ePrescribing Requires Continued Industry Focus; More AzHeC-Like Initiatives Needed


By Tony Schueth, CEO & Managing Partner

ePrescribing has become an integral component of healthcare delivery and the preferred method of prescribing non-controlled medications.  Last year,  58% of eligible non-controlled prescription were transmitted electronically through the Surescripts network. In addition, 73% of office-based physicians ePrescribed, a 4% increase over 2012.[1] The 4% increase is less than I would have expected in year 3 of Meaningful Use (MU), 11 years after the passage of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) and 6 years after the passage of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), landmark pieces of legislation that paved the way for ePrescribing.   

Electronic prescribing of controlled substances (EPCS), however, is just starting to take root after the DEA’s Interim Final Rule allowed it on June 1, 2010.  In 2013, 13% of our total 3.85 billion retail prescriptions were for controlled drugs and 330,000 NewRx EPCS messages were sent across the Surescripts network.  This means that approximately .07% of controlled prescriptions were electronically prescribed via Surescripts last year.  At NCPDP’s August Workgroup meeting, Surescripts reported that through July 31, 570,000 EPCS prescriptions (or .11%) were transmitted via their network.

What can we do as an industry to meaningfully advance EPCS?  Consider that a significant percentage of EPCS prescriptions last year were filled in Arizona, where a focused multi-stakeholder initiative to advance EPCS was orchestrated through the  Arizona Health-e Connection (AzHeC).  As reported in  a previous POCP blog, this initiative removed EPCS barriers and provided a model for achieving EPCS growth.   

From May to December 2013, Arizona saw a greater than 10-fold increase in the number of ePrescribing Controlled Substances (EPCS) prescribers, and an increase from less than 200 to nearly 16,000 EPCS transactions transmitted per month via five different EHR and ePrescribing systems.  This effort worked because of a coordinated state-wide effort, eliminating the “which comes first, the chicken or the egg?” problem; meaning, in some areas pharmacies were ready but physicians not, or vice versa.  Point-of-Care Partners supported the state’s Regional Extension Center (REC) in this effort.  

The 2013 Results: Arizona EPCS By The Numbers

AzHEC_GraphTranslating the Value

The DEA believes that EPCS could save up to $700 million annually. Between 3% and 9% of drugs that are diverted for abuse are tied to fraud and forgery of paper prescriptions.[2] EPCS holds great promise for reducing drug-related deaths and improving medication management through EHRs and pharmacy systems, if these systems are enabled and their users are prepared for EPCS. This is no small task, considering that the requirements for each contributor to the EPCS equation are unique and laws vary by state.

As conveyed in our AzHeC case study, “Each state — and situation — is different, and a multitude of  key variables must be taken into account in putting together a successful plan. While Arizona achieved noteworthy success with its program, the fact is, what worked in Arizona worked in Arizona, and may not be optimal for other geographies.”

 “Danger, Danger” Healthcare Industry

So, as an industry we’ve accomplished a heck of a lot when it comes to ePrescribing.  Is it enough?  The answer is absolutely not, especially when it comes to EPCS.  For MU, EPCS is just part of the ePrescribing equation, and physicians can achieve their measures if they don’t prescribe controlled substances electronically.

For EPCS, regulations aren’t going to get us where we need to go.    ePrescribing still requires geographically-focused efforts, particularly for EPCS, to reach its potential and justify EHR and other investments.  We need more AzHeC-like initiatives.

As an industry, we don’t want it to take 10 years for EPCS to reach the tipping point, and we do not want ePrescribing to lose momentum.   With  focused efforts and the continued support of industry leaders, we can spur EPCS adoption and begin to reap its many benefits in much less time.

[1] and [2] Surescripts 2013 National Progress Report and Safe-Rx Rankings


Does formulary decision support improve patient compliance?


By Michael Burger, Senior Consultant

Policymakers, payers and providers view health information technology (health IT) as a tool to help improve patients’ medication compliance, among its many benefits. This is important because patient non-compliance with their drugs costs billions of dollars annually in unnecessary care, adverse outcomes and deaths. 

Research that investigates the relationships between health IT, costs and patient outcomes slowly is emerging. Findings are mixed. For example, a new study published at Biomed Central, explored, in part, whether a formulary decision support (FDS) function in an ePrescribing system might improve patient compliance and reduce costs. 

Using claims data from 2004 and 2005, the researchers examined the impact of ”non-interruptive” vs. “interruptive” FDS on patient compliance for angiontensin receptor blockers and inhaled steroids. In the end, it apparently didn’t matter which FDS method was used because there was no real impact on patients’ compliance or out-of-pocket costs.  It appears to us that this finding was less a result of the FDS method, but more to do with the study medications, which had only marginal price differences between them.The researchers noted that in order to impact cost-related non-adherence, formulary decision support will likely need to be paired with complementary drug benefit design.

The study did show an impact of FDS on brand selection at the point of prescribing, since generic alternatives were not available for the study medications. In the study, depending on the ePrescribing system that was used, non-interruptive FDS displayed a symbol indicating that an alternative was available. The interruptive FDS was more directive, automatically displaying a message suggesting that prescribers consider specific alternatives.  Study results indicated that prescribing decisions were more directly influenced by the interruptive FDS. This suggests that FDS might be a tool to help physicians choose among brands; however, more work needs to be done to better understand the effectiveness of formulary representation and messaging on prescribing decisions.

To our mind, the study also illuminates the challenges that such research designs and findings pose for policymakers and vendors owing to the age of the data that were used and the technological advances that have taken place since then. The researchers used 2004 Horizon Blue Cross/Blue Shield data from prescribers using a standalone ePrescribing application (iScribe), and 2005 claims data from Caremark. The vast majority of ePrescribing is done within EHRs today.  Formulary decision support and formulary status in ePrescribing systems—standalone and EHR — have come a long way in the intervening years. While studies based on happenings of a decade ago are instructive in today’s world, they clearly lack the value of studies grounded in current data and technology.  We hope the researchers get a chance to try this study again, using more current information from claims and from EHRs themselves. 


Electronic Prior Authorization – Now is Finally the Time


By Tony Schueth, CEO & Managing Partner

If you want to hit the healthcare jackpot in 2015, there’s one place you should place your chips:   electronic prior authorization (ePA) for medications.  The medication prior authorization process can now be dramatically streamlined via an ePrescribing transaction. The “endpoints” are now building or have built the infrastructure to take medication prior authorization from a days to weeks long endeavor to a fully electronic process that can be completed in 1-2 minutes within existing prescriber and pharmacy workflows.  There is no need to “pass GO” – the industry is at GO! 

Prior authorization is intended to be a cost-saving measure that helps ensure the safe and appropriate use of selected prescription drugs and medical procedures.   Current manual processes involving paper/phone/fax are very costly to administer for physicians, pharmacies and PBMs and, without automation, their administrative burdens will grow exponentially as volume and requirements for PA increase, particularly for specialty medications.

Paper-based ePA is a very time consuming process, and the cost of phone calls and faxes to gain approval is well understood by physicians and pharmacies. The current process, which takes 15 days on average, often results in prescription abandonment.

Electronic prior authorization enables providers to deliver more proactive care and keep patients healthy with efficient access to medications. In 2011, the National Council for Prescription Drug Plans (NCPDP) ePA Task Group learned that  ePA is #1 ePrescribing capability desired by doctors. Then last year, NCPDP approved an electronic data interchange (EDI) standard for ePA, after a successful pilot supported by industry leaders Allscripts, CVS Caremark, Navinet/CoverMyMeds and Surescripts.  

While prior authorization can be simplified through prescriber and PBM/payer portals, its full potential can be achieved with full integration into the ePrescribing workflow of EHRs. This ePA workflow is supported by the NCPDP SCRIPT standard described above, and is “prospective” because it is initiated by the prescriber and occurs before the electronic prescription is sent to the pharmacy.  When the prescriber is notified in real-time of a PA requirement, four things typically happen  when the NCPDP SCRIPT standard is integrated with the EHR: 

  1. The prescriber answers PA specific questions based on the patient, plan and medication. Patient information may be pre-populated from the EHR.
  2. The PA request is transmitted in real-time to be PBM and the prescription is pended.
  3. The PBM returns an approval (or rejection) typically within 1-2 minutes.
  4. The preapproved, clean ePrescription is routed to the pharmacy.

More advanced implementations will support appeal requests/responses and cancel requests/responses.  

EHR vendors are evaluating requirements for integrating ePA into their applications, and prioritizing ePA into their development roadmaps.  Considering that  Surescripts found that 28% of physicians surveyed would switch their EHR vendor for ePA, this is a good move for EHR vendors.

Companies to watch in the ePA space include CoverMyMeds and Surescripts.  CoverMyMeds introduced the industry’s first API for EHR vendors earlier this year and has a long track record of success with their ePA Portal.  Surescripts is rolling out CompletEPA, their real-time ePA solution integrated into the EHR workflow. Services such as CoverMyMeds offer connectivity for all ePAs because even if the PBM or payer aren’t electronically enabled, electronically-initiated ePAs are delivered via fax. 

Looming overhead are regulatory requirements. A number of states, including MN, ND, MD and CO have mandated use of ePA beginning in 2015, and 10 other states have active regulatory activity which involves ePA. The coming regulatory mandates afford EHR vendors the opportunity to be ahead of the curve.  Rather than scrambling to meet multiple state regulatory deadlines at the last minute, vendors can begin development now to include ePA functionality while there is still breathing room to concentrate on workflow enhancements.With this approach, ePA will become as valuable to providers as ePrescribing.

Now is the time to spread the word about the new SCRIPT standard for ePA and its value.  To learn more, visit www.ncpdp.org.  If you are an EHR, health plan, PBM or pharmacy information network, now is the time to integrate ePA through implementation of the SCRIPT standard or through partnering with a company that offers a plug-and-play solution.

The time is right for standardized electronic prior authorization for medications.