. True enough, I do not have any slides up there and one of the reasons is I wear a lot of hats, many hats, and I am going to talk through several of those for you, and you will, please bare with me just a moment as I take you on a little bit of journey as I talk through how I got, where I am today in my particular career. But before we start out, I want each of you to think about in your own mind and acknowledge the fact that it does not matter if you here as an individual or a company with a particular physician practice group or you here with a state, whatever it is, there is some motivation that you are looking for, if you do not already have it, some motivation to get involved with e-prescribing. You need to find what that motivation is. Now, you heard mine earlier. My current motivation is my granddaughter, Caroline Elizabeth, born 24 days ago. I used to say in some of the positions I was in when I was writing regulations in Rules and Guidances, I used to say my motivation was my mother. Kim’s mother was the reason we did this because if it did not work at the street level, it did work at the pharmacy or in the physicians’ office, we have done something wrong in healthcare and I believe that today. Only, today I do not have my mother anymore. She is no longer with us, but Caroline is. I just do not want us wait 83 years for Caroline to see some success. So, that is my motivation. Now, if you will, follow me on my journey. I am going to talk you through a lot of ways that I have been out there and understand I am a really old pharmacist. I have been around a long time, owned an independent store, have been through chain management, have been through health plans as pharmacy director and PBM in charge of clinical operations, and a lot of other things over the time, and I overlaid about 15 years of long-term care consulting while I was doing that. So, I have been in a lot of practices that involved health care in a variety of settings and what I have seen in many cases were places where I wished we had a tool. It would have made a big difference if we had that. And here, we can talk about the fact that all, you know, physicians they get in hurry, and they scribble, and they write really bad. They do not think about what they are doing. They put it on there because they are thinking so fast and some of that is true and I told a moment ago a true story where a physician’s office across the street from around my store, the staff came over and they brought his patient’s chart they ran in and they said that neither they nor the doctor could read what he had written, would I try to tell them what it said. And that is a true story and there are a few cases where there is some scribble that is out there and we all know when those are, it is not that those by themselves cause an accident or something wrong, what it does is cause time and hassle and call backs and so we don’t want to have those. But those are really not the issues. The issues to me are how many products out there have similar sounding or similar spelled names. How many products out there have 8, 10, 12 different dosage drinks and those drinks are very similar and the only difference is a decimal point. And think about some of the paper that is out there today. It is hard to tell what you think is a decimal point is really a decimal point or is it just an ink blob or is it just something in the paper. If we can stop some of those as an old pharmacist, we could have saved some of the things that went wrong and I think at the same time we can save of the hassle factors, for me calling the doctor, the doctor have to get on the phone and answer it. So, those are the things we all keep in mind.

I am a state regulator. I am starting my 12th year on the Texas State Board of Pharmacy. Twelve years, so you think all those years back when I first went on that board, we did not have in Texas anything that would really allow electronic prescribing. Today, we are deep into automation and technology and we clearly support and drive for electronic prescribing anyway we can because that is a good thing to do from a regulation point of view for a variety of reasons. Yes, we try to do the good things with the pharmacies and pharmacist out there; we want to help the physician and practitioners as we can but our job is to protect the citizens of Texas and if we can do that by encouraging the use of these automation and technology tools then we have done something right. But, I have had the pleasure of working with colleagues in other states, especially some of the large states as they were writing their own rules and I am also a part of NABP (National Association of Boards of Pharmacies), and I have helped them write a model role on goods to put in place the capability for states to allow for e-prescribing. Now, when I began this, very few states around the country would allow it. Now, there were some that it could be allowed by default because they did not have anything that prohibited it. Today, virtually every state will allow it and somewhat encourage electronic prescribing in some former fashion. In some former fashion, that is initiating thing if you think about it because we have listened to CMS talk about all the things that are mandate. These are preemptive if you look. If you know anything about MMA in 2003, there is a preemption that these rules will kick in and CMS can tell the states all the way across and the territories that these were the statues, these were the standards, these were the guidances that needed to be used. However, you did not realize that is only for the patients that are eligible for Medicare part D and that is only for drugs that are part D drugs. They have no preemptive authority for other patients or other drugs. So in fact, states can have multiple rules and regulations as a fact. Now, we need to work together as states and people working in those very states and providers or physicians whatever it maybe to make sure that we only run with one set of rules on those states, obviously they need to be the ones that CMS have in place. Not everyone has gotten to that. They have not all moved up to the same dock at that back of the warehouse, let us get there. So, those are things just to keep in mind. Do not let anyone tell you that fixing the handwriting issue won’t save mistakes. As a Board of Pharmacy person who has dealt with awful lot of injury and death, I know the things take place and it is really harmful. But at the same time, let us do not buy end of the fact and just ignore the fact that there are still hazard out there. So even if we have the tools, we have to be mindful about what is going on. So, you got to be mindful that you choose the right drug, that you choose the right strength, and you use the right sig, because when it gets to a pharmacy, they are going to take it as gospel that that is the right thing. Unfortunately, I think, one of the things is a downside if we are not thinking about it and if we are not proactive, is the fact that we would just accept it as it is. I did something risky a few years back. I decided to try a new venture. So, I accepted an opportunity to go to an e-prescribing company. That company was Parkstone. It is no longer there. It is a defunct company. It was victim to one of the downturns in the stock market many years ago. It was in 1999 and 2000, but I will tell you it was a great thing. I enjoyed it and it inspired me to continue to move in this direction and it was, kind of, likely a Joto vitamin on the way towards getting something done. I am glad we got to do it, but our focus was on the physician only. Not on pharmacies, not on payers, and not on anything else. It was on the physician how can we get information to them, fill those gaps, give them information about alternatives, try to give them some of those formularies, although there were not as many formularies but give them information about formularies and do it instantly and we had a lot of doctors that actually used the device. What we did not have was a business plan. Cheap enough. In our case, cheap was too cheap. When the market tanked, the venture capitalist pulled their moneys and we did not exist. It was a good software, mediocre hardware and that is not around anymore. I am a former division director for CMS. I was one of two people that was asked to go in and actually write Medicare part D rules. That was a lot of fun. I would never ever do that again. No it was no fun, but it was a right thing to do. My division which had clinical and economic performance, we also owned the data. We were business owners for a variety of things including over sight, complaint tracking and reporting, all those things. But we also were the business owners for e-prescribing as it related to part D. We were not the CMS business owner for e-prescribing. There is another group that was doing that. They were in the process of writing their own rules, structure and they put it out for the comment period and my division was part of the ones that stood up and made sure that what they came out with in final rules would not limit plan’s ability to augment this. So, we had to work internally and it was a great thing to be there onsite and to get to work with others at CMS so that we tried to make this work. We tried to put in play because we are going to hold the plans accountable for the fact that they had to adhere to whatever the standards were once they came up. So, it was nice being in that setting as we see where we are going. That carries me to delay. I worked for one of the plans. I worked for Humana, but I am not really in the plan operations. I have a different division, competitive health analytics. Our job is to look at all the data and to do outcome studies. And that is, you know, a lot of fun due to the fact that it is one of the most fun thing I have ever gotten to do in my career and I have done a lot of need things in my career. But I am also a business owner for Humana Pharmacy Solutions versus health information technology and e-prescribing and that is why I am here today. I want to talk to you a few minutes about things that Humana is trying to do and think about one of the differences is we are national plan. Now in part D, we are in all the states and all the territories. Commercially, we are not in all of those locations because in fact there are not all those commercial opportunities for Humana based on where some of our large employers might be. But we are out there and we are tying to figure out how can we do the right thing to help our providers, help our members, which in fact means they are helping our employers and purchasers. We want to do those things, but we cannot do it overhanded because we are not the big dog and ever predicted a territory. So what have we found out, the best thing that we can do plays exactly into what you heard earlier, collaboration. You have got to work together. We had to make sure that we did everything we could to link up with RxHub and SureScripts before they became one. So, it didn’t matter what tool the doctor use or what tool the pharmacy had. It still will allow the communication of all of the appropriate Humana data, so when we are talking about the membership, the benefit eligibility, the relative cost difference and that is a very important thing, relative cost difference because it means something to the patient. What is the interior placement of particular drugs? What are the allergies? What are the risks that might be there for the physician to look at? We had to make sure that they are presented in such a format that the physician could look at them, understand them, use them, and message through our pharmacies and by the way they can get to all of our pharmacies. That is important for a variety of reasons because not only do we have an extremely large network, we have pharmacies. We have a few pharmacies in Florida. They are still Humana pharmacies and we have a mail order pharmacy and we are standing up with specialty pharmacy. So, if you put those altogether, we have to look at it from a variety of hats and we have to find ways so we can play together. So, we have joined in as many opportunities as we can to try to use Humana influence to thrive to success. We are a sponsor and we have a board seat with a center for improvement of medication management. We are a part of E-Prescribe Florida, E-Prescribe America. We believe it is important that we collaborate with others. We do not think that we know all the answers. In fact, we are sure we do not have all the answers. We need to learn from others. We have a collaboration in Florida with availability and Blue Cross Blue Shield of Florida to provide an Rx solution for the physicians there. Now this is the solution that we put all the information and the tools in the doctor’s hand. It doesn’t cost them anything, but we have only stood this up since June. We do not really have a lot of prescriber in that yet. We are being very selective as we rolled it out to make sure that we are not rolling out something that is not purposely clear and we know what is moving, so we have been slow and deliberate. We do not have dated report. If we have this conference next year, which I hope we do not have this conference next year, may be we would have something to give to, but that is something that we have tried to get out now. We planned and we are funding some pilot projects for 2009. I have hired two new people to focus a 100% of their time on e-prescribing for Humana. We have some very intense goals or things that we want to deliver, and I am hoping a year from now we can say that we are much more successful and we have a bigger percent of the number of prescriptions that were electronically surprised. Let me give you a few closing comments, I have nothing to do with Humana necessarily. These are just .... You probably know this, but if you do not, by the end of this year 10,000 of us baby boomers are going to start hitting Medicaid or Medicare qualifying age every single day. Every time someone hits that particular time period in their life cycle, they start using more prescriptions. Think about the growth of volume. We are now almost 4 billion prescriptions per year. We are not there yet, but we will exceed that. Think about the new products that come out. Not just a new pharmaceutical product but how complex they are, the biologicals and everything else. Think about how tedious it is to try to understand all the information that goes with it. If you have new prescriptions, greater number of prescriptions, more complex drugs, who is going to know the information, how they are going to keep up with all of it, and by the way do we use multiple doctors? Yes, we do. Do we use multiple pharmacies? You bet and if you have Wal-Mart in target and K-Mart and everyone else offering $4 generics or less than that. Some people would not adjudicate through a system. So, if they do not have an electronic tool that they can combine the medical and pharmacy records, you are not going to know where all the products are and who prescribe them, when they got them, and by they way if they have taken them more appropriately. So, some of those tools are pretty darn critical, I think. Per capita as we all reach our magical age baby boomers getting order, we are going to have less prescribing physicians and less dispensing pharmacist per capita that we have ever had in modern history. Think about that. If we do not have the tools, we are going to have more mistakes. If we have more mistakes, we have more injuries. Cost containment is one of the big things we have heard before; evidence-based medicine is something we have heard before. These aren’t just phrases just like do no harm. If we do not take the opportunity to move into the systems, we are part of the problem.
Thank you.

We have about 5 or 10 minutes for questions and if you could, please use the microphones because this is being recorded.

Hi, I am Steve Zuckerman, I am a neurologist in Louisiana and I am fortunate enough to have the Zix product through Blue Cross which is a wonderful program and I am just bringing up for consideration of perhaps unintended consequence which is in Louisiana, if you do not check off the dispense as written, the pharmacist have the right to substitute of course and in my field as neurologist, there are many-many people on anticonvulsants which have been proven to not work as well as generics. The drug reps come to me and say, “you have by far the least number of substituted generics in the anticonvulsants than other prescribers”, so I am wondering if it is the fact that I am e-prescribing, it is going into the pharmacist computer sort of automatically and bypassing, whichever step they have in their workflow which then switches it over to a generic and so in a sense using this electronic system may actually reduce the generic filling. I was wondering if that is a possibility and if anybody else has observed that?

Massachusetts is a mandatory generic state, so the DAW is not an issue here. I will let other representatives speak to it. I think the larger point in your very appropriate question, it shows how important it is that all the states holders come together to really understand. I am happy in the addition to talk to odd the Louisiana and I will ask him your direct question. We recently the Blue Cross Blue Shield Association just released a couple of days ago a press release. More important than the press release was the fact that 39 Blue Cross plans agreed on e-prescribing vendor functionality. Principles of functionality that are obviously to support Medicare part D, but the point is that there is a list of fundamental principles that we all believe need to happen that all vendors need to do whether you are stand alone, EMR, so that your situation whether it is or is not tied to a particular vendor and I do not think it is. But that we can ensure that it works the same in the Louisiana as it does in Boston and that ultimately if it becomes a state regulation or state issue, but I defer that question actually if there is a chain rep or someone here that might answer that. We just do not see that here.

I would like to address that in fact. From a variety of the rules I have but primarily from the board of pharmacy, we have awful lot of issue around things that could fall under the proposed label of the NTR or something else. So, we have a lot of tools out there, but no in fact refining a greater generic utilization with the electronic tools because it puts it into a position, especially if they do not something but each of the tools that are made available through our systems or through the state have to have at least something where a physician has to do something, either check it off or do a line drew or something to indicate dispense as written. Since they cannot do the other as mandated by Medicaid right where medically necessary or brand necessary on the face of prescription. So, there had to be something that is out there that was one of the things that was made available and we have put it in the rules and we act it, so that has to happen but we are not seeing just the offset where there is unattended consequences of less generics. It is not at all. So in your case, I would be curious, have you been checking dispense as written and then they are filling them as generics and if that is the case then I think there is a real risk somebody is doing something wrong by accident.

No the program works appropriately in that when I write the brand name, it says, “you are an idiot” you need to write generics and I tell them no I am not. I want this. So, I am overwriting.

In our case, you would actually have to tick a box or do something else to indicate that you purposely are saying, yes, dispense as written and that is satisfying medicating.

In fact, in Massachusetts, we have seen our generic fill rate is 73% and we are still seeing increases in the generics, but I know that the Zix folks are here and they might be able to help you.

Thank you gentleman, you have been very good today. My question has been a sort of touched on indirectly by Mr. Fox just now with his reference to the press release and the 39 specifications. But earlier today, I heard in the session that there are currently 149 e-prescribing vendor offered products on the market today of which approximately 45 of them are C-chip certified. Now no practice of five doctors or less has got the time or energy to research 70 different products in order to determine which one is appropriate for their office. Where is the consumer report or PC magazine that reviews, evaluates, interacts these products including vendor support so that we are attending to support these offices and offer them a list of 12 products to look at as opposed to 70?

I think it is a great question. I think it is a comment and I think two things, CCHIT just announced that they are going to be looking at standalone system. The CCHIT certification has been for the EMRs largely and just because they are certified and, you know, Patrick has covered this earlier, it does not mean that version that is certified is in use and I would say you want to cut that list down, ask how many of them tied under SureScripts and RxHub. That list will be very small and you can probably count it on this many things. So, it is not just good enough that you have the solution but it has got to do all the things; it has got to check drug history, it has got to check formulary, benefits, it has got to do all the things that we wanted to do. EMRs are enough themselves. They will take us where we need to go. But if they do not have decision support fired underneath them, then all it does just become an electronic filing cabinet. It is not about the technology, it is the use of it and the industry knows this and believe me these are conversations we have with them everyday, I think the rule, NEPA, CCHIT, the plans. So, I think that list will come down and then from a transparency perspective and I think to Patrick’s earlier point and Tony mentioned this too. We do not want to tell anyone who to use. We want to tell who needs the certification. I think if certification gets tougher, that list will come down. I think many of them will come together, so I think this is a great point.

I think, the other thing that we tell providers when they are saying, I do not know what system to pick conditioned to if it is an EMR or the CCHIT, but SureScripts and RxHub have their own certifications for functionality specifically and there is a wide variety of levels of being certified and so we just direct people to really try to better understand what those levels are and find out if the products absolutely has that level of certification and I think from a market-based perspective, if 12 to 24 months from now you are not CCHIT certified, you are not doing the full range of these certifications from RxHub and SureScripts, you are out of business and I do not know how you are going to sell a product literally. So, I mean, I think the market is going to be a big force in this progress process.

I was just going to add one thing and then we are going to followup was the CMS administrator asked us to give feedback from all these concurrent sessions, so I think that is one message that we can take back to the administrator is and we heard secretary Leavitt today say, you know, I have gotten one chance to get this right, I do not want to make a mistake. So, if CMS could put out such a guide that would have recommend plans but say, okay these are the products that meet these certifications and these functionalities that that would be a valuable tool for the provider.

When you are recommending, say a half a dozen or a dozen different products to your various providers which have a wide range of different functionality. Do you find that that is a barrier to getting all of them to envision a truly paperless office?

No, I don’t see any sort of conflict or barrier there in terms of that. I think where we are is sort of in this in between place with a lot of EMR with very mixed levels of functionality. One of our core platforms that is a good chunk of the state talks to SureScripts but does not talk to RxHub so all those questions have no access for formulary and benefits information. Also the vendors are becoming CCHIT certified, so we will be able to have that.

It really depends on the practice, so I think at the end of the day, what works for a single practitioner, a small community practice of two or three may or may not have an administrator versus a practice of 10 to 15 academic medical certified is very different and, you know, we do not prescribe billing systems today and I think somehow you can have a proliferation of billing systems and somehow it works. This is just we were seeing that that we went from no vendors, a few vendors to a lot of vendors and now with standards in regulation, I think it will come back down and I think it is an excellent takeaway point. But if there could be a guide and if there could be something so that you or any practitioner that is here can look at that type of a report, I think that would be great.

Final question and ....

Could it be a competitor to SureScripts and RxHub? Sure, they have a lot of work to do but we don’t let the market decide who ought to do that, but from a utility perspective and I am differentiating between software and technology versus infrastructure and highways and so right now the SureScripts and RxHub with the backing they have between the PBMs, all the payer information formulary eligibility and they are not by means all. There are certainly other players out there but I think the part that we think that Blue Cross Blue Shield or Mass the thing that we think is important. Data has to go through those highways less is until there is another highway that get put out there. So, you could pick your product whatever the phone end is, back end has got to connect.

I think it is very similar. I used to work for a health plan a decade ago and at that time everybody was using clearing houses for claim submission from the providers and eventually those clearing houses were largely cut out and the providers were going directly to the health plans and I think there are other models in history we can look at and perhaps that is the future, but I think in terms of really speeding up the adaption of technology, I think, we do have two very good utilities in these two companies. They are very easy to connect to and I think at least may be not for ever to your point which is a long time but for some period of time there are way to rapidly move this conversation forward.