CV: The Highmark eHealth Collaborative is an initiative funded by Highmark through the Pittsburgh Foundation – a charitable organization that collects grants – to promote the adoption of electronic health documentation and information transmission by physicians in Pennsylvania. The project will provide $26.5 million in grants to physicians who agree to purchase electronic prescribing software, hardware and connectivity. One of the requirements for the service purchased by the physician is that it be interoperable with an electronic health record. Individual physicians can receive up to 75 percent of the cost of the purchased program or $7,000 – whichever is less. At this time, the grant is concentrated on electronic prescribing – software and hardware such as a handheld computer device, a laptop computer, notebook computer or desktop computer.

CV: No. They may have an EHR in place, but they do not have to have one. The electronic prescribing system purchased has to be interoperable with an EHR record chart, and most of the electronic prescribing vendors have made their product interoperable with many different types of the EHR products.

CV: Last year Dr. Ken Melani, CEO of Highmark, convened a group of stakeholders to have a summit to look at the cost of health care delivery in Pennsylvania. Stakeholders included representatives from the employer community, government and the provider community – including hospitals and physicians. That summit was designed to discuss what was causing the cost of health care to rise rapidly, what problems were resulting in people becoming uninsured, and what problems were creating an inability to deliver the best care to patients. A number of recommendations came out of that summit, but one was around the lag in the adoption of technology by physicians and hospitals – not only in the state, but across the country. Participants of the summit believed that causes of the adoption lag included the lack of financial incentives for physicians to adopt this technology – that physicians were not paid by any payer, whether an individual or an insurer, to use the advanced technology, nor did it seem that patients chose doctors or hospitals based on their use of the technology. At the same time, the summit participants believed strongly that this lack of technology created many problems in health care, such as the inability to reduce medication errors and treatment errors, inability to keep up with the current standard of care, inability to keep up with what patients were missing in terms of preventive health care or follow-up care, inability to track duplicate services.

Highmark concluded that the summit was correct, that adoption of technology could improve the delivery of care, and that in particular the use of electronic prescribing technology would accomplish a number of positive events for patients. We know that patients sometimes receive duplicate medications because they’re seeing multiple physicians and going to different pharmacies, and that getting multiple prescriptions for the same medication can lead to mortality and morbidity, based on overdoses. We also know that patients frequently don’t know all the medications they’re taking, which can result in a physician inadvertently prescribing a medication that reacts negatively with another medication the patient is using. We know that patients sometimes forget that they’re allergic to certain medications. We also realize that doctors don’t have, in all cases, a robust tracking system to note what medications the patients were supposed to be on, because they have a paper system or another system that doesn’t remind the physician about medications that have been prescribed in the past – or, the patient never picked up the prescription that they were given. We also are aware that doctors feel pressured to give the patient samples of a more recently released drug that may not be the best drug for the patient, because the pharmaceutical company just happens to be promoting a new drug that’s on the market. We know that patients are frustrated. Doctors are frustrated with the patient’s pharmacy benefit formulary restrictions. There are financial restrictions that apply to the dispensing of medication.

All those problems can be addressed with an electronic prescribing system. And so, we at Highmark felt that after investigating other parts of the country with programs that had been put in place, that promoting electronic prescribing to the physicians in Pennsylvania would result in improved patient safety and improved care of patients, as well as provide a convenience to physicians and patients.

CV: We are considering putting the use of electronic prescribing in our pay-for-performance program for primary care physicians. We did consider other approaches to helping physicians adopt electronic prescribing. There are other approaches done in other parts of the country. In Massachusetts, a number of organizations, including Massachusetts Blue Cross Blue Shield, provided money that encouraged the adoption of one vendor. A similar approach was adopted by Independence Blue Cross. We looked at those models and we decided that physicians, particularly early adopters of EHRs, were not necessarily interested in just one vendor. What if the vendor we picked didn’t fit their EHR? What if it didn’t fit their practice? What if the technology that this vendor was promoting depended on hand-held devices, but the practice really liked using notebook PCs? We decided a better approach would be to offer a number of vendors that met the minimal specifications, but would still allow the physician to go out and find the vendor that best met their needs, and then get the grant from Collaborative.

CV: The Collaborative is requiring that the vendor be CCHIT-certified – that’s a national organization that certifies electronic prescribing technology. That there be bi-directional capability, in other words, their cellular or Internet connection connects between the physician at the point of care and the pharmacy, and that the information of how the pharmacy has dispensed the medication is transmitted back to the physician. It’s not a system where the doctor just hands a fax to the pharmacy. There has to be decision support as part of the software, in other words, the system must be able to identify contraindications to the medications being prescribed, must be able to remind the physician of the patient’s allergies, and other information the physician can use before deciding what to order. The technology must be connected to a central server that has the patient’s pharmacy benefit program information and drug dispensing history – it would be able to tell the physician immediately what formulary restrictions that patient has with their plan, what out-of-pocket obligations that patient will have with the drug that has been picked, as well as tell the doctor if the patient is using a similar medication or if they need a refill on their medication. Those are the primary requirements of the program.

CV: Physicians who practice in the 49 counties in Pennsylvania where Highmark does business as both a Blue Cross and Blue Shield plan. It’s throughout the state except for the very southeastern five counties of the Philadelphia area and the northeastern area counties that are covered by the northeastern Pennsylvania Blue Cross plan.

CV: No. Once Highmark made the grant to the Pittsburgh Foundation, Highmark cannot direct the use of the money. Whoever applies and meets the specifications can get the money. It cannot be tied to the Highmark network participation – charitable rules dictate against Highmark trying to put that type of restriction on it. And frankly, that’s not a concern of ours. Highmark has close to 80 percent of all practitioners – not just physicians – in our networks; I think physician participation is even higher. So, we did not feel concerned that we were going to be giving money to physicians who had no impact on Highmark.

CV: Up to the point when we made the announcement about this initiative, we found only five doctors throughout the whole state who had this electronic prescribing capability as I’ve described. The use of bi-directional connectivity with a central server, called RxHUB, that holds on to the patient’s information – that entity was only established within the last two years by the larger pharmaceutical benefit management companies like Medco. Physicians told us in focus group meetings over the past few months that they wanted primarily to go with EHRs, that if they were going to spend their own money, there would be more value in EHRs than electronic prescribing because EHRs would help the doctor gain efficiencies within their practice. They would not need storage and staff to retrieve records and maintain paper records. Electronic prescribing is more convenient for patients, but was not on the radar of physicians. It was hard to show a return on investment for physicians with electronic prescribing, but it was possible to show a return on investment with EHRs.

CV: None. That’s part of the problem. That’s why we believe the Highmark e-Health Collaborative had to be put into place. However, in our investigation, particularly in Massachusetts, we did find that the physicians who adopted the technology were very happy with it. It did eliminate those calls that they get from the pharmacy saying, "The drug you prescribed is not on the formulary. What are you going to prescribe now?" Those angry calls from patients who said, "You prescribed me a drug that I’m going to have to pay a 50 percent copayment. Why didn’t you know that, doctor?" Calls by patients at 5:45 in the afternoon saying their prescription has run out and they need their blood pressure medicine for that night. That inconvenience to the physician is eliminated.

CV: Based on some limited studies, errors were reduced significantly when full adoption was taken in places like Michigan, Massachusetts and a couple of other smaller areas. I can’t give you a statistic because it wasn’t a controlled study. There were fewer callbacks from mistakes. Physicians catch most of the mistakes anyway, but this system caught them quicker and was more complete.

CV: I don’t think there is any. Curtailed spending by electronic prescribing has never been touted, as far as I know, because it was wasn’t designed to directly reduce spending. It has the ability, depending on the connection to RxHUB and the software, of reminding physicians that there’s a generic equivalent substitution, but in Pennsylvania we already have a generic substitution requirement at the pharmacy level. What we needed was some way to remind the physicians that they could use a different medication, a first-generation or second-generation medication, that would work just as well – and there is a generic available when they do that. If they go to a fourth-generation medication, usually there’s not a generic available. In theory, it’s possible that more generics will be prescribed, but there is no evidence that in fact that’s going to happen, particularly in a state like Pennsylvania where there’s a mandatory generic substitution rule. In those states where there is not a generic substitution rule, it did have an impact – something like a 25 to 30 percent increase of the rate of generic prescribing. For Pennsylvania we have no evidence that spending is going to really change. But because of enhanced patient safety and reduction in errors, in theory this should improve care over time and, in theory, costs should decrease because there are fewer mistakes made, and fewer complications. But we’re not aware of any study that has proven that to be the case.

CV: So far, we’ve received over 1,800 applications – in the first three weeks. We can support between 4,000 and 6,000 physicians.

CV: It supports purchase of the package, and most of the vendors we’ve seen have training and support as part of that purchase. We encourage doctors to pick a vendor that provides support and training to make it work. Highmark is providing a limited number of staff who are going to help physicians find a vendor that is best for them, and help some practices implement the technology and continue to use it. This is not going to be a widespread service, but we have already tried to take steps to help some of our larger practices get started with this.

CV: The practice has to be structured to optimally use the new system. The individual physician needs to be ready to use a technology that is different from what they’re used to. For instance, the physician needs to be facile with the use of computers. The information needs to be entered into the computer, so to really work effectively, the patient needs to have already told the staff about their pharmacy benefit and their pharmacy of choice. For it to work best, there ought to be one system where all this information is typed into the business management software, which is connected to the EHR, which in turn is connected to electronic prescribing. Information that the EHR would have, like the patient’s allergies, their past medical histories, their problem list, ought to be in there too, so that the decision support software can work effectively. All those things require a physician to think in terms of what needs to change in their practice style in order to optimize the use of this technology. It’s not a simple substitution of paper versus computer.

CV: Electronic prescribing is just the first step – you’re only addressing one particular situation. The next step is to start moving to a more broad EHR capability. That is probably is not going to move much faster until the federal government releases its standards for EHRs. That’s supposed to come out sometime in 2006 or 2007 and everybody is afraid of trying to establish connectivity until those standards are available. There’s a lot of talk about RHIOs – Regional Health Information Organizations. The Pennsylvania Medical Society and Quality Insights of Pennsylvania are already discussing whether we can have a RHIO-like system in Pennsylvania. The concept would entail some type of central server for the doctor, hospital and lab to draw from a central repository information they need about the patient, and in turn deposit new information they gather back into this repository. It sounds very good, potentially, as a way to have interconnectivity, but no one is really pushing hard on this until funding is available and the specifications are clear. There’s another approach that would use a search engine model, somewhat patterned after Google: instead of all the information being housed in one central location, each individual service provider is connected and physicians can find where a patient has been, while all activity would be updated on the patient’s record, electronically housed.