The Evolving Role of DDI Clinical Decision Support in E-Prescribing and Consumer-Oriented DDI Databases

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1 The Evolving Role of DDI Clinical Decision Support in E-Prescribing and Consumer-Oriented DDI Databases October 14, 2009 Ed Weisbart, MD, CPE, FAAFP Chief Medical Officer, Medical Affairs

2 Express Scripts: Transparency and Alignment Business model built on unique heritage of independence Business Model Aligned Interests Lowest Net Cost Legacy of independence Not reliant on pharmaceutical funding Commitment to clinically sound formulary Appropriate promotion of generic drugs

3 Who Is Express Scripts? Over 43,000,000 covered lives (soon to be over 70,000,000) 50,000 pharmacies in broadest national retail pharmacy network Own and operate multiple state-of-the-art mail-order pharmacies Segmented business divisions to serve unique needs Commercial Division Managed Care Other Areas of Focus National Accounts Medicare Specialty Pharmacy Middle Market Medicaid Worker s Compensation Public Sector Commercial HMOs Many others

4 Research and Education Knowing what works and sharing that knowledge Over 80 articles published in medical literature and peer-reviewed journals Reported to the national media Presented at scientific and professional conferences Annual Outcomes Conference Drug Trend Report Not funded by manufacturers

5 ADEs Are Growing Faster Than Prescriptions 4.0 Total Outpatient Rxs, Billions Serious Reported ADEs 100,000 20,000 Fatal ADEs ,000 15, ,000 10, ,000 5, Archives of Internal Medicine, September 10, 2007

6 What Would You Dispense?

7

8 It s Not Just About Handwriting The rate of preventable events was the same for practices with computerized prescription systems and those with manual systems. Advanced systems could have prevented 7 of the 20 preventable events. Gandhi, TK. NEJM 2003; 348:

9 What Is E-Prescribing? Basic Electronic Prescribing Rx printed and given to pt Passive references Intermediate Electronic Prescribing Electronic pharmacy transmission Decision support (Med Hx, benefit, etc) Advanced Electronic Prescribing Sophisticated data streams Proactive advice; prevention Center for Information Technology Leadership The Value of Computerized Provider Order Entry in Ambulatory Settings, 2003

10 80% Avoidance of Preventable Errors 1.5 Avoidance of Ambulatory Visits 60% 40% 20% Millions Millions 0% Basic Intermediate Advanced Avoidance of ADEs 0.0 Less is less. 250, , , ,000 50,000 Basic Intermediate Advanced 0 Basic Intermediate Advanced Avoidance of Hospitalizations Basic Intermediate Advanced Center for Information Technology Leadership The Value of Computerized Provider Order Entry in Ambulatory Settings, 2003

11 US Lags in EMR Adoption and Functionality Percent Reporting EMR Percent Reporting 7 Or More Fx NET NZ UK AUS GER US CAN 0 NZ 8 UK AUS NET GER US CAN 2006 Commonwealth Fund Survey

12 Benefits for Prescribers Reduce administrative time Formulary compliance Reduce call backs Safety checks Cost effective

13 Why the Reluctance to Start? % of Physicians Concerned About Cost Productivity Vendor Survival Patient Acceptance Security / Privacy 0% 10% 20% 30% 40% 50% 60% AAFP 2005 EHR Survey

14 Estimated First Year Costs per Provider $50,000 or more $40,000 - $49,999 $30,000 - $39,999 $20,000 - $29,999 $10,000 - $19,999 $5,000 - $9,000 <$5,000 0% 5% 10% 15% 20% 25% CHIT: AAFP 2005 EHR Survey, conducted: 8/2005 with 2,659 respondents

15 Estimated Annual Costs per Provider $3,000 or more $2,500 - $2,999 $2,000 - $2,499 $1,500 - $1,999 $1,000 - $1,499 $500 - $999 <$500 0% 5% 10% 15% 20% 25% CHIT: AAFP 2005 EHR Survey, conducted: 8/2005 with 2,659 respondents

16 What Features Would Benefit Your Practice? Decision Support Support Research Manage Guidelines/Protocols External Communications Allergies/Adverse Reactions Manage Problem List E-Rx Search for Data Manage Documents/Notes Medication List Quick Access to Records 0% 20% 40% 60% 80% 100% 2005 AAFP Survey

17 Benefits for the Pharmacy Safety Convenience Satisfaction Cost savings Efficiency

18 E-Rx Positive Features for Pharmacies Increased Integrity Reduced Interruptions Other Efficiency Legibility Rupp, MT and Warholak, TL. J Am Pharm Assoc 2008

19 E-Rx Is Not Without Problems Too Reduced Communications Incomplete Script E-Rx Lost Technical Problems Others Delays in Receiving Prescribing Errors Rupp, MT and Warholak, TL. J Am Pharm Assoc 2008

20 Community Pharmacies Are Satisfied with E-Rx Pharmacist Technician Intern Very Dissatisfied Mod. Dissatisfied Somewhat Dissatified Somewhat Satisfied Mod. Satisfied Very Satisfied 0% 20% 40% 60% 80% 100% Rupp MT. Computer Talk, 2005

21 Dispensing Pharmacists Prefer e-rx vs Traditional Safety Effectiveness Efficiency Pt Relations Much Worse Somewhat Worse No Change Somewhat Better Much Better MD Relations 0% 20% 40% 60% 80% 100% Rupp MT. Computer Talk, 2005

22 E-Prescribing Now Includes Controlled Substances September 14, 2009: First controlled substance prescription sent electronically as part of an AHRQ Pilot in Massachusetts

23 MIPPA: Carrots and Sticks Combined

24 E-Rx Will Grow Even Faster With ARRA American Recovery and Reinvestment Act 2009 (ARRA) $19 B to drive HIT adoption Biden and Sebelius: Aug. 20, 2009 $598 M for approximately 70 Health Information Technology Regional Extension Centers $564 M for State Information Sharing Networks

25 ARRA Nearly Doubles MIPPA s Impact 100% Projected E-Rx adoption 75% 50% 25% e-rx with MIPPA 2008 e-rx trajectory e-rx with ARRA 3,510,000 ADEs prevented by ARRA 585,000 hospitalizations 0% Source: Visante study for PCMA,

26 Surescripts Makes e-rx Easy and Consistent

27 SureScripts Is a Conduit, Not a Repository Patients Clinics and Hospitals Pharmacies PBMs and Payers

28 Simply put, Surescripts makes E-Prescribing work

29 Simply put, Surescripts makes E-Prescribing work. Certification Physician and pharmacy software vendors Pharmacies Payers Standards Collaborate with standards bodies Develop, implement, and drive evolution of standards Education and Research Adoption, Utilization, and Advocacy

30 SureScripts Has Certified Over 200 Vendors EMR Standalone Rx Routing Rx Benefits Rx History All 3 Services Accessed Oct. 3, 2009

31 Pharmacy Adoption Is Approaching Saturation 50,000 40,000 30,000 4,000 6,000 10,000 20,000 10,000 31,000 35,000 36,000 Independents Chains Accessed Oct. 3, 2009

32 Surescripts Coverage Is Deepening Nationally Percent of patients by state for whom Surescripts can provide benefit and history information Over 60% 41 to 60% 0 to 40% Source: Surescripts and The 2008 National progress Report on E-Prescribing (www. Surescripts.com/report)

33 Surescripts Now Finds Most Patients Surescripts positive results from eligibility request 75% 70% 65% 60% 36% improvement in 13 months 55% 50% Jul 08 Sept 08 Nov 08 Jan 09 Mar 09 May 09 Jul 09

34 Over 5 Million Rx Histories Delivered per Quarter

35 Surescripts POC Vendor Certification Requirements No specific requirement addresses DDI functionality Many of the requirements discuss it indirectly. Medication history check must: Be based on an individual patient s dispensed claim history Include history from all prescribers, not just the e- prescriber Up to 12 months of real-time drug history

36 Surescripts POC Vendor Certification Requirements Surescripts does not specify a DDI database Most POC vendors choose applications with at least some level of DDI checking Most popular options among certified POC vendors: Drug-Drug interaction Drug-Allergy Drug-Food

37 Surescripts POC Vendor Certification Requirements Comprehensive drug information source Industry-accepted Map-able to NDC drug codes Updated at least monthly Diverse applications Therapeutic interventions Detect drug-drug interactions Detect duplicate therapy Detect over-prescribing

38 E-Rx Successful at Henry Ford Health System Launched in 2005 By 2006, more than 500,000 e-prescriptions filled Physicians e-alerted to 6,500 potential allergic reactions More than 80,000 e-prescriptions changed or cancelled due to DDIs 16%!

39 E-Rx Successful at Health Alliance Plan 300 primary care physicians, 24 medical centers 1.7 million e-prescriptions in ,000 e-rxs changed or cancelled due to drug/allergy warnings Over 150,000 e-rxs changed or cancelled due to 9%! DDI interaction warnings

40 Health 2.0: Participatory Healthcare The transformation of health care through social networks, open standards and the latest web and mobile technology. Concept began at Health Camp, San Francisco, 12/06 Now international and semiannual Next Health Camp: April 6-7, 2010, Paris France

41 Health 2.0: Participatory Healthcare Beyond and static websites Social networking, blogs, advanced searches Beyond CDHC Patient-empowered healthcare Beyond price Genuine outcomes Connectivity, price, quality and incentives A virtuous cycle of innovation

42 More Than Half of Consumers Use the Web for Health Information Today Millions of patients searching on-line Any health information Rx drug information Manhattan Research s Cybercitizen Health v9.0, accessed Oct. 5, 2009

43 PHRs hold great promise but not wide adoption

44 Drug Digest (www.drugdigest.org)

45 Drug Digest (www.drugdigest.org)

46 Drug Digest (www.drugdigest.org)

47 Drug Digest (www.drugdigest.org)

48 Drug Digest (www.drugdigest.org)

49 Drug Digest (www.drugdigest.org)

50 Drug Digest (www.drugdigest.org)

51 Drug Digest (www.drugdigest.org)

52 Drug Digest (www.drugdigest.org)

53 No Shortage of Public Domain DDI Sites

54 Public Domain Tools Vary Language levels vary Some target professionals, some lay audiences, some try to do both with one site. Data sources vary Some import, some write, many don t reveal sources Kinds of data vary PK, PD, alcohol, OTCs, herbals Site interactivity varies Some are just catalogues, some are highly interactive

55 Pharma Surveyor A Health 2.0 Accelerator

56 Pharma Surveyor A Health 2.0 Accelerator

57 Pharma Surveyor A Health 2.0 Accelerator

58 ESI Oncology Capabilities Examples of Health 2.0 Program Support Express Alliance Leverage pharmacy data to enhance care First-fill diagnoses, adherence gaps, etc. Pharmacists provide personalized, detailed clinical case reviews IntellAct Integration of medical and pharmacy data. Lab and self-reported data in development Over 1600 clinical rules to identify prioritized gaps in care Flexible outreach channels, e.g., Medical Home

59 Go to

60 Find Your E-Rx Doc Today at Surescripts.net Step 1: surescripts.net Step 2: Your zip code Step 3: Search

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