By Tony Schueth, Editor-in-Chief
After years in the minor leagues, it looks like electronic prescribing (ePrescribing) has finally arrived. The story is told in large part via Surescripts’ newly issued National Progress Report 2013 and Safe-Rx Rankings. It indicates the company routed more than 1 billion electronic prescriptions in 2013, representing a majority (58%) of all eligible prescriptions in the United States, sent by 73% of all office-based physicians. The report also shows mail-order ePrescription volume increasing and nearly all community pharmacies are good to go. Outside sources estimate an additional 21 million prescriptions are flowing through other networks.
All in all, it’s safe to say that ePrescribing is rounding third base. However, it’s too soon to say the game is over, as some stakeholders keep saying. Despite its strong showing in major-league health care, we at Point-of-Care Partners (POCP) don’t believe ePrescribing will be sliding into home anytime soon. We still need to increase adoption, utilization and volume from the remaining types of prescribers, prescriptions and transactions.
Increasing transaction volume. Nobody can fully quantify who and how much still is missing from the ePrescribing lineup. The Surescripts report provides some clues, beginning with ePrescribing for controlled substances (EPCS). While gaining traction, EPCS is still a low-volume proposition – so much so that these prescriptions are not yet included in Surescripts’ denominator. Although the Drug Enforcement Administration (DEA) predicted it would take some 15 years for EPCS to become mainstream, others are more optimistic. David Yakimischak, Surescripts’ Executive Vice President and General Manager for Medication Network Services, estimates 5 to 10 years. He notes the major progress thats been made even though we are only just a few years removed from issuance of the DEA interim final rule in 2010, which set forth its criteria for EPCS. Physicians are increasingly perceiving EPCS as important and are becoming certified. There are other drivers that will spur EPCS, including legislation (such as New York’s I-Stop) that will make EPCS mandatory to help curb controlled substance diversion and abuse. Yakimischak expects the shorter horizon if mandates become more commonplace.
Although renewal requests will always be a small percentage of the total, increasing their use and volume will enhance overall ePrescribing numbers and complete the picture. The report noted a 29% increase in renewal requests in 2013, but they only accounted for roughly 10% of the Surescripts network volume within the past couple of years.
Next up is medication history, which registered 19% growth to reach nearly 700 million Surescripts transactions in 2013. While we’d like to see more, this growth is encouraging because this transaction can fuel medication reconciliation at the transitions of care as well as adherence messaging and improved drug-to-drug alerts. Again, more can be done. ‘We are seeing situations where certain markets are much more interested in working to create a collaborative environment providing timely, filtered information in addition to understanding what happens to the Rx around things like adherence,’ said Kevin Mahoney, Executive Vice President for Pharmacy Services, Emdeon, a collaborator with and competitor of Surescripts. ‘More and more, we’re seeing our clients wanting to know if an Rx was filled and, if not, why not.’
‘Finally, there are the ‘benefits’ transactions, which surprisingly were not covered in this year’s report. These have traditionally been the eligibility requests and responses that fed the formulary information provided to electronic health records (EHRs) in batch transactions, but may take on new meaning as the National Council for Prescription Drug Plans (NCPDP) works on a solution for a preadjudication transaction that will give prescribers likely benefit information at the patient level.
All these transactions represent the sweet spot in the lineup because they can significantly improve quality and safety, though they will admittedly take some work on the parts of payers, pharmacies, vendors and providers. Payers need to improve the timeliness, availability and accuracy of information provided in formulary and benefit files, particularly the prior authorization flag. Pharmacies must increase their accuracy and availability of medication history information – issues that have served as barriers for physician usage of ePrescribing. Vendors will need to improve representation on ePrescribing systems. Providers must better understand the value of this information and do a better job of integrate it into their work flows, once they are assured of its veracity.
Specialty prescribing was also missing in the report, but could become a heavy hitter in years to come. Although such prescriptions also are low in volume (1% today) in the overall scheme of things, they represent a huge growth area with big price tags. Specialty medications run at least $2,000 per month per patient; those at the high end cost upward of $100,000 to $750,000 per year. The high price tags of specialty drugs are a major reason why expected outlays for them are projected to reach some $402 billion annually. A recent study estimates that nearly half of all prescription drug sales will be for specialty medications by 2021 due to their use by the growing elderly and chronically ill populations. These factors undoubtedly will bring specialty prescribing onto payers radar; they soon will recognize this as an area for cost containment and will be looking for ways to wring savings from the process. Moreover, these prescriptions are ripe for automation.
People tend to consider specialty prescribing to be a single transaction; in fact, it is a series of transactions that are done mostly by paper, phone and fax. Enter ePrescribing of specialty medications, which is used today but on a limited basis. Standards and ePrescribing infrastructure already are available to handle the basic prescription process. Other necessary elements, such as electronic prior authorization (ePA), are emerging that will facilitate automation of other specialty prescribing processes. Given the complexity of specialty prescribing, arriving at meaningful metrics will be challenging. Prescription volume alone is not enough.
Gaps in the provider roster. Mahoney points to several provider types that are missing from the ePrescribing lineup. Rural providers and long-term care facilities need to get connected and up to speed. In addition, many other providers are connected but have a low transaction volume due to churning in the EHR market. Significant numbers of physicians are changing EHR systems because they are fed up with their current system or they are joining value-based systems and need to have the ‘corporate’ model. They then need to learn the new EHR system and integrate it into their daily work flow. As a result, it will take time for their transaction volume to meaningfully increase and significantly affect the ePrescribing denominator.
Bringing up the bottom of the roster are those providers who are doing the minimum or plan to do nothing at all. Some simply have bought an ePrescribing system to garner various incentives and use it at a threshold level to avoid statutory payment penalties. The result: their utilization will never do much to increase the ePrescribing numerator. Sadly, there will always be a small percentage of providers who will never ePrescribe despite the best efforts of the government and industry and the benefits to multiple stakeholders.
State rankings. Surescripts also released its SafeRx rankings for 2013. The top rankings didn’t change all that much, although North Dakota and Connecticut moved up into the top 10. There was churning in the middle, and some states, like California, stayed near the bottom. How this all works is somewhat mysterious. According to Surescripts, ‘the rankings recognize the full utilization of [ePrescribing] based on volume of use of Surescripts’ Prescription Benefit, Medication History and Prescription Routing Services.’ Despite all of this, we do know a couple of things. A few blips can really change the rankings of states with small populations and/or small geographic areas, which accounts for the Dakotas being in the top 10 for 2013. We also know that payer nonparticipation with Surescripts can skew these ratings. We are aware of one state in which the major commercial payer is not a Surescripts contributor, serving to knock it down 10 to 15 spots. This means that their transactions for medication history and benefits transactions, for example, are not included in Surescripts’ totals. We wonder how widespread this situation might be and how much it could affect outcomes overall. On the other hand, its probably safe to say that the SafeRx rankings don’t have the impact they once had. In the early days, these rankings really did a lot to spur competition among states and boost the cause of ePrescribing. We wonder if the orientation should shift to EPCS and get some competition going among states to champion this important piece of the ePrescribing puzzle.
Looking to next year. Surescripts’ report provides a partial annual snapshot of an industry that has rapidly moved beyond its humble beginnings, which focused on transaction volume. As we hit the midpoint of 2014, POCP finds that vendors, infrastructure providers and standards development organizations are concentrating on adding value and innovation to the ePrescribing process. For some, that means working to create a collaborative environment that provides timely, filtered information. Plans are afoot in many quarters to add various kinds of clinical and administrative data to ePrescriptions, such as diagnosis, height and weight, and insurance policy number, to determine whether coverage will fall under a patient’s medical or pharmacy benefit. This will increase accuracy and usefulness of ePrescriptions for tracking costs, quality and outcomes, as well as reduce administrative overhead. Mobile applications are rapidly coming onstream. Payers and providers are becoming interested in understanding what happens to a prescription with regard to such considerations as adherence. Work is beginning on more advanced functionalities for ePA that will enhance its usability for specialty prescribing. The list is long and growing every day. Let Point-of-Care Partners help you understand how ePrescribing is a becoming a whole new ballgame and how the new value-adds can be home runs for your organization.