Barriers to Provider Adoption of eRxBarriers to Provider Adoption of eRxLessons Learned from the NEO CMS eRx Pilot

AHRQ National Meeting, BethesdaSeptember 8th, 2008

Bob Elson, MD, MS (MetroHealth)John Kralewski, PhD (U MN)Dave Gans, MSHA, FACMPE (MGMA)

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NEO eRx Project ParticipantsNEO eRx Project Participants

UH Medical Practices + Ohio KePRO

MGMA Center for Research

Univ. of Minnesota Division of HSR

InstantDx (OnCallData™)

RxHub, SureScripts, NDC

Aetna, Anthem, Medical Mutual of Ohio

Partners (Bates / Seger)

… and CMS, AHRQ, and the other pilots

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NEO eRx OverviewNEO eRx Overview

eRx adoption, including “incumbent” transactions– Eligibility, Med Hx, NEWRX

Impact on workflow

Transaction interventions– Medication Hx, Fill Notification, Prior Auth

Impact on safety and utilization

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Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

NEO eRX PROJECT TIMELINE 2006

RxFILL

Training

Prior Auth

Training

Med Hx (new)

Training

270/271SCRIPT

FormularyMed Hx

SiteVisits

Planning, Tool DevelopmentPractice Recruitment, IRB

Health Plan Data Acquisition / Analysis

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Provider Adoption of eRxProvider Adoption of eRx

Practice vs. provider adoption

Workflow realities

Role of practice culture

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UH Medical Practices (UHMP)

285 physicians, 73 practices, 42 communities46 primary care; 27 specialty1.25 million office visits / yr

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Small Practice Adoption: Magic MixSmall Practice Adoption: Magic Mix

eRx offered free to all UHMP practices

Out-of-the-box integration w/ practice management system

Minimal equipment requirements

ASP delivery; robust remote training and support

Each practice allowed to determine optimal workflow

Malpractice subsidy if met threshold utilization criteria

You can lead a horse to water…

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0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Pre-Project eRx Adoption (All of UHMP)Pre-Project eRx Adoption (All of UHMP)

Total e-Rx / mo, 1/05 -> 1/06

AND make it drink (voluntarily) … !

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Pre-Project eRx Adoption (by Practice)Pre-Project eRx Adoption (by Practice)

UHMP Primary Care, Jan -> August ‘05

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eRx (Study) and Control PracticeseRx (Study) and Control Practices

Study (eRx) group (n=25 practices, 130 physicians)

Part of University Hospital Medical Practices (UHMP)– Community-based, primary care practices in Northeast Ohio

Access to OnCallData™ e-prescribing software

At least one doctor in the practice generated a minimum of 150 eRx in any month of 2006 prior to enrollment

Control group (n=22 practices, 77 physicians)

Independent primary care practices in NEO– Not currently e-prescribing

Convenience sample – Practices w/ Ohio KePRO relationship under 8th SOW

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eRx and Control PracticeseRx and Control Practices

1210

3

14

6

2

0

6

12

18

eRx Control

Small (1-3 docs)

Med (4-8 docs)

Large (9+ docs)

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14

6

108

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0

6

12

18

eRx Control

Fam Med

Int Med

Peds

eRx and Control Groups:

25 UHMP practices with access to eRx (130 MDs)

22 non eRx practices (100 MDs)

Loosely matched by size and specialty (separately)

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e-Prescribing @ 25 Practices (2006)e-Prescribing @ 25 Practices (2006)

MonthAll UHMP

eRxStudy Group

eRx % of Total

January 32,153 21,095 65.6

February 31,723 21,304 67.2

March 40,079 26,549 66.2

April 35,680 23,406 65.6

May 42,646 27,497 64.5

June 40,451 26,588 65.7

July 37,795 24,349 64.4

August 43,560 27,977 64.2

September 42,228 27,660 65.5

October 47,998 31,402 65.4

November 46,440 30,343 65.3

December 44,674 29,131 65.2

TOTAL 485,427 317,301 65.4

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eRx / prescriber / mo (10/06 by practice)eRx / prescriber / mo (10/06 by practice)

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100

200

300

400

500

600

700

800

pppppp

p = pediatric practice# at top of each bar = number of physicians in that practice

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4 6 6

53

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61 2 13 9 5 3 1 11 5 9 6

4 2 8 7 8

25 UHMP primary care practices130 physicians

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Provider Adoption of eRxProvider Adoption of eRx

Practice vs. provider adoption

Workflow realities

Role of practice culture

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Surrogate-Based e-PrescribingSurrogate-Based e-Prescribing

48,013 eRx in October (all UHMP)– 16,715 entered directly by MD

• 15,724 NewRx (~1000 Renew)

– 97 / 219 e-prescribers did at least some data entry themselves • 122 did none

38%

62%

18%

82%

43%

57%

0%

20%

40%

60%

80%

100%

Fam Med Int Med Peds

Physician Other

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Renewal Workflow FindingsRenewal Workflow Findings eRx decreases dependence on phone / fax

– Incoming Rx renewal requests from local pharmaciesreceived by:

eRx practices still depend on paper for internal processing– For phoned-in requests, 81% communicated to MD by paper

• Only 7% entered into OnCallData™ on the front end

– For faxed requests, fax itself used for internal communication 91%

73% sent back to pharmacy via eRx – only 33% come in by eRx, but most entered into OCD on back end

– 25% of authorizations called or faxed to pharmacy vs. 90% in control

eRx Control

Phone 41% 62%

Fax 25% 36%

eRx 33% 0%

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eRx Impact on Call TypeseRx Impact on Call Types

Inbound / outbound Ratio

Relative % of outbound callsgoing to pharmacy

5.54.1

1.5

3.6

0

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Inbound Outbound

eRx Control

59.7%75.7%

0%

50%

100%

% Outgoing Calls to Pharmacy

eRx Control

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Practice Adoption SummaryPractice Adoption Summary

eRx w/ advanced transactional capabilities can be rapidly adopted by small, community-based practices– PMS integration, no license fee + small incentive– Large (>2/3) dependence on surrogates

• Implications for decision support and safety benefits unclear• Policy guidance? P4P?

– Big impact on efficiency and communication channels, but…• Paper-based internal communication still predominates• Faxing is tough to beat re: overall resource requirements• Opportunity for additional efficiency with more pharmacy participation plus

true e-messaging within the practices

– Conventional wisdom challenged:• eRenewals drive adoption (?)• Surrogates provide bridge to MD adoption (?)• eRx is a stepping stone to a full EMR (?)

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Provider Adoption of eRxProvider Adoption of eRx

Practice vs. provider adoption

Workflow realities

Role of practice culture (in provider adoption)

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In press…In press…

“Factors influencing physician use of clinical electronic information technologies after adoption by their medical group practices”– Kralewski, JE et. al.– Health Care Management Review, October-December 2008

“Culture as a management tool in medical group practice”– Physician Executive Journal

• (http://www.acpe.org/Publications/PEJ/index.aspx?expand=pej )

– Kralewski, JE et. al. Measuring the culture of medical group practices. Health Care Management Review; 2005; 30:184-193

krale001@umn.edu

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MGP Culture Survey: 8 DimensionsMGP Culture Survey: 8 Dimensions

Collegiality

Quality emphasis

Management style

Cohesiveness

Organizational trust

Adaptive

Autonomy

Business

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Related to eRx Adoption?Related to eRx Adoption?

Physician age Age in years

Physician gender 1 = female, 2 = male

Physician specialty 1 = family practice, 2 = general pediatrics, 3 = general internist

Practice size Number of FTE physicians

Patient work load Number of pt encounters for each physician per week

Practice complexity 0 = single specialty, 1 = multispecialty

Practice culture Mean score for practice on 1-4 scale, with 4 being more so (8 dimensions)

Dependent variable Proportion of total prescriptions written by each physician during a 2 month period that were sent electronically

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Hierarchical ModelHierarchical ModelIndividual-level characteristics Coefficient SE z

Age -.001 0.003 -0.25

Gender 0.009 0.042 0.21

Internal medicine -0.187 0.077 -2.45*

Family medicine -0.095 0.106 -0.9

Workload -.000 0.000 -0.84

Clinic-level characteristics Coefficient SE z

Practice size 0.070 0.026 2.70*

Multispecialty practice 0.218 0.087 2.50*

Collegiality 0.220 0.172 1.28

Quality emphasis -0.558 0.246 -2.27*

Management style 0.185 0.148 1.25

Cohesiveness -0.387 0.144 -2.68*

Organizational trust 0.417 0.071 2.44*

Adaptive 1.416 0.387 3.66**

Autonomy 0.422 0.143 2.96**

Business 0.413 0.112 3.69**

*Significant at the 0.05 level; **Significant at the 0.01 level

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Practice Culture and eRx UsePractice Culture and eRx Use

Driving practice adoption is just the beginning

Practice culture has major influence on eRx use patterns by providers within the practice

Personal characteristics of physicians do not– other than specialty

Good news:– Can predict physician cooperation by assessing practice culture– Gauge amount of passive or active resistance

Bad news:– Cultures are not easy to change!– Better to shape the innovation process to accommodate the culture