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Trends and benefits of electronic
prescribing in upstate New York
Upstate New York: 2009*
Physicians who e-prescribe:
24.3%
Physician assistants and nurse
practitioners who e-prescribe:
20.6%
Total new and renewed prescriptions:
21.1 million
Prescriptions sent/filled electronically
(new and renewed):
12% (2.5 million)
Central New York Region: 2009*
Physicians who e-prescribe:
21.8%
Physician assistants and nurse
practitioners who e-prescribe:
17.3%
Total new and renewed prescriptions:
4.6 million
Prescriptions sent/filled electronically
(new and renewed):
12% (552,000)
Finger Lakes Region: 2009*
Physicians who e-prescribe:
26.4%
Physician assistants and nurse
practitioners who e-prescribe:
20.2%
Total new and renewed prescriptions:
3.9 million
Prescriptions sent/filled electronically
(new and renewed):
12% (468,000)
Utica/Rome/North Country Region: 2009*
Western New York Region: 2009*
Physicians who e-prescribe:
27.0%
Physician assistants and nurse
practitioners who e-prescribe:
23.8%
Total new and renewed prescriptions:
6.4 million
Prescriptions sent/filled electronically
(new and renewed):
12% (768,000)
Physicians who e-prescribe:
23.8%
Physician assistants and nurse
practitioners who e-prescribe:
22.7%
Total new and renewed prescriptions:
3.7 million
Prescriptions sent/filled electronically
(new and renewed):
12% (444,000)
Southern Tier Region: 2009*
Physicians who e-prescribe:
18.0%
Physician assistants and nurse
practitioners who e-prescribe:
17.9%
Total new and renewed prescriptions:
2.4 million
Prescriptions sent/filled electronically
(new and renewed):
12% (288,000)
*Estimated. See methodology on page 9.
Sources: See endnotes on page 9.
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For more than a century, the way that physicians and other medical professionals prescribe drugs for
patients has not varied much. This report shows that rapid change is under way as doctors’ offices,
neighborhood drugstores and mail-order pharmacies convert to Internet-based electronic prescribing (e-prescribing). This report also highlights the benefits resulting from e-prescribing, including a
reduction in prescribing errors, an increase in the use of money-saving generic alternatives, and an
increase in convenience and efficiency for patients, providers and pharmacists.
Active prescribers using e-prescribing
E-prescribing in the U.S.
(in millions)
200
200
175
175
156,000
150
156
150
125
125
100
100
75
191
35
75
74,000
68
13
55
50
50
36,000
25
25
29
5
24
0
0
2007
2008
2009
2007
2008
2009
New prescriptions routed electronically
Renewed prescriptions routed electronically
Source: Surescripts. “Advancing Healthcare in America – 2009 National Progress Report on E-prescribing, Plus What’s Ahead in 2010 and Beyond.” 2010, pages 10 and 8.
http://www.surescripts.com/downloads/npr/national-progress-report.pdf
Nationally, by the end of 2009:
• 25 percent of all office-based prescribers routed prescriptions electronically
(more than double the previous year’s rate).1
• 85 percent of pharmacies could receive prescriptions electronically.1
• Six of the largest mail-order pharmacies could receive prescriptions electronically.1
• At least 12 percent of the 1.63 billion new prescriptions and renewals eligible for electronic
routing were sent electronically.2
• The number of e-prescriptions exceeded 190 million, which was a 181 percent increase from
the previous year.2
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Who uses prescription drugs and how often do they use them?
In any given week, four of five U.S. adults will use prescription medicines, over-the-counter drugs or
dietary supplements, and nearly one-third of adults will take five or more different medications.3
At a glance: Prescription drug use in upstate New York
In 2009, in upstate New York:
Clinton
Franklin
St. Lawrence
Essex
Jefferson
Lewis
Hamilton
Oswego
Niagara
Orleans
Oneida
Wayne
Monroe
Erie
Livingston
Yates
Seneca
Cattaraugus
Allegany
Steuben
Otsego
Cortland
Schuyler
Chautauqua
Madison
Cayuga
Tompkins
Chemung
Tioga
• 25 percent had three or more different prescribers;
Chenango
Broome
• Two-thirds of the population used at least one
prescription drug;
• 25 percent used six or more different drugs;
Fulton
Montgomery
Ontario
Wyoming
Herkimer
Onondaga
Genesee
• 21.1 million new and renewed prescriptions were filled;
Delaware
• 5 percent used 13 or more different drugs; and
• 5 percent had six or more different prescribers.
Source: FLRx Pharmacy Management. “Upstate New York Assessment of Prescription Drug Use.” May 2010.
E-prescribing in upstate New York, 2010 trend
The e-prescribing rate in upstate New York increased from 12 percent in 2009 to 17 percent in the
first quarter of 2010. This represents 3.6 million new and renewed prescriptions on an annual basis.
(3.6 million Rx)
17%
s
Prescriptions sent electronically
(e-prescribed).
18%
s
Prescriptions telephoned or faxed.
s
Prescriptions handwritten or
printed on paper.
(3.8 million Rx)
65%
(13.7 million Rx)
Estimate based on an FLRx review of a sample of claims submitted for new and renewed prescriptions from January 2010 through March 2010.
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Greater accuracy – fewer legibility and prescribing errors
Although the percentage of office-based prescribers who sent prescriptions electronically more than
doubled from 2008 to 2009, most prescriptions are still handwritten and carried by the patient to the
pharmacy or relayed to the pharmacy via telephone or fax machine. With these manual and verbal
handoffs, medication errors can occur, which can place patients’ lives at risk.
The illustration to the right is widely referenced as an extreme
example of how some prescriptions that are handwritten by
physicians can be mis-read by pharmacists and lead to the
death of patients. In this particular case, a patient in Texas who
complained of chest pain was allegedly given the wrong medication and subsequently died from an apparent heart attack.
The physician wrote a prescription for Isordil, used to relieve
chest pain, but the pharmacy mis-read the handwritten prescription and gave the patient Plendil, a blood pressure medicine.4
According to the nonprofit Institute for Safe Medication
Practices, handwritten prescriptions and drugs with similar
names are among the most risky conditions associated with
medication use.5 As examples, the pain medication Celebrex is
close in spelling to the antidepressant Celexa and anti-seizure
medicine Cerebyx.6 Other examples include the blood pressure
medicine Norvasc and the tranquilizer Navane, and the tranquilizer Zyprexa and the antihistamine Zyrtec.7 Handwritten
versions for some of these medicines are illustrated here:
Example of illegible paper prescription
One study conducted in June 2006 in the predominantly rural and suburban Hudson Valley region of upstate
New York analyzed prescribing error rates at six medical practices before and after they started using
e-prescribing systems. The e-prescribing systems included clinical decision support such as dosing
recommendations and checks for drug allergies, drug-drug interactions and duplicate therapies. The results
were compared to a control group of six similar medical practices that continued to issue paper-based
prescriptions.
After one year, the practices that used e-prescribing systems reduced prescribing errors nearly sevenfold,
from 42.5 per 100 prescriptions to 6.6 per 100 prescriptions, and legibility errors from 87.6 per 100 prescriptions to zero. The error rate for the practices that continued to issue paper-based prescriptions remained
steady at about 38 errors per 100 prescriptions.8
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Greater security – potential to reduce prescription forgeries
Forging a prescription is relatively simple in the current environment dominated by paper-based prescriptions.
That’s despite the efforts of pharmacists to determine whether the prescriber and prescription are legitimate.
According to the American Pharmacists Association, e-prescribing could improve patient safety while
advancing the Drug Enforcement Administration’s goals of preventing illicit prescribing, doctor shopping,
and drug diversion.9
System alerts to potential adverse drug events
E-prescribing systems can include a clinical decision support function that issues alerts about dosing recommendations and checks for drug allergies, drug-drug interactions and duplicate therapies.8
In a random sample survey of 300 Massachusetts ambulatory care clinicians who used a commercial e-prescribing system, 35 percent of prescribers said that electronic alerts caused them to modify a potentially
dangerous prescription in the last 30 days.10
One study classified adverse drug events as "nonpreventable," "preventable," or "ameliorable." Preventable
events were those due to errors that could have been entirely avoided. Ameliorable events were those
whose severity or duration could have been substantially reduced had different actions been taken. The
reviewers determined preventability on the basis of the physician's presumed knowledge at the time the
drug was prescribed. If insufficient information was available, the reviewers assumed that the physician's
decision was correct. If an event was preventable or ameliorable, the reviewers specified the type of error
and how it might have been prevented.11
Adverse drug events in upstate New York, 2009
Region
Total number of
new and renewed
prescriptions
Preventable
3.0%
Ameliorable
7.7%
Western New York
6,421,000
192,630
494,420
Finger Lakes
3,850,000
115,500
296,450
Central New York
4,611,000
138,330
355,050
Utica/North Country
3,749,000
112,470
288,670
Southern Tier
2,441,000
73,230
187,960
21,071,000
632,130
1,622,470
Upstate New York
To estimate the number of adverse drug events in upstate New York, percentages from the Boston-area study referenced above were applied to the total
number of new and renewed prescriptions in upstate New York in 2009.
Applying data extracted from another study12, it can be estimated that if all physicians in upstate New York
used e-prescribing systems and responded to the drug interaction alerts on new and renewed prescriptions
in a similar way, 137,000 prescriptions would be changed to minimize the identified risk, preventing:
35 deaths
161 permanent disabilities
391 emergency room visits
449 hospitalizations
564 potentially serious adverse drug events
1,439 significant adverse drug events
2,624 minor adverse drug events
3,073 office visits
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Physicians recognize the clinical value of e-prescribing system alerts
The greatest potential for medication safety improvements may occur with the use of e-prescribing
systems.
A random survey of 300 Massachusetts ambulatory care clinicians who used a commercial e-prescribing system concluded that the alerts could lead to clinically significant modifications to patient
care that were not readily apparent.10
Survey respondents indicated that e-prescribing alerts:
{
4 Changed the way they would monitor
the patient (33 percent)
4 Caused them to modify a potentially
dangerous prescription in the past
30 days (35 percent)
4 Triggered them to look up information
(44 percent)
4 Prompted them to counsel a patient
about reaction potential (49 percent)
4 Induced them to take some action
other than modifying or stopping the
prescription (63 percent)
4 Improved quality of care delivered
(78 percent)
4 Prevented medical errors (83 percent)
A 2008 survey of upstate New York providers conducted by Univera Healthcare had 88 percent of
respondents who e-prescribe report positive feelings about e-prescribing’s ability to provide patient
care.
Calculating the cost of adverse drug events
The Institute of Medicine concluded that adverse drug events not only cost patients and their
families pain, suffering and lost wages, but also cost dollars and cents to them and their employers,
hospitals, health care providers and insurance carriers. The IOM cited one study which found that
each preventable adverse drug event that took place in a hospital added about $8,750 (in 2006
dollars) to the cost of the hospital stay.13
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Potential to reduce patients’ out-of-pocket costs
E-prescribing systems can alert prescribers to money-saving opportunities with generic or other
lower-cost alternatives to prescription drugs.
If increased use of e-prescribing systems raised the generic fill rate by just 1 percentage point, health
care spending in upstate New York could be reduced by more than $64 million.
Potential savings for each one point increase in the generic fill rate
Upstate New York
$64.4 million
$14.2 million
$12.3 million
$19.5 million
$11.0 million
$7.3 million
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Benefits of e-prescribing
E-prescribing can:
• Permit easy retrieval of prescription history for each patient, which may provide important
clues when diagnosing a patient’s condition.
• Alert the prescriber to safety and drug reference information, which may lead a provider to
check additional aspects of the patient’s history or physical exam, counsel the patient about
potential side effects and reactions, change the way the patient is monitored or modify care
management.
• Decrease callbacks due to illegible prescriptions. An estimated 30 percent of prescriptions
that are not e-prescribed require a callback for clarity, missing information, etc.14
• Provide an efficient means of generating and recording new prescriptions.
• Transmit prescriptions electronically to a pharmacy (including mail-order pharmacy) in
seconds.
• Supply prescriber and pharmacist with accurate patient information, such as which
drugs have a higher or lower member copay and whether additional information is required
to assure insurance coverage for a particular drug.
Government support for e-prescribing
Centers for Medicare &
Medicaid Services
New York State’s
Medicaid Program
American Recovery and
Reinvestment Act
Starting in 2009, the Centers
for Medicare & Medicaid
Services began awarding
incentives to Medicare
physicians who e-prescribe.
Through 2010, eligible
professionals receive a 2
percent incentive payment.
In 2011 and 2012, that
incentive payment will be
reduced to 1 percent and in
2013 to 0.5 percent.15
Beginning in 2012, eligible
professionals who aren't
"successful electronic
prescribers" will be subject
to a penalty.16
New York State’s Medicaid
program has an incentive to
encourage prescribers and
pharmacies to e-prescribe.
Medicaid prescribers can
receive an incentive payment
of 80 cents per dispensed
Medicaid e-prescription,
while eligible retail pharmacies can receive an incentive
of 20 cents per dispensed
Medicaid e-prescription.17
The federal government’s
economic stimulus package
included the Health
Information Technology for
Economic and Clinical Health
Act, which allocated $20
billion to invest in health
information technology
infrastructure. The legislation
provides significant financial
incentives through Medicare
and Medicaid programs to
encourage doctors and
hospitals to use health
information technology.18
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Methodology
Note: the information below is a compilation of the methods that have been used to derive the information in this report, particularly how it relates to the use
of our specific population and then extrapolating this information to what we would expect or anticipate in the total 39-county census population. It includes:
• The number of prescriptions (new, renewed, refills).
• The cost savings (generic fill rate increase).
• The incidence of adverse drug events.
Background
FLRx claims data provide a large sample of pharmacy dispensing events for insured residents of upstate New York. FLRx manages prescription benefit services for
approximately 1 million of the 4.9 million people who live in upstate New York's 39-county region. The set of all claims that were paid in 2009 for FLRx members
who live in one of our 39 upstate New York counties was used.
Methodology used for estimating the total upstate New York population's drug utilization
To arrive at estimates used in this report for the entire upstate New York population, we:
• Determined the number of FLRx members in each month in each of the 39 counties by gender and the 18 age groups reported in the U.S. Census Bureau’s
population estimates for these counties;
• Calculated the average number of FLRx members in each quarter of 2009 in each of these 39 counties and multiplied it by 2 (male and female) and then by
the 18 age group categories;
• Added the observed utilization by the same (specifically identified) members in each quarter of 2009 and extrapolated the observed utilization to the total
population by multiplying by the ratio of the total census population (in each gender and age category) to the average FLRx sample population.
Methodology used for the estimated number of prescriptions used
The fraction of new prescriptions in the last six months of 2009 was estimated by identifying those prescriptions that were the first claims for a specific drug
(Medispan GPI_NBR) for the patient since January 1, 2009. This fraction is applied to the total number of new + renewed prescriptions to estimate the number of
new and the number of renewed prescriptions in one year.
Endnotes
1 Surescripts. “Advancing Healthcare in America – 2009 National Progress Report on E-prescribing, Plus What’s Ahead in 2010 and Beyond.” 2010, page 4.
http://www.surescripts.com/downloads/npr/national-progress-report.pdf
2 Surescripts, page 8.
3 Institute of Medicine, under charter of the National Academy of Sciences. “Preventing Medication Errors.” Report Brief, July 2006, page 1.
http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.ashx
4 Institute for Safe Medication Practices."Handwriting On The Wall?" From the July 16,1997, issue. http://www.ismp.org/Newsletters/acutecare/articles/19970716.asp)
5 Institute for Safe Medication Practices. "Progress With Preventing Name Confusion Errors." From the August 9, 2007, issue.
http://www.ismp.org/Newsletters/acutecare/articles/20070809.asp
6 Institute for Safe Medication Practices. "A Call to Action: Eliminate Handwritten Prescriptions Within 3 Years! Electronic Prescribing Can Reduce Medication Errors."
2000. http://www.ismp.org/Newsletters/acutecare/articles/Whitepaper.asp
7 Roberts WC. "Facts and Ideas From Anywhere." Baylor University Medical Center Proceedings. Vol. 13, No. 1., January 2000.
http://www.baylorhealth.edu/proceedings/13_1/13_1_roberts.html
8 Kaushal R, Kern LM, Barrón Y, Quaresimo J, Abramson EL. “Electronic prescribing improves medication safety in community-based office practices.”
Journal of General Internal Medicine. Vol. 25, No. 6, June 2010. Pages 530-536. http://www.ncbi.nlm.nih.gov/pubmed/20186499
9 Statement of the American Pharmacists Association, Submitted to the United States Senate Committee on the Judiciary. “Electronic Prescribing of Controlled
Substances: Addressing Health Care and Law Enforcement Priorities.” December 4, 2007, pages 1,2.
https://www.pharmacist.com/AM/Template.cfm?Section=Home2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=17910
10 Weingart SN, Simchowitz B, Shiman L, Brouillard D, Cyrulik A, Davis RB, Isaac T, Massagli M, Morway L, Sands DZ, Spencer J, Weissman JS. “Clinicians' Assessments
of Electronic Medication Safety Alerts in Ambulatory Care.” Archives of Internal Medicine. Vol. 169, No.17, September 28, 2009. Pages 1627-1632.
http://archinte.ama-assn.org/cgi/content/abstract/169/17/1627
11 Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger DL, Shu K, Federico F, Leape LL, and Bates DW. “Adverse Drug Events in Ambulatory
Care.” The New England Journal of Medicine. Vol. 348, No. 16, April 17, 2003. Pages 1556-1564. http://content.nejm.org/cgi/content/full/348/16/1556
12 Weingart SN, Simchowitz B, Padolsky H, Isaac T, Seger AC, Massagli M, Davis RB, Weissman JS. "An Empirical Model to Estimate the Potential Impact of
Medication Safety Alerts on Patient Safety, Health Care Utilization, and Cost in Ambulatory Care." Archives of Internal Medicine. Vol.169, No.16, September 14,
2009. Pages 1465-73. http://archinte.ama-assn.org/cgi/content/abstract/169/16/1465
13 Institute of Medicine, page 2.
14 CommonwealthRx.com/Pharmacists. “Pharmacists and Pharmacies.” http://www.commonwealthrx.com/pharmacists.shtml
15 Centers for Medicare & Medicaid Services. "Medicare's Practical Guide to the Electronic Prescribing (eRx) Incentive Program." Revised February 2010, page 3.
http://www.cms.gov/partnerships/downloads/11399-P.pdf
16 Centers for Medicare & Medicaid Services, page 13.
17 Surescripts, page 17.
18 U.S.House of Representatives Committee on Ways and Means. “Health Information Technology for Economic and Clinical Health Act or HITECH Act.”
January 16, 2009. http://waysandmeans.house.gov/media/pdf/110/hit2.pdf
Sources: The number of physicians, physician assistants and nurse practitioners who e-prescribe was determined by:
– Using the National Plan and Provider Enumeration System public use files and the Annual New York Physician Workforce Profile published by the University at
Albany School of Public Health to identify all licensed New York state physicians and other prescribers.
– Using a prescription utilization sample from the FLRx member population to identify upstate New York prescribers who were active during the fourth quarter of
2009. (The FLRx sample is approximately 20 percent of the census population. FLRx is the pharmacy benefits management division of Univera Healthcare.)
– Comparing that list with the Surescripts provider directory for the 39-county upstate New York area to identify individuals who are certified with Surescripts for
e-prescribing and who transmitted at least one prescription during the fourth quarter of 2009.
According to Surescripts, 12 percent of new prescriptions and renewals are electronically routed. “Advancing Healthcare in America – 2009 National Progress Report
on E-prescribing, Plus What’s Ahead in 2010 and Beyond.” Surescripts. 2010, page 8. http://www.surescripts.com/downloads/npr/national-progress-report.pdf
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