Meaningful Use of Electronic Prescribing in 5 Exemplar Primary Care Practices

INTRODUCTION

Prescription drugs are among the most commonly used treatments in primary care, and the prescribing process has been a central target of primary care transformation efforts. Early efforts to transform prescribing focused on electronic prescribing (e-prescribing) as an initial step that could be achievable for most practices.¹ Although 234,000 US physicians have adopted e-prescribing over the last decade, many adopters revert to handwriting for most of their prescriptions.^2–4 The American Recovery and Reinvestment Act of 2009 (ARRA) created a new program to promote the “meaningful use” of more-comprehensive electronic health record (EHR) systems.⁵ The meaningful use criteria include requirements that prescribers transmit 40% of permissible prescriptions electronically using certified EHR technology in order to qualify for incentive payments.⁶ Although incentives are likely to spur adoption of e-prescribing, experience to date suggests that a majority are likely to fall short of the meaningful use mark.⁷ New approaches to e-prescribing adoption are thus needed if federal policy goals are to be achieved and practices are to qualify for incentive payments.

Previous work has documented some of the challenges faced by those adopting e-prescribing in primary care settings, including unrealistic expectations among users, inadequate technical support, and poor functioning of the technical infrastructure for e-prescribing.^8,9 These challenges have slowed adoption while leading some early adopters to either abandon e-prescribing or delegate its use to support staff, thereby neutralizing its potential to influence prescribing decisions.^8,10 Nonetheless, some e-prescribers have successfully transformed their practices to make use of the technology, and lessons from these successes can inform wider adoption of e-prescribing.

We present findings from a study of practices that have successfully adopted and meaningfully used e-prescribing to identify key lessons for primary care transformation efforts.

METHODS

We conducted a comparative case study among 5 exemplar e-prescribing practices. Successful strategies were identified at each site and then compared, across sites, to identify generalizable lessons. Exemplar sites were identified in collaboration with an Expert Advisory Committee (EAC), composed of executives whose organizations had been involved with e-prescribing implementation initiatives (Supplemental Table 1, available at http://www.annfammed.org/cgi/content/full/9/5/392/DC1). First, EAC members identified practices that submitted a high volume of their prescriptions electronically and had innovative implementation processes. Second, we purposively sampled from that group to ensure inclusion of safety net settings, practices of varying size, practices that had implemented e-prescribing in the context of a full EHR adoption, and those that implemented e-prescribing as a stand-alone application. An advance questionnaire was used to ensure that practices met the criteria of our purposive sample (Supplemental Appendix, available at http://www.annfammed.org/cgi/content/full/9/5/392/DC1).

From March to May 2009, we conducted 3-day site visits at each practice that included in-depth interviews with practice members and observations of practice culture and prescribing processes. During site visits, we checked observations with practice members to ensure accuracy of field notes. Interview transcripts, field notes, and responses to the advance questionnaire were entered into ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) for coding and analysis by a multidisciplinary team using a template organizing style.¹¹ Coding proceeded in a 3-stage process. We used an initial codebook to code data from 1 practice and to develop a shared understanding of code definitions and use. Next, we coded data from a second practice independently, and discrepancies were resolved through group consensus, refining code definitions where necessary. The remaining data were coded independently by 2 coauthors (J.C.C., R.S.E.), and discrepancies were resolved by consensus. Coding reports were generated and analyzed using a grounded theory approach to identify common themes and to select representative text segments.¹²

Institutional review boards at UMDNJ-Robert Wood Johnson Medical School, RAND Corporation, and University of California at Los Angeles approved the study.

RESULTS

All sites were ambulatory primary care practices of varying size and organizational affiliation (Table 1). Three sites used an e-prescribing system that was integrated with an EHR, whereas 2 sites used a stand-alone e-prescribing system. All sites had substantial on-site information technology (IT) resources to supplement vendor-provided services. Meaningful use of e-prescribing in these practices proceeded through 3 phases: planning, implementation, and use. Best practices for each of these phases are described below and summarized in Table 2. As indicated in Table 2 and in the descriptions below, many of the strategies associated with successful uptake of e-prescribing were important across phases.

DISCUSSION

E-prescribing features prominently among the technologies that are expected to transform health care in the near future, offering the potential to increase medication safety through the use of automated alerts delivered at the point of care, reduce costs through greater use of generics and lower-cost medications, and reduce call-backs due to poor handwriting.^13,14 The planning, implementation, and use strategies followed by exemplary sites suggest some factors that may enable a broader range of practices to achieve meaningful use. We found that successful adoption of e-prescribing required substantial investments of planning time and the ongoing transformation of work processes. Specifically, it required that practices (1) have at least 1 practice member able to articulate the importance of e-prescribing within the process of clinical care delivery; (2) develop communication strategies for introducing and orienting patients and pharmacies to e-prescribing processes; (3) have access to technical support throughout the implementation process capable of responding to problems before user frustration impeded adoption success; and (4) focus on transforming work processes to effectively incorporate e-prescribing.

Careful planning and implementation of redesigned work processes was a common element among all exemplar sites. In particular, all practices had implemented protocols allowing office staff to assist in handling prescription renewal requests, thus helping to offset the extra time that e-prescribing often takes for prescribers to generate prescriptions.¹⁵ In addition, we found that the staff in exemplar practices typically welcomed the opportunity to expand their job responsibilities.

The Health Information Technology for Economic and Clinical Health Act (HITECH) provisions of ARRA have established health IT regional extension centers (RECs) intended to provide practices with technology implementation assistance.¹⁶ Our findings suggest that the RECs will serve an important role in fostering adoption of health IT in that all of the successful practices we observed had strong external assistance for making the transition to e-prescribing. Key elements of this assistance included technical support for setup and troubleshooting for hardware, software, and network connections. At 4 sites, this support was delivered by internal IT staff, while the 5th site successfully used their independent physician association to contract for this support, an approach that is more likely to be followed by the majority of smaller practices in the United States.

Furthermore, technical support appeared to work best when support personnel were readily available to visit practices for setup, training, and troubleshooting. By contrast, technical support in sites that struggled or failed with e-prescribing in an earlier study appeared to be less accessible, spend less time in the practice near the launch time, exhibit longer lags in response to support calls, and deliver more support by telephone rather than in person.⁸ These findings regarding appropriate levels of technical support should be considered when determining the extent of services offered by the RECs.

The qualitative methods that we used to examine these practices helped us to identify factors associated with successful implementation and use of e-prescribing in these sites; however, our study is limited in that these methods do not allow us to determine the relative importance of individual factors. An assessment of their relative importance would require a larger observational study, and the findings from such a study would be of obvious benefit to primary care practice leaders as they work toward more meaningful use of this technology. In addition, because we did not interview patients in this study, we were unable to directly determine what role they played in the implementation process.

E-prescribing is seen as one way to reduce health care costs by helping prescribers and patients select effective but lower-cost medications.^17,18 Reducing patient costs could address a common barrier to adherence to medication therapies.^19,20 To realize these aims, however, our study suggests that better functioning health information exchange for e-prescribing is needed. The accuracy and completeness of individual patient formularies and medication histories presented and exchanged in e-prescribing systems still falls short of prescribers’ expectations. Providing such information reliably will be essential if e-prescribing is to contribute effectively to the improved safety, quality, and cost-effectiveness of health care.

The HITECH provisions of ARRA are designed to encourage widespread EHR and e-prescribing use after a large, but relatively short-term, investment. Our results suggest that e-prescribing success, and likely that of other health ITs, will require a longer-term commitment to supporting practice transformation, sufficient resources to aid in making these changes, and improvements to the infrastructure for health information exchange.