The Relevance of E-Prescribing - Coursework Example

Running Head: E-prescribing E-prescribing of the of the E-prescribing E-prescribing can lead to fewer harmful drug interactions by alerting physicians to possible risks. It also may eliminate the errors that occur with poor handwriting οf prescriptions. According to an estimate use οf e-prescribing could cut as many as 2 million harmful drug events per year. E-prescribing also could cut waste in the system, such as patient wait-times at pharmacies. An inventory οf situational approaches, passive inquiry οf physicians, collateral health-care providers, and review οf literature, identified the following opportunities recognized secondary to the effective use οf IT. The central role οf the physician is the provision οf care to individual patients. This process centres around the consultation between the physician and the patient. This process requires and generates information, historically recorded on a paper based medium. The limitations οf paper records as a standard repository οf information, is universally recognized as lacking the dynamic which electronic data medium promise: in effect, paper strangles the process οf delivering timely high quality health-care delivery. So what’s wrong with a medical system based on paper? Paper gets lost, degrades, and no matter how voluminous, paper files are limited in the quality and quantity οf data they contain@ (Scalet, 2003). Entities which are converting to electronic patient records, report greater flexibility in their ability to deliver timely, high-quality patient care. Factors enabling such flexibility are; * A means οf transfer οf computerized records when patients move between practices. * Continuing efforts to improve ease οf use in the consulting room: - This is essential to enable consistent data uptake and capture without disruption οf the doctor-patient relationship. * Ability to incorporate patient-related information received from outside the practice into the patient record held by the practice. * Many practices surveyed were considering the use οf scanners to append information in paper documents to patient records. * Availability οf access at all the places where the health-care provider is likely to be consulted by the patient: - Workstations/terminals in every consulting room. - Ideally, mobile systems that can be used during home visits or in outlying clinics. Entities which are converting to computerized electronic patient records state the system provides positive benefits to its users. Factors enabling such benefits are: * Reduction οf bureaucratic tasks. * Effective sharing οf information with others involved in the care οf the same patient. * Assistance with decision making. * Decision support services (DSS), which address the quality and/or cost-effectiveness οf care provided to patients including: - Prescribing - Referrals - Investigations - Other forms οf treatment/patient management. - Reference material available on request via local access from CD-ROM, locally stored data, or from online information sources including the World-Wide-Web. - On-screen warnings, guidelines or protocols. - Structured patient records in which information is represented with consistent unambiguous terms and codes. - Agreement on appropriate advice at a national and/or local level. - A common computer-readable form in which to represent the advice. * Comparative data from other providers and practices to audit decisions. * Assistance in the provision οf advice to patients: - Printing appropriate advice leaflets, possibly including patient-specific information. - Provision οf references to other sources οf patient advice including self-help groups, books, leaflets and relevant online services. From the viewpoint mainstream medicine, IT has long offered the promise οf significant improvements supporting the business οf provider operations. An inventory οf situational experiences, passive inquiry οf physicians, collateral health-care providers, and review οf literature, identified the following business support opportunities recognized secondary to the effective use οf IT: * Accounting * Payroll * Office productivity tools * Word processing * Spreadsheets * Contact databases. Promises οf transformation through IT have reverberated through my decade long career in health care. Yet, progress to date has been slow. The Institutes οf Medicine’s 2001 report bemoaned the fact that AIT has barely touched patient care,@ as evidenced by the storage οf the vast majority οf clinical information in paper form@ (as cited in Fromberg, 2003). Analysis οf passive inquiry and observation οf physicians, collateral health-care providers, and review οf literature, buttresses a frequently voiced sentiment: Electronic medical records, and increased IT applications, should top hospital CIO=s agendas because they can prevent errors, enforce standards, make staff more efficient, simplify record keeping and improve patient care. However, the current reality experienced by the author οf this essay, mirrors behaviours observed in the Austin, TX, health care market: Personal laptops, palm pilots, and various other IT devices abound, however, there exist no data access-terminals which support their use. Usually, these individually owned IT devices serve to complement existing network data-access terminals. There are some attractions in focusing attention on individual development practices and priorities. However, analysis οf literature, and observed practices, illustrates a longer term more general vision οf the future οf integrated IT systems is a prerequisite for realizing their development and implementation. The plan should be developed in consultation with users, suppliers and policy makers. The analysis οf IT utilization within the health care industry, served as a springboard to analysis οf management practices, wherein, the realization that the role οf leader and manager are blurred. Although leadership and management roles are different, they are frequently intertwined. Leadership is defined as the process οf influencing others@ (Tappen, 1995). Management involves not only leadership but also coordinating, directing, and controlling to accomplish specific institutional goals and objectives@ (Huber 2000). Recognizing that health care providers are the consummate users οf medical information and health technology, why has management@ failed to more effectively harness the power οf computers? One reason expressed, is we’ve done the easy part-the automation,@ says Darin Garza, director οf IT for the for-profit hospital South Austin Hospital, HCA. The test οf culture is now in how caregivers and others accept the changed process. They have to trust and agree with the process. Collectively, we’re not there yet@ (Bilchik, 2003). Analysis οf situational experiences, passive inquiry οf physicians, collateral health-care providers, managers, and review οf literature, led to a distillation οf the current health care environment as being a conglomeration οf mini-cultures and pockets οf innovation, with few role models leading the way. What this author, as both a future health care manager, and clinical provider, would have health care management prosecute, is more openness to experimentation to ensure that IT deliver on the promise in the delivery οf timely, high quality health care. Additional analysis οf health care managers current application οf IT, reveals computers are still almost exclusively used to submit bills, order lab tests or document treatments in compliance with governmental mandate. Each οf these practical tasks revolves around separate systems with their own codes or languages, none οf which actually enhance the delivery οf care nor communicate with each other. This detraction from pure clinical thinking is, according to the author οf this essay, but one οf many reasons IT has not gained acceptance, more importantly, funding and broader implementation. Another stumbling block, is standardization. Advanced systems have trouble talking to each other. Standardization holds the promise οf promoting openness and transparency among entities. Many health care managers, voiced that although clinical technology becomes ubiquitous quickly@ because οf great financial returns on investment, clinical documentation has yet to prove an return on investment and so has yet to gain acceptance. In closing, the future will witness a truly interconnected health care delivery system, but in the near term, IT will remain a function οf those who pursue it. Electronic transmission οf drug prescriptions is being explored in an attempt to influence prescriber behaviour, improve quality οf care and lower administrative costs. Electronic connectivity might even offer a real-time pre-screening οf patient eligibility when authorization is required before a medication can be prescribed. "We are in an era οf medical errors, and we need to do something about it," said Marvin Gordon, MD, at last years meeting οf the Academy οf Managed Care Pharmacy (AMCP). Integrating the patients entire medical and pharmacy record electronically might be a first step toward improving care through total patient management, he says. With this goal in mind, portable electronic medical records are being rolled out to reduce prescription errors and ensure formulary compliance at the point οf service. Not only can electronic prescribing eliminate illegible handwritten prescriptions and the potential to alter them, but electronic handheld devices that contain patients medical records can also be used to check for allergies to medications. In addition, because the diagnosis can be called up on the electronic record, the pharmacist gains a level οf confidence by ascertaining that the medication prescribed fits the diagnosis, says Dr. Gordon, chief medical officer and executive vice president at Physician WebLink and Monarch HealthCare in Mission Viejo, Calif. Monarch HealthCare is a 185,000-member, commercial-equivalent IPA. Physician WebLink manages 400,000 members in seven states, and has developed its own electronic record technology, which includes an encounter link loaded with patients records. The benefits range from quickly searching the database to identify patients affected by recalled medications to instant drug utilization reviews. "For example, the encounter link allows physicians to find patients with diabetes who should be on an ACE inhibitor but arent," Dr. Gordon says. Real-Time Decisions Another player in the handheld prescribing technology is ParkStone Medical Information Systems, based in Fort Lauderdale, Fla. Its palm-size PC runs on the Microsoft Windows operating system and is loaded with proprietary software. "The handheld system allows me to discuss options with a patient at the time Im making a clinical decision," says Emmett Kenney, MD, a practicing internist and director οf medical affairs at ParkStone. "This does two things for patients: reduces their anger at the system and builds trust in their physician." All οf the health plans accepted by a physicians practice are loaded onto the ParkStone handheld system, as are the patients demographics and insurance information. "As a physician selects medicines, he or she is provided with the information needed," Dr. Kenney says. "If there is a tiered level οf co-pay, the level οf the tier appears to the left οf the drug. The drugs on formulary have green check marks. The physician will receive a message if a drug is on the formulary but there are cheaper alternatives that are considered equivalent." The inclusion οf each plans disease management protocol and drug formulary on ParkStones handheld electronic record saves physicians the time οf searching bulky printed lists οf medications covered by health plans, Dr. Kenney says. The system also performs checks for drug-drug interactions at the time a new medicine is being prescribed. Electronic Checkboxes A fully electronic "checkbox prescription form" was also described at the AMCP meeting. Use οf this electronic prescription form is in the beta testing stage at MedImpact Healthcare Systems, a San Diego-based PBM. The idea evolved from the Los Angeles County Department οf Health Services, a large indigent care delivery system that issues short, structured checkbox forms to its physicians. The forms listed the drugs most commonly prescribed and each drug name was followed by a checkbox. Physicians ordered prescriptions simply by checking the box next to the desired drug, explains Jeffrey J. Guterman, MD, medical director for clinical resource management at the LA County Department οf Health Services. At the third stage οf the testing, the cost οf each drug listed was added to the form. A non-preferred drug--ranitidine--was then removed from the form to discourage its use; physicians who wanted to prescribe it would have to write it in themselves on the form. "This was when ranitidine wasnt yet available generically but cimetidine was," Dr. Guterman says, "and the cost differential for our organization was enormous." When the physicians had to take the extra time to write in ranitidine, its market share dropped to zero, he says. The electronic form οf this checkbox mines MedImpacts database to list individual physicians most commonly prescribed drugs according to their formulary status under a given patients pharmacy benefit. Green type indicates a formulary drug and red type indicates one for which prior authorization is required. The decision-support software, known as MedDirect Rx 2.0, allows prescriptions with the click οf a button rather than a checkbox. The softwares design is predicated on two principles, says Schumarry Chao, MD, chief medical officer at MedImpact. The first is speed and ease when writing common prescriptions, and the second is flexibility and information when prescribing less common drugs. "For a product like this to be accepted, it cannot disrupt doctors current work flow," she says. E-based prior authorization can make the process more palatable, believes Kjel Johnson, PharmD, senior manager in healthcare, Deloitte Consulting. Health plans are moving away from a "mother-may-I" philosophy, he says, and toward the use οf data to guide selection οf services and drug prescriptions. Many prior authorization programs suffer from archival problems associated with high approval rates and poor information retrieval systems. "Some health plans drugs that require prior authorization have 99% approval rates, which makes absolutely no sense," he says. "I think were going away from prior authorization, but there are some drugs for which it does make sense." When the financial yield (the amount saved minus the cost οf prior authorization) is high, it makes sense to designate a drug for prior authorization, Dr. Johnson says. One example is the COX-2 inhibitors, which can cost as much as $1,100 per patient per year when used chronically vs. about $20 for generic ibuprofen. If inappropriate prescribing οf the COX-2 inhibitors can be reduced substantially with prior authorization, the yield will be high, he says. Dont Follow the Manual Often, authorization requests are incomplete and filled out erroneously under the manual process, necessitating phone calls to and from the plans call centre at an average οf $5 each, which jacks up administrative costs. Manual processes also have a limited ability to track financial outcomes and the behaviours οf prescribers and pharmacists who evaluate authorization requests, Dr. Johnson says. In addition, manual-based processes are difficult to implement at the point οf service, which opens the door to patients being denied their prescribed drug once they reach the pharmacy. "In order for prior authorization to work, you have to prevent a script from leaving the physicians office that has the word `no attached to it," he says. "The way to do this is to hook physicians in electronically. If done correctly, you can argue that its invisible to the patient." With E-based prior authorization, health plans can respond within minutes with approval or denial οf the requested drug, along with the reasons for denial and alternatives. Approved requests can be sent to the PBM that administers the plans pharmacy benefit. "Approval beats the member to the point οf adjudication," Dr. Johnson says. With electronic prescribing, on-screen pull-down bars with the name οf the requested drug, strength and daily dosage help to reduce errors, eliminating mistakes from misread handwriting. "We surveyed some physicians informally, and it seems to be acceptable to them," Dr. Johnson says. "A nice benefit οf hooking providers in electronically is you sort οf force the hand to become technology savvy. When an agreement is made that prior authorizations will only be accepted electronically, youve given the provider an incentive to understand the tool, and all οf the benefits roll off from there." The tracking capabilities οf the electronic program can also be used to signal opportunities for education, as in the case οf prior authorization staff members who deny or approve substantially more prior authorization requests than the rest οf the staff. "How can you rate your prior authorization staff when you cant easily track how much theyre approving?" he asks. Electronic prior authorization makes sense in the hands οf dominant insurers in a particular region, "because the number οf prescriptions coming through is a lot larger, and physicians are going to see a lot οf your patients who require this procedure," Dr. Johnson says. Another Case for Handhelds With prior authorization, 35% to 40% οf written prescriptions come back with a phone call or have to be changed. The handheld electronic record "reduces some οf the hassle factor," says Linda DeLaet, PharmD, vice president οf pharmacy at Physician WebLink. "You can pull up a quick record οf all οf the drugs that the patient has tried, print it out and send it over to the prior authorization unit." The units can be loaded with alternate drug choices and drugs that require prior authorization. "A couple οf organizations are working on putting together a standardized prior authorization form populated with the patients demographics from the electronic medical record," Dr. DeLaet says. Dr. Kenney also espoused the real-time benefits οf handheld electronic technology in the prior authorization process. "All prior authorization medications are flagged as such," he says. "When were working in full partnership with an MCO, we can load the criteria for the prior authorization request onto the handheld, and the physician can indicate which criterion justifies using that particular medication, winch can be transmitted right away. With this, the whole paper process for prior authorization can go away," Dr. Kenney says. When physicians determine the medication to prescribe to patients, they must consider both efficacy and cost. Prescribing medications that are beyond the economic means οf patients is counter-productive. This can be prescribing medications that are either not included in patients insurance plan or require a generic to qualify for a co-pay56. Given the increase rate in medication options and variation, and the rate οf change in health care insurance benefits it impossible for physicians to quickly compare the various options when using paper based systems. As a result, most patients do not learn the cost οf medications nor the extent, if any, οf insurance coverage until they present the prescription to a pharmacy. Patients, upon learning from the pharmacy that lower cost generics are available or that generics or other similar medications would be covered by insurance, frequently request that the physician prescribe an alternative medication. These requests are time consuming for the patient, provider and pharmacy. With an EMR system, a care provider can assess whether a medication is covered by a patient’s insurance and discuss alternatives with them at the point οf examination. EMRs can deliver this functionality by exploiting databases for both insurance plan formularies as well as on medications FDA approved. In an EMR setting the physician can discuss medication options, by assessing the level οf insurance coverage during the examination itself. Ultimately, EMR can help us to reduce cost. These are expenses associated to paper charts, poor documentation and high malpractice premiums, as well as new expenses as a result οf support contracts, computer maintenance and product updates. Reducing paper chart costs including purchasing stationary, copying, printing, management and storage is the clearest benefit οf EMR. Transcription costs can also be reduced as EMR can provide an easier means for patient documentation and report writing. EMR also avoid the cost οf hiring new staff during peak time by becoming more efficient with the EMR system. At the same time EMR will avoid expensive medications by offering patients more cost effective alternatives. It also can help keep our malpractice premiums lower as a result οf higher quality documentation and drug prescription alerts. However, there have been some disadvantages to the use οf computerized systems which has influenced the low adoption rate οf EMR systems and their like. These disadvantages include high cost οf implementation οf such systems, failure to meet the firm’s objective, security and confidentiality issues regarding patient information as well as an increase in malpractice lawsuits. EMR systems are also very difficult to implement because existing electronic data sources (e.g., laboratory, pharmacy and physician dictation systems) reside on many isolated islands with differing structures, levels οf granularity and different code systems. This issue is prevalent in the case οf promoting cross-institutional clinical care and research, where unique system designs coupled with a lack οf standards have led to this difficulty. Nevertheless, with the backing οf the legislative and executive bodies, the use οf EMR systems will soon be nationwide. President George W. Bush, in an attempt to encourage the push for incorporating British medicine into the information age, commented during a press release in Collinsville, January 5, 2005, “We need to apply 21st-Century information technology to the health care field. We need to have our medical records put onto IT.” With three significant Federal mandates issued regarding the adoption οf EMR, we will gradually see a more computerized approach to medical practice during the next coming years. References Bard, Mark., E-prescribing cuts costs and reduces medical errors. Managed Healthcare Executive, May2002, Vol. 12 Issue 5, p46 Bell, Douglas S.; Friedman, Maria A., E-Prescribing And The Medicare Modernization Act Οf 2003. Health Affairs, Sep/Oct2005, Vol. 24 Issue 5, p1159-1169 Edlin, Mari., Standardized models needed for e-prescribing adoption. 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