Adoption of e-prescribing Yields Surprising Benefits to Practices

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1 Adoption of e-prescribing Yields Surprising Benefits to Practices by Bryan Cote By speaking with practices and companies we have found that e-prescribing provides unexpected and favorable operational outcomes for oncology practices. A Web-based survey we conducted confirms that it s not just about the government s incentive, but staffing and patient needs as well. By implementing e-prescribing technology, participating community oncology groups have begun to track their oral oncolytics prescription business. Adopting this new technology is allowing these practices to readily prepare for the impact oral medications are having on staff, patients, treatment decisions, and, oh yes, their balance sheets. Seemingly, it appears to these groups that more patients will be utilizing oral anti-cancer agents and therefore are expected to need greater medication management. This may be a significant, albeit quiet phenomenon to emerge from increased adoption of the e-technology boosted this year by the government s decision to pay physicians 2 percent of total Medicare allowed charges (if, at least, half of their scripts are electronically generated). Of the 100 community cancer care providers polled in March, 22 oncology groups are currently e-prescribing; and all but four have informally discussed how to use e-prescribing data to explore oral utilization trends. Figure 1. Are you using e-prescribing technology to mine for oral agent data on use? (N=100) 18.2% Mining for data on oral use Have yet to discuss 81.8% According to Carol Murtaugh, RN, OCN, a veteran oncology nurse who serves as clinical administrator for Hematology and Oncology Consultants, PC, a five-site practice in Omaha, Nebraska that began e-prescribing in February of this year, Being able to use e-prescribing to track the number of patients taking oral oncology agents is huge for us financially, operationally and clinically. By mid-april, HemOnc of Omaha realized its e-prescribing technology would help the staff recognize oral prescribing patterns and then be able to use that information to strategically figure out, for example, how best to implement resources to meet the increasing demand of oral agents. Murtaugh explained that by getting an exact count of patients taking these oral medications we can determine how many need time, education, follow up, who s compliant, and then dedicate staff to assist as needed. Additionally, in less than a month after integration of the technology, HemOnc of Omaha noticed an unexpected benefit to emerge: Their number of prior authorizations had declined. Unlike before, says Murtaugh, we can now see the patient s history; and if they already have failed on a drug, we can see what the plan formulary will allow, and adjust, rather than having to go to the UnitedHealthCare Web site [for example] to look up 20 different plans. Incentives to e-prescribe Even before Medicare s bonus incentive, commercial payers started to lure physicians with other incentives to e-prescribe. For instance, Wellpoint offers a Web-enabled smart phone with e-prescribing access, and BCBS of North Carolina and other Blue network plans offer a $1,000 incentive to providers to adopt e-prescribing. North Carolina oncologists were among the top five specialties to take the deal from BCBS, a spokesperson for the insurer said. How these bonus packages shake out on an oncologist s balance sheet is unknown, however, according to Michael Koerner, RPh, Director of 24 ONCOLOGY BUSINESS REVIEW ONCBIZ.COM MAY 2009

2 Pharmacy Services, ION, the majority of practices preparing late last year to e-prescribe estimated a $5,000 bonusper-practitioner per year for meeting the incentive s requirements. To calculate payments and estimate time savings, AMA members can go to a new online e-prescribing learning center (see Resources at the end of the article for the link). At the time of the government s e-prescribing incentive announcement in 2008, most oncology groups were not e-prescribing, and currently many are still considering, but signs indicate that the financial incentive is catching on. In a separate online survey ION conducted in November 08, 10 percent of the 200 community oncology practice respondents reported that they were e-prescribing, however, by February 09, the number catapulted to 33 percent from the same sample. We expected this, Koerner said, since integration takes under six weeks typically, and a large number of practices in the November poll indicated they would be ready, due mostly to the government s incentive. Of those groups yet to adopt, some with electronic medical records systems (EMRs) told the GPO that they were waiting for their EMR vendor to produce an e-prescribing module rather than purchase standalone software. But I don t think it s wise to wait for an EMR vendor given the incentive and benefits available now, said Koerner. One Company s Solution McKesson Specialty Care Solutions has helped its customers take advantage of the bonus incentive by adding an e-prescribing menu choice to its two-year-old Web-based, proprietary charge capture and inventory management Lynx technology. With a menu bar add-on, an oncologist has immediate access to all patient information and an ability to transfer over to Relay Health s escript e-prescribing system to file medication refills and renewals. The company also offers a reimbursement and reporting analysis tool to allow a practice to dive deeper into the effects of e-prescribing. Using the three billing G-codes required to get bonus credit from Medicare, McKesson s Lynx TotalView system takes a copy of the outbound claim and uses it to produce a status report of a group s e-prescribing habits. Prescribers, informed Mike Kelly, Chief Information Officer for McKesson Specialty Care Solutions, can access patient infusion history and electronically send additional information to pharmacists through a Notes feature. Administrators can track Medicare scripts and adjust to meet the 50 percent threshold for payout (see Figure 2). The government s incentive applies only to a physician s Medicare patients, but after a month, nurses at HemOnc found the McKesson tool so useful that they convinced Murtaugh to use the system for its commercial population as well. cont. on pg 26 >> Figure 2. Tracking e-prescribing Compliance By Provider. Source: McKesson Specialty Care Solutions MAY 2009 ONCBIZ.COM ONCOLOGY BUSINESS REVIEW 25

3 We ve already seen formulary and labor savings just on the Medicare side [since] everything about this is faster, like searching for pharmacies. Most vendor systems, including escript, store medication histories including doses taken by the patient and a patient s preferred pharmacy. Savings on Labor End The Sacramento Center for Hematology and Medical Oncology in California started writing scripts electronically in 2004 when local pharmacies were not as prepared as they are today for e-transactions. In as much as the technology has helped the group more safely track and fill scripts and manage cancer patients who see multiple doctors, there have been bumps. For example, getting all of the clinicians onboard to use the technology took some time, said Robert Miller, MD, the Center s President. Robert Miller, MD President, Sacramento Center for Hematology & Medical Oncology, Inc. He thought that practices yet to adopt the technology should expect some resistance. The Center uses Rcopia s DrFirst, a Web-based system physicians can access remotely, and one which is available through a contract to all US Oncology network practices. By the time the Center joined the US Oncology network in late 2005 it began experiencing workflow rewards. It retired its answering machine prescription line that year, and by Dr. Miller s estimates, doing so saved the group about 30 minutes a day checking messages. From an MD standpoint, I can t really quantify how this extra time has helped me, but from the staff standpoint, managing refills with e-prescribing has had a favorable impact on our FTEs. Before e-prescribing, Dr. Miller said the group would have likely had to have replaced a staff member who left the group. Effects on Therapeutic Decisions For physicians, clinical treatment decisions for cancer patients haven t changed all that significantly but there are winds of some small, but meaningful effects that may emerge with e-prescribing. For instance, more cancer care prescribers are likely to see a fail-first requirement/ step edit or a prior authorization pop-up during or after a patient visit before submitting the e-script. Will this messaging notice factor into a physician s treatment decision? According to more than threequarters of our survey respondents, it may have an impact. Seventy-two percent of the 100 community oncologists and practice administrators said e-prescribing will likely have somewhat of an effect on treatment decisions, if for no other reason than because of the instant formulary information access and list of therapeutic equivalents (see Figure 3). When asked to think about their practice s decision to e-prescribe, 29 percent said Medicare s incentive Figure 3. What effect will e-prescribing have on cancer treatment decisions? (N=100) 14% 10% 4% Somewhat of an effect No effect whatsoever 72% Too early to tell Highly likely to effect treatment decisions has or will influence their decision a lot, second only to the 35 percent who said it has/will not influence their decision in any way. Of the 100 polled, 58 percent shared comments suggesting that use of some supportive cancer care agents, like those for nausea, pain, and stomach conditions in cancer patients are more likely to be effected than, for example, chemotherapy products or first- and second-line treatments for certain tumor types (see Figure 4). Drug cost information accessible on a PDA or an in-office e-prescribing Web site may increasingly affect therapeutic choices at the point of product selection. We know that a significant number of prescriptions, about 50 percent, are given a formulary message or a message that makes the physician know that there is a less costly alternative for the patient, said Ronald Smith, Vice President 26 ONCOLOGY BUSINESS REVIEW ONCBIZ.COM MAY 2009

4 Figure 4. Has the Medicare bonus influenced e-prescribing adoption among community oncologists? (N=100) 20% 16% Will not influence decision / Has not influenced decision Will influence decision a lot / Has influenced decision a lot Will influence decision a little / Has influenced decision a little Don t know 29% 35% of Employer Health and Corporate Pharmacy, BCBS. And we know that a significant amount of the time, physicians choose that alternative. Interestingly, of the 22 respondents in our poll who are e-prescribing, 16 said cost is sometimes a factor in their treatment decision, whereas just 30 of the 78 yet to officially e-prescribe said cost is a factor in drug selection sometimes as well. The sample is small, but the results may mean that e-prescribing technology is giving doctors more information than they re used to before writing a script, including access to a treatment s cost to the patient and the practice. Having this access is one new piece of data oncologists are now more easily able to evaluate. Dr. Miller said there s another nuance to consider. Part of the clinical decision support you have with e-prescribing is built-in safety alerts if a drug has an interaction, a warning will pop up on the screen. Dr. Miller s issue with this is two-fold: (a) that all alerts are not the same and the alert may be irrelevant for the specific patient s case; and (b) physicians may get alert fatigue. To be honest, there can be a temptation to ignore the alerts and overwrite them, he said. For the five practices in our survey with EMRs in place, each said e-prescribing has allowed doctors in their group to customize a favorites list of their most commonly prescribed medications, by tumor type. Doing so has helped in three ways according to respondents: (a) it saves time in selecting treatments; (b) it determines treatment protocols for similar patients; and (c) allows groups to compare how these so-called favorites are reimbursed and positioned on payer formularies. In the Case of Controlled Substances Sheldon Josephs, administrator for the Center for HemOnc in Sacramento states that access to medication histories with the group s e-prescribing technology has had numerous benefits, including some less than expected ones. For example, a narcotic prescription request came in to one of the group s on-call physicians, but the staff used the e-prescribing software to detect an abusive pattern of docshopping by the patient for narcotics. That patient may cont. on pg 28 >> MAY 2009 ONCBIZ.COM ONCOLOGY BUSINESS REVIEW 27 NOW AVAILABLE! PIPELINE Compiled by Don ONLINE Welcome to the OBR Pipeline Online Simply put, we provide the most comprehensive and up-to-date oncology pipeline information resource on the web. Interactively explore the current state of the entire oncology pipeline by selecting one of the tabs below or discover detailed information by performing your own custom pipeline search now. BEGIN PIPELINE SEARCH NOW VIEW PIPELINE BY: TUMOR TYPE COMPANY CLASS PHASE PRODUCT TUMOR TYPE PRODUCT INDICATIONS BY PHASE NSCLC Breast Ovarian Non-Hodgkin Lymphoma Colorectal Renal Pancreatic AML Prostate Head & Neck A searchable database capturing the entire oncology pipeline. Gastric CML CLL Melanoma Glioma Small Cell Lung Cervical Glioblastoma Biliary Tract Bladder Cancer of Unknown Primary Myeloma Lung Soft Tissue Sarcoma Lymphoma Myelodysplastic Syndrome Hepatocellular Carcinoma Search by: Tumor Type Company Class Product ALL CONTACT OBR TERMS OF USE PRIVACY POLICY ONCBIZ.COM What s next? What phase? Find out NOW AT oncbiz.com Wit in P (FDA an e -Anth (Forbes.c announce in its Pha treatment Disease (G marrow tr (Forbes.c Inc., a bio velopmen for the tre diseases, clinical tri treatment

5 very well have had the script filled before we implemented our e-prescribing system, contends Josephs. For 72 percent of the respondents in our survey, these types of medications such as Vicodin, a drug widely used to treat cancer pain account for 25 to 50 percent of prescriptions. In the next year, physicians can expect some decisions about how to fix what many say is a glaring gap in e-prescribing: That a physician cannot e-prescribe a controlled substance. The Drug Enforcement Agency (DEA) has developed initial guidance that would legalize the e-prescribing of controlled substances. According to ION s Koerner, I think the DEA proposed guidance is a bit too stringent for people to adopt for e-prescribing as is. We re miles apart still. Dr. Miller s group doesn t find the DEA regulation a huge burden, but the draft guidance in his opinion doesn t appear to fix the gap either. I don t understand how [the current DEA regulation] provides safety by faxing the paper script, he says. I can call any pharmacy now and ask for them to please give the patient a prescription for Vicodin, and you d be amazed at how few times they ask for my DEA information. Conclusion It s evident from our survey that even for those practices e-prescribing, the transition is still a kind of pilot test for what 85 percent in the poll said is their long-term goal to implement an EMR system. In the interim, the Medicare bonus incentive has clearly stirred up a frenzy of activity and dialogue among providers, oncology GPOs, and payers, and there is a refreshing tone of teamwork across the cancer care continuum. ION, for example, is using its relationship management team in the field to lead oncology practices to resources as well as facilitate site visits for inquiring groups to observe a practice that is already e-prescribing. This helps the visiting group to understand what they should want and expect from an e-prescribing system. Practices can then find vendors able to customize their needs. Questions such as: Do you want to have access during the patient encounter to all information, i.e., patient histories and drug-to-drug interactions and formularies? Or something more basic? should be asked before selecting a vendor. Other questions surely will emerge as more practices adopt the technology, perhaps none bigger to the oncology industry than how access to script data at the practice level will affect the adoption, utilization and treatment of oral anti-cancer medications. BC What to expect Tips for e-prescribing integration 4 to 6 weeks to implement 30-minute to 1-hour Web-based physician training, often self guided Set-up costs vary: $500 to $2000 depending on infrastructure, exam rooms, laptop and other preferences (Lynx set up waived through June 2009) RESOURCES A Clinicians Guide to e-prescribing: e-prescribing_clinicians_guide_final.pdf SureScripts: Center for Improving Medication Management: Fewer in-bound/outbound calls and faxes for renewals, refills Reduced prior authorization demands Support staff free time to dedicate elsewhere Learning Center (includes vendor prices; calculators to estimate time savings and determine Medicare e-prescribing incentive payments): Data on oral agent prescriptions to apply to business decisions ASCO: 28 ONCOLOGY BUSINESS REVIEW ONCBIZ.COM MAY 2009