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EPrescribing Standards and Beyond OHIT Health IT Grantee Meeting

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Title: EPrescribing Standards and Beyond OHIT Health IT Grantee Meeting


1
E-PrescribingStandards and BeyondOHIT Health
IT Grantee Meeting
  • Prashila Dullabh MD
  • NORC
  • November 6th, 2007

2
Status Quo
  • The current means for prescribing and dispensing
    medications in the United States is neither
    efficient nor safe.
  • Over 7,000 deaths each year due to manual-process
    prescribing errors (IOM)
  • A shift to interoperable e-prescribing systems
    could avoid more than 2 million ADEs annually,
    and has the potential to create significant cost
    savings to the US healthcare system. (Bates et
    al)
  • Today e-prescribing systems do not consistently
    employ standards.

3
Todays Prescribing Process
3
Source RxHub
Chelle Woolley
4
Current Status of E-Prescribing
  • Only 10-15 of physicians are using e-prescribing
    but that number is ramping
  • 45 physicians said it improved compliance with
    formularies
  • 36 of physicians said e-prescribing improved
    efficiency
  • 33 physicians said it had a major impact on
    quality of care
  • Source Harris Interactive and Boston Consulting
    Group Poll, 2003

5
E-Prescribing Real Time End-to-End Solution
5
Physicians/Prescribers
Patients
PBM/Payers
Pharmacy
Source RxHub
6
Federal Response to Current Prescribing Problems
  • The 2003 Medicare Prescription Drug Improvement
    and Modernization Act (MMA) requires that
  • All health plans and pharmacies participating in
    the new Medicare prescription drug benefit (Part
    D) support an e-prescription program,
  • The Secretary of Health and Human Services (HHS)
    establish federal standards that all
    e-prescribers must follow for Part D patients.
  • The six initial standards are pilot tested to
    investigate their interoperability with
    foundation standards as well as clinical and
    economic outcomes associated with e-prescribing.

7
CMS-funded E-Prescribing Pilots
  • In 2006 CMS funded 5 Pilots to test the standards
    and assess the outcomes and impact of
    E-Prescribing
  • Rand Health
  • SureScripts Florida, Massachusetts, Nevada, New
    Jersey, Tennessee
  • Achieve (Long Term Care) - Minneapolis
  • Ohio KePRO
  • Brigham and Womans hospital
  • Pilots were in diverse healthcare settings
    including long-term care
  • Included a wide range of participants including
    prescribers in ambulatory settings, pharmacies,
    PBMs, transaction networks (RxHub,
    SureScripts),payers and technology vendors

8
E-Prescribing Standards
Initial Standards
Foundation Standards
NCPDP Telecommunications Standard ASC X12N
270/271 NCPDP SCRIPT for Change, New, Renewal
and Cancellation Messages
NCPDP Formulary Benefits Standard NCPDP
SCRIPT Medication History NCPDP SCRIPT Fill
status Notification Structured and Codified
Sig Prior Authorization RxNORM
Interoperability
9
Description of Initial E-Prescribing Standards
  • Medication History - provides a uniform means for
    prescribers, dispensers, and payers to
    communicate about the list of drugs that have
    been dispensed to a patient regardless of which
    physician seen or pharmacy visited.
  • Formulary and Benefits - provides prescribers
    with information about a patients drug coverage
    at the point of care which includes whether
    drugs are considered to be "on formulary,"
    alternative medications for those drugs not on
    formulary, rules for prior authorization and step
    therapy, and the cost to the patient for one drug
    option versus another.
  • Prescription Fill Status Notification - notifies
    the prescriber after a patient has picked up a
    prescribed medication at the pharmacy.
  • Prior Authorization offers a streamlined,
    electronic process to communicate the need for
    prior authorization directly to the prescriber,
    and allow the prescriber to send the needed
    information along with the prescription.
  • Structured and Codified SIG includes patient
    instructions for taking medications (such as by
    mouth, three times a day) at the end of a
    prescription.
  • RxNorm provides a standardized vocabulary for
    name, dose, and form of available drugs.

10
Bell DS, Cretin S, Marken RS, and Landman AB, A
Conceptual Framework for Evaluating
Outpatient Electronic Prescribing Systems Based
on Th ear Functional Capabilities, Journal of
the American Medical Informatics Association,
Vol. 11, No. 1, January/February 2004,
11
Findings from the Pilot evaluation
  • Standards that are ready for implementation
  • Medication History
  • Formulary and Benefits
  • Prescription Fill Status Notification
  • Implementation considerations
  • Medication history
  • Generally underutilized because of software
    usability issues
  • Providers concerned that the list is not
    comprehensive and they still need to collate
    information from multiple sources
  • Formulary and benefits
  • Plan coverage
  • Correct patient matching to ensure that
    eligibility information will be available
  • Eligibility checking should support real-time
    changes in patient status
  • Prescription Fill status
  • Currently no good workflow to inform providers
    that script that was filled was picked up at
    pharmacy
  • Limited perceived utility for providers

12
Results of the impact of E-Prescribing Use
  • Workflow
  • Prescriber workflow
  • Prescribers staff (e.g., surrogate prescribers)
    played a much more important role in the
    e-prescribing process than anticipated
  • E-prescribing almost never fully replaced the
    need for paper-based prescribing
  • E-prescribing tools may decrease reliance on
    verbal orders and generate certain efficiencies
    for small physician offices.
  • E-prescribing reduces the number of phone time
    for physician practices
  • Pharmacy workflow
  • E-prescribing creates dramatic paradigm shifts
    in pharmacy workflow, which requires that
    pharmacies allocate sufficient resources to deal
    with substantial workflow and change management.
  • General
  • True end-to-end prescribing is rare
  • Critical need for training, education, and
    understanding of key value propositions for both
    prescribers and pharmacists

13
Results of the impact of E-Prescribing Use
  • E-Prescribing Adoption and Satisfaction
  • Providers
  • Providers seemed generally optimistic about the
    use of e-Prescribing
  • Effective use of requires a re-examination of
    workflow
  • In order to facilitate prescriber adoption,
    institutions need to assess and the role of their
    organizational culture
  • The use of surrogate prescribing is real and
    needs to be factored into the new workflow
  • Patients
  • Most patients are satisfied with e-prescribing
  • Offers new opportunities for medication
    management
  • Pharmacists
  • Generally optimistic
  • Significant workflow impact
  • There are significant efficiencies that can be
    realized
  • E-Prescribing will create new challenges still
    need to intervene due to issues with structured
    patient instructions (codified sig), lack of
    integration of systems require information to be
    re-entered, fax still more efficient

14
Other outcomes related to E-Prescribing Use
  • Reductions in new prescription rates
  • LTC facilities reported a reduction in new
    prescription rates, indicating the possibility
    that e-prescribing may reduce unnecessary
    accumulation of active medications.
  • Call Backs
  • Improved efficiency in practice setting
  • May create additional burden at the pharmacy
  • Increase in generic prescribing
  • Early results indicate that the use of generic
    prescribing is increased but this may occur as
    part of any CPOE system that shows generic
    alternatives
  • Too early for definitive results on
  • ADEs
  • Impact to inappropriate prescribing practices

15
Current Initiatives
  • CCHIT certification for eRx software
  • Vendors upgrading/updating software to support
    new standards
  • Part D plans required to accept electronic Rx
  • 2006 Pilot testing of initial eRx standards
  • 2007 HHS reports to Congress on standards that
    are ready to be adopted
  • 2008 Part D initial eRx standards implemented
  • Ongoing work on standards that are currently not
    ready

16
Conclusions
  • Standards are a critical component to promote
    end-to-end e-Prescribing
  • Three of the six standards are deemed ready for
    implementation
  • Standards may be ready but there are
    implementation considerations
  • Work still need to be done on clinical drug
    terminologies (RxNorm), structured patient
    instructions (codified sig) and prior
    authorization messaging
  • CCHIT certification of e-Prescribing vendors will
    motivate vendor industry to respond
  • E-Prescribing has significant workflow impacts at
    both the prescriber and pharmacy end and will
    need to be addressed to promote adoption and use
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