NewCrop has been in business since 2003, and has directly benefited from the knowledge and experience of two industry veterans, founders Lawrence Susnow, M.D. and Craig Wagener. They have been involved in all aspects of electronic prescribing for the last ten years. Their unique depth of understanding of the quality and efficiency of electronic prescribing drives NewCrop.
The concept of NewCrop began as a quality improvement project when Lawrence Susnow, M.D. was serving as medical director for a 500,000 member HMO in Houston. His idea was to tie doctors together in a real-time network, providing care support for diabetics, embedded in an electronic prescribing user interface. The member physicians and HMO staff would see an immediate benefit from safety and efficiency improvements, while providing a platform for improved patient management.
The project was never completed at the HMO, however, soon after concept development, it became the basis for the mature product you see today. Dr. Susnow supplied to concept and Craig Wagener joined to provide the technical know-how and vision to create the user interface and web design.
We decided at the outset to provide all services over the Internet. The virtues of scalability and ease of maintenance, combined with the inherent need to connect to pharmacies, drove the decision to operate in “The Cloud”. Recall, this was 10 years ago and the Internet was still in its infancy. On occasion, an investor or customer presentation was interrupted to explain “the Internet.”
The biggest differentiation for NewCrop was that it was designed hand-in-hand with physician input. To that end, the user interface was to be kept clean and intuitive with a minimum of disruption to the prescribing process. The NewCrop philosophy then and today was, “If doctors were inconvenienced or slowed down, they simply would not use the system.” Other e-rx systems at the time displayed frequent disruptive “alerts,” many of which doctors considered unimportant distractions. NewCrop choose to place all but the most severe items on a single “Review Page,” color-coded for instant review. It is interesting to note 10 years later, that we have kept our core workflow unchanged: it works and the end user appreciates the simplicity.
Another early NewCrop decision was to focus on providing services to electronic medical records (EMRs) rather than to individual doctors. Deemphasizing “retail” marketing, allowed us to direct our resources to building the robust and versatile system we have today. By concentrating on providing value to partnering EMRs and others, we have built a system that is quickly and easily installed, providing the transparent workflow needed for efficient use. (We now provide a full range of integration options, from the complete integrated user interface, to use of all or some of our individual comprehensive drug content and connectivity data services.)
The first barrier was the inclination of the doctor to hand-write the prescription. Even today, it can be difficult to generate a new prescription more quickly than to simply write it on the trusty prescription pad. The extent of issues with legibility, and other reasons for re-work, were not well appreciated then, and that continues to be an issue today. Yes, the doctor may take a few extra seconds initially, but much more time is saved later in the day in avoiding pharmacy calls for clarification, managing managed care formulary, and not having to find a paper chart to review a medication list, among many other reasons.
Initially, patient safety was not an obvious factor in the adoption of electronic prescribing. It was certainly recognized that prescribing errors could occur rarely until To Err is Human, a report from the Institute of Medicine in 1999, estimated that medical errors, and particularly prescribing errors, resulted in 50,000+ deaths yearly. Patient safety became a given, no longer needing explanation.
Early production had its own challenges and seemed to be a tremendous barrier. Our use of now standard https Internet communication, at the time, broke new ground, forcing all parties to build new infrastructure. When our first e-prescriptions hit pharmacies, we discovered the phenomenon of the “missing” prescription. The Rx was in their system, but often there was little, if any, visual indication. Thus, the pharmacist would tell the patient and the doctor it had not been received. To this day, we always know when a doctor is the first e-prescriber in town: we get a cluster of “missing prescription reports.”
Along with our friendly user interface, we needed all the pieces of back-end infrastructure. Initially, this was only the Surescripts retail delivery system, no known as Routing. Next was RxHub, now Surescripts Benefit and Drug History. At an early meeting, we pointed out that the all-doctor drug history could be available to the treating doctor, pulled from the healthplan’s record of paid prescriptions: a very useful quality and safety tool. The response was the information was “confidential.” (This was before HIPAA was completely understood!) However, upon further consideration, it was recognized that providing information to the treating physician was not a breach of confidentiality.
E-prescribing infrastructure was challenging from the outset. It has only become more so. Full use of the Surescripts systems now requires several in-depth certifications that require much effort and time from each EMR. In addition, data standards have been updated frequently, with attendant additional required certifications. Electronic prescribing of controlled substances, soon to be available, will bring additional certification requirements. This demanding aspect of e-prescribing has steadily increased the value to the EMR of outsourcing all aspects to NewCrop.
Despite the many benefits of e-prescribing, wide-spread implementation required, literally, an act of Congress. Actually, three acts of Congress.
Electronic medical records have been around for many years, however usage was limited to large enterprises and medical groups, plus a small number of doctor early adopters. Very few of the 80% of doctors in small offices participated.
This began to change on 2005 when the Department of Health and Human Services began to cite the requirement for EMRs certified by a “Recognized Certification Body.” In conjunction with HHS, the Certification Commission for Health Information Technology (CCHIT) was created to fill this role. Electronic prescribing was a required component.
CCHIT was a significant driving force, but the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) that created Medicare Part D, also provided financial incentives for doctors to implement, followed in 3 years by penalties for not participating. For the first time, there was a formal definition of e-prescribing. (Electronic faxing was disallowed and formulary information, specifically from Surescripts Benefit was required.)
The American Recovery and Reinvestment Act of 2009 (ARRA), the Stimulus, included the Health Information Technology for Economic and Clinical Health Act (HITECH.) Orchestrated by the Office of the National Co-coordinator (ONC), Meaningful Use (MU) became the new and universal standard for EMRs. Not surprisingly, e-prescribing was a significant feature. A $44,000+ bonus in the first implementation phase was one incentive for adoption, and in later phases, that incentive expires and becomes a penalty. These incentives have had the expected result: 234,000 doctors, 34%, were e-prescribing by the end of 2010 and numbers continue to grow rapidly.
HITECH and MU, beyond the financial incentives, have also addressed the concern of “choosing too soon.” Prior to MU, each EMR was unrelated to the next. Information was difficult if not impossible to exchange and there was always the risk that the EMR would fail. This had been the case in the past, leaving early adopting doctors with a very bad experience. MU, by emphasizing interoperability and creating a common standard, has mitigated this concern. Thus, doctors can choose from a wide, and growing, range of EMRs, finding one that matches their needs.
Financial incentives and disincentives combined with resolution of structural barriers have resulted in rapid and growing adoption. Thus, in the next few years, we will see near universal use of e-prescribing.
NewCrop has now built, interconnected and implemented electronic prescribing on a wide, national scale. We believe that Meaningful Use, in its current state, with the creation of data standards and the emphasis on communication and interoperability, is a close parallel to the early phases of e-prescribing. We view this not only as the challenge, but also the opportunity. We continue to put our experience and expertise to use, building the infrastructure that will pull the disparate pieces together, creating a whole greater than the sum of the parts.
MU’s components include laboratory ordering and results, vaccine registries, PQRS reporting (formerly known as PQRI), and CCD/CCR generation. In addition, ONC has added a new interoperability standard, “Direct.” EPCS adds another new aspect. Each of these has its own complex architecture and data requirements. Over the next year, NewCrop will be expanding our capabilities to address aspects of Meaningful Use … and whatever else comes along. We are on top of it!
NewCrop began by connecting doctors to improve patient care. 10 years later, we find ourselves doing exactly the same thing. We invite you to join us as the adventure continues.