What might your reaction be if a longtime adversary handed you an expensive gift--no strings attached? You'd likely eye that person warily, study the gift closely and ask a whole lot of questions. Some physicians say that would be a prudent approach for any doctor considering one of the recent offers from health plans that are offering free hand-held computers.
Since last fall, there have been at least a half-dozen announcements from health plans offering free or deeply discounted personal digital assistants, or PDAs, to thousands of their network physicians in an effort to jump-start the plodding move toward electronic prescribing.
WellPoint Health Networks is spending $40 million offering almost 19,000 of its highest-prescribing physicians in California, Georga, Missouri and Wisconsin their choice of either free desk-top or PDA-based computer systems and software. PDA users also get a year of free electronic prescribing service.
Many experts say health plan incentives are key to advancing adoption of electronic prescribing, which promises fewer phone calls to the pharmacy, more convenience for doctors and patients, and, most importantly, fewer medication errors. For the health plans, it promises lower costs by making it more convenient for physicians to stick to the preferred drug list.
But many say doctors should approach PDA freebies with a healthy dose of caution. "In the global picture, it's a wonderful idea, because most of the financial benefits will accrue to the health plans," says internist Patricia Hale, M.D., chief medical informatics officer at 332-bed Glens Falls (N.Y.) Hospital and chairwoman of the medical informatics subcommittee of the American College of Physicians, or ACP. "But there are a lot of concerns over how much the physician's behavior could be manipulated."
Hale cautions that electronic prescribing software can be designed to steer a doctor toward prescribing one drug over another-statin drug Pravachol instead of the more-expensive Lipitor, for example.
Hale says the ACP recommends that physician committees work with health plans to ensure the formulary list, drug-reference information and other features are not intended to influence prescribing patterns.
Health technology pundits also say doctors should know what happens to the data generated from their PDAs.
"Physicians need to do a lot of probing with regard to how that prescribing information is being shared," says pulmonologist William Bria, M.D., medical director of clinical information systems at the University of Michigan Medical Center and president of the Association of Medical Directors of Information Systems. "Is it only going to Blue Cross, or is it going to Blue Cross and Pfizer and AstraZeneca?"
Pools of aggregated prescription data from medical practices have long been valuable marketing tools for drug companies. Health plans and pharmacy benefit managers also use the information for quality improvement and to measure formulary compliance. But some physicians assert that an electronic platform will make it quicker and easier to generate neat, rich bundles of physician-specific prescribing information for use by PBMs, electronic prescribing vendors, drug companies and other third parties.
"With electronic prescribing, the doctor does all of the data entry, which makes the information a lot easier and less expensive to get at," says Thomas Sullivan, M.D., president of the Massachusetts Medical Society.
Sullivan, a cardiologist and ardent proponent of electronic prescribing, says the cloudiness around the data issue should not keep doctors from accepting a free PDA from a health plan. But they should be asking a lot of questions, he says: Where are those prescription data going? Who will own them? Will the practice have access to its own prescription information?
"There are plenty of areas in which that information can be put to legitimate and ethical use," Sullivan says. "But it's always in a physician's best interest to be aware of where it goes."
Others are more skeptical. "I think the managed-care industry is keen to move to an electronic format so they can manipulate data more easily," says David Cook, executive director of the Medical Association of Georgia. "Electronic prescribing is all well and good, unless the free software provided by the managed-care company routes the information to its pharmacy benefit manager, which then changes the prescription."
But health plans and some experts say those suspicions amount to paranoia and are largely a byproduct of the sometimes-bitter relationship between doctors and managed-care companies.
"We will not have any more information about our physicians than we already have," says Janet Carr, M.D., senior medical director at Group Health in New York.
The health plan last fall announced a partnership with electronic prescribing provider Zix Corp. to offer deep discounts on systems to more than 5,000 doctors in its network. "It might allow us to get the information a little faster or with a little more validity, but there's no additional information," Carr says.
Ron Ponder, WellPoint's chief information officer, says, "There is absolutely no effort being made here to gather data." He says the prescription information emanating from physician offices will be handled in the same way it always has been.
"There's no way for a drug company or anyone else to be able to exert any influence over that doctor's prescription," Ponder says. "With this project, to the best of my ability and knowledge, there are no strings attached." Ponder says WellPoint has no return-on-investment target for the project; its goal is fewer medication errors and increased convenience.
But health plans are also eyeing the cost savings that could come from increased formulary compliance once electronic prescribing becomes widespread, according to Mark Bard, president of Manhattan Research, a consulting firm focused on healthcare technology.
"Health plans aren't doing this to be altruistic," Bard says. "They have the potential to save a lot of money. But they also want access to prescription-level data."
And that's not a sinister thing, he says. Health plans increasingly sift through claims data to link treatment modalities with positive outcomes in an effort to improve quality. Today that process can be cumbersome and expensive, Bard says, but it could be made vastly easier if the data were in digital form.
He concedes, though, that it's a new ballgame with respect to how electronic, physician-specific information will be stewarded. "It is an unknown in terms of who owns it, who has access to it and in what form," Bard says.
Physicians have a "latent anxiety" about that lack of control, says David Kibbe, M.D., of the American Academy of Family Physicians. "The biggest string attached to free hardware or software has been the use of the data that emanate from them," says Kibbe, who is director of the AAFP's Center for Health Infor-mation Technology, created last fall to link a group of 10 large IT vendors offering discounts on electronic health record technology to family practices.
Kibbe says the center wants to raise awareness of the market value of the data physicians generate by designating "data stewardship" as one of its guiding principles. The others are affordability, compatibility and interoperability. "Data from physician practices that is aggregated and de-identified is still valuable to certain people for research, quality improvement, marketing or other uses," he says. "Theoretically we have no problem with that information being used by third parties. But physicians ought to be sophisticated enough to understand what that information is and to not simply give it away."
Kibbe says the AAFP negotiates discounts on behalf of its members, and vendors sell directly to the practices. He says there is no financial arrangement between the AAFP and vendors.
The AAFP has released a report titled Future of Family Medicine, which says technology soon will transform the way family doctors practice medicine. It envisions a day when every practice has an electronic health record and doctors make care decisions with the help of a regularly updated database of evidence-based guidelines. Also, the Medicare reform law re-quires HHS to establish electronic prescribing standards for Medicare by 2008.
Mike Colias is a freelance writer based in Chicago. He can be reached at [email protected].