Adoption of e-prescribing has surged over the past decade, spurred in part by federal incentives, consumerism, increased emphasis on reduction of drug abuse and fraud and efforts to reduce medication errors.
Owned jointly by heavyweights CVS and Cigna, the Arlington, Virginia-based IT company Surescripts controls roughly 80% of the market after getting in on the ground floor almost two decades ago. It processed almost 18 billion clinical transactions last year, a 29% jump from the year prior.
The Surescripts Network Alliance, the company's e-prescribing partners, includes virtually all EHR vendors, pharmacy benefit managers, pharmacies and clinicians, plus a growing number of payers, long-term and post-acute care organizations and specialty pharmacy organizations.
That market dominance prompted the Federal Trade Commission to sue, alleging monopolistic behavior. Surescripts, which has an estimated annual revenue of $47.5 million, is also engaged in a fight with Amazon's PillPack: Earlier this year it ousted a third-party data company from its network that contracted with the prescription drug delivery business, a rival of its parent companies.
Healthcare Dive talked with Surescripts CEO Tom Skelton about the highly-publicized quarrel, the role health IT can play in lowering skyrocketing healthcare costs and the power of clinical interoperability.
ReMy Health and the FTC
The FTC sued Surescripts in April for acting anticompetitively to maintain monopolies in the e-prescribing markets for routing orders from providers to pharmacies and for determining patient eligibility for coverage of the drugs.
The private, for-profit company has maintained at least a 95% share in both markets for a decade.
In its complaint, the FTC said Surescripts engaged in corporate tactics like a pricing policy rewarding companies for remaining loyal to Surescripts, requiring long-term exclusivity from almost all of its customers, pressuring EHR vendor Allscripts into keeping its business and entering into an agreement prohibiting a competitor, RelayHealth, from joining the routing market for six years in 2003.
These actions were all to the detriment of consumers, FTC said, alleging the illegal practices have resulted in higher prices, reduced quality, stifled innovation and stymied alternative business models.
Surescripts filed a motion to dismiss the case in July, claiming the FTC made several false statements in its complaint and mischaracterized the e-prescribing market. But the case is still ongoing.
"These things take time to unfold. They don't move as rapidly as folks might expect," Skelton told Healthcare Dive. "I won't speculate where we'll go, but we're really confident that our approach to the market, one where we're driving down costs and showing the type of quality increase that we're showing over an extended period of time — we think that really shows exactly who we are and what we're trying to achieve."
In September, Surescripts terminated third party data startup ReMy Health's access to its prescription data over alleged fraudulent behavior. ReMy is used by Amazon's at-home prescription drug delivery business PillPack, a fact that spurred speculation the move was meant to stymie Amazon's entrance into the drug delivery industry.
Surescripts alleged ReMy requested not only patient medication history but also health insurance and prescription price information and included National Provider Identifier numbers for physicians who did not have a relationship with the patients.
ReMy denied the allegations and called the punishment an overreaction. But from Skelton's point of view, it's Surescripts job to police the market, calling the ouster "appropriate and necessary."
"The rules are still being codified and there are going to be a lot of things the market has to learn," he said. "We're at the forefront of this."
Skelton declined to comment if Surescripts was in talks with ReMy about potentially getting them back into the network.
Role of private sector in interoperability, privacy
When Surescripts was founded in 2001 by associations representing the major pharmacy chains and pharmacists, barely any prescriptions were issued or managed electronically. Now, about 75% of prescriptions are digitized.
But the company's interoperability plays aren't confined to e-prescribing. Surescripts has a record locator and exchange offering that allows physicians to electronically ask for a patient's records from any other providers in the same system.
That information is available to roughly 100,000 providers across the U.S. and the patient information spans the almost 260 million Americans in Surescripts' master patient index, which covers 79% of the U.S. population and 93% of insured patients.
"It's got a pretty broad footprint for an emerging product, and we're seeing really good uptake of it and high utilization of it as well," Skelton said. But "the industry still has work to do there," a work that's being spearheaded of late by the government.
Earlier this year, HHS issued twin rules meant to foster the free, unfettered exchange of data between disparate healthcare systems and patients' agency over their own health information. HHS hopes to have the regulations, which are currently under review at the Office of Management and Budget, finalized by the end of the year.
But "even when there are standards in place, that doesn't necessarily guarantee that everybody implements the standards the same way and that can result in quality challenges," Skelton said. As part of its efforts to crack down on shoddy data sharing practices, Surescripts introduced the Sentinel program in 2016, an automated system that measures the accuracy of e-prescriptions by monitoring quality and flagging prescription errors and workflow issues across billions of prescriptions annually.
"We think [the rules] will do a lot to help open up the market, but we need to make sure we keep our eye on quality, at a pace everybody can get behind," he said.
The Office of the National Coordinator for Health IT is "well-intentioned," Skelton said, but he's not sure it's striking the right balance between fostering the free flow of patient data and ensuring the privacy and security of that data.
Surescripts called for clarification around what constitutes information blocking under the requirements, along with the interaction between the proposed rules and HIPAA privacy legislation, in its June comments.
"It's a tough task that ONC has taken on here," Skelton said. "Information can't flow without regards to privacy. But on the other hand, privacy rights can't put us in a situation where no information moves. So we've got to find a way to throttle this and protect patients' rights while, at the same time, making it possible for this information to flow effectively."
Unlike the European Union and even California, the U.S. as a whole doesn't have privacy legislation at a national level, leaving significant white space where the law isn't 100% clear on balancing access and privacy. Such uncertainty leads to lawsuits, like a recent New Hampshire case over whether Fourth Amendment protections against unreasonable searches and seizes applies to drug records contained in the state's prescription drug monitoring program.
"The government needs to provide guidance to the states to help make it more feasible for private industry to innovate around a very comprehensive framework," Skelton, who sits on the board of Blancco, a data erasure company based in the United Kingdom, said.
Healthcare and real-time technology
Health IT efforts to lower costs are relatively upstream from the biggest factors driving price increases — hospital and prescription drug pricing. Some critics say tools like a real-time benefits check, though effective, are little more than a stopgap measure for systemic problems.
But taken along with increases in value-based care arrangements and the drive and energy of consumers, technology has a big role to play, Skelton said.
Real-time benefits technology allows patients to shop between comparable medications at the point of prescription, a situation that's "extraordinarily simple in any other purchasing scenario in our lives except for healthcare," Skelton said. For healthcare, though, he called it "groundbreaking. This isn't publishing a stagnant list of medication prices online."
Last August, CMS finalized a rule requiring hospitals post standard charges online in a machine-readable format, a transparency effort patient advocates found relatively toothless.
Real-time benefits check is the fastest growing product Surescripts has ever introduced, with 200,000 providers currently using the tool after two years in the market.
"It took us seven years to get to 50% of the market in the world of e-prescribing and, for real-time benefits check, we're sitting here right now more than 20% just two years in," Skelton said.
This efficiency and transparency can be leveraged in other niches in the healthcare system, like how patients get access to specialty medications, which is one of the fastest growing areas in terms of offerings and cost. Branded specialty drugs are projected to surpass half of all drug spending in the country in just three years, and the patient enrollment process for such drugs is complex.
Surescripts has technology automatically populates the enrollment forms with data from a patient's medical record, manages potential prior authorization or prescriber issues within the EHR and keeps track of where a patient is in the procedure, Skleton said.
But such steps toward lower costs and care coordination mean little without a IT ecosystem allowing the free ebb and flow of data.
"Interoperability marries into a lot of the work we're doing with prior authorization and specialty patient enrollment, our ability to put all these products together in a comprehensive suite, to electronically access via the EHR the information needed to populate these forms," Skelton said."That's what we're all chasing here. That's where the power of interoperability makes a difference."