Linking physicians to pharmacies and, ultimately, to patient data may be the dream of almost every managed care organization.

Marlene Z. Bloom

The concept of physician connectivity is a part of the growing field of pharmacy informatics and electronic data interface. The desire to connect with physicians is fueled both by the need for information and by the increasingly sophisticated electronic link between pharmacies and pharmacy benefit management (PBM) companies. But the new wrinkle–and one that has been a long time in coming–is the connection between physicians and managed care organizations (MCOs).

Dan Segedin is vice president of product development at PCS Health Systems, a subsidiary of Eli Lilly and Company, based in Scottsdale, Arizona. PCS–the country’s largest PBM, covering 56 million patients–is a leader in connectivity. According to Segedin, connectivity in the broadest sense means electronically linking the physician’s office with the PBM, the health plan, the pharmacy, and other health care provid-ers to improve patient care.

"Connectivity goes way beyond electronic prescribing," Segedin said. "It means electronically having access to patients’ complete medical records, laboratory data, and pharmacy records. It allows for total patient management."

That vision is far from a present reality. According to William Lockwood, Jr., executive director of the Society for Auto-mation in Pharmacy, fewer than 1% of the 3 billion prescriptions written in 1997 were written with a computer. Only a few pilot programs exist that connect some chains, PBMs, patients, or HMOs. But there is increasing recognition that connecting physicians to pharmacies by computers can improve medication use decrease adverse drug reactions, im-prove patient care, and save money.

A recent article in the Journal of the American Medical Association by Gordon D. Schiff, M.D., and T. Donald Rucker, Ph.D., said flatly, "Physicians should never again write a prescription. Given the explosion of scientific information and advances in computer technology, prescribing medication on a blank piece of paper will soon seem as antiquated as ordering tinctures of botanicals in Latin." The authors outline eight clinical reasons computers should be used to write prescriptions:

Although most scripts are checked for drug interactions, not all can be, Lockwood pointed out, particularly if patients fill their medications at different pharmacies or if the prescription is not covered by third-party payment.

Some PBMs see the connectivity issue differently. The databases they develop and make available to physicians are de-signed to improve clinical practice, but they also are set up to influence physician prescribing practices. By giving physicians formulary and clinical information at the point of prescribing, PBMs help doctors avoid patient drug interactions while allowing them to more easily prescribe a formulary drug.

Sharing this information also avoids two problems: making the patient wait until the pharmacist contacts the physician if a medication change is needed, and avoiding the telephone tag pharmacists play with doctors’ offices. When physicians write prescriptions that are on the formulary, it eliminates the need to call their offices, allowing pharmacists to do more clinical work or counsel patients. "Pharmacists primarily want to do clinical work, not administrative work," said Brian Stuhlmuller, president of InfoScan, which publishes formulary information. "Using physician-pharmacist connectivity will increase the importance of what the pharmacist is doing."

Stuhlmuller said InfoScan’s surveys show that doctors, nurses, and physicians’ staffs spend approximately 1.25 hours per day handling calls about changing prescriptions. The surveys found that doctors believe the ability to look up formularies is the most important reason for electronic prescribing. "It’s the number one reason physicians want electronic prescribing," he said.

"That sort of connectivity makes the process easier and efficient for all parties." said Segedin. "The fundamental issue at PCS is to help its clients manage drug spending and give physicians infor-mation in a timely manner to enable them to take better care of patients."

Providing physicians and pharmacists with a patient’s complete drug history improves patient care. It allows physicians to see medications the pa-tient is taking that they didn’t prescribe. "There’s a lack of coordination sometimes even in an HMO," acknowledged Segedin. "By accessing complete prescription drug data, physicians can help ensure that patients take their medication or avoid taking drugs that will interact adversely."

The many potential facets of pharmaceutical informatics has led Anthony Blash of Drake University College of Pharmacy and Health Sciences–a pharmacist with a computer degree–to start a discussion group to "make sense of all the talk about technology and pharmacy." He said it also will give people a place to examine the different needs of hospital and retail pharmacies as well as those in industry and academia. Blash’s Web site-based discussion group is pharmacy.drake.edu/virtual_health_center.

Physician Automation

For the most part, the prescribing process still begins with a scribbled script from the physician that is hand-delivered by the patient to the pharmacist. Although most physicians’ offices now have computers, they are largely used for administrative tasks such as billing and scheduling appointments. Few have computer-based patient records.

"Online interaction, even with prescriptions, would be a change in practice for the majority of doctors," said Renato Cataldo, president of Health Tech Solutions, a software and health care con-sulting company in St. Louis. "Doctors see computers as an intrusion, unless they are being used in a teaching role."

The computer technology that now exists is used almost exclusively for electronically filing claims. "Ninety-nine percent of pharmacies already are fully computerized," said Lockwood. Most pharmacies already have electronic links to payors as well as to benefit managers. About 86% of all prescription claims are filed electronically, according to Faulkner & Gray’s 1997 Health Data Directory.

Cataldo noted that different parties want different things from electronic connectivity. Managed care groups want to give physicians information on their practices, their patients, and MCO formularies. Doctors often just want to check reference works online, such as prescribing guidelines or dosages. But no matter what the reason, said Cataldo, physicians will not use such a system unless there is an incentive to do it. "It’s either got to save the doctor time or save money. Otherwise, it will fail," he said.

A growing managed care trend toward capitating pharmacy benefits in physician practices could provide that financial motivation. Patricia Salmon is a Philadelphia-based consultant who helps physicians with their medical practices. She believes that younger physicians may be more in tune with a computer link-up, but that most doctors would not want to do it unless their managed care risk contract required connectivity. "They’d want to know who would pay for the training and the time to do this," she said. "As much as they would like to have the clinical information, time is still an issue."

Lockwood believes widespread connectivity of physicians and pharmacists is still 10 years away. Doctors’ offices simply are not yet ready to connect directly to pharmacy computer systems, partly because of the need for compatible software to move transactions, he said. And, Lockwood added, most current transactions are local, and do not need to be routed through networks. "The information is only going from Main Street to Elm Street," he noted.

In the meantime, some pharmacists now are faxing refill authorization re-quests directly from their computer to the doctor’s office. This saves time by keeping the pharmacist and the doctor off the phone. "No one wants to play telephone tag," said Lockwood. He added that connectivity will work very well in a closed system and makes sense, but is difficult in the retail setting. "It’s an idea looking for a market," he said. An additional issue is that state boards of pharmacy may oppose connecti-vity if the prescription is filtered through a PBM. "I believe state boards will have a problem with that," Lockwood added.

The Academy of Managed Care Pharmacy (AMCP), however, believes the movement toward automating ex-change of health care information would improve drug therapy, help with collecting and analyzing patient data, and increase operating efficiency for managed care plans and physicians. This, in turn, would produce better health care outcomes. "Using integrated standardized data, pharmacists will be able to share patient information and outcomes with other providers," said Richard Fry, AMCP director of professional affairs. "This collaborative effort will help pharmacists provide pharmaceutical care."

The issue, at this point, still seems to be the viability of connectivity. Any use of a computer in the clinical setting, other than for billing and administration, is still seen as an intrusion, said Cataldo. "You must make connecting to the computer as comfortable for the doctor as writing on the note pad."

But that time may not be far off. Phy-sicians are looking for hand-held computers that they can use in a patient’s room and tie directly into the network, Cataldo said. "The technology is almost there. There are $500 palm-size computers, but there needs to be a better tie-in with the network. The ability to be connected to the rest of the world is important, and health care is only part of that process," he said. Another issue, Cataldo noted, is that most of the data for managed care and PBMs are on custom-designed software that cannot interact with more commonly used, off-the-shelf software.

One big step in the direction of sharing information came last year when National Data Corporation in Atlanta, a leading electronic claims processing firm, and InfoScan of North Wales, Penn-sylvania, a database publisher of managed care formulary information, joined forces to offer managed care formulary information to medical practices using electronic prescribing systems. InfoScan’s formulary database also has joined with that of MediSpan, a well-known drug interaction database. This new database allows physicians to electronically access the formularies of more than 825 HMOs, PPOs, and PBMs nationwide. When us-ing electronic prescribing software, doctors can check which drugs are approved, preferred, or reimbursed under various managed care plans.

Although InfoScan’s Stuhlmuller agreed that physicians have been reluctant to use electronic prescribing programs in the past, several pilot programs have shown some success with linking doctors to patient information. Pat Abercrombie, a consulting industrial engineer, worked for six months with an 84-physician medical practice, the Santa Cruz Medical Clinic, in Santa Cruz, Cali-fornia. Doctors in one of the clinic’s seven sites were given hand-held compu-ters that looked like an Etch-a-Sketch,tm which allowed them to post an electronic "sticky note" or draw pictures to show the location of a particular medical prob-lem. The device brought up protocols to remind physicians which laboratory tests to order, transmitted orders to the onsite lab, allowed doctors to fax prescription orders directly to pharmacies, and checked for formulary requirements based on a patient’s health plan. In short, said Abercrombie, it was an electronic medical record–one that was updated continuously by radio wave transmitters to servers installed in the office’s ceiling.

The primary goal was to improve billing turnaround–which it did dramati-cally, cutting submission of charges from 22 days to one day. But the unexpected benefit was that the doctors were thrilled with the machines. "The doctors didn’t want to give them up after the pilot program," said Abercrombie. "They said they couldn’t imagine going back to a paper system." The other benefit, he said, was that the patients were happy because their prescriptions were waiting for them at the pharmacy. The company that made the computers is defunct now, but some of those involved in the experiment are trying to start another company and bring them back to the market.

The government now is getting into the issue of electronic transfer of data as well. The Health Care Financing Admini-stration’s (HCFA) proposed standards for health plans, clearinghouses, and provid-ers in electronically transferring patient data were published May 7, 1998, in the Federal Register. These standards were accompanied by proposed rules for estab-lishing health care provider numbers to be used with electronic transmissions. HCFA said these standards and codes would improve federal and private health programs by enabling "the efficient electronic transmission of certain health information."

The standards are scheduled to be adopted by February 2000. While these standards apply only to financial and administrative transactions, they set the stage for establishing standards for clinical transactions.

Cataldo believes that while connectivity will continue to grow over the next five to 10 years, most companies today are focused on a more immediate issue–the Year 2000 problem. "For them, spend-ing time on connectivity is not as important as making sure the computers are running on Jan. 1, 2000," Cataldo said.

Author

Marlene Z. Bloom is Director of Communications at the Academy of Managed Care Pharmacy.

Copyright© 1998, Academy of Managed Care Pharmacy, Inc. All rights reserved.