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Presented by NDPCP and HIMSS for the Pharmacy Informatics Community
ePrescribing FundamentalsPatricia Hale
Albany Medical Center
Michael Van Ornum
Martha Jefferson Hospital
Scott Roberston
Kaiser Permanente
October 18, 2012
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Agenda/Objectives
Assess the current state of ePrescribing highlight byexploring incentive programs, benefits and drivers foradoption presented from a physician perspective.
Explore the benefits and challenges of pharmacistsenabling ePrescribing and the workflow for prescribers
and pharmacists who process ePrescriptions. Summarize technical interoperability issues related to
ePrescribing, including semantic Interoperability (use ofa common vocabulary) and systemtosysteminteroperability issues
2
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Agenda #1
Assess the current state of ePrescribing
highlight by exploring incentive programs,
benefits and drivers for adoption presented
from a physician perspective.
Patricia L. Hale MD, PhD, FACP
Associate Medical Director of Informatics
Albany Medical Center
3
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ePrescribing Physicians
4
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ePrescribing Physicians
TEXT
5
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Specialties with Highest Rate of Adoption
6
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Adherence
7
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E-Prescriptions Routed Electronically
8
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TEXT
9
E-Prescribing by Physicians
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Prescribers Routing E-Prescriptions
TEXT
10
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Benefits and Drivers for Adoption of e-Prescribing
11
The Problem:
4 out of 5 patients who visit a
physician leave with at least one
prescription
65% of the US population with at
least one prescription
medication each year
Between 1.5%-4.0% handwritten
prescriptions are in error with
adverse drug events occurring in
5%-18% of ambulatory patients
The Solution:
52%of office-based physicians now use e-prescribing (increased from less than 10% 3 yrsago) with >75% using full EHRs
69% of e-Prescribing physicians are in primarycare (Family practice, Internal Medicine,Pediatrics)
91% of retail pharmacies nationwide arereceiving e-prescriptions (73% of independentpharmacies)
41% of patient visits benefit from electronicmedication history information
From SureScripts Report November 2011 www.surescripts.com
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E-Prescribing Benefits:
12
Eliminates illegible handwriting
Promotes access to more complete prescription history Decreased costs and increased formulary compliance
Decreased risk for adverse drug events through drug-drug and drug-allergyinteraction alerts 30-50% decrease in adverse drug events and 0.25% reduction in ER and hospital costs
Increased access to clinical guidance including drug safety alerts, adherence
reminders, and alerts for possible gaps in care of chronic disease 15% decrease in cost for Diabetes management, increase from 50 to 90% compliance with cholesterol
treatment
Decrease time spent on process (especially for pharmacy callbacks andrenewals) A study by MGMAs Group Practice Research Network estimated that the time spent managing
unnecessary administrative complications related to prescriptions is estimated at approximately $15,700
annually for each full time physician Improved Convenience for Patients and improved Patient medication
adherence. A study by IMS and Walgreens showed an 11 percent increase in prescriptions reaching the pharmacy
when e-prescribing was used
15% increase in patient compliance
MGMA, IMS Health Press Release, Visante and SureScripts reports
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Challenges for E-prescribing :
13
Acceptance and trust of process by patients Federal requirements for controlled substances
Variations in rules and regulations between states
Implementation challenges Cost
Workflow changes
Communication challenges
Incomplete Standards for: drug terminology and codified instructions which can
result in errors translating data between systems,
Prior authorization approval messages from insurancecompanies, which causes increased risk of errors andmanual processes
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Challenges for e-prescribing :
Federal Requirements for e-Prescribing of Controlled Substances (EPCS)
14
The DEA now permits prescriptions for controlled substances to be issuedas long as its regulatory requirements are met
Prescribers that wish to manage these prescriptions electronically must usetechnology that has been certified for this transmission
Prescribers themselves must undergo an ID Proofing process before theybegin to submit prescriptions for controlled substances electronically
Prescribers must use a two-factor authentication process each time theysend a prescription for a controlled substance electronically something you know (user name and password)
something you have (authentication device)
Some states have not yet aligned their prescribing regulations with that ofthe DEA and DEA regulations do not pre-empt regulations issued by states.
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Challenges for e-Prescribing:
State Laws, Rules and Regulations
15
Contradictory prescription requirements across different sets of statutesand regulations; Example = Requirement for hand writing of brand necessary
Pharmacy recordkeeping requirements mandating that electronicprescriptions and other pharmacy records be maintained in hard copy
(rather than electronically); Direct transmission requirements for e-prescribing that may interfere withemploying an electronic data intermediary; and
Patient consent requirements for the electronic transmission of aprescription.
Permission for out of state electronic prescribing
Legislation has been proposed in several states that would prohibitphysicians from seeing messages from third-party information providers asthey write an e-prescriptions.
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Incentives and Penalties:
The Medicare Improvements for Patients and Providers Act (MIPPA)
16
Incentives and Penalties: The incentive for e-Prescribing has decreased from a maximum of 2 percent to 1 percent of total
allowed charges in 2012
Starting in 2012 penalties also begin with a decrease in Medicare fee reimbursement of 1% for not
using e-Prescribing. This penalty increases to 1.5% in 2013 and 2% in 2014.
Prescribers must e-prescribe 10 times using a qualified e-Prescribing system by June 30, 2011 to
avoid the penalty in 2012. To avoid a 2013 penalty, prescribers must e-prescribe 25 times by
December 2011.
Exemptions:
Not a physician (includes MDs, DOs, and podiatrists), nurse practitioner, or physician assistant as of
June 30, 2011
Do not have at least 100 cases (that is, claims for patient services) that contain the applicable e-
prescription service code for dates of service between January 1, 2011 through June 30, 2011. Claims reflect that less than 10 percent of estimated total allowed charges for the January 1, 2011
through June 30, 2011 reporting period are comprised of applicable e-prescription service codes.
Hardship Exemption requests submitted by Nov. 8 2011 for a rural area without sufficient high
speed internet access , or an area without sufficient available pharmacies for electronic prescribing
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Incentives and Penalties:
The Health Information Technology for Economic and Clinical Health Act
(HITECH)Meaningful Use Program
17
To receive incentive payments, physicians must prove that they meet government requirements for
meaningful use of EHR technology which will evolve over 3 Stages from 2011 through 2015.
Stage 1 of meaningful use requires:
at least 40 percent of eligible prescriptions are prepared and sent to pharmacies electronically
Active medication and allergy lists
Drug-drug and drug-allergy interaction checking Medication reconciliation
Formulary checking (menu option in Stage 1, expected to be required in Stage 2
Future stages of meaningful use place increasing importance on the send and receipt of clinical
information between health care providers to inform patient care. This includes:
the receipt and use of patient formulary and eligibility information from payers accessed through use
of e-prescribing technology certified for this communication.
increasing requirements for the percentage of eligible prescriptions prepared and sent to
pharmacies electronically
Physicians can only participate in either the Medicare (up to $44,000) or the Medicaid ($63,750) incentive
program but are subject to Medicare penalties either way.
Physicians participating in the Medicaid program can receive reimbursement for implementation costs
and can also participate in MIPPA
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Incentives to Increase Adoption
18
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Incentive Program Examples
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Program name Description
ePrescribe Florida Collaborative effort of several health plans, provider organizations, pharmacies and vendors aimed at accelerating the adoption
of e-prescribing. In the first phase, the initiative offers free educational and implementation programs to prescribers, including
information related to how to select and implement the right application.
Highmark eHealth
Collaborative
(Pennsylvania)
Sponsored by Highmark, a health insurer in Pennsylvania, the Highmark eHealth Collaborative works with providers to pay up to
75% of the cost for a physician practice to acquire, install and implement the electronic technology system, up to a maximum of
$7,000 per physician
Massachusetts
eRx Collaborative
Broad collection of health plans, pharmacies, technology vendors, and supporting organizations that sponsors programs and
education activities to accelerate e-prescribing adoption in Massachusetts, including hand-held devices loaded with e-prescribing
software, license fees and support, and internet connectivity. In five years, 17.8 million prescriptions have been sentelectronically through Collaborative prescribers; in 2008, nearly 83,000 prescriptions were changes as a result of drug alerts
Southeast Michigan
e-Prescribing
Initiative (SEMI)
Collaboration of automakers, health plans, vendors, pharmacies and pharmacy benefit managers to encourage
the adoption of e-prescribing throughout Michigan by providing incentives to prescribers and measure the impact
of e-prescribing patient safety. In 2007, Michigan became the #5 e-prescribing state in the nation, with 90% of
prescriptions coming from the area covered by SEMI.
NYS Medicaid e-Prescribing Incentive
Program
Effective January 1, 2010, Medicaid prescribers can receive an incentive payment of $0.80 per dispensed Medicaid e-prescription,and eligible retail pharmacies can receive $0.20 per dispensed Medicaid e-prescription. Incentives are calculated and dispersed
by Medicaid program without need for submission of data.
Includes one original fill and up to five (5) refills within 180 days are each eligible for an incentive payment to both the prescriber
and pharmacy, provided that the refilled item is picked up by or delivered to the beneficiary
From eHealth Initiative and The Center for Improving Medication Management. Electronic Prescribing: Becoming Mainstream Practice. June 2008
and Examples of E-Prescribing Initiatives from Surescripts. November 2008 and Deloitte The evolving e-Prescribing landscape 2010
AMA interactive site with listings of incentive programs by state: http://www.ama-assn.org/ama/pub/eprescribing/financial-
assistance-and-support.shtml
http://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtmlhttp://www.ama-assn.org/ama/pub/eprescribing/financial-assistance-and-support.shtml7/29/2019 E-Prescribing Fundamentals 2012.10.18
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Explore the benefits and challenges of
pharmacists enabling ePrescribing and the
workflow for prescribers and pharmacists who
process ePrescriptions.
Michael Van Ornum , RN, RPh
Information Systems Pharmacist
Martha Jefferson Hospital
20
Agenda #2
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Fundamental Shifts
WorkflowPharmacyReview What did the prescriber mean?
Prescriber
Selection What should I choose?
OperationsPharmacy
Technical IntegrationWhy doesnt this work?
PrescriberTechnical Learning Curve How does this work?
21
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Rx: Select -> Review
Biggest AdvantageSpeed
Hardest ChallengeAttention to Details
Greatest AssetCommunication
22
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MD: Prescribe -> Select
Biggest AdvantageSpecificity
Hardest ChallengeKnowledge Base
Greatest AssetGuidance
23
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Rx: Case Examples
Pharmacy Service ExpansionAutomated Refill ReminderInteractive Voice Response System
Electronic Prescribing
Internet integration for ordering
Automatic Renewals (Refill Requests)
Inventory management innovation
24
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MD: Case Examples
Medical Service ExpansionAutomated Appointment ReminderAdvanced Voice Mail (Lab Results, scheduling, refills)
Electronic Prescribing
Internet integration for appointments
E-consultations
Integrated Care systems (Practice Management, Billing,
EMR, CPOE)
25
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Rx: Operational Shifts
IVRSRedundant FaxingNeed for better interfaces
Automated Refill ServiceRedundant Refill Requests
Inventory Management InnovationIncreased Product Variability
26
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MD: Operational Shifts
CPOE vs EMRNeed for synchronized medication lists
Advanced VoicemailMore pharmacy faxes and electronic renewal requests
Favorite PrescriptionsIncreased prescribing (translates to increased volume in
pharmacies)
27
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Rx/MD: Zingers
Wrong PatientWrong Formulation
Conflicting Comments
Wrong Administration TimesDuplicate medications
Wrong sequencing of requests
28
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Summarize technical interoperability issuesrelated to ePrescribing, including semanticInteroperability (use of a common vocabulary)
and systemtosystem interoperability issues
Scott M Robertson, PharmD
Principal Technology Consultant and Health I.T.Strategy and Policy
Kaiser Permanente Information Technology
29
Agenda #3
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Interoperability
The ability to exchange and use information
Three Aspects to consider
Physical Interoperability
The cables, networks and systems that connect the prescriber
and the pharmacist
Syntactic InteroperabilityThe information being sent and how that information is
assembled into the ePrescription
Semantic Interoperability
How the information within the ePrescription is expressed.
Speaking the same language
30
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Interoperability
31
Patient
Med
Sig
Rx
Patient
Med
Sig
Rx
Patient
Med
Sig
Patient
Med
Sig
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Physical Interoperability
32
Direct connections
Networks
Intermediaries
Standards for Transport
Mailbox vs direct messaging Address for recipient
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Physical Interoperability
Networks
Direct connections
Intermediaries
Standards for Transport
Mailbox vs direct messaging Address for recipient
33
Secure Network
Connection
(secure channelover public
network)
Direct Connection
Intermediary
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Syntactic Interoperability
34
Rx
Patient
Med
Sig
Rx
Patient
Med
Sig
Standards for Content
NCPDP SCRIPT 10.6
In regulation:
42 CFR 170.205 , 42 CFR 423.160
Future versions
EDIFACT and XML
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Semantic Interoperability
35
Patient
Med
Sig
Rx
Patient
Med
Sig
Rx
Patient
Med
Sig
Patient
Med
Sig
Exchanging Concepts
Vocabularies, Code lists, Value Sets,
Identifiers people, products, services
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Semantic Interoperability
36
Patient
Med
Sig
Rx
Patient
Med
Sig
Rx
Patient
Med
Sig
Patient
Med
Sig
Identifiers
NPI Providers and Prescribers
DEA
NCPDP Number - Pharmacies
? Patients Registries
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Semantic Interoperability
37
Patient
Med
Sig
Rx
Patient
Med
Sig
Rx
Patient
Med
Sig
Patient
Med
Sig
Standards
RxNORM - Medication
FMT Drug descriptive terms
SNOMED Medical Terminology
ICD-9-CM / ICD-10 CPT
LOINC
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Semantic Interoperability
RxNorm
Overview -
http://www.nlm.nih.gov/research/umls/rxnorm/overview.html
Incorporated into all major Drug Knowledgebases
Ties to NDC numbers, Structured Product Labels
Structure
SCD Semantic Clinical Drug897666 Verapamil hydrochloride 120 MG Oral Tablet
SBD Semantic Branded Drug
897667 Calan 120 MG Oral Tablet
RxNav - http://mor.nlm.nih.gov/download/rxnav/rxnav.jnlp
http://www.nlm.nih.gov/research/umls/rxnorm/overview.htmlhttp://mor.nlm.nih.gov/download/rxnav/rxnav.jnlphttp://www.nlm.nih.gov/research/umls/rxnorm/overview.htmlhttp://www.nlm.nih.gov/research/umls/rxnorm/overview.htmlhttp://www.nlm.nih.gov/research/umls/rxnorm/overview.htmlhttp://mor.nlm.nih.gov/download/rxnav/rxnav.jnlphttp://www.nlm.nih.gov/research/umls/rxnorm/overview.html7/29/2019 E-Prescribing Fundamentals 2012.10.18
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Semantic Interoperability - RxNorm
RxNorm
Overview -
http://www.nlm.nih.gov/research/umls/rxnorm/overview.html
RxNav - http://mor.nlm.nih.gov/download/rxnav/rxnav.jnlp
Structure
SCD Semantic Clinical Drug897666 Verapamil hydrochloride 120 MG Oral Tablet
SBD Semantic Branded Drug
897667 Calan 120 MG Oral Tablet
http://www.nlm.nih.gov/research/umls/rxnorm/overview.htmlhttp://mor.nlm.nih.gov/download/rxnav/rxnav.jnlphttp://mor.nlm.nih.gov/download/rxnav/rxnav.jnlphttp://www.nlm.nih.gov/research/umls/rxnorm/overview.html7/29/2019 E-Prescribing Fundamentals 2012.10.18
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Thank You!
Patricia L. Hale MD, PhD, FACP
Michael Van Ornum , RN, RPh
Scott M Robertson, PharmD, RPh
40
S h D !
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]7/29/2019 E-Prescribing Fundamentals 2012.10.18
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Pharmacy Informatics Town Hall Series:
Thursday, November 15 12:00pm CT /1:00pm ET:
Improving Medication Reconciliation with Standards
http://www.himss.org/ASP/topics_pharmacyInformatics.asp
Save the Dates!
http://www.himss.org/ASP/topics_pharmacyInformatics.asphttp://www.himss.org/ASP/topics_pharmacyInformatics.asphttp://www.himss.org/ASP/topics_pharmacyInformatics.asphttp://www.himss.org/ASP/topics_pharmacyInformatics.asphttp://www.himss.org/ASP/topics_pharmacyInformatics.asp7/29/2019 E-Prescribing Fundamentals 2012.10.18
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