Health IT Quality

In the workflow for electronic prescription routing, there are two core message flows. The first deals with the routing of an entirely new prescription, called “NewRx” in the NCPDP standard. A new prescription may authorize one single dispensing, or more than one, depending on the therapeutic requirement specified by the prescriber. On a NewRx message, the prescriber can indicate how many additional dispensings are authorized beyond the one that is implicit in the new prescription message. The number of authorized dispensings can range from zero to ninety-nine, although the most common values are zero, two, and eleven. Two is typically used when each dispensing provides thirty days worth of medication. Therefore two authorized refills provides a total of three dispensings (slang in the industry is “1 + 2”) which would last a total of ninety days.

After the total number of authorized dispensings are exhausted, the pharmacy must contact the prescriber to seek further authorization before additional dispensings can be made. Before e-prescribing, renewal authorization communications was done by phone or fax (if permitted by state and federal law.)

With e-prescribing, the second core workflow deals with a renewal authorization requests and responses. These messages are called refill requests and refill responses, abbreviated as RefReq and RefRes respectively.

When the pharmacy needs to obtain further authorization to make another dispensing to a patient, they send an electronic RefReq message to the provider who issued the original prescription. The provider can reply with a response message back to the pharmacy. A RefRes message comes in one of four flavors. The straightforward “Approve” and “Deny” responses are self-explanatory. “Approved with Changes” allows the prescriber to indicate that the renewal is approved, but modest changes are being made to the request, usually the number of refills is being changed.

The fourth response type is “Denied New Prescription to Follow” (DNTF). This type of response indicates that the request that has been made is being denied, but that an entirely NewRx will be sent instead.

The DNTF response type was developed years ago, before e-prescribing was really active. The intent of that response type was to communicate to the pharmacy that a clinical change was required. Literally “Deny this one you asked for, and substitute it with this NewRx instead.”

The issue that we observed in practice is that the DNTF was being used for more than a clinical change. If a technical change was required, say something as benign as wanting to send a different NDC number, or a slightly different formatted drug name text string, the DNTF workflow was being used by many e-prescribing or electronic medical record (EMR) vendors. The reasons for needing to make a technical change are complex and intricate, based on some of the nuances of the NCPDP standard like the use of drug names as free text fields, the use of disparate drug reference database compendia, and a lack of standardization on improvements such as RxNorm (a new drug identification standard) and Structured and Codified SIG. This practice of using the DNTF for technical changes instead of clinical changes frustrates pharmacists, because they are getting a message that communicates “Deny this one you asked for, and substitute it with this NewRx instead.” The problem is that much too often the medication information being denied is IDENTICAL to the information that is in the NewRx. There are two problems with that in pharmacy:

 

1. There is a different workflow for a DNTF compared to Approved. The DNTF workflow sometimes requires re-work which introduces inefficiency and the potential of an error.
2. The pharmacy is paying for messages and is paying two fees, one for the DNTF and one for the NewRx, when the semantic meaning of the messages was in fact “Approved” and could have been relayed in one message that would only incur one fee.

 

NCPDP has recognized this issue and is in the process of redefining the DNTF response type. Once approved and ratified, we think there will be only one message going back to the pharmacy, that indicates both “Deny the request” and “Here’s the NewRx” within one message.

Instead of waiting for the industry to approve, adopt, and start using that new message, Surescripts has decided to change its billing practice in advance of the NCPDP change by eliminating the fee for DNTF. While there still is a percentage of DNTF messages that indicate valid clinical change, the numbers of DNTF with technical only content changes have been increasing, and we are taking this step in the best interests of the industry and the balance of the network.

The billing change does not change the current use of the DNTF, which still presents workflow and processing challenges at both ends of the network, but it does relieve a pain point which has been growing, and sets a path toward an NCPDP change that we think is going to help alleviate the problem in the long run. Surescripts will be performing additional analysis of DNTF usage to encourage the proper and optimal use of the message over time.

 

It has been a banner year for healthcare in America, and especially for health IT. Not only have adoption and implementation rates been increasing steadily for e-prescribing, electronic records-keeping and other HIT advances, but policymakers, regulators, administration officials and others more and more are recognizing the value of health IT and its ability to improve patient safety and care quality while reducing healthcare costs overall.

We have seen huge strides in health IT this year, but we still have a ways to go. As we reflect on the past year and all that we achieved, it’s important to also recognize where there is room for improvement – particularly where patient safety and care quality are concerned. As someone who has been leading the charge for improving quality and safety by developing metrics and reporting criteria to measure quality and safety and establishing a set of standards for users to meet, I am always trying to identify ways to improve care quality and patient safety – not only within the Surescripts network, but throughout the healthcare delivery system.

Next year will be a critical year for health IT -- from meaningful use to secure messaging, interoperability to clinical decision support, not to mention the health insurance exchanges and the technological challenges they are anticipated to bring. With all of this in mind and in the spirit of the season, I would like to propose a few New Year’s Resolutions for health IT (they’re easier to stick to than your yearly vow to start going to the gym!).

My Health IT New Year’s Resolutions:

1. Increase e-prescribing and electronic health records adoption amongst providers, pharmacists and others
2. Improve patient access to electronic records
3. Increase interoperability amongst providers, pharmacists, hospital groups and caretakers in order to improve care coordination
4. Empower patients and patient advocates by improving patient engagement
5. Combat alert fatigue
6. Increase e-prescribing of controlled substances
7. Find new ways to incorporate mHealth technologies – particularly to engage patients

What are your New Year’s resolutions for health IT? Tell us below in the comments.

The Surescripts team will definitely be working towards achieving these resolutions in the new year, and making other strides towards improved interoperability, patient safety and care quality, too – so be sure to check back to the HIT Quality Blog for updates on our progress, the latest HIT quality and safety news and more!

And from all of us at the HIT Quality Blog, Happy Holidays!

Right now, heart disease is responsible for one out of every three deaths in the United States. It’s a staggering statistic, and one that is especially tragic when you consider that many of those deaths could have been prevented.

That’s why Surescripts is proud to be partnering with the Department of Health and Human Services (HHS) and the Office of the National Coordinator for Health Information Technology (ONC) on their Million Hearts^TM initiative, employing a variety of proactive strategies to prevent one million heart attacks and strokes by the year 2017. It’s an ambitious, but incredibly worthwhile, goal.

 It’s estimated that, by 2016, 350 million working adults will be using smartphones. Seeing the potential benefits mobile applications could have on public health, the American healthcare industry is beginning to develop mobile applications to help people take steps to protect and strengthen their own well-being. Million Hearts^TM is one such initiative that will enable us to test the linkage between mobile technology and improved healthcare.

Part of the Million Hearts^TM initiative involves community pharmacies providing health screenings, enabling people to know if they’re at risk for a serious heart-related health episode. And that’s where Surescripts, which has interactive connectivity with approximately 95 percent of the nation’s pharmacies, has an important role to play.

ONC envisioned the creation of a mobile application that would have health self-assessment tools for consumers and also the ability to locate nearby pharmacies offering health screenings. To accomplish this, ONC issued the Million Hearts^TM Risk Check Challenge– charging developers with the task of creating an app to help the millions of Americans at risk for cardiovascular disease take action to improve their health. Surescripts is supporting the technology development and connectivity to make that happen.

As much as we discuss the ability of data networks to enable healthcare functions like e-prescribing and the sharing of patient data between health providers, it seems that even those of us who work with these networks every day are still realizing the enormous potential of digital connectivity to create a healthier society. Imagine what kind of healthy society we can achieve simply by enabling tens of millions of people to proactively protect against a health crisis simply by using a device they carry with them every day.

It makes you think that stopping one million strokes and heart attacks might just be the beginning of what we can do. Stay tuned for updates as this initiative has just gotten underway.

It only makes sense that pharmacies and pharmacists would be playing an increasingly important role in our healthcare system. One basic reason is proximity. More than 90 percent of Americans live within five miles of a community pharmacy. Even in less-populated rural areas, a drugstore is normally close by. That’s not always the case with hospitals and clinics that provide comprehensive health services.

So, it’s very positive that we’re seeing an evolution of the role of the pharmacist in the nation’s healthcare system. More often than not, today’s pharmacy is more than just a place to pick up a bottle of pills. Chains like Walgreens, CVS and Wal-Mart, as well as independent community pharmacies, are increasingly offering wellness programs, health screenings, immunizations and disease management services. Many provide in-store health clinics. Pharmacies are transforming themselves into multi-purpose health centers.

This significant change is being empowered, in large part, by information technology. Interoperable data networks began improving the pharmacy component of the healthcare continuum through e-prescribing. Roughly 95 percent of the nation’s pharmacies are linked to the Surescripts interoperable network. This makes it possible for the rapidly rising number of physicians using e-prescribing technology to communicate digitally with pharmacists, improving both patient safety and medication adherence. Reduced drug-related medical errors and greater prescription adherence are also significantly reducing health system costs.

But we’ve only begun to tap into the potential of digital networking. As pharmacists begin offering more healthcare services, particularly through in-store clinics that can conduct physical examinations and offer routine immunizations, it becomes increasingly important to link those pharmacies with patients’ primary healthcare providers. This two-way electronic street over which patient information can flow enables the best possible care to be delivered wherever the patient happens to be – in the pharmacy, in the hospital, or in the physician’s examination room.

A research paper published by the consulting firm Booz and Company, written by the company’s global healthcare experts, noted that “pharmacies are uniquely positioned to help meet the top two goals of reform:  providing convenient, expanded access to medical care and controlling costs.”

This can only happen effectively if the pharmacy is linked electronically to the other players in the healthcare continuum. With that data linkage, the options for quality healthcare available to American patients and healthcare consumers are dramatically and beneficially expanded.

It’s always important to recognize the connection between principles and practice and, at the same time, the differences between the two.

Take, for example, e-prescribing. The principles behind e-prescribing are unassailable. Digitizing the information a physician provides to a pharmacist significantly reduces medication errors. It takes the guesswork out of pharmacists trying to read doctors’ handwriting. Studies have shown it also boosts medication adherence among patients. If a prescription goes electronically from the doctor to the pharmacy without going into a patient’s pocket, wallet or pocketbook in between, there is a much greater likelihood that prescription will be filled and utilized as the physician intended.

But in order for these e-prescribing principles to be effective, there must be constant vigilance in the way they are put into practice. And that’s why Surescripts created the White Coat of Quality program– to ensure that physicians who had adopted e-prescribing had done so in such a way that it yields increased care quality and patient safety.

This is an award presented to vendors who not only apply best practices to the use of e-prescribing technology, but also engage in continuous quality improvement and training of prescribers. There are four criteria involved in selecting White Coat of Quality recipients:

• It is essential for senior leadership of the organization to formally, in writing, affirm their commitment to a goal of zero electronic prescription content errors.

• Organizations must keep detailed metrics on their e-prescription content errors and report those findings to Surescripts.

• Vendors must be diligent in making necessary software changes in order to minimize any e-prescription clinical content errors.

• Organizations must provide educational programs to help e-prescribing users better understand and utilize the technology to minimize their own clinical content errors.

The effectiveness of evolving technologies must be mirrored by the commitment of the professionals who put those technologies into practice. That’s certainly Surescript’s intent with e-prescribing. We have never accepted the notion that simply having a good idea is good enough. Constant improvement must be part of the equation.

The good news is that we are not the only ones who recognize this, as evidenced by the fact that the number of White Coat awardees keeps rising, which means that the quality and safety of the care patients are receiving is improving... In which case, it seems to me that everyone wins.