Monday, July 7, 2008

The Surescripts/RxHub merger

Last week, I spoke with the Associated Press and Wall Street Journal about the recent merger of Surescripts and Rxhub.

My basic message was:

"The merger of Surescripts and RxHub provides a single medication data stream, supporting medication safety. It also provides an easy e-prescribing implementation path for electronic health record vendors and an enhanced medication workflow for clinicians nationwide."

Here's the reason I made these comments. In the world of e-Prescribing, the stakeholders are

- the patient
- the physician writing the prescription
- the retail pharmacy or mail order pharmacy
- the payer
- the pharmacy benefit manager (PBM), which acts on behalf of the payer to adjudicate claims
- RxHub: the connection to most PBMs
- SureScripts: the connection to most retail pharmacies

Here's the data flow:

1. A clinician begins to e-Prescribe and electronically queries for the patient's insurance eligibility and the appropriate payer's formulary. Before the merger, both RxHub and SureScripts had eligibility services but RxHub processed the majority of these transactions.

2. The clinician queries for medication history to check for drug/drug interactions. RxHub has medication history based upon claims data and SureScripts has the actual dispensed information from the pharmacies (which includes cash, third party claims and $4 generic programs). Before the merger, the clinician's EHR would have to issue separate queries via two separate interfaces to get a complete history.

3. The physician completes the prescription. Retail pharmacy transactions are transmitted to SureScripts for delivery to community pharmacies and smaller mail order firms. Mail order transactions served by one of the 3 large PBMs are transmitted to RxHub for fulfillment. Again, two separate interfaces were required.

As SureScripts-RxHub integrates its services, there will no longer be a need to send out 2 queries for eligibility/formulary, medication history or routing. Also, the two sources of medication history data will be de-duplicated, providing an accurate and usable medication data flow to all stakeholders.

In addition to the Surescripts-RxHub merger, two other important events will accelerate e-Prescribing in 2009.

1. Regulatory changes proposed by the Drug Enforcement Agency will enable electronic prescribing of scheduled/controlled medications. Having separate workflows for controlled medications verses all others has been a real barrier to process change in many medical care settings. I look forward to the regulatory change.

2. Incentives to adopt and use e-Precribing via the Medicare Electronic Medication Safety Protection Act of 2007. Clinicians have been reluctant to adopt electronic prescribing because of the investment and time commitment to change change their workflow. Currently only 4% of the clinicians in the country e-prescribe (although Massachusetts is at 13% and BIDMC is at 50%). A one time payment when e-prescribing is implemented helps a physician acquire the technology. An ongoing incentive ensures they continue to use it.

Let's hope 2009 is the year of e-prescribing. Everyone wins through reduced cost, enhanced quality and better workflow.

12 comments:

Richard Dale said...

John... E-prescribing stakeholders: great list ... except where is the patient! I know you well enough to be sure that you place the patient at the center of the healthcare world. I take this as commentary on the e-prescribing transaction itself, and not a reductionist view of health-care!
Based on your previous comments, and talks I have heard you deliver, I understand e-prescribing is about better patient care at lower cost.
Amen to that.

John Halamka said...

Absolutely! I'll add patients to the stakeholders list. I have spoken with Surescripts/Rxhub leadership about ensuring patients have access to all their own data.

willrice said...

How are you measuring BIDMC eRx rate (50%)? Writing the prescription electronically is only half of the transaction. It must be received by the pharmacy electronically (not e-fax, not viewed in one system and typed into another system). How do you measure the true eRx rate at 50%?

Usman said...

Hi John. I'm one of your students from the Healthcare Quality course this year (Dr. Leape). The workflow you described looked like this to me:

Clinician begins e-prescribe --> Query to insurance --> if eligible --> Query drug hx for interactions --> if no interaction then transmit transaction to pharmacy.

I assumed this part:
If some interaction found --> re-prescribe alternative --> repeat.

I was wondering why the interaction query doesn't come before the query to insurance company?

John Halamka said...

Responding to Willrice's question - 95% of the pharmacies in Massachusetts are electronically (not fax) connected to Surescripts, so we're in good shape. Our BIDMC EMR does not have a fax option, just an NCPDP Script 8.1 electronic routing option.

Responding to Usman's question - the insurance query leads us to the formulary, which specifies the list of prescribing possibilities. The clinician chooses medications from the list and if there is a conflict, formulary alternatives are shown which are safe.

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Football Matches said...

How are you measuring BIDMC eRx rate (50%)? Writing the prescription electronically is only half of the transaction. It must be received by the pharmacy electronically (not e-fax, not viewed in one system and typed into another system). How do you measure the true eRx rate at 50%?

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