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Electronic Prescribing: Toward Maximum Value and Rapid Adoption

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Electronic Prescribing: Toward Maximum Value and Rapid Adoption Recommendations for Optimal Design and Implementation to Improve Care, Increase Efficiency and Reduce Costs in Ambulatory Care A Report of
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Electronic Prescribing: Toward Maximum Value and Rapid Adoption Recommendations for Optimal Design and Implementation to Improve Care, Increase Efficiency and Reduce Costs in Ambulatory Care A Report of the Electronic Prescribing Initiative ehealth Initiative Washington, D.C. April 14, 2004 Copyright 2004 Foreword April 14, 2004 Dear Colleagues: We are pleased to present the ehealth Initiative s formal report on Electronic Prescribing: Toward Maximum Value and Rapid Adoption, which highlights recommendations for optimal design and implementation to improve care, increase efficiency, and reduce costs in ambulatory care. Given recent significant national attention paid towards electronic prescribing, especially in light of its inclusion in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the timing of this report could not be more important. The culmination of valuable information presented in this final report reflects the consensus of a diverse group of stakeholders and national experts who began their work in More than 70 of the nation s top experts on electronic prescribing volunteered their time and expertise to this important multi-stakeholder effort. Working Groups were comprised of representatives of each of the many constituencies involved in and impacted by the prescribing chain, including practicing clinicians, hospitals and other healthcare organizations, medical societies and associations, health plans and other third party payers, healthcare IT suppliers, pharmacies, manufacturers, patient and consumer groups, insurance providers, federal agencies, and connectivity providers. Ever since the founding of our organization three years ago, the ehealth Initiative has focused on bringing together forward-thinking people from all sectors of the U.S. healthcare system to develop practical strategies for driving the adoption of health information technology to improve the quality, safety and efficiency of healthcare for all Americans. The findings of this report are substantial and practical, and will help us move towards that goal. It is findings such as these that ehealth Initiative works every day to bring to the attention of public and private sector healthcare leaders, policy-makers, and the general public. We tell them there is a strong financial case to be made for prudent public and private sector investment in interoperable, electronic applications such as electronic prescribing and the mobilization of data across systems to support patient care, and an even more compelling case given information technology s role in addressing quality and safety challenges. This report is also intended for use by the members of the same stakeholder groups that were involved in its creation. For healthcare providers, including clinician and pharmacist groups, it offers independent information regarding what they can and should expect from their system providers, as well as offering guidelines for successful implementation and best ways to gain safety and quality benefits. For payers, insurance providers, and healthcare purchasers, it presents material on value propositions, incentive programs, current demonstrations and early adoption successes, and on high-value 1 features such as clinical decision support. For system producer/vendors and connectivity providers, it is a compendium of recommended and desired features and system components, best practices and known issues. Thus, it is intended not to homogenize all product offerings, but rather to provide valuable research and development and userrequirements information to help them produce better products more quickly and easily. The information on standards and vocabularies should be of value to all of these groups, as well as to standards developers and policy-makers. Congratulations to the dozens of members of the Working Groups, named at the beginning of this report, who generously volunteered their time and expertise to this effort. Without their knowledge and dedication, this report would not be possible. We owe special thanks to the outstanding set of leaders who chaired the working groups and, in so doing, put in a great deal of extra effort to pull this report together. Bob Elson, MD, MS, Vice President of Healthcare Services of RxHub and Patricia Hale, MD, PhD, FACP, Chair of Medical Informatics for the American College of Physicians and Chief Medical Information Officer of Glen Falls Hospital, served as co-chairs of the Design and Implementation Working Group. Mark Frisse, MD, Vice President of Health Delivery of First Consulting Group and John Glaser, PhD, Vice President and Chief Information Officer of Partners HealthCare System served as co-chairs of the Incentives Working Group. Congratulations and our deepest appreciation also go to Jennifer Covich Bordenick, our program director, whose tireless energy and enthusiasm helped to make this initiative a success. In Washington and across the country, there has been increasing momentum for the use of health information technology and electronic prescribing to improve the quality, safety and efficiency of healthcare. But much work is ahead of us; moving this agenda to its ultimate goal will require sustained focus and commitment. Working together, we can foster and support electronic prescribing, other clinical applications and the creation of an interconnected, electronic health information infrastructure to advance our shared agenda leading to better healthcare for all. Sincerely, Jonathan M. Teich, MD, PhD, Project Chair Senior Vice President and Chief Medical Officer, Healthvision Assistant Professor of Medicine, Harvard University Physician, Department of Emergency Medicine, Brigham and Women s Hospital Janet M. Marchibroda Chief Executive Officer, ehealth Initiative Executive Director, Foundation for ehealth Initiative 2 Table of Contents Foreword... 1 Electronic Prescribing Initiative Team...5 Highlights of the Report... 9 Executive Summary SECTION I: INTRODUCTION TO ELECTRONIC PRESCRIBING Introduction Definition of Electronic Prescribing; Levels of Sophistication Stakeholders in Electronic Prescribing Why Electronic Prescribing Is Important Prescribing Error Rates, Quality Issues Prescribing Efficiency: The Burden of Callbacks and Rework Compliance and Renewals Other Cost Savings: Adverse Drug Event Prevention and Drug Spending The Current State of Adoption of Electronic Prescribing Momentum in the Public Sector for Electronic Prescribing Momentum in the Private Sector Summary Introduction to Electronic Prescribing SECTION II: OVERVIEW EHI ELECTRONIC PRESCRIBING INITIATIVE.. 39 Objectives and Purpose of the Initiative Electronic Prescribing Statement of Principles Overview of the Initiative: Process, Participants, Strategies SECTION III. ANALYSIS AND RECOMMENDATIONS The Prescribing Process Electronic Prescribing Component List (Table 1) Usability for the Prescriber Overview Signing On Identifying the Patient Loading and Reviewing Patient Active and Archival Medication Data Selecting the Drug, Entering Parameters, Signing Use of Different Devices in Multiple Environments Workflow within the Office Summary Usability for the Prescriber Clinical Decision Support Overview Types of Clinical Decision Support Usability and Design Issues Surrounding Clinical Decision Support Relevant Literature and Contemporary Projects Ranking the Value of Clinical Decision Support Functionality Notes and Additional Recommendations Formulary Decision Support Formulary Management Summary Clinical Decision Support Communication Overview Current Methods of Communicating Medication Information Key Issues and Barriers Removing Barriers Ideal Design Considerations Summary - Communication Standards and Vocabularies Overview Electronic Prescribing Messaging Standards NCPDP SCRIPT HL Messaging Standards Need to Meet Business Needs Factors for Success Summary Standards and Vocabularies Implementation Overview Key Issues Understanding Implementation Issues before Selecting a System Implementation Management Cultural Issues / Managing Behavior Change Startup Issues and Problem Resolution Rollout Timing and Sequencing Beyond Electronic Prescribing: What Comes After a Successful Implementation? Summary - Implementation SECTION IV. INCENTIVES FOR ELECTRONIC PRESCRIBING Alignment of Incentives Stakeholder Costs and Benefits Addressing Stakeholder Tensions Representative Incentive Methods Economic Incentives Legislative and Regulatory Incentives Preliminary analysis of incentives Summary Incentives SECTION V: MOVING FORWARD Next Steps for the ehealth Initiative Next Steps for Stakeholders Incentives Advancing the Process SECTION VI: APPENDICES Appendix A: Overview of the ehealth Initiative Appendix B: Overview of Federal Legislation in Information Technology and Health System Improvement Appendix C: Clinical Decision Support Feature List: Further Descriptions and Comments: Appendix D: Sample Implementation Plan REFERENCES Electronic Prescribing Initiative Team The ehealth Initiative created this document through a process that included continuing input, many group discussions, and ongoing feedback from many stakeholders and experts through their active participation in the Steering Group and Working Groups of the ehealth Initiative s Electronic Prescribing Initiative. Consensus was achieved on much of this document through this feedback process. However, the opinions and recommendations offered in this document should be considered those of the ehealth Initiative. The ehealth Initiative is extremely grateful for the many volunteers who demonstrated their commitment to the advancement of ambulatory electronic prescribing by contributing to the creation of this document. Questions, comments, requests for educational materials, and other inquiries can be directed to the Project Chair or the Project Director. Their contact information is listed below. Project Chair Jonathan Teich, MD, PhD, Senior Vice President and Chief Medical Officer, Healthvision; Assistant Professor Of Medicine, Harvard University; Physician, Department Of Emergency Medicine, Brigham and Women s Hospital Telephone: or Project Director Jennifer Covich Bordenick, MA, Director of Strategic Programs, ehealth Initiative. Telephone: ehealth Initiative Janet Marchibroda, Chief Executive Officer, ehealth Initiative Telephone: Steering Group Andrew Balas, MD, PhD, Dean and Professor, School of Public Health, St. Louis University Peter Basch, MD, Medical Director ehealth Initiatives, MedStar Health James P. Bradley, Chief Executive Officer, RxHub Sam Brandt, MD, Vice President, Chief Medical Informatics Officer, Siemens Medical Solutions Nancy Brown, Senior Vice President, Strategic Development, McKesson Corporation Bob Elson, MD, MS, Vice President Medical Affairs, RxHub Mark Frisse, MD, MBA, Vice President, First Consulting Group Peter Geerlofs, MD, Chief Medical Officer, Allscripts Healthcare Solutions John Glaser, PhD, Chief Information Officer, Partners HealthCare System Patricia L. Hale, MD, PhD, FACP, Chair of Medical Informatics Subcommittee, American College of Physicians; Chief Medical Information Officer, Glen Falls Hospital C. Martin Harris, MD, Chief Information Officer, Cleveland Clinic 5 Yin Ho, MD, Director ebusiness, Pfizer Inc Kevin Hutchinson, Chief Executive Officer, SureScripts William F. Jessee, MD, Chief Executive Officer, Medical Group Management Association Kevin B. Johnson, MD, MS, Associate Professor and Vice Chair, Department of Biomedical Informatics, Vanderbilt University Ned McCulloch, Government Executive, IBM Corporation J. Marc Overhage, MD, PhD, Associate Professor of Medicine, Indiana University School of Medicine; Senior Investigator, Regenstrief Institute Thomas E. Sullivan, MD, Women s Health Center Cardiology, Partners HealthCare System, Massachusetts Medical Society Robin Thomashauer, Executive Director, Council for Affordable Quality Healthcare John Tooker, MD, MBA, FACP, Executive Vice President, American College of Physicians and American Society of Internal Medicine Susan M. Welsh, MD Design and Implementation Working Group Co-Chairs: Bob Elson, MD, MS, Vice President of Medical Affairs, RxHub Patricia L. Hale, MD, PhD, FACP, Chair of Medical Informatics Subcommittee, American College of Physicians; Chief Medical Information Officer, Glen Falls Hospital Members: Patricia A. Abbott, PhD, RN, FAAN, FACMI, Director WHO/PAHO Center for Information Systems in Nursing Care, Johns Hopkins School of Nursing Sam Brandt, MD, Vice President, Chief Medical Informatics Officer, Siemens Medical Solutions Richard K. Brook, Vice President Pharmacy Network Development, ProxyMed, Inc. Christopher G. Chute, MD, FACP, Mayo Clinic Avi Erlich, Project Manager, WellPoint Pharmacy Management Lynne Gilbertson, Director, Standards Development, National Council for Prescription Drug Programs (NCPDP) Jason D. Gottlieb, Director, Physician Programs, Express Scripts, Inc. Jill Helm, Pharm.D., VP Pharmacy Services, Allscripts Healthcare Solutions Kevin B. Johnson, MD, MS, Associate Professor and Vice Chair, Department of Biomedical Informatics, Vanderbilt University Peter N. Kaufman, MD, Chief Medical Officer, DrFirst Jennifer Lis, Deputy Director, Council for Affordable Quality Healthcare Ross D. Martin, MD, MHA, Senior Manager, Business Technology, Pfizer Inc Andrew Mellin, MD, MBA, Director of Physician Strategy for Horizon Clinicals, McKesson Brett Meyers, MD, MS, Director of Medical Affairs, Healthvision Stuart Nelson, MD, Head, Medical Subject Headings, RxNorm, National Library of Medicine Rick Ratliff, Chief Operating Officer, SureScripts 6 Terrie Shepard, R.Ph., Manager, Pharmacy Messaging Systems, Walgreens Health Services Deborah L. Stroup, VP Operations and Support, Electronic Commerce Solutions, NDCHealth Allison Stover, Managing Director, MedStar ehealth Initiative Tom Sullivan, MD, President, Massachusetts Medical Society, Practicing Clinician, Women's Health Center Cardiology - Partners HealthCare System Heng Soon Tan, MD, Primary Care Internist, Brigham and Women's Jeff Taylor, R.Ph., MS, Pharmacy Director, Aetna, Inc. Paul Thomas, DO, Practicing Clinician Virginia E. White, Pharm.D., FCSHP, Senior Vice President, Chief Clinical Officer, Health Net Pharmaceutical Services Ken Whittemore Jr., R.Ph., MBA, Vice President, Professional and Regulatory Affairs, SureScripts Incentives Working Group Co-Chairs: Mark Frisse, MD, MBA, Vice President, First Consulting Group John Glaser, PhD, Chief Information Officer, Partners HealthCare System Members: Steven D. Atwood, MD, FACP, Practicing Clinician Richard Brook, Vice President Pharmacy Network Development, ProxyMed, Inc. Dennis Brooks, MD, Practicing Clinician David Chess, MD, Patient Advocate, Project Patient Care, Practicing Physician Michael Cohen, Chairman, Institute for Safe Medication Practices Richard Ellison, MD, Practicing Clinician Lynne Gilbertson, Director, Standards Development, National Council for Prescription Drug Programs (NCPDP) Isabel V. Hoverman, MD, FACP, Practicing Clinician, Austin Internal Medicine Association Jim Jirjis, MD, Director of Vanderbilt Ambulatory Primary Care Center, Vanderbilt University, Assistant Chief Medical Officer, Vanderbilt Medical Group David Lansky, PhD, President, Foundation for Accountability (FACCT) James D. Legler, MD, Clinical Informatics Specialist, University of Texas Health Science Center San Antonio, University Health System Jennifer Lis, Deputy Director, Council for Affordable Quality Healthcare Tammy Lewis, Executive Vice President, Marketing and Communications, SureScripts David Love, Director of Communications, Medical Society of District of Columbia Ned McCulloch, Government Executive, IBM Corporation Debra Milburn, CMPE, Administrator, Dublin Primary Care Michael L. Nochomovitz, MD, President and Chief Medical Officer, University Primary and Specialty Care Practices, at University Hospitals Health System in Cleveland Eric Pan, MD, Senior Analyst, Center for Information Technology Leadership Shay Pausa, Vice President and General Manager, NDC Health Tom Rodgers, McKesson 7 Luke Sato, MD, Chief Medical Officer and Vice President, Loss Prevention and Patient Safety Risk Management Foundation, Harvard Medical Institutions, Inc. Tom Sullivan, MD, President, Massachusetts Medical Society, Practicing Clinician, Women's Health Center Cardiology - Partners HealthCare System Kasey Thompson, Pharm.D., American Society of Health-System Pharmacists Chelle Woolley, Communications Officer, RxHub 8 Highlights of the Report 1. Errors and adverse drug events in ambulatory care errors can be common, serious, and preventable, according to research. 2. Electronic prescribing can improve safety, quality, efficiency, and cost. Studies suggest that the national savings from universal adoption could be as high as $27 billion. 3. Electronic prescribing systems are available in a variety of graduated levels, Systems at the highest levels of sophistication afford much greater opportunities for benefit, although all of the middle and higher levels convey some significant benefits. 4. Despite the benefits of electronic prescribing, adoption is still modest. Current surveys estimate that between 5% and 18% of physicians and other clinicians are using electronic prescribing. Key barriers to clinician adoption include startup cost, lack of specific reimbursement, and fear of reduced efficiency in the practice. 5. The adoption and use of electronic prescribing should be encouraged through the deployment of appropriate incentives. These incentives will be critical to widespread adoption. Promising incentives are reviewed in the report. 6. Continuing progress toward better-designed, more usable systems is likely to help adoption. A number of techniques and best practices are reviewed. 7. Clinical decision support interventions should follow certain design principles for maximum acceptability and impact. 8. Electronic communication offers numerous advantages: it is faster, more work-efficient, more secure, more reliable, less error-prone, and less prone to abuse than paper or fax prescriptions. Current barriers include expense, broadband availability, and variant standards. 9. Software should inform but not mandate a clinician s and patient s choice of medications and pharmacies. Patient confidentiality must also be protected. 10. A number of enhancements in standards and vocabularies are needed to improve quality, efficiency, and to facilitate interoperability between the various electronic systems involved in the electronic prescribing process. Unifying state prescription-form standards, establishing a consistent doctor-level drug vocabulary, and standardizing formulary information are among the highest needs. 11. Careful management of the initial use period in any practice is essential. Access to registration, schedule, and prior medication information is important. 12. Integration of electronic prescribing with an overall electronic health record adds value in a number of ways. Many lessons about adoption of electronic prescribing can be applied to the widespread adoption of robust, connected electronic health records as well. 9 10 Executive Summary Electronic prescribing refers to the use of computing devices to enter, modify, review, and output or communicate drug prescriptions. Value of Electronic Prescribing Ambulatory care errors are common and preventable; electronic prescribing can improve safety, quality, efficiency, and cost. In inpatient care, electronic medication ordering has been shown to have a significant impact in reducing Adverse Drug Events (ADE s) and guiding better drug utilization. 1 2 In the ambulatory environment, recent research shows that adverse events are common and can be serious. According to the Center for Information Technology Leadership (CITL), more than 8.8 million ADE's occur each year in ambulatory care, of which over 3
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