AMDIS: Execs Vent on ePrescribing, MU, and EHR Weaknesses

At the annual meeting of the Association of Medical Directors of Information Systems, CMIOs and their peers celebrated some victories in using technology to successfully improve healthcare, but the overall mood was somber.

I learned a lot at last week's Association of Medical Directors of Information Systems (AMDIS) Physician-Computer Connection Symposium in Ojai, CA:

• Physicians are reporting there's trouble in e-prescription land
• Lots of childrens' hospitals have pulled the plug on participating in Meaningful Use Stage 2 and 3
• U.S. senators have copied-and-pasted a new healthcare informatics industry association report as the blueprint for a current set of hearings underway.

This annual meeting, AMDIS's 24th, brought together a room full of brilliant, connected CMIOs and equivalent executives from healthcare systems and practices around the country. While they celebrated certain victories in using technology to successfully improve healthcare, the overall mood was somber.

AMDIS members shared their frustrations with the many business and government mandates and technology challenges that often are perceived as getting in the way of improving that care.

ePrescribing Complaints
The grumbling over how e-prescriptions usage is doing was among the loudest. It's getting even louder now that the Meaningful Use Stage 3 proposed rules are out, and it's clear that e-prescribing will be mandatory for all providers who don't want to be penalized in 2018—three short years from now.

The problem is that the largest provider of e-prescribing services, Surescripts, largely does not permit physicians to cancel e-prescriptions once they are transmitted. Some physicians say the issue has to do with pharmacies at the other end of the Surescripts network either not being prepared for or not wanting the burden and cost of filling those prescriptions, only to have to process a cancellation.

"This is a particularly difficult problem in teaching hospitals, where the residents might send out prescriptions, but the attending comes in the day of discharge and says, 'no I want that [other medicine], this dose and so on,'" says Richard Schreiber, MD, CMIO of Holy Spirit Hospital, now part of the Geisinger Health System. "How do you account for that?"

"Absent a requirement on the part of partners with whom we need to work, whether they're SNIFs, or pharmacies, or other practices with which we're exchanging CCDAs, without putting some requirement on them to be able to do something like accept cancellation messages within e-prescribing paradigms, then we're kind of stuck in the water," says Harris Stutman, MD, chief medical informatics officer at MemorialCare Health System in Fountain Valley, California.

During a break, I spoke with another physician who preferred not to be named, and he described a pharmacy behavior that, if true, must infuriate physicians. Initial e-prescriptions from a provider to a pharmacy typically include several refills for the patient. When the refills are depleted, in theory the patient contacts the provider and has a checkup visit or at least requests the refill be sent again to the pharmacy.

In practice, though, patients often just contact the pharmacy even when they have zero refills, expecting the pharmacy to contact the physician. But, according to this physician, even some national chain pharmacies still fax such refill requests to the physician, creating extra work for the medical staff, introducing a possibility of error as faxed information is manually entered. The physician I talked with claims that pharmacies are reverting to faxing to avoid paying a transaction fee to Surescripts.

ONC: 'No Regulatory Authority' Over Transaction Fees
All of this can happen because pharmacy behavior is not regulated by ONC. Michael McCoy, MD, ONC's chief health information officer, who I interviewed earlier this month, was also at AMDIS, and says that "ONC doesn't have regulatory authority over financial impact" of the transaction charges that Surescripts collects – even though e-prescribing is rapidly becoming mandatory at all providers.

On Monday, I reached out to Surescripts to hear their perspective on all of this. Company officials were not available for interview, but did provide a statement from Ajit Dhavle, the company's vice president of clinical quality:

"A CANCEL Rx message is used by prescribers to notify the pharmacy that a previously sent prescription including any remaining prescription refills should be cancelled and not filled," Dhavle states. "This message is part of the widely implemented NCPDP SCRIPT standard, version 10.6, and is supported by Surescripts.

 

"However, the industrywide adoption and utilization of CANCEL Rx is very low. Surescripts continues to diligently work with all stakeholder groups to increase awareness of this message and help them implement this new functionality into their workflows. Prescribers and pharmacies should reach out to their technology vendors and request them to implement and enable this functionality within their software systems."

"Lots of finger pointing," says my unnamed physician source, upon hearing Surescript's statement. Stay tuned.

Children's Hospitals Balk on MU Stage 2 and 3
Another mini-bombshell at AMDIS was delivered by Christopher Longhurst, MD, chief medical information officer at Stanford Children's Health. "In the children's hospital community, which gets Meaningful Use funds through Medicaid, not Medicare, the bulk of our standalone children's hospitals have made the decision not to pursue Meaningful Use stage 2 and 3," Longhurst says.

"That was a conscious decision, recognizing the fact that Medicaid does not penalize us for not pursuing Meaningful Use stages. We're currently pursuing stage 1 at Packard Children's Hospital at Stanford, and having an active discussion about whether we will move forward as well. I think what that represents from my perspective is a community perspective in a very mission-driven sector of healthcare that this is not adding value to our patients or to our clinicians."

Toward Better EHRs
While attendees at the AMDIS gathering pondered the future of Meaningful Use, they also learned that the American Medical Informatics Association (AMIA) has a new-found influence over renewed Senate scrutiny of EHRs. In May, AMIA issued a five-point program for improving EHRs by 2020. The EHR 2020 Task Force Report called for simplifying and speeding documentation in EHRs, refocusing regulation, increasing transparency and streamlining EHR certification, fostering EHR innovation, and putting the patient at the center of EHR-powered care delivery.

The most important of the five aims, I believe, is increasing transparency. To be precise, researchers seeking to scrutinize the workflow of EHRs are often forbidden from taking and publishing screen shots to shed light on EHR inefficiencies. EHR vendors say this ban is to protect their intellectual property from being copied without permission.

"Sometimes you aren't sure exactly how a particular product has met the criteria," said new AMIA president Douglas Fridsma, MD, speaking at AMDIS. "Maybe the smoking cessation isn't integrated into your note, but there's another window that pops up and you have to do 12 clicks, and then you can meet the criteria. That worked for certification for Meaningful Use, but it doesn't work in the workflow. So increasing transparency says, 'let's at least get the information out there so people can make informed decisions, and if it doesn't make sense, we can say, this is how they did this.' Do people think this is a good way?"

Fridsma says Sen. Lamar Alexander, (R-TN) who chairs the Senate Committee on Health, Education, Labor and Pensions, otherwise known as the HELP Committee, quickly adopted the five aims of the EHR 2020 report and scheduled hearings on each aim.

Two such hearings have occurred so far. If, like me, you wondered where Sen. Alexander, his Republican colleagues, and Democratic committee members from across the aisle got their current bipartisan investigatory inspiration, now you know.