By John Halamka, MD; Jerilyn Heinold, MPH;

Gail Fournier; Diane Stone; Kate Berry

The recent Institute of Medicine report, Preventing Medication Errors (July 2006), indicates that computerized systems for prescribing drugs show promise for reducing the number of drug-related errors compared to paper-based prescribing. Electronic prescribing (e-prescribing) is thought to be safer because it eliminates legibility-related mistakes and can alert prescribers to possible drug interactions, allergies, and other potential problems. The committee said that by 2008, all healthcare providers should have plans to implement e-prescribing, and by 2010 all providers should be using e-prescribing systems with all pharmacies that are able to accept them.

In April 2004, the eHealth Initiative estimated the financial benefits of e-prescribing to be $2.9 billion for the nation. Benefits for providers include information about drug counterindications and allergies, reduction of handwriting interpretation errors, drug history information leading to better clinical decision-making, real-time FDA Safety Alert information, formulary checks with associated decrease in patient calls, and improvements in office efficiency. Benefits to physician office staff include reduction in calls from pharmacies regarding non-covered medications and handwriting issues; reduction in calls from patients regarding covered medications, prior authorizations, and renewals; and increased likelihood of patient compliance. Benefits for patients include lower out-of-pocket costs with improved prescriber knowledge of formulary, saving time at the pharmacy with prescriptions sent before arrival, and reduction of risk of adverse drug events because of prescriber knowledge of counterindications and allergies. Pharmacy benefits include reduction in phone calls to prescribers and fewer data — entry errors (MA eRx Steering Committee, 2006).

The number of prescriptions is rapidly increasing, with 3.22 billion prescriptions filled in 2003, and that number rising to 4 billion by 2007 (NACDS, 2006). Four out of five patients leave their doctor with at least one prescription, and 65% of the U.S. population uses a prescription medication annually (AHRQ, 2000).

According to the Center for Information Technology Leadership, more than 8.8 million adverse drug events occur each year in ambulatory care, and an estimated 3 million of those are preventable. One out of 131 ambulatory patient deaths can be attributed to a medication error, according to the Institute of Medicine. The Institute for Safe Medication Practices reports that many errors result from:

• miscommunication due to illegible handwriting,
  
  
• unclear abbreviations and dose designations,
  
  
• unclear telephone or verbal orders, or
  
  
• ambiguous orders and fax-related problems.

Electronic prescribing is the use of computing devices to enter, modify, review, and communicate prescription information. Electronic prescribing provides clinical decision support for the provider including patient medication history, allergy information, drug interaction alerts, formulary, and benefits eligibility information. Electronic prescribing also provides secure, bi-directional electronic data interchange (EDI) connectivity between clinicians and dispensing pharmacies.

The entire prescribing process can be automated — from the prescriber's fingertips to the pharmacist's eyes. With the prescription information transmitted from the prescriber's electronic prescribing software through EDI into the pharmacy system, the database on the pharmacy side is automatically populated with the prescription information in a standard format. This eliminates the need for the pharmacist to re-key the prescription information into their system. Furthermore, since the prescriber has more complete information available at the time of prescribing, it is much less likely that the pharmacist will need to call the provider back to clarify information.

E-prescribing enables physicians and pharmacists to communicate prescription information electronically, replacing time-consuming phone calls and faxes that can take several hours per day. Physicians can use computing devices to create and transmit new prescriptions, access benefits and formulary information, as well as clinical decision support at the point-of-care. Pharmacists can send renewal requests to physicians electronically, and physicians and their staff can review and transmit their responses back to the pharmacy's computer with a few keystrokes. Because electronic prescribing is bi-directional, renewal requests and change requests can be sent electronically.

Massachusetts Takes the Lead
The Commonwealth of Massachusetts has been recognized as a leader in health information technology and recently received the SafeRx award for demonstrating outstanding leadership through its use of e-prescribing technology. According to SureScripts, an organization established in 2001 to create the pharmacy "consortium" infrastructure needed for e-prescribing, more than half of the nation's pharmacies are "live" on their network with active systems and trained pharmacy staff. Massachusetts ranked third based on the percent of prescriptions received electronically at the pharmacy in 2005. At the SafeRx award ceremony, Secretary Tim Murphy from the Massachusetts Executive Office of Health and Human Services stated, "We appreciate the recognition being bestowed on Massachusetts, acknowledging the collaborative efforts of all healthcare organizations working together to improve quality and control costs of medical care... We have been deeply involved in leading-edge demonstrations of the implementation of electronic record systems and health information technology. Our recognition of the value of these functions is reflected in our level of involvement in these activities."

Some of the Massachusetts e-prescribing projects are described below.

In 2003, the Massachusetts Medical Society developed a prototype for e-prescribing that included connectivity to retail and mail order pharmacies, connectivity to eligibility status and plan formularies, and connectivity to a drug-drug interaction database. The challenges included, among others, legal restrictions requiring signed prescriptions, workflow interruptions, adaptation to physician prescribing behavior, and cost to physicians. In 2005, the Massachusetts Medical Society offered subsidized e-prescribing functionality as part of their membership as well as guidelines for clinicians to use when choosing an e-prescribing vendor.

The health plan community also has promoted e-prescribing. In 2001, Tufts Health Plan and their vendor partners offered their physicians PDAs that enabled providers to electronically write and securely fax prescriptions. This pilot demonstrated a reduction of medication errors, a reduction in the rate of increase of inpatient admissions, a decrease in hospital days, improved office efficiency (providers and pharmacies), a decrease in rejection of illegible prescriptions and those with drug-drug interactions, and cost savings for generic versus brand prescriptions.

In 2002, Blue Cross Blue Shield of Massachusetts (BCBSMA) and its partners initiated its own e-prescribing pilot initiative with PocketScripts. Building on the successful strategy and philosophy of collaborative efforts, in 2003, Blue Cross Blue Shield of Massachusetts and Tufts Health Plan (with the addition of Neighborhood Health Plan in 2004) created the eRx Collaborative to advance e-prescribing efforts. This unique collaboration continues today and underwrites some of the cost of e-prescribing for program participants to maximize the use of this technology. Clinicians receive a hand-held device loaded with an e-prescribing software application, one-year license fee and support, and assistance with deployment. Participants can also use a browser version of the software from any PC with Internet access.

The steering committee of the eRx Collaborative broadened the stakeholder group by the addition of pharmacies (Brooks, CVS, Stop & Shop, and Walgreens), technology vendors (Zix and DrFirst), and supporting organizations (Massachusetts Health Data Consortium, and SureScripts). A fact sheet on the benefits of e-prescribing has been developed that displays the specific benefits to providers, office staff, patients, pharmacies, and payers/employers (MA eRx Steering Committee, 2006). It states that reduction of errors, cost, and resources all are enhanced by e-prescribing.

In addition to the above initiative, BCBSMA has developed a pay-for-performance program for participating primary care providers that includes financial incentives for using e-prescribing. In 2004 approximately $1.5 million was awarded for e-prescribing usage with recipient providers more likely to adopt and e-prescribe at higher levels compared to non-participating primary care prescribers. eRx Collaborative statistics for 2005 indicate that there were more than 2.6 million electronic prescriptions transmitted, representing a 136% increase (eRx, 2006).

A change in setting, from physician office to the hospital emergency department was the focus for a medication history project by the Massachusetts Health Data Consortium's MA-SHARE Regional Health Information Organization (RHIO). The data sources were six health plans and the emergency departments of five area hospitals. The project, named MedsInfo-ED, focused on two components of e-prescribing: identifying patients with health plan drug coverage and, if available, returning prescription medication history on that patient. The project provided insight into the needs of clinicians, the difficulties of implementation, as well as the clinician commitment to working through those challenges (Gottlieb et al., 2005).

E-prescribing education was also addressed in a project supported by the eHealth Initiative in 2005 (Grant number 1D1BTM00095-01 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS, to the Foundation for eHealth Initiative). It demonstrated that clinicians are the most appropriate experts for physicians considering e-prescribing adoption and created e-prescribing curricula for providers. The study also concluded that resources such as vendor lists, questions to ask, and hardware and software requirements, need to be readily available and in a form that "non-technical" staff can read and understand. Physicians who know "why" would also like to know "when" and "how" to begin. More importantly, they want to know "who" will hold their hand once they begin (Mass. Health Data Consortium, 2005).

Currently, the e-Prescribing Gateway (Rx Gateway) of the Massachusetts Health Data Consortium's MA-SHARE organization will improve the speed of adoption, accuracy, and value of e-prescribing applications by electronically linking them with all major payers, prescription benefit managers (PBMs), and prescription dispensing locations, including retail pharmacies and mail order services. Ultimately, the MA-SHARE Rx Gateway will serve as the prototype for a broader clinical data exchange.

The MA SHARE Rx Gateway provides 24/7 access to Rx information. Standards-based interfaces facilitate connectivity and provide e-prescribers with flexibility to choose the right e-prescribing software solution for their situation. MA SHARE Rx Gateway users only need to build one interface and negotiate a single contract with MA-SHARE, saving time and money, and increasing the value of their initiatives. Customers include provider organizations, e-prescribing software vendors, Rx connectivity "wholesalers" as well as retail pharmacies, PBMs and mail order companies. The technical architecture was developed by Computer Sciences Corporation (CSC) under contract to Massachusetts Health Data Consortium's MA-SHARE LLC.

Although the initial release of the Rx Gateway supports the e-prescribing pilot at the Beth Israel Deaconess Medical Center using their existing electronic medical record system, subsequent releases will expand the community utility to support additional provider organizations, expand the scope of data offered through the RxGateway, including eligibility and formulary data from RxHub and other payers, and expand the functionality of the RxGateway, including the introduction of mail-order prescriptions and provider-initiated renewals, medication history, pharmacy-initiated prescription renewals, and prior authorization.

A summary of early Massachusetts' e-prescribing projects can be found in a paper entitled "e-Prescribing Collaboration in Massachusetts: Early Experiences from Regional Prescribing Projects" (Halamka, et al., 2006).

Lessons from these e-prescribing initiatives and projects have shown us that there are needs for

• a community-wide approach;
  
  
• one-on-one training and support including on-site software support, customization by specialty, and office workflow integration;
  
  
• strong marketplace support from payers and health plans; and
  
  
• vendor monitoring and outreach.

Collaborative efforts are the cornerstone of Massachusetts' success. The healthcare stakeholders have demonstrated their long-term commitment to advancing the use of health information technology with some of the initial steps to include the implementation of e-prescribing. The projects and organizations described have catalyzed and accelerated the progress of e-prescribing in the Commonwealth.