Like robins and cherry blossoms, Surescripts’ annual National Progress Report on ePrescribing has been a harbinger of spring. We’ve eagerly awaited warmer weather and the data release. However, neither has been easy to find. Surprisingly, the 2012 Surescripts report recently was posted without fanfare on the Surescripts website.
This years’ report is a slim volume with a sleek chartbook look and virtually no analyses. Surescripts combined its annual spring ePrescribing statistics with its Safe-Rx award data (mostly on states), which generally have been released in the fall. Having the two data sets together provides a more complete picture of the industry’s status. The following analysis focuses on key data points and opportunities for improvement.
ePrescribing.
In general and as expected, the report showed how ePrescribing is maturing: the gross numbers are ratcheting up as are the percentage increases (with a few exceptions), but there is still work to be done. Here are some interesting elements:
- More than 380,000 (69 percent) office-based physicians were ePrescribing in 2012. According to the Rogers adoption/innovation curve, that means half of the majority of late adopters into the ePrescribing fold. The laggards – the very last group of adopters on the curve – are yet to go, and some may never ePrescribe. For example, some older physicians avoid ePrescribing because they plan to retire in the near future and will not buy ePrescribing technology. That may be a bigger cohort than immediately meets the eye. About 42 percent of the nation’s 1 million physicians are older than 55 and 21 percent are older than 65, according to the American Medical Association. There also may be cultural issues among the laggards. Even with the penalties for nonadoption, some physicians will be willing to take the hit and have their Medicare payments reduced rather than implement an EHR system. Some laggards also may hold back until they can be absorbed by an integrated delivery system, rendering their ePrescribing problem moot.
- Forty-four percent of prescriptions (788 million) were routed electronically in 2012, up from 36 percent at the end of 2011. The 2012 number might be a little low as it just counts Surescripts data and does not take into account ePrescriptions that flow through other intermediaries bypassing Surescripts or closed systems like Kaiser or the VA. Also, in reading the fine print, the calculation entails the entire year of prescriptions divided by the entire year of ePrescriptions, which is not reflective of the trend, which is likely closer to 54 percent.
- Nearly half of patient visits (48 percent) resulted in electronically generated medication history requests while a third made use of electronically accessed benefits information. These numbers may be lagging because providers are still concerned about gaps and inaccuracies, which serve as barriers to use.
- Electronic prescription renewals dropped in 2012 to 82 million from the peak of 96 million in 2011. This is an interesting but troubling statistic that bears further analysis. A possible explanation for this significant drop is that, because of workflow integration issues, physicians are turning off these features and doing the minimum electronically. Furthermore, faxes and paper are still an entrenched part of the renewal process – in part due to ePrescribing workflow integration issues in both physician offices and pharmacies. Moreover, physicians neither want to incur nor sort out duplicates, so they go with what they know: paper. The most potentially troubling reason may be an artifact of government incentive programs. As the penalty phases began to loom, physicians may have implemented EHRs and sent just enough prescriptions electronically in 2012 to avoid penalties to their Medicare payments. They never intended to do anything more (like electronic renewals) or use ePrescribing to its full potential.
- Pharmacy connectivity was up slightly over 2011. There were 39,600 chain pharmacies (98 percent) connected for ePrescribing routing in 2012, while 85 percent of independent pharmacies (19,200) accepted ePrescriptions. Recent federal efforts to expand broadband connectivity in rural areas will help bring the remaining independents along, though independent pharmacies may perceive the costs as prohibitive. Specialty pharmacy data are rarely included in the totals because few are able accept ePrescriptions. Getting them wired is the next frontier for vendors and policymakers alike. This is important because specialty drug spending has grown by double-digit rates over the past six years and increased by 18.4 percent in 2012. This growth represents just the spending associated with the pharmacy benefit; approximately half (47 percent) of the specialty drug spend is billed through the medical benefit. Experts estimate that specialty drug outlays will go from $290 per-member per-year (PMPY) in 2012 up to $845 PMPY by 2018. That adds up to big money very quickly.
State rankings.
The report also presented the annual state rankings. Delaware led the pack in 2012 for the first time, although it traditionally has ranked near the top. It was followed by Minnesota, Ohio, New Hampshire, Massachusetts, North Carolina, Vermont, Missouri, Maine and South Dakota. Ohio jumped to third, up from 12th in 2011, and Missouri surged from 17th to eighth. Stalwarts Connecticut, Pennsylvania and Michigan dropped out of the top 10. Rhode Island dropped to the middle after being close to the top for many years.
According to the report, the rankings “recognize the full utilization of [ePrescribing] based on volume and use of all three [ePrescribing] services: Prescription Benefit, Medication History, and Prescription Routing” in the Surescripts network. With the use of this methodology, a larger state with a higher percentage of electronic prescriptions could rank lower than a smaller state with fewer electronic prescriptions, depending on its performance in other measures. That may explain why South Dakota, Maine, New Hampshire and Vermont – all with relatively small populations of patients and physicians – ended up in the top 10 in 2012. That may also explain why California dropped from 45th to 49th, despite significant differences in populations, patient visits and number of physicians.
Here’s the good news: some 24 states had more than 70 percent of physicians ePrescribing; a handful even exceeded 90 percent. No state had physician ePrescribing adoption below 40 percent.
Moving the adoption needle forward.
The Surescripts reportmade no recommendations this year about moving the adoption needle forward and ePrescription volume upward, but here are a few things that must happen to ensure future progress:
- More needs to be done to make medication history available at the right time for the right patient. Medication history is still not a part of many office visits or transitions of care. Because of the way billing happens in hospitals, for example, drugs for inpatients end up getting put into the medical claim, not into a separate drug claim. This makes it extremely difficult for medication reconciliation to take place. Changes are needed for these and other processes to allow broader access to medication history, which ultimately impacts the quality and costs of care.
- More also needs to be done to make formulary and benefit information more accurate and useful. Currently, what is presented to prescribers is representative, normalized and, well, not exact.
- Analysis is needed to find out why electronic prescription renewals dropped so much between 2011 and 2012. One reason is because the easiest way to bump up ePrescription volume is to get more refills requested and approved electronically. So, what’s behind the drop? Are there workflow and training issues that need to be addressed? Is the drop an artifact of federal policy making that may need to be revised? Another reason to analyze this drop is because of its patient safety implications: eRefills are more accurate than paper and the lack of refills can be an important indicator of patient medication noncompliance.
- Barriers surrounding the ePrescribing of controlled substances (EPCS) need to be addressed. EPCS remains at low levels, which certainly doesn’t help move the total ePrescription volume needle upward.
- The National Council for Prescription Drug Programs’ (NCPDP) electronic prior authorization (ePA) framework should be available for public use later this year. ePA is a value-added feature that makes the prescribing process more effective. The timing is right, given the major rise in specialty drug spend – much of which requires PA. ePA also helps to get the correct medication to patients without delays due to administrative hassles. This is important from cost, safety and satisfaction perspectives.
To be sure, ePrescribing is maturing but it’s far from mature. The challenge going forward will be the hard work of getting ePrescribing through the last mile of adoption. On the other hand, new markets are opening up. A recent study estimates that the global ePrescription market, which was $170 million in 2011, will expand in coming years due to strides made in the North American market.
Edited by
Rich Steeves
