E-prescribing: Get paid for doing it

 

Electronic prescribing, or commonly known as e-prescribing, holds a promise to reduce medication errors and help achieve cost savings. In this article, I will provide a brief background of e-prescribing and then discuss its advantages and disadvantages. Finally, the end of the article will describe how providers can get money for e-prescribing and detail some steps you can follow to get started. I use Medicare Part D medications as an example, but please remember that e-prescribing can be used for any medication. The incentive payment structure, requirements of use and regulations governing, however, may be different for non-Medicare Part D medications.

What is e-prescribing?
There are many definitions of e-prescribing. Take, for instance, the CMS definition: “a prescriber’s ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point of care”.
Is e-prescribing a new idea?
E-prescribing is not a new concept. In 2003, it was mentioned in the Medicare Prescription Drug Improvement and Modernization Act. This established a prescription drug benefit for seniors (Part D) and mandated organizations to establish a program by which the prescription could be transmitted electronically from provider to the pharmacy.
Potential benefits of e-prescribing:
Electronic prescribing does provide certain benefits. Most of these relate to canceling out any errors that would be made through humans in the process of getting a prescription from the provider to the pharmacy. Additionally, added benefit is derived from useful information (drug- drug interactions, insurance info, etc.) that computers can provide at the point-of-care. Finally, patient satisfaction may be manifested in reduced time it takes to get the prescription from the provider to the pharmacy and the reduction of errors in prescribing. The benefits of e-prescribing are:
• Decreased incidence of medication errors
• Not dependent on deciphering provider handwriting
• Immediate checking of drug-drug interactions
• Analytics that enable patient-specific drug use considerations
• Immediate checking of insurance plans that will pay for the drug
• More timely transfer of Rx to pharmacy
• Enhances quality of care through reductions in medication errors
• Analytics that enable evidence-based prescribing
Areas of care e-prescribing may not help with:
Most of these points have to do with behaviors that are out of the physician’s control.
• Patient non-compliance with medications
• Patient misuse of over-the-counter medications
• Physician prescribing errors due to bad judgment
• Pharmacy dispensing errors due to bad pharmacist judgment
• Patient benefit of medication explanation from face-to-face interaction with pharmacists
How it works
The e-prescribing model is analogous to the traditional model of when a prescription goes from the provider to a pharmacy directly, pharmacy benefit management company (i.e. Medco) or the patient’s insurance company. The difference is, however, before it reaches those entities the prescription is cycled through a software program. This is where the drug-drug interactions, patient specific use information and evidence based recommendations are provided. Notice e-prescribing allows direct interfacing with the software program through a variety of inputs –computer, PDA or other handhelds. After passing through the e-prescribing software program, the prescription can be sent back and forth between pharmacies, PBMs and insurers, as done currently. Examples of some e-prescribing software applications include Touchworks v 10.1.1 by Allscripts and EpicCare EMR Spring 2007 by Epic.
Standards used
Whenever transfer of data occurs or exchange of information is occurring there is a need for data standards. There are initial standards that are part of any e-prescribing program. Regulations dictate what standards need to be used. Medicare Part D is a good example to use since there is lots of published information about their regulations. Below are standards and specifications required for e-prescribing medications covered by Medicare Part D.
For the exchange of eligibility information between prescribers and Medicare Part D sponsors: Accredited Standards Committee X112N 270/271, Version 4010, May 2000
For the exchange of eligibility inquiries and responses between dispensers and Part D sponsors: The National Council for Prescription Drug Programs Telecommunication Standard Specification (NCPDP), Version 5.0, September 1999
For the exchange of new prescriptions, changes, renewals and cancellations: NCPDP SCRIPT Standard, Implementation Guide, Version 5.0, May 12, 2004
There are other standards available but not yet adopted.
RxFill for Fill Standard notification- this enables a pharmacy to communicate to a prescriber when a prescription is picked up, partially filled or not picked up and returned to stock
Rx Norm standard for clinical drug terminology- this provides a database for drug names, active ingredients, dosage and form
NCPDP Structured and Codified standard 1.0- standardized format and vocabulary used in patient instructions
Standard for prior authorization- certification from drug benefit plan to provider that patient meets criteria for a certain drug to be covered
Important Dates regarding prescriptions
Health plans covering Part D medications must offer it by May 2009
As Jan 1, 2012 Part D prescriptions can longer be offered by computer fax. Must be handed to patient or manually faxed.
How to get incentive money for e-prescribing

• Only 25 e-prescribing events required over course of the year
• Must be must be done by an eligible provider using a qualified EMR system
• Use the G code 8553 for the numerator and # of codes for denominator

Denominator codes
90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014,
96150, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214,
99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326,
99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350, G0101, G0108, G0109

• Requirement is that at least 10% of a provider’s Medicare allowable charges must be coded using one of the above denominator codes to qualify

Qualified EMR (electronic medical record) systems have the ability to:

1. Produce a complete list of medications for that particular patient (PBMs or pharmacies can get this for you)
2. Ability to select medications, print them, send electronically using the required standards (please see standards section above) and giving clinician warning that unwanted or unsafe prescribing is being done
3. List any lower cost and therapeutically indicated alternative medications
4. Provide drug plan information such as authorization, patient eligibility and formulary meds

Chart showing how e-prescribing affects Medicare Part D reimbursements

Year	Incentive Money	Penalty for not e-prescribing
2009	2%	None
2010	2%	None
2011	1%	None
2012	1%	1%
2013	.5%	1.5%
Beyond 2013	None	2.0%

Some important rules regarding e-prescribing for Medicare Part D prescriptions

• MIPPA (The Medicare Improvements for Patients and Providers Act) stipulates that submitting prescription information electronically is acceptable for
  part D medications in lieu of claims based reporting
• If get MIPPA e-prescribing incentives then can’t also get money under HITECH program.

Practical Advice for Physicians in Outpatient Practice

1. Consider using e-prescribing in your practice to reap the benefits and satisfy meaningful use criteria
2. Confirm whether your EMR can support e-prescribing. Some EMRs that can are:

Qwest, Patagonia, Centricity, Epic

1. Buy and utilize a handheld device (ie. PDA, palm, iPad) to write prescriptions and make

sure that the device can connect to your EMR software

1. If you get stuck or have additional questions please contact your EMR vendor. If you are a Patagonia customer we can help you through the entire process.

Conclusion and Final Comments
Electronic prescribing is certainly an important development in modern healthcare information technology. The adoption rates are currently quite variable and often depend on whether providers can derive financial benefits from their insurers for using such technology. The “meaningful use” criteria as established by the government will dictate largely how e-prescribing, among other health IT initiatives, are used. There continue to changes in the regulations of governing e-prescribing Part D prescriptions.
Individual providers and organizations should do a risk/ benefit and return of investment analysis before venturing into a particular e-prescribing program. With many vendors available, it is important to assess how the program will integrate into the existing system (ie. current EMR, etc.)
By Jitesh Chawla, MD

Retail Medical Clinic

The Retail Medical Clinic: Healthcare trend analysis by Dr. Jitesh Chawla

Is there a consumer-driven market business trend offering a cost-effective and highly convenient means of receiving care for basic and routine conditions? Retail health clinics such as those found in CVS or Walmart might be the answer. The appeal of such clinics is increased access to care (generally open from 10-12 hours/day, on weekends). This set-up is ideal for busy working people and the care received complements that given by the patient’s primary care doctor. Furthermore, the total charges billed to the patient are shared up front. The patient demographics are pretty similar to those in those elsewhere, with 80 percent insured and 20 percent uninsured. Retail clinics will only treat minor problems and perform preventative care (immunizations, etc.) –the rest must be referred out.



A SWOT analysis provides a framework by looking at the advantages, disadvantages and opportunities for improvement regarding a particular business venture. As relates to retail health clinics, the SWOT results are below.

Strength:


• Reduces barriers to access to service (increased wait times in ER, doctor’s office)


• Cost transparency facilitates patient decision-making


Weakness:


• Not part of the local health care system and provider network, thereby, more difficult to track data for quality of care studies. Although this is the current state of affairs, it certainly leads to an opportunity of being part of an Accountable Care Organization going forward.


• Interrupts continuum of care established with primary care physician


Opportunities:


• Potential to improve low-income patients’ access to basic preventive and low-level acute services.


• Staffed primarily by nurse practitioners. This is important with the current shortage of primary care physicians, and even fewer physicians going into primary care, resulting in a shortage of as many as 44,000 physicians in the fields of general internal medicine and family medicine by the year 2025


Threats:


• In June 2007, the American Medical Association (AMA) asked state and federal officials for an official probe of retail health clinics. The AMA cited, among other objections, the potential conflicts of interest posed by joint ventures between store-based health clinics and pharmacy chains, since retail health clinic employees could write prescriptions to help pharmaceutical sales.


• May erode a patient’s “medical home” by fostering a dependence on the clinic rather than an ongoing relationship with one primary care physician.


Closing Comments

 With health care reform, many of these clinics may not get patients since health coverage could become universal. However, on the other hand, many could be forced to enlist into high-deductible plans and so end up coming to these clinics which would make more sense (since costs are transparent to the patient).

In a healthcare system that is as complicated as the one here in the United States, there are always new ideas generated on how to optimize delivery of services. No one form of healthcare delivery is ideal but the important thing is to be adaptable to changes in the environment. Retail clinics, whether they are the new successful consumer-driven market trend or not, definitely have made their mark in American healthcare.


-by Dr. Jitesh Chawla


Dr. Jitesh Chawla is a Family Practice Physician with a focus on quality service. Dr. Chawla is particularly popular for his lecture on the developments in the field of health policy, healthcare reform, practice management and quality service. As a student of Healthcare Administration, Dr. Chawla presents unique insights ranging from practical challenges that clinicians face to opportunities that lie untapped in delivering world class healthcare.

YouTube videos by Dr. Chawla site links -OpeEMR Scheduling and OpenEMR SOAP Note

Accountable Care Organizations

Dr. Jitesh Chawla explains the role of Accountable Care Organizations

An accountable care organization or ACO, is a relatively new concept that may be an important tool to achieve greater quality of care for our patients and overall control costs for the entire healthcare system. There are 3 main components to any ACO, which are summarized as follows:

1. The ability to provide and manage patients across a variety of institutional settings (inpatient, outpatient and post-acute care).

2. The ability to prospectively provide budget and resource planning.

3. The infrastructure to support comprehensive, valid and reliable measurement

The ACO differs from other types of payment reform initiatives such as the medical home and bundled payments models as” total per capita costs” are not part of those arrangements. Full capitation does account for total per capita costs but requires patient “lock in”, which may not appeal to most providers. Patient “lock in” means that the insurance benefits will allow the patient has to use only that provider

Under the Patient Protection and Affordable Care Act, ACOs are voluntary options to adopt for those who treat Medicare beneficiaries. The Secretary of the US Health and Human Services may give favor to providers that are in certain arrangements with other payers besides the federal government. These groups include professionals in group practice arrangements; networks of individual practices of professionals; partnerships or joint venture arrangements between hospitals and professionals; hospitals employing professionals and such other groups of providers and suppliers of services that the Secretary deems appropriate.

It is will be interesting to see if ACOs really end up doing what they are designed to. Critics dub it as a form of HMO (health maintenance organization). Only time will tell.

PART 2 ACOs:

As providers we are always bombarded with new regulations, government mandates and creative insurer plans or programs designed to help us increase our revenue. But with limited time and other resources, doctors and mid-levels need to quickly and clearly understand if some new program is right for them. With that in mind, here is a summary of Accountable Care Organizations based on what we know about them from the latest CMS regulations and a pros/cons analysis to help you decide if it is something you want to participate in.

Definition:

An accountable care organization is a group of providers and suppliers of services that coordinate to provide high quality care (as defined by CMS) to a group of Medicare beneficiaries who are not in a Medicare Advantage program

• Providers from individual practices, group practices or a network of ACO professionals can participate regardless of speciality
• The financial benefit is that providers can get the savings from care provision in an ACO program as extra revenue
• The risk is that providers may share in the loss of money from care provision in an ACO program

The requirements to participate are:

• File application with CMS,

• Form a legal entity that is linked through bank accounts with CMS,

• Have at least 5,000 Medicare beneficiaries over 3 years in panel,

• From governing body with at least 75% of individuals participating in ACO.

• Have a Board certified physician as medical director, CMS liason on ACO leadership
  committee

• Have quality improvement program and abiility to identify high-risk individuals in place

Approval is a for a 3-year period at stretch

What quality measures are tracked:

• Patient-care giver experience

• Care coordination

• Patient safety

• Preventative health
• At risk population/frail or elderly

These measures are tracked by comparing to benchmark data sent by CMS and scores 1-5 are assigned to each.

If the performance is better than the benchmark then savings occurs, if not then loss.

Pros- ACOs:

• Can result in extra revenue through cost savings
• Help organizations establish valuable care processes (ie. quality improve program, tracking certain data, better of electronic medical record functions)
• Results in better coordination of care for the patient

Cons-ACOs:

• Time-consuming to set up an ACO and run it
• Could be costly from setting up the ACO, loss from performance below benchmarks
• Too many unknowns -not sure what new rules CMS will require in years to come

The ideal ACO participants:

Practices that have several providers and staff, have a QI program, use the EMR to track outcomes and have a large Medicare population.

Quotes about ACOs from different experts in the field:

“But if ACOs models are to work, they’ll eventually have to embrace smaller practices, which make up the vast majority of U.S. medical groups overall. And if those groups are either EMR-less or just getting started, it’s going to be pretty tough to share value-based payments, coordinate across episodes of care and track quality jointly” -Kathryn Rourke (EMR and EHR)

“But here’s the problem with ACOs: They are a tool in a big tool box of care and cost management tools but, like all of the other tools over the years like HMOs and IPAs, they won’t be used as they were intended because everybody—providers and insurers—can make more money in the existing so far limitless fee-for-service system.” – ROBERT LASZEWSKI (The Healthcare Blog)

Conclusion:

Accountable care organizations represent, yet, another paridigm to deliver high-quy ality care. The summary about ACOs presented here is very cursory with specific details that are available on the CMS website .

I hope the information presented here will give you, as provider, a feel for wether the ACO program is something that you qualify for and want to participate in. My opinion is that ACOs are not a good return of investment for small practices with 1-3 providers or any practice without the extra resources do devote to this.

-by Dr. Jitesh Chawla

Dr. Jitesh Chawla is a Family Practice Physician with a focus on quality service. Dr. Chawla is particularly popular for his lecture on the developments in the field of health policy, healthcare reform, practice management and quality service. As a student of Healthcare Administration, Dr. Chawla presents unique insights ranging from practical challenges that clinicians face to opportunities that lie untapped in delivering world class healthcare.

YouTube videos by Dr. Chawla site links - http://youtu.be/BaowHBKFmW0 and http://youtu.be/MjeIv5_z7K4

Challenges in Healthcare

Dr. Jitesh Chawla comments on the challenges in healthcare

As the picture below depicts, healthcare is a complex and challenging web of co-depenedant systems. In this series of posts, Dr. Jitesh Chawla brings along solid, on-the-ground experience and insightful perspective about the many challenges facing the healthcare industry.

Some of the biggest challenges around healthcare include cost, access and quality.

Cost: Spending on new medical technology and prescription drugs has been cited as a top contributor to the increase in overall health spending. Such advances can lead to consumer demand for more intense, costly services even if they are not necessarily the best treatment or most cost-effective. On a consumer level, this translates into high healthcare premiums.

Access: US healtcare continutes to suffer from lack of quality healthcare professionals in underserved areas. However there are other aspects of access, such as timely access to diagnosis, reports and personalized healtcare services.

Quality: Medicine is as much art as it is science hence making it difficult to putting a tag on quality. There is a lot of subjectivity in diagnoses and treatment. The first steps in tackling the quality challenge is getting medical experts together to reach a consensus on which metrics work best, when they should be measured and set benchmarks for quality improvements. Healthcare organizations regardless of the size, patient panel can successfully balance the cost-quality pendulum by finding more effective ways to drive productivity and manage capacity in existing operations.

Dr. Jitesh Chawla is a Family Practice Physician with a focus on quality service. Dr. Chawla is particularly popular for his lecture on the developments in the field of health policy, healthcare reform, practice management and quality service. As a student of Healthcare Administration, Dr. Chawla presents unique insights ranging from practical challenges that clinicians face to opportunities that lie untapped in delivering world class healthcare.

Kiosks at Medical Clinics

Kiosks at medical clinics - what an idea! We use them at airports and grocery stores. Think about when you go to a doctor's office and have to fill out all that paperwork. We fill out a new set of information in every time we go to a different office- one for the primary care physician and another one for the specialist, and still another onefor hospital admissions. Furthermore, with insurance reimbursement rate declines over the past several decades, many clinics have to see more patients to make revenue and cover their expenses. What that means to you is longer wait times. There is no reason why we need to wait for a live person to complete a new patient registration form or check-in for an appointment. In fact, computer entry results in more accuracy than manual data entry, which is prone to errors committed by the clerk.

Well, I am sure my idea is not a new one. Though they agree that current wait times and error rates will improve; many critics of such kiosks have voiced concerns about the practicality of such a system. I will discuss five main objections identified towards implementing this idea. The biggest issue is concerns of violating HIPPA laws. But, with kiosks in private areas, patients don't risk having their personal medical information visible to others. Also, technology is such that information is secure. Think about all the times we purchase goods with our credit cards online. By using a kiosk, the personal information of a patient will instantly be transferred into the electronic medical records where it can be stored.

Another concern of critics is the inability of such kiosk to be considered user friendly to different types of people. It is understood that certain groups such as the elderly may have difficulty with hand eye coordination which is often required with a touch screen set up. Also, there is a subset of people of who I have met that are not comfortable with computers, and avoid using anything that is automated. But, actually, touch screen is easy to learn. Voice activation can be installed to guide people through the screens. I find that people are usually uncomfortable with computers because of their inexperience with it. Using a PC will be a lot more complicated then such a kiosk.

A fourth objection is the loss of the human touch. Sure, for a new patient, talking with the receptionist is often the first time an impression is formed. If in this interaction the patient gets treated with care, he/she will likely find the rest of the visit more satisfying. Yet, I feel with the kiosk system, the human touch factor doesn't get cancelled out but just delayed to a later time in the visit. The first impression (for a new patient, for example) will now be with the nurse. Often times, a nurse is able to spend more time and attention with the patient then a busy receptionist struggling to do an intake and answer phones.

Finally, the argument that is probably the make or break factor in the decision to implement such a new technology in a clinic is cost (at least according to the administrators. Again, if we look at other businesses such as in the airline industry it appears that there must have been some cost savings, otherwise, it would not have been implemented by even a single carrier (much less all of them).In medicine, the costs are largely due to administrative redundency. As electronic medical records become more popular, companies will start selling them for lower prices to stay competitive. Therefore, kiosks may be a little strain on the budget initially, but they will save money in the long run. Furthermore, kiosks will interface well with EMRs which already becoming commonplace.

I have introduced an idea that many may write off as silly or impractical, but as you can see, I have several good reasons to support my proposal. There are probably other factors present why many organizations have not embraced the idea of kiosks in their medical clinics, but I believe some of main issues were covered in this blog. I encourage people to "think out of the box" and come up with ways we can make our healthcare system more effective and less costly over the long run. In the next blog, I will discuss specifics about how such a kiosk would work.