All Things E

August 9, 2007

It has been said that healthcare is in the early stages of a digital revolution. The prescription pad is being replaced by the Blackberry; medical journals and manuals have transitioned to the PDA...

It has been said that healthcare is in the early stages of a digital revolution. The prescription pad is being replaced by the Blackberry; medical journals and manuals have transitioned to the PDA and the Internet; patient charts and records can be accessed with just a few keystrokes; and the superfluous telephone calls and office visits that are made simply to ask questions are being swapped for a quick e-mail. Nowadays, physicians--albeit some more than others—are getting connected, and it’s making the practice of healthcare more efficient and enabling physicians to focus more on medicine and less on the hassles and hurdles that seem to consume so much valuable time. In this article, we'll a brief look at five major technologies that are shaping the face of medicine—e-mail consultations, ePrescrib-ing, eDetailing, evidence-based medicine, and electronic health records/electronic medical records—and tell you why you should be using them if you aren’t already.

E Prescribing(Slowly) Making the Prescription Pad Obsolete

For nearly a decade, health information technology experts have maintained that electronic prescribing can offer physician practices greater efficiency and improve formulary compliance and generic substitution, patient safety, and compliance with chronic-care treatment regimens that enhance health outcomes. Yet, according to a 2005 study cited in a report from California Healthcare Foundation—titled “The Prescription Infrastructure: Are We Ready for ePrescribing?”—only 14% of physicians use any type of ePrescribing. “Doctors are notoriously slow to adopt technol-ogies that do not immediately generate revenue or save time,” states the report, which was published in January 2006. “They have not been receptive to the promise that eRx will generate efficiency-related savings." However, according to the report, ePrescribing is becoming increasingly attractive for a number of reasons:

• Potential cost savings at the pharmacy and an opportunity to generate savings through better enforcement of formulary compliance have spurred the formation of two large networks: RxHub and SureScripts.

• Electronic health record (EHR) adoption is gaining momentum, which has paved the way for pay-for-performance incentives from health plans, employers, and Medicare.

• Smart phones, cheaper wireless Internet costs, and better interfaces for EHR and eRx applications are making it easier and less expensive for physicians to accept these technologies.

• Several health plans are subsidizing the deployment of ePrescribing applications in physician offices.

• Physician practices that have adopted EHRs and eRx are starting to see savings in reduced overtime and call-back hassles.

• Patient safety and compliance are becoming more important to providers and payers.

The bottom line is this: the successful implementation of an ePrescribing system “can make physician offices and pharmacies more efficient,” according to the report. Many physicians agree, including MDNG board member Dr. Daniel Sands, who is also a fellow of the American College of Medical Informatics and sits on the on the board of the American Medical Informatics Association. We spoke with Dr. Sands—who was profiled last year by MD Net Guide as one of nine Faces of Medicine for his achievements in the field of Internet medicine—to gain a first-hand perspective on the topic of ePrescribing.

Q&A With Dr. Daniel Sands

What are the main benefits that ePrescribing offers to physicians?

ePrescribing is something that benefits the patient, the health plans, and the physician. The specific benefits for physicians are improved office efficiency and fewer callbacks from pharmacies. In addition, there are malpractice insurers who are starting to offer discounts on premiums to physicians who use it, because it improves safety of prescribing and, subsequently, improves the care we deliver.

What are the primary obstacles still deterring widespread adoption of ePrescribing?

The main obstacle is that physicians are often reluctant to try new technologies. Money is always somewhat of an obstacle, but health insurers are increasingly providing this to clinicians because they’re seeing a reduction in drug expenditures. Blue Cross Blue Shield of Massachusetts reported that they’ve cut their drug expenditures by 1.5%, which is very good.

How is EHR adoption affecting the growth of ePrescribing?

I think that physicians are in three camps right now: those who are going to use an

EHR in the next year or so, those who are going to do nothing, and those who are goingto use ePrescribing in the foreseeable future. It used to be that physicians either used EHRs or nothing, but now we’re seeing that ePrescribing offers a lightweight alternative for physicians who might be willing to use some technology in their practice to improve efficiency and improve safety and yet not have the huge investment in both workflow redesign and financial commitment that an EHR entails. ePrescribing gives physicians an incredible amount of value in terms of improved office efficiency, reduced call-backs from pharmacies, and safety for patients.

Do you think that Medicare Part D will enhance or hinder ePrescribing?

I think is probably going to have a neutral effect on ePrescribing adoption. It certainly isn’t going to hinder it at all; it might help it a little bit because physicians are just totally frustrated with the large number of formularies that they have to contend with for Medicare Part D recipients. Because of that, they see ePrescribing as a tool that will help them through this massive, ridiculous list of medications, and I think that it will.

Is pay-for-performance affecting the adoption of ePrescribing?

I think that it is. We’re seeing programs where doctors are given a financial incentive

to actually use ePrescribing, and in those cases, it certainly drives utilization.

From what you have seen, is use of ePrescribing becoming more widespread?

It definitely is; when we remove the financial impediment through sponsorship models, I think physicians are definitely joining up and doing this. We have programs

going on in a number of different states, and it is an attractive technology for many

physicians. So, I think we’re getting over the hump, and we’re riding up the adoption

curve. I think that all the factors that will lead to adoption are accumulating, and all

the obstacles are sort of melting away. We’re getting to the point where it’s going to

reach critical mass sometime in the next few years, and we’re excited about it.

The Best Thing You're Not Doing

E-mail Consultations

To Daniel Z. Sands, MD, MPH, FACMI, MD Net Guide Editorial Board member, Chief Medical Officer and Vice President for Clinic Strategies, Zix Corporation, and Assistant Professor of Medicine, Harvard Medical School, a longtime proponent of the use of e-mail consultations in the medical setting, the fact that more physicians aren’t making use of the technology is baffling. “I think electronic communication is very important in the practice of medicine, both for clinicians communicating with other clinicians and doctors interacting with their patients,” said Dr. Sands. “It’s really a tremendous opportunity to enhance the relationship between physicians and patients and improve the care that we deliver.”

However, despite the fact that more than 85% of physicians in the US have high-speed Internet access, a recent study published in the Journal of Medical Internet Research states that just 16.6% of physicians surveyed in Florida interact with patients via e-mail, and just 2.9% reported using this method of communication frequently. The study’s authors, Robert G. Brooks, MD, and Nir Menachemi, MD, of Florida State University College of Medicine, Tallahassee, FL, attribute physicians’ hesitancy to utilize e-mail consultations to two primary factors: time and money.

TIME: Although e-mail is an efficient means of communication, it still absorbs “valuable time and resources” and therefore “represents an ‘opportunity cost’ to some physicians, particularly if the e-mail system in place does not replace other modes of communication such as telephone messages, postal letters, etc.”

MONEY: According to Drs. Brooks and Menachemi, “the purchase and maintenance of encryption software, required to achieve maximum privacy, adds expense to the practice. Only recently have several pilot programs in the United States begun to reimburse physicians for the expenses associated with direct e-mail consultation.”

Both of these concerns, however, can be easily dealt with, according to the authors, who feel that the main barriers to use may have more to do with “the physician’s initiation than with the patient’s compliance.”

Dr. Sands, who provides an Electronic Patient Centered Communication Resource Center on his site for those who want to learn more about the technology, asserts that while many physicians point to reimbursement as the key issue, oftentimes cost is used “as an excuse for not wanting to change what they are doing.” Another concern he has seen is that physicians fear they’ll get an overload of messages. However, “Studies have shown that that generally doesn’t take place and that those situations can be controlled through educating patients and even cutting them off if necessary,” said Dr. Sands, citing a study from Manhattan Research that “suggests that most of these can be done in two minutes or less. That only translates to about 10 minutes a day, which is not a huge time commitment.”

As far as money, more health insurers are starting to cover online consultations, according to an article published in the Orlando Sentinel, which reports that Aetna began reimbursing physicians in Florida and California in May 2006 and that Cigna has announced plans to start paying physicians for time spent online with patients in January 2007. Blue Cross Blue Shield of Florida, the trailblazer, began covering e-mail consultations in January 2005.

Dr. Sands is optimistic that the practice of e-mail consultation will start to gain momentum once physicians see how beneficial it can be. “It’s really quite empowering for physicians and patients alike. Physicians get a huge benefit from it because it enables them to communicate when it’s convenient for them,” explained Dr. Sands. “I think we’re going to start to see more adoption of it, because I think it’s something we really need to do for our patients and something we need to do for ourselves.”

E DetailingAn Easier Way to Communicate With Pharma Reps

According to a survey conducted by Manhattan Research, the number of physicians in the US who participate in eDetailing—an Internet-based technology used by pharmaceutical, biotech, and medical device companies to communicate product and service messages and related information to healthcare professionals—has nearly doubled in the past three years, jumping from 141,000 physicians in 2002 to 246,000 in 2005.

eDetailing—which can involve viewing multimedia presentations while talking with a sales representative on the phone or by video conferencing—offers several advantages, according to PharmiWeb Solutions. Aside from the obvious factor of time savings, eDetailing enables physicians to communicate with “greater depth of information than a traditional sales call” and conduct business when it’s convenient for them, either in or out of the office. According to the aforementioned Manhattan Research study, “Electronic Detailing: Trends in Adoption and Use of Web-based Applications,” the five most important characteristics physicians look for in “the ideal electronic detail” have been ranked as follows:

• Short in duration (less than 5 minutes)

• Available around-the-clock

• Contains fresh information (not the same information that was provided by the representative)

• Is interactive or a self-guided learning program

• Has an incentive attached

Major pharmaceutical companies have begun offering eDetailing programs on their websites, including a Novo Nordisk program focusing on diabetes treatment and an AstraZeneca Oncology program centered on breast cancer care. As more physicians express interest in eDetailing, services will likely become more widespread and cover a greater range of products, making life easier for both physicians and sales representatives.

MDNG eDetailing Survey

In February of 2006, MD Net Guide surveyed our physicians on their use of eDetailing.

Have you ever participated in an eDetail?

No — 59%

Yes — 41%

If you have never participated in an eDetail, what is your main reason for not doing so?

Never had the chance — 52%

Would rather talk to a live rep — 12%

Others — 35%

Which eDetail format do/would you prefer?

Archived eDetail on Internet — 53%

No preference — 24%

CD-ROM/DVD — 17%

Live eDetail — 4%

What is the optimum duration of an eDetail program?

4-6 minutes — 42%

7-10 minutes — 31%

1-3 minutes — 17%

11-15 minutes — 6%

16+ minutes — 3%

Evidence-Based Medicine on the InternetAccessing the Latest Clinical Data & Applying It in Practice

With literally hundreds of journals now available on the Internet, along with countless other sites offering expert opinions and analysis on treatments for every condition known to medical science, it can be slightly overwhelming for the tech-savvy physician who seeks information on evidence-based medicine (EBM), defined as “the integration of best research evidence with clinical expertise and patient values.” But fear not; in this section, we’ll provide you with a guide to the top Internet sites dedicated to EBM, a concept that integrates three key elements—research evidence, clinical expertise, and patient values—to “form a diagnostic and therapeutic alliance” between physicians and patients that “optimizes clinical outcomes and quality of life."

This growing movement entails using “the best evidence available in our medical decision making,” drawing data from “clinical trials of sufficient rigor and statistical power that enable extrapolation of results with confidence to our patients.” Below, we feature websites, centers, tools, tutorials, and handheld software programs that effectively cover all things EBM.

Websites

Evidence-Based Clinical Prevention

Using evidence-based recommendations from the Canadian Task Force on Preventive Health Care, this site covers a wide variety of preventive health interventions.

HealthWeb: Evidence-Based Health Care

This site features links to associations, databases, discussion groups, journals, electronic texts, practice guidelines, and tools and tutorials that offer information about EBM.

Netting the Evidence

Along with an extensive Virtual Library, this site features links to systematic reviews, information on controlled trials, research methods, information on EBM implementation, and information on various types of software.

Resources for Practicing Evidence-Based Medicine

At this site, find links explaining what EBM is, how to critically appraise medical literature, statistics and trial designs for clinicians, how to understand systemic reviews, and EBM in critical care.

Centers

Evidence-Based Practice Evidence Reports

Check out this site to read reports and technology assessments developed by the Agency for Healthcare Research and Quality that are “based on rigorous, comprehensive syntheses and analyses of the scientific literature on topics relevant to clinical, social science/behavioral, economic, and other health care organization and delivery issues.” Choose from more than a dozen reports.

Centre for Evidence-Based Medicine

Here, visitors can learn about the practice of EBM, how it improves outcomes for patients, and what are its limitations; read about the five steps of practicing EBM; access tips on teaching EBM; and view a glossary of terms.

Tools & TutorialsEvidence-Based Medicine Subject Guide

Evidence-Based Medicine Toolkit

Introduction to Evidence-Based Medicine

University of Massachusetts Medical School, Lamar Soutter Library Evidence-Based Medicine

PDA ProgramsClinical Evidence for PDA

Evidence-Based Diagnosis

Evidence-Based Medicine Guidelines

EHR/EMRs

Going from the Exception to the Rule

Nearly every day brings another news story involving EHRs or electronic medical records (EMRs), whether it’s a bill proposed, new standards set, or another major organization endorsing or adopting the technology. In the last two weeks of May alone, the following were announced:

• On May 24, the House Ways and Means Subcommittee on Health approved a bill (HR 4157) that would promote the use of health care IT and establish national standards on privacy and implementation of EHRs. The bill “would codify the Office of the National Coordinator for Health IT within HHS and would establish a committee to make recommendations on national standards for medical data storage and develop a permanent structure to govern national interoperability standards.”

• The Maryland/DC Collaborative for Healthcare Information Technology announced plans to develop an electronic network that would link physicians and hospitals in Maryland and Washington, DC as part of an effort to reduce medical errors and improve access to patient data.

• Nearly 500,000 patients in Texas are participating in Indigent Care Collaboration’s I-Care database of medical records. The system is used to track patients without insurance to help manage their health.

• Arizona’s Banner Estrella Medical Center uses no manual charting and has adopted an EMR and CPOE system that every practicing physician must use.

• Several major healthcare foundations in California are collaborating to fund a $4.5 million, three-year program to encourage adoption of EHRs in the state’s community clinics and health centers.

• The CDC has selected a team of Utah investigators to use the computerized medical records and alert systems at University Health Care, Intermountain Healthcare, and the VA Salt Lake City Health Care System to improve methods to detect and prevent hospital infections.

• New York City officials unveiled plans for an EHR system to be installed in 150 city health centers.

Another recent development that can potentially have an enormous effect on the adoption of EHR/EMRs was the completion of work by the Certification Commission for Health Information Technology on its initial criteria and processes to certify ambulatory care EMR systems. This certification is “designed to level the playing field for physicians, enabling them to select an electronic records system from vendors who have demonstrated their product meets certain criteria for functionality, interoperability, and ensuring the privacy and security of data." So far, more than two dozen companies have applied to have their software certified, and it’s likely that many will follow.

Q&A With Dr. Reed Gelzer

Reed Gelzer, MD, MPH, CHCC, is co-founder of the non-profit organization Advocates for Documentation Integrity and Compliance, and will be serving for the next two years on the Ambulatory Function Work Group for the Certification Commission for Health Information Technology.

How did you first become familiar with CCHIT’s work?

I’ve been following the standards process for several years now, starting particularly with HL7, then watched as the dynamics brought forth an entity that would essentially act in advance of the finalization of HL7 standards, which CCHIT came to serve. It was originally established partly to give payers some means of discriminating between products for use and pay-for-performance programs. I watched it from its birth because of my interest in the entire standards.

What affect do you think the publishing of CCHIT certification criteria will have on EHR/EMR adoption?

I think it will help a great deal to establish the principle that, first of all, functional standards should be applied to these tools, and second, it will tend to help focus a broad discussion that’s been held in a number of different places. It will help focus that simply because now there is a designated entity that’s been charged by HHS to expedite that process...I think essentially what CCHIT has brought to the overall discussion is a fairly well-defined scope for the discussion that’s clearly solvable in an incremental way.

Do you agree with some experts who say that CCHIT standards are so valuable not because they are the final answer, but because they are a huge step in the right direction?

I think that’s an excellent way to look at it; it’s just a step in a process. The initial functional standards are exactly that. Everyone including CCHIT understands that they’re not sufficient standards to meet all needs for all domains.

What do you think of the critics who say that flaws exist in the CCHIT standards?

I encourage people to ask questions because it is intended to be an evolving process. I’m not 100% comfortable with where it stands right now either, so it’s no surprise to me that a lot of people have questions about how this whole thing is going to move forward.

Do some of the problems stem from the standards being so new, and therefore, involving a learning curve?

Yes, and also because there are an awful lot of people who have very strong vested interest that the process goes in a particular way. We shouldn’t be surprised that people speak to their interests; that’s exactly what CCHIT was intended to also be: a forum for major stakeholders to put their interests on the table in a transparent discussion.

With this criteria now established, do you think that the adoption of EHR/EMRs will continue to move forward?

Yes. I think that it’s proceeding from a small base, and I think caution is very rational and due diligence is very much required, but I think that it is definitely on the way up. I think that what I’m seeing that’s most encouraging is people coming forward with practical experience and presenting at trade shows like TEPR with actual documented, measured experience. That’s what’s really going to help others learn about EHRs and EMRs.