New Approaches In Medication Management and Care Transition e-Prescribing and Remote Dispensing in Long Term Care

1
New Approaches In Medication Management and Care
Transitione-Prescribing and Remote
Dispensingin Long Term Care
AHRQ Annual ConferenceSeptember 27,
2007Presenter Michael Bordelon
2
Long Term Care Background

• Reimbursement Model
• Roughly 15 capitated Part A
• 58 Medicaid/Part D
• 27 Private Pay and Commercial Insurance
• Typical Number of Beds 90-120
• Pharmacies are almost never co-located with LTC
  facilities
• Physicians per facility 10-40
• Nurse Practitioners per facility 1-2
• Nurses per facility 50-80
• Med passes per day 4-7
• Pharmacy trips to the facility 2-3
• Admissions per week 1-10
• Many facilities already manage their own orders
  in electronic systems

3
The Infamous LTC Prescribing Slide
Physician
Patient Allergies
Clarify and update order with physician
Order Update (Phone or fax)
Start
Decide on patient order
Patient Orders
Written order
Physician signs copy of the order
Faxed order
Verbal order
Physician writes order on Order Sheet
Signed copy of order
Copy of order (mail, on-site)
Nursing
Evaluate order, clarify if needed and file in
Patient Record
Evaluate order, clarify if needed
Updated Order Sheet
Patient Record
File Signed copy in Pt. Record
Patient Allergies
Resident Status (phone call, fax, on-site)
Notice updated Order Sheet, evaluate order and
clarify if needed
Write order on Physician Order Sheet
Write order on Physician Order Sheet and send
copy to physician
Order Sheet
Manage on-hand medications (Pt Meds, Stock and
Emergency Kit)
Patient MAR
Start
Resident Change in Condition New admission
Med
Check patient choice for pharmacy
Update the MAR
Administer and Chart
Med
Resolve Discrepancy
Receive and check medication (patient, med, doc)
Follow pharmacy-specific procedure including
after hours rules
Clarify and update order with nursing
Order Update (Phone or fax)
Order (phone, fax, pickup by driver, auto-fax
from SNF order management application)
Pharmacy
Order Question (phone or fax)
Patient Allergies
Consultant Pharmacist
Patient Orders
Receive new order
Resolve issues with order (clinical, payor, etc.)
Receive updated order
Drug Regimen Review or other Patient Status Review
Patient MAR
Med
MAR Update (optional)
Order Exception
Process order and dispense includes payor
verification and formulary compliance
4
LTC Prescribing Nuances

• Three way communication between
• Prescriber Nurse Pharmacy
• Most orders have no end date or quantity
• Refill requests represent 80 of orders
• No concept of Renewals
• Need unique formulary and benefit information
• Part A, Part D and Medicaid

5
e-Prescribing in Long Term Care

• e-Prescribing is new to LTC
• 2006 CMS Pilot Study was first official standards
  based e-prescribing study in Long Term Care
• There are less than 5 standards based
  e-Prescribing installations today

6
LTC e-Rx Pilot Study Abstract

• 2006 study focused on e-Rx standards most
  relevant to LTC
• SCRIPT
• Formulary Benefits
• Electronic Prior Authorization
• Other Capabilities Studied
• Facility Managed Electronic Orders
• Patient Safety Checks (DUR)
• Electronic Signature
• Automated Refill Requests
• The study included two geographically diverse
  treatments facilities and two comparison
  facilities

7
Flow of Information
RNA eRxRequest Refill Scanner
8
e-Rx Findings - Facility Impacts

• Benefits
• Facilities currently using electronic Physicians
  Orders will see modest change or disruption to
  current workflow
• Ability to transmit orders directly to the
  pharmacy yielded benefits in reduced rework and
  callbacks
• Management of Orders at the facility streamlines
  reconciliation processes
• New Challenges
• Prescriber adoption is vital
• Integration with clinical systems (EHR) is
  critical
• Nurses do not effectively use patient safety
  (DUR) tools
• Even with Formulary Benefits data, managing
  complex Part D health plans is an ongoing
  challenge
• Nursing staff now has to enter and manage data
  that the pharmacy once managed
• Data entry errors can still happen

9
e-Rx Findings - Pharmacy Impacts

• Benefits
• Demographics pre-populated on new admissions
• Straightforward new order processing
• Discontinued orders
• Readmissions streamlined
• Do not have to manage MARs and Order Sheets
• Refill requests streamlined
• New challenges
• Combination Tapered Orders Need codified SIG
  standard
• Transcription accuracy
• Timely transmission on admission orders
• Fax mode for controlled substances leads to
  process inconsistencies

10
Standards Findings

• NCPDP SCRIPT Standard works with new changes in
  Version 10.1
• NCPDP Formulary Benefits V1.0 technically works,
  but is dependent on greater prescriber adoption
• Electronic Prior Authorization Technically works,
  but will require greater prescriber adoption
• A Refill messaging standard is needed in LTC
• An Admission, Discharge, Transfer (ADT) messaging
  standard is needed

11
What is Remote Dispensing?

• Automated oral solid dispensing in healthcare
  settings, such as nursing homes and correctional
  facilities, that have no onsite pharmacist

Remote dispensing can work hand in hand with
e-Prescribing
12
Oral Solid Packaging
Medication Canister
Remote Dispensing Packager
13
Process Overview
14
Process Dispense Data From Central Pharmacy
System
15
On Site Strip Packaging
16
On Site Strip Packaging

• Daily Dispense
• Med Pass/Resident Sort
• Multi Dose Packing
• PRN, New, Re-dispense

17
Process Data Feedback Loop
18
Process Inventory Monitoring
19
Process Canister Fill at Pharmacy
20
Process Canister Delivery
21
Value Proposition

• Virtually eliminates drug waste
• Significantly reduces delivery costs
• Eliminates delay of first dose
• Decreases administration time
• Reduces medication errors
• Eliminates the need for a refill process

22
Experience in early commercial pilots

• High Adoption Rate with nursing staff
• On demand PRNs and quick access to meds for new
  admissions are big wins
• Will save a typical nursing facility more than
  25K per year in Part A drug waste
• May save 150K per year per facility for Part D
  drug waste savings
• Robust canister logistics is the key to success

23
Medication ReconciliationinLong Term Care
AHRQ Annual ConferenceSeptember 27,
2007Presenter Michael Bordelon
24
Long Term Care Background

• Reimbursement Model
• Roughly 15 capitated Part A
• 58 Medicaid/Part D
• 27 Private Pay and Commercial Insurance
• Typical Number of Beds 90-120
• Pharmacies are almost never co-located with LTC
  facilities
• Physicians per facility 10-40
• Nurse Practitioners per facility 1-2
• Nurses per facility 50-80
• Med passes per day 4-7
• Pharmacy trips to the facility 2-3
• Admissions per week 1-10
• Many facilities already manage their own orders
  in electronic systems

25
The LTC Prescribing Slide
Physician
Patient Allergies
Clarify and update order with physician
Order Update (Phone or fax)
Start
Decide on patient order
Patient Orders
Written order
Physician signs copy of the order
Faxed order
Verbal order
Physician writes order on Order Sheet
Signed copy of order
Copy of order (mail, on-site)
Nursing
Evaluate order, clarify if needed and file in
Patient Record
Evaluate order, clarify if needed
Updated Order Sheet
Patient Record
File Signed copy in Pt. Record
Patient Allergies
Resident Status (phone call, fax, on-site)
Notice updated Order Sheet, evaluate order and
clarify if needed
Write order on Physician Order Sheet
Write order on Physician Order Sheet and send
copy to physician
Order Sheet
Manage on-hand medications (Pt Meds, Stock and
Emergency Kit)
Patient MAR
Start
Resident Change in Condition New admission
Med
Check patient choice for pharmacy
Update the MAR
Administer and Chart
Med
Resolve Discrepancy
Receive and check medication (patient, med, doc)
Follow pharmacy-specific procedure including
after hours rules
Clarify and update order with nursing
Order Update (Phone or fax)
Order (phone, fax, pickup by driver, auto-fax
from SNF order management application)
Pharmacy
Order Question (phone or fax)
Patient Allergies
Consultant Pharmacist
Patient Orders
Receive new order
Resolve issues with order (clinical, payor, etc.)
Receive updated order
Drug Regimen Review or other Patient Status Review
Patient MAR
Med
MAR Update (optional)
Order Exception
Process order and dispense includes payor
verification and formulary compliance
26
Typical Admission in LTC

• Most admissions in LTC are from a hospital
  setting
• Most residents begin stay under Medicare Part A
• Generally, discharge orders from the hospital are
  admission orders at the facility

27
Typical Order Management Process New Admission
Pharmacy Fills Orders and Delivers Medications
Resident Enters Nursing Home From Hospital with
Discharge Orders
Pharmacist Manually Enters Orders in PhIS
with DUR Check
Nurse Faxes Discharge Orders to Pharmacy
Pharmacy Provides Paper Based MARs and Order
Sheets
28
Typical Order Management Process New Admission
Pharmacy Fills Orders and Delivers Medications
Resident Enters Nursing Home From Hospital with
Discharge Orders
Pharmacist Manually Enters Orders in PhIS
with DUR Check
Nurse Faxes Discharge Orders to Pharmacy
Pharmacy Provides Paper Based MARs and Order
Sheets
RISK Physicians often do not review admission
orders in a timely way
RISK Data entry errors can lead
to inconsistencies
RISK Paper MARs and Order Sheets are Stale
almost immediately
29
Typical Order Management Process During last 10
days of the month
Pharmacy Delivers Final MARs Before Start of New
Month
Physician Reviews, Modifies and Signs Orders on
Order Sheets
Nursing Staff Faxes Handwritten MAR Updates to
Pharmacy
Pharmacy Sends Revised MAR to Facility
Nurses Perform Secondary Review of MAR
and Handwrite Corrections
Nursing Staff Manually Reviews and Updates Orders
on MARs
30
Typical Order Management Process During last 10
days of the month
RISK Is the Order Sheet Up to Date with MAR?
RISK Paper MARs and Order Sheets are Stale
almost immediately
Pharmacy Delivers Final MARs Before Start of New
Month
RISK High Potential for Transcription Error
Physician Reviews, Modifies and Signs Orders on
Order Sheets
Nursing Staff Faxes Handwritten MAR Updates to
Pharmacy
Pharmacy Sends Revised MAR to Facility
Nurses Perform Secondary Review of MAR
and Handwrite Corrections
Nursing Staff Manually Reviews and Updates Orders
on MARs
RISK New MAR May Be Stale due to New Admits
and Order Changes
RISK Easy to Make Mistakes When Handwriting
Changes to MAR
RISK Very Time Consuming and Often not Performed
with Rigor
31
Typical MAR Flowsheet
Blank Space To Handwrite New Orders During The
Month
32
Medication Reconciliation withe-Prescribing

• Facility owns all orders
• Orders are managed in facility CPOE system
• MARs are printed from the CPOE system
• New orders are transmitted electronically to
  pharmacy
• Discontinued and changed orders are Transmitted
  electronically to pharmacy

Note CPOE Computerized Physician Order Entry
33
Order Management with e-Prescribing New Admission
Resident Enters Nursing Home From Hospital with
Discharge Orders
Pharmacy Receives Order Electronically
Pharmacy Fills Orders and Delivers Medications
Physician Enters and Signs Orders in Facility
CPOE System with DUR and Formulary Checks
Facility Prints MARs and Order Sheets From CPOE
System
34
Order Management with e-Prescribing New Admission
BENFIT Pharmacy Does Not Manage MARs or Order
Sheets
Resident Enters Nursing Home From Hospital with
Discharge Orders
Pharmacy Receives Order Electronically
Pharmacy Fills Orders and Delivers Medications
Physician Enters and Signs Orders in Facility
CPOE System with DUR and Formulary Checks
Facility Prints MARs and Order Sheets From CPOE
System
BENFIT Physician Upfront Review of Orders
and e-Signatures
BENFIT MARs and Order Sheets are Always Up to
Date
BENFIT Reduction In Data Entry Errors
35
Order Management with e-Prescribing Ongoing
Processes
Physician Writes or DC's Orders In Facility
CPOE System with e-Signature
Pharmacy Receives Order Electronically and
Resolves DUR Issues
Nursing Staff Notified of Changes and Prints MAR
Updates From CPOE System
Nursing Staff can Print Entire Up to Date MAR and
Order Sheet at Any Time
36
Order Management with e-Prescribing Ongoing
Processes
BENFIT Reduction In Data Entry Errors
BENFIT Eliminates Monthly Review Because Orders
are Always Up to Date
Physician Writes or DC's Orders In Facility
CPOE System with e-Signature
Pharmacy Receives Order Electronically and
Resolves DUR Issues
BENFIT Pharmacy System Always Up to Date
BENFIT No Handwritten Updates and MAR Always Up
To Date
Nursing Staff Notified of Changes and Prints MAR
Updates From CPOE System
Nursing Staff can Print Entire Up to Date MAR and
Order Sheet at Any Time
37
e-Prescribing in Long Term Care

• e-Prescribing is new to LTC
• 2006 CMS Pilot Study was first official standards
  based e-prescribing study in Long Term Care
• There are less than 5 standards based
  e-Prescribing installations today

38
LTC e-Rx Pilot Study Abstract

• 2006 study focused on e-Rx standards most
  relevant to LTC
• SCRIPT
• Formulary Benefits
• Electronic Prior Authorization
• Other Capabilities Studied
• Facility Managed Electronic Orders
• Patient Safety Checks (DUR)
• Electronic Signature
• Automated Refill Requests
• The study included two geographically diverse
  treatments facilities and two comparison
  facilities

39
e-Rx Findings - Facility Impacts

• Benefits
• Facilities currently using electronic Physicians
  Orders will see modest change or disruption to
  current workflow
• Ability to transmit orders directly to the
  pharmacy yielded benefits in reduced rework and
  callbacks
• Management of Orders at the facility streamlines
  reconciliation processes
• New Challenges
• Prescriber adoption is vital
• Integration with clinical systems (EHR) is
  critical
• Nurses do not effectively use patient safety
  (DUR) tools
• Even with Formulary Benefits data, managing
  complex Part D health plans is an ongoing
  challenge
• Nursing staff now has to enter and manage data
  that the pharmacy once managed
• Data entry errors can still happen

40
e-Rx Findings - Pharmacy Impacts

• Benefits
• Demographics pre-populated on new admissions
• Straightforward new order processing
• Discontinued orders
• Readmissions streamlined
• Do not have to manage MARs and Order Sheets
• Refill requests streamlined
• New challenges
• Combination Tapered Orders Need codified SIG
  standard
• Transcription accuracy
• Timely transmission on admission orders
• Fax mode for controlled substances leads to
  process inconsistencies

41
Med Reconciliation Conclusions

• e-Prescribing forces facilities to take ownership
  of their orders
• Once a facility manages their own orders, they
  typically have up to date data for MARs and Order
  Sheets
• e-Prescribing can significantly streamline
  processes and reduce reconciliation errors during
  new admissions from hospitals
• e-Prescribing can reduce reconciliation errors
  between the nursing facility and the pharmacy
• It is difficult to keep a facility managed CPOE
  system in sync with a pharmacy system without
  e-Prescribing