Comparing e-Prescribing in the United States with Australia’s Model ––>
Do you realize that it’s been nearly 10 years since the Centers for Medicare and Medicaid Services (CMS) published the initial “foundation” standards for electronic prescribing (eRx)? The standards were effective Jan. 1, 2006. You may recall that eRx was included in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. The law also included some other programs very important to your patients: Medicare Part D prescription drug coverage and medication therapy management services. MMA also required testing of the standards for eRx. Pilot tests were conducted and additional standards were adopted, with the final eRx rule being published in January of 2009. At the time, use of eRx was not required, but MMA required the use of endorsed standards for any Medicare Part D prescriptions that were to be sent electronically.
Today, a top-down approach is still the primary driver of eRx. The meaningful use program, found in the American Recovery and Reinvestment Act (ARRA) of 2009, includes minimum requirements for electronic prescriptions sent by eligible providers and hospitals. If you are not familiar with the meaningful use program, you can read more about it here: http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives or you can read our column in the January/February 2015 issue of ComputerTalk. As the meaningful use program marches forward, requirements for the use of eRx grow. We wonder, however, are your patients’ voices growing in support of eRx? Are your patients creating a bottom-up demand for eRx? As patients, we appreciate the convenience of not dealing with paper prescriptions. We also recognize that you face challenges with eRx, such as the patient arriving before the prescription or before it is ready, prescriptions that are filled upon receipt but that the patient actually wants on hold, transmission errors, selection of the drug, wrong dose, route, etc., and a host of other problems that you (unfortunately) experience on a regular basis.
Despite the technical, financial, and “human” challenges to eRx, over 90% of community pharmacies are connected to Surescripts’ e-prescribing network, and more than 70% of office-based physicians have e-prescribed. One area that was hindering growth was e-prescribing of controlled substances. You likely know that all schedules can now be sent electronically, per federal law. However, the additional requirements both for prescribers and technology vendors to meet the DEA’s interim final rule are proving quite challenging to really seeing a large volume of Schedule II medications sent via eRx. Additional barriers include potentially conflicting state laws and general confusion. Despite the challenges and previous hiccups, we anticipate that eRx will become the norm, not the exception, in the near future.
Safety, efficiency, and connectivity: shared drivers for electronic prescribing in the United States and Australia. Expectations of decreased costs and increased collaboration among providers are additional important drivers for eRx. The approaches to development and payment for eRx services are quite different.
But how do we compare to other countries? Well, it’s extremely difficult, if not impossible, to directly compare the United States to other countries due to differences in healthcare structure and financing, as well as our approach to regulation. However, there are some similarities with Australia that do allow us to make some interesting comparisons. If you want to go straight to the source for some of the information we present below about Australia, go here: http://www.erx.com.au.
The Australian Model
While the United States and Australia are similar in total landmass, Australia’s population is roughly 15% of that of the United States. Based on what you know about Australia’s interior being desert or desert-like (i.e., the “outback”), you may have expected this difference. Currently, 72% of Australian doctors and 87% of pharmacies use eRx Script Exchange (Australia’s electronic prescribing system). While these percentages represent smaller raw numbers of users, these numbers are very similar to rates in the U.S. The difference in raw numbers is exemplified by the number of eRx’s sent: 782 million total in Australia so far compared to six billion annually in the United States.
The approach to launching eRx was quite different in the two countries. In Australia, the government worked with Fred IT (Australia’s largest IT services provider to pharmacy) to develop the service. In the United States, NCPA and NACDS created Surescripts, due to recognition that eRx was coming and that pharmacy needed to be a leader in the effort. Surescripts is not the only eRx network in the United States and it does not set policy, but it is arguably the major player and has been a leader, working in conjunction with private and public groups (e.g., government) to advance and expand the service.
Because the two countries’ approaches to developing eRx were different, Australia was much quicker to launch than the United States. Fred IT began the process to develop eRx Script Exchange in 2008 and launched the service in 2009. In the United States, Surescripts was founded in 2001, MMA included eRx for Part D patients in 2003, and eRx was legalized nationally in 2007. Despite the slower ramp up, the United States has experienced steeper adoption rates than Australia.
The Pharmacy Guild of Australia is the primary professional association for community pharmacy. Pharmacies known as “Friendly Society Pharmacies” are notfor- profit, regulated by jurisdictional legislation, and are professionally organized in the Australian Friendly Societies Pharmacy Association. Together, the guild and the Friendly Societies Pharmacies Association purchased over 11 million eRx transactions around the time that eRx Script Exchange was launched, to provide free transactions for their members. That was 2008/2009. Today, the Australian government essentially subsidizes eRx transaction fees, which are paid to the pharmacies, who then pay the eRx Script Exchange. The money is then divided between eRx Script Exchange and the prescribing and dispensing software vendors. Clearly, this is not the financial model found in the United States.
Safety, efficiency, and connectivity: shared drivers for electronic prescribing in the United States and Australia. Expectations of decreased costs and increased collaboration among providers are additional important drivers for eRx. The approaches to development and payment for eRx services are quite different. Looking at percentages, adoption rates are fairly similar. There are certainly other metrics that would greatly inform any comparison of the two countries’ experiences — both at the provider and the patient level. For example, are users satisfied with the experience? What error rates are being observed? What has been the impact on workflow? Ultimately, we can probably each learn valuable lessons from our colleagues’ experiences. Maybe it’s time for a site visit down under.
We also continue to welcome your comments and questions. CT
Brent I. Fox, Pharm.D., Ph.D., is an associate professor and Bill G. Felkey, M.S., is professor emeritus, in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University. They can be reached at firstname.lastname@example.org and email@example.com.