Part one of a two-part series (Access part two):
Software vendor Allscripts Healthcare Solutions assembled a coalition of healthcare plans, technology companies and provider organizations to back an offer to provide a free, Web-based electronic-prescribing service to all U.S. physicians in an effort to boost what so far has been lackluster use of the technology.
Members of the coalition, called the National ePrescribing Patient Safety Initiative, announced the strategy last week during a media event at the National Press Club in Washington, and introduced the eRx Now service. Others who have signed on as corporate sponsors are computer makers Dell and Fujitsu Computer Products of America; software developer Microsoft Corp.; network equipment maker Cisco Systems; data-miner Wolters Kluwer Health; telecommunications provider Sprint Nextel Corp.; and SureScripts, the for-profit consortium formed by two leading pharmacy trade groups that provides an e-prescribing technology platform connecting doctors offices with retail pharmacies and pharmacy benefit managers.Health plan sponsors include Aetna, Horizon Blue Cross and Blue Shield of New Jersey and WellPoint. There also are a host of providers acting as "regional supporters" of the free e-prescription offering, including Brown & Toland Medical Group, San Francisco, and the University of South Florida Physicians Group, Tampa. Allscripts and its partners have tried to make the service as accessible as possible via desktop, laptop or handheld computer, and partner Sprint is offering a limited number of "smart phones" that can be used as script writing tools.
But Allscripts and its fellow boosters will be wading into a decade-long battle with physician resistance to e-prescribing specifically and information technology systems in general.
Other groups previously have given away e-prescribing technology in the hopes of enticing doctors to put away their prescription pads -- something theyve been reluctant to do. According to a report on IT usage by the Robert Wood Johnson Foundation released in October 2006 that cites data from multiple surveys as of 2005 -- the most recent year available -- while 24% of physicians used an electronic health record, only 9% used a system that had advanced functions such as e-prescribing.
In addition, adoption of EHRs varies significantly by practice size, according to an authoritative 2005 survey of physician office practices by the Medical Group Management Association and the University of Minnesota School of Public Health, which was funded by the federal Agency for Healthcare Research and Quality. Just 10% of physicians in practices of five physicians or fewer had a fully implemented EHR, the lowest adoption rate of the four size classifications in the survey, while groups with 11 to 20 physicians had a 14% adoption rate, the highest rate of the size classifications used.
However, neither survey measured the use of stand-alone e-prescribing tools like eRx Now or similar systems offered by several competitors.
Back in the dot.com heyday in healthcare in the late '90s, dozens of software companies sprang up financed by venture capital and pharmaceutical company money. The e-Rx companies often threw in personal digital devices as well as provided free software, all with the aim of capturing the attention of physicians in primary care who write the bulk of drug prescriptions. Few of those companies are around today.
"We in the industry have used the mantra that free is not good enough," said Rick Spurr, chief executive officer of ZixCorp, which, like Allscripts, is a survivor of the dot.bomb shakeout of 2000 and 2001. ZixCorp offers a competing, Web-based e-prescribing service. The ZixCorp e-Rx system also is provided without charge to physicians because ZixCorp sells the system not to doctors but to health plans, which then offer it to physicians.
"There have been any number of these things that have not succeeded," Spurr said. "This is an extremely complex area, and its highly, highly sensitive. You can kill people. So your quality control has to be off the charts and so does your reliability. If it doesn't work every time, the doctors wont use it.Thats why we say free is not good enough.
Spurr said he thinks if the Allscripts effort creates a rising tide of physician acceptance of e-prescribing, it could lift all IT vendors boats for other systems, such as EHRs. It should spur patient awareness, too.
There are 225,000 high-prescribing physicians in the U.S practicing in offices, Spurr said. Were really talking about the primary-care physicians, pediatrics, internal and family medicine. Eighty percent of them practice in groups of 10 or less. The best way to reach those small office practitioners is with Web-based IT systems, he said.
All and all, were very excited about this, Spurr said. It raises to a very significant extent the problem here, which is patient safety. We are not afraid of competition. Well get more than our fair share of the market and well do as well as a result.
In Massachusetts, where ZixCorp counts about 2,000 e-prescribing physicians, its highest concentration of physician users, the software fires off 8,000 alerts a month, or about four per physicians a month, warning them of possible drug-drug, or drug-allergy reactions, Spurr said. Avoiding adverse drug reactions will save plans money, but that is just one of a number of benefits to the plans from e-prescribing, he said.
The most tangible benefit to them is on drug spend(ing), most notably through increase in generic substitution, Spurr said. Weve seen in our data that customers see a 5% increase in generic substitution. Theyve noticed in Massachusetts the plans get a 3% to 3.5% reduction in drug spending by using e-prescribing.
Spurr said the average prescription is $65, and the physician most often approves up to three refills, of which, industry numbers are that one to 1.5 of the refills get picked up, Spurr said. So, on the low end, with a 3% cost reduction, the plan saves about $1.80 per picked up prescription, or $3.60 to $4.50 per patient, counting refills.
Prescription drugs accounted for $200.7 billion, or roughly 10% of the nearly $2 trillion total U.S. healthcare bill in 2005, the latest year national numbers are available, so there is, potentially, a lot to gain -- between $6 billion and $7 billion a year -- and even with modest 3% to 3.5% reductions in drug spending.
We have a (payer) customer who has said, if one of the docs using your tool is writing five new prescriptions a week using the device and where the scripts are (written for) my members theyve agreed to pay us $1,100 a year, Spurr said. When you do that math, theyre paying us $4.50 a script, and so, at a minimum, theyre breaking even on that. Theyre saying theyll go down as low as a doc writing just five a week. To Spurr, thats pretty strong evidence of the bottom-line that benefit plans see in e-prescribing.But its those side benefits that have privacy experts worried. According to Deborah Peel, an Austin, Texas, psychiatrist and founder of the Patient Privacy Rights Foundation, in a written response to the eRx Now proposal, the effort to boost e-prescribing without adequate patient privacy protections is a bad idea. If doctors e-prescribe, they will violate the laws and ethics they are required to uphold by disclosing sensitive patient records into electronic systems that allow e-prescriptions to be reused for purposes other than filling prescriptions, Peel said. It is bad medicine to use the current e-prescription system, which was not engineered to obtain patient consent before secondary uses or to segment access to sensitive prescriptions.
It is really good news that healthcare industry players like NEPSI members and the IOM are finally proposing ways that prescription data can be used to benefit patients, she said. But NEPSI and the IOM should simultaneously call for e-prescribing systems to be rebuilt to ensure that patients have ironclad control over access to their sensitive e-prescriptions.
Don Schoen is chairman of the Electronic Health Records Vendors Association of the Chicago-based Health Information and Management Systems Society and the CEO of MediNotes, Des Moines, Iowa, a developer of an EMR system for physicians in solo and small group practices.
Schoen praised Allscripts initiative in rounding up a broad range of participants in the program and for raising awareness about e-prescribing.
Ive talked with my colleagues on the (EHRVA) executive board, and from our perspective, any type of automation is a step forward, Schoen said. The more comfortable they (physicians) are using a computer or a PDA, the more it will enhance adoption.
On the other hand, Schoen questions whether it is wise to have physicians adopt a lower form of technology, only to have to abandon it when they move up to a higher technology such as an EHR.
You are incentivizing doctors with only a specific (e-prescribing) product and is that the right message to be sending to the marketplace? he asked. You dont want to make automation a process that doctors rework again and again. Its hard enough to make them do it one time. It might cause them real heartburn.Tomorrow: E-prescribing and the question of quality