Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies.

OBJECTIVE: A core feature of e-prescribing is the electronic exchange of prescription data between physician practices and pharmacies, which can potentially improve the efficiency of the prescribing process and reduce medication errors. Barriers to implementing this feature exist, but they are not well understood. This study's objectives were to explore recent physician practice and pharmacy experiences with electronic transmission of new prescriptions and renewals, and identify facilitators of and barriers to effective electronic transmission and pharmacy e-prescription processing. DESIGN: Qualitative analysis of 114 telephone interviews conducted with representatives from 97 organizations between February and September 2010, including 24 physician practices, 48 community pharmacies, and three mail-order pharmacies actively transmitting or receiving e-prescriptions via Surescripts. RESULTS: Practices and pharmacies generally were satisfied with electronic transmission of new prescriptions but reported that the electronic renewal process was used inconsistently, resulting in inefficient workarounds for both parties. Practice communications with mail-order pharmacies were less likely to be electronic than with community pharmacies because of underlying transmission network and computer system limitations. While e-prescribing reduced manual prescription entry, pharmacy staff frequently had to complete or edit certain fields, particularly drug name and patient instructions. CONCLUSIONS: Electronic transmission of new prescriptions has matured. Changes in technical standards and system design and more targeted physician and pharmacy training may be needed to address barriers to e-renewals, mail-order pharmacy connectivity, and pharmacy processing of e-prescriptions.

Physician practices, e-prescribing and accessing information to improve prescribing decisions.

Hoping to reduce medication errors and contain health care costs, policy makers are promoting electronic prescribing through Medicare and Medicaid financial incentives. Many e-prescribing systems provide electronic access to important information--for example, medications prescribed by physicians in other practices, patient formularies and generic alternatives--when physicians are deciding what medications to prescribe. However, physician practices with e-prescribing face challenges using these features effectively, according to a new qualitative study by the Center for Studying Health System Change (HSC) funded by the Agency for Healthcare Research and Quality (AHRQ). While most of the 24 practices studied reported that physicians had access to patient formulary information, only slightly more than half reported physician access to patient medication histories, and many physicians did not routinely review these sources of information when making prescribing decisions. Study respondents highlighted two barriers to use: (1) tools to view and import the data into patient records were cumbersome to use in some systems; and (2) the data were not always perceived as useful enough to warrant the additional time to access and review them, particularly during time-pressed patient visits. To support generic prescribing, practices typically set their system defaults to permit pharmacist substitution of generics; many practices also used other tools to more proactively identify and select generic alternatives at the point of prescribing. Overall, physicians who more strongly perceived the need for third-party data, those in practices with greater access to complete and accurate data, and those with easier-to-use e-prescribing systems were more likely to use these features consistently.

Key findings from HSC's 2010 site visits: health care markets weather economic downturn, brace for health reform.

Lingering fallout--loss of jobs and employer coverage--from the great recession slowed demand for health care services but did little to slow aggressive competition by dominant hospital systems for well-insured patients, according to key findings from the Center for Studying Health System Change's (HSC) 2010 site visits to 12 nationally representative metropolitan communities. Hospitals with significant market clout continued to command high payment rate increases from private insurers, and tighter hospital-physician alignment heightened concerns about growing provider market power. High and rising premiums led to increasing employer adoption of consumer-driven health plans and continued increases in patient cost sharing, but the broader movement to educate and engage consumers in care decisions did not keep pace. State and local budget deficits led to some funding cuts for safety net providers, but an influx of federal stimulus funds increased support to community health centers and shored up Medicaid programs, allowing many people who lost private insurance because of job losses to remain covered. Hospitals, physicians and insurers generally viewed health reform coverage expansions favorably, but all worried about protecting revenues as reform requirements phase in.

Physicians slow to e-mail routinely with patients.

Some experts view e-mail between physicians and patients as a potential tool to improve physician-patient communication and, ultimately, patient care. Despite indications that many patients want to e-mail their physicians, physician adoption and use of e-mail with patients remains uncommon--only 6.7 percent of office-based physicians routinely e-mailed patients in 2008, according to a new national study from the Center for Studying Health System Change (HSC). Overall, about one-third of office-based physicians reported that information technology (IT) was available in their practice for e-mailing patients about clinical issues. Of those, fewer than one in five reported using e-mail with patients routinely; the remaining physicians were roughly evenly split between occasional users and non-users. Physicians in practices with access to electronic medical records and those working in health maintenance organizations (HMOs) or medical school settings were more likely to adopt and use e-mail to communicate with patients compared with other physicians. However, even among the highest users--physicians in group/staff-model HMOs--only 50.6 percent reported routinely e-mailing patients.

Even when physicians adopt e-prescribing, use of advanced features lags.

Physician practice adoption of electronic prescribing has not guaranteed that individual physicians will routinely use the technology, particularly the more advanced features the federal government is promoting with financial incentives, according to a new national study from the Center for Studying Health System Change (HSC). Slightly more than two in five physicians providing office-based ambulatory care reported that information technology (IT) was available in their practice to write prescriptions in 2008, the year before implementation of federal incentives. Among physicians with e-prescribing capabilities, about a quarter used the technology only occasionally or not at all. Moreover, fewer than 60 percent of physicians with e-prescribing had access to three advanced features included as part of the Medicare and Medicaid incentive programs--identifying potential drug interactions, obtaining formulary information and transmitting prescriptions to pharmacies electronically--and less than a quarter routinely used all three features. Physicians in practices using electronic medical records exclusively were much more likely to report routine use of e-prescribing than physicians with stand-alone e-prescribing. systems. Other gaps in adoption and routine use of e-prescribing also exist, most notably between physicians in larger and smaller practices

Electronic medical records and communication with patients and other clinicians: are we talking less?

Commercial electronic medical records (EMRs) both help and hinder physician interpersonal communication--real-time, face-to-face or phone conversations--with patients and other clinicians, according to a new Center for Studying Health System Change (HSC) study based on in-depth interviews with clinicians in 26 physician practices. EMRs assist real-time communication with patients during office visits, primarily through immediate access to patient information, allowing clinicians to talk with patients rather than search for information from paper records. For some clinicians, however, aspects of EMRs pose a distraction during visits. Moreover, some indicated that clinicians may rely on EMRs for information gathering and transfer at the expense of real-time communication with patients and other clinicians. Given time pressures already present in many physician practices, EMR and office-work flow modifications could help ensure that EMRs advance care without compromising interpersonal communication. In particular, policies promoting EMR adoption should consider incorporating communication-skills training for medical trainees and clinicians using EMRs.

Are electronic medical records helpful for care coordination? Experiences of physician practices.

BACKGROUND: Policies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination. OBJECTIVES: We examine whether and how practices use commercial EMRs to support coordination tasks and identify work-around practices have created to address new coordination challenges. DESIGN, SETTING: Semi-structured telephone interviews in 12 randomly selected communities. PARTICIPANTS: Sixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders. RESULTS: Six major themes emerged: (1) EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging; (2) EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange; (3) managing information overflow from EMRs is a challenge for clinicians; (4) clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination; (5) realizing EMRs' potential for facilitating coordination requires evolution of practice operational processes; (6) current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity). CONCLUSIONS: There is a gap between policy-makers' expectation of, and clinical practitioners' experience with, current electronic medical records' ability to support coordination of care. Policymakers could expand current health information technology policies to support assessment of how well the technology facilitates tasks necessary for coordination. By reforming payment policy to include care coordination, policymakers could encourage the evolution of EMR technology to include capabilities that support coordination, for example, allowing for inter-practice data exchange and multi-provider clinical decision support.

Does telemonitoring of patients--the eICU--improve intensive care?

Intensive care units are an essential and costly component in most U.S. hospitals. However, little is actually known about what staffing and work-process interventions produce the best balance of quality and costs. We explore the reasons hospitals chose to either adopt or reject an innovative telemedicine approach to supporting delivery of intensive care. Hospital clinical leaders hold strong views but have little objective information on which to judge the worthiness of this innovation. We argue that comparative effectiveness initiatives should emphasize delivery-system and work-process innovations, which are relatively understudied compared to specific drugs, devices, and services.

Information gap: can health insurer personal health records meet patients' and physicians' needs?

Personal health records (PHRs), centralized places for people to electronically store and organize their health information, can benefit both patients and doctors. This qualitative study of health insurers' PHRs for enrollees reveals potential benefits and challenges. Insurers' ability to put claims-based data into the PHR offers an advantage. However, consumers are concerned about sharing personal health information with insurers and about Internet security. Physicians question (1) the validity of claims data in making treatment decisions and (2) whether accessing these PHRs is worth the disruptions to their workflow. This paper offers possible solutions that may lead to more widespread adoption of insurer PHRs.

Despite regulatory changes, hospitals cautious in helping physicians purchase electronic medical records.

While hospitals are evaluating strategies to help physicians purchase electronic medical records (EMRs) following recent federal regulatory changes, they are proceeding cautiously, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Hospital strategies to aid physician EMR adoption include offering direct financial subsidies, extending the hospital's ambulatory EMR vendor discounts and providing technical support. Two key factors driving hospital interest in supporting physician EMR adoption are improving the quality and efficiency of care and aligning physicians more closely with the hospital. A few hospitals have begun small-scale, phased rollouts of subsidized EMRs, but the burden of other hospital information technology projects, budget limitations and lack of physician interest are among the factors impeding hospital action. While it is too early to assess whether the regulatory changes will spur greater physician EMR adoption, the outcome will depend both on hospitals' willingness to provide support and physicians' acceptance of hospital assistance.

Hospitalists and care transitions: the divorce of inpatient and outpatient care.

We interviewed hospitalist and nonhospitalist respondents as part of the Community Tracking Study site visits to examine how the growing use of hospitalists has affected care delivery systems. The growth of hospitalist programs contributes to a loss of physicians' participation on hospital medical staffs, which increases the burden of coordination and blurs accountability for the quality of postdischarge care. Arrangements where companies and multispecialty medical groups employ hospitalists are more likely than others to establish routines for ensuring coordinated transitions upon hospital admission and discharge. Policymakers could support the development of guiding principles for care coordination, greater reliance on nonphysicians, and reintegration of inpatient and outpatient providers.

Creating sustainable local health information exchanges: can barriers to stakeholder participation be overcome?

Local health information exchanges (HIEs) hold the promise of collecting patient clinical data across sites of care to provide more complete and timely information for treatment, as well as supporting quality improvement and reporting, public health activities, and clinical research. Findings from a study of stakeholder perspectives on participation in four HIEs by the Center for Studying Health System Change (HSC) and the National Institute for Health Care Management (NIHCM) Foundation suggest, however, that barriers to achieving data exchange remain high. Concerns about loss of competitive advantage and data misuse impede provider and health plan willingness to contribute patient data. Additionally, uncertainty about who benefits from HIEs is affecting stakeholder willingness to fund the exchanges. The more mature exchanges--Cincinnati-based HealthBridge and the Indiana Health Information Exchange (IHIE)--have achieved some viability by meeting a specific business need--more efficient delivery of hospital test results to physicians. The newer exchanges--CareSpark, serving northeast Tennessee and southwest Virginia, and the Tampa Bay Regional Health Information Organization (RHIO)--have struggled to identify and finance initial services without a similar critical mass of hospital participation. While narrow data exchange efforts that improve transaction efficiency may be a pragmatic first step to overcome barriers to stakeholder participation, expanding HIEs to achieve the broad-based data exchange necessary for quality reporting and pay-for-performance (P4P) activities raises more challenges.

Clinical information technology adoption varies across physician specialties.

This Data Bulletin presents findings from the HSC Community Tracking Study Physician Survey, a nationally representative telephone survey of physicians involved in direct patient care in the continental United States conducted in 1996-97, 1998-99, 2000-01 and 2004-05. The sample of physicians was drawn from the American Medical Association and the American Osteopathic Association master files and included nonfederal, office- and hospital-based physicians who spent at least 20 hours a week in direct patient care. Residents and fellows were excluded. Questions on information technology were added to the 2000-01 survey and continued in the 2004-05 survey. The 2004-05 survey includes responses from more than 6,600 physicians, and the response rate was 52 percent. More detailed information on survey methodology can be found at www.hschange.org.

Physicians moving to mid-sized, single-specialty practices.

The proportion of physicians in solo and two-physician practices decreased significantly from 40.7 percent to 32.5 percent between 1996-97 and 2004-05, according to a national study from the Center for Studying Health System Change (HSC). At the same time, the proportion of physicians with an ownership stake in their practice declined from 61.6 percent to 54.4 percent as more physicians opted for employment. Both the trends away from solo and two-physician practices and toward employment were more pronounced for specialists and for older physicians. Physicians increasingly are practicing in mid-sized, single-specialty groups of six to 50 physicians. Despite the shift away from the smallest practices, physicians are not moving to large, multispecialty practices, the organizational model that may be best able to support care coordination, quality improvement and reporting activities, and investments in health information technology.

Physicians' experiences using commercial e-prescribing systems.

Public and private efforts are under way to promote electronic prescribing to improve health care safety, quality, and efficiency. Findings from this qualitative study of physician practices suggest that substantial gaps may exist between advocates' vision of e-prescribing and how physicians use commercial e-prescribing systems today. While physicians were positive about the most basic e-prescribing features, they reported major barriers to maintaining complete patient medication lists, using clinical decision support, obtaining formulary data, and electronically transmitting prescriptions to pharmacies. Three factors help explain the gaps: product limitations, external implementation challenges, and physicians' preferences about using specific product features.

Clinical information technology gaps persist among physicians.

Physicians in smaller practices continue to lag well behind physicians in larger practices in reporting the availability of clinical information technology (IT) in their offices, according to a new national study from the Center for Studying Health System Change (HSC). The proportion of physicians reporting access to IT for each of five clinical activities increased across all practice settings between 2000-01 and 2004-05. Adoption gaps between small and large practices persisted, however, for two of the clinical activities--obtaining treatment guidelines and exchanging clinical data with other physicians--and widened for the other three--accessing patient notes, generating preventive care reminders and writing prescriptions. In contrast, clinical IT was generally as likely or more likely to be available to physicians in practices treating larger proportions of vulnerable and underserved patients as other physicians, a pattern that did not change between the two periods

Hospital-physician portals: the role of competition in driving clinical data exchange.

Recent policy efforts to encourage the use of health information technology are emphasizing development of communitywide health information exchanges to share clinical data across patient care settings. Interviews in twelve U.S. communities show that most large hospitals have or are developing physician portals to provide admitting physicians with remote access to patient records, but there is little data sharing among unaffiliated organizations. Competition among hospitals for physicians is a key factor driving adoption of these proprietary systems. In contrast, provider and health plan competition and adversarial relationships between providers and plans are viewed as major barriers to communitywide clinical data sharing.

When the price isn't right: how inadvertent payment incentives drive medical care.

Unintended overpayment of some services, in combination with other market factors, is driving increased use of expensive care, which in turn could be an important driver of health care cost trends. Reimbursement systems are highly dependent on provider charge data that rarely provide accurate and up-to-date indicators of relative costs. As a result, newer services, in which productivity is increasing over time, tend to be more lucrative. As the largest payer, and one whose reimbursement policies are followed by private insurers and Medicaid programs, Medicare can address this issue by taking steps to make its prospective payment rates reflect relative costs more accurately.