Statement by RxHub®, LLC
Subcommittee on Standards and Security
National Committee on Vital and Health Statistics
May 1, 2007
Understanding the Outcomes of the Medication
History Standard Tests in the MMA E-Prescribing Pilots
RxHub® the largest national patient health information network providing clinical decision support information to the ePrescribing industry–is pleased to provide testimony to the NCVHS Subcommittee on Standards and Security concerning the importance and clinician usage of patient medication claims history information. The data were gathered by RxHub through focus groups held in the first quarter of 2007 to better understand the findings of the e-prescribing pilots sponsored by the federal government in response to requirements of the Medicare Modernization Act of 2003 (MMA). RxHub appreciates the opportunity to share the findings of its focus groups to help NCVHS, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS) and others in their deliberations on future rulemaking, ePrescribing implementation for Medicare Part D, and increasing the national adoption of ePrescribing.
The inability for multiple systems to share information with standard formats and vocabularies has been a hurdle to ePrescribing implementation. To address this situation, MMA directed the Secretary of Health and Human Services (HHS) to establish federal standards that all ePrescribers must follow for patients enrolled in Medicare Part D. When HHS promulgated rules proposing standards for electronic prescribing, the rules identified three well-accepted standards ready (“foundation” standards) for immediate implementation, and several other areas in which standards are needed. In these areas, HHS proposed six “initial” standards for pilot testing: NCPDP standard for formulary and benefits, which was based on the RxHub-developed protocol; the NCPDP medication history message standard, which was based on the RxHub-developed protocol; Structured and Codified SIG, developed through standards development organization efforts; RxNorm, to see whether this terminology translates to NDC for new prescriptions, renewals and changes; and the new version of ANSI ASC X12 278 for prior authorization messages.
The pilots were selected through a competitive process, including rigorous review of applications by a panel that consisted of national experts in pharmacy, e-prescribing, health IT. Five pilots were selected and funded:
NJ e-Prescribing Action Coalition, including RAND, Horizon, Caremark (PBM, mail, iScribe), Allscripts, RxHub, SureScripts, UMDNJ and Point-of-Care Partners
SureScripts, Brown University, Allscripts, DrFirst, Gold Standard, MedPlus/Quest Diagnostics, ZixCorp, and pharmacies in FL, MA, NV, NJ, TN and RI
- Achieve Healthcare (Long-term Care)
Benedictine Health System, Preferred Choice Pharmacy, RxHub, Prime Therapeutics, Blue Cross/Blue Shield of Minnesota
- Brigham & Women’s (Massachusetts)
B&W Hospital, Partners Healthcare, MA-Share, CSC, Blue Cross/Blue Shield of Massachusetts, RxHub, SureScripts
- Ohio KePRO-UPCP
University Primary Care & Specialty Physicians (UPCP), Ohio KePRO, InstantDx, NDC Health, RxHub, SureScripts, Qualchoice, Aetna, MGMA Center for Research and the University of Minnesota
The pilots were completed on December 31, 2006. Findings of the pilot tests and a collaborative evaluation project with AHRQ and CMS were summarized in a Report to Congress, which was presented in mid-April by CMS. Copies of the reports are available on the AHRQ website at http://healthit.ahrq.gov/erxpilots
RxHub Focus Groups
As a major participant in four of the five MMA pilots, RxHub was aware of the major findings of the pilot tests before the official results were released by CMS. Of particular concern were the findings concerning medication history: there was poor integration of the medication history functionality into the ePrescribing workflow, and clinicians received very little education about it. However, those who were aware of it found it to be useful.
To better understand these results, RxHub convened focus groups of clinicians in the first quarter of 2007 in Indianapolis, Detroit, Boston, and New York/New Jersey. The goal was to obtain additional in-depth, objective information that could be used by point-of-care (POC) vendors and pharmacy benefit managers (PBMs) in the development of guidelines for the use and display of medication history information obtained from outside physician practices through e-prescribing. This was the focus of an RxHub-convened industry workshop on April 23-25, 2007, and potential solutions will be taken forward by RxHub to NCPDP and worked on as well by the POC vendors and PBMs.
The total of 18 clinicians, primarily physicians, participated in the RxHub focus groups. They represented both academic and private practices, small and large group practices, and utilized a range of e-prescribing applications, from home-grown to commercially available systems.
Guided by an independent consultant as moderator in professional focus group facilities, the clinicians were asked about their prescribing practices and views of medication history functionality in ePrescribing. Specifically, they discussed the extent to which they were using external medication history; how valuable they considered it to be; what additional information or functions would they like to have; how medication history fits into their workflow; and what could be done to improve the workflow.
Although the number of participants was relatively small, we believe that their focus group conversations were extremely valuable and echo findings from the MMA ePrescribing pilots, other studies and anecdotal evidence.
RxHub Focus Group Findings
Current state of e-prescribing. All focus group participants were ePrescribing to some degree and were strongly supportive of it. Many, in fact, showed pride in their involvement, characterizing themselves or their practices as leaders in the local medical community. Early adopters tended to be from larger groups with more sophisticated internal systems and more coverage of a patient’s needs. Therefore, these clinicians get good and fairly comprehensive internal histories from their own systems; as a result, the incremental value of an external medication history may be somewhat lower for this group.
Wide variability was found in ePrescribing usage. Some clinicians used it solely for refill renewals, while others had fully adopted ePrescribing, including both internal and external medication history information. The most common situation was a few years of ePrescribing experience, used for most prescripttions, and supported by internal medication history only. Not surprisingly, larger groups were more sophisticated in their use, both in terms of the functions they used and the information they accessed. Most use internal medication history from their practice, but not from external sources. In fact, most were unsure that external medication history could be available to them. It should be noted that in some cases, the POC vendor did not supply external medication history and even when it did, some physicians were unaware that it was there. Overall, there was trust and confidence in the correctness of the data.
Medication History: What Prescribers Want to See. Prescribers believe that medication history is valuable for all patients. They want a clean, relevant medication history list: one with active medications and without duplicate prescriptions and outdated episodic prescriptions. However, the clinicians wanted the ability to drill down into the full history, seeing all of the medications prescribed in their internal system and those that were filled in external systems. They also wanted to see the medications that were discontinued and the reasons for it. Additionally, clinicians wanted to see what others prescribed and had no concerns that others could see what they had prescribed.
There was no clear consensus on the “right” time frame for the history to cover. It varied from a recent snapshot (6-12 months) to lifetime coverage (“forever”). Having information on the dispensing pharmacy and SIG were not seen as particularly important, although some clinicians want to have look-back capability on the pharmacy from time to time.
Medication History Functions: What Prescribers Want to Do. Clinicians were excited about the safety improvements enabled by including all prescriptions in the DUR done on prescriptions they write, especially for drug-drug interactions. However, they wanted DUR “running in the back,” with a minimum of alerts. There also was strong interest in using ePrescribing to help spot abuse, such as through multiple prescriptions by different providers and scripts filled too quickly.
There was variability in how much the clinicians wanted to know about compliance. Most wanted to know about compliance problems for particular types of patients (such as those taking coumadin) or therapeutic classes (did the patient pick up their antibiotic). They thought it would be helpful to have medications grouped by therapeutic class.
Real concerns were expressed about the potential liability associated with alerts. For example, there could be liability attached to a clinician not acting on compliance lapses identified through ePrescribing. This concern was especially strong for information that might be presented outside the context of a patient visit, and this view tended to be prevalent in larger, urban practices. This concern could be ameliorated, however, by tracking only selecting patients or flagging only the outliers.
Finally, there is a need to reconcile lists from multiple sources and alert ePrescribers to where things are different, such as what was prescribed vs. what was filled.
Medication History Workflow. There was no clear consensus on how medication history should be presented. For those still working with paper, there was value seen in having a support person access and print information. For clinicians who ePrescribe in the fully electronic mode, they wanted to access the medication history during the patient visit.
Some users expressed frustration with navigating through a detailed medication history list. There was receptivity to alternate ways of displaying the information, such as through icons or color coding.
There was no consensus on alerts and obtaining information outside the context of the patient visit. Some clinicians wanted to be able to find the backup information offline, but most did not. Users were frustrated about seeing the same warnings over and over again, and urged caution about adding new alerts associated with medication history.
Advice and Comments. Focus group participants believe that if the value is substantive, clinicians will adopt additional applications, such as external medication history, within their ePrescribing use. There was widespread belief that medication history could support pay-for-performance (P4P), especially if tailored to support specific P4P metrics (rather than adoption in general). However, there were concerns that doing this would be subverted from tracking quality into ratcheting down utilization.
Finally, clinicians find it difficult providing feedback to their POC vendor. This exchange of information needs to be encouraged so that ePrescribing systems can better incorporate prescriber needs into the system functionality and practice workflow.
Summary and Conclusions
Medication history is underused in practice today, even by clinicians who prescribe electronically. Most clinicians were unaware that external medication history was or could be available to them. However, they recognized that medication history does or can provide them with very useful information and, as such, could contribute to practice efficiency and improved quality of care.
In general, clinicians want basic medication history lists (the drugs they prescribed) with the ability to drill down for additional information. They would like to have the external medication history available within the scope of the patient visit, along with capability of tailoring functions for particular types of patients (such as those with chronic conditions) or particular types of drugs. There was no consensus on the ideal workflow for using medication history.
Clinicians need to be led in the adoption of medication history—they are not asking for it but appreciate its value once they have it. They also need to be educated about the timeliness of the medication history they receive through ePrescribing. Many erroneously believe that pharmacy claims history has a 6-12 week lag, like medical claims. Unlike medical claims—which often are delayed for manyweeks before getting to the claims database—pharmacy claims are available immediately once the prescription has been adjudicated by the dispensing pharmacy. As a result, medication histories are actually quite current.
Finally, the value build for ePrescribing depends on the level of adoption by the clinicians. Figure 1 (below) depicts the value of electronic prescribing builds along with functionality. Clinicians along any point of this adoption curve would say they are e- prescribers, but there obviously is wide variability based on usage of all functionalities.
RxHub thanks NCVHS for the opportunity to provide this testimony. Questions or clarifications may be addressed to the contacts listed below.
About RxHub, LLC
RxHub (www.rxhub.net) electronically routes up-to-date patient-specific medication history and pharmacy benefit information to caregivers at every point of care. Our end-to-end solution enables physicians to prescribe the most clinically appropriate and cost effective prescription to be sent electronically to the patient’s pharmacy of choice. RxHub partners with stakeholders in the prescribing industry to improve patient safety, increase workflow efficiency and reduce the overall cost of health care delivery.
Ken Majkowski, Pharm D
Clinical Affairs and Product Strategy
380 Saint Peter Street
Saint Paul, MN 55102
Vice President, Information Technology
380 Saint Peter Street
Saint Paul, MN 55102
Maria A. Friedman, DBA
Director, Federal Affairs
380 Saint Peter Street
Saint Paul, MN 55102