NCVHS Hearing on Standards for E-prescribing
Statement by Vassil Peytchev,
Epic Systems Corporation
Epic Systems Corporation (Madison, WI) develops integrated inpatient, ambulatory, and payor information systems for large healthcare organizations, academic medical centers, and children’s healthcare systems. Epic provides the information backbone for many of the largest, most progressive healthcare organizations in the United States. All Epic applications incorporate the safety net of embedded clinical and financial decision support throughout the care continuum, helping organizations transform clinical care, streamline patient access, and manage revenue cycles.
We have provided customers with the ability to send ambulatory medication orders in electronic format to pharmacies since 1995. We have also implemented electronic refill authorization functionality throughout our applications. Based on these experiences, we offer the following observations.
2. CPOE and E-prescribing
Our customers which use e-prescribing functionality are usually organizations with their own pharmacies. Under these circumstances, e-prescribing is simply an interface added to the CPOE functionality in our systems. This improves patient safety in that drug interaction checking and other decision support is part of the process, the electronic transfer eliminates the possibilities of misreading the prescription, and clinically relevant information is shared between the pharmacy and EMR. In order to achieve these benefits, the interfaces we built had to have a shared format, with the capability to send the required information, and shared nomenclature.
3. Standard Format
The format we have used for sending of prescription information, receiving the dispense information, and handling of refill requests/authorizations is HL7 (spanning versions 2.2 through 2.5). This format satisfies the requirements outlined above – it has the ability to send detailed drug information, detailed patient information, detailed insurance information, and important clinical information like an allergy list. Historically, the HL7 format for pharmacy related data interchange has its roots in hospital settings, but it has evolved much beyond that and recent versions of the standard contain comprehensive set of messages able to handle the complexities of ambulatory settings and commercial pharmacies.
An additional advantage with using HL7 as the format for pharmacy data exchange is that it is an international standard, adopted in many countries in Europe, Canada, Japan, Australia, and others.
4. Shared Nomenclature
Our experience had the advantage of one organization controlling the nomenclature (provider identifiers, medication codes, etc.) This significantly contributed to the success of the implementations. When expanding to cases including commercial pharmacies, the following key areas need to be addressed:
- Patient identification. While a single organization can easily assign unique patient identifiers for all patients that use their internal pharmacy, this is not the case when commercial pharmacies are involved. The ability to send various identifiers (e.g. drivers license, insurance identifier, etc.) as well as other identifying information is important to allow for proper identification of patients at the pharmacy, and appropriate interaction between the pharmacy and the provider’s system.
- Provider identification. With the recent approval for a National Provider Identifier, the identification of providers will become a much easier problem to solve. Still, the ability to send and receive multiple identifiers is important (e.g. the provider’s DEA number when a controlled substance is prescribed).
- Medication nomenclature. In our experience in a single organization environment, each customer chose one of several available medication code sets. When this is expanded to multiple organizations working with commercial pharmacies, there is a need for a standard code set that can be shared by all participants. Since “RxNorm is one of a suite of designated standards for use in U.S. Federal Government systems for the electronic exchange of clinical health information” [http://www.nlm.nih.gov/research/umls/rxnorm_main.html], it seems to be well suited as the standard nomenclature for e-prescribing.
We would like to note that NDC codes also play an important role in the communications between the pharmacy and the physician’s system. When sending the prescription information to the pharmacy the specificity of NDC codes is usually not needed, however, when the pharmacy sends the dispense information back to the physician’s system this specificity becomes useful, as it conveys the exact form, brand, packaging, etc., of the medication dispensed to the patient.
- Allergy nomenclature. Usually the different vendors providing decision support for drug interaction information also supply a code set for allergies and allergens. We are not aware at this time of the wide adoption of a universal allergy nomenclature, although there is ongoing research worldwide in the area (e.g. within the World Allergy Organization [http://www.worldallergy.org/], [http://www.biomedcentral.com/pubmed/15131563]). If allergy information is to be exchanged between providers’ systems and pharmacy systems (and we believe it should be), there is a need for a standard allergy nomenclature.
It is our hope that the observations presented here are found useful by the Commission. We believe that e-prescribing should not be considered in isolation and separate from ambulatory CPOE. It is important to choose standards that provide the capabilities outlined above so that the full benefits of e-prescribing can be achieved. It is also important to consider the overall infrastructure that can enable the communications between physician offices and retail pharmacies.