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Electronic Prescribing:Electronic Prescribing:
Planning and Implementation to Planning and Implementation to Achieve Success and Maximize ValueAchieve Success and Maximize Value
Jonathan TeichJonathan TeichPat HalePat Hale
Peter BaschPeter BaschBob ElsonBob Elson
Rick RatliffRick Ratliff
Electronic Prescribing: Electronic Prescribing: Introduction - the Value - Stages of Introduction - the Value - Stages of
eRxeRx
Jonathan Teich, MD, PhDJonathan Teich, MD, PhD
SVP and Chief Medical OfficerSVP and Chief Medical Officer
HealthvisionHealthvision
Chair, eHI Electronic Prescribing Chair, eHI Electronic Prescribing ProjectProject
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What is electronic prescribing?What is electronic prescribing?
““Electronic prescribing” or Electronic prescribing” or “Computerized prescribing” = all “Computerized prescribing” = all systems that use a computer to systems that use a computer to enter, modify, review, and enter, modify, review, and communicate drug prescriptions. communicate drug prescriptions.
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PDA’sPDA’s
•Useful where space is limited, or for multi-room practice
•Wireless and stand-alone
•Security concerns – “the floor and the door”
•EHR/EMR connected systems usually desktop-based
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Rx in EHR
Rx in EHR
ConnectivityConnectivity
Med Profile Management
Med Profile Management
Allergy, Formulary, AgeAllergy, Formulary, Age
Basic Rx Entry / Dose checkBasic Rx Entry / Dose check
Reference onlyReference only
Stages of Stages of eRxeRx
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eRx ValueeRx Value
There are significant errors and ADE’sThere are significant errors and ADE’sGandhi: ADE’s in 5-18% of ambulatory pts/yrGandhi: ADE’s in 5-18% of ambulatory pts/yr
CITL: Nationwide adoption of “ACPOE” predicted CITL: Nationwide adoption of “ACPOE” predicted to eliminate 2.1 million ADE’s/year (136,000 life-to eliminate 2.1 million ADE’s/year (136,000 life-threatening)threatening)
There are significant inefficienciesThere are significant inefficienciesCGEY: Nurses save 2.87 minutes per faxed RxCGEY: Nurses save 2.87 minutes per faxed Rx
Illinois study: 50% reduction in pharmacy Illinois study: 50% reduction in pharmacy callbackscallbacks
Electronic Prescribing: Electronic Prescribing: Planning and Implementation to Achieve Planning and Implementation to Achieve
Success and Maximize ValueSuccess and Maximize Value
A Provider’s PerspectiveA Provider’s Perspective
Peter Basch, MDPeter Basch, MD
Medical Director Medical Director
MedStar e-Health InitiativeMedStar e-Health Initiative
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MedStar’s e-Health InitiativeMedStar’s e-Health Initiative
MedStar Health – 7-hospital system in the MedStar Health – 7-hospital system in the Baltimore-Washington corridorBaltimore-Washington corridor
MeHI started in 2000 toMeHI started in 2000 toProvide guidance to physicians from physicians, on Provide guidance to physicians from physicians, on practical e-health technologiespractical e-health technologies
Syndicate selected e-health products and servicesSyndicate selected e-health products and services
e-Prescribing was an early target for syndicatione-Prescribing was an early target for syndicationFar easier and cheaper than inpatient CPOE, a “near Far easier and cheaper than inpatient CPOE, a “near term doable”term doable”
Goals – enhance patient safety while improving Goals – enhance patient safety while improving workflow within the physician’s practice (as well as workflow within the physician’s practice (as well as wins for other stakeholders)wins for other stakeholders)
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MeHI’s approach to eRx – 2001 MeHI’s approach to eRx – 2001
Investigated marketInvestigated marketUsed a consultant to do a preliminary vendor Used a consultant to do a preliminary vendor analysisanalysis
Demos + “demo-lition derby”Demos + “demo-lition derby”
Selectively engaged with finalist vendorsSelectively engaged with finalist vendorsFar easier to do in an emerging market with startupsFar easier to do in an emerging market with startups
Became part of process / political redesignBecame part of process / political redesignBetter productBetter product
Align costs / benefitsAlign costs / benefits
15
MeHI’s approach to eRx – 2003-nowMeHI’s approach to eRx – 2003-now
Preferred pricing arrangements for any MD Preferred pricing arrangements for any MD affiliated with our hospitals with 2 vendorsaffiliated with our hospitals with 2 vendors
Participation in the eHealth Initiative report on eRxParticipation in the eHealth Initiative report on eRx
1-yr pilot with DrFirst and CAQH1-yr pilot with DrFirst and CAQH4 of every 1000 prescriptions (~2/day) were deemed 4 of every 1000 prescriptions (~2/day) were deemed by the prescriber to be by the prescriber to be significantsignificant mistakes (and mistakes (and were changed before being sent to the pharmacy)were changed before being sent to the pharmacy)
93% of meds were written as generic or allowed to 93% of meds were written as generic or allowed to be substitutedbe substituted
30% of meds were substituted for a formulary 30% of meds were substituted for a formulary alternativealternative
Benefit for providers is less clearBenefit for providers is less clear
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Moving ahead with eRx…Moving ahead with eRx…
Getting clinicians’ attentionGetting clinicians’ attention
Choosing a vendorChoosing a vendor
A lingering question… standalone A lingering question… standalone eRx vs. EHR?eRx vs. EHR?
Incentives – aligning costs / benefitsIncentives – aligning costs / benefits
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Getting clinicians’ attentionGetting clinicians’ attention
Creating the imperativeCreating the imperativePaper-based prescribing is fraught with error - sure Paper-based prescribing is fraught with error - sure there’s bad handwriting, missing decimal points, there’s bad handwriting, missing decimal points, and just bad judgment…and just bad judgment…
But if you want to be But if you want to be heardheard by doctors… by doctors…• Exponential increase in new drugsExponential increase in new drugs• More patients with multiple conditions taking More patients with multiple conditions taking
multiple medsmultiple meds• Multi-tasking is efficient but can lead to errorsMulti-tasking is efficient but can lead to errors• eRx is the right thing to do, and can be done eRx is the right thing to do, and can be done
todaytoday• eRx will be the standard of careeRx will be the standard of care
The challenge – busy clinicians still have to The challenge – busy clinicians still have to slow down to listen to this messageslow down to listen to this message
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Choosing a vendorChoosing a vendorDesign and usabilityDesign and usability
Web-based for PC, tablet, and PDA useWeb-based for PC, tablet, and PDA usePDA issuesPDA issues
• Pocket PC vs. PalmPocket PC vs. Palm• Synchronous vs. asynchronousSynchronous vs. asynchronous
Consider incremental adoptionConsider incremental adoption if office e-readiness is low if office e-readiness is low (start with refills, progress to point-of-care prescribing)(start with refills, progress to point-of-care prescribing)Usability is criticalUsability is critical
WorkflowWorkflowPhysician and staff workflowPhysician and staff workflow
Integration with practice management systemIntegration with practice management systemRobust bidirectional connectivityRobust bidirectional connectivity
Information gatewayInformation gatewayTransactional gatewayTransactional gateway
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Standalone eRx vs. EHRStandalone eRx vs. EHR
Standalone eRx is cheaper and easier than an EHRStandalone eRx is cheaper and easier than an EHRBut it doesn’t do the functions that makes embedded eRx But it doesn’t do the functions that makes embedded eRx desirable (Rx + med list + chart documentation)desirable (Rx + med list + chart documentation)
To make it fit clinician workflowTo make it fit clinician workflow• Either keep medication database separate from the chartEither keep medication database separate from the chart• Always print it for the chart, orAlways print it for the chart, or• Always open the eRx application with the chart (for staff and Always open the eRx application with the chart (for staff and
doctors)doctors)
Point-of-care prescribing and renewals should never be done in Point-of-care prescribing and renewals should never be done in a vacuuma vacuum
Embedded eRx in an EHREmbedded eRx in an EHRClear advantages to workflow and staff efficiencyClear advantages to workflow and staff efficiency
May not require any additional incentivesMay not require any additional incentives
20
SummarySummary
Without mandates and/or incentives, getting Without mandates and/or incentives, getting clinician attention / engagement takes workclinician attention / engagement takes work
Even with mandates, incentives are Even with mandates, incentives are necessary to align costs and benefits necessary to align costs and benefits
Choosing a good vendor should make the Choosing a good vendor should make the work of implementation much easierwork of implementation much easier
While standalone eRx may work for some While standalone eRx may work for some clinicians, for others it may make more clinicians, for others it may make more sense to start by adopting eRx as part of an sense to start by adopting eRx as part of an EHREHR
Electronic Prescribing:Electronic Prescribing:Managing Implementation - Managing Implementation -
Pointers and PitfallsPointers and Pitfalls
Patricia L. Hale, MD, PhDPatricia L. Hale, MD, PhD
CMIO Glens Falls HospitalCMIO Glens Falls Hospital
Chair of MISC - American College of Chair of MISC - American College of PhysiciansPhysicians
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Implementing eRxImplementing eRx
PlanningPlanningGather key stakeholdersGather key stakeholdersUnderstand your needs and your feasibilities Understand your needs and your feasibilities
System SelectionSystem SelectionFeaturesFeaturesPrice – pricing modelsPrice – pricing modelsPotential for upgrading to EHRPotential for upgrading to EHR
Hardware and servicesHardware and servicesWorkflow issuesWorkflow issuesDesktopDesktopPDA’sPDA’s
ListsListsTraining/startup periodTraining/startup period
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Implementation RecommendationsImplementation Recommendations
Access important resources including the Access important resources including the vendor and similar organizations that have vendor and similar organizations that have already deployed the same application. already deployed the same application.
Ensure adequate infrastructure and devices. Ensure adequate infrastructure and devices.
Pay attention to organizational culture and Pay attention to organizational culture and behavior change management from the behavior change management from the start.start.
Before selecting and implementing an Before selecting and implementing an electronic prescribing application, plan for electronic prescribing application, plan for migration towards a complete EMR.migration towards a complete EMR.
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Implementation ProcessImplementation Process
Purchase and install system hardware
Establish users and roles
Load lists: patients, pharmacies, formularies, favorites, etc.
(Possibly) load prior patientmedical or medication data
Identify and address major implementation issues before selecting a system.
25
Implementation Implementation IssuesIssues
Address startup and interface issues Address startup and interface issues early:early:
Integration with a practice Integration with a practice management system to gain access to management system to gain access to registration and schedule information, registration and schedule information, Loading patients’ initial medication lists Loading patients’ initial medication lists from the previous system or from paper from the previous system or from paper records; and records; and Selecting and loading the appropriate Selecting and loading the appropriate payer and formulary information.payer and formulary information.Communication with pharmacies, Communication with pharmacies, health plans, etc.health plans, etc.
26
Implementation IssuesImplementation Issues
Identify Hardware and Service Needs:Identify Hardware and Service Needs:
In-office siting and connectionsIn-office siting and connections
Networking / Internet / wireless Networking / Internet / wireless
Communications services (e.g., to Communications services (e.g., to pharmacies)pharmacies)
What are your pharmacies ready for?What are your pharmacies ready for?
How will you access Health Plan How will you access Health Plan information?information?
Can you communicate with other Can you communicate with other providers?providers?
27
Implementation IssuesImplementation Issues
Prepare Lists:Prepare Lists:UsersUsers
Patient load Patient load oror PM connection PM connection
FormulariesFormularies
FavoritesFavorites
Initial medication loadInitial medication load
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Implementation IssuesImplementation Issues
Keys to Success:Keys to Success:
Strong leadership & commitmentStrong leadership & commitment
Incremental approachesIncremental approaches
High support staff involvementHigh support staff involvement
Medication history preloadMedication history preload
The “basics” well planned in The “basics” well planned in advanceadvance
PMS interface, network, devices, PMS interface, network, devices, training & supporttraining & support
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Implementation IssuesImplementation Issues
Challenges:Challenges:Good application not sufficientGood application not sufficientCultural issues/managing behavior Cultural issues/managing behavior changechangeStartup issues and problem resolution.Startup issues and problem resolution.Rollout timing and sequencing.Rollout timing and sequencing.Higher relative cost for small practicesHigher relative cost for small practices
Electronic Prescribing:Electronic Prescribing:Managing Implementation – Managing Implementation –
Clinical Decision Support, Formulary, Clinical Decision Support, Formulary, Medication ListsMedication Lists
Bob Elson, MD, MSBob Elson, MD, MS
VP Medical AffairsVP Medical Affairs
RxHub, LLCRxHub, LLC
31
Implementation: Decision Implementation: Decision SupportSupport
List maintenanceList maintenanceActive medications, allergies, problemsActive medications, allergies, problemsOther key data: weight, lab resultsOther key data: weight, lab results
Warnings management / workflowWarnings management / workflowUser roles / privilegesUser roles / privilegesOverride justification / documentationOverride justification / documentationDe-activation / disabling of warningsDe-activation / disabling of warnings
Knowledge base updatingKnowledge base updatingCustom warnings?Custom warnings?
Understand decision support “holes”Understand decision support “holes”ApplicationApplication safety “czar” safety “czar”
Bell, DS. A conceptual framework for evaluating eRx systems. JAMIA, 2004.11:60-70.
Fernando, B. Prescribing safety features of GP computer systems. BMJ. 2004;328:1171
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“Intelligent Intervening Provider”
Application Safety: User vs. System Application Safety: User vs. System ErrorError
33
Implementation: FormularyImplementation: Formulary
Getting the dataGetting the dataOn vs. off-formulary, preferred, restrictions, On vs. off-formulary, preferred, restrictions, copaycopayHealth plan coverageHealth plan coverageData costs?Data costs?
Mapping a patient to the right formularyMapping a patient to the right formularyWorkflowWorkflow
Pointers to preferred alternativesPointers to preferred alternativesOverridesOverridesPrior authorizationPrior authorization
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Implementation: Medication Implementation: Medication ListsLists
Building initial medication listsBuilding initial medication listsThe “backfile conversion” problemThe “backfile conversion” problem
Medication list maintenanceMedication list maintenance““brown paper bag” intakebrown paper bag” intake
Active vs. inactive medsActive vs. inactive meds
Medications prescribed by other Medications prescribed by other physiciansphysicians
Assessing complianceAssessing compliance
35
Implementation: “Front-End” Implementation: “Front-End” ConnectivityConnectivity
Eligibility-driven formulary mappingEligibility-driven formulary mapping
Claims-based prescription historyClaims-based prescription history
36
Member ID Load
Member ID Load
Member ID Load
Eligibility-driven Formulary MappingEligibility-driven Formulary Mapping
PBM
PBM
PBM
Multiple responses combined
Clinic System(eRx, EMR)
Master Person Index
MPI
Eligibility Request
Unique patient
identification
Eligibility Request
Eligibility Request
Eligibility Response
Eligibility Response
Eligibility Response
eRxUtility
37
Claims-based Prescription HistoryClaims-based Prescription History
PBM
PBM
PBM
Medication History Request
Medication History Request
Med History Response
Medication History Response
Clinic System(eRx, EMR) eRx
Utility
38
Sample Rx Claims History Sample Rx Claims History “Report”“Report”
Patient Filled Prescription Report:
Patient ID: PATID1234Name: JONES, WILLIAM A.Address: 1200 N ELM STREET
GREENSBORO, NC 27401-1020DOB: 06/15/1961 Gender: Male
Filled Prescription Date Range: 08/01/2002 – 08/01/2003
CAUTION: Certain information may not be available or accurate in this medication claims history, including over-the-counter prescriptions, prescriptions paid for by the patient or non-participating sources, or errors in insurance claims information. The provider should independently verify medication history with the patient.
----------------------- FILLED PRESCRIPTION SUMMARY -------------------Summary:Drug Name: Strength Oldest Most Recent #of
Dosage Fill Date Fill Date FillsHYDROCHLOROTHIAZIDE 50 MG 07/01/2002 08/01/2003 2INSULIN 100 U/ML 08/01/2002 08/01/2003 13GLUCOVANCE 2.5/500 12/15/2002 07/25/2003 8GLUCOTROL XL 10 MG 8/01/2002 07/20/2003 12PREVACID 30 MG 10/23/2002 06/30/2003 7
15 MG 09/23/2002 09/23/2002 1SLOW K 10 MG 10/29/2002 06/29/2003 6
----------------------- FILLED PRESCRIPTION DETAIL --------------------HYDROCHLOROTHIAZIDE Drug: HYDROCHLOROTHIAZIDE 50 mg Filled: 08/01/2003Form: 50 mg TABLETQuant: 30 Days: 60 Pharm: JOES PHARMACY #02236 Source: PBM AMD/DO: JEFFRIES,RHONDA
39
Impact of Rx Claims on Clinical Impact of Rx Claims on Clinical DetectionDetection
Bieszk. Detection of nonadherence through review of pharmacy claims data Am J Health-System Pharm. 60:360-366, 2003.
231 visits w/ or w/o 6 months Rx claims report231 visits w/ or w/o 6 months Rx claims report
Mean age 61 yrs; 5.5 drugs per patientMean age 61 yrs; 5.5 drugs per patient
Abstractor-detected non-adherence: 57 vs. 58%Abstractor-detected non-adherence: 57 vs. 58%
MD-detected non-adherence: 30.5% vs. 0%*MD-detected non-adherence: 30.5% vs. 0%*
Drug changes: 1.3 vs. 0.3* (*p < 0.001)Drug changes: 1.3 vs. 0.3* (*p < 0.001)Dose changes, drug additions, discontinuations (all Dose changes, drug additions, discontinuations (all p<0.05)p<0.05)
46% of MDs saved 1-3 min per encounter46% of MDs saved 1-3 min per encounter
Henry Ford Health System Clinics
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Implementation: A Few Key Implementation: A Few Key AreasAreas
Decision SupportDecision Support
FormularyFormulary
Medication ListsMedication Lists
Electronic Prescribing:Electronic Prescribing:Physician - Pharmacy Issues; Physician - Pharmacy Issues;
Building Community InitiativesBuilding Community Initiatives
Rick RatliffRick Ratliff
Chief Operating OfficerChief Operating Officer
SureScriptsSureScripts
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Four Core IdeasFour Core Ideas
1.1. Electronic prescribing is a Electronic prescribing is a processprocess
2.2. Quality and efficiencyQuality and efficiency
3.3. The journey begins with a first The journey begins with a first stepstep
4.4. Community and trustCommunity and trust
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The prescribing process is more than just The prescribing process is more than just writing a prescription and dispensing a writing a prescription and dispensing a
medicationmedication
Before EncounterBefore Encounter
Schedule patient
Pull patient chart
Review patient chart
After EncounterAfter Encounter
Re-file chart
Clarification calls
Prescription benefits issues
Renewal authorizations
P H Y S I C I A NP H Y S I C I A N
Acquire PrescriptionAcquire Prescription
Drop Off, Phone, Fax, IVR
Insurance ID card
Data input into computer
CommunicateCommunicate
Review of DUR alerts
Handling of payer issues
Patient counseling
Renewal requests
P H A R M A C I S TP H A R M A C I S T
EncounterEncounter
Interview patient re: meds
Decide medication therapy
Write prescription
Document Rx in note
Process PrescriptionProcess Prescription
Pharmacy DUR
Claims: Payer DUR
Claims: Eligibility / benefits
Order fulfillment / dispense
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Errors and inefficiencies in the Errors and inefficiencies in the encounterencounter
Patient monitoringPatient monitoring
Unknown meds?Unknown meds?
Did pt fill the prescription?Did pt fill the prescription?
Clinical decisionsClinical decisions
Access to expert infoAccess to expert info
Complex drug coverage rulesComplex drug coverage rules
Writing the scriptWriting the script
Handwritten scripts are error-Handwritten scripts are error-proneprone
Est. 2.1 million ADE’s could be Est. 2.1 million ADE’s could be prevented with eRx (CITL)prevented with eRx (CITL)
Before EncounterBefore Encounter
Schedule patient
Pull patient chart
Review patient chart
After EncounterAfter Encounter
Re-file chart
Clarification calls
Prescription benefits issues
Renewal authorizations
P H Y S I C I A NP H Y S I C I A N
EncounterEncounter
Interview patient re: meds
Decide medication therapy
Write prescription
Document Rx in note
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Productivity and satisfaction…Productivity and satisfaction…key moment: after the encounterkey moment: after the encounter
Callbacks for clarification Callbacks for clarification
Handwriting, abbreviations, Handwriting, abbreviations, unclear verbal orders, fax unclear verbal orders, fax problems…problems…
Coordinating prescription benefit Coordinating prescription benefit issuesissues
Payer formularies and prior Payer formularies and prior authorizationauthorization
Managing the renewal authorization Managing the renewal authorization processprocess
Calls and faxes taking unnecessary Calls and faxes taking unnecessary hours of staff and physician time hours of staff and physician time (>2 hrs/day in a 3-MD practice)(>2 hrs/day in a 3-MD practice)
Nurses burdened with admin tasksNurses burdened with admin tasks
Before EncounterBefore Encounter
Schedule patient
Pull patient chart
Review patient chart
After EncounterAfter Encounter
Re-file chart
Clarification calls
Prescription benefits issues
Renewal authorizations
P H Y S I C I A NP H Y S I C I A N
EncounterEncounter
Interview patient re: meds
Decide medication therapy
Write prescription
Document Rx in note
46
Physicians and pharmacists Physicians and pharmacists collaborate for improvementcollaborate for improvement
Patient Safety&
Care Quality
Patient Safety&
Care Quality
Clinical PracticeEfficiency
Clinical PracticeEfficiency
&
Before EncounterBefore Encounter
Schedule patient
Pull patient chart
Review patient chart
After EncounterAfter Encounter
Re-file chart
Clarification calls
Prescription benefits issues
Renewal authorizations
P H Y S I C I A NP H Y S I C I A N
EncounterEncounter
Interview patient re: meds
Decide medication therapy
Write prescription
Document Rx in note
Acquire PrescriptionAcquire Prescription
Drop Off, Phone, Fax, IVR
Insurance ID card
Data input into computer
CommunicateCommunicate
Review of DUR alerts
Handling of payer issues
Patient counseling
Renewal requests
P H A R M A C I S TP H A R M A C I S T
Process PrescriptionProcess Prescription
Pharmacy DUR
Claims: Payer DUR
Claims: Eligibility / benefits
Order fulfillment / dispense
47
Roadmap of prescribing services for physician Roadmap of prescribing services for physician and pharmacy collaborationand pharmacy collaboration
Services Providing Services Providing True ConnectivityTrue Connectivity
Renewals Renewals
New scriptsNew scripts
Foundation for Foundation for future future collaborationcollaboration
Fair and open Fair and open networknetwork
Services Impacting Services Impacting Patient CostPatient Cost
Payer formulariesPayer formularies
Prior authoriz’nPrior authoriz’n
Rx change messageRx change message
Switch in classSwitch in class
Services Impacting Services Impacting Patient SafetyPatient Safety
Drug interaction Drug interaction checks + safety netchecks + safety net
Medication historyMedication history
Patient compliancePatient compliance
Patient-focused Patient-focused care managementcare management
Prescribing Plus: Prescribing Plus: Collaborate in the Collaborate in the JourneyJourney
Billing and Billing and schedulingscheduling
Lab resultsLab results
Payer Payer communicationscommunications
ReferralsReferrals
Diagnostic Diagnostic reportsreports
Charge capture Charge capture and codingand coding
Clinical notesClinical notes
BasicBasicPrescribingPrescribing
BasicBasicPrescribingPrescribing
Advanced Advanced PrescribingPrescribingAdvanced Advanced PrescribingPrescribing
Toward anToward anAutomated PracticeAutomated Practice
Toward anToward anAutomated PracticeAutomated Practice1 2 3
48
Elements of Community Adoption Program Elements of Community Adoption Program (CAP)(CAP)
Alignment of stakeholdersAlignment of stakeholdersPhysician organizations, health plans, health systems, Physician organizations, health plans, health systems, pharmacies, pharmacist organizations, government agencies, pharmacies, pharmacist organizations, government agencies, othersothers
Key outcomesKey outcomesShared vision and public endorsement of initiativeShared vision and public endorsement of initiative
Physician outreach through educational seminarsPhysician outreach through educational seminars
Incentive programs (best are pay-for-utilization)Incentive programs (best are pay-for-utilization)
Tipping point modelTipping point modelStart with key opinion leadersStart with key opinion leaders
Develop proof points in local marketsDevelop proof points in local markets
Develop physician to physician programsDevelop physician to physician programs
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Market Example: Rhode Island Electronic Market Example: Rhode Island Electronic Prescribing ProjectPrescribing Project
Stakeholders engaged in the project by Rhode Stakeholders engaged in the project by Rhode Island Quality InstituteIsland Quality Institute
Physician involvement was driven by a core Physician involvement was driven by a core group of physicians who collaborated on the group of physicians who collaborated on the planning and implementation of the projectplanning and implementation of the project
Over 70% of the state’s retail pharmacies Over 70% of the state’s retail pharmacies connected into the electronic prescribing networkconnected into the electronic prescribing network
Approximately 300 physicians participating with Approximately 300 physicians participating with an expectation of 50% of physicians within Rhode an expectation of 50% of physicians within Rhode Island participating by end of Summer 2004Island participating by end of Summer 2004
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