E-Rx > What you need to know and do: Step-by-step

Steps 3, 4 & 5 – System costs and implementation

 

3.    Understanding costs and financing options

·         Planning

·         Identify a member(s) of the project team to research the costs and potential subsidies or reimbursement programs available, including health-care provider incentives

·         Identify any existing national and state initiatives for which the practice may qualify

·         Calculate your practice’s projected reimbursement under the new Medicare incentive legislation and research pay-for-performance programs

·         Technology

·         Document price differences between a stand-alone and EHR system and include associated costs

 

4.    Selecting a system

·         Planning

·         Involve the entire project team in system selection by defining specific evaluation criteria for comparison and facilitate open discussions about the pros and cons of each product and the rationale

·         Develop your own test scripts or scenarios reflecting your practice’s common workflows, and ask each vendor to demonstrate how their product would work in those scenarios

·         Contact other practices in your area that currently use the products you are evaluating

·         Evaluate usability features of each software vendor

·         Make sure you clearly understand what training is offered by the vendor and the costs

·         Technology

·         Ensure that the hardware required by the system supports your practice’s desired workflow, including efficiency, security, and hardware synchronization

·         Select Internet connectivity with a redundant Internet connection backup in place

 

5.    Deployment

·         Planning

·         Commit staff time during implementation for training and workflow integration

·         Ensure that all affected members of the practice receive appropriate training

·         Create an incremental approach to training over several days and schedule a few additional training sessions over the next few months

·         Ask your vendor if they provide access to learning materials

·         Technology

·         The project leader should keep your software vendor informed about any technical problems or usability issues

·         Log support cases with the technology provider

·         Set default routing to electronically send prescriptions to the pharmacy rather than faxing them because the feature will be under used

·         Utilize electronic prescription renewal functionality as this increases efficiency and improves patient service when they are able to get their prescriptions renewed more quickly

·         Integrate patient demographic information from the practice management system in advance of e-prescribing implementation

·         Designate a prescriber or staff person to retrieve and manage responses for renewal authorization requests that are sent electronically from pharmacies

·         Make sure you know how to select your patient’s pharmacy of choice using your e-prescribing application

·         Respond to electronic renewal requests as soon as possible, and always within 24 hours on business days to avoid duplicate renewal authorization requests

·         Avoid queuing or “batching” prescriptions before sending them to pharmacies electronically to provide pharmacies adequate time to receive and fill the prescription

·         Follow DEA regulations by refraining from electronic transmission of prescriptions for controlled substances until these regulations are changed to allow electronic transmission

·         Communications

·         Inform local pharmacies that you are getting ready to exchange prescription information electronically

·         Communicate with patients about electronic prescribing and its benefits and remind them to call the pharmacy rather than the practice when they need their prescriptions renewed

E-Rx > What you need to know and do: Step-by-step

Steps 1 & 2  – Your practice

1. Assessing your practice readiness 
   • Planning
     • Are your practice staff and leadership open to change?
     • Has your practice endured unsuccessful technology implementations or workflow
       changes in the past?
     • Are there other major projects on which your practice is currently focused?
     • Do your practice leadership and staff agree that e-prescribing can lead to clinical or operational improvements?
     • Have you discussed and planned for e
       known e-prescribing challenges?
   • Communication
     • Does your practice have a culture of open, honest communication?
     • In the past, have decisions been effectively communicated to the practice?
2. Defining your practice needs
   • Planning
     • Establish your vision and identify the specific objectives
     • Identify a project team experienced in the prescribing process and its workflow
     • Choose a project leader who is respected, knowledgeable of the practice, and is skilled at conflict resolution
     • Plan for known e-prescribing changes
   • Workflow and change management
     • Make a list of your practice’s specific medication management needs
     • Prioritize your practice needs to identify the trade-offs
     • Anticipate how your processes and workflow will change
   • Technology needs
     • Think about your computing needs
     • Consider hardware and network demands
     • Determine who will maintain your system
   • Communication
     • Describe the vision and objectives to the entire practice and their involvement in the project, especially input collection
     • Involve all parts of the practice when defining needs

Steps to create a prescription

1) Review patients’ current medication list and medication
       history information:

• Update medication history

• Correct medication history

• Reconcile with multiple history sources

 

2) Work with an existing medication:

• View details of a medication

• Discontinue or remove a medication

• Change dose, etc., for a medication

• Renew one or more medications

 

3) Prescribe or add new medication:

• Search for a medication

– From quick choices/favorites

– By name (generic or trade)

– By indication

– By formulary

• Display medications with prefilled, known, favorite,
              or standard dosing

• Select medication

• Review warnings

• Enter SIG and other parameters

• Automatically populate and update favorites list of drugs
                with prefilled known dosing based on frequency of
                utilization by clinician

 

4) Complete the prescription and authorize (electronically
        sign)

• One item

• Multiple items

• Items created by ancillary staff, residents, or others

 

5) Transmit prescriptions

• Choose print, fax, transmit options in real-time or batch
              mode

• Print formats and prescription information, conforming to
             state regulations

• Handle restrictions on certain medications (e.g., class II
                 controlled substances cannot presently be e-prescribed)

• Ensure prescription is sent to preferred patient pharmacy
                 (identified by practice staff prior to interaction with
                  prescriber)

A CLINICIAN’S GUIDE TO ELECTRONIC PRESCRIBING

Challenges to a E-prescribing

• Financial cost and return on investment (ROI)
• Hardware and software might need to be invested for stand-alone or EHR systems
• Larger practices can achieve ROI earlier
• Change management
• Difficulty changing to a new electronic system
• Workflow
• People need to adapt to the new system
• A full EHR system will take more time
• Controlled substances
• Electronic transmission of prescriptions for controlled substances is prohibited
• State regulatory restrictions
• All states allow electronic prescribing
• Medicaid in New York require a “dispense as written (DAW)” in a handwritten form
• Hardware and software selection
• This can be a daunting task
• Limitations on e-prescribing system remote access
• No easy remote access optimal
• Cell phone gaps for digital service and limitations of broadband internet service
• Pharmacy, payer/PBM and mail order connectivity
• Not all pharmacies are connected using certified software like SureScripts-RxHub
• Do not want to pay a fee
• Medication history information is not comprehensive
• Medication history and medication reconciliation
• Confidence cannot be placed in the completeness and currency of information
• Reconciliation from multiple sources must occur
• Doctor's must consult with patients on accuracy
• Medical history information
• Not all stand-alone systems include a history which could impact a medication decision
• Prescribing from multiple office sites
• Must accommodate this because there are differing registration numbers and passwords
• Must be able to work elsewhere, but that function is not always available
• Small and rural practice challenges
• Challenges are magnified
• Lack of access to broadband and to skilled information technology professionals
• Longer to achieve ROI
• Patient acceptance and usage issues
• Patients may fee uncomfortable with e-prescriptions and demand paper prescriptions
• Frequent travelers may feel prefer a written one

A CLINICIAN’S GUIDE TO ELECTRONIC PRESCRIBING

Choices for an e-prescribing system

Stand alone systems are less costly and complex, thus they can be implemented must faster than an EHR system.  Having a system is important in receiving a Medicare e-prescribing bonus.  Software is offered as a package that can be downloaded to a office computer system, or more commonly, though the internet using an application service provider (ASP) for a fee.  Multiple hardware devices can access this service.  A standalone system can be a gateway to an EHR service because prescribers can become more technologically proficient and comfortable with electronic systems

An EHR system with an integrated e-prescribing module has immediate access to all patient data in the system.  They have better quality and safety.  They also have a larger clinical decision support.  More EHR systems are now including e-prescribing.  Full automation and interoperability make an EHR system a better choice.  However, they are more costly and complex than stand alone.

 

A CLINICIAN’S GUIDE TO ELECTRONIC PRESCRIBING

Benefits of e-prescribing

• Improving patient safety and care
  • Ineligibility from hand-written prescriptions
  • Oral miscommunications
    • Less phone calls between prescribers and dispensers
  • Warning and alert systems
    • Automatic checks for certain conditions
    • Could connect to drug reference software
  • Access to medical and medication history
    • Supports alert systems
• Reducing time spent on phone calls and call-backs
  • Questions, clarifications, and renewals
  • Consumes 1/3 of the work day
• Reducing time spent faxing prescriptions to pharmacies
  • Reduces labor, unreliability, and paper expenses
• Automatic renewal and authorization
  • Efficient for both prescribers and pharmacies
• Increasing patient convenience and medication compliance
  • 20% of paper-based prescriptions go unfiled by the patient due the hassle
  • Automatic prescriptions reduces this
  • Physicians can check if prescriptions were filled
• Improving formulary adherence permits lower drug substitutions
  • Health insurance companies can be checked for generic substitutions
  • More patient compliance
• Allowing grater prescriber mobility
  • A mobile device can be used to write and authorize prescriptions anywhere
• Improving surveillance and recall ability
  • Automated analytical queries and reports, such as drug recalls

 

A CLINICIAN’S GUIDE TO ELECTRONIC PRESCRIBING

HIT movies

Health information technology, including interoperable electronic records, e-prescribing, physician order entry systems, and clinical decision support systems can reduce errors, improve coordination, and diminish administrative inefficiencies. The RAND Corporation reports that properly implemented and widely adopted, HIT would save money and significantly improve health care quality. Annual savings from efficiency alone could be $77 billion or more, and health and safety benefits could double savings while reducing illness and prolonging life.

A panel of prominent experts with experience in industry, government, academia, and medicine seek to define a vision for digital healthcare.

Careers in health information technology include medical records clerks and medical records technologists. Learn about jobs in medical billing and coding with help from a career counseling specialist in this free video on health information technology careers. Expert: Robbie Hurtado Bio: Robbie Hurtado is a career counseling specialist at the Richmond Works One-Stop Career Center. Filmmaker: Sam Lee

This is a discussion of the benefits of the electronic health record. Specifically the author evaluated CPOE and BCMA for cost and quality

The adoption of a computerized order entry system has reduced medical errors by 35 percent at the Cincinnati Children's Hospital Medical Center.

To combat growing quality and safety concerns, a bi-partisan coalition is trying to pass legislation aimed at expediting the use of electronic prescribing. "E-prescribing" is when a physician uses a computer or hand-held computing device to electronically generate and send a prescription to a pharmacist's computer. The benefits of this technology include reducing potentially harmful drug interactions by alerting physicians of possible risks, eliminating illegible physician hand-written prescriptions and cutting patient wait time at the pharmacy. Produced for General Motors.

What is E-prescribing?

Electronic prescribing, or “e-prescribing” is the computer-based electronic generation, transmission and filling of a prescription, taking the place of paper and faxed prescriptions.  E-prescribing allows a physician, nurse practitioner, or physician assistant to electronically transmit a new prescription or renewal authorization to a community or mail-order pharmacy.

It must provide the following:

• Generating a complete active medication list incorporating electronic data received from applicable pharmacy drug plan(s) if available

• Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all safety checks (safety checks include: automated prompts that offer information on the drug being prescribed, potential inappropriate dose or route of administration, drug-drug interactions, allergy concerns, or warnings or cautions)

• Providing information related to the availability of lower cost, therapeutically appropriate alternatives (if any)

• Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan

http://www.ama-assn.org/ama1/pub/upload/mm/472/electronic-e-prescribing.pdf

Example of EHR/PHR use

• Log into health-care provider PHR
• Click on Vaccinations
• Import due date reminders --
  • To Microsoft Outlook
  • To Apple iCal
• Export reminders to smartphone or PDA
• Schedule appointments based on --
• Medical facilities offering the vaccine in your area
• Time-slots available at the medical facility
• Your availability (based on software scheduler)
• Go to appointment
• Confirm patient information and payment
• Get your vaccination
• PHR information automatically updated
• And you're DONE!  It's that EASY!  (Maybe)

Preserving EHRs with XML

While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records.  Due to the evolution of technology, the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution is to standardize information fields in a time-invariant way, such as with XML language.

XML is the most common tool for data transmissions between all sorts of applications.  It can alleviate many of the interoperability problems associated with the sharing of documents and data.

---

Example of EHR XML:

<?xml version="1.0" encoding="utf-8"?>
<CodeGroup ID="CG1" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:ihe="urn:ihe:iti:svs:2008" xsi:noNamespaceSchemaLocation="../schema/Collaborative/Measure.xsd">
<ihe:ValueSet id="1.2.6.1.4.1.21367.2008.3.1.2008.1" displayName="ACEIs - NHIQM - Appendix C, Table 1.2" version="2.5" />
<ihe:SourceCodeSystem id="2.16.840.1.113883.6.88"/>
<ihe:ConceptList>
<ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="349442" displayName="Amlodipine 10 MG / benazepril 20 MG Oral Capsule" />
<ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="629569" displayName="Amlodipine 10 MG / benazepril 40 MG Oral Capsule" />
<ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308137" displayName="Amlodipine 2.5 MG / benazepril 10 MG Oral Capsule" />`
<ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308138" displayName="Amlodipine 5 MG / benazepril 10 MG Oral Capsule" />
<ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308139" displayName="Amlodipine 5 MG / benazepril 20 MG Oral Capsule" />

---

EHR exportation structures:

 

Sources:

http://en.wikipedia.org/wiki/Health_informatics

http://www.xml.gov/

http://www.w3schools.com/xml/xml_whatis.asp

http://www.ihe.net/Events/upload/ihe_webinar_2008_session_7_Quality-Research-Public-Health_white_paper_perf_measures_July10_2008_Eisenberg.pdf

Going HITECH

The Health Information Technology for Economic and Clinical Health Act (HITECH Act), part of the 2009 economic stimulus package (ARRA) passed by the US Congress, aims at inducing more physicians to adopt EHRs. Maximum incentive payments are promised for Medicaid to those who adopt and use "certified EHRs" beginning in 2011.  Doctors who do not adopt an EHR by 2015 will be penalized. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to show "meaningful use" of an EHR system. As of June 2010, there are no penalty provisions for Medicaid.  HIPAA was also extended to cover electronic records, which covers proper disclosure and security breaches. 

http://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act#HITECH_Act:_Privacy_Requirements

HI / HIS vs. HIT in IT

Health informatics (also called health care informatics, healthcare informatics, medical informatics or biomedical informatics) is a discipline at the intersection of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health and (bio)medical research.

Health information technology (HIT) provides the umbrella framework to describe the comprehensive management of health information and its secure exchange between consumers, providers, government and quality entities, and insurers. Health information technology (HIT) is in general increasingly viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.

Sources:

http://en.wikipedia.org/wiki/Health_informatics

http://en.wikipedia.org/wiki/Health_information_technology

Barriers to EHR implementation

• Doctors do not know where to begin
• Absence of incentives
• High costs of implementation and maintenance
• Uncertain beneficiaries of the return on HIT-EHR investment – i.e. providers incur the acquisition costs of equipment and training, while plans receive the financial benefits of reduced lab tests and lengths of stay
• Transition to HIT-EHR system presents numerous challenges:
  time and cost of personnel training, uneven financial rewards, equipment costs, and lack of technical computer expertise
• Poorly integrated into cost and reimbursement models
• Privacy and security concerns

www.library.ca.gov/crb/08/08-013.pdf

Benefits of EHR implementation

More efficient processing system
Accelerated transfer of information and substantially decreased administrative activity

 

Fewer medical tests
Redundant tests now often performed because of lost or inaccessible past records

 

Less medical errors and increased overall quality
Sends alerts of adverse drug interactions and reminder for proper timing of tests, etc.

 

Increased public health monitoring and disease management
Disease trends and other medical conditions can be easily aggregated and detected over a wide variety of patients, and individually tailored treatments can be established and monitored for complex patients

 

Improved emergency care
Fast access to patient records can optimize treatments and procedures

 

More accessible and better developed measures of transparency

Includes comparisons on outcomes, quality, costs, adherence to protocols, reimbursement rates

 

Potential to dramatically accelerate clinical research

Makes possible the combination of clinical data from millions of patients, enables rapid learning of the value of new medical technology and disease
treatment

 

Potential for system-wide costs savings

As a result of improved efficiency and quality and decreases in error and redundancy

 

www.library.ca.gov/crb/08/08-013.pdf

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More benefits:

• Improve health care quality
• Prevent medical errors
• Reduce health care costs
• Increase administrative efficiencies
• Decrease paperwork
• Expand access to affordable care
• Early detection of infectious disease outbreaks around the country
• Improved tracking of chronic disease management
• Evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared

http://en.wikipedia.org/wiki/Health_information_technology

Glossary of Common Terminology

Electronic Health Record (EHR)
Electronically stored and transmitted medical record that contains patient demographics, medical history, lab tests, X-rays, scans, prescription lists, and any other relevant information.

Personal Health Record (PHR)
A patient-managed electronic medical record.

Electronic Medical Record (EMR)
The legal patient record created in hospitals and ambulatory environments that is the data source for the EHR.

Health Information Exchange (HIE)
Data transfer between separate healthcare entities in the same facility or across great distances.

Telemedicine
The transfer of health information using telecommunications technology; it can be as simple as a general practitioner and specialist discussing a patient’s case on a secure line or as complex as remote procedures and examinations through digital imaging.  It can be used in rural geographies.

Electronic Prescribing (eRx)
A tool that can electronically process and communicate the prescription of medication between providers and pharmacies; can be a stand-alone product or incorporated into an EHR system.

Computerized Physician Order Entry (CPOE)
This tool, most frequently used in a hospital setting, allows for the electronic ordering of medications and tests; was originally a stand-alone closed-system product, but can also be incorporated into an EHR system.

Regional Health Information Organization (RHIO)
A group of healthcare entities in the same geographic area, which agree upon a standardized electronic network in order to communicate health information.

Sources:

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.2.w236
http://en.wikipedia.org/wiki/Electronic_health_record

Nimble for the iPad

A new EMR application is available for the iPad called Nimble.  It was created by the company ClearPractice.  They host a SaaS-based EMR for ambulance care.  The iPad allows them to do things they cannot do on other platforms.  The program is easy to learn.  The device communicates by WiFi or 3G, so no information is stored on the device.  Patents can visually see their medication history and may even mention that a medication is no longer used.  One drawback of the system is that information cannot be printed currently.  One of the beta testers of the application claims to    hat he will purchase the iPad at a later date.  ClearPractice is giving away free iPads with the application to physicians if they sign up for EMR or PM services. 

                     

http://www.be-nimble.com/
http://www.healthcareitnews.com/news/docs-can-be-nimble-new-emr-ipad
http://itunes.apple.com/us/app/394460930/id394460930

Windows Live Writer

Publish your blogs with Windows Live Writer included with Windows 7. 

Microsoft's HealthVault

Microsoft established HealthVault in 2007 after two years in the making. Microsoft used its old strategy of using partners when it built the database. The website includes a personal health record and an internet search tool. Personal information is secured and encrypted. Privacy controls are handled by the user. Dr. Deborah Peel, chair of the Patient Privacy Rights Foundation, says “Microsoft is setting an industry standard for privacy.” Mr. Neupert of Microsoft states that people need to see a good history of trust and the convenience of personal health records. Originally, people did not want to use online banking for privacy reasons, but now it is commonplace.

Optimally, the user does not need to enter health data. Health data will be transferred automatically. Creating partnerships is essential for this to happen and Microsoft has already enrolled health care companies.

As people use more online tools and the population ages, personal health management could be very important in the future. Many other technologies have struggled to launch health initiates, while Microsoft pushed ahead. Dr. Daniel Jones, the president of the American Heart Association, says, “The potential here is very great. And we all recognize the power of Microsoft to reach millions of households.” Mr. Neupert claims that “To make a difference in health care, it is going to take time and scale. And Microsoft has both.”

http://www.nytimes.com/2007/10/04/technology/04nd-soft.html?_r=3&ex=1349236800&en=a2e0ff5e7e643bc6&ei=5088&partner=rssnyt&emc=rss