e-prescriptions

'To E or not to E'

Pharmacies have been handling e-prescriptions for some time, but the technology has reached the world of DME. How should DME pharmacies weigh the pros and cons?

• By Holly J. Wagner
• Aug 19, 2020

Pharmacists have been using e-prescription systems for years, yet only an estimated 10 percent of DMEs use them. Could using e-prescription systems save your business time and money, reduce errors and build your clientele? Like most technology installations or upgrades, that depends a lot on your business.

The basics are simple: instead of getting paper or fax scripts, the referrer sends the prescription to you electronically so it comes into your system directly via a closed network instead of through the door, phone or email. Physician instructions and other documentation travel with the script and optimally, it all goes into the system before you even see the order.

“The benefits for most e-Rx platforms is you are accepting the order in the same way as you did before with the fax method, the difference is that you have the data in front of you,” says David Gelbard, founder and CEO or Parachute Health. “It is not much of a change for the workflow, just you are looking at the information digitally.”

The benefits of using e-prescriptions are measured in minimizing chances for errors, streamlining documentation and workflow, potential faster payments and new business opportunities.

“This is an emerging trend and has an opportunity to solve a lot of pain points,” says Nick Knowlton, Vice President of Business Development at Brightree and Vice Chairman of the CommonWell Alliance interoperability group. “We talk a lot in the industry about interoperability, and this is one of the easiest concepts for folks to grasp.”

So why hasn’t there been a stampede to switch to e-prescribing DME? There are a few reasons: no pressure from payers or incentives from CMS; a multitude of closed systems with fragmented adoption among prescribers; and perhaps most importantly, DMEs alone bear the cost.

None of that should put you off of using e-prescriptions entirely. It makes sense for some businesses today, and industry experts say the day will come when e-prescribing dominates the DME landscape the way it does in medical prescribing. It’s just not there yet.

“In general, hesitancy by providers to participate in adoption of e-prescribing for DME creates a growing risk of loss of patient referrals and orders from adopting prescriber and referral sources,” says Jason Farmer, CEO of Stratice Health.

DON’T LOOK FOR OUTSIDE INCENTIVES

If you are a DME pharmacy, chances are you are already using e-prescriptions for medications. As part of its ongoing efforts to digitize health records, CMS used some carrots and sticks to get pharmacists on board. “They used to be able to do incentive payments to those hospitals and physician practices for using a certain parts of an EHR. It was called ‘meaningful use’…I’m not sure if meaningful use even exists anymore,” says Kim Brummett, Vice President of Regulatory Affairs at AAHomecare.

There’s a chance your pharmacy e-prescription vendor has an add-on module for DME, but don’t count on it. As Knowlton explains, the e-prescription systems for meds and for DME evolved separately and often aren’t compatible.

“The e-prescribing for medications by and large flow through a couple of large national networks that have been around and been large enough to be relevant for more than a decade,” he says. The largest, Surescripts, handles about 80 percent of medication prescribing. “That is not the same thing we see in the HME world. There is some capability for HME [in pharmacy systems], but by and large they are separate technology platforms.”

Hence the rise of competing independent DME e-prescribe platforms. “Those are systems that were designed from the needs of the HME provider perspective, and a little bit less from what the EHRs are capable of doing perspective,” Knowlton explains. “We kind of have a convergence out there between those two concepts, where some of the EHRs can produce and transmit electronic orders, and where there are now several reputable platforms for providers to choose from.”

Therein lies the rub. The market for DME e-prescribe is young and the number of competing platforms can make shopping for the right fit a challenge. “The whole e-initiative that CMS had to get physicians, hospitals and practices to adopt EHRs, it had all this standardized programming and interfaces,” Brummett notes, while there’s a lot of variation DME e-prescribe platforms.

In the absence of incentives, your referrers may not have made the switch. There’s no empirical research on e-prescription use among DMEs; there are no set standards or payer incentives. To some extent the DME part of the industry is playing catch-up, so the cost/benefit analysis rests solely with the individual business.

TOO MANY CHOICES?

Remember when you (or your parents) went out to buy the family’s first video player? Back at the beginning, you had a choice between VHS and Betamax. Even with just two choices, it took a couple of years of parallel marketing before the VHS format won out.

One reason DMEs have been slow to adopt e-prescriptions is that there are several platforms, and – like VHS and Betamax – they don’t talk to each other. Some are geared more to use in a physician office environment, while others are more suited to hospital and institutional use. They offer different features to support different markets.

“Providers typically select one primary e-prescribing solution and persuade their prescribers and referrals to both initiate and receive new and resupply orders for faster, more reliable fulfillment,” Farmer says. “To a lesser degree, some providers participate in additional e-prescribing solutions to ensure they are an available fulfillment option for those prescribers and referrals using other e-prescribing solutions.”

That’s definitely not a selling point for DMEs. Staff having to learn each individual system and then switch among them can outweigh the value of the change, Brummett says. “Some of them are using two or more of the applications, and they’re so different. You’ve got practices and hospitals that are using Parachute and you’ve got other ones using GoScripts and others on DMEHub. Your poor staff.”

FOLLOW THE FEATURES

The number of players in the space can both complicate and simplify your choice. At first glance, the field looks so crowded it’s intimidating. But the vendors have focused on different capabilities and, in some cases, geography, that will make it easier to rule some out.

A good e-prescription system should reduce claim rejections up front by ensuring documentation is complete. Most have a dashboard user interface that’s simple to navigate. If a question should arise, all of a patient’s information should be in one cyber-place, easy to find and pull up for review. Many systems can pre-check claims to make sure the patient is covered. Some systems interface with physician EHR systems, but many of the stand-alones don’t. Some can allow for nonphysicians to place orders – think facility ordering and hospital discharge management. “There is even connectivity available to inventory closets and the like to help drive electronic orders,” Knowlton says.

An e-prescribing system that offers a catalog-like interface will let the prescriber choose and order a specific item from your business. “It is almost a storefront. The DME company has to figure out how to stock the shelves and what capabilities they need,” Gelbard says. “That’s how I would evaluate e-prescribing software, is what is going to give the greatest experience to my ordering providers that will enable them to convert to digital. I think it should really be supplier driven.”

Some of the platforms integrate with other software you may already be running, while others are entirely stand-alone. “Parachute works with most of the billing systems that exist in the DME market,” Gelbard says. “When a referral sends an e-prescribe from Parachute’s ordering platform to our intake platform, that order gets transferred to the billing system whether it is [the DME’s] own system or a third-party system. The order should flow right into that billing system to avoid conflicting data.”

YOUR MARKET IS THE KEY

The cost makes the path to the benefits a bit steeper, but not necessarily a dead end. Depending on your situation and which platform you choose, digitizing your prescription system can help reduce labor and errors, speed up your payments, manage inventory and build your business. The benefits depend a lot on where you are now, and where your market is – probably the most critical part of your decision about if, or when, to implement e-prescribing, and which platform to choose.

“The opportunity to move forward with electronic prescriptions is this year. The first thing to do to participate is to become educated. And the second thing is to go to the referrers,” Knowlton says. Are the bulk of your referrals coming from individual physicians? Hospitals? Facilities or home care managers? How many of your referrers are already using EHR and DME e-prescription systems? Which ones are they using?

“A lot of [DMEs] are going out in the marketplace and finding out the referral source has already made a selection and is using one platform or another,” Knowlton says. “For some of the providers out there, their EHRs actually have the capability to e-prescribe for home medical equipment as part of their core functionality. If you work in the user interfaces for those EHRs, ordering home medical equipment is right next to ordering medications or lab tests or radiology studies, in that physician’s native workflow.”

A big promise of e-prescribing is the possibility of picking up business you are missing because those referrers prefer e-prescribing. “If you have 100 orders coming into your operation, 20 are will be from a hospital. Who can be interoperable with the hospital to get those orders done efficiently? Then you have a number of scattered doctor offices. How do you get e-prescribing into that order workflow?” says Gelbard.

That’s why it’s also important to look outside your existing referral base. Look at your whole market: are there referrers out there that send business elsewhere because you don’t use an e-prescription system? Are there facilities in your area that could become your customers if you could accept e-prescriptions? What system(s) do they use? If e-prescribing opens a significant book of new, institutional business for you, it could be worthwhile.

“We see [e-prescribing] a lot with larger health systems. They have a motivation to make sure that those patients are discharged in the most expedient manner to get them home after treatment and at the same time they must ensure that the patient has what is necessary to be successful at home, be it reserved Medicare skilled nursing or home medical equipment, to make that transition,” Knowlton says. “For HME, we are still early as an industry in our journey. Less than 10 percent of possible orders are transmitted electronically.”

The systems are designed “to solve more than just knowing that patient’s going to be cared for,” Knowlton says. “It can mobilize the equipment for home use faster and it can also present to the referral sources the documentation that needs to be executed for that equipment to be reimbursed.”

WORKING TOWARD TYPE O

If running parallel platforms is too cumbersome for your business, there’s still hope – at least for Brightree customers.

GoScripts came under the ResMed umbrella in a 2015 acquisition, and Brightree has been building e-prescriptions capabilities ever since. Brightree has a universal interface that lets Brightree users receive e-prescriptions via most of the major vendors, including Stratice Health, Parachute Health, GoScripts and “to some extent, DMEHub,” Knowlton says. “We are involved from the Brightree perspective in pushing this out into the industry. Facilities, home care, there is a lot of large HME organizations switching. A lot of stakeholders now are actively helping referral sources to move forward vs. two years ago.”

Stratice Health’s eOrdersPlus is one of the systems that works with Brightree. The integration enables prescriber and referral sources to e-prescribe orders and send supporting documentation directly into Brightree order intake and documentation management, and billing and claims management functions.

For non-Brightree customers, eOrdersPlus is offered on a standalone basis via its web portal. The range of users spans retailers and pharmacies and prescribers and referrers including post-acute care settings such as medical practices, hospital systems, home health agencies, skilled nursing facilities and others, Farmer says.

NOT ALL SUNSHINE AND ROSES

Documentation with e-prescribe systems is a sticky wicket: it may help your business run more smoothly, but nobody is really sure if it’s sufficient to support a DME response in the event of an audit. “Some systems do create documentation and some suppliers are using it, others are not. The question is does it meet the documentation coverage criteria? That has never been truly answered,” Brummett says. “We have been advocating for these e-prescribing platforms to be recognized as an extension of the medical record and therefore be sure they qualify.”

That’s partly because of the more rigorous documentation requirements for DME than for medications. “The level of paperwork required, it is not something that e-prescribing for meds have to deal with as much as we do in the HME world. One of the key powers of an e-prescribe platforms is the ability to call forth those complex documentation workflows,” Knowlton says.

DME providers also have to consider the cost – usually the initial installation and a per-transaction fee – of using e-prescriptions. “The challenge for us is, we pay for it,” Brummett says. “Prescribers don’t pay for it. On the supplier side it’s a per-transaction fee. Unless they can see significant increase in efficiencies in their business because it’s not manual, it’s not worth it.”

There are some variations in fee structure depending on the vendor and the system capabilities. Knowlton says about 80 percent of the functionality in most of the leading DME e-prescription systems is the same. The other 20 percent is how those vendors set themselves apart.

“The primary e-prescribing solutions differ greatly in terms of initial and ongoing costs of solution adoption and ongoing use by HME/DME providers,” says Farmer. “Some solutions charge annual or monthly subscription fees and transactional order-based fees, while others solely charge transactional fees for service for each order transmitted.”

If there’s not a lot of uptake in your market and you really want to switch to e-prescriptions, persuading your referral sources to make the move falls to you – something that doesn’t sit well with some DMEs.

Brummett recounts a conversation she had with an AAHomecare member. “He said, ‘I found a software application and I really liked it, but they’re not in my geography where I have businesses. So if I sign up for them, I am expected to go sell their product to my referral sources to use. Then as a supplier I have to pay the software vendor for that privilege, as opposed to using my sales staff to sell my products, goods and services.’”

“That, to me, is the probably the biggest dilemma.” Brummett says.

Some vendors will offer training and support materials for getting your referral sources on board, but it’s up to you to decide whether it’s worth the staff time and effort.

With Stratice, “Once enrolled, providers have access to a variety of introductory sales and training materials, as well as collateral marketing materials that can be co-branded for delivery to providers’ prescriber and referral sources,” Farmer says. The company also offers individual provider implementation sessions and online demonstrations for providers’ field sales forces and administrative staff coordinating order fulfillment.