In this interview, eRx Network's VP of Clinical Services, Rick Sage, talks to ComputerTalk senior editor Will Lockwood about where he sees ePrescribing right now and the role companies like eRx play as adoption increases.

CT: What's the current state of ePrescribing?

Sage: We've seen continued adoption by physicians with a real ramp up toward the end of 2008 into 2009. This is due in large part to MIPPA [Medicare Improvements for Patients and Providers Act of 2008], which is offering incentives to physicians that adopt electronic prescribing, and ARRA [American Recovery & Reinvestment Act] signed into law on February 17, 2009. The health IT component of the ARRA Bill, the HITECH Act, appropriates $19.2 billion dollars to encourage the adoption of electronic health records, including ePrescribing. The Stimulus Bill should help provide most physicians with an EHR [Electronic Health Record] system at little to no cost to the physician. Health and Human Services is working through the details on this stimulus, and a key to the EHR incentives will require vendors to demonstrate "meaningful use" of EHR systems. What constitutes "meaningful use" is still being discussed, but it will get worked out.

CT: Where do pharmacies stand related to ePrescribing and the federal stimulus?

Sage: While most chain pharmacies are now live on ePrescribing, the majority of independents are not yet enabled with this technology even though many software vendors have the capabilities to support ePrescribing. Beyond subscribing, the pharmacy must pay for the software upgrades, enhanced communications, training their staffs, and transaction costs associated with these electronic prescriptions. While we have all heard about the $80 billion stimulus money for Health Information Technology, there are no current programs to pay pharmacies for any services related to their participation or performance in HIT. Clearly, pharmacies and their patients benefit from ePrescribing, but should also be eligible for federal adoption funding. This is why many in the pharmacy industry, including eRx Network, are actively communicating the need to include pharmacy in health information technology initiatives and the related stimulus incentives.

CT: What are the barriers that concern physicians?

Sage: Beyond the financial issues to purchase, implement and support ePrescribing, physicians are also concerned about the inability to e-prescribe controlled substances. The good news is that there is movement towards the legalization of controlled substance ePrescribing, and physicians are supportive of electronic prescribing. We hit one of the major milestones at the end of 2008, and that was to get to double-digit penetration with physicians. Industry estimates are that there are somewhere between 10-12% of physicians using ePrescribing. There's definitely still a long way to go, but we're gaining momentum. State and commercial-health plan sponsored education efforts and incentives are increasing and will continue to help increase adoption. We must eliminate the financial barriers to adoption as well as supporting other industry initiatives that will help eliminate these barriers, like the National ePrescribing Patient Safety Initiative, NEPSI, that offers physicians a no-cost solution to participate in ePrescribing. eRx and Emdeon support NEPSI at the member level because it provides another viable option for our 340,000 connected physicians to get started with ePrescribing.

CT: What about incentives for pharmacists?

Sage: As I mentioned earlier, this is definitely a challenge. Pharmacies, like physicians incur a cost to participate in ePrescribing. At some point, its stands to reason that physicians using subsidized solutions are going to have to support ePrescribing financially. On the pharmacy side, ePrescribing's benefits and costs have been a continuing source of concern. From the transaction standpoint, pharmacies are bearing the cost. Physicians usually pay a subscription fee for ePrescribing solutions that vendors offer, but they also have no cost solutions available. The turning point will likely be when EMR [Electronic Medical Records] systems become mainstream and even though this kind of solution carries a cost, physicians see significant benefits for the physician as well as the entire healthcare delivery system.

CT: So the no cost solutions are going to be fairly rudimentary, but to get full solutions there'll have to be a cost?

Sage: Absolutely, there's a need to provide some physicians with a steppingstone to an EMR solution. The cost for a physician practice to implement a full EMR solution is significant but many practicies have made the transition and are bearing the cost. Pharmacy understands the need to support ePrescribing as do companies such as eRx Network. Emdeon and eRx Network have worked a long time to enable our pharmacies and physicians for ePrescribing and are very excited that the recent merger of our two companies will enable us to play a key role in advancing the overall adoption of ePrescribing. For the last six or seven years, our chain customers have provided most of our ePrescribing growth. Chains are pretty much ready to take advantage of our connectivity to physicians. Our push now is to help independents understand ePrescribing and how to put it into place. We want to help address the unique barriers independent pharmacies face.

CT: What are the barriers you see independent pharmacies facing?

Sage: The pharmacy needs more of an IT presence and the technology infrastructure is going to be a little different than they currently support for claims processing. Cost is a big factor, which independents realize. True, there is a cost associated with paper prescriptions, primarily labor, but now there's a new transaction fee that does not directly correlate to the cost of time with paper prescriptions. What may not be as apparent is the potential marketplace disadvantage if doctors in the area are ePrescribing and the pharmacy is not ready. Patients may choose a pharmacy that can accept  ePrescriptions. That's, of course, a concern for both chains and independents. Bottom line, as physician adoption increases, independent pharmacies definitely want to make sure that they are able to support ePrescribing transactions.

CT: And what are some of the problems with ePrescribing that pharmacists who are using it are seeing?

Sage: The messaging format can come in different flavors and versions. Most applications support the NCPDP SCRIPT industry standard, but there are different formats and versions supported within this standard, including EDIFACT and XML. As the industry is moving and more players become involved, there are a lot of things being requested that may not be in the standard. For example, allergy information can't be transmitted in the current transaction because different formats or versions of the standard are in play between physician and pharmacy. To address this issue, eRx can upgrade or downgrade the transaction to the appropriate version of the standard for the recipient. Creating backwards compatibility will sometimes mean that information cannot be sent, since an older version won't necessarily include all the fields of a newer version, but many versions are simply adding new data options or clarifying fields. eRx and Emdeon place considerable resources and emphasis on addressing issues like this so ePrescribing can fit well within the existing pharmacy/physician technology and workflow. 

CT: Are there other times when an intermediary like eRx Network is going to be able to add value to the ePrescribing transaction?

Sage: The way we look at the connectivity and ePrescribing is very similar to the way the adjudication switching environment works. There's room for many players to offer solutions to pharmacy and to physicians, and there needs to be interoperability. We work cooperatively but we also offer competing solutions. Our customers are both pharmacies and prescribers who look for solutions that will allow them to support ePrescribing with minimal effort and minimal drain on their resources within the context of their IT. When we go to implement a solution, we obtain answers to many questions such as: What type of software do they have? How far along are they in supporting ePrescribing? And how can we best help to connect them to physicians or pharmacies in their area? We have connections to pharmacies and physicians directly, and we also have a partnership with Surescripts that allows us to use their network when it makes sense for our customers. This is where interoperability comes in, to allow transactions to flow back and forth that will improve the productivity of both pharmacists and physicians.

CT: What else are you doing with the solutions and network you've built?

Sage: With ePrescribing still in its infancy, many pharmacies have to support two workflows for refill requests: one for electronic and one that's based on calling or faxing. We've designed a solution to make a single workflow for all refill requests, which is called Intelligent Routing. With it, pharmacies send all refill requests to eRx and we determine the best route to the physician. This eliminates the need to maintain a record of the physician's electronic prescribing status at the pharmacy and allows the pharmacy to use the same workflow for all refills requests. If the physician is able to accept an electronic prescription, then we route the prescription to their prescribing application. If the physician is not yet electronically enabled, then we convert the electronic refill request into a fax and deliver it to the physician using the pharmacy's fax template. We also work with the software vendors to provide an electronic tracking of the refill request that tells the pharmacy whether it was delivered electronically or by fax. Ultimately, the medium of delivery shouldn't be a concern for pharmacists. They should be able to hit "send" and the system handles the routing logic. Pharmacy is really all about workflow, which is probably why we've seen a tremendous amount of additional transactions from pharmacies that use our Intelligent Routing solution compared to those that do not.

CT: In what other ways can pharmacists look for added value with the connectivity that comes with ePrescribing?

Sage: As the transaction flow is increasing between the physician and the pharmacy, we're gaining a gateway to provide more clinical information. For example, most physician applications have some means of checking for formulary compliance and some even check for eligibility. More and more information is becoming available, not only benefits information, but medication history as well. This enables physicians to understand what is happening with a patient outside of their practice or in emergency situations. This means that by the time a prescription is getting to the pharmacy, there's been a lot more data brought into the prescribing decision. In addition, we've seen studies that show that patients are much more likely to pick up prescriptions that their doctors have sent electronically. Essentially, we eliminate the "prescription on the refrigerator" issue. On the flip side, some pharmacies report seeing a larger return to stock issue because some of these electronically transmitted prescriptions are being filled, but not picked up. One way to combat this issue is for the pharmacy to place pickup reminder phone calls. Even with the issue of some prescriptions not being picked up, the benefits of ePrescribing far outweigh the limited issues.

In some cases, the ePrescribing transaction also includes patient eligibility information. This can be a great time saver for pharmacies and patients because prescriptions that were previously set aside due to lack of billing information can be filled and ready when the patient arrives. eRx provides a service to check if eligibility information has been included in the  ePrescription and, if not, eRx will perform an eligibility check and provide this information to the pharmacy with the prescription.

CT: How are you doing this?

Sage: We have a service flag that we can turn on or off for both the physician and the pharmacy. Once that check is flagged on, there's a section within the message that holds the eligibility information. If this section is complete, then we know the physician did the check and is transmitting the information. If it isn't, then we send an eligibility check for the patient, and include this information on the ePrescription going to the pharmacy. We call this real-time service eRx CardFinder. The prescription coming through has enough information for us to go out, find a patient match, and see if they have commercial or Medicare coverage. Even if the patient is already in a pharmacy's database, this service is great to validate coverage. If it's a new patient, they'll have enough information to adjudicate the prescription and then collect other details for the profile when the patient visits the pharmacy. It is a great service to make sure that the prescription will be ready when the patient arrives at their pharmacy.

CT: Thanks for your thoughts, Rick. Anything you want to say to wrap up?

Sage: The important thing to remember about ePrescribing is that it doesn't replace the need for a pharmacist to check for interactions and allergies and the need to make sure that the prescription is accurate. All ePrescribing is doing is delivering information more efficiently. The information delivered is based on selections made at the physician's office. These applications are adding more validation checks and improving options constantly to ensure timely, accurate and helpful information between the physician and pharmacist. As ePrescribing applications begin connecting to HIE [Health Information Exchanges] and other central points of medication and medical information, these applications will be able to offer better decision support that checks for interactions, suitability of the prescription for the patient, etc. Just remember, none of this technology is a replacement for the pharmacist counseling and quality checks performed with each pharmacy.

What's exciting about automation in pharmacy is that we are getting closer everyday to allowing pharmacists do what they are trained to do, which is to perform clinical services for their patients. There's less and less need to do the manual data entry and count and pour. This is increasingly automated and is more and more systematic. The pharmacist is getting more time to spend with the patient with important clinical tasks, such as counseling and medication therapy management.

Also, it is critical to keep in mind the big push from the current administration to make sure that healthcare is automated and that healthcare providers have the best information they can to deliver care to patients. We believe pharmacy is going to be a key component in electronic health records, patient health records, and supporting portals for being able to deliver that information as well.