LTC E Prescribing Standards Adoption

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LTC E- PrescribingStandards Adoption
Shelly SpiroPresident, R. Spiro Consulting
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Overview

• Standards and overview
• E-Prescribing team
• E-Prescribing pilots
• Pilot conclusions
• Summary

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What is e-Prescribing?

• Bi-directional computer to computer
• Paperless
• Not faxing
• Not emails
• Connects in real time
• Prescriber to pharmacy
• Prescriber to provider (nursing)
• Provider to pharmacy
• Prescriber to payer

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Types of Standards Supporting e-Prescribing

• Message format
• Communication protocols
• Data content
• Medication decision making
• Terminologies
• Data comparability
• Interoperability
• Identifiers
• Tracking and communication

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e-Prescribing Standards (By Organization)

• NCPDP National Council for Prescription Drug
  Programs
• SCRIPT (foundation standards)
• SCRIPT (initial standards)
• Formulary and Benefits (FB), Medication History
  and Fill Status Notification
• Other (initial standards)
• Codified SIG and RxNorm
• ASC X12N - Accredited Standards Committee
• Eligibility (270/271)
• Prior Authorization (278/275)
• HL7 - Health Level Seven
• Electronic Health Record (EHR) message

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Why Standards are Relevant

• Reduces total information technology expenditures
• Allows for broader connectivity
• Consistency in capability
• End of expensive and limited proprietary solutions

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e-Prescribing LTC Stakeholders

• Prescribers
• Physicians, Nurse Practitioners, Physician
  Assistants
• Supportive staff (nurse or agent of the
  prescriber)
• Pharmacies
• Pharmacists, consultant pharmacist, pharmacy
  technical staff
• Facilities
• Residents, nurses, and administrative staff
• Payers
• PBM, PDP
• Router/Intermediary
• Software vendors

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Role of e-Prescribing Router/Intermediary

• Through vendor certification they secure
  standards-based communication between
  prescribers, pharmacies and payers
• Facilitate a standard information exchange in LTC
  between the facility, pharmacy and payer
• Reduced implementation and operational costs

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Impact to Facility Staff

• Nurse the agent of the prescriber model
• Need an integrated EHR prior to e-Prescribing
  implementation
• Theoretically an integrated eMAR and EHR would
  help reduce adverse drug events (ADE) and
  medication errors

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Prior to e-Prescribing Pilots

• Physician adoption is low (5-18)
• ePrescribing can improve safety, quality,
  efficiency and cost
• Pharmacy staffing efficiencies exist
• Formulary adherence increases
• Reduction in ADEs occurs
• Studies suggest that national savings could be as
  high as 27 billion

Source Executive Summary Electronic Prescribing
Toward Maximum Value and Rapid Adoption, eHealth
Initiative, April 14, 2004
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e-Prescribing Pilot Background
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Grantee/Contractor Project Titles for
e-Prescribing Pilot Project
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e-Prescribing Pilot Settings and Stakeholders
Source http//healthit.ahrq.gov/portal/server.pt/
gateway/PTARGS_0_1248_227312_0_0_18/eRxReport_0416
07.pdf
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e-Prescribing Pilot Outcomes

• Workflow
• Prescriber utilization of e-Prescribing
• Physician uptake
• Patient satisfaction
• Formulary versus generic prescribing
• Medication history utilization
• Inappropriate prescribing/adverse drug events
• Callbacks

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e-Prescribing Standards in the LTC Setting

• Three way communication prescriber, nurse,
  pharmacy
• Modifications to NCPDP SCRIPT 8.1 were needed
• Medication history already available
• Opportunity for a more complete picture when
  prescribing
• Unique payer mix
• Medicare Part A, Part D, Medicaid
• Formulary and Benefits and ePA helps with Part D
  Plans
• Prescriber adoption is a challenge
• Nurse as an agent, Nurse Practitioners, Physician
  Assistants

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e-Prescribing Pilots Summary of Standards Tested
Source http//healthit.ahrq.gov/portal/server.pt/
gateway/PTARGS_0_1248_227312_0_0_18/eRxReport_0416
07.pdf
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LTC e-Prescribing Standards Enhancements

• Resident is not a patient - SCRIPT adjustments
  for unit/room/bed, resident, facility information
  
• Medications are delivered Communicate admission
  and discharge information to the pharmacy (new
  census message)
• Medication chart orders are open-ended - Orders
  need to be cancelled or discontinued
• Facility needs to know the medication was
  actually dispensed
• Resupply requests represent 80 of LTC orders
  needed a resupply message

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LTC SCRIPT Enhancements

• Need ADT information
• Payer / Responsible Party information
• Medical Record Number
• Unit/Room/Bed
• Allergies
• Diagnoses
• Need Discontinue/Change Order message
• Need Refill Request message
• Need Prior Authorization status
• Need Do not Fill indicator

Currently in NCPDP DERF Process
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Future LTC Enhancements and Opportunities

• Continued SCRIPT enhancements to LTC practices
  and nuances
• Medications with multiple directions
• Facility MAR is different from how the pharmacy
  submits the claim to a payer
• Structured and Codified SIG should help handle
  combination orders
• Transfer of clinical information (allergies and
  diagnoses)
• Transmission on admission orders
• Electronic Prior Authorization
• Further integration of electronic medication
  administration records (eMAR) and inventory
  management
• LTC facility vendor adoption of SCRIPT LTC EHR
  through CCHIT (Certification Commission for HIT)

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Pilot Conclusions

• Foundation standards worked
• Three initial standards were found to be
  effective
• FB, Medication History and Fill Status
  Notification
• Additional work to be done on the three remaining
  standards in order to make them suitable for
  adoption for Part D
• Prior Authorization, Codified SIG and RXNorm
• Additional research should be done on electronic
  prior authorization (e-PA)
• In the LTC setting, e-Prescribing can be
  supported with some technical accommodations to
  the standards

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Summary

• Further standards of eMAR and inventory
  management is needed
• Additional research should be done on electronic
  prior authorization (e-PA)
• In the LTC setting, e-Prescribing can be
  supported with some technical accommodations to
  the standards
• HHS should in regulations adopt a higher version
  of NCPDP SCRIPT to accommodate LTC e-Prescribing

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Questions
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Shelly Spiro President, R. Spiro Consulting 1200
First Street, Suite 1632 Alexandria, VA
22314 703-599-5051 shellyspiro_at_yahoo.com