Helping Providers Manage e-Prescribing

At Health IT Outcomes, we’ve made it our mission to provide the healthcare industry with expert guidance on technology system selection, integration, project management, and change management. To help achieve this goal, we speak with industry leaders on everything from EHRs to HIEs to HIM, and then share these conversations with you. We recently travelled to Chicago to attend HIMSS15 where we had the privilege to speak with the President of DrFirst, Cam Deemer, and his company’s efforts in medication management and adherence, as well as care collaboration.

Health IT Voices: Tell is about you and your background and what brought you to DrFirst.

Deemer: Before I joined DrFirst, I was with PCS Health Systems for 10 years. I spent a couple of years with NDC Health working primarily on e-prescribing and EMR. I joined DrFirst in 2004, so I just had my ten year anniversary, going on eleven with the company now.

I had been through some of the very early days of e-prescribing when I was with PCS. It was a time when there were really no standards, nobody knew what to do. We were doing one-off pilots. I was involved in the original standards development on the National Council for Prescription Drug Programs (NCPDP) as one of the co-chairs on the SCRIPT 1.0 committee. I just had a real interest in that, so the opportunity to get in with a relatively-small company at the time doing some interesting things around e-prescribing was appealing to me. I thought it was a real sweet spot, so I was happy to join.

Health IT Voices: Medication management, medication adherence, and care collaboration are all very critical. Why is that such an important part of the work DrFirst does?

Deemer: About 10 years ago — about the time I joined the company — we were looking at what we were going to do long-term. We were a stand-alone e-prescribing company at that time and could see some real problems with that moving down the road. We figured 10 years from that point, nobody would be doing e-prescribing anymore, or stand-alone e-prescribing. It would all be subsumed into EMR companies and applications. Instead, we decided to take a whole different approach to the market.

We thought we would go horizontal through the healthcare space and really focus on the point of encounter. For us, that meant focusing on medication management. Medication management really encompasses all those other things you were talking about: adherence and collaboration. If you think about it, before the doctor prescribes something, he needs to understand fully the patient’s background and the care other providers have brought to the table, so that’s sort of like assessment and reconciliation. Then, they move into prescribing. They prescribe something and they have to monitor the outcome. Did the patient stick with the therapy? Did they get off of it? Did it have the outcomes they intended? We really try to cover that whole space horizontally, just taking a slice right out of healthcare and pay special attention to that whole med management process.

Health IT Voices: Many people who are prescribed medications follow the protocol wrong, not because they are bad people or are careless or reckless. Sometimes, it’s complicated, and they don’t take the meds right and it causes obvious problems. Is that part of the problem you are trying to address here?

Deemer: That’s a piece of the problem set. For us, when we think about adherence to therapy, we are a little more concerned that the patient gets on the therapy to begin with. So, we spend a lot of time first giving the physician what they need to make the right prescribing decision. Then we make sure that, if the patient doesn’t pick up the drug, we take that information back to the doctor.

It’s creating a feedback loop so the physician actually knows what happens when you’re not in the practice anymore. So when you come back and the therapy hasn’t had the impact intended, the physician can look at his report card for the patient and say, “Well, I see why that’s not working. It looks like you’ve never actually picked it up to begin with.” If you have been picking up the drug, the doctor can check, “Well, have you been taking it? How have you been taking it? Oh, I see what the problem is. What I asked you to do was this, but you are actually doing it this other way. It’s not giving you the results you want, so let’s get you back on track.”

Health IT Voices: It sounds like you are more focused on helping the physician versus the patient.

Deemer: Oh, absolutely. It’s our company’s name: DrFirst. We try to make the physician the center of everything we do. One of the things we realized early on was that the physician needs to get inputs from a lot of different stakeholders in the healthcare process. Think about how much of your healthcare as a patient is driven by your plan. If your plan doesn’t have an effective way to communicate with the physician, the physician is not aware of all your options. He doesn’t know how you can save money or what therapies you may be receiving from another provider that would impact what he needs to do.

In addition to providing tools for physicians, we try to take our position at the point of encounter and open it up to other stakeholders as well so they can access the physician in real time. The doctor wants to know what you have to say when the patient is there. When the patient is not there, he is way too busy with other things to deal with it, but he’s more than happy to have a conversation with a patient when they are face to face. That’s a large part of what we do: bringing those stakeholders into the conversation between the physician and the patient.

Health IT Voices: Let’s go down a little different path and talk about New York’s I-STOP Act. Describe that for us.

Deemer: I-STOP was the state of New York saying, “We recognize the value of the e-prescribing process, and we want to make sure it happens for every patient, every time.” So, it’s a requirement that physicians write all scripts electronically and submit them to the pharmacy. That was both legend drugs and controlled substances, so that was very exciting.

We were working very hard to have everybody in the state ready by the end of March 2015. Recently, you’ve probably heard the legislature moved it back one more year, which is fine. It gives the doctors that much more time to be ready, but we think now they really need to go ahead and implement. Don’t wait another year. You need to have time to work it into your workflow, make it part of your practice to be successful with it.

Health IT Voices: There is a pretty unique challenge when it comes to medication management versus medication adherence. One seems to be a problem with the provider and another seems to be a problem with the patient. What’s the right way to look at that?

Deemer: That is a common way to look at it, that one is doctor, one is patient. I actually think the whole thing is a shared problem. As the physician I can prescribe you a therapy and send you out into the world to adhere to the therapy. I don’t even think about it again until the next time you come in, and then I find out that you are not adhering to the therapy, you haven’t changed. Your lipid levels haven’t changed, or some other condition, I can’t see a difference in your lab values, so what do I do? Well, maybe I up your dosage now and you don’t pick that one up, so next time you come back, I up your dosage again.

You know, compliance requires the patient to feel like they have their financial and clinical needs taken care of, but you also have to deal with the behavioural aspect of “Why don’t they pick up drugs?” So, we try to bring the physician into that, make the physician aware of whether the patient is complying, provide them a full set of tools so I can say, “Hey, you’re not picking up your drugs.” Perhaps the patient replaces, “I can’t afford it.” Then the physician can say, “Let me help you. I’ve got some co-pay assistance programs that I can prescribe to you along with the drug.” That’s the kind of thing we are trying to do to make sure that we drive compliance all the way involving both the physician and the patient.

Health IT Voices: A lot of people are talking about the fact that healthcare is more distributed now. How does mobile — and other forms of modern communication — impact that?

Deemer: First, you think about, “Are we distributing it out to the patient?” Well, that’s certainly happening in a big way right now. I mean, health plans have been working on this for a couple of years. They are distributing responsibility by saying, “I’m going to have you pay more of the cost of this healthcare, so you better pick a doctor wisely, and you better decide what treatments you need.” We’ve already got that happening in the market today.

In terms of care and diagnosis, patients are certainly better informed than they’ve ever been — for good or for bad — so that’s certainly happening. But, the next wave of what’s coming —personalized medicine, the impact of genomics, — I think we are going to need professionals leading us in that area as we enter into it. Maybe, eventually, that will be distributed out to patients, but for now I think it’s primarily around making wiser choices with how healthcare dollars are spent, and certainly on working with physicians with more understanding of what kinds of treatment options are available to you. Those things seem to be pushed down to the patient today.

If you think about distributing it out to the other stakeholders, there hasn’t been a whole lot of work done on that. Health plans are still sending letters to doctors hoping they will read it and do something about it. That’s what I was speaking about earlier: I think we need to open up that dialogue space when the physician and patient are face-to-face and really help the physician understand what he can do right then that will make a big difference in the patient’s care.

Health IT Voices: With regard to mobility, how do we ensure the protection of data vis-a-vis HIPAA compliance?

Deemer: On the face of it, that’s a very simple answer: make sure nothing is stored on the device, make sure you are using very strong encryption for everything that is transmitted, anything that is stored, and make sure it’s stored encrypted. Security is something we’ve already locked down; we just have to do it.

It’s not rocket science. The real question is how you get people to use a secure system. Tokens are very cumbersome. People are working on biometric solutions. It’s all harder to do than a non-secure system, so working very hard on how to make it part of the workflow that you just need to do, that you get used to doing it so that you don’t think of it as a chore anymore. Instead, you think of it as, “Hey it’s lending efficiency to me in the work that I do.” I think that’s what’s important at this point with secure systems.