Slow adoption of e-prescribing forces Medicare to try hard sell

Boston -- With electronic prescribing still far off the radar screen for many physicians just weeks before new Medicare e-prescribing incentives kick in, the Centers for Medicare & Medicaid Services hosted an event here in October to jump-start an all-out push for widespread adoption of the technology.

More than 1,400 people gathered Oct. 6-7 for the National E-prescribing Conference. CMS intended to use the event to reach out to physicians trying to get started with e-prescribing before the Medicare incentives begin Jan. 1, 2009. But it ended up being more of a "train-the-trainer" event, as attendees consisted mostly of vendors, state officials, medical association representatives and physicians who are already e-prescribing.

Kerry Weems, CMS acting administrator, wasn't discouraged by the low attendance of physicians who had yet to adopt the technology. He said the conference would provide valuable talking points for the organizations in attendance to take back to their respective members. With federal incentives soon being offered, he said, those e-prescribing discussions might attract more interest. "Talking about it is one thing and putting money on the table is another. And we have put money on the table."

Starting in January, Medicare will pay a 2% bonus to physicians who successfully e-prescribe under Part D. CMS will assess how often and how consistently physicians prescribe electronically to determine whether they qualify. The bonuses will phase down to 1% in 2011 and 0.5% in 2013 before ending. Weems said a final definition of successful e-prescribing will be issued later this month, along with the CPT codes that can be associated with paperless drug orders.

"Doctors in general are never quite sure where they should focus their efforts, and they usually follow the money," said David Brailer, MD, PhD, former national health IT coordinator, who spoke at the conference. After leaving his government position, Dr. Brailer founded the investment firm Health Evolution Partners. The company's first investment was e-prescribing vendor Prematics.

Bonuses won't be the only money on the table. Starting in 2012, physicians not complying with the mandate will be docked 1% of their Medicare pay. These penalties increase to 1.5% in 2013 and 2% in 2014 and beyond.

"You can accept it and survive or you can lead and prosper," Health and Human Services Secretary Michael Leavitt said at the conference.

The American Medical Association was initially opposed to any mandate. But in May, AMA Board of Trustees member Steven J. Stack, MD, outlined a new AMA e-prescribing framework that said any Medicare penalty must not take effect until at least two years after CMS finalizes e-prescribing standards for physicians. The AMA, a conference sponsor, joined with other event sponsors to release a new publication, "A Clinician's Guide to Electronic Prescribing." The guide offers practical advice for physicians who want to adopt the technology in their practices as well as a list of incentives offered in various states.

Dr. Stack, who presented at the conference, told the crowd he was "preaching to the choir" after every hand went up when he asked who was already an e-prescribing convert. But he said he was confident that those in attendance would help spread the word to their doubting colleagues.

Studies suggest that early adopters have their work cut out for them.

Only 6% of physicians currently e-prescribe, according to a December 2007 study by SureScripts, the nation's largest provider of electronic prescribing services. While the report also found that many more physicians prescribe through electronic medical records systems that send the prescriptions via fax machines, this method is not considered true e-prescribing. Under the Medicare statute, most computer-generated fax orders no longer will be allowed for Part D starting Jan. 1, 2009.

Barriers to e-prescribing

Physicians attending the conference cited some of the barriers that prevent many of their colleagues from adopting the technology. One mentioned was the Drug Enforcement Administration's ban on e-prescribing controlled substances, which forces physicians to maintain two separate systems. The DEA has proposed rules to lift this ban, but none is yet final.

Rex McCallum, MD, associate medical director of the Private Diagnostic Clinic at Duke University Medical Center in Durham, N.C., said Medicare needs to provide a patient database to ease e-prescribing and ensure patient safety. Medicare patients are not included in the health information exchange provided through SureScripts-owned RXHub, which provides prescription eligibility, benefit, formulary and medication history information for patients with private pharmacy benefit managers.

"I think if you provided that, it would help adoption of e-prescribing tremendously," Dr. McCallum told Weems.

Vendors also were on hand to offer ideas on what is needed.

Michael Milne, CEO of Canadian e-prescribing vendor Scriptnetics, said Medicare has not made it easy for vendors to incorporate formularies into their programs, as required for system certification. No standard format exists, which means programmers must build the databases on their own or hire someone to do it.

Weems said the agency would take some of the feedback into consideration as it finalized the definition of successful e-prescribing.

Another barrier is the resistance of small pharmacies to make the necessary changes to receive electronic prescriptions, he said. While the adoption rate of large pharmacy chains is about 97%, it's only about 27% for small pharmacies. Weems encouraged physicians to talk to their local pharmacies about upgrading.

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