Project Problem

1. E-Prescribe: Adopting Health Care Information TechnologyADG associates presenting:Barbara AntunaJessica CarpenterPatrick EsparzaBrian Frazior

2. Project Problem • Need to reduce medication errors • Currently seeing about 62.5 errors per 1,000 medication orders • American Recovery and Reinvestment Act • CPOE needed for “Meaningful Use” • Medicare Incentives • CMS offering financial incentives • Proposed Solution: • Computerized Physician Order Entry Sources: The Leap Frog Group. Factsheet: computerized physician order entry. Accessed from: http://www.leapfroggroup.org/media/file/FactSheet_CPOE.pdf on October 1, 2009. Centers for Medicare and Medicaid Services. E-Prescribing Measure. Accessed from: http://www.cms.hhs.gov/ERxIncentive/06_E-Prescribing_Measure.asp on October 1, 2009. Dolan, PL., Prepare to meet "meaningful use" EMR requirement. American Medical News. June 15, 2009. Accessed from: http://www.ama-assn.org/amednews/2009/06/15/bica0615.htm on October 1, 2009.

3. CPOE Readiness Assessment • Strategy • How needed is this project and how committed to the project is the organization? • Stakeholder involvement and expectations • Structure/Culture • Timeline, financials and staff expectations • Technology • Does the hospital have enough technology resources • Electronic records already in place? • Management Control Processes • Does the organization have the proper management in place to implement a project of this size • Clinical IT/Project Management • Does the IT department have the expertise and tools needed Source: Health Care Excel. CPOE Readiness Assessment Version 1. Accessed from: http://www.hce.org/Education/ToolKits/CPOE_Toolkit/03_TOOLS/05-CPOE-ReadinessAssessment-DRAFT-Tool.pdf on October 1, 2009

4. Readiness Assessment Results and Strategic Fit

5. Qualify • HIMSS(Healthcare Information and Management Systems Society) EMR Adoption Model

6. Justification - Financials • American Recovery and Reinvestment Act (ARRA) • Health Informatics Initiative • Require a meaningful use system by 2011 • Non-compliance results in financial penalties starting in 2015 • Reduction in cost due to fewer medication errors • Reduced risk of liability • Reduced costs associated with Adverse Events • Reduction in cost due to more efficient methods • More accurate methods for cost tracking • Time and efficiency savings in finding/recording information in charts • Medicare incentives • 2008 Medicare Improvements for Patients and Providers Act • Bill provides economic incentives for physicians to e-prescribe

7. Justification - Regulatory • ARRA • Will have a system that functions under federal guidelines • Better ability to provide Joint Commission requirements • Increase efficiency for producing required reports • More accountability • Assist with compliance of policies at the point of prescribing • Accurate record of all drugs administered • Up to date information on drug availability at the point of prescribing • Reporting Requirements • National Health Quality Measures (NHQM) • Reporting Hospital Quality Data for Annual Payment Updates (RHQDAPU) • Physician Quality Reporting Initiative (PQR)

8. Patient Safety and Quality of Care • Studies show a vast reduction in errors • Hospitals that use CPOE have fewer complication and death rates • Reduce transcription errors prescriptions • No legibility issues • Notes can be attached to record with clarifying decisions • Allergy warnings always available and linked to drug selection • Reduce missed doses • Ability to track and audit changes in drug treatment during admission • Identifies drug interactions at the point of prescribing • Availability of up to date medication histories Source: Bobb, A., Gleason, K., Husch, M., et al. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med, 164., 2004.

9. Patient Satisfaction • Increased efficiency • Quicker turnaround from time physician orders prescription to when patient receives • Improved patient safety • Fewer problems with unclear orders, dosage mistakes, and duplication of drug therapies • Keeping up with technological advances Source: McCarthy, G., Deliver Tangible ROI: Three healthcare organizations see reduced costs, enhanced efficiency and increased compliance with CPOE systems. Health Management Technology., Accessed from: http://www.healthmgttech.com/features/2009_june/0609_deliver.aspx on October 5,2009.

10. Initial and Ongoing Costs • Organization already has existing clinical information system , leads to reduction in up-front costs. • Approximately $1.5 Million in initial costs for a 200 bed facility – best case scenario • Approximately $4.2 Million in initial cost for a 200 bed facility – worst case scenario Source: Ohsfeldt., RL, Ward, MM., Schneider, JE., et al., Implementation of hospital computerized physician order entry systems in a rural state: feasibility and financial impact. JAMIA., 12 (1)., 2005.

11. ROI • Case Studies • Early Case Study: • Brigham and Women’s Hospital • Implemented in 1992 – saw profits 6 years later that are continually and steeply increasing. Source: Kaushal, R., Jha, AK., Franz, C., et al., Return on investment for a computerized physician order entry system. JAMIA., 13(3), 2006. • State of Massachusetts Study • CPOE systems could prevent 55,000 medication errors in Massachusetts and save $170 million statewide per year ($2.7 million per hospital). • Expect to see payback within 26 months through reducing hospitalizations generated by errors. Source: Blue plan: EMRs don't offer good ROI, but CPOE does. Accessed from: http://www.fiercehealthfinance.com/story/blue-plan-emrs-don-t-offer-good-roi-but-cpoe-does/2008-03-12#ixzz0UPgd0E7s.,on October 5, 2009.

12. Stakeholders Direct Stakeholders Indirect Stakeholders Patients Prescribing Providers CEO Pharmacy/ Pharmacist CFO HOSPITAL Payers/Pharmacy Benefits Managers (PBMs) CIO Government (Federal and State) Healthcare Facility

13. Stakeholders • Patients • Prescribing Providers • Pharmacy/Pharmacists • Payers/Pharmacy Benefit Managers (PBMs) • Government (Federal and State) • Healthcare Facility

14. Stakeholders - Patients • Power and Interest • Reasonable level of power and minimal interest • Goal is to keep the patients satisfied • Responsibilities • Financial asset to the healthcare system • Paying for a portion of the hospital services including e-prescription • Needs and Wants • Accurate, timely, and authorized prescriptions • Increased safety and quality of care • Role in Driving System Architecture • Reduce involvement in prescribing workflow • Increase access to prescription history

15. Stakeholders - Prescribing Providers • Power and Interest • “Committed” with a great deal of power and interest • They must find the system easy and efficient to use • Responsibilities • Primary users of the system • Highly affected by changes in current workflows • Needs and Wants • Reduction in medical errors • Increased efficiency in medical prescription • Role in Driving System Architecture • Design considerations to improve and not hinder current workflows

16. Stakeholders - Pharmacy/Pharmacists • Power and Interest • “Committed” with minimal power but high interest • Must be willing and able to accept e-prescriptions • Responsibilities • Pharmacies must be willing to upgrade systems to support e-prescribing • Needs and Wants • Increased efficiency due to problems with current paper-based prescriptions • Automated prescription renewals • Patient safety and care • Reduction in time spent mediating between payers and providers resulting in reduced costs • Role in Driving System Architecture • Partners in working through common concerns • Ensure electronic prescription standards are met

17. Stakeholders - Payers/Pharmacy Benefit Managers (PBMs) • Power and Interest • “Committed” with high power and high interest • They will need to be managed closely • Responsibilities • Will need to work with providers as well as pharmacies • Possibly upgrade systems to accept electronic prescriptions • Needs and Wants • Reduction in prescription costs through the promotion of cheaper therapeutically equivalent drugs • Reduction in medical errors resulting in lower medical costs • Role in Driving System Architecture • Must interact with the e-prescription system to act as an intermediary between the provider, patient, and pharmacy

18. Stakeholders - Government (Federal and State) • Power and Interest • “Committed” with high power and high interest • Goal is to reduce health care costs • Responsibilities • Provide patients safe and high quality health care • Promote electronic prescription through financial incentives, laws, and education • Needs and Wants • Increase quality of care • Cost savings through the use of generics and formulary compliance • Role in Driving System Architecture • Defining e-prescription requirements and data standards

19. Stakeholders – Healthcare Facility • Power and Interest • “Authorized” with high power and high interest • Goal is to maintain an efficient, cost effective prescription system • Responsibilities • Put forth financial backing to implement e-Prescription system • Needs and Wants • Return on investment • Improved quality scorecard results • Satisfied physicians and community • Role in Driving System Architecture • Provide budgetary approval

20. Workflow – Actors • People • Providers • Provider Office Staff • Dispensers • Dispenser Staff • Payers • Patients • System • EMR, both at provider locations and hospitals • PIS • Payer IS • HIE

21. Workflow Current State – Patient/Provider

22. Current State – Dispenser/Payer

23. Future State – Patient/Provider, Dispenser/Payer

24. Staff Satisfaction and Productivity • Satisfiers and Improved Productivity • Eliminates provider office staff and transmission of prescription • Improvement in dispenser workflow due to increased legibility of prescriptions • Improvement in dispenser workflow due to less payer covered formulary checking • Provider able to identify payer covered meds • Provider given access to dosing at point of care • Provider given drug-drug and allergy information at point of care • Better security of provider license and DEA information • Dissatisfiers • Change in workflow for provider • Will not entirely eliminate office staff involvement • May not necessarily change anything for the patient

25. Questions?