The Rise of Non-Traditional Prescribers in the US and the role of ePrescribing

[00:00:00] Dear listeners, welcome to Faces of Digital Health, a podcast about digital health and how healthcare systems around the world adopt technology with me, Tjasa Zajc. In many countries, electronic prescribing is not the norm yet. But in the US, ePrescribing has become a norm quite a while ago.

[00:00:21] Now, the expanded role of pharmacists and the integration of non-physician prescribers into the healthcare system signifies a move towards a more accessible healthcare model, potentially alleviating some of the clinician's burdens. ShureScripts is the national provider of the ePrescribing infrastructure in the US.

[00:00:43] And in this short discussion, I spoke with Dr. Lynn Noet, Chief Data and Analytics Officer and Melanie Marcus, Chief Marketing and Customer Experience Officer at ShureScripts. We discussed the importance of ePrescribing on a national level in the US,

[00:01:01] the changing role of pharmacists and how exactly can it facilitate the redistribution of healthcare provision burdens. Enjoy the show and if you haven't yet, make sure to subscribe to the podcast wherever you get your episodes and also check out our newsletter.

[00:01:20] You can find it at fodh.substack.com. That's fodh.substack.com. It's published on a monthly basis and offers an in-depth explanation of a specific topic. Now, let's dive in. Lynn and Melanie, hi and thank you so much for joining the discussion on ShureScripts

[00:01:54] and what you are providing in the healthcare space in the US. So maybe how would you basically describe what you do and the services that you provide? The brief overview because the audience is global, so it's not just the US audience

[00:02:10] and I would just like to put things in context. Sure. ShureScripts is a health information network in the United States. We facilitate the exchange of healthcare information across the US to the tune of 22 billion transactions a year.

[00:02:25] That information could be about a prescription, it could be about a patient's benefit around that prescription or it could be about their medication history or even their clinical history. So that's basically what we do. And what does the data say about the trends in medication prescribing?

[00:02:42] What do you see given the long history of the infrastructure that you've been providing in the US? ShureScripts infrastructure is, is it 20 years old or 15 years old? 22 years old. Yeah, okay good. So what does the data say about prescribing practices or just any insights?

[00:03:01] At this point most of the country is electronic prescribing. So there are very few paper prescriptions. The last thing that went electronic was really controlled substances and then as prescribing continues to increase with an aging population

[00:03:15] and more drugs being prescribed, of course that's an important part of it as well. Lynn you might want to address some of that. Yeah and I would also add that as we're seeing more and more e-prescribing as Melanie said virtually all providers and prescribers are electronically prescribing now.

[00:03:31] We're also seeing more non-physician prescribers entering the network and joining the ShureScripts Alliance Network. Largely for the reasons Melanie described earlier which is around just that health information exchange. Even if they're a clinician or a provider who's not prescribing,

[00:03:48] they're still using the network to facilitate that data about clinical information for their patients. Can you explain a little bit how the whole prescribing landscape is changing? So there's clearly a need to decrease the burden on physicians.

[00:04:04] So the number of pharmacists that are prescribing medications is also increasing. So can you put that in context of U.S. healthcare? How can a pharmacist become a prescriber who decides and how do patients find the pharmacists that can also prescribe medications?

[00:04:22] Yeah I'll start and then Melanie can can fill in here a little more. So one pathway which has actually been increasing over across the last several years is through collaborative practice agreements with physicians. So we now finally have in all 50 states and in Washington DC,

[00:04:39] pharmacists do have the ability to go into collaborative agreements with physicians. And that often allows them permission to prescribe. We also have I believe it's in five states now where pharmacists actually have independent ability to prescribe in certain situations not full authority for prescribing but in

[00:04:57] certain circumstances they can prescribe. We have seen as Lynn said an increase in pharmacists being prescribers still very small numbers. What's happened is we've got in the United States we have an incredible issue with provider burnout and the number of primary care physicians in the country is really

[00:05:20] set to underserve the country. About 50% of counties in the country have less than one primary care physician per 1500 population and that's just not enough. In about two-thirds of those we've got enough pharmacies so that pharmacists could help take some of the burden off the primary care needs.

[00:05:41] So that's what we're seeing there's lots of issues here. We don't they don't get paid for this work except for in those five states that that Lynn was talking about they don't get paid for that work.

[00:05:52] There aren't the policies in place in the state or at the federal level that would do that. And so there's a lot of work still to do in the U.S. before you see that those numbers really rise

[00:06:02] to help alleviate this shortage. Yeah and I would add that there's just a tremendous opportunity for us to help fill the healthcare the care provider shortage with expansion of that care team. So whether it's pharmacists or other nurse practitioners or other non-physicians

[00:06:21] as an expansion of the care team not as a replacement to physicians I'm a physician myself I'm a primary care physician I have trained in internal medicine I practiced for many years and there's it's really that team-based approach where we're allowing everyone to really help care

[00:06:37] for patients to the ability of their experience and training and to do so safely. And I think certainly over the last several years with the pandemic we've seen expanded capabilities across many non-physician groups and it's been able to really help

[00:06:52] deliver access to patients who otherwise would not have had it. You mentioned earlier that there's still a very small proportion of pharmacists that basically do prescribing so can you maybe talk a bit more about who's driving that change towards more

[00:07:05] pharmacists prescribing and also what do pharmacists think about that because it's a huge shift also in the way they deliver care so it's not just the workflows as you said the whole policy the payment models how is change progressing from that perspective?

[00:07:21] I can give a start here as we said there are about five states in the country that have really started to enable this and it's driven at the state level at this point states actually have

[00:07:31] to have the legislation in place that allow a pharmacist to prescribe but we also did a survey in this area and we found that of both prescribers like physician prescribers and pharmacists and we found that both actually are concerned about the shortage in primary care and very supportive

[00:07:51] of team-based care to help support that and both are supportive of pharmacists prescribing it's not the only thing that pharmacists could do to help alleviate they can give more more vaccinations they can do some of the screening for whether it be some of the diabetes screenings and that

[00:08:11] kind of thing or smoking cessation those kinds of things that they can do. I think there's also beyond the prescribing pharmacists are on the front lines they're seeing patients in in their

[00:08:22] retail clinics or coming in whether it's to pick up a prescription or otherwise so they've got that frontline touch points with patients which also puts them in a terrific position to close other gaps in care so again through that facilitation of the health information sharing

[00:08:39] sure scripts can tee up gaps in care that if a patient comes in to just pick up a prescription theoretically or and we actually do this we can have alerts to the pharmacist say hey while that

[00:08:50] patient's there to pick up their prescription ask them if they've had their A1C checked or other sorts of clinical alerts or things that because that pharmacist is on the front line having those direct engagements with the patients they're perfectly suited to help close other

[00:09:05] gaps in care even well beyond prescribing medications. Yeah let me take it to one more area is that we've talked a lot about the pharmacist there's also just a lot of work to be done

[00:09:19] to make the process of providing care more efficient and effective right so if we're talking about burnout from the perspective of the doctors for example there's a lot of work to be done

[00:09:31] and we are doing a lot of that work right now in the prescribing area yes electronic prescribing are far more efficient you can take that further and bring it into the cost of a medication so you

[00:09:42] don't get so so patient leaves with one that they can afford and there isn't back and forth afterwards or to an automatic prior authorization in the U.S that's important right to the again

[00:09:54] the clinical information exchange if it's just there you don't have the faxes and phone calls that go back and forth between all of the providers in the ecosystem here in the U.S that causes incredible burnout it's a lot of administrative work that's happening on the backs

[00:10:10] of our clinicians across the country that really can be automated and since you basically mentioned the whole support around information that needs to be in place in order for this to work can you talk a little bit more about how the information workflows are done in the states

[00:10:32] that are already doing this so basically what i'm asking is other countries like UK are also thinking how can they transfer more work or just more care into the pharmacies because they're in the communities they're closer to the patients but how do you then feedback

[00:10:46] the information of what happens in the pharmacy back to the clinician and also does this mean that basically the IT systems in the pharmacies need to be updated so the pharmacies have the prescribing ability that the doctors have yeah i think you've just given a beautiful description

[00:11:01] of why we think the sharescripts alliance network is so powerful it's because our health information sharing spans across all of those stakeholders you mentioned the sharescripts network connects virtually every physician pharmacy and payer or pharmacy benefit

[00:11:18] manager in the united states all of that information is connected is being shared across the sharescripts network today whether it's a physician prescribing or a pharmacist dispensing or maybe prescribing they're able to connect in to the payer source to check

[00:11:34] how much is that medication going to be for the patient is it covered is it on their formulary does it have a copay how much is that copay is there a lower cost alternative possibly available all of that information is available to the physician at the point of

[00:11:49] prescribing that also then get shared with the patient when they go to pick up their prescription at the pharmacy because the pharmacist can see that so it's truly that connectivity and the sharing of information across the network that is what allows this to work and really

[00:12:05] does help facilitate that expansion of the care team where it can best be delivered in real time to the patient and how is this whole transformation of care delivery transferred to the patient in terms of the awareness so how are patients informed that they can go

[00:12:21] to the pharmacy to get their medication reconciliation done to get their prescriptions not just filled but basically written if they want to change the medication how is basically that's addressed that's on the that's the pharmacies needing to do their

[00:12:36] their marketing the network we're talking about is behind the scenes and it's really those customers are pharmacy customers are physician customers all of them who are doing the marketing directly to the patient so that's how they find out what's your biggest challenge you know as the

[00:12:52] network perspective thinking about how else you want to contribute to care delivery and changes in basically the work distribution inside healthcare i'll take that one there there are many challenges as we really try to expand the value that we can deliver across the

[00:13:10] network i would say one of our largest is that right now it's pretty well accepted and very much permissible to share data about patients for treatment purposes there's tremendous opportunity in reducing administrative burden reducing provider burnout in more

[00:13:29] administrative areas around healthcare operations healthcare payments we're right now a lot there are a lot of restrictions on the flow of that data and the sharing of that data we're working across all the different stakeholders on the network to how do we expand use cases for information sharing

[00:13:46] while still respecting patient privacy certainly respecting patient all the data security but we really think that expanding data sharing beyond just treatment use cases is going to unlock a lot of opportunity to reduce administrative burden even further

[00:14:02] melanie anything you'd like to add the only other thing i would add and this could be unique in the u.s. though i'm i'm not sure that it necessarily is that when you're talking about

[00:14:10] this kind of network as lin just described with the show scripts network alliance across all different parts of healthcare finding the space where everybody can both generally agree on the problem and generally agree that they're going to work together in a way on a network to exchange

[00:14:32] information that is a challenge so there could be things that look like hey that could go a lot faster and could be a lot more efficient yeah that's probably true it just takes a little bit of time

[00:14:43] when you've got all these vested interests in different parts of the ecosystem that you need to bring together so that's challenging if you are starting fresh in a different country you

[00:14:53] may not have all of those challenges is there any statistics that you might have or want to share in terms of analysis that has been done around the whole shift towards pharmacists prescribing more

[00:15:06] and basically the decreased burden on primary care physicians or other physicians sure we saw a 47 percent increase in electronic prescriptions sent by pharmacists between 2019 and 2022 and overall during that time prescriptions grew by about 33 percent so it was outsized in pharmacists

[00:15:31] but before we get too excited that's 1.2 million prescriptions in 2022 which actually isn't it's just a drop in the bucket right pharmacists on the network actually prescribing grew by 122 percent during that time period again though before we get too excited that means we have 3.600

[00:15:53] or 3600 pharmacists on the network prescribing in 2022 so still a drop in the bucket but it's going in the right direction and certainly outpacing other areas on the network mm-hmm so pharmacists are definitely the experts around medications so I think that's quite it's

[00:16:11] safe to say that there's not much to be worried about if a pharmacist prescribes because they can do all the medication reconsolations do you disagree they need information about their their they still you still need the physician who's the one diagnosing the patient i'm gonna

[00:16:27] let yeah i'm sure lin will have something to say about that and also to the extent that they can prescribe it all they need access to at least some clinical information about the patient

[00:16:38] yeah that's true so how is that actually managed do they get any information and basically what I was aiming at is that i'm not as skeptical about pharmacists prescribing but expanding nurse prescribers is something that I have a bit potentially more reservations about so I just

[00:16:55] wanted to see what you thought about that and what insights do you have around that yeah so i'll put my physician hat on here for a sec and as I said before I think this is about how do we

[00:17:05] expand the care team and help support and augment the role of the physician not replace the role of the physician so you know there's there are very safe places where pharmacists can prescribe and we've shown that but it doesn't mean that they should have full prescriptive authority

[00:17:23] beyond the training that they've had and Melanie touched on that is a pharmacist is not going to have the depth of training in diagnosis and understanding what's patient symptoms to a

[00:17:34] deep degree there will be some things that are you know i'll say some simple things like a urinary tract infection or conjunctivitis or pink eye strep throat some simple things that I think could be

[00:17:46] pretty tough to argue that they're not qualified to do that but I would not want to come into a pharmacy with chest pain and have a pharmacist give me pain medication right that needs to be

[00:17:58] evaluated and thoroughly worked up and diagnosed by a physician but a full care team again I think it's really about enabling all of the clinicians across the health care spectrum to deliver care

[00:18:11] to the extent that they've been trained and have experience to do whether it's a nurse or a pharmacist or a physician assistant it's not just about pharmacists there they're very highly trained nurses out there with degrees and training and experience that they can absolutely safely prescribe

[00:18:27] that's what the laws and the scope of practice rules and regulations come into play at the state level is there anything else that you would like to add around this topic that we haven't

[00:18:37] covered so the one thing we haven't talked about is the patient right in the end this is all about getting the patient in some case on the right care whether it's a medication or other

[00:18:51] type of care getting them the right diagnosis at the right time with the right medication at the right time and right place and keeping them on that medication and whoever it is that is providing

[00:19:02] the care they need access right we need in America access is an issue right now with the shortages especially in more rural communities we need access to the right people and we need the processes

[00:19:15] once we've gotten access to be smooth and quick so that you can get on the right medication at the right cost without much delay you've been listening to Faces of Digital Health a proud

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