Editorial: Prescription abuse

Florida‘s medical examiners recently reported that prescription medicines caused more deaths in 2008 than illicit drugs. The medical examiners also reported sharp increases in deaths caused by prescription tranquilizers and painkillers, such as Oxycodone and hydrocodone.

The results of the year-end report weren’t surprising. Since the middle of last year, physicians, pharmacists and law enforcement officials have warned of a near-epidemic of deadly prescription medicine abuse. In 2005, the Medical Examiners Commission began reporting the drugs discovered in bodies subject to autopsies. The percentage of decedents with at least one drug in their bodies has increased each year; to 53 percent last year.

“The vast majority” (4,924) of the 8,556 drug-related deaths studied last year by the state’s medical examiners involved the presence of more than one drug, according to the 2008 report. The presence of at least one prescription drug caused the death of 2,184 people last year.

To put the scale of those numbers in perspective, consider: There were 2,983 deaths on Florida’s roads last year; 1,169 of those fatalities were alcohol-related. Prescription drugs caused more deaths than alcohol-related crashes in Florida.

Of particular concern: Death-related occurrences of both benzodiazepines and oxycodone were up by more than 20 percent in 2008 compared with 2007. The drugs that caused the most deaths in Florida: oxycodone (941), benzodiazepines (929), methadone (693), cocaine (648), alcohol (489), morphine (300), hydrocodone (270).

This year, the Legislature finally passed a law that calls for creating an electronic database to monitor the prescription and sale of certain painkillers and tranquilizers. The database should help investigators track the worst offenders once it is operational next year, but even proponents of the law concede it was watered down.

Other initiatives are likely to be necessary because the personal and societal problems associated with the misuse of prescription drugs aren’t getting better.

E-prescribing gains traction in Michigan

He gave up the paper pad four years ago and now only writes prescriptions for patients electronically.

While Dr. Richard Smith can’t specifically quantify the results, he knows without any doubt that e-prescribing has generated efficiencies in his medical practice.

“As you accept it in your practice, it’s a phenomenal tool,” said Smith, an obstetrician with the Henry Ford Medical Group and president of the Michigan State Medical Society. Smith, who’s been in practice for nearly 30 years, is among a growing number of physicians in Michigan and nationwide who now use e-prescribing, as health care rushes to catch up with other industries in the use of information technology. A June report shows Michigan is one of the leading states in e-prescribing rates, ranking third behind Rhode Island and Massachusetts. It moved up from fifth in 2007 and three spots from two years earlier.

In 2008, doctors in Michigan ordered 9.03 percent of all prescriptions electronically – 4.2 million new prescriptions and more than 603,000 refills – more than twice that of 2007 and more than quadruple the 2006 rate, according to Surescripts, a national provider of electronic access to health information that issues the annual Safe-Rx Awards to the top 10 states. The use of e-prescribing in other leading states has grown by similar rates since 2007. The rate in Massachusetts, for instance, grew to 20.5 percent in 2008 from 13.43 percent the year before and 8.80 percent in 2006.

Advocates of e-prescribing suspect Michigan’s 2009 rate is now in the mid-teens and say it will continue to rise rapidly. “We’re on a continuum right now,” Smith said. “We’ll see more and more.” At Grand Rapids-based health plan Priority Health, the e-prescribing rate by participating doctors was 14 percent as of May, up from just 3 percent at the end of 2008, pharmacy administrator Steve Marciniak said. Despite the strong growth in Michigan’s e-prescribing rate the past two years, Health Alliance Plan’s Denice Asbell says advocates need to maintain the push to go much further.

“Nine percent leaves a lot of room for growth and improvement,” said Asbell, project manager of purchasing initiatives at HAP, a unit of Henry Ford Health System.

A 20 percent e-prescribing rate is a “realistic goal” for 2009, Asbell said. “We’ve had a significant number of physicians come on board and start using the technology just since December,” she said. “Physicians are recognizing this is the way the world is going and they have to get on board. Patients are expecting it now.”

Helping to drive the rate higher is a 2 percent incentive payment for 2009 that doctors can receive from the federal Center for Medicare and Medicaid Services for e-prescribing when writing prescriptions for Medicaid and Medicare recipients.

In Michigan, Surescripts credits the February 2005 formation of the Southeast Michigan e-prescribing Initiative, or SEMI, with the growing adoption of e-prescribing technology by physicians. The group consists of representatives from Ford Motor Co., Chrysler and General Motors, Blue Cross Blue Shield of Michigan, Health Alliance Plan, the Henry Ford Medical Group, Medco Health Solutions and CVS Caremark Corp.

E-prescribing advocates cite its ability to improve the operating efficiency of physician practices and reduce potentially dangerous drug interactions in patients.

Since 2005, the use of e-prescribing in Southeast Michigan has generated a 24 percent reduction in the incidence of adverse drug reactions, according to SEMI.

Between 2005 and 2008, some 2.75 million prescriptions for patients were changed or canceled because the electronic network alerted participating doctors to a potential drug-to-drug adverse reaction, according to a SEMI analysis of 9.5 million prescriptions that were ordered electronically.

Doctors changed or canceled another 260,000 prescriptions because a drug allergy warning. A HAP survey of physicians found 77 percent agree that e-prescribing improves patient safety. Physicians also cited a reduction in staff time for handling prescription renewals, reduced pharmacy call backs and faster patient transactions at the pharmacy. The 500,000-member HAP estimates the collective administrative savings for Henry Ford Medical Group physicians at $560,000 annually. Another $540,00 a year is saved by reduced ER visits and hospital admissions resulting from prevented adverse reactions.

Governors Announce State Rankings for E-Prescribing

Massachusetts Prescribers Now Route More Than 20 Percent of Prescriptions Electronically, Followed by Rhode Island at 17 Percent

Tennessee Gov. Phil Bredesen and Vermont Gov. Jim Douglas Accept Safe-Rx™ Award, Highlighting States’ Improved Use of E-Prescribing

WASHINGTON, – At an event at the National Press Club, Surescripts announced today that Massachusetts ranks first in the nation when it comes to routing prescriptions electronically. According to the results of an annual nationwide audit of electronic prescriptions routed in 2008, it was determined that prescribers in the Bay State sent more than 6.7 million prescriptions electronically, representing 20.5 percent of all eligible prescriptions in the state – as compared to 2.3 percent in 2005. For this accomplishment, Massachusetts was recognized, along with 14 other states, at the fourth annual Safe-Rx Awards.

Surescripts created the Safe-Rx Awards to raise awareness of e-prescribing as a means of enhancing patient safety by providing a more secure, accurate and informed prescribing process.

“Congratulations to all the Safe-Rx Award winners for increasing the use of e-prescribing and for the benefit it has brought to the economy, safety and quality of patient care in communities throughout their states,” said Harry Totonis, president and CEO of Surescripts. “And as much as this program is about measuring and recognizing real success, its greater purpose is to highlight the leaders who are driving that success and the stories of how they are doing it. As the numbers and rankings suggest, each year there are more and more examples of how a state and the various stakeholders within the state can work together to drive e-prescribing adoption and use. We congratulate those leaders and hope that their examples will inspire and inform many more successful efforts in many more states in the year ahead.”

“The Massachusetts model should serve as a roadmap for the rest of the nation,” said U.S. Sen. John Kerry (D-Mass.). “Electronic prescribing saves money, improves efficiency and, most importantly, reduces life or death medical errors. While we debate how to reform our healthcare system, improve quality and lower costs, one of our top priorities should include modernizing the way physicians write prescriptions.”

In its first three years, the Safe-Rx Award was given annually by Surescripts to the top 10 e-prescribing states in the nation. In an effort to measure and recognize critical progress occurring outside states that finished in the top 10, Surescripts has introduced a new category of state rankings: the Top 5 Most Improved (see both lists for 2008 below).

Top 10 E-Prescribing States Top 5 Most Improved States

1. Massachusetts 1. Vermont 2. Rhode Island 2. Tennessee 3. Michigan 3. Kansas 4. Nevada 4. Illinois 5. Delaware 5. Missouri 6. North Carolina 7. Pennsylvania* 8. Connecticut 9. Maine* 10. Arizona *New to the top 10

Today’s event featured Tennessee Gov. Phil Bredesen and Vermont Gov. Jim Douglas, co-chairs of the State Alliance for e-Health and co-hosts of the Fourth Annual Safe-Rx Awards. The State Alliance was created by the National Governors Association Center for Best Practices in January 2007 to improve the nation’s healthcare system by forming a collaborative body that enables states to increase the efficiency and effectiveness of the health information technology initiatives they develop. The State Alliance has recognized the potential for e-prescribing to improve both patient safety and the health of all Americans and has encouraged states to be proactive in creating and implementing policies that advance this and other e-health initiatives. Govs. Bredesen and Douglas were also on hand to receive Safe-Rx Awards recognizing their states’ sizable jumps in e-prescribing use.

“The State Alliance recognized early on that encouraging states to make e-prescribing a top priority would have an immense value in our electronic health efforts,” said Bredesen. “Paperless prescribing is making its way into the health care mainstream in Tennessee and across the nation. It’s our hope to see e-prescribing become a natural part of every health care provider’s workflow because of its practical benefits to patients in providing better care.”

“To the State Alliance, e-prescribing is important to building momentum toward the goals of an effective health care system and improved public health,” said Vermont Governor Jim Douglas. “And I’m proud that e-prescribing has been an integral part of Vermont’s Health Information Technology strategy from the start. That’s because e-prescribing is a fundamental system improvement for ensuring accurate, timely health care communication. Much of Vermont health care reform is about utilizing the right tools to enhance our systemic approach to health care reform and the evidence regarding the value of e-prescribing is clear.”

Surescripts Announces A Meaningful Change to Future State Rankings Historically, the Safe-Rx Awards have been based on an analysis of data from new prescriptions and refill responses electronically routed over the Surescripts network. States were ranked and recognized according to the number of prescriptions routed electronically in 2008 as a percentage of the total number of prescriptions eligible for electronic routing.

In January 2010, Surescripts will release a new state ranking. Using data from 2009, the rankings will measure use of not one, but three critical steps in electronic prescribing:

1. Prescription Benefit: Electronically accessing a patient’s prescription benefit information. 2. Prescription History: With a patient’s consent, electronically accessing that patient’s prescription history from pharmacies and payers. 3. Prescription Routing: Electronically routing the patient’s prescription to their choice of pharmacy and electronically reviewing and responding to a prescription renewal request that pharmacies send to the physicians’ practices for approval.

This approach recognizes the combined role that prescription benefit, history and routing play in improving the overall safety, efficiency, cost and quality of the prescribing process. It is Surescripts’ position that measuring and reporting the actual use of all three of these services helps define ”meaningful use of electronic prescribing” under the American Recovery and Reinvestment Act of 2009.

For a full description of the change in ranking methodology, go to www.surescripts.com/Safe-Rx.

What About My State? Individuals who are interested in finding out how their state is progressing in its efforts to move to e-prescribing can go to the Safe-Rx Awards Web site at www.surescripts.com/Safe-Rx. The site shows a complete ranking of all 50 states and the District of Columbia based on prescription routing. For an in-depth statistical review of each state’s progress across a number of e-prescribing use and adoption metrics, go to the U.S. maps on either www.surescripts.com/Safe-Rx orwww.surescripts.com/stats and click on your state.

Blue Cross Blue Shield of Massachusetts Honored With Safe-Rx Evangelist Award The Safe-Rx Evangelist Award goes to a single person or organization whose leadership has made an extraordinarily positive impact on raising awareness and reducing medication errors by promoting the adoption and use of electronic prescribing. In 2008, the Safe-Rx Evangelist Award went to Health and Human Services Secretary Michael Leavitt. In 2007, the Safe-Rx Evangelist Award went to the Institute of Medicine for its breakthrough report Preventing Medication Errors.

Blue Cross Blue Shield of Massachusetts (BCBS MA) is widely known as a leader in electronic prescribing and health information technology initiatives. It was one of the very first organizations to embark on an initiative to encourage electronic prescribing with physicians because of the many patient safety, practice efficiency and cost saving benefits. BCBSMA took a very collaborative approach, bringing in multiple health plans to create the eRx Collaborative – itself a prominent advocate for e-prescribing – and ensuring that prescribers would have access to more comprehensive prescription benefit and prescription history information on their patients.

“Working together sends a message that e-prescribing is important for everyone in the community,” said Steve Fox, vice president of provider network management at BCBSMA. “As a leader in e-health initiatives and e-prescribing programs, BCBSMA will continue to focus on the delivery and promotion of technology to enable a delivery system that reliably provides safe, effective and affordable patient-centered care.”

Surescripts Salutes E-Prescribers of the Year This year, Surescripts is recognizing six prescribers for the outstanding leadership they have shown through their own use of e-prescribing. Three users of standalone e-prescribing software and three users of electronic medical record software received Safe-Rx Awards and were recognized as E-Prescribers of the Year:

Standalone E-Prescribing Users EMR Users Dr. Amando Garza (Laredo, Texas) Dr. Narinder Batra (Adrian, Mich.) Dr. Steven Green (Lancaster, Ky.) Dr. Michael Brewer (Springfield, Ill.) Dr. Abdul Kabir (Monroe, Mich.) Dr. Mark Earhart (Watkinsville, Ga.)

”More and more doctors, nurse practitioners and physician assistants are turning to e-prescribing for the safety, efficiency and quality advantages it provides them and their patients,” said Dr. Peter Basch, medical director for ambulatory clinical systems at MedStar Health. “In fact, for many clinicians, their introduction to and use of e-prescribing has helped them emerge as leaders in their communities towards the effective use of health information technology as part of everyday medical care.”

Special Health IT Report: Electronic Prescribing Increasing Despite Glitches

 Dr. Marek Durakiewicz initially welcomed the opportunity to send prescriptions to drugstores electronically, using free computer equipment provided by a state pilot program.

The chief of staff at Hickman Community Hospital in Centerville, Tenn., Durakiewicz recognized the potential benefits of “e-prescribing.” Special software allows doctors to see instantly if the drug they are ordering is covered by a patient’s health insurance plan; if there’s a less expensive, generic alternative, or if the patient is already taking medication that may interact dangerously with the new one. For patients, there’s no piece of paper to misplace.

Advocates say e-prescribing is a key advance toward health care’s digital future because of its potential to reduce medical errors, cut drug costs and save doctors and patients time and money. E-prescribing is growing – the number of doctors doing it is now more than 120,000, 20 percent of all office-based prescribers, according to an industry source. But kinks need to be worked out to spur more rapid acceptance.

Doctors and patients in a number of states have complaints, including Durakiewicz. Malfunctioning hardware and cumbersome security features — such as software that logged him out automatically every 30 minutes — left him frustrated. Patient prescription histories provided by the system weren’t as current as he had expected. In addition, federal restrictions prevented him from e-prescribing certain pain medications.

Now, a year later, he doesn’t use the pilot system at all. Instead, he types prescriptions into another computer and prints them out. “It’s faster,” said Durakiewicz, one of 50 doctors participating in the pilot offered by the state’s Medicaid program and the technology company Shared Health.

Emily Bagley, product development consultant with Shared Health, says electronic prescription histories should be immediately available; paper prescriptions take longer to retrieve. Log-offs, she says, result from federal regulations requiring e-prescribing software to log out doctors at regular intervals to prevent unauthorized use of systems.

There are other obstacles to e-prescribing, which helps explain why currently only about 10 percent of eligible prescriptions nationally are sent electronically. (Prescriptions for controlled substances, such as certain pain medications, aren’t eligible.) E-prescribing requires special computer equipment, which can be costly, and seamless coordination of an immense amount of data from doctors, health plans and pharmacies.

But federal money for health technology in the stimulus package and other incentives are expected to drive greater adoption of e-prescribing in coming years. Another key step occurred in 2008, when two prescription processing networks combined to form Surescripts. The e-prescribing company maintains the largest secure network through which doctors send prescriptions to patients’ pharmacies.

For the system to work, the doctor’s office must have e-prescribing software and an Internet connection; the patient’s health plan must participate, so the doctor can electronically check the patient’s drug benefit, and the patient’s pharmacy must be connected to Surescripts.

Currently, about three-quarters of U.S. retail pharmacies participate in Surescripts and support the network by paying transaction fees. Doctors generally don’t pay to send prescriptions, but they bear the costs of maintaining their computer system with periodic upgrades.

Rick Ratliff, president of the Virginia division of Surescripts, says the network, which processes 15 million prescriptions a month, is extremely reliable. However, with more than 130 different software programs certified to link with the network and many medical practices relatively new to e-prescribing, it’s inevitable that there will be problems, whether with the technology itself or with the people learning to use it, according to the company.

To encourage greater participation, Medicare, the federal health plan for the elderly, in January began giving e-prescribing doctors a bonus of 2 percent of their overall Medicare reimbursement. That incentive may be helping: Surescripts reports in the first three months of 2009 a 49 percent increase in e-prescriptions compared to the last quarter of 2008.

Tennessee — where only 3 percent of prescriptions are sent electronically – is giving grants to more than 1,800 rural doctors to help them buy or upgrade electronic prescribing and medical records systems. The state also is offering training sessions.

Other states are encouraging doctors, too, hoping to contain prescribing costs and improve care. Arkansas is one of seven states that fully link their Medicaid programs for the poor to Surescripts. After the state began heavily promoting e-prescribing in December, the number of doctors using it shot up from 225 to 665 in March.

Pilot programs in states such as Mississippi and Florida have reduced Medicaid costs, mainly by elimination of duplicate prescriptions and increased use of generic drugs.

When it works as intended, doctors and patients are enthusiastic. “I love it,” said Amber Blackwell, a working mother whose Clarksville, Tenn., pediatrician prescribes electronically. “I have an 18-month-old, so I don’t have to carry anything else to keep track of. And when I get to the pharmacy it’s ready.”

Challenges persist, especially at small practices that lack in-house technical support. Cumberland Family Care, a three-office doctor group in Sparta, Tenn., obtained a state grant for e-prescribing software. But the system hasn’t always worked well. “We send about 150 to 200 electronic prescriptions a day,” said Mischelle Ferrell, the practice manager. The failure rate is now about 20 percent.

When that happens, patients arriving at their drugstores may find no record of their prescriptions. “There’s a mother with a kid with a fever at the pharmacy who drove 15 miles and waited in line, and they have no record of the prescription,” Ferrell said. “You’ve got one mad mother on your hands.”

“There will be problems,” conceded Melissa Hargiss, director of Tennessee’s Office of E-Health Initiatives. “But I would say to doctors that this is the best time for providers to start using it, while there’s grant money available to offset the costs.”

Medicare to Pay Bonuses for 'E-Prescribing'

Starting next year, doctors can earn additional money from Medicare if they use electronic prescribing systems, U.S. health officials said Monday.

The bonus program, which will continue for four years, is designed to streamline the prescription process and cut down on errors. In 2009 and 2010, Medicare will give doctors an additional 2 percent bonus on top of their fee for “e-prescribing.” In 2011 and 2012, the bonus will drop to 1 percent, and in 2013, the bonus will drop again to 0.5 percent, officials said.

“There are terrific human and financial costs to illegible prescriptions,” Mike Leavitt, secretary of the U.S. Department of Health and Human Services, said during a Monday afternoon teleconference.

According to the Institute of Medicine, 1.5 million Americans are injured every year by drug errors, Leavitt said. Another study found that each year pharmacists make more than 150 million phone calls to doctors to clarify what was written on the prescription, he added.

“That’s a lot of people needlessly hurt and a lot of time spent trying to sort out bad handwriting,” Leavitt said.

“E-prescribing will help deliver safer or more efficient care to patients,” Leavitt said. He noted that the law that set up the Medicare prescription drug program in 2006 mandated that participating pharmacies be able to accept e-prescriptions.

After five years, bonuses for e-prescribing will be phased out; doctors who haven’t adopted e-prescribing will be reimbursed at lower rates, Leavitt said. There will, however, be exceptions for doctors who have legitimate reasons for not complying.

“We expect this will have a profound effect on the adoption and use of e-prescribing,” Leavitt said.

Medicare started paying bonuses to doctors last year for using the Physician Quality Reporting Initiative, which collects data on the quality of care delivered by doctors. Medicare recently paid the first bonuses to more than 56,000 doctors, totaling more than $36 million. Payments ranged from $600 for individual doctors to $4,700 for group practices.

The new bonuses for e-prescribing will be on top of those paid as part of the Physician Quality Reporting Initiative and other Medicare reimbursements. Medicare expects to save up to $156 million over the life of the e-prescribing program in fewer adverse drug events.

Despite the advantages of e-prescribing, barriers to implementing such systems remain. One of the largest barriers is the cost.

“It is fairly costly for a small practice to begin to change over to e-prescribing,” Dr. James King, a family physician in Tennessee and president of the American Academy of Family Physicians, said during the teleconference. “These incentives will help.”

It’s estimated that it will cost about $3,000 per doctor to initiate an e-prescribing system. It also takes between $80 and $400 a month to maintain and operate a system, Kerry Weems, acting administrator of the U.S. Centers for Medicare & Medicaid Services, said during the teleconference.

Other barriers include state laws that prohibit e-prescribing across state lines, King said. And, there are areas in the country where computer systems are slow and inefficient, he said.

E-prescription boost for 1,800 hospital beds

The ePrescribing and Medicines Administration (EPMA) system will manage medicines for the more than 1,800 hospital beds at Heartlands, Solihull and Good Hope hospitals, as well as their take-out prescriptions.

The system includes access to the Multilex Drug Data File database, which allows clinicians to check how drugs will interact with each other, potential duplicate therapies and allergies that can be triggered by certain medications.

Niall Poole, electronic prescribing project manager at Birmingham’s Heart of England NHS Foundation Trust, said in a statement: “E-prescribing minimizes the risk of medication errors in many ways: from the very basic, such as producing legible prescriptions which are not subject to the difficulties and potential dangers of reading and interpreting handwriting, to the very advanced such as drug-interaction information at the point of prescribing.”

American College of Cardiology Supports E-Prescription Mandate

The American College of Cardiology is separating itself from a number of other physician groups by favoring a mandate for Medicare physicians to adopt electronic prescriptions, Modern Healthcare reports.

ACC said it supports the mandate because it has moved quicker than other physician groups in embracing e-prescribing. Many cardiologists are part of large physician practices that already have adopted the technology, Jack Lewin, CEO of ACC, said.

A Senate Medicare bill likely will include a financial penalty for physicians who do not adopt e-prescribing technology, Modern Healthcare reports.

ACC supports increased reimbursements for e-prescribing rather than cuts. In a recent letter to the Senate Finance Committee, the group urged Congress to set the e-prescribing adherence deadline for Dec. 31, 2011.

“We’ve learned from those early adopters that we’re seeing actual cost savings, in addition to improving patient safety,” Lewin said.