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!

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.

There are different types of adverse drug reactions. There are the kinds that patients can’t control, but that e-prescribing may prevent – when pharmacists can’t read a physician’s handwriting or when different doctors prescribe potentially conflicting drugs. We already know that the use of digital information creates a firewall to minimize these mistakes.

But then there are the drug events that people inflict upon themselves. More than 15,000 people die annually from prescription drug abuse. In fact, according to the Centers for Disease Control, misuse of prescription medication kills more people than the use of cocaine or heroin combined. There’s a large and growing black market in America, driven by individuals seeking prescription painkillers for non-medical purposes. That population is estimated at 12 million and rising.

By better understanding how people gain access to prescription drugs not prescribed for them, we can develop a strategy to prevent it. The key lies in utilizing data to stop what is commonly known as ‘doctor shopping’.

Doctor shopping occurs when patients count on the fact that physicians don’t have the means to share information with each other. In such a situation, a patient might see one doctor for a physical ailment and get a prescription for Percocet, then drive a couple of counties over, see a different doctor and take the prescription to a different pharmacy to collect a bottle of Vicodin. Multiple doctors, multiple pharmacies and you have the recipe for prescription drug abuse.

But, using electronic prescription drug data, authorities are able to fight back. A total of 3 states have now created prescription drug monitoring databases (PDMPs) to keep track of when pharmacies are being asked to fill prescriptions for powerful pain relievers. With a PDMP in place, it will become easier to determine when an individual visits different pharmacies to acquire those medicines on the target list.

That’s one level of protection, but we can do even better. We’re gradually moving toward using e-prescribing data networks to do more than transmit prescription drug information. Each day, we’re adding more physicians and clinics that are plugging into the network to share clinical information. As this evolution occurs, we’ll not only enable better healthcare but we’ll add another layer of detection against prescription drug abuse. Every physician should, and eventually will, have the ability to see a patient’s complete medical record before determining treatment and prescribing medications. So before they prescribe a patient a prescription, they will be able to quickly review their medical records to make sure they haven’t already received a prescription for the same or a similar medication. This data interoperability will make ‘doctor shopping’ virtually impossible.

Just as data can be used to do a better job of preventing disease, it can also be used to keep patients from inflicting harm upon themselves. We have a growing prescription drug abuse problem in this country. Let’s use every technological tool at our disposal to defeat it.

We have a growing immunization problem in the United States.

Before we get into the severity of the problem, let’s put it in perspective. Just a one percent decrease in the number of children being immunized against illnesses like measles or whooping cough could mean literally hundreds of thousands of potential contagious illness cases that could have easily been prevented. It becomes a major public health issue.

And the fact is, it’s happening right now. Last year, there were over 27,000 cases of whooping cough in the United States, more than double the number reported in 2007. In fact, according to the Infectious Diseases Society of America, we’re seeing 85,000 cases of vaccine-preventable diseases in the U.S. each year – and those are just the cases being reported.

So how do we get a handle on this problem? How do we better identify the households in which children are not getting recommended vaccinations? How do we make certain parents are properly informed about the vaccines their children should be receiving? For that matter, during flu season, how can physicians be assured that their patients are receiving protective flu shots?

The potential exists for a data network, not unlike Surescripts’ national interoperable network, to address this challenge.

A Surescripts survey of physicians found that a major contributing factor is the difficulty of maintaining complete medical records. Nearly 39 percent of doctors said they are frequently missing immunization records when they see patients.

Paper-based records can’t handle the problem. Paper doesn’t allow the rapid, unfettered movement of patient information between physicians, hospitals, clinics, nurses and other healthcare professionals who see patients and can advise on vaccination issues. Electronic data enables the presence of a complete medical record every time a patient interacts with the healthcare system. Therefore, when a child has not received a recommended vaccination, that can be flagged and protocols can be put in place to automatically alert physicians and parents accordingly.

At Surescripts, we’re already putting this theory into practice. This past March, we entered into an agreement with Walgreens. All of the nearly 8,000 Walgreens and Duane Reade pharmacies and the company’s 350 Take Care Clinics^TM, located in many of its stores, will use the Surescripts network to provide immunization reporting to primary care providers as well as state and local public health agencies.

This is just the beginning of a process that will one day allow every healthcare professional to not only know what care a patient has received but, just as importantly, what they have not.

The protection of public health depends on using every tool available to us to guard patients from preventable, communicable diseases. A comprehensive data network is one of these tools, and another one of the ways that health IT stands to improve public health in this country.