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ePrescribing and Self-Pay Patients

August 28, 2009
by Joe Bormel
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(graphic from Dr Eric Poon, presentation "Errors Associated with the Use of E-Prescribing", August 2008, highly recommended!)

Last night, a close family friend went to a night-time, walk-in clinic (run by a large, multi-hospital system) for what seemed like a lingering syndrome with elements of sore throat, sinus pain, mild neck pain, and the like. So far, a very common presentation. On examination, they found that she had some airway involvement and diagnosed bronchitis. Great diagnostic pick up! Our friend responded positively to a breathing treatment at the clinic and walked out stronger than she entered. Fabulous!

Here's where it gets interesting. They sent her home with a prescription for an antibiotic that has a retail price of over $100. There were three other prescriptions, for a net, out-of-pocket bill of about $300. Our friend happens to be a full-time student; although she has a modest form of health insurance, it will be weeks to months of administrative claims work before she'll even know what the final cost-to-patient will be. For now, it's $300 for the clinic discharge prescriptions for this effectively self-pay situation.

Now that universal e-Prescribing is destined, thanks to ARRA/HITECH, my question is, do any of the e-Prescribing solutions help the physicians write prescriptions that are both clinically and economically appropriate for patients? Do any of them inform the patient that Motrin 800mg tablets are almost free when taken as 200 mg ibuprofens? I haven't seen that kind of clinical/economic clinical decision support in commonly deployed e-Prescribing. I hope it's out there and we should draw attention to it, as HCIT professionals.

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Comments

This was the strength of an ePrescribing system from a company called Wellinx. Unfortunately, that product is no longer available. It was way ahead of its time. For one, it was a cloud service that we started using in 2001. It provided physicians feedback when there were more cost-effective options of similar efficacy. We documented millions of dollars of savings to our patients and the health plan.

As we moved to a full-blown EHR with integrated ePrescribing we could not find anything with such capabilities.

Frank,

Thanks for your comment.

As you may not know, I cannot mention specific products or services such as QCPR in this blog. I will, however, send you a private email regarding "clinical/economic clinical decision support in commonly deployed e-Prescribing" solutions.

Joe,
I understand the problem your friend is facing, which is not really self-pay, but a problem with reimbursement perpetuated by prescribers and payors. Both are culpable.

Too often, simple applications that can help disappear into the unknown, ie Wellinx. How sad. The first question that needs to be asked is "why" and then "how" did this app disappear?

Although I don't have a need for very many prescriptions, thank God, my pharmacist has consistently filled the few I have needed with the most cost-effective (I think), alternatives where available. But I still think the docs should have decision support software available everytime they write a script.

Jack

Joe,
Great observation. As a former hospital CFO I always wondered about that issue.
But I am not going to let you off that easily...here's my question for you. As the MD leading the design of a major vendor's clinical apps - is this capability in QCPR?? If not, why not? Is it planned for QCPR?

Deborah,
Thanks for your comment. Like you, I am hopeful that the committees, Policy and Standards, will be able to move the e-Prescribing cause forward. There is already evidence of that, with the explicit references to favoring generic medications where appropriate.

Will,
Thank you as well. Your comment more squarely addressed the decision support issue of providing busy clinicians with "more cost-effective options of similar efficacy."

I have seen inpatient functionality that advises on appropriate antibiotic ion. The software not only factors in cost (to the hospital), but also the local antibiogram (susceptibility of bugs to drugs), dosing, and other clinical factors. Even with strong clinical leadership and available products, these capabilities have not become commonplace.

The stated goal of healthcare reform has included both lowering healthcare costs and using HCIT to do so. Deborah and Will, both of your comments and my original post would seem to indicated that e-Prescribing could do exactly that.

The HIT Standards Committee has been working on specific requirements that identify, among other things, requirements for medication reconciliation issues. Perhaps you will be able to find the information you are looking for from the report released last week. Information written by Dr. Halamka, Chair of the US Healthcare Information Technology Standards Panel (HITSP)/Co-Chair of the HIT Standards Committee, can be found at http://geekdoctor.blogspot.com/2009/07/hit-standards-committee-deliverab...

Jack,
Thanks for your comments.

Two reactions to share. First is that the HCIT market doesn't behave like a market.  Many "markets" dont.  New entrants without financing and market access for the long run have a hard time against mature incumbents. And, often wisely, buyers choose the mature over the innovative. The world doesn't always beat a path to the door of the vendor with the better mousetrap. Most of us have seen a moderate number of really cool solutions disappear.

Second, I don't know who my pharmacist is! I know who my preferred pharmacy is, which is driven nearly entirely by location, not competency at converting my prescription into a clinically and economically optimal potions. I agree with your point we really need the doctor to write better scripts than they needed to in a simpler day.

This is very good information.It is very helpful.
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Joe Bormel

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