Mandates, Mandates -- Who's Got a Mandate?

by Tony Schueth, Editor-in-Chief

As stakeholders in ePrescribing, we continue to hear the chorus about an impending Medicare ePrescribing mandate. Will it happen? A mandate as most of us would define it is doubtful. BUT there is a very high probability of legislation this year that would require clinicians to ePrescribe for Medicare beneficiaries.

The top contender is S.2408: The Medicare Electronic Medication and Safety Protection (E-MEDS) Act of 2007. It is backed by top Congressional leaders and endorsed by a large and diverse coalition of health stakeholders including consumer groups, employers, labor, health plans, pharmacies and physicians.

E-MEDS is not a mandate, but a requirement program with a “carrot, carrot, stick” approach. The first carrot is an incentive bonus for those meeting a minimum threshold of ePrescribing volume for their Part D patients. The second carrot is one-time grants to physicians to help offset the start-up costs for implementing ePrescribing technology. Start-up grants would be $2,000 for 2008 or 2009, $1,500 for 2010 or 2011, and $1,000 for 2012 and any subsequent year.

The stick would hit in year 3. Physicians who don’t ePrescribe for their Medicare patients by January 1, 2011 will get docked 10% of the payments they would normally receive for “evaluation and management” services.

If E-MEDS starts driving adoption as intended, its impact will occur much later, if the Health Insurance Portability and Accountability Act (HIPAA) adoption experience is any indication. If it doesn’t, the federal government will likely implement the draconian policy of not paying for Medicare prescriptions that are not transmitted electronically. 

There seems to be wide-spread support for a mandate.  At HIMSS, Michael Leavitt, Secretary of Health and Human Services, called for one.  Former speaker of the House of Representatives, Newt Gingrich, and Senator John Kerry, D-MA, said on March 4 that the legislation is likely to pass.

Their reason for optimism is the broad-based support for the legislation.  Part of the support comes from frustration over slow adoption.  Part of it is the intolerable number of medication errors.  On that note, did you see 60 Minutes on Sunday, March 16 at 7 pm ET/PT.  Dennis Quaid and his wife, Kimberly, talked about medical mistakes that nearly killed his newborn twins.  This kind of attention just turns up the heat to do something about medication errors.  As stakeholders of ePrescribing, you don’t need to be told that ePrescribing has been proven to improve the quality of care and reduce errors.

This ability to reduce medication errors is what makes the issue of the Drug Enforcement Agency (DEA) not permitting the transmittal of Schedule 2-5 medications so perplexing.  As we have written in the past, great deal of pressure has been put on the DEA to get this Notice of Proposed Rulemaking issued ASAP. We understand the draft (not yet been made public) is not yet crafted in a manner acceptable to the industry or government. 

In terms of a real mandate, the Centers for Medicare and Medicaid Services (CMS) will eliminate the computer-generated fax exemption for ePrescribing for Medicare Part D beginning on January 1, 2009. The rule does, however, allow use of eFaxs in the case of emergencies, such as network outages. Long-term care facilities continue to get a bye. This news was buried in the voluminous Medicare Physician Fee final rule, which was published on November 27, 2007 and is as voluminous as the Manhattan phone book.

This isn’t necessarily the last word. It has been reported that CMS may revisit its decision in response to major pushback from the pharmacy industry.

In the meantime, five leading physician groups have launched a Web site and campaign designed to help doctors move to ePrescribing and determine whether their current ePrescribing systems comply with the new Medicare eFax prohibition described above.

The “Get Connected” campaign  sponsored by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Cardiology (ACC), American College of Obstetricians and Gynecologists (ACOG) and Medical Group Management Association (MGMA)  is the first effort by physicians to promote ePrescribing in a very public and organized manner. We expect this to be the start of increasing physician support in the future.

On related subjects, did you notice that … SureScripts named its SafeRx Awards.   The top 5 states are: 1. Massachusetts,  2. Rhode Island, 3. Nevada, 4. Deleware and 5. Michigan.  Allscripts ranked No. 1 among the vendors.  Note that this is for total electronic prescriptions that flow through SureScripts as a percent of total prescriptions.  In the past, we have pointed out that they did not have all of the EDI scripts to retail, mentioning that they did not have Medavant.  Well, they purchased that company last year, so it’s getting more comprehensive.  The EDI prescriptions that they do not yet have are RxHub (to mail); Relay Health and eRx Network that don’t go though SureScripts; Kaiser and other closed-loop systems; and government systems such as the Department of Defense and the Veteran’s Administration. … The Southeastern Michigan ePrescribing Imitative (SEMI) released the findings of a telephone survey of physicians.  Of a survey of 500 users, 78% said they were highly satisfied with their ePrescribing systems and 90% said their ePrescribing system either met or exceeded their expectations.  More than 70% said that ePrescribing improved quality of care and more than 70% said they saw a reduction in telephone calls. … Kevin Hutchinson landed at Prematics as the CEO.  Prematics is a newer ePrescribing solution whose chairman is Jim Bradley, former CEO of RxHub.  They also have an all-star team for an advisory board.  Two weeks after the Hutchinson announcement, Availity said that it had engaged Prematics in rolling out its ePrescribing solution.  Availity is a connectivity company owned by Blue Cross Blue Shield of Florida, Humana and Health Care Service Corporation (Blue Cross Blue Shield of Illinois, New Mexico, Oklahoma and Texas). … On February 12, Medco announced that it was launching a Medicare PDP ePrescribing pilot with 500 physicians.  They chose RxNT as a partner for the study. … Meditech and DrFirst showcased medication management at HIMSS08.

by Michael Solomon, Executive Editor

Consumer-centric care has been a buzzword for a while in health information technology (HIT).  But if recent events are any indication, it is becoming a reality. More vendors and corporate entities are providing online or HIT-based self-management tools for consumers in the form of personal health records (PHRs) and other applications. The expectation is that patients will become more proactive in managing their health and health care. But will consumers -- especially those with chronic illness, who stand to realize the most gains from these applications -- step up and log in?

This hope is embodied in a newly launched pilot project between The Cleveland Clinic and Google’s new PHR system, which was demonstrated at HIMSS08. Patient volunteers -- who could range from between 1,500 and 10,000 -- will have the ability to transfer their records from the hospital’s internal system to the Google system, thus giving them external Internet access to prescription information, medical histories, and details about conditions and allergies.

In a demonstration project being conducted in South Carolina, the Centers for Medicare and Medicaid Services (CMS) is banking on 100,000 Medicare beneficiaries stepping up and logging in for their PHR.   Those who sign up will have access to a commercially created PHR populated with two years of their Medicare claims information. CMS will monitor the project to see how many beneficiaries are actually using the PHR, once they have signed up for it, and other usage issues, such as the number of beneficiaries who make this information available to their health care providers. However, CMS did not mention how it plans to address the digital divide. Although the number is shrinking, many seniors do not have ready computer access.

Vendors are also making it easier for consumers to access their health information through a variety of applications, including online, mobile phone, portable (such as a thumb drive) and desktop. Not only is the technology available, market research shows this is a void to be filled. For example, more than 80 million consumers are interested in online communications with their physicians (Manhattan Research) and more than two-thirds are interested in using remote monitoring devices to report information about their medical condition to providers (Deloitte Center  for Health Solutions). The HIMSS08 exhibit hall was filled with vendors showing such consumer-oriented offerings. They and their investors are betting big capital that now these applications have been built, consumers will buy them  and use them.

Various platforms -- including MicroSoft’s Health Vault and the employer-sponsored DOSSIA -- are making these consumer-facing applications possible in innovative ways. So are the latest standards-related offerings from two major groups. HL7 has created a standardized model of the functions that may be present in PHR systems. The HL7 PHR-FM has the potential to accelerate efforts for the exchange of subsets of patient data appropriate for storage and retrieval in PHRs. America’s Health Insurance Plans (AHIP), in conjunction with Blue Cross/Blue Shield of America, has developed a payer-based PHR data transfer standard framework that, if embraced by the payer community, could elevate consumer acceptance by providing portability of a patient’s PHR when health plan coverage changes. 

So, we see several forces converging. Consumer e-health needs are becoming a major blip on the radar screen. There is a lot of activity focusing on consumer-centric care, which raises the potential for harmonization, especially among the platforms, definitions and standards that undergird PHRs and other consumer-facing applications. But the big question is: even before all this sorts out, will consumers step up and log in?

Odds and Ends

The Brooklyn Health Information Exchange (BHIX) is set to launch its first services this summer. Supporting our position previously stated in HIT Perspectives, delivery of health records that will help physicians to manage their patients with chronic diseases is a cornerstone of this HIE organization’s strategy (Healthcare IT News).

Zix Corporation has launched an innovative service for disease management as part of its ePrescribing solution. If a patient is eligible for the Blue Cross Blue Shield of Massachusetts disease management program, an alert is issued to the physician during the electronic prescribing process. This is an interesting model that leverages connectivity already in place for medication history and formulary data to deliver additional value to the physician and his or her patient. We will monitor physician acceptance of this service.

According to a recent survey by HHNMostWired, hospitals are providing patients with online care management for the following chronic diseases: asthma, 14%; diabetes, 22%; chronic obstructive pulmonary disease, 15%; congestive heart failure, 21%; and heart disease, 21%.

Policy makers must develop clear policies on privacy and security to alleviate consumer concerns about PHR use, according to HIT executives at an Agency for Healthcare Research and Quality (AHRQ)-sponsored conference in February. A clear and concise policy framework to consumer access must address such issues as the Health Insurance Portability and Accountability Act (HIPAA), authentication, transparency, and secondary data use (iHealthBeat).

Participants in a survey sponsored by the American Academy of Family Physicians have named the Praxis EMR as the top electronic medical record vendor. In a 2008 survey based on 422 family physicians currently using electronic medical records, Infor-Med's Praxis EMR won first place in overall customer satisfaction, ease of use and flexibility, customer support and training and overall cost savings. The Praxis EMR was the only system listed to have 100% of respondents agree they would never return to using paper records (Healthcare IT News).