Given the breadth of pharmacy and patient care services spread throughout the network of Allina Hospitals & Clinics in the Twin Cities metropolitan area—11 hospitals, more than 80 clinics, and 15 pharmacy locations—we were both fortunate, and challenged, to implement electronic prescribing (e-prescribing) throughout our health-system continuum. The primary goal of this initiative was to enable clear and concise information exchange during the entire prescribing process and consequently improve refill request turnaround time for our pharmacies. As a result of our successful implementation, our prescribers now have prescription insurance formulary and prior authorization information available to them at the point-of-care, and our overall refill turnaround time has dropped significantly. While the ends have justified the means for this project, there were several challenges, both in conception and in execution, to making e-prescribing a success.
An Open-minded Approach
Imagine attending your first clinic leadership meeting and the physicians open (and perhaps close) by expressing a long-standing frustration with nonformulary rejects and medication prior authorization (PA) calls coming from the pharmacies. As this was happening to me, my first thought recalled my past experiences working for a prescription benefit manager wherein these very issues, common among hospitals and health systems of all sizes, were addressed through the compilation of formulary files and PA information via e-prescribing systems. The concept was fairly simple; using an e-prescribing system, where real-time formulary and PA information is available at the physician’s fingertips, will reduce the number of interceding calls from the pharmacy and automate the entire process.
I am sure we all agree that a patient should have the proper formulary agent prescribed from the onset, as this provides savings on patient prescription costs and reduces delays at pharmacies waiting for PA approvals, among other benefits. In our case, the clinic patients also were experiencing up to three-day delays in response to their refill requests. I left that first clinic leadership meeting with a better understanding of the challenges faced by our physicians, as well as the beginnings of how to tackle those challenges. I knew that e-prescribing, which features electronic refill request and electronic refill response mechanisms, could potentially provide vast improvement to the refill request process. I also knew this would improve physician and patient satisfaction by reducing pharmacy call backs for physicians and expediting refill turnaround time for patients.
Once we decided to move forward with enabling e-prescribing in our health system, our electronic medical record (EMR) vendor agreed to work with us on building e-prescribing capabilities into our existing medical record technology by configuring the EMR with new interfaces to connect to e-prescribing vendors. As our old system was configured for automatic faxing of prescriptions after selecting a patient’s preferred pharmacy, the workflow was essentially the same, except with e-prescribing, the prescription—as well as a refill request—is sent to the pharmacy electronically and is automatically entered directly into the EMR. One process that did not change was controlled substance prescriptions, which continue to be sent directly to a printer for physical prescriber signature—a process we decided still required manual action steps. For all staff that would be working with the system, we produced updated workflow training materials describing how to send prescriptions electronically and how to manage an electronic refill request within the EMR.
Prior to system-wide rollout, we decided to run pilots in two clinics and one hospital to test the prescription technology in a live environment, work out any issues, and gain experience with, and determine the effectiveness of, the training materials. After running the pilots for approximately four weeks, we made final decisions regarding features we wanted to include, as well as when to push the system out, enterprise wide. The pilots proved especially effective in training, as the first drafts we used during the pilot were then augmented by end-user feedback to update final training materials.
Process Challenges and Workflow Management
During the pilot phase, we discovered a few unexpected challenges. While some processes, such as faxing versus electronic transmission of a prescription, may seem to function in the same fundamental way, you should compare the way in which your pharmacy information system (PIS) populates a pharmacy record with the way in which the e-prescribing system will. One of the early issues with our implementation was that we had established a state-wide pharmacy record database (name, location, phone and fax numbers, etc) that our PIS used during automatic faxing of prescriptions. This became a problem when the download of the e-prescribing pharmacy data interacted with the existing pharmacy database. Pharmacy location records were being duplicated during the download if there was not a match on the pharmacy’s National Council for Prescription Drugs Programs (NCPDP) number. In the pilot test environment, we were able to identify the pharmacy records that were being duplicated and resolved them by manually calling local pharmacies and by using prescription pharmacy claim data to identify NCPDP numbers. These issues can be presumed and handled ahead of time by reviewing your pharmacy record data, identifying how it is recorded, and factoring in how the e-prescribing database will mesh with existing records.
Another issue arose when we were setting up providers as e-prescribers within the prescriber database. Early provider records failed, as our internal interface had missing fields, unrecognized abbreviations, and extra spaces within the records that prevented a successful setup. Each record that failed needed to be manually updated in order to function correctly. For those facilities working toward e-prescribing, it is invaluable to manage this problem by submitting provider records early and resolving systemic failed provider files well ahead of the go-live date.
For pharmacies not familiar with e-prescribing or not used to significant e-prescription volume, a new workflow may be required. With e-prescribing, pharmacies should obviously expect to see a significant uptick in e-prescriptions while faxes are phased out of the new workflow. Also, work with your e-prescribing vendor to have them provide ideal communication formats to facilitate the new electronic delivery of prescriptions. In our case, each location identified their local high volume pharmacies to receive the change-of-prescribing-format communication fax blast, which explained the date of setup and provided information on how to become an e-prescribing pharmacy.
For our prescribers, a new workflow was required as handling electronic refill requests was different from traditional hand-entered, faxed, and phone-in requests. To ensure a smooth transition to electronic refilling, training materials for nursing and prescribers were developed to detail each step in the request and refill response approval processes. These workflow tip sheets were reviewed at prescriber and nursing staff meetings prior to implementation to ensure all affected parties were represented.
Best Practices for e-Prescribing
One of the best practices we discovered to ensure optimal use of e-prescribing was to default all prescription delivery to e-prescribing versus leaving the default to printed prescription and simply adding e-prescribing as an option. Our pilot experience revealed that prescribers quickly became comfortable with e-prescribing and were frustrated when they had to change a prescription from print mode to e-prescribing. Our prescribers felt that by setting prescription delivery default to e-prescribing the number of data entry clicks required to complete the prescription ordering and delivery process was minimized.
With this in mind, pharmacy administrators can get prescribers on-board by explaining what is in it for them. Prescribers want prescription processes to be more intuitive, take less time, and mitigate any rework. Thus, emphasize that with e-prescribing, after data entry, an e-prescription is automatically delivered to the pharmacy of the patient’s choice. Clarify that prescribers will have formulary and PA information at the point-of-care during the prescription writing process, and that this puts the onus on the prescriber to get their order information correct the first time, thereby preventing rework and calls from the pharmacies to change to formulary products and to complete PA approval processes. Last of all, test new workflows with prescribers to ensure the setup meets their expectations for ease of use and time saving.
e-Prescribing System Benefits
One of the benefits we expected from the onset of instituting e-prescribing was to improve the refill request and response turnaround time. Using our e-prescribing vendor’s provider-level data on usage and response time to prescription refill requests, we can monitor our prescribers and continue to improve refill response times. Our outlier clinics and prescribers are now fed data on their refill response times emphasizing our expectations of 48 hours of business time or less to respond to refill requests.
Overall, the results of e-prescribing have been positive with providers seeing more formulary and prior authorization information during the prescribing process. Although nonformulary and PA calls still come in from pharmacies, it is no longer a hot topic at clinic leadership meetings, as physicians now know they have the information they need at their fingertips to make any necessary changes. Refill turnaround time also has been dramatically improved; previously, after a weekend it took up to three days to respond to refill requests. Now, after a weekend, all refill requests are completed in half a day or less. On average, 88% of all refill requests are responded to in 48 hours of business time or less. Thus, reduced refill request turnaround has improved patient satisfaction with the refill process at our clinics and pharmacies.
An early key to success was gaining buy-in from our physician chief medical officer. After explaining the benefits of e-prescribing to him, he shepherded the request for resources though the organization and was an advocate for the technology at a physician lead project review committee. This advocacy was key to obtaining project funding approval and prioritization before beginning the project.
Another key to success was the use of a project team with an assigned project manager. Our team consisted of experts from our EMR vendor, internal EMR developers, data interface managers, and hospital and pharmacy administration members. The project manager kept the team moving though tasks and maintained the predetermined schedule for project delivery. Using an issues log to track problems, then fully vetting them in team meetings, provided successful, team-driven solutions.
e-Prescribing, Medicare, and the DEA
When examining e-prescribing for your institution, consider not only the benefits and challenges to implementation, but also what ramifications it will have on other areas of your practice. For example, to qualify for the e-prescribing incentive from Medicare (see the sidebar on page 24), prescribing professionals must have adopted a qualified e-prescribing system. To meet this definition, the system must, at least, have an active medication list and medication dispense history, it must transmit e-prescriptions, and it must provide formulary information and alternatives to nonformulary or higher cost/tier medications. In order for us to implement a qualified system, it took two separate implementations: one for e-prescribing, and the other for medication lists, formulary, and alternative information. Our approach was to add e-prescribing after the pilot to all sites, and then to add the formulary information to all sites. The e-prescribing addition required new workflows to be developed, but adding formulary information was automated and was simply inserted into the ordering process without significant prescriber training or adjustment to workflow.
Controlled substance e-prescribing is currently being addressed with rules by the DEA that will allow for and define the practice. At this time, e-prescribing transmission vendors are still defining workflows and developing the infrastructure technology to support this sensitive element. Early pilots for e-prescribing of controlled substances are expected by vendors in the spring of 2011.
As an early adopter, we found that while formulary and PA information was available for patients on Medicare part D plans, this same information was lacking for insured commercial populations. I met personally with the commercial insurers’ pharmacy directors to explain the advantages and benefits of e-prescribing. I explained that with formulary and PA information available at the point-of-care, formulary adherence would improve and prescribers could limit PAs, and thereby limit calls to insurers to process PA requests. Improved formulary adherence will lead to lower cost formulary products and more generic opportunities with less PA processing work. While all the commercial insurers I spoke with were receptive to this idea, technology and resource limitations were commonly mentioned constraints to immediate implementation.
Our implementation of e-prescribing has brought much needed clarity and control to the prescription ordering and refill process, and yet there is a positive potential for expanding the system further. At this point we are looking to add formulary and PA information to our inpatient medical record system allowing prescribers writing discharge prescriptions to have access at the point-of-care. We also plan to add controlled substance e-prescribing once DEA rules are defined and vendors enable the practice. I see the future of e-prescribing in the hospital setting expanding as more hospitals add an EMR to take advantage of Meaningful Use incentives provided by the CMS. I also expect to see electronic PA processing being done at point-of-care in the future, moving the process upstream, eliminating rework by the prescriber and smoothing the prescription fill process at the pharmacy.
Lee A. Mork, MS, RPh, MBA, has been director of ambulatory pharmacy services for Allina Hospitals and Clinics for the last three years. In this role, he is responsible for the ambulatory Pharmacy & Therapeutics Committee, medication policies, pharmaceutical purchasing, medication storage and handling, patient medication assistance programs, and prescription technologies for 63 primary care clinics. Lee’s professional interests include prescription technologies and vaccines.
Incentives for e-Prescribing Implementation
The Centers for Medicare & Medicaid Services (CMS) provide physicians with incentives, such as the current 2% discount on Medicare patient visits, for e-prescribing setup and use during Medicare part B patient office visits, currently through 2013. Providers must report on their adoption and use of a qualified e-prescribing system and show at least 25 unique electronic prescribing events during a calendar year in order to qualify for the incentives. Due to the size of our physician base of 500 providers, the CMS incentive covered the costs of the e-prescribing installation within our EMR. For more information on the CMS e-prescribing incentive, visit www.cms.gov/eprescribing/
Managing Legal Issues
Among possible attendant legal issues with e-prescribing is that patient consent may be required in your state to access that patient’s medication dispense history. For example, Minnesota has a patient opt-out rule for use of a medical record locator service. We have found two solutions to the patient consent issue: either use a separate patient consent form to obtain medication dispense history or use a nonseparate patient consent to obtain medical record and medication dispense information in the same patient consent form. Our setup has a single patient consent form for both types of information.
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