E-prescribing Impacts Chronic Disease Care & Cost
E-prescribing has been around for two decades but the growth of remote healthcare, other electronic health IT systems and more tech-minded providers and patients have come together to propel its use forward.
Chronic diseases cause seven out of 10 deaths each year in the U.S., and healthcare for patients with chronic diseases accounts for three-quarters of national healthcare spending annually, according to the Agency for Healthcare Research and Quality (AHRQ).
AHRQ funding and monies from other organizations has allowed more than half of office-based healthcare providers to adopt e-prescribing, one of the more widely used health IT tools.
Benefits such as the virtual elimination of illegibility errors are inherent to e-prescribing use but the system has its limitations.
"Let's say we have a patient with five chronic illnesses—diabetes, hypertension, arthritis, thyroid disease and high lipids—who takes, for example, five tablets in the morning, three at noon and four in the evening," she says. "It can be confusing for patients to manage that. E-prescribing can help us look at a range of medication options and choose those that ideally can each be taken just once a day."
E-prescribing also can help improve medication adherence rates among patients with multiple chronic diseases, as well as all patients, she says. In a traditional system, patients get a handwritten prescription and take it to the pharmacy, but neither pharmacists nor providers can tell whether the initial prescription was taken to a pharmacy to be filled.
"With e-prescribing, pharmacists know about each prescription ordered and which ones are dispensed to a patient," she says. "It's a slam dunk approach. It's easy to track who's taking their meds."
Justin Graham, MD, MS, CMIO of Fairfield, Calif.-based Northbay Healthcare, notes that e-prescribing reduces transactional costs, but researchers believe e-prescribing can do more to contain costs.
Outside of transactional costs, Michael A. Fischer, MD, MS, of Brigham and Women's Hospital in Boston, believes that clinical decision support (CDS) integrated with formulary information can help to lower costs associated with chronic disease care by alerting providers to the availability of cheaper drugs, either because they're generic or because they're covered by a patient's insurance.
Fischer and his colleagues researched the potential cost-saving benefits of formulary CDS by analyzing prescriptions ordered by several Massachusetts outpatient providers before and after implementing e-prescribing systems with formulary CDS functionality. The study calculated that nationwide use of e-prescribing systems with effective formulary CDS could reduce prescription drug spending by up to $3.9 million per 100,000 patients per year.
He also notes that getting patients onto the right medications can, regardless of cost, help to avoid hospitalizations and other complications, which is more important, both in terms of outcomes and cost, for patients with chronic conditions.
"Non-adherence to non-chronic medications tends to play itself out quickly and doesn't become a long-term health issue," Fischer says, "the way non-adherence to medications for cardiovascular disease, for example, often plays itself out with adverse clinical outcomes." ;
She also says that e-prescribing is more effective in a healthcare organization like Kaiser Permanente. An umbrella, nonprofit organization headquartered in Oakland, Calif., Kaiser Permanente has regionally operated integrated healthcare networks across the country that incorporate health plans, hospitals, pharmacies and primary care providers.
The separate components of each integrated network share a database, which means a patient's comprehensive medication history is available to both pharmacists and providers.
"That's the slam dunk I'm talking about; it's easier to figure out who is taking his or her medication and who is not," Raebel says.
Fischer says that the more integrated a healthcare organization, the better, but "we're not going to have highly integrated systems everywhere in the near future." Outside of integrated healthcare organizations, he says that an inconsistent standard for data storage and transmission means that data are often out-of-date, incomplete and unreliable.
The lack of data not only prevents providers from delivering a higher quality of care, it prevents greater cost savings.
Mihir H. Patel, PharmD, a consultant with Coral Springs, Fla.-based Point-of-Care Partners, says that providers often ignore formulary information provided by e-prescribing systems because, "unfortunately, that data aren't as granular as they could be."
Additionally, many of e-prescribing's benefits can't be realized without effective CDS alerts, but many systems provide frequent, insignificant alerts, prompting providers to ignore them.
"CDS is a two-edged sword," says Graham.; "It has a lot of promise and one day will be tremendously beneficial, but it's currently difficult to implement it in a way that is meaningful and not frustrating and annoying to physicians. The crude pop-up alert that we see in so many e-prescribing systems really can be more of an annoyance—as physicians click through the alerts, many seem to lack specificity for the patient at hand."
"I'm optimistic about what e-prescribing can do, but I'm concerned that we haven't found the best ways to implement it yet." He also wonders whether e-prescribing's impact is being measured accurately.
"We have to be open to the possibility that maybe it's not helping as much as we'd like, which is why generating better evidence is so important." ;
Patel points out that even though the majority of providers use e-prescribing, there's still a long way to go before full adoption is reached.; Once that happens, he believes that more functions will be available.
Vendors, Patel says, "still have to make these systems as efficient as possible to get widespread adoption, and that's been their focus. Now that the majority of physicians are using e-prescribing systems and with more advanced meaningful use requirements on the way, we're going to start moving more quickly towards advanced functionality."
Graham imagines a future with more subtle CDS alerts. Rather than appearing as error messages, they'll look more like the passive recommendations made by websites like Amazon and Netflix.
"E-prescribing has been around for 20 years but we're just now getting to adoption," Patel says. More tech-savvy patients and providers will continue to drive its use.
Chronic diseases cause seven out of 10 deaths each year in the U.S., and healthcare for patients with chronic diseases accounts for three-quarters of national healthcare spending annually, according to the Agency for Healthcare Research and Quality (AHRQ).
AHRQ funding and monies from other organizations has allowed more than half of office-based healthcare providers to adopt e-prescribing, one of the more widely used health IT tools.
Benefits such as the virtual elimination of illegibility errors are inherent to e-prescribing use but the system has its limitations.
Improving medication adherence & management
Patients with chronic conditions often need to manage several different prescription drugs each day. Marsha A. Raebel, PharmD, a pharmacotherapy investigator at the Denver-based Kaiser Permanente Institute for Health Research, refers to this as the "drug burden.""Let's say we have a patient with five chronic illnesses—diabetes, hypertension, arthritis, thyroid disease and high lipids—who takes, for example, five tablets in the morning, three at noon and four in the evening," she says. "It can be confusing for patients to manage that. E-prescribing can help us look at a range of medication options and choose those that ideally can each be taken just once a day."
E-prescribing also can help improve medication adherence rates among patients with multiple chronic diseases, as well as all patients, she says. In a traditional system, patients get a handwritten prescription and take it to the pharmacy, but neither pharmacists nor providers can tell whether the initial prescription was taken to a pharmacy to be filled.
"With e-prescribing, pharmacists know about each prescription ordered and which ones are dispensed to a patient," she says. "It's a slam dunk approach. It's easy to track who's taking their meds."
Lowering costs
Improving medication adherence rates among patients with chronic conditions and reducing their drug burden presumably leads to better patient outcomes and, therefore, improved quality of care. But, quality is only half of the equation.Justin Graham, MD, MS, CMIO of Fairfield, Calif.-based Northbay Healthcare, notes that e-prescribing reduces transactional costs, but researchers believe e-prescribing can do more to contain costs.
Outside of transactional costs, Michael A. Fischer, MD, MS, of Brigham and Women's Hospital in Boston, believes that clinical decision support (CDS) integrated with formulary information can help to lower costs associated with chronic disease care by alerting providers to the availability of cheaper drugs, either because they're generic or because they're covered by a patient's insurance.
Fischer and his colleagues researched the potential cost-saving benefits of formulary CDS by analyzing prescriptions ordered by several Massachusetts outpatient providers before and after implementing e-prescribing systems with formulary CDS functionality. The study calculated that nationwide use of e-prescribing systems with effective formulary CDS could reduce prescription drug spending by up to $3.9 million per 100,000 patients per year.
He also notes that getting patients onto the right medications can, regardless of cost, help to avoid hospitalizations and other complications, which is more important, both in terms of outcomes and cost, for patients with chronic conditions.
"Non-adherence to non-chronic medications tends to play itself out quickly and doesn't become a long-term health issue," Fischer says, "the way non-adherence to medications for cardiovascular disease, for example, often plays itself out with adverse clinical outcomes." ;
Limitations
"There are a laundry list of things" that could be improved with e-prescribing systems, Raebel says, but the systems do "decrease transcription errors, decrease interpretation errors and facilitate the appropriate dosing of drugs."She also says that e-prescribing is more effective in a healthcare organization like Kaiser Permanente. An umbrella, nonprofit organization headquartered in Oakland, Calif., Kaiser Permanente has regionally operated integrated healthcare networks across the country that incorporate health plans, hospitals, pharmacies and primary care providers.
The separate components of each integrated network share a database, which means a patient's comprehensive medication history is available to both pharmacists and providers.
"That's the slam dunk I'm talking about; it's easier to figure out who is taking his or her medication and who is not," Raebel says.
Fischer says that the more integrated a healthcare organization, the better, but "we're not going to have highly integrated systems everywhere in the near future." Outside of integrated healthcare organizations, he says that an inconsistent standard for data storage and transmission means that data are often out-of-date, incomplete and unreliable.
The lack of data not only prevents providers from delivering a higher quality of care, it prevents greater cost savings.
Mihir H. Patel, PharmD, a consultant with Coral Springs, Fla.-based Point-of-Care Partners, says that providers often ignore formulary information provided by e-prescribing systems because, "unfortunately, that data aren't as granular as they could be."
Additionally, many of e-prescribing's benefits can't be realized without effective CDS alerts, but many systems provide frequent, insignificant alerts, prompting providers to ignore them.
"CDS is a two-edged sword," says Graham.; "It has a lot of promise and one day will be tremendously beneficial, but it's currently difficult to implement it in a way that is meaningful and not frustrating and annoying to physicians. The crude pop-up alert that we see in so many e-prescribing systems really can be more of an annoyance—as physicians click through the alerts, many seem to lack specificity for the patient at hand."
Making e-prescribing better
Evidence of e-prescribing's benefits is developing "frustratingly slowly," says Fischer."I'm optimistic about what e-prescribing can do, but I'm concerned that we haven't found the best ways to implement it yet." He also wonders whether e-prescribing's impact is being measured accurately.
"We have to be open to the possibility that maybe it's not helping as much as we'd like, which is why generating better evidence is so important." ;
Patel points out that even though the majority of providers use e-prescribing, there's still a long way to go before full adoption is reached.; Once that happens, he believes that more functions will be available.
Vendors, Patel says, "still have to make these systems as efficient as possible to get widespread adoption, and that's been their focus. Now that the majority of physicians are using e-prescribing systems and with more advanced meaningful use requirements on the way, we're going to start moving more quickly towards advanced functionality."
Graham imagines a future with more subtle CDS alerts. Rather than appearing as error messages, they'll look more like the passive recommendations made by websites like Amazon and Netflix.
"E-prescribing has been around for 20 years but we're just now getting to adoption," Patel says. More tech-savvy patients and providers will continue to drive its use.