Leveraging Momentum for E-Prescribing
Kevin Hutchinson
10/7/2008

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Now, I want to introduce another health IT pioneer and that is Kevin Hutchinson. Kevin is currently CEO for Prematics but until very recently, he founded and served as SureScripts CEO. Kevin through SureScripts was at the forefront of an effort to finance, build, and deploy a national network for electronic prescribing and health information exchange. While Kevin was CEO, the Pharmacy Health Information Exchange grew from an industry concept to the largest electronic prescribing network in the country. During Kevin’s tenure, SureScripts certified more than 95% of all the pharmacies in the US and connected over 150 various physician technology vendors and processed over 50 million electronic prescription transactions. Well in addition to his day job, Kevin serves on the eHealth Initiative’s board of directors, the Markle Foundation connecting for health steering group and in 2005, Secretary Mike Leavitt appointed him to the American Health Information Community. So Kevin, thanks for taking time to be here and we look forward to your remarks. Thank you Kerry for that nice introduction. I also want to thank Secretary Leavitt for his leadership in health IT. It has really been a pleasure to work with Secretary Leavitt over the number of years on driving standards and process and change. This is a big ship to try to turn and at many instances we have to lay down foundations to make that turn but I look at the caliber of speakers that are here today and I was thinking …. governors, senators, administrators, David Brailer, and Secretary Leavitt and a lot of other people. So what can I add to this discussion that would be of value to this audience and it occurs to me number #1 I think that attendance was relatively low early on since I know half of you, and the other half of you I know I have pictures on as well. They recruited me to try to get people to attend and I am happy to say not only did we fill it up but we have a waiting list of people who are trying to get into this room. It also occurs to me that, “Do you ever know that you are that guy? You are that person?” And, I’m thinking what is it that I can share? I am that main street person and we are going to talk about main street. E-prescribing! These days, as you can see, whether you are seeing the vice presidential debates that have occurred recently, is about main street and we are going to get down to some nitty gritty details about E-prescribing. “So dog-on-it Kerry, we are going to talk about E-prescribing!” And I appreciate you being here. Okay, since this is not Saturday Night Live, and I am no Tina Fey, let’s get down the business here.

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Skipped Slide

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Description of key drivers of e-prescribing momentum

So, some of the momentum around E-prescribing? I think that the drivers are pretty clear. We know that the Institute of Medicine reports that there are 1.5 million Americans are injured every year due to medication errors and over 7000 deaths that occur every year due to medication errors and some studies suggest that 25% of those can be preventable by just using electronic prescribing. We know that it improves safety. It drives down cost. It drives higher generic utilization. It avoids drug interactions. You can actually view a complete patient’s medication history record, through sources of RxHub and SureScripts pharmacies and PBMs. But what are the building blocks to take advantage, you know, of this momentum and those building blocks? #1, we have to start with standards and sometimes those had to be regulated, sometimes they had to be legislated, sometimes they had to be collaborations to get together and work on those standards but they are the basic DNA of what is needed to really successfully deliver on the promise of electronic prescribing. Then we have to move to this backend infrastructure that is required. How do we exchange this information? How do we get from point A to point B? And, how many different points are there? Is it a single point to point? Or is there a lot of information that needs to be shared as a part of electronic prescribing? How do we ensure that there is a standard process for how technology systems are actually applying those standards? What is the certification process, so there is a uniform approach to how we get electronic prescribing to be prevalent in this industry? And finally, how do we get those darn physicians to start adopting?

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Some of this has been mentioned today, so I am not going to repeat a lot of what has been discussed today but as we look at the standards … we have standards! They have been tested. They are in place. The Medicare Modernization Act actually established what those standards would look like and then we went in and started creating the implementation guides for the use of those standards and certification processes associated with that. But we still have work to do. We still have standards work to do, around things like standardize SIG, RxNorm, standard medication terminologies … “change Rx, cancel Rx”. Those standards are not implemented widely inside the industry yet, so we have not fixed all of the workflow issues to go along with the need for electronic prescribing inside the physician’s office, pharmacies, patients, and physicians. In 2004, roughly half of the states in the United States still outlawed electronic prescribing, not because they were against electronic prescribing but because there were old laws on the books that would not allow electronic prescribing to occur. Happy to say that we stand here today several years later with all 50 states approved legislatively regulations to be able to do electronic prescribing, including the District of Columbia, which by the way was one of the last remaining geographies to approve electronic prescribing.

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I am very pleased to have been part of the creation of SureScripts and I am really pleased to see the merge between SureScripts and RxHub occur and I want to take my hat off to the executives and the team members of both SureScripts and RxHub and the executives from the Pharmacy Industry and the executives from the PBM Industry who really came together and said you know what we are going to put all of our differences aside and we are going to make this successful. We are going to create an infrastructure that can actually be utilized to make electronic prescribing in this marketplace successful and so I really appreciate the hard work that has gone in to create that merger and let me tell you from working on it myself while still at SureScripts, it was a difficult challenge and I think I have an opening at the United Nations next. Ninety-five percent of the retail pharmacies in the United States are in fact certified and have the capability to do electronic prescribing. Eighty percent of those pharmacies in the United States are in fact processing electronic prescriptions. There are over 200 million covered lives in the RxHub Services that have access to eligibility formulary medication history information that can be shared with over a 150 different certified vendors across the United States.

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Adoption of e-prescribing in the final quarter of 2007 was 35,000 physicians

When the co-CEOs of SureScripts and RxHub, tell me that they are now adding 3000 to 4000 physicians a month to the network, so we are starting to see that growth. In 2007, the network ended with about 35,000 physicians that were actively prescribing on the network and we stand here today looking at a forecast in 2008, with somewhere between 75,000 and 80,000 physicians that will be on that network by end of this year. Keep in mind, this is not counting the physicians that are utilizing EHR systems that are printing or faxing. These are live EDI transactions. We do not include faxes or prints as a definition of EDI or Electronic Prescribing. Much how, we do not include writing a check and mailing it to someone as e-banking.

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Annual growth is estimated to be 100 million

So how does that translate into transaction volume? If you look at the network’s performance in 2007, there are over 35 million transactions in that year alone that were sent electronically, but that is only 2% of the total prescription volume in United States. In 2008, it appears the goal was to try to get to a 100 million transactions by the end of this year and it appears that we are going to get close, but it is going to be somewhere between the 75 and 85 million transactions. But look at the growth from 35 million to nearly 85 million transactions in a single year across the network. Now, we are getting in the range of 5% to 7% prescriptions that are sent electronically but it also tells you how much work we still have to do.

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Physician, patient, health plan and pharmacy are linked together in development of e-prescribing solutions

We need to remind ourselves that electronic prescribing is a multistake -holder relationship. A lot of people start thinking this is between the physician and the pharmacy and in fact, it is a four-way relationship. It is about the patient. It is about the health plan. It is about the pharmacy. It is about the physician, and it requires multiconnectivity between all of these parties if we are really going to be successful. We are just in the really early stages of seeing the results of that interconnectivity. We know it saves time. We know it saves money. We’ve heard a lot about that today. We know it improves the quality of care but did you know it also improve compliance. Walgreens did a great study about a year and half ago that actually looked at, so of all the prescriptions that are coming electronically, are we in fact increasing our restocking cost because now, we have got patients not show enough to pick up their medications, you now those patients that take that paper prescription and stick it in the glove box, never show up at pharmacy and go to their doctor, “Taking your medications? Absolutely doctor I am taking my medications.” Prescription never even made to the pharmacy that is why they are back in the office visit again. So now, we did this study to see are having an issue with these restocking cost, are we having an issue with the patients not coming in and picking up their electronic prescriptions and in fact, the study shows a reverse. The patients are more complaint. When prescriptions are sent electronically to the pharmacies, 11.2% prescriptions are dispensed per physician more than before they were doing electronic prescribing. Which means that the prescriptions are making it to the pharmacy and the patients are in fact picking up that first pill and if they pick up the first pill, then they are more compliant with the refills as well. There are multiple benefits that relates to both the patients obviously. They are more likely to pickup their medications, it is more convenient for patients to have prescriptions go electronically without dropping them off and coming back in a couple of hours to actually pickup their medications. From a health plan standpoint, now we are able to drive a more inform decision down to the point of care. At the time when the decision is being made in front of the patient, we can deliver not only medication history information and avoid drug interactions with other medications that physician did not prescribe, but also drive more formulary compliance and more generic utilization, drives efficiencies, and safety obviously in the pharmacy world in processing orders and it reduces to call backs and decreases the risk of errors made in the physician’s practice.

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Focus on the high prescribers

But here is a kicker. I get asked by various different press about, you know, are we seeing the latest study and there are lots of research, surveys, studies out there that suggest that the vast majority of physicians do not value electronic prescribing. I agree with that every time, because 30% of physicians in United States write 80% of the prescriptions and so if 30% of physicians in United States write 80% of the prescriptions and 70% of physicians are writing 20%, probably do not value electronic prescribing to the degree that the 30% that write 80% of the volume do and we have to keep that in mind. It is not necessarily by getting every physician of United States to eprescribe. Obliviously, that is the ultimate goal, but if we can focus our energies and our efforts in the right area around those high prescribers. Governor Carcieri mentioned this early in the state of Rhode Island they are actually driving toward those high prescribers. It is about automating the volume and when 30% write 80% of prescriptions, we want to automate that volume. Now interesting stat is the vast majority of those high prescribers are in small to medium practices. So when we see the use of all these EHR systems and other systems that are in the large practices, it is great that technology has been implemented, but that is not where the high prescribers actually resonate. So we need to get down into the small to medium size practices if we are really going to automate the volume. We need to imply incentives into those small practices to be able to drive that volume up.

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Well, that presents a lot of challenges because in the small to medium size practices, a very unique environment, they do not have health IT staff. They do not have network operations groups. They do not have a limited infrastructure for connectivity. Many physician practices now do in fact have highspeed internet access, but I am surprised as we have been deploying this in multiple markets across the country in rural America, that is still not true. In metropolitan America that is absolutely true and we are seeing a high degree of physician practices that have internet connectivity high speed but in rural America, that is not true. We are starting to see a divide in that case. So if we are really going to be successful, we need to drive incentives and I would challenge an offer up every private health plan to match CMS’s proposal and programs to drive incentives into those practices, to drive the volume of electronic prescriptions and take a look at this How To Guide (Clinician’s Guide to Electronic Prescribing) that Janet (Marchibroda) brought up from the eHealth Initiative and the leadership group of physicians in the Center for Improving Medication Management that published the study. Physicians need this complete toolkit. They need a way to implement and execute. Physicians need help with this. It can just simply be “download an application and good luck with that” and here is the training material. and we have to find a way to get technology into those small and medium size practices. We need to ensure that these systems that are used in the small practices are in fact certified. CCHIT recently announced that they are going to be certifying stand alone electronic prescribing systems as well as EHR systems. That is a good process so as long as it does not become overburdensome or cumbersome because we need consistency, and how these are implemented across the country.

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We need to be able to align incentives obviously with health plan investment in E-prescribing, it delivers a lot of value into a number of different categories. But when we think about electronic prescribing in many cases, we always think about the formulary, or we always think about safety drug interactions and that is a good thing. We also have to consider that it is also about medication compliance, medication adherence. You now have access to complete medication history record across that patient and we need more data sources to make it 100% complete so that we can get all of the health plan information participating and all the pharmacies participating in those databases so that we can have a full medication history but it needs to be applied appropriately. These incentives need to go toward those physicians that are the highest prescribing physicians that are writing 80% of the volume.

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Major initiatives are informed by e-prescribing

It does not always equate for people that E-prescribing also informs, and is part of other initiatives. I think about the patient-centered medical home as an example, and the work that TransforMED is doing which is an organism that is owned by American Academy of Family Physicians in trying to create a patient centered home where the family physician, the primary care physician is actually helping to coordinate care across multiple specialties for that patient and in fact, electronic prescribing to some degree informs that effort because you are allowed to share patient information across those physicians specifically around medication history. Database health records, personal health records, physicians having access or patients having access into their physician systems to be able to request a renewal, schedule an appointment, these are systems and integration in standards that we have today unavailable to use and which we take an advantage of that. But simply E-prescribing is a medication management tool, centered on the exchange a relevant patient data at the time that medical decisions are being made, and we need to think about that versus simply just writing a script and replacing that paper script.

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You think about interoperability and you think about all the things that you can do with this. E-prescribing is not simply futuristic dreaming. It is actually here today and it is something that we should be taking full advantage of. The networks are here, the standards are here, the certification process is here, and the technology is here on all levels … on the pharmacy side, the payer side, the patient side, and the physician side. We should be putting all of our energy and incentives around trying to drive the adoption and the use of that technology. If we can do that, it is available today and we as an industry should be embracing the value that E-prescribing brings to the table… and with that I thank you.

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As it turns out, we have time for a couple of questions so if, there is a question for Dr. Brailer or for Mr. Hutchinson, we would like to hear them now. Question: From a process standpoint is there a way that the pharmacy could inform the physician that the prescription has actually been picked up or not picked up? Answer: KH: Actually you could do both. There is a standard that is not widely implemented yet either by the pharmacies or the physician vendors that actually can be used for that purpose, so it is a part of this standard but it is not widely implemented. We need to do a better job with that. It is implemented in the network. It is not necessarily in every pharmacy system and every physicians system today. Question: I had a question about the difference for e-standards between the DEA and E-prescribing and terms of liability mismanagement, patient care and accessing information. Answer: KW: The DEA has a proposed rule. The comment period for that rule closed about 10 days ago so right now, DEA and HHS are actively reviewing those comments and frankly in a very tight policy discussion to see how we can bring that rule in for landing in a way that provides DEA the type of security that they need but also that it does not create a barrier for E-prescribing. So, more on that once we go to final active rule making. It is difficult for me to say much more than that but thank you for your questions. Let me thank David Brailer and Kevin Hutchinson one more time.