ISU: Our ePrescribing pilot program offers to approximately 500 physicians throughout our five-county region a handheld device from one of two companies, AllScripts or ZixCorp, that will allow them to do electronic prescribing in their offices. The pilot is voluntary on the part of physicians and we’re looking to demonstrate the effectiveness and the value to physicians of electronic prescribing in their offices. In mid-October we targeted 1,200 to 1,300 IBC network physicians in an outreach mailing who tended to have a significant volume of prescriptions and, once a physician indicated interest, we tried to encourage the entire practice to use the same technology – either AllScripts or Zix. At this point the pilot is closed and we’re in the process of deploying the technology for the 500 physicians. We’re going to look through 2006 as the initial pilot phase and then evaluate how it’s going and move on from there.

ISU: The package includes a wireless router in the office that allows the handheld devices to work, and that hub is where the data exchange occurs. The handheld device allows the physician to write prescriptions using a process in which certain demographic information for their patients, drugs that they commonly prescribe, and things such as the patient’s preferred pharmacy are are input into the system. When a patient comes into the office, the handheld device will allow the physician to write the prescription electronically and send it to the patient’s selected pharmacy using dropdown menus. It then is available to be picked up by the patient, who doesn’t have to wait for a piece of paper because it goes to the pharmacy automatically. It eliminates handwriting errors. At the time the physician is writing the prescription, it has capability to alert the physician to drug interactions, based on other prescriptions the patient is on, and also can give them formulary information about preferred alternatives, generics, etc. We’ve heard feedback from some of the early participants that it makes the process for refilling prescriptions much easier and more accurate for the physician’s office. The data that’s made available to physicians may not simply be for IBC patients, to the extent that other insurers have their pharmacy information sent through a national clearinghouse that’s called RxHUB. Most of the major pharmacy benefit management companies have made arrangements to allow their data to be shared through RxHUB. So, it’s not a solution that is limited to IBC members, but we are piloting it only with physicians who are part of our network.

ISU: There are slight differences in the two vendors, but the basic functionality between the two is very similar. I think they actually use the same type of hardware handheld device. We thought that it was important to give physicians some choice, given how different physician offices have started down the pathway of installing electronic medical records. There are slight differences in the integration between the two. AllScripts had already done some installations in this region, and is compatible with some things that were already installed in certain physicians’ offices. We thought Zix was another good alternative: we wanted to make sure that if there was a problem with one company for an unforeseen reason – not that we anticipate one – that we had a backup company to provide support and service.

ISU: We’ve committed about $1 million to this pilot and, other than physicians having Internet access in their office, the investment in terms of hardware and software capacity is really all made by IBC. The physicians obviously have to learn how to use the system, and their office staff need to be trained. We have a group here in our e-business area that works with AllScripts and Zix to do that training.

ISU: We decided to do it as a pilot for several reasons. First of all, when President Bush of made the initial challenge to try to move towards electronic medical records and full implementation of health information technology, we saw the ePrescribing area as one that, while being defined in scope, was potentially very useful to physicians, patients and us as a way to begin to move in that direction. In fact, our ePrescribing pilot is being done in partnership with the Pennsylvania e-Health Initiative and we have shared information about this pilot with that collaborative. We think that before this gets disseminated more widely, we need to understand exactly how to do these implementations, to learn from a more limited scope, and to get it right before we do it on a broader basis. If there are going to be issues with implementation, with physicians incorporating this into the work flow in their offices, we think that it is better learned on a limited basis with the 500 physicians than putting it out to thousands and thousands. We don’t know until we go through the pilot what volume of support issues physicians are going to need. We wanted to move forward deliberately, but in a way that we could be responsive to physicians as we roll this out.

ISU: We certainly would consider other ways. We don’t have any specific incentives in mind right now. As part of our primary care quality incentive payment program to primary care physicians we do have an evaluation of their generic prescribing rates. We think that appropriate generic prescribing is a good thing and, to the extent that they are doing that appropriately, that is a component where they can be rewarded for it. We believe that the electronic prescribing platform will help physicians in appropriate prescribing practices. If through this pilot program we encounter issues and/or barriers to physicians adopting electronic prescribing, then we would use that information to tailor future initiatives – incentives or otherwise – to encourage the adoption of electronic prescribing. If you look at the larger area of electronic medical records and technology in physicians offices, I think it’s fairly well-recognized that simply providing the technology may not be enough to get physicians to use the technology. That’s the other reason why we think the pilot is important, because we’re providing the technology but we don’t know if there will be other issues that are important factors in a successful deployment. I think the largest barrier is the fact that the work flow in a physician’s office needs to change. Using an electronic handheld device is different from writing on a piece of paper. It requires a transition. Our sense is, from some of the earlier users, that once they get accustomed to that change, they find it a better way to write the prescriptions, but it does require a change.

ISU: I’m not sure I know the answer to that. This is not a proprietary solution that is only useful for IBC members, so we believe that this solution can be used more broadly. It requires standardization of data coming through RxHUB, but that is the predominant clearinghouse vehicle to-date so I don’t see that as insurmountable. Both of these companies are willing to migrate the way this platform operates on a stand-alone basis with full electronic medical record capability in physician offices. So, we donsee a problem down the road of a physician’s office starting with the ePrescribing pilot and then saying they want to have ePrescribing be part of a broader electronic medical record solution. There are some offices that were very interested in this pilot, but said they were beginning to launch an electronic medical record initiative within their practices and they didn’t want to do both at the same time. We think that this approach is entirely compatible with a large electronic medical record deployment in an office and we can work with those offices, moving forward.

ISU: One purpose of the many ePrescribing pilots underway throughout the U.S. is to flesh out data on the impact of ePrescribing. There is some data out there. The Journal of Managed Care Pharmacy reported in 2001 that one group in Boston saw a 55 percent decrease in prescription errors with ePrescribing. The Journal also reported on a 15-physician practice in Indiana that saved 4.5 FTEs after six months on an ePrescribing program due to the decrease in phone calls for renewals and clarifications, and the associated decrease in chart pulls for further information. A Rand study published in 2005 said that ePrescribing systems have the potential to reduce medication errors by decreasing the incidence of adverse drug events due to allergies and drug-drug interactions. What we’re hoping that the pilot demonstrates is that ePrescribing is more efficient for the physician’s office, that it is easier for the patient, that it improves safety by reducing medication prescribing errors, and that it improves the cost-effectiveness of prescribing and hence the affordability of pharmacy coverage to members by reminding physicians of generic alternatives and preferred drugs on the formulary list.

ISU: We would like to see that it has a high level of acceptance by physicians, that it’s viewed favorably in terms of being a more efficient approach to prescribing, that we have data to show improved safety and improved cost-effective prescribing habits, and that patients also find it beneficial. We have some anecdotal information along those lines already from some offices that have already started.

ISU: We don’t have that completely structured now. We will be doing that towards the end of the pilot program.

ISU: No, we have not set specific targets. We certainly have expectations about the improvements that we could see, but that’s why we’re doing this pilot. A one percent change in generic prescribing, for example, would be a very significant improvement that, if done on a network-wide basis would have substantial cost savings associated with it. And if there are substantial cost savings, that can be one reason to move forward with broader implementation. There are also tiered pharmacy benefit incentives in product design that have lower co-pays on generics and higher co-pays on brands, and that’s also going to presumably create an incentive for people to try generics. It may be that the technology makes it a lot easier for the physician to respond to a member’s questions like, "Doctor, I’d like to get a generic or formulary drug so that my out-of-pocket costs are less." If we start the pilot with 40 percent of people in a tiered benefit and we end the pilot with 60 percent of people in tiered benefit, that’s something we need to factor into our evaluation of the pilot. But we’re not only doing this to save money. This is an initiative to improve safety and to give physicians a tool that will help their offices be more efficient in prescription management. We need to evaluate all aspects of the program in that regard before we move beyond the pilot.