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HITPC - Information Exchange Work Group Meaningful Use Stage 3 Subgroup 1: Quality and Efficiency

HITPC - Information Exchange Work Group Meaningful Use Stage 3 Subgroup 1: Quality and Efficiency. Chair: Dave Goetz Members: Cris Ross, Chris Tashjian, Steve Stack. Agenda. Controlled substance e-prescribing Presentation from Ken Whittemore , Surescripts Medication history

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HITPC - Information Exchange Work Group Meaningful Use Stage 3 Subgroup 1: Quality and Efficiency

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  1. HITPC - Information Exchange Work GroupMeaningful Use Stage 3 Subgroup 1: Quality and Efficiency Chair: Dave Goetz Members: Cris Ross, Chris Tashjian, Steve Stack

  2. Agenda • Controlled substance e-prescribing • Presentation from Ken Whittemore, Surescripts • Medication history • Presentation from Jon D. Duke, Regenstrief Institute • Review lab orders language

  3. IE Workgroup Timeline

  4. Recommendation Options • The Subgroup is tasked with reviewing and developing prioritized recommendation in four key areas. The Subgroup has a number of options for addressing these areas including: • Stage 3 • Explore in RFC • Certification only • No recommendation • Push to Stage 4

  5. Status of Electronic Prescribing for Controlled Substances (EPCS) Implementation and Related Surescripts Initiatives: Briefing for the Information Exchange Workgroup of the ONC HIT Policy Committee Ken Whittemore, Jr., RPh, MBA Senior VP, Professional & Regulatory Affairs September 4, 2012 5 PRIVILEGED & CONFIDENTIAL

  6. General EPCS Issues PRIVILEGED & CONFIDENTIAL

  7. Summary of EHR/e-prescribing andpharmacy application requirements • DEA EPCS compliant systems must: • Allow access controls for EHR/e-prescribing and pharmacy systems • Require two-factor credential use for prescription signing • Incorporate internal audit trails for EHR/e-prescribing and pharmacy systems • Have the ability to digitally sign and archive records at prescriber and pharmacy ends* • Include all DEA-required information in prescription records • Be able to import, display, and store DEA information in pharmacy records • Be capable of generating records of controlled substance prescriptions for review from EHR/e-prescribing and pharmacy applications *(Intermediaries should also have this capability.)

  8. Surescripts support of EPCS • Beyond what is required by the DEA EPCS IFR: • RestrictEPCS messaging to applications that have passed DEA Part 1311 auditas well as Surescripts EPCS certification • EHR/e-prescribing and pharmacy application vendors will not be enabled for EPCS until third-party audit documentation is received by Surescripts • Enhance new prescription, refill, and change message formats to support DEA requirements: • Prescriber DEA numbers will be validated at signup • Electronic faxing of controlled substance prescriptions to pharmacies will be blocked • NDC codes will be required on all prescriptions to facilitate controlled substance checking • Controlled substance, compound drug, and supplies flags will also be utilized • Support for state EPCS rules will be developed • Add the EPCS service to the Surescripts directory (additional validation for DEA and NPI numbers)

  9. Surescripts approach to EPCS implementation • Barriers to implementation: • Substantial development and coding of systems to comply. • New prescriber workflow regarding authentication. • Certification of systems by Systrust, Webtrust, CISA auditors, InfoGard and Drummond Group. (Significant cost factor.) • Conflicting state laws. • Surescripts two-phase approach to implementation: • Limited availability (LA) • A controlled roll-out within specific geographic areas (CA, DC, MD, TX & VA), with measurements for limited participants, for a defined period of time. • Four prescriber vendors • DrFirst, NextGen, GE Healthcare, RxNT • Two chain retail pharmacies • SuperValu, Walgreens • One pharmacy vendor (independents, small chains) • Cerner/Etreby • Intermediary - RelayHealth • General availability (GA) (full rollout). • Product is released for all participants.

  10. EPCS Limited Availability (LA) process • All vendors and pharmacies actively exchanging EPCS messages in production have completed the DEA-required third-party audit and Surescripts Certification process • Surescripts EPCS Participants: • Pharmacy • Cerner Etreby • RiteAid • SUPERVALU • Walgreens • Intermediaries • RelayHealth • Prescriber Software Vendors • DrFirst • NewCrop • NextGen • RxNT

  11. General industry readiness and plans • Most major chain pharmacies have indicated that they will be certified for EPCS by the end of 2012. • EHR/e-prescribing vendors that support approximately 35 percent of physicians connected to Surescripts have indicated that they will be certified for EPCS by the end of 2012. • In general, prescriber vendors seem to be slower to adopt EPCS. • Remaining prescriber and pharmacy vendors are expected to be certified by the end of 2013. • Education on the value of EPCS may be required to ensure that all prescribers and pharmacists adopt. Confidential and Proprietary

  12. State EPCS Issues PRIVILEGED & CONFIDENTIAL

  13. State EPCS Rules • EPCS for all schedules is okay in • AK, AL, AZ, CA, CO, DC, DE, IA, ID, IL, KY, LA, MA, MD, MI, MN, NC, ND, NH, NM, OH, OK, OR, PA, SC,SD, TN, TX, VA, VT, WI, WV & WY (Total = 33 states) • EPCS for schedules III through V is okay in: • FL, KS, ME, MO, NV, & WA (Total = 7 states) • Surescripts is assisting with state EPCS rule compliance • State controlled drugs • EPCSs transmitted across state lines • I-STOP (Internet System for Tracking Over-Prescribing) Act recently signed by Gov. Cuomo in New York • Allows e-prescribing for controlled substances (EPCS) in the state by making e-prescribing mandatory for both controlled and non-controlled substances • Creates a prescription drug monitoring program (PDMP) for NY that requires real-time reporting of PDMP information PRIVILEGED & CONFIDENTIAL

  14. State EPCS Status Map (see website for latest information) PRIVILEGED & CONFIDENTIAL

  15. Useful EPCS InformationLinks • Surescripts EPCS page: http://www.surescripts.com/about-e-prescribing/e-prescribing-of-controlled-substances.aspx • EPCS 101 Slides: http://www.surescripts.com/media/646521/surescripts-epcs-101-slides.pdf • State Status Map:http://www.surescripts.com/about-e-prescribing/e-prescribing-of-controlled-substances/regulatory-status-map.aspx • Surescripts Update for State Authorities: http://www.surescripts.com/media/864815/surescripts%20epcs%20update%20for%20pharmacy%20stakeholders%2005-17-2012.pdf PRIVILEGED & CONFIDENTIAL

  16. Questions? ken.whittemore@surescripts.com (703) 921-2114 16 PRIVILEGED & CONFIDENTIAL

  17. Electronic Prescribing of Controlled Substances • How does the subgroup want to proceed? • Stage 3 • Explore in RFC • Certification only • No recommendation • Push to Stage 4 HITPC: MU Workgroup Stage 3 Recommendations

  18. Improving Drug Adherence through Advanced Clinical Decision Support Jon D. Duke, MD, MS Regenstrief Institute

  19. Background • Communicating drug adherence information effectively to providers remains a challenge • Reviewing dispensing histories is not practical within the timeconstraints of typical visit

  20. Enhanced medication history

  21. Background • Often physicians do not ask about adherence, assuming the patient is taking as prescribed • Cost of non-adherence > $290B annually, $106B for DM, HTN, and dyslipidemia alone K Nasseh, SG Frazee, J Visaria, A Vlahiotis, Y Tian. Cost of Medication NonadherenceAssociated With Diabetes, Hypertension, and Dyslipidemia. Am J PharmBenefits. 2012;4(2):e41-e47.

  22. Project Goals • Improve provider awareness of non-adherence to diabetic medications • Increase conversations between providers and patients regarding adherence • Evaluate impact of 2 clinical decision support interventions on adherence rates and glycemic control in DM patients

  23. Clinical Decision Support at Regenstrief Institute • Active in CDS research for past 30 years • Performed seminal work on CPOE, preventative reminders, corollary ordering • Cited as a benchmark institution in generating high quality evidence for CDS

  24. 1984 - 2010 1984 2010

  25. Regenstrief’s New Platform: G3

  26. Clinical Decision Support in G3

  27. Context-Aware Alerting Original Alert Patient Context Institutional Context Physician Context Final Alert

  28. Alerting Zones

  29. IFTTT (If this, then that) CDS Model • Triggers • Orders, diagnoses, observations • Chart opening / data lookup • NLP-based concept detection • Actions • Alerts • Generate patient handout • Add structured observations to chart • Detailed logging

  30. Study Interventions • Intervention 1 • Chart opening  alert with diabetic medication adherence rates, recommendations for patient discussion • Visit documentation: diagnosis of DM or diabetic drug order  alert with medication adherence rates, one-click renewals

  31. Intervention 1

  32. Intervention 1

  33. Interventions • Intervention 2 • Chart opening  non-interruptive alert with medication adherence rates • Visit documentation: diagnosis of DM or diabetic drug order  alerts adherence rates, orderable ‘Drug Adherence Review’

  34. Intervention 2

  35. Intervention 2

  36. Intervention 2

  37. Adherence Metric • Proportion of Days Covered (PDC) • the total number of medication-covered days divided by the number of days in a time period • Data source • SureScripts and Wishard hospital dispensing data • Indiana Health Information Exchange • Medications • Oral meds only • NDC / GPI mapping

  38. Target Medications • Acarbose • Acetohexamide • Chlorpropamide • Glimepiride • Glipizide Powder • Glipizide-Metformin • Glyburide • Glyburide-Metformin • Linagliptin • Linagliptin-Metformin • Metformin • Metformin SR • Miglitol • Pioglitazone • Pioglitazone -Glimepiride • Pioglitazone-Metformin • Repaglinide-Metformin • Rosiglitazone • Rosiglitazone -Glimepiride • Rosiglitazone -Metformin • Saxagliptin • Saxagliptin-Metformin • Sitagliptin • Sitagliptin-Metformin • Sitagliptin-Simvastatin • Tolazamide • Tolbutamide • Troglitazone

  39. Study Timeline and Outcomes • Two-wave, 3-arm, randomized study will be conducted using HIT clinical decision support and user acceptability methodology • 3 types of outcomes will be elicited: • improvement in patient adherence / HbA1c (patient health outcomes measure) • increase in frequency of provider conversations with patients (process measure) • ability of the system to engage physicians (user acceptability measure)

  40. Study Status • Study launching 9/15/2012 • Final results expected Fall 2013

  41. Conclusions • Adherence is a high-priority area for multiple stakeholders including patients, providers, payors, pharma • We look to leverage our advanced CDS platform to evaluate a range of novel approaches to increasing medication adherence

  42. Questions? jduke@regenstrief.org Thank you to Paul Dexter, Heather Black, Kim Heithoff, LinasSimonaitis

  43. Medication History • MU WG recommendation • Does the IE WG have any suggestions or does the group concur? HITPC: MU Workgroup Stage 3 Recommendations

  44. Lab Order Recommendation Language • Certification Only for EPs: The EHR must have the ability to electronic order of laboratory test within a providers workflow. • Are the existing standards for laboratory adequate to support including this certification criteria?

  45. Next Steps • Finalize recommendation language to present on the IE WG call tomorrow.

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