Welcome to the Brave, New (Electronic) World, Doctor
MANAGED CARE June 2004. ©MediMedia USA
Providing free handheld or even desktop computers is a small step toward minimizing medication errors. Will docs finally abandon pen and pad?
Physicians react to change in a many ways. Some are "early adopters," some are "late adopters," and some are "non adopters," clinging stubbornly to the way they have always done things. If WellPoint had its druthers, physicians would embrace electronic prescribing wholeheartedly. And to jump start the movement toward electronic prescribing, WellPoint is spearheading an electronic initiative at a cost of $40 million that will reach 19,000 physicians.
In California, Georgia, Missouri, and Wisconsin, physicians will be given the opportunity to choose from either of two electronic packages: a Prescription Improvement Package or a Paperwork Reduction Package.
Choose your package
The Prescription Improvement Package consists of a wireless handheld personal digital assistant (PDA) — really a small computer, a wireless access point to the Internet, and a one-year subscription to an e-prescribing service.
Ron J. Ponder, PhD, executive vice president for information services at WellPoint notes that physicians will be able to use this system to write prescriptions and have them automatically faxed or e-mailed to the pharmacy of their choice.
"If you think about it, nothing is more efficient than writing out a prescription on a pad of paper, and handing it to the patient," says Charles D. Kennedy, MD, MBA, vice president for clinical informatics at WellPoint. "We are substituting the PDA for the prescription pad and now look at the options the physician has at his fingertips."
The physician can check formulary information and drug interaction data as well as send the prescription to the pharmacy.
The Paper Reduction Package consists of a desktop computer and printer. Physicians who choose this package will also be able to access the provider Web sites of WellPoint's operating subsidiaries (or any other health plan's Web site) where member eligibility, claim status, and medical policies can be reviewed and verified.
WellPoint has identified these 19,000 candidates using administrative claims data sets. Physicians were chosen based on number of member office visits over the past year. All specialties were reviewed with the exception of hospital-based specialties (e.g., anesthesiologists and radiologists). WellPoint then ranked each physician, selecting the practices with the most visits by their medical members.
The $40 million was then allocated among WellPoint's product brands based on membership and the number of patient visits per physician. WellPoint has roughly 175,000 physicians in its networks.
"The other physicians can purchase either of these packages at a substantial discount," says Ponder. "The discount is dependent upon vendor and electronic package purchased and arranged via our agreements with our vendor partners on this initiative."
At this writing, WellPoint is actively promoting the program. About 40 percent of the targeted physicians have signed on.
Minimize the hassle
Ponder says that 3.5 billion prescriptions were written last year in physicians' offices in the U.S.
"Of those, fifty-five million contained some sort of error. Studies report there were 7,000 deaths alleged to have occurred due to prescription errors." With these startling numbers, it would seem that physicians would be clamoring for some way to minimize these errors. But that's not entirely the case.
So why the resistance? Just what you might guess.
"Cost is the number one reason for resistance," says Ponder. "If physicians are going to incur out-of-pocket expenses for this technology, they want to be sure the technology is going to truly ease their administrative costs and simplify the lives of their office staff."
"The implementation of this initiative could be met with skepticism from providers," says Kennedy, "because in the past, small vendors began offering electronic prescribing and electronic records systems, but many went out of business. Physicians had a negative experience because the vendor went out of business and they were stuck with an unsupported application."
The hassle factor is not minimal as well, according to Kennedy.
"Sometimes when this technology is implemented, it interferes with the existing office workflow, and a physician's productivity is tied to his revenue stream, so he's sensitive to these issues."
Horizon Blue Cross Blue Shield of New Jersey echoes a similar sentiment, according to Jay Patel, PharmD, manager of business development. Horizon will be rolling out a similar, albeit smaller, initiative by the end of the year.
"Our program will include not only provision of hardware and software, but also extensive education and technical support to the selected physicians. We do not want to give physicians these great tools only to have the equipment sit idle due to a gap in technical capability," says Patel.
The Horizon initiative earmarks $5 million for providers to receive a free desktop computer or PDA. "We'll reach 2,000 network physicians," says Patel.
The Horizon effort will also have multipayer abilities, so that other health plans' formularies, and patient eligibility data are available to the provider for review.
Other health organizations, most notably Cedars-Sinai Medical Center in Los Angeles, have tried moving to an electronic medical record system, with disastrous results.
"Physicians get trained in a paper-based world, so their thought patterns are intimately connected to a paper record, and it's no small challenge to try to change what a physician does — his intellectual process and his workflow — and place him in an electronic-based world, and not expect bumps," says Kennedy. "We should not underestimate the size of the challenge in front of us."
WellPoint hopes to minimize the hassle, however, with its partnerships with Microsoft (providing the software), Dell (providing of the hardware), and Capgemini (managing the project).
"We chose to partner with Dell because of their good logistics," says Ponder. Dell ships the loaded hardware, assembles it, tests it in the physician's office, and trains the office staff and physician.
Benefit to provider
WellPoint is hoping the doctor will experience greater administrative efficiency, better quality of care, favorable malpractice premium rates, and improved marketing.
"When you count the number of times the physician receives a call back from the pharmacy because the pharmacy can't read the handwriting, or the medication isn't on formulary, you see the opportunity to increase office efficiency," says Kennedy.
At the point during the patient-physician interaction when a prescription will be written, an electronic device can help the physician make a decision about which drug to prescribe, and it can provide information about drug interactions and contraindications related to the patient's age or disease state.
"There is a quality-of-care bonus that we think will be important as the public becomes aware of the importance of quality of care and opportunities to improve it," says Kennedy.
Kennedy also thinks these advances can have an effect on the cost of malpractice insurance.
Finally, Kennedy says most patients are accustomed to information technology in other aspects of their lives and are distinctly unimpressed by the paper-based world that a physician operates in.
"So there will be a patient perception that the physician's practice is state-of-art, rather than back in the dark ages of paper," says Kennedy.
WellPoint's Kennedy likes to describe the physician's office as three areas: the front area, the back area, and the clinical area.
The front office is for intake, where the patient first makes an entrance; the back office is where the scheduling and billing occur; and the clinical area is where the physician does his work.
The vast majority of technological advancements have targeted either the front office or the back office. The clinical area has been minimally touched.
"It's difficult to bring the clinical area into the information age because there is no easy path from an all-paper world to an all-electronic world," says Kennedy.
"Moving to electronic medical records requires a big transition that involves taking the paper history and converting it to the electronic environment, and that has never worked," continues Kennedy.
"Electronic prescribing is unique in that it offers a beach head into that clinical world that allows us to deliver value both in terms of quality improvement and cost reduction," says Kennedy. "But it also gives the physician the first exposure to the value and return of information technology."
"Electronic prescribing is an intermediate step; it doesn't disrupt the physician's workflow; it just substitutes a PDA for a prescription pad. That's a logical entry point. The doctor still has to write a prescription; he's just writing it electronically, and now look at the additional information that is coming through this device versus a pad of paper," says Kennedy. "It gives the physician a chance for some buy-in, some adoption to take place."
And then if the physician sees the value of this advancement, the challenge of going from a paper-based world to an electronic-world is not quite so daunting. "They can take another step by bringing in another patient module, moving in a deliberate stepwise fashion rather than an all-or-none fashion."