Transcript ePrescribing Quality: Current Progress and the Path Ahead

ePrescribing Quality:
Current Progress & the Path Ahead
Webinar Release Date – August 23, 2016
Brad Croft, D.O., MBA, FACOFP
Ajit Dhavle, Pharm.D., MBA
Michele V. Davidson, R.Ph.
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About NCPDP
Founded in 1977, NCPDP is a not-for-profit, ANSI-accredited, Standards Development
Organization with over 1,600 members representing virtually every sector of the
pharmacy services industry.
NCPDP members have created standards such as the Telecommunication Standard
and Batch Standard, the SCRIPT Standard for e-Prescribing, the Manufacturers Rebate
Standard and more to improve communication within the pharmacy industry.
Our data products include dataQ®, a robust database of information on more than
76,000 pharmacies, and HCIdea®, a database of continually updated information on
more than 2.3 million prescribers. NCPDP's RxReconn® is a legislative tracking product
for real-time monitoring of pharmacy-related state and national legislative and regulatory
activity. www.ncpdp.org
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About Surescripts
Formed in 2001, Surescripts has evolved into the nation’s most comprehensive clinical
network. Surescripts connects pharmacies, payers, pharmacy benefit managers,
physicians, hospitals, integrated delivery networks, health information exchanges and
health technology firms to enable the efficient and secure exchange of health
information. More than 500,000 prescribers, 600 EHR applications and 94% of
community pharmacists are active on the Surescripts network.
Guided by the principles of neutrality, transparency, physician and patient choice, open
standards, collaboration and privacy, Surescripts provides information for routine,
recurring and emergency care. Together with our network participants, Surescripts is
committed to saving lives, improving efficiency and reducing the cost of health care for
all. For more information, go to www.surescripts.com and follow us at
twitter.com/surescripts.
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About HIMSS
HIMSS North America, a business unit within HIMSS, positively transforms health
and healthcare through the best use of information technology in the United States
and Canada. As a cause-based non-profit, HIMSS North America provides thought
leadership, community building, professional development, public policy, and events.
HIMSS North America represents 61,000 individual members, 640 corporate
members, and over 450 non-profit organizations.
Thousands of volunteers work with HIMSS to improve the quality, cost-effectiveness,
access, and value of healthcare through IT. Major initiatives within HIMSS North
America include the HIMSS Annual Conference & Exhibition, National Health IT
Week, HIMSS Innovation Center, HIMSS Interoperability Showcases™, HIMSS
Health IT Value Suite, and ConCert by HIMSS™.
HIMSS Vision: Better health through information technology.
www.himss.org
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Dr. Brad Croft, D.O., MBA, FACOFP
Bradford Croft, DO, a 1980 graduate of the Philadelphia College of
Osteopathic Medicine, completed his post-doctoral training at Phoenix
General Hospital. He earned his MBA degree from University of
Phoenix in 2004. For over thirty years, his multi-provider clinic
continues to serve Flagstaff and Northern Arizona, providing primary
care and occupational medicine services to a growing population. As
an early adopter of electronic medical records in 2002, he continues to
promote EMR and eRx utilization to his colleagues and medical
community.
Dr. Croft is affiliated with a number of state and national organizations,
served in many capacities, and has received multiple service awards
from the Arizona Osteopathic Medical Association. He was a keynote
speaker for the NCPDP October 2013 meeting, presenting “Maximizing
Prescription Quality Through ePrescribing – Prescribing Pearls and
Pitfalls”. Most recently, he presented the physician perspective of Eprescribing Quality Improvement in the February 2014 Pharmacy Town
Hall series. Today he will discuss the transitions since his last
presentation.
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Ajit Dhavle, Pharm.D., MBA
Vice President of Clinical Quality, Surescripts
Ajit Dhavle is the Vice President of Clinical Quality at
Surescripts. Dhavle built and now runs the Clinical Quality
program at Surescripts that helps prescribers, pharmacies,
pharmacy benefit managers and health systems achieve
the three fundamental pillars of e-prescribing: accuracy,
efficiency and patient safety. Dhavle joined Surescripts in
its early stages as a Product Manager. He is a frequent
speaker at industry events and has extensively published
on e-prescribing quality issues most recently in the JAMA
Internal Medicine and the Journal of American Medical
Informatics journals. Dhavle received his Doctor of
Pharmacy and his Masters of Business Administration
degrees from the Bernard J. Dunn School of Pharmacy
and the Harry F. Byrd School of Business at Shenandoah
University in Winchester, Virginia, USA.
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Michele V. Davidson, R.Ph.
Senior Manager, Pharmacy Technical Standards,
Development & Policy, Government Relations
Walgreens
Michele Davidson graduated from the University of Florida
with a B.S in Pharmacy. Before joining Walgreens in 2009,
she served as the Director of Telecommunication
Standards for the National Association of Chain Drug
Stores (NACDS) where she led the chain pharmacy
industry’s’ effort in the implementation of the National
Provider Identifier (NPI). Before NACDS, Michele had over
25 years’ experience with Eckerd Drugs in which she held
various positions of increasing responsibility from Store
Pharmacist to Director of Government Programs. She has
been very active in NCPDP over the past 15 years and is
currently serving as NCPDP Immediate Past Chair of the
Board of Trustees for 2016-2017. She was co-chair of WG
11 (ePrescribing and Related Transactions) for 8 years.
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Accreditation Statement
• The Institute for Wellness and Education, Inc., is accredited by
the Accreditation Council for Pharmacy Education (ACPE) as
a provider of continuing pharmacy education. Participants of
the session who complete the evaluation and provide
accurate NABP e-Profile information will have their credit for
1.0 contact hours (0.10 CEU) submitted to CPE Monitor within
60 days of the event. Please know that if accurate e-Profile
information is not provided within 60 days of the event, credit
cannot be claimed after that time.
• ACPE program numbers are:
0459-0000-16-005-H04-P & 0459-0000-16-005-H04-T
• Initial release date is 08/23/2016.
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Learning Objectives
• Identify metric values that should be used to describe quantities
• List two message types that are recommended for industry wide
implementation
• Describe the proper use of the notes field
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Pre-test Questions
1. What challenges do pharmacist face with
medication prior authorization today?
2. How should prescribers use the Notes fields?
3. What new transactions can improve the
ePrescribing workflow?
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ePrescribing Facts:
• Over 1.41 billion ePrescriptions were sent in 20151
• 75% of all prescriptions are now electronic1
• Nationally 61% of all prescribers sent an eRx in the last 30 days2
• Nationally 96% of all pharmacies received an eRx in the last 30 days3
• 12.6 Million ePrescribing of Controlled Substances (EPCS)
transactions were sent in 2015
• 21.4 Million EPCS have already been sent through July 2016
• New York I-STOP, mandates all prescriptions be electronic, is driving
NY to the nation’s highest usage rate of ePrescribing and EPCS
1.
2.
3.
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Surescripts 2015 National Progress report, www.surescripts.com/report
Total Prescribers: total prescribers in both acute and ambulatory settings based on Enclarity data excluding dentists. Prescribers licensed in multiple states only counted
once towards National total; Source: Surescripts network data July 2016
Total Pharmacies: total number of retail pharmacies in the country based on NCPDP data; Source: Surescripts network data July 2016
Now is the time to focus on quality and
workflow improvements.
Adoption
Utilization
Optimization
Eliminate paper prescriptions
Legalization in all 50 states
Workflow efficiencies
Deliver important medical
information electronically
DEA proposed EPCS rule
Improved customer
experience
Build positive experiences
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ARRA $19 billion to drive adoption
Meaningful use incentives
Enhanced usability and
quality
Provider Experience: ePrescribing is
popular and effective, but better
training is needed
• Increasing popularity of ePrescribing by providers
• Most have access to ePrescribing thru EMR, but not yet all
• Initial training may be available with the implementation of
EMR
– Vendor training available to create appropriate eRx’s
• Control of blank eRx composition combinations
• Taper or ramp dosing
• “Superusers” – concept, not reality
• General satisfaction of providers but problems persist
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Northern Arizona providers surveyed in
July to take pulse on their experiences
with ePrescribing
• 218 providers queried; 32 responses
• Received feedback from a diverse sampling
of providers
– Cross section of specialties
• PCP, hospitalist, surgeon, ER, etc.
– Health system employed and independent
– Inpatient and outpatient settings
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Survey Results: Most providers found
ePrescribing to be beneficial
• Only 2 providers (6%) do not currently ePrescribe
• Overall satisfaction rating with ePrescribing was 72/100
• General consensus of benefits
– Faster
– Convenient
– No lost prescriptions
• Usage
– 2/3 spend less than 1hour/week ePrescribing
– 1/3 spend 1-2 hours/week
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Survey Results: While beneficial, they
saw room for improvement
• Common difficulties and complaints
– Changing ePrescription once submitted
– Canceling ePrescription once submitted
– Training upon initial setup and subsequent updates
– Majority of respondents do not have EHR with EPCS
capabilities (however, those who do are overall satisfied)
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Survey Results: observations
• E-Prescribing works well for routine day-to-day
• Difficult when errors occur e.g. SIG/Notes
discrepancies (duration and dispensing)
• Continuous training and retraining is needed, but
not common
• Non-medication Rx challenges: Durable Medical
Equipment (DME), Physical Therapy, etc.
• Workflow short cuts still needed that facilitate
writing a complex prescription
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Here is a sampling of the common
errors that occur
• Incorrect/mismatch continues: name, strength, packing and/or sig
– Amoxicillin 250/5 cc
tab one every eight hours
– disp one box or disp #30 tabs = disp #30 boxes
• Unable to initiate change of provider for pharmacy
– Chronic med refill w/ new provider cannot be eRx requested
• Unable to “refresh” an expired Rx, must rewrite
• Disconnect among screens “duration/dispense”
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This small error could require a call
from the pharmacy to clarify
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The “written” Rx
• Problems and process of eRx
– Default menu of commonly Rx generally ok
– Difficulty in finding occasional Rx in menu choices
• Modification of default Rx
• Free hand texting new Rx
• Rx reset to default information if not sequentially
drafted
• Lack of proof prior to submitting
– Look at your eRx prior to submitting
– Version upgrades may not highlight process changes
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EPCS: adoption is growing, but there
are still barriers
• EPCS slowly gaining prescriber support
• Not readily available / implemented by EMR
• A “feared and difficult” process
• Adds one-time and/or monthly fees
• Massive adoption in NY – “it’s the law”
• Additional requirement of Prescription Drug
Monitoring Program (PDMP) in some states
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ePrescribing improvements have been
made over the past few years
• Query issues:
– Can now edit and comment on eRx reply
• Total refill requests are evident:
– Previously ambiguous
• Confirmation of pharmacy receipt
– eVerify confirmation
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These continued challenges should be the
next focus to improve the experience
• Software related challenges
– Mismatches of RX/disp/sig information
– Default Rx edits if process interference
– Existing Rx: adjust/refill/discontinue meds
• Pharmacy related challenges
– Automated unsolicited refill requests from pharmacy
– Meds change (RxChange) or d/c notification to pharmacy
(CancelRx) in improvements and needing adoption
– “Realtime” bidirectional info w/ pharmacy
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ePrescriber’s Wish List
• Current and correct formulary access / edits
• Current, correct, complete med reconciliationintegrated pharmacy HIE
• “ez” EPCS from initiation thru utilization
• Incorporate PDMP documentation in process
• “Diagnosis (DX)” populates to Medicare
prescriptions
• Patient phone number appears on Rx
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Current quality issues and
recommendations
• eRx has addressed many issues associated with paper Rx
– That said, opportunities to further improve the process do exist
• eRx needs to be unambiguous and complete
– Accurately represent prescriber’s intent
– Must be easily interpretable by the pharmacy
– Data content should be structured and standardized
• Three critical success factors:
1. Continuous end user training and feedback loop
2. Usability related user-interface enhancements
3. Adoption and utilization of newer functionalities, data
elements and bi-directional messaging transactions
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Drug Descriptions
Observed Behavior:
• 120+ variations of the same exact drug concept in a single
day
• Free-texted drug names often incomplete or ambiguous
Solution:
• Regular and timely drug database updates at the practice site
and/or by the EHR vendor
• Limit ability to free text drug descriptions
• Limit to sending preferred e-prescribing drug description
names as recommended by drug compendia or use the
RxNorm names1
1 http://www.ncpdp.org/NCPDP/media/pdf/SCRIPT-Implementation-Recommendations.pdf
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Drug Identifiers
Observed Behavior:
• Text drug description does not match with the drug description associated with
drug identifiers (NDC or RxNorm)1, 2
• Drug identifiers (NDC and RxNorm) sent in the eRx point to different drug
description concepts 1, 2
• ‘Unrepresentative’ NDCs sent in the message (obsolete, repackaged, unit
dose, private label) 2
Solution:
• RxNorm holds promise; begin sending the RxNorm identifier in addition to NDC
• Only send valid RxNorm codes, Term Types, and representative NDCs
• Confirm that the drug concept associated with the RxNorm and NDC identifiers
in the eRx exactly matches to the free-text drug description before transmission
1 Dhavle AA, Ward-Charlerie S, et al. Evaluating the implementation of RxNorm in ambulatory electronic prescriptions. J Am Med Inform Assoc. 2015 Oct 28. pii: ocv131. doi: 10.1093/jamia/ocv131.
2 Dhavle AA, Ward-Charlerie S, et al. Analysis of National Drug Code Identifiers in Ambulatory E-Prescribing. J Manag Care Spec Pharm. 2015 Nov;21(11):1025-31.
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Quantity and Quantity Qualifier (QQ)
Observed Behavior:
• Receipt of generic and/or non-metric QQ values at the pharmacy may result in
clarification calls, incorrect dispensing, or trigger third-party audits
Solution:
• Display available commercial package sizes along with corresponding metric
Quantity / QQ to the end user; send the selected metric QQ value in the
outbound message
• Accurate mapping of proprietary drug database codes to NCPDP QQ code list
• Example:
– Drug Description Name: Amoxicillin 250/5 mg/ml Suspension
– Quantity = “1”, QQ = “EA” (Each) should be instead sent as Quantity =
“100” and QQ = “mL”
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Patient Directions (Sig)
Observed Behavior:
• Abbreviated and / or incomplete Sig received at the pharmacy
– “Daily” or “QD” by itself
• Supplementary or conflicting Sig populated in the free text Notes field
Solution:
• Patient Directions should be complete, clear and unambiguous
– Action, Dose, Route and Schedule or Frequency, auxiliary information such as
duration/indication
– Example: “Take one tablet by mouth every day for blood pressure”
• End user education is critical
– End users should be trained on appropriate usage of the Sig builder tool (if
deployed)
– Application should provide users with ability to append free text Sig to the
structured Sig generated by the Sig Builder
• Implement the Structured and Codified Sig format as recommended by NCPDP
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Prescriber Notes
Observed Behavior:
• Frequently used to send information that already has a
designated, standard field available in the 10.6 NCPDP
SCRIPT version, which can then result in workflow disruptions
and can cause potential patient harm1
Solution:
• End user training and feedback
• Usability related enhancements to user interfaces
• Adoption of bi-directional messages (RxChange and
RxCancel), newer functionalities (COO segment, etc.) and
newer versions of the SCRIPT standard
1 Dhavle AA, Yang Y, et al. Analysis of Prescribers' Notes in Electronic Prescriptions in Ambulatory Practice. JAMA Intern Med. 2016 Mar 7. doi: 10.1001/jamainternmed.2015.7786
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Best Practices and Recommendations
• Days Supply is an optional field; if sent, implement Clinical Decision
Support (CDS) checks to ensure data does not conflict with other
prescription data elements
• Observation Segment enables the transmission of the patient’s height,
weight, and/or blood pressures in a structured format
– Send most recent data along with the corresponding date stamp
– The transmission of the OBS data is especially important for
infused or injected products such as oncology and pediatric
medications
• Diagnosis / Clinical Indication serves as an additional patient safety
check point and this information should be consistently sent in the eRx
• Enforcement and consistent use of the final prescription summary
review screen by the end user to ensure clear, complete and accurate
prescriptions get delivered to the pharmacy
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Workflow improvements
Additional ways to improve workflow with
implementation of:
• RxChange
• CancelRx
• Electronic Prior Authorization (ePA)
• ePrescribing of Controlled Substances (EPCS)
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Change Request (RxChange)
• Allows pharmacy to request prescriber for a change to a new
prescription order.
– Drug change
– Generic Substitution
– 90 Day Supply
– Prior Authorization
• Today, these scenarios generate a large volume of phone
calls between physicians/prescribers and pharmacies.
Benefits
• Reduction in call volume
• Automated documentation of changes to prescription
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RxChange is used to request a change
to a new or refill response prescription
when an adjustment is needed
1. NewRx sent to the pharmacy and the pharmacist identifies that a change to
the prescription may be appropriate.
2. Pharmacist submits the RxChange Request to the original prescriber.
3. Prescriber system processes the Rx Change Request and returns the
prescriber’s Change Response message to the pharmacy
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Cancel (CancelRx)
• Allows a prescriber to cancel a previously sent
prescription order.
Benefits
• Automated cancellation of prescriptions within the
pharmacy system.
• Better patient care as the pharmacy is aware patient
should no longer be taking a certain medication
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CancelRx notifies the pharmacy that a
previously sent prescription should be
cancelled or not refilled
1. Prescriber initiates CancelRx Request in their EHR and transmits request
to the pharmacy
2. Pharmacy processes the CancelRx Request and returns Cancel Rx
Response
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Electronic prior authorization (ePA)
transactions were approved in July 2013 as
part of the NCPDP SCRIPT Standard
Prescriber / EHR
Reducing
administrative burden
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PBM / PAYER
Increasing
workflow efficiency
New standard enables workflow
options for electronic prior
authorization
• Prospective workflow initiated at prescriber level before
sending ePrescription to pharmacy
o Prescriber identifies drugs requiring a PA before prescription is sent
• Retrospective workflow initiated at pharmacy after
prescriptions is sent and rejected by PBM
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NCPDP electronic PA standard eliminates
faxes and phone calls, delivering electronic
PA approvals in 5 minutes or less
without pharmacy intervention
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Electronic Prescribing of
Controlled Substances (EPCS)
• Allows prescribers to securely send prescriptions for
controlled substances
• Currently legal in all 50 states + DC
Benefits
• Reduced fraud and abuse
• Secure electronic records
• Improved safety and patient care
• Enables one efficient workflow for all prescriptions
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Two factor authentication makes EPCS
more secure than standard ePrescriptions
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Post-test Questions
1. Which of these transactions improve ePrescribing
workflow?
a) RxChange
b) ePA
c) EPCS
d) CancelRx
e) All of the Above
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Post-test Questions
1. Which of these transactions improve ePrescribing
workflow?
a) RxChange
b) ePA
c) EPCS
d) CancelRx
e) All of the Above
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Post-test Questions
2. Electronic Prescribing of Controlled Substance is
now legal in all 50 states and the District of
Columbia?
a) True
b) False
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Post-test Questions
2. Electronic Prescribing of Controlled Substance is
now legal in all 50 states and the District of
Columbia?
a) True
b) False
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Post-test Questions
3. What type of electronic prior authorization does
not require pharmacy intervention?
a) Prospective
b) Retrospective
c) Automated
d) All of the above
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Post-test Questions
3. What type of electronic prior authorization does
not require pharmacy intervention?
a) Prospective
b) Retrospective
c) Automated
d) All of the above
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Post-test Questions
4. Which of the following is not an acceptable value
to quantify the e-prescription quantities?
a) GRAM
b) Milliliter
c) Bottle
d) Tablet
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Post-test Questions
4. Which of the following is not an acceptable value
to quantify the e-prescription quantities?
a) GRAM
b) Milliliter
c) Bottle
d) Tablet
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Post-test Questions
5. Days Supply is an optional field in the NCPDP
SCRIPT standard
a) True
b) False
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Post-test Questions
5. Days Supply is an optional field in the NCPDP
SCRIPT standard
a) True
b) False
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Questions?
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Surescripts 2015 National Progress
Report Now Available
www.surescripts.com/report
Interactive report with:
• Interactive analysis
• Videos
• Value calculator
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