e-prescribing Presentations and Next Steps.txt GOVERNOR PHIL BREDESEN: All right, if 4 things to do on the subject of e-prescribing.

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1 118 1 P.M. SESSION, 1:43 p.m. 2 GOVERNOR PHIL BREDESEN: All right, if 3 we can go ahead and get restarted. We have two 4 things to do on the subject of e-prescribing. We 5 have some presentations, which together will take 6 about an hour, and then we have about 45 minutes to 7 talk about the subject in general and carry on from 8 there, and we can work at moving through that. 9 I would like to welcome everybody back. 10 We've invited three speakers today to update us on 11 current e-prescribing activities and challenges and 12 after we hear from them and they answer any 13 questions you might have, would like to hear your 14 thoughts on the issue, and particularly perspective 15 on whether folks are in agreement with maybe trying 16 to move this one area along a little bit, in these 17 terms, as a way of beginning to establish some 18 beachheads. 19 I'd like to introduce our speakers. Kevin 20 Hutchinson is CEO of SureScripts, which is the 21 largest network of electronic prescribing services. 22 Patricia Anderson is here, Commissioner of the 23 Minnesota Department of Employee Relations, and 24 joining us by phone, and, I guess, is Patrick 25 Miller. Is Patrick on the phone now? Do we know now? 2 MR. MILLER: Yes, I'm here, thank you. 3 GOVERNOR PHIL BREDESEN: Okay, 4 great -- who's a research professor at the Page 1

2 5 University of New Hampshire's Institute for Health 6 Policy. And I've been asked to ask people to hold 7 their questions until the speakers have spoken on 8 this particular subject. 9 First we'll hear from Kevin Hutchinson, 10 provide us with greater information about 11 e-prescribing. As I said, he's the President and 12 CEO of SureScripts. Since August 2002, when he 13 joined SureScripts, he's led the effort to establish 14 a neutral nationwide network for electronic 15 prescribing by connecting the nation's numerous 16 physician technology applications and pharmacy 17 software systems and enabling pharmacists to 18 communicate electronically. 19 I guess when we talked last night, I came 20 away with the impression that SureScripts is the 21 Mastercard of the e-prescribing world, or something 22 like that. Kevin? 23 MR. HUTCHINSON: Thank you very much, 24 Governor Bredesen. Appreciate that. I appreciate 25 the invitation to discuss with you the status of electronic prescribing and where we stand today, and 2 the progress that's being made in this particular 3 area. 4 First of all, I have been sitting in the 5 back of the room most of morning, and I have to tell 6 you, of all of the hard-working men and women that 7 sit around this table, there is no harder-working 8 individual at this table than this young lady right 9 here over here. I don't know how these hands move 10 so quickly, but for two and a half hours, the Page 2

3 11 fingers did not stop this morning. 12 There was a couple of things that I was 13 asked to GOVERNOR PHIL BREDESEN: Could I -- I 15 was asked to make an announcement, which I forgot to 16 do, which reminded me. You were having some 17 difficulties because of cell phones. Could you 18 please all put your phasers on stun, or something 19 like that, so that she can hear better. Thank you 20 I'm sorry to interrupt. 21 MR. HUTCHINSON: That's okay. I was 22 asked to do a couple of things, and one I will do 23 very quickly. I spend half of my time running 24 SureScripts, and the other one hundred percent of my 25 time, which I didn't know it was going to take that much, as a commissioner on Secretary Leavitt's 2 American Health Information Community, on AHIC. So 3 what was supposed to be a part-time role on AHIC has 4 turned out to be more of a part-time role, as you 5 well know, and I was asked to give a real quick 6 update of what AHIC has been doing and kind of what 7 the next stages of are is are, as well. So I'll 8 take a couple of minutes and just cover that. 9 As you know, AHIC is very focused on 10 standards development. The number one thing it is 11 focused on is making sure that there are standards 12 that allow this health care interoperability and 13 that Medicare intends to enforce through its 14 contracts to require the use of those standards to 15 come out of that process. Page 3

4 16 You hear a lot about the Health Information 17 Technology Standards Panel, and that is the 18 standards panel that reports in to the AHIC process 19 to create those standards. We've already passed 20 version 1.10 of those standards. 21 Version 2.0 of those standards, which 22 enable electronic prescribing, lab information 23 exchange, and a number of other information 24 exchanges between health care providers, 2.0 is in 25 progress is to be presented to AHIC within the October time frame, which we'd anticipate acceptance 2 of that, as well. 3 Also, the certification commission that 4 certifies electronic medical records is part of the 5 AHIC process. The standards that are created within 6 the Health Information Technology Standards Panel 7 are then passed over to the certification 8 commission, which then requires them to test and 9 certify the use of those standards inside of the 10 electronic medical records. 11 Today, there are around 89 electronic 12 health, electronic medical records systems, that 13 have been certified by the certification commission, 14 which represents about 40 to 50 percent of all EHR 15 and EMR systems that exist. 16 By CCHIT's estimates, there's around various different electronic medical record, with 18 the functionality of an electronic medical record, 19 that exist in the marketplace. Some will tell you 20 there is a vast larger number than 200, but they 21 tried to narrow it down to those that actually had Page 4

5 22 more medical record functionality built inside of 23 it. 24 There are a number of work groups Privacy, Security, Confidentiality Work Group, Consumer Empowerment Work Group, Surveillance Work 2 Group -- that are all working on use cases that come 3 out of the AHIC process to demonstrate those 4 interoperability standards that exist. Medication 5 history information, as an example, being exchanged 6 between personal health records and pharmacies, or 7 personal health records and physicians, as well, are 8 part of the use cases. 9 There were three in '04, '05, there were 4 10 in '06, and now there appear there are going to be 6 11 in the 'O8 time frame that will be demonstrated. 12 RFIs and RFPs are left to various different 13 organizations to actually show and demonstrate those 14 interoperability standards work. 15 Last, but not least, the next stage of 16 AHIC, as you know, Secretary Leavitt is on a very 17 strong and accelerated path to privatize the AHIC 18 commission and to move it out of federal government 19 and move it into a private entity. 20 In fact, Friday, as we go back to DC this 21 week, the Secretary will be holding a public forum 22 meeting to describe and invite organizations who 23 choose to bid on becoming the organization that 24 would establish what the private AHIC organization 25 would appear to be like, and they intend to put the 124 Page 5

6 1 power of Medicare behind it and say what comes out 2 of this private AHIC commission would still be what 3 Medicare would enforce in its use of those 4 contracts, as far as implementations of standards 5 and the various different likes of what's going on 6 on privacy, security, confidentiality, and those 7 kinds of things, as well. So that's my 8 down-and-dirty AHIC update as part of that. 9 I don't need to tell this audience, and I 10 was pleasantly impressed this morning with the 11 conversation of all the various different factors 12 and elements that have to go into thinking around 13 what needs to be done when we're talking about 14 interoperability. 15 The purpose of the slide in front of you is 16 really to show this is not about -- there's not a 17 single silver bullet here. There are a number of 18 different things that are happening in health care 19 right now that's actually driving this 20 transformation. It's not just cost. Cost is one 21 element, one item. 22 Privacy and security issues are driving it, 23 as well. Outcomes and the need for higher quality 24 are driving change, as well. So even though I was 25 born in the '60s, I call this my lava lamp slide, because it shows that there are these bubbles that 2 grow and they increase in size at times, and they 3 decrease and they come back, and then we see them 4 also merge with other things that are happening. 5 But what employers are doing, what payers 6 are doing, what patients want to see happen inside Page 6

7 7 of health care, what technology companies are doing 8 in driving various different implementations and use 9 of standards, is really driving this health 10 interoperability phase. 11 I think we all, as patients, have said 12 enough is enough. We have to move our health care 13 system forward, and we cannot move it forward in 14 this paper process. 15 So the what is focused on patient 16 centricity, the why is we need better outcomes, and 17 how do we get there is through better interoperable 18 care. 19 I'm happy to report, and thankful and 20 grateful to each and every one with you sitting 21 around this table today that represents the various 22 different states, that effective Sunday, this past 23 Sunday, we finally cleared all 50 states are now 24 legal for electronic prescribing. Alaska was our 25 final frontier, and it was the last state that became legal on Sunday, August the 12th, to allow 2 electronic prescribing to occur. There are still 3 some variations in legislation and variations in 4 regulations. Doesn't cause major heartburn, but 5 does cause some inefficiencis in how we have to 6 process it based upon different rules in different 7 states. But for the most part, it's pretty 8 even-keeled across all states to allow electronic 9 prescribing to occur. 10 That was not the case, if you notice, in 11 February of The red states indicate states Page 7

8 12 that it was illegal to represcribe and the yellow 13 states indicate states that they were in process of 14 making it legal in those particular markets, but now 15 everyone's green, and that makes us all very happy. 16 You know, a lot of people talk about 17 electronic prescribing, e-prescribing -- there's a 18 lot of buzz words that center around this particular 19 space -- but it really is about automating the 20 prescribing process, no matter what phrase or what 21 terminology you'd like to use, and it is 22 bidirectional. 23 We've been, for a number of years, in this 24 space, people considered e-prescribing to be a 25 physician enters -- can order it into a computer, and then, no matter how it gets to the pharmacy, 2 it's still considered electronic prescribing, even 3 if it goes by fax. 4 That is not the definition of electronic 5 prescribing in In 2007, the definition of 6 electronic prescribing is bidirectional. This is 7 when I enter something into a computer in a 8 physician's office, it shows up in the computer in 9 the pharmacy. There is no paper involved. 10 Also allows the pharmacy to send refill 11 requests, as an example, back to a physician, and 12 actually if you evaluate the efficiency scale of 13 that process, the pharmacy's efficiency factor of 14 getting new orders electronically, the physician 15 efficiency factor are getting the refill requests 16 from pharmacies electronically, because there is a 17 number of -- a large amount of time savings on the Page 8

9 18 physician side, and quite frankly, a larger amount 19 of time savings on the physician office side of 20 getting those refill requests electronically and 21 getting off the fax and the phone calls and those 22 kinds of things. 23 So the point of this is to make sure that 24 everyone understands it's not just about writing an 25 order and sending it -- and faxes are not electronic, not by today's definition of 2 electronic -- and we're also talking about formulary 3 information, eligibility information, medication 4 history exchange information, both from your 5 pharmacies and your payers and BBMs, so that 6 physicians and patients alike can gain access to 7 their medication information. 8 There's been a number of different studies 9 out there, but we like to highlight -- this is the 10 most recent one, and actually Henry Ford Health 11 System did a wonderful job in looking at -- they had 12 a centralized solution for electronic prescribing, 13 and they were looking at real savings, real safety 14 issues that were addressed, real efficiencies that 15 were addressed, and in fact, since it was a 16 centralized solution, they could look and see when 17 physicians changed their drug orders based upon 18 alerts that were given to them, and in this case on 19 the safety, they found 150,000 canceled orders due 20 to a drug-to-drug interaction check, that without 21 electronic prescribing, might have gone through in a 22 paper system. Page 9

10 23 11,000 that were canceled due to drug to 24 allergy checks and that estimated $540,000 in 25 savings alone, by reducing the adverse drug events, the ADAs, that occur in the paper prescribing 2 process. 3 From an efficiency standpoint, there were 4 over 70,000 changed or canceled due to formulary 5 warnings that would have been orders that would have 6 been placed, the patient would have gone to the 7 pharmacy, the pharmacy would have said this is a 8 drug that's not on your current insurance plan, 9 phone calls would occur between physician and 10 pharmacy, and then decisions would have to be made 11 on financials, and they saw 70,000 of those changed 12 before it ever went to the pharmacy, to be in 13 compliance with the formulary. 14 So as you can see, it's very centered on 15 the patient. 85 percent of the physicians that were 16 part of it agree that e-prescribing improved the 17 practice of medicine at their clinic. Prior to 18 SureScripts, it was actually nice to do the GE tour 19 this morning because I was the Chief Operating 20 Officer of MedicaLogic, which is the EMR system that 21 we sold to GE. 22 It was kind of like the prodigal son. I 23 was sitting in the audience, and they put up these 24 screen shots of the EMR and there it is, there's 25 Logician -- it lives, it breathes. And I haven't seen a screen shot of Logician in a number of years, 2 and so it was great to actually see it still in Page 10

11 3 existence and even interoperable now with the IDX 4 applications and others. 5 But even then, back in the EMR days or 6 e-prescribing days, you will see resistance by 7 physicians on the change or the implementation of 8 this technology. But I will tell you, our biggest 9 champions, our biggest physician champions, both in 10 an EMR world and in the e-prescribing world are 11 those that resisted the most prior to making the 12 change, and once they've made the change and they 13 recognize the benefits, those are the ones we always 14 put on stage, and those are the ones that we always 15 had case studies written on, because of the dramatic 16 change in their opinion from where they were before 17 to where they are today. 18 We actually coined a phrase -- it was 19 probably internal, but since I'm not at MedicaLogic 20 anymore I'll use it -- we coined a phrase the 21 technodoc. Internal. It was a loving attribution 22 to physicians who loved the use of technology, but 23 the technodocs actually caused us the most 24 heartache, because they understood the technology so 25 well, they wanted the technology to do things that it just wasn't quite ready to do. 2 But you take an average physician. They 3 would take the EMR system, with proper training, 4 proper implementation, proper work flow improvement, 5 and that physician would be the one that would be 6 the most champion, because they're using the 7 features and functions that best fit their need of Page 11

12 8 their practice. 9 So we don't -- we embrace the resistance by 10 the physicians to the use of this technology, 11 because we know, once it's implemented, they're 12 going to see the benefits and they do become your 13 biggest champion. 14 From a SureScripts standpoint, Governor 15 Bedersen already used the term -- it was a great 16 term last night as we were chatting at the reception 17 that this is a Mastercard/Visa type of approach. We 18 are completely owned by the pharmacy industry. We 19 run like a nonprofit in that sense. Any dollars or 20 moneys made through SureScripts, those dollars are 21 returned back to the pharmacy industry. There is no 22 outside venture capital, outside funding, other than 23 the pharmacy industry inside the company. 24 I think that business model, from a health 25 care interoperability, works. All of our revenue is tied to the pharmacies who are the members of 2 SureScripts. We charge nothing on the physician 3 side, and we don't charge a certification fee by 4 software companies, or any of the like. We are the 5 network in between. We don't sell an end-user 6 application to physicians, and we don't sell an 7 end-user application to the pharmacies, but we make 8 sure that these disparate applications can in fact 9 exchange information between each other, as well as 10 with payers and PBMs, as well. 11 This is just intended to give you kind of a 12 flavor for the -- you know, the four groups that we 13 focus on -- the patients, the pharmacies, the Page 12

13 14 physicians, and the payer PBMs, as well, and the 15 types of exchange of information that happens. 16 This is kind of a national health 17 information exchange, except it is very, very 18 focused on just one thing, and that's automating the 19 medication management process. 20 We are not trying to be labs, discharge 21 summary reports, or other types of transactions 22 between health care providers. It is strictly 23 focused on trying to improve the medication 24 management process. 25 Today, from a status standpoint, there are over 95 percent of the nation's pharmacies in fact 2 have certified on this particular network. 3 Two-thirds of the pharmacy stores in the United 4 States are now live on this network, as well. That 5 was a very huge missing component in the early days 6 of e-prescribing. Back in the early to mid-'90s, 7 when a lot of e-prescribing tools were being 8 delivered to physicians free of charge by 9 manufacturers and others, there was no conductivity 10 to pharmacy in those days. Everything was by fax. 11 Going back to my initial statement, 12 remember, the physicians will tell you over and over 13 again, my major efficiency benefit of doing this is 14 the refill process. So without conductivity to 15 pharmacies, they're losing a huge value item by 16 simply having everything driven by fax to those 17 pharmacies. Now, with refills coming 18 electronically, the physicians see the value in Page 13

14 19 getting engaged. We are adding several thousand 20 physicians to the network every month. 21 This was an appropriate slide for this 22 audience, and I apologize for the bubbles, because I 23 can't even read them from here, but I'm sure they'll 24 appear better in your printouts, to show you the 25 status of pharmacy activations in your own individual states. 2 This is not about the transaction volume. 3 This is the number of pharmacies per capita in your 4 state that are in fact live within your borders. 5 The good news is, in most states, an average across 6 the country is around 65 percent of all pharmacies. 7 Some states have 70 and 80 percent activations. 8 Some states are down to the 45 and 48 percent 9 activations. 10 I will tell you that 100 percent of the 11 chain stores in the United States are live on the 12 network. We have about 20 percent of all 13 independent pharmacies live on the network right 14 now. The independents come when the physicians 15 come. If you tell them in their area that Dr. Jones 16 is in fact just activated on the network, we send a 17 communication to the independent pharmacies in that 18 area, and they activate, as well, once the 19 physicians they work with get activated. 20 The same on the physician side, the EMR 21 world, we have around 75 to 80 various different 22 electronic medical record, e-prescribing-type 23 applications that are also certified on the network. 24 They represent about 70 percent of all physicians Page 14

15 25 that are using an EMR. Their software is in fact certified and available to do the electronic 2 prescribing on the network. 3 I'm not going to beat a dead horse here. 4 The benefits of automated renewals we've talked a 5 lot about, but this gives you numbers behind that. 6 MGMA estimates that the practice is to spend over 7 10,000 a year per physician on refill practice 8 alone. Brown University did a research project as 9 part of the MMA pilots that were done, and showed 10 that they cut half the time, both in the physician 11 staff and staff time in half by automating the 12 refill process. 13 Our own research suggests that if you were 14 to add staff time and physician time, each practice 15 spends about $50,000 a year just managing the refill 16 process. I'm not going to suggest that all of that 17 goes away, but by cutting it in half, there's at 18 least a $25,000 savings in labor, just on the refill 19 process alone. 20 The pharmacy industry a couple of years ago 21 started a process of saying we should reward the 22 states that have really begun to embrace electronic 23 prescribing and implement electronic prescribing. 24 And, in fact, Massachusetts in 2006 was the number 25 one state in the country on a per capita basis, as the number of prescriptions that go electronically 2 compared to the number of prescriptions that are 3 dispensed within that state. Page 15

16 4 So we had to make sure it couldn't always 5 be won by California and Texas and the large states, 6 so we looked at it on a per capita basis, and 7 Senator Moore actually accepted the award earlier 8 for the safe Rx awards. 9 There are definitely key challenges 10 associated with the implementation of electronic 11 prescribing. One in particular that I think this 12 esteemed organization should actually embrace is it 13 is still illegal to this day to process controlled 14 substances electronically. The DEA has yet to 15 embrace electronic prescribing. With all of the 16 discussions at the federal level about the need for 17 electronic prescribing, Schedules II through V are 18 still illegal to process prescriptions 19 electronically. 20 And we've made a lot of progress with the 21 DEA. They've looked at a variety of different ways. 22 They want to embrace electronic prescribing, but 23 they're looking for ways to make sure that they can 24 without any hesitation identify that that physician 25 is who they say they are, either through a thumbprint, retinal scan, or some other means, other 2 than just simply ID and password. And we are 3 getting there to where they understand that simply 4 the ID and password process an initial 5 identification of the physician, in fact, is a much 6 much, much better process than the one that we have 7 today that is paper-based, where a physician's 8 signature with can be copied or scanned into a 9 computer and used. Page 16

17 10 And in fact, if the patient never receives 11 the order in their hand, then you also prevent 12 pharmacy shopping and the physician and the order 13 goes from the Point A to Point B, and it can be 14 audited and it can be tracked. So highlighting the 15 DEA issue would be a good one, and it is a challenge 16 for us as an organization. 17 There is also a proposed fax elimination 18 rule, and when the MMA passed in 2003, it said you 19 must use the standards as defined by the AHIC 20 process, which is the NCPDP standard for all 21 prescriptions to go electronically, and then there's 22 that little asterisk next to that, and down at the 23 bottom it says, However, if you cannot adhere to the 24 standards, you can still fax the prescriptions. So 25 it was considered to be the fax exemption Standards were required, but if you couldn't meet 2 that requirement, then you could still fax. And the 3 reason that was important to separate out is it sent 4 a signal to the market that this is going to be a 5 temporary exemption, so start now to get in 6 compliance with the standard, because at some point 7 we're going to pull this out. 8 Now it's been published, and the comment 9 period ends on August 31st, as part of the physician 10 incentive fee for Medicare, they included that 11 they're eliminating the fax exemption effective 12 January 1, 2009, embracing that fax exemption. What 13 that means is that if I as a physician can write a 14 prescription in a computer, and my system has been Page 17

18 15 certified and can send it electronically, then I 16 must eliminate the fax. 17 Think about today. today, if 18 someone were to you something, but it showed 19 up on your fax machine, they wrote it in the 20 computer, they hit "send," and it shows up on the 21 fax machine. That's the way that electronic 22 prescribing is working 80 percent of the time in 23 today's market. 24 Even though physicians are using EMRs, 25 using e-prescribing, we still see the vast majority of prescriptions written electronically going by 2 fax. Primarily because the physicians are unaware 3 wear that their software can even send it 4 electronically, and the physician vendors are trying 5 to do a better job of communicating to them the fact 6 that they have this new capability. 7 So last, but certainly not least, I was 8 asked to discuss what I believe the governors could 9 do to drive e-prescribing. Your demonstration in 10 this meeting alone, your leadership that this is an 11 area that you intend to take on, is a huge step 12 forward. Where we have seen states like 13 Massachusetts, like Rhode Island, like Tennessee, 14 like other markets that have said we are going to 15 make e-prescribing a priority, we have seen activity 16 start in that state, both within the physician 17 associations, within payers, and others, to get 18 ahead of what they expect will come down the pike as 19 a requirement to send prescriptions electronically. 20 We'd love to see introduction of Page 18

19 21 legislation that would either encourage or incent, 22 but send a direction that the paper prescription is 23 going by the wayside in a certain period of time. 24 Activity will begin immediately when they see that 25 kind of momentum happening in those states This can't happen without a collaborative 2 effort. So where we have seen the best activity is 3 where physician groups, hospital groups, government 4 agencies, payers, pharmacies get together and work 5 on this as a collaborative within that market. And 6 there are a number of collaboratives within your -- 7 within the states and within your packets that you 8 can look at, where that has been very successful. 9 I might highlight to you, and I would also 10 openly admit, that we authored a document and Kate 11 Barry, who's sitting in the back of the room here, 12 is our Senior Vice President of Business 13 Development, works with a number of you and your 14 staffs and a number of states in the deployment of 15 electronic prescribing, authored a document that's 16 in your packet called the State Roadmap, Communities 17 to Collaborate In Increased Adoption and Use of 18 Connective Technologies, Automating the Prescribing 19 Process. 20 I read this for the first time last night, 21 because it was in my prepacket, as well. And this 22 is an excellent document on steps that states can 23 take to really drive the next stage of electronic 24 prescribing. I did not even know this was our 25 document, because nothing is on here that says 141 Page 19

20 1 authored by SureScripts, so I had to ask Kate this 2 morning, Is this ours? And she said in fact, yes, 3 she wrote this in preparation for this meeting, and 4 the fact that a number of states that have been 5 asking the same questions about how we get started, 6 so I'd encourage you to take a look at that. 7 Just to show you that we put our money 8 where our mouth is, as part of this process on 9 collaborations, we just launched today a Center for 10 Improving Medication Management, and we are putting 11 one million dollars of our own money into this, and 12 it's a collaborative effort with Intel, Blue 13 Cross/Blue Shield, Humana, the American Academy of 14 Family Physicians, and the Medical Group Management 15 Association, who is going to focus on how to take 16 this technology and not only improve new 17 prescriptions and refills, but how do we improve 18 patient medication compliance with this 19 interoperability that now exists between patients, 20 physicians, and pharmacies? 21 And this announcement of the Center for 22 Improving Medication Management will really focus on 23 learning those technologies to share things like 24 reminders, reminder for alerts that a refill is 25 coming due. A reminder to a patient, ten days after picking up their medication, of the importance of 2 taking their medication percent of all patients, within six 4 months, who have chronic diseases, fall off 5 compliance with their medications. That costs us Page 20

21 6 over 100 billion dollars as a health care industry 7 in unnecessary additional health care services, 8 because of lack of compliance. 9 So those are things that are enormously 10 important to us as an organization and we ever' 11 happy to have this collaboration come together to 12 focus on this. 13 My last slide just says here's the top ten 14 states that occurred in 2007, based upon their volume, that are in per capita basis for electronic 16 prescribing. There has been a number of things 17 happen, and Senator Moore can tell you more about 18 this, but the Governor of Nevada has challenged the 19 Governor of Massachusetts that they will not be 20 number one after We've also seen Alabama 21 challenge the state of Georgia to say that they will 22 be the first state that will have 100 percent of 23 their prescriptions go electronically. 24 That tells me that they must have an in 25 with the DEA, because someone's going to have to get to the DEA to make that happen. So we look forward 2 to answering your questions, and I look forward to 3 working with you going forward. 4 GOVERNOR PHIL BREDESEN: Thank you 5 very much. I think way we had organized this was to 6 go ahead and have the presentations and suggestions, 7 so if you'd remain here for just a little bit. 8 Now, to share with us considerations for 9 state government agencies in rolling out 10 e-prescribing, we're going to hear from Pat Page 21

22 11 Anderson, who is down there, as well. Miss Anderson 12 is Commissioner of the Department of Employee 13 Relations and charged with overseeing Minnesota's 14 efforts to move the Department's functions to other 15 state agencies, while continuing to maintain 16 consistent, responsive service. Pat? 17 MS. ANDERSON: Thank you, Governor, I 18 will try to be as quick as I can here in the 19 discussion, to get us back on time. I'd like to 20 start here -- I'd like to just very quickly show you 21 some of the initiatives that are occurring in 22 Minnesota. 23 We have a health cabinet. Governor 24 Pawlenty. Minnesota takes a little different tack. 25 We actually mandate these things in advance, and it's something that I think that -- would hope that 2 you would consider in your own states. We have a 3 mandate that electronic and uniform billing, or 4 electronic, where it has to be electronic, as of 5 January of On the next slide, a requirement 6 that everyone has to -- has to be -- interoperable 7 by 2015, and as you know, there's a federal 8 recommendation that people are, by Well, in 9 Minnesota, it is a mandate. 10 We've been active for over a decade with 11 e-health initiative in our own state and trying to 12 work, as Kevin talked about, we try to do things 13 together as a group, and we're working with both the 14 payers, the providers, the health care systems, to 15 try to implement this jointly together. 16 Minnesota has an e-health collaborative. Page 22

23 17 It was established in 2004, and this is a 18 public-private partnership. We have just 19 incorporated as a nonprofit, and the members include 20 most of the large state health plans, the providers, 21 us in state government, and some HMOs. Our goal is 22 to accelerate the use of health technology and to 23 really provide this an infrastructure or a support 24 platform that can help create interoperability. 25 Now I'll get into e-prescribing quick This last year, the state employee benefit program, 2 which I run, has moved to one PBM, and we did this 3 for a variety of reasons. One, it will -- we 4 estimate it will save us about 5 million dollars. 5 There's also efficiencies with using a single PBM -- 6 formulary, ease of pulling data, and so on. In the 7 past, our state employee benefits program, we did 8 have three PBMs. Each of our providers was their 9 own or had their own. 10 I'm going to move these up quick. I think 11 the bottom one is the one that's most important. 12 Why are we targeting this? And frankly, it's 13 because we can, and I think this is the easiest 14 thing to implement on a statewide level. It's the 15 beginning. It helps to create buy-in in the 16 electronic medical records process, and because we, 17 between my program and what's done through DHS, we 18 already by 35 to 40 percent of the health care in 19 the state of Minnesota, so we we did drive the 20 market together with our groups. 21 Our PBM is Navitus. They're going to be Page 23

24 22 creating a hub that does essentially what Kevin 23 talks about. Kevin and I aren't sure where his 24 company fits in, but we know it fits in somewhere 25 within that, and doctors can have access to the network information and direct prescriptions 2 directly to retail. 3 This is perhaps what's very unique about 4 Minnesota. In our -- we have an RFP going out, and 5 we're going to require medical networks to use 6 e-prescribing. We're going to require all 7 pharmacies in the state to accept e-prescriptions in 8 16 months from now, or they will not be part of our 9 network as a state employee plan. We're going to 10 mandate that providers have the ability to 11 e-prescribe a year after that, or they're going to 12 be off of our network. So we're using leverage as a 13 purchaser of health care to drive the market, and 14 we're giving them a year or two warning. 15 This is just a slide, it's similar to a lot 16 of e-health slides. This shows what we're creating 17 in Minnesota and hopefully what -- it's going to be 18 similar to what you're creating in your own states. 19 And I'm -- there we go. I got through. 20 Five minutes. I'll wait for questions. Thanks. 21 GOVERNOR PHIL BREDESEN: Okay. And 22 our last presenter in the statewide e-prescribing 23 effort is Patrick Miller, who again is with us by 24 phone. Mr. Miller serves as research associate 25 professor at New Hampshire Institute for Health Policy and Practice. He's currently working on Page 24

25 2 information technology projects for New Hampshire 3 Citizens Health Initiative, and is supporting health 4 policy initiatives for the New Hampshire Department 5 of Health and Human Services. Patrick? 6 MR. MILLER: Thank you very much, 7 Governor. I appreciate you allowing me to 8 participate by phone this afternoon, and good 9 afternoon to the Green Mountain State from the White 10 Mountain State. My remarks today are really focused 11 on New Hampshire's e-prescribing initiative, some of 12 the challenges that we face, accomplishments, and 13 what we see as a next step. 14 Slide two has a little bit of history about 15 the New Hampshire Citizens Health Initiative. It 16 was commissioned by Governor John Lynch about two 17 years ago, with the idea that it would outlive a 18 single governor, and would probably take ten or more 19 years to complete its aim, which really is to 20 improve access to affordable quality health care for 21 all New Hampshire citizens, and it's comprised today 22 of more than 100 different health care organizations 23 and policymakers. 24 There's three core goals for the 25 initiative: One to promote improved health and disease prevention; two, improve quality of health 2 care; and three, openness of information. Each of 3 these policy goals is being addressed by a working 4 team, and e-prescribing fits in right now under the 5 Quality of Health Care team. Additionally, that 6 group is looking at things like primary care Page 25

26 7 workforce. But there's obvious overlap with the 8 Information team in terms of health information 9 technology and exchange. 10 Next slide, please. 11 The project was launched not quite a year 12 ago by our governor. The vehicle to do so was a 13 press conference, versus an executive order, and it 14 was launched in partnership with clinicians, payers, 15 pharmacies and SureScripts, and the goal that was 16 laid out for the medical industry in the New 17 Hampshire was that by October of 2007, that we would 18 have the ability for all primary care prescribers to 19 be able to transmit electronically prescriptions, 20 and that by October of 2008, the remainder of the 21 specialty care providers. 22 There was no state money appropriated along 23 with this. It was really a challenge to the 24 marketplace to be responsible for the implementation 25 of this particular initiative Next slide. The challenges that we face, I 2 think, are primarily around how do we move something 3 in the marketplace and how do you move the 4 marketplace itself further forward? Everybody that 5 we talked to within the provider community thinks 6 that it's a great idea, but we're hearing some 7 consistent themes back from providers over the last 8 ten months, one of which is, well, I have lots of 9 different things in my queue of IT projects. Where 10 does this fit? 11 And I think one of the things that we have 12 seen that's been very positive is that because we Page 26

27 13 did have the governor out front saying that this was 14 something that we wanted to see in the state, we've 15 actually seen certain providers -- there's at least 16 four hospital systems that have accelerated where 17 this project fits within their queue, so it is 18 starting to see some movement. 19 I think the ongoing funding of 20 e-prescribing is an issue. The licensing fees to 21 tack on to, say, an existing product like a 22 G-Centricity product, you know, can run $500 per 23 prescriber per year, and it's just additional 24 budgetary constraints that need to be thought about. 25 We also hear, too, that, well, I'm e-faxing today, how much better will it be? And I think this 2 really goes to Kevin's point that we're really 3 talking about full bidirectional capacity, and it's 4 really been an education effort to show providers 5 what the benefits are going to be once we have that 6 complete loop with the pharmacy closed. 7 The next bullet is really just addressing 8 what technology. Again, there are dozens of 9 different solutions out there. The majority of our 10 providers that have electronic medical records will 11 use whatever is available within their EMR, so that 12 cuts down the technology question for many. But for 13 others, it's still an issue. 14 And then, so the last one's tied to the 15 anonymous quote at the bottom in terms of free is 16 not cheap enough for the providers. We're 17 consistently hearing again, Well, how do I get Page 27

28 18 reimbursed for this? It's costing me more money, 19 and I think sort of the whole value of who's 20 actually achieving savings in the equation is 21 requiring additional education. 22 Next slide, please. But given all the 23 challenges, we have made significant progress. We 24 have, right now, in excess of 50 percent of 25 clinicians in the state are using electronic medical records with some level of electronic prescribing. 2 Many are doing what I call e-rx Light, where they 3 might be entering it electronically but then it's 4 getting faxed to the pharmacy, but the basic 5 technology is in place, and we're really primarily 6 just waiting for the institutions to, you know, turn 7 on the full-blown functionality. 8 We believe that more than 95 percent of our 9 pharmacies are ready to accept. We've had very good 10 support from the independent pharmacy chain 11 association group on this. And then in terms of 12 funding, we've been trying to get creative here. 13 All of our federally qualified health centers have 14 full-blown electronic medical records today, and we 15 do have a pending grant to try to get them over the 16 hump to be able to turn things on, and this week, 17 actually, there's a mailing going out to all 18 prescribers in the state from Anthem, and they're 19 announcing a partnership with the NEPSI initiative 20 and Sprint to provide the e-prescribing software 21 free to any provider who wants it, along with a 22 Sprint phone PDA device that is linked back to the 23 NEPSI solution, and the idea here is that those that Page 28

29 24 do not have EMR, but want to get going, this is a 25 way to make that happen We also have Concord Hospital is one of the 2 three national pilot sites for the GE Centricity 3 rollout of the e-prescribing solution, and our 4 Municipal Association, through their PBM contract, 5 is actually providing some funding to assist high 6 prescribers to move forward. I think the sort of in 7 closing on the progess slide, you know, the majority 8 of the infrastructure is in place today via Rx Hub 9 and SureScripts. 10 We in New Hampshire, being a small state, 11 are pretty fortunate that we don't have a lot of 12 major payers. Essentially there are three 13 commercial payers, and Medicaid that have the bulk 14 of the marketplace. Unfortunately, only two of 15 those four are actually on Rx Hub today, so Cigna 16 and Anthem are, but Harvard, Pilgrim and Medicaid 17 are not, so we are missing about 250,000 lives out 18 of 1.3 million people in this state, but we do 19 expect that over time, that they will be able to 20 come on, and the infrastructure will be complete for 21 them. 22 So to wrap up, the next steps for us really 23 are to step up the campaign and the PR that we've 24 been working on with folks like the medical society, 25 and MGMA and others, to try to push folks towards further adoption and really finding value for all 2 the stakeholders that exist. Page 29

30 3 We're also actively exploring creation of 4 the revolving loan fund for small provider 5 practices, initially around EMR implementation, 6 because the costs for EMR are much higher than 7 e-prescribing, but we think for some of the 8 technology purchases for e-prescribing, the funds 9 might be available, and we're continuing to find 10 other grant-funding opportunities, and finally, 11 measuring and reporting success of our efforts. 12 I don't believe that there are really a lot 13 of implementation barriers related to the technology 14 itself. It's fairly straightforward. It's been in 15 place for years. It's robust, and we know how to 16 get things implemented. I think the primary 17 barriers today are really around some of the 18 up-front initial costs to move it forward, and 19 getting the provider community to really embrace the 20 benefits. 21 I think it would be ideal if perhaps even 22 CMS could mandate, especially, to kind of move the 23 whole marketplace further forward. All of the New 24 Hampshire payers today participate in a 25 pay-for-performance program that was developed with the Citizens Health Initiative that went into effect 2 in January of this year, and e-prescribing is a 3 component of that, but some of the back-end 4 incentives, I think sometimes just aren't quite 5 enough. It's really getting people over that 6 up-front technology purchase and training and work 7 flow adoption within the offices that's required to 8 get people to move forward. Page 30

31 9 So with that, thank you very much. 10 GOVERNOR PHIL BREDESEN: Thank you. 11 Thank you very much. 12 This discussion of e-prescribing this 13 afternoon, and these three presentations, is being 14 conducted in the context of this group perhaps 15 looking at e-prescribing as a way of doing some of 16 the specifics to move forward and begin to actually 17 cause some change out there. 18 I think all of us want to finish this 19 process up, when it's finished, with the notion that 20 something really has been accomplished, as opposed 21 to we've all gone to nice places and had 22 conversations and met. And from various different 23 directions, I think it's come to Jim's and my and 24 others' attention, that this may well be, this idea 25 of rather than trying to solve all the problems in the world across the brook, going a rock at a time 2 may be a way of tackling this. 3 The context is that just trying to take 4 this huge problem and cut it down into some 5 manageable pieces that we can tackle, some people 6 might see that as a narrowing of focus, and I don't 7 mean that, but I think it might represent some real 8 progress. I don't know what all of your experience 9 has been, but I think that success in a complex 10 environment often results from establishing a 11 beachhead and really trying some things and getting 12 the experience that comes from working with this, 13 and then using that beachhead to expand our breach. Page 31

32 14 I think the reason that e-prescribing 15 became such an important part of the agenda this 16 afternoon, and this following discussion, is that 17 first of all, it does offer meaningful improvements 18 in the quality of costs and care. I mean, what it 19 can do to reduce errors is obvious to ensure 20 compliance, to attack fraud, things that were 21 mentioned here. 22 It is a conceptually relatively simple 23 piece of the health care equation. It's a known 24 finite universe of products and transactions that 25 take place. It cuts across the entire spectrum of patients. It does some straightforward simple 2 things for nearly hundred percent of the patients, 3 as opposed to very complex and difficult things with 4 5 percent or 8 percent or some smaller proportion. 5 You touch nearly all patients, you touch nearly all 6 doctors. And as such, it's a good beachhead. 7 And I think, also, that a lot of these 8 things that we have struggled with this in group and 9 had have heard presentations about, it's going to 10 require some practical solutions for issues of 11 confidentiality, issues of patient identification 12 that are out there. 13 And last of all, and I think ultimately 14 most important, it really does force us to confront 15 the challenges of widespread adoption. To make this 16 work, we need to sell it not only to the technodocs 17 you were talking about, but also to those, you know, 18 straightforward physicians operating in small 19 offices out in rural parts of the county who, for Page 32

33 20 whom, again as it was said on here, free is already 21 too expensive for trying to incorporate something 22 like this. 23 So in that context, we asked for these 24 presentations here today, and set some time aside and I believe we have up to 45 more minutes. We certainly can shorten if from that if you want, to 2 get some perspectives and to engage in a little 3 discussion, to have a conversation, questions or 4 thoughts to the presenters, but also like to get 5 some conversation from you, as is this an area which 6 is worth pursuing through this, as we begin to wrap 7 up and come to some conclusion on some of these 8 other things, is this an area that's worth pursuing 9 for this committee? 10 So with that, I just would throw it open 11 and not put any more structure on it than that. 12 Gayle? 13 MS. HARRELL: Thank you so much, and I 14 know Florida has been very, very involved in 15 e-prescribing. This is something that we are 16 really, really trying to promote, and in fact, this 17 last year, I passed some legislation to use 18 e-prescribing and to -- and really for a different 19 context that I'd like to kind of throw out there. 20 We have a huge prescription drug abuse 21 problem in the State of Florida. And after looking 22 at other mechanisms and trying to do a state 23 database on scheduled drugs that became politically 24 impossible to do, we wound up taking a route of Page 33

34 25 really empowering physicians to use e-prescribing software to use to look at drug histories, so that 2 they would be able to see the drug history of a 3 patient, and then perhaps choose not to prescribe 4 whatever they were asking for. OxyContin or 5 whatever drug out there that the patient may have 6 been coming in for, so they could see that it had 7 been prescribed by several other practitioners in 8 the area. Doesn't deal necessarily with pill mills 9 and that kind of thing, but it does help with 10 doctor-shopping. 11 And what we did was to say we would waive 12 the relicensure fee for physicians who used 13 e-prescribing. So this was an incentive that we did 14 for physicians to get into e-prescribing. 15 Unfortunately, that segment of the whole 16 project was within a Medicaid implementing bill that 17 wound up getting vetoed for other reasons, but we'll 18 be back next year to do that same kind of thing, and 19 really expand the whole idea of encouraging and 20 incentivizing our physicians to do e-prescribing, 21 and I think any mechanisms that you, as other 22 states -- we have several representatives here, and 23 different health commissioners and whatever -- but I 24 think we need kind of a clearing house of these 25 kinds of ideas to promote e-prescribing, and we this is very helpful to see what other states are 2 doing, but that I would love to see expanded, and 3 where you could go on the website and pick up what 4 other states are doing in promoting e-prescribing. Page 34