From the Center for Studying Health System Change (hschange.com) comes a study on e-prescriptions, and how providers and pharmacies work together to electronically transmit and fulfill prescriptions. Now, I don’t know how reliable this organization or its research is (the .com in its name, for example, is something that bothers me. Also the report focuses almost exclusively on SureScripts). But the study is interesting to me for what it reveals statistically.

HSChange.com conducted 114 phone interviews with 24 physician practices, 48 community pharmacies, divided between local and national companies. The national respondents included 3 mail-order pharmacies, and 3 chain pharmacy headquarters. Those of you who are interested in the numbers, the methodology and other sundries, go ahead and read the report in its entirety. Here’s a quick summary from the report’s results the rest of us. My comments are bolded.

According to the report:
Two-thirds of the practices sent at least 70% of their prescriptions electronically. Which means about 46.2% of the prescriptions are e-prescribed. Plenty of room for growth, methinks.

Pharmacists at more than 50% of Community said their pharmacies received less than 15% of their prescriptions electronically. The reasons: providers didn’t transmit electronically, or sent out computer-generated prescriptions by fax or mail. Interesting – could be indicative of either lack of knowhow, or infrastructure that allows for e-transmission.
New prescriptions are more likely to be e-prescribed than prescription refills (renewals). The report states that many pharmacies don’t use this feature in order to avoid SureScripts fees for renewals.

There are plenty of inefficiencies. E.g. a) multiple requests for the same prescription were sent (say by phone, fax and through SureScripts) by pharmacies b) providers mistakenly deny prescriptions and then re-send the same prescription as a new one.

E-prescribing to mail order pharmacies is a different process – (apparently providers need to be Surescripts certified to e-prescribe with community pharmacies, and also need to be certified to e-prescribe to mail order pharmacies. So, even when a provider selects a mail order pharmacy to fulfill an e-prescription, the prescription is delivered by fax to the the mail order pharmacy by Surescripts.)
Prescription specificity falls on the provider – tablets, capsules, and liquid formulations might have different costs. Pharmacists can’t change the prescription from a capsule to a tablet on their own, without consulting with the prescribing provider. This might result in unexpected costs.
Providers’ patient instructions are still incomprehensible! Pharmacists often have to play translator (maybe because as the report alludes to, the instructions are intended for pharmacist eyes, not the patient.)

an independent pharmacist explained, ‘A lot of times we can’t copy the directions word for word because the patient doesn’t understand them, just like with paper prescriptions. We have to go in and erase ‘t.i.d.’ and put in, ‘One tablet three times a day’.’

On my far-too-frequent visits to my younger daughter’s pediatrician, I’ve noticed pristine new monitors and keyboards wrapped up and sitting in the corner of the exam rooms. Over the last six months, there they’ve sat, waiting patiently to be unwrapped and plugged in. “What’s the hold up,” I think? As a parent, I’m hoping this new system will offer the doctors e-prescribing capabilities. As a healthcare IT observer, I’m wondering why what I presume to be an electronic health record (EHR) is taking so long to come out of the box and into operation. Is it a question of resources? Is the facility waiting for a training team to be made available? Is there back-end infrastructure that has yet to be put in place? These are the things I think about while dealing with low-grade fevers and scheduled immunizations.

Needless to say, my interest is always piqued when I come across stories of pediatricians adopting EHRs and/or realizing the benefits of that technology. So when I came across news that Sandhills Pediatrics had received $184,000 in EHR incentives, I was intrigued. The Columbia, S.C.-based practice has been using an EHR from SRS since 2010.

“Even our initially most skeptical physicians became committed SRS EHR users in a very short period of time,” said Kevin O. Wessinger, M.D., president of Sandhills Pediatrics, in the release announcing the pay out. “All fourteen physicians and their staff value the efficiencies that SRS has delivered and the patient care and practice improvements that SRS has facilitated.”

I recently spoke with SRS CEO Evan Steele to learn more about how Sandhills implemented the EMR back in 2010, and the benefits they’ve realized from it.

This being the practice’s first EHR, what prompted them to make the move from paper to digital?
ES: “The driving force was the quality of care Sandhills was providing. With 4 locations and Saturday and Sunday office hours only at the central location, patient chart review was a big challenge. The patient charts that were housed at the satellite offices, because that’s where the patients were normally seen, and so were not available to review for weekend care. Additionally, the practice provides nurse triage in the evenings until 10:00pm and again, the satellite patients’ charts were not available.”

Did you, as the vendor, encounter any barriers to adoption from the Sandhills staff?
“No, we did not encounter any barriers to adoption. Our implementation plan is highly developed and assures 100% adoption. In addition, the Sandhills team’s dedication to success allowed them to achieve their EHR goals. Furthermore, the decision to implement the SRS EHR was driven from the top down. Sometimes the age of the physicians may impact adoptability. At Sandhills, 12 of the 14 physicians are under the age of 50 so they are more computer-savvy and willing to make the change.”

What sort of “extras” do the pediatric practices look for when selecting an EMR?
“Unique to pediatrics are immunizations. The SRS development staff worked closely with Sandhills on immunizations and pediatric growth charts. SRS secured the integration between Sandhills and the World Health Organization, developed a table for displaying and storing vaccine information, and enabled Sandhills to provide this information to their patients in a usable format.

“With a patient population of 57,000, Sandhills had to provide every kindergarten, grade school, and day care with proof of immunization. In the past, the practice had to hand-write 20,000 immunization certificates each year. SRS was readily available to provide a solution to this issue and saved the Sandhills staff many hours of aggravation. SRS created a form that auto-populates the immunization information so now the Sandhills staff no longer needs to hand-write each certificate.

The same process and benefits were developed for growth charts. The SRS EHR provides the patient’s age, and the Sandhills staff only has to enter height and weight, and this information auto-populates on the growth charts.

SRS created efficiencies, which coupled with our uniqueness in allowing physicians to continue to document notes as they are accustomed, has led to a successful implementation and positive EHR experience.”

How have clinical outcomes and patient satisfaction been improved since the EMR was installed?
“Clinical outcomes have improved as the physicians have access to pertinent clinical data at any time from any place. Additionally, the staff is quicker to respond to patient inquiries. They’ve experienced tremendous improvements in efficiencies and patient outcomes as a direct result of using SRS Order Management. Sandhills used to have manual paper tracking of lab tests and now with the SRS EHR, an expected date pops up in the system and if a test is not back by then, an alert is shown calling attention to the fact that it needs to be addressed.

“The patients, especially those seen on the weekends and evenings, have commented that they appreciate the improved and quick service. When they call in to the office with questions and concerns, they are comforted and given peace of mind knowing that the Sandhills’ staff is completely familiar and up-to-date with their situation.”

What do you think will be the next evolution of EHRs for pediatrics?
SRS Development recently unveiled vaccine inventory control. This process is entirely manual now, but the new enhancements will automatically track down the vaccine to the lot number. It’s also a double-check for safety that the lot numbers they have match what’s in computer. This is a double benefit – quality control and inventory control. This new development will especially find favor with the nurses, who are so happy that a daily occurrence that used to take 2 hours will now take 2 minutes.”

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I hope you’re enjoying the series.

35. CPOE is important, but every EMR will have it.
I think that the CPOE discussion hit a head for me when I saw the CPOE requirements that were baked into meaningful use. Then, I heard someone from the often lauded (appropriately so) IHC in Utah who said that IHC didn’t have CPOE and it would be hard for them to meet that benchmark. Ok, so I’m more of an ambulatory guy than I am hospital, but this surprised me. In the clinics I’ve helped with EHR, CPOE is one of the first things we implemented. No doubt that every EMR has CPOE capabilities.

34. Make sure adverse drug events reporting is comprehensive
Yes, not all drug to drug, drug to allergy, etc databases are created equal. Not to mention some EHR vendors haven’t actually implemented these features (although, MU is changing that). I’d really love for a doctor and an EMR company to go through and rate the various drug database companies. How comprehensive are they? How good can you integrate them into your EHR? etc etc etc.

33. Make certain drug interactions are easy to manage for the physician
I won’t go into all the details of alert fatigue in detail. Let’s just summarize it this way: You must find the balance between when to alert, what to alert, how to alert and how to ignore the alert. Plus, all of the opposites of when not to alert, what not to alert, and how to not ignore the alert.

32. Ensure integration to other products is possible
Is it possible that you could buy an EMR with no integration? Possibly, but I have yet to see it. At a bare minimum clinics are going to want to have integration with lab software and ePrescribing (pharmacies). That doesn’t include many of the other common interfaces such as integration with practice management systems, hospitals, radiology, etc. How well your EMR handles these integration situations can really impact the enjoyment of your EHR.

31. Ensure information sharing is easy
This tip could definitely be argued, but I believe we’re headed down the road of information sharing. It’s going to still take a while to get to the nirvana of information sharing, but we’ve started down the road and there’s no turning back. Kind of reminds me of Splash Mountain at Disneyland where the rabbit has a sign that says there’s no turning back now. My son didn’t like that sign so much and I’m sure many people won’t like that there’s no turning back on data sharing either. However, it’s going to happen.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

Carl Bergman, from EHRSelector.com, sent me the following email which poses some interesting questions about various certified EHR vendors and the software that they depend on to be certified.

Many of the [certified EHR] products relied on several other software companies to function. Usually this was Dr. First’s Rocopia, Surescripts, etc. However, many others had required several subsidiary modules to work. For example, Pearl EMR lists: MS .NET Framework 3.5 Cryptographic Service Provider; SureScripts; BCA Lab Interface; Oracle TDE.

There is nothing inherently wrong with this, but it raises three questions. Does the vendor include the price, if any, for subsidiary software? More importantly, how well integrated are these programs integrated into the main program? Does the vendor take responsibility if the subsidiary software changes making them incompatible?

He definitely asks some interesting questions. I’d say that in most cases, there will be little issues with the dependent software. Any changes by the dependent software are going to have to be dealt with or in some cases replaced by the EMR vendor. That will just be part of the EMR upgrade process that the EMR vendor does for you.

The only exception might be things like the third party ePrescribing software. Depending on how this is integrated it could be an issue. In most cases, integration with the ePrescribing software can be very much like an interface with a PMS system or even a lab interface. If you’ve had the (begin sarcasm) fun (end sarcasm) of dealing with these types of interfaces you know how it can be problematic and often a pain to manage. I believe the interface with an ePrescribing module is less problematic, but it will exhibit similar issues depending on how the EMR software works with the ePrescribing.

Personally, I don’t have much problem with these types of integrations. As long as the EMR vendor is providing all of the software for you. The reason this is important is because if you get the EMR software from one vendor and the ePrescribing software from another vendor and then tell them to work together, you’re just asking for a lot of finger pointing. However, if your EMR software chooses to integrate a third party software to flesh out the certified EMR requirements and provides you all of the software, then you’re in a much better position. As they say, then you only have one neck to ring if something goes wrong. You don’t want to have to call both vendors and have each vendor point the finger at the other. That’s a position that no one enjoys.

You know how I love to keep track of all the iPad EMR that are announced or marketed. Seems like the latest trend is to give the doctor a free iPad for selecting an iPad EMR. Not a bad strategy. Now if I could just get one of them to provide me a free iPad for reviewing their EMR *wink* *wink* but I digress.

I first read about this EMR that is available on the iPad on the Essinova site. This iPad EMR is being offered by Dr Chrono. Yes, another EMR vendor I’d never heard of before I saw this. Although, there site has them being on CNBC, Fox Business and The Wall Street Journal.

Dr Chrono’s approach is to provide a free iPad EMR app, but they take over the billing for you. Sounds a bit like Athena to me. They also say that they’re the only SureScripts certified ePrescribing app for the iPad. Maybe this was true when the video was made. I know that now there are others.

I guess maybe the next question is whether there’s an EMR vendor that won’t have something available on the iPad in the next 6 months.

I got the following email from an EMR vendor that highlights a number of interesting things about what it’s like for customers interacting with their EMR vendor. It’s very much in line with the experiences I’ve seen and heard. I’ve removed the specific EMR vendor names since the names don’t matter as much as the general experience. Instead I’ve used “small EMR vendor” and “large EMR vendor” and “ePrescribing solution.”

I was looking for an ePrescribe solution to interface to our small EMR vendor about a year ago and settled on using ePrescribing solution. As you probably know, they bailed out of the business and sold their service to large EMR vendor. Now we’ve interfaced our product with theirs.

The thing that makes me chuckle is my clients beat me up all the time on saving “clicks” and yet they don’t say a negative thing about the steps associated with large EMR vendor. I guess its because they know I have control over my product and they realize there is zero from the large EMR vendor.

As an observation, questions and low-level technical support was very, very good from the old ePrescribing solution. It appears to be non-existent with large EMR vendor – maybe because they’re busy dealing with so many conversions from the purchased ePrescribing solution? Don’t know. I also know from first-hand experience that support is rather poor with large EMR vendor.

One of my readers pointed me to an article talking about the potential Medicare penalties that will be enforced starting in 2012 to physicians who don’t use e-Prescribing. Here’s the relevant info:

As previously reported, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes incentive payments for eligible professionals who are successful e-prescribers. Under the MIPPA, the incentive payments are set at 2 percent for 2009 and 2010, 1 percent for 2011 and 2012, and 0.5 percent for 2013.

However, the MIPPA provides for a penalty to arise in 2012 for not successfully satisfying e-prescribing requirements. The penalty will be a percentage reduction in Medicare physician fee schedule payments equal to 1 percent for 2012, 1.5 percent for 2013, and 2 percent for 2014 and subsequent years.

It’s interesting to see these penalties. They’re almost as large as the penalties for not showing meaningful use of a certified EHR. Yet, I see so little discussion about these penalties. Is there a reason doctors aren’t worried as much about this as the EMR Stimulus Medicare penalties?

Also, it’s no wonder that many doctors are wondering whether they should continue to accept Medicare or not. First, the 21% Medicare cuts that have been floating out there. Second, the EMR stimulus medicare cuts. Now, the cuts for those that aren’t ePrescribing. Of course, all of these cuts are to the “insurance” that has in general the smallest reimbursement already. Are the insurance companies next to implement these cuts?