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Electronic Prescribing: Where We Stand And Lessons For Policymakers



May 16th, 2012
 
by Seth Joseph and Ken Majkowski

Editor’s note: For more on the adoption of electronic health systems, see these recent Health Affairs articles by Decker and coauthors, DesRoches and coauthors, and Hsiao and coauthors, which were discussed at an April 25 event.

Since the American Recovery and Reinvestment Act passed in 2009, healthcare professionals, researchers, analysts and policy makers have been paying close attention to the up to $30 billion in incentives (EHR Incentive Program) for the adoption and meaningful use of certified electronic health records (EHR) technology. Much consideration — by thought leaders in the public and private sectors — was put into developing the objectives, measures and proposed stages that comprise the Meaningful Use requirements that eligible providers must meet in order to qualify for the incentives.

Following the passage of the stimulus bill and news of the EHR Incentive Program, however, there were plenty of skeptics (and many reasons to be skeptical) of whether up to $44,000 – $63,750 per provider would be enough to overcome the many different types of barriers that contributed to low adoption of EHRs through the late 2000s. In addition to questions of whether the market would respond, the EHR Incentive Program itself faced many immediate challenges to get the program up and running. These included: establishing, vetting, and publishing Stage 1 meaningful use objectives and measures  (and the corresponding certification and implementation criteria) by July, 2010; identifying and working with certification bodies to ensure that EHR vendors had access to and time available for going through the certification process; and developing a reporting infrastructure.  There were many more challenges, all on an extraordinarily tight timeline.

Furthermore, the EHR Incentive Program was being developed and would be tested against a broader backdrop of economic uncertainty, political pressure over the role of government in health care, and a body politic increasingly sensitive to fiscal matters. Thus, getting the meaningful use objectives and measures right — by setting the bar high enough to create real value but low enough for  providers to realistically achieve — was critical to demonstrate program integrity and an effective investment on taxpayers’ behalf.

The Centers for Medicare and Medicaid Services (CMS) has now paid out more than $5 billion to 93,650 eligible providers and hospitals; payments are behind the Congressional Budget Office’s original projections but have ramped up significantly over the past several months. Clearly, a substantial number of eligible providers have begun attesting to meaningful use; yet, questions about whether the meaningful use “bar” has been set at the right level remain. Recent studies suggest that as many as four in five providers may be eligible for participation in the program (Bruen et al, 2011), but at least one survey indicates that a far lower percentage have adopted certified EHRs and have the functionality do meet the meaningful use requirements (Hsiao et al, 2012).

Remaining questions include:
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  • What proportion of providers who have a certified EHR are in a position to meet core meaningful use Stage 1 objectives
  • Whether providers in different specialties – in particular those in non-primary care – are more or less likely to achieve meaningful use objectives
  • Whether provider use of certified EHRs is likely to increase or decrease over time

A Progress Report

The 2011 Surescripts National Progress Report (NPR) (release briefing tomorrow) contains a new and novel analysis that leverages provider adoption and actual e-prescribing utilization data as a proxy indicator of meaningful use attainment. The results are noteworthy, as they provide a first insight into e-prescribing utilization levels on a per-provider basis by specialty and system type (integrated EHR vs. standalone e-prescribing system) over time, and estimated meaningful use attainment rates of the e-prescribing core measure of Stage 1 meaningful use.

Surescripts studied a cohort of providers who adopted e-prescribing in 2008. Reviewers identified 48,993 individual provider records, for which the reviewers could uniquely identify specialty and e-prescribing system type for 39, 798 providers. No data reviewed contained protected health information.  Data included prescribers practicing in 50 states and 9 districts and U.S. territories. E-prescribing transaction data for the cohort was available from the point of adoption through December 31, 2011, thus providing insight of up to four years of provider utilization. Reviewers paired the e-prescribing data with external prescription volume data from IMS Health in order to develop models of e-prescribing measure attainment by provider specialty.
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FIGURE 1

The data suggest that between 54 percent and 60 percent of all active e-prescribers were in a position to meet the core e-prescribing measure for meaningful use by the fourth quarter of 2011. (Figure 1 above, click to enlarge) This proportion was up from a year earlier, when an estimated 45 percent to 52 percent would have met the forty percent threshold. In line with recent literature, the Surescripts data suggest that primary care physicians (including those categorized in the NPR as family practitioners, internists,  pediatricians and obstetricians) were more likely to achieve the e-prescribing core measure (Figure 2 above, click to enlarge), with as many as 74 percent of family practitioners in a position to do so. However, the data also suggest that many non-primary care providers had high achievement rates: cardiologists, neurologists, dermatologists and endocrinologists were among those groups with more than 50 percent of providers sending more than forty percent of their eligible prescriptions electronically.
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FIGURE 2

The data also confirm and further earlier findings (DesRoches et al, 2010) that providers using an integrated e-prescribing system within an EHR demonstrate different utilization characteristics than those using a standalone e-prescribing system. More than four in five providers who adopted in 2008 use an integrated EHR, and those who do demonstrated far higher utilization of e-prescribing: the average provider using an EHR routed 150 percent more e-prescriptions than the average provider using a standalone e-prescribing system. Furthermore, providers using an EHR were more likely to be in a position to meet the e-prescribing meaningful use measure, with as many as 67 percent using an integrated EHR in such a position, versus up to 50 percent of those using a standalone system.

Importantly and optimistically, e-prescribing utilization consistently increased over time across all specialties, practice settings and e-prescribing systems. This suggests that provider comfort with and buy-in to the workflow and benefits of e-prescribing should continue to improve well into the future as e-prescribing becomes a standard of care. In addition, the findings suggest that those providers who may not yet be meeting the forty percent meaningful use threshold for e-prescribing may be likely to do so in the coming months.

Lessons For Policymakers

We believe these results can be instructive for policy makers and the CMS in its facility as the rulemaking and governing body overseeing the implementation of the EHR Incentive Program. In particular, we believe the results are an early indicator that the meaningful use measures for e-prescribing appear to be set at a level that was attainable for the majority of providers as of the fourth quarter of 2011.  While one could argue that this may mean that the bar was set too low, we would point to the discrepancy between estimated attainment levels between primary care providers and non-primary care providers; if the bar was set higher, non-primary care providers may have refused to participate, which would have been a significant blow to the program and the health care system more broadly.

In addition, CMS has proposed increasing the threshold for prescriptions sent electronically to more than sixty-five percent for Stage 2 meaningful use; given the moderate increase in the objective and that providers have close to 24 months to meet it, this again seems to be a reasonable target that should achieve the twin objectives of ensuring use without alienating providers.

Based on the findings and the context around meaningful use Stage 2 objectives, we believe the findings should be an encouraging sign for regulators and policymakers alike that the Stage 1 meaningful use bar was set at a reasonable level, at least with respect to the e-prescribing core objective.

That said, there are reasons for CMS to continue to thoughtfully consider its approach as it weighs comments regarding Stage 2 objectives. In particular, while we have pointed out that some non-primary care specialties appear to be well positioned to meet the Stage 1 measure for e-prescribing, overall they consistently lag behind primary care providers in the metrics we have described. While we believe the Stage 2 e-prescribing measure is achievable for all specialties, we recognize that CMS may be well served by coordinating with regional extension centers and health information exchanges to focus on the needs of non-primary care providers. In addition, we would suggest that, given the mature infrastructure in place to support e-prescribing, CMS should confirm the proposed inclusion of electronic drug formulary checking as proposed for Stage 2 of the EHR Incentive Program.

In addition, CMS should consider incorporating other higher order functionality into core objectives. These could include requesting a patient’s medication history through an electronic exchange with other data sources (upon receiving a patient’s consent to do so) for ambulatory office visits as well as when a patient is admitted to an acute care facility or emergency department as part of the medication reconciliation process.

Our hope is that the meaningful use analysis presented in the Surescripts NPR is used to demonstrate both the apparent success to date of the EHR Incentive Program and as a touch point as stakeholders broadly consider the Stage 2 requirements.

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    May 17th, 2012 at 4:21 am

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