Long Term Care Case Study: ePrescribing Applied

1. Long Term Care Case Study: ePrescribing Applied ePrescribe Florida � Fall Summit Rachelle �Shelly� Spiro, RPh, FASCP President, Spiro Consulting 1

2. Discuss the Standards Tested During the LTC ePrescribing pilot Discuss Electronic Prior Authorization Results Discuss the Outcomes Noted During the LTC ePrescribing Pilot LTC EHR Standards and Next Steps Summary 2 Overview

3. 3 Grantee/Contractor Project Titles for e-Prescribing AHRQ Pilot Project

4. To study the effects of the electronic prescribing standards in long-term care (LTC) on cost, quality and safety Validate that the ePrescribing and electronic Prior Authorization (ePA) standards work in a LTC setting 4

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6. ePrescribing LTC Stakeholders Prescribers Physicians, Nurse Practitioners, Physician Assistants Supportive staff (nurse or agent of the prescriber) Pharmacies Pharmacists, consultant pharmacist, pharmacy technical staff Facilities Residents, nurses, and administrative staff Payers PBM, PDP Router/Intermediary Software vendors 6

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9. ePrescribing Pilots Summary of Standards Tested 9

10. LTC specific requirements and messaging solutions were tested during the LTC ePrescribing pilot Solutions were piloted through modifications to SCRIPT version 8.1 These changes were added to the SCRIPT version 10.0 and 10.1 SCRIPT 10.1 became ANSI approved 9-6-07 10

11. Patient residency in an LTC facility : Unit-Room-Bed Patient admission: Census message Patient information change: Census message Patient discharge: Census and Cancel message Medication changes: Open ended orders Discontinued orders: Cancel message Profile orders: Do Not Fill (DNF) message Order re-supply: Re-supply message 11

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20. Solicited and unsolicited models Solicited model - the prescriber requests questions from the health plan or PBM Unsolicited model - the questions and criteria reside on the point-of-care software systems and the clinician knows all the questions needed for a particular drug before ending the PA request LTC pilot selected to test the unsolicited model 20

21. Tested a single payer, 5 drug classes and short testing timeframe Only 3 ePA opportunities were presented 2 were processed successfully and 1 not submitted by prescriber ePA request forms were completed by the prescriber, forwarded to the payer and receipt acknowledged within 1 minute 21

22. Prescriber/agent answered (2) and (4) clinical questions before submission Both the facility and the pharmacy were able to view the real-time status, approval or denial of the ePA request The pilot demonstrated the ePA is technically feasible 22

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24. LTC ePrescribing Pilot Standards Testing Conclusions Problems with multiple directions (e.g. BID and PRN) orders LTC setting ePrescribing can be supported with some technical modifications to the standards LTC ePrescribing standards will work using NCPDP SCRIPT 10.1 or higher Additional research should be done on ePA 24

25. Workflow Prescriber utilization of ePrescribing Physician uptake Patient satisfaction Formulary versus generic prescribing Medication history utilization Inappropriate prescribing/adverse drug events Callbacks 25

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27. Collection Periods and Implementation Dates Data Collection Periods Baseline: 4/6/2006-5/26/2006 (Pre-pilot) Phase 1: 7/25/2006-10/25/2006 Phase 2: 11/6/2006-12/1/2006 Software Implementation Go Live Dates: Phase 1: 6/26/2006 Interim release of readmission-related feature: 9/8/2006 Phase 2 : 10/20/2006 27

28. Research Approaches and Methodology (1) Stop watch was used for data collection to measure each event�s start and completion time Data collection records noted the number of medications in the order A baseline study was conducted to establish workflow performance measurements prior to the implementation of the ePrescribing standards 28

29. 29 Research Approaches and Methodology (2)

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31. Prescriber adoption and clinical outcomes 95% of the orders were entered into the CPOE system by the agent of the prescriber Primary responsibility of LTC agents of prescriber is to accurately enter verbal or written orders Problem with agents of the prescriber responding to clinical alerts Slight decrease in the possible affect on quality and safety The pilot could not determine the cause of the decrease or determine if it was due to ePrescribing 31

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33. Labeling vs. Scanning Refill scanning took place only in the treatment facilities as part of the ePrescribing system Marginal differences between facilities in the amount of time required to complete labeling and scanning (Prob = 0.0532) were found No statistical differences between the treatment and comparison groups for the label/scan task were found 33 A Wilcoxon Rank Sum test was conducted to compare the typical time spent in scanning at the two treatment facilities A Wilcoxon Rank Sum test was conducted to compare the typical time spent in scanning at the two treatment facilities

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35. Task Category: Communication 35

36. Task Category: Fax Communication 36

37. Other Categories No effect of ePrescribing system on other task categories that were compared over time between the treatment and comparison groups was found Communication: Other Communication: Person Communication: Phone Communication: Written Communication: Pharmacy Communication Physician Deleting orders Entering orders Reviewing orders Verifying orders 37

38. Time studies at the nursing facility Pilot showed the time saved from faxing and order was and average 1 minute for the ePrescribing facilities Time studies at the pharmacy No significant time saving difference in receiving electronic prescription orders instead of faxes Overtime, there was a decrease in time spent for fax sorting, processing new admissions and new orders 38

39. Pharmacy Data Analysis (1) There was not enough evidence to suggest that the ePrescribing system affected the typical time spent on any of the tasks but some evidence was worth noting The number of occurrences requiring fax sorting was reduced after the implementation of ePrescribing system Only 2 observations noted in Phase 2 as compared with 7 observations at baseline 39

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42. Cost reductions- providing eligibility, formulary-benefits and ePA Due to limited prescriber adoption and the short time frame of the pilot, the team was unable to provide definitive cost reduction data Anecdotal feedback -Prescriber participants noted it was helpful to see drug coverage as new orders are entered for the resident 42

43. Workflow SCRIPT transmission from facility to pharmacy processed automatically and took less than 1 second Eliminated duplicate order entry Electronic failure notification mechanism is more reliable than the traditional fax transmission alerts 43

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45. Nursing staff ratings ranged from 0 to 8 with an overall mean of 4.15 indicative of a slightly dissatisfied rating The ratings by the staff of the two facilities differed with the rating at one facility staff as neutral (5.16) and at the other facility as somewhat dissatisfied (3.28) A variation in the perspective of the staff was evident in that some described the use of the ePrescribing system as a hassle and others indicated it made their work easier 45 Nursing Staff Satisfaction

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49. Report to the National Commission for Quality Long-Term Care Essential but Not Sufficient: Information Technology in Long-Term Care as an Enabler of Consumer Independence and Quality Improvement

51. Recommendations 1-4 1. Make quality long-term care a national priority 2. Accelerate industry-wide collaboration and leadership around the use of HIT in long-term care 3. Explore legislative options to promote long-term care�s transformation through HIT 4. Establish federal leadership entities and positions dedicated to long-term care technology

52. Recommendations 5-8 5. Support the development of innovative technologies and the adaptation of existing technologies for use in the long-term care setting 6. Reduce or remove barriers to innovation in and the adoption of technology in long-term care 7. Pursue regulatory reform and professional licensure enhancements to enable the expanded use of remote care 8. Develop a global market for long-term care technology through information exchange and market development

53. Recommendations 9 - 11 9. Promote a research agenda to evaluate the cost, quality, and efficiency benefits of applying information technology solutions to long-term care in order to establish scoring models for Centers for Medicare and Medicaid (CMS) and other third-party coverage decisions 10. Pursue sustainable funding models that accelerate the adoption of HIT in long-term care 11. Encourage the adoption and application of consumer-centric, continuous process improvement methodologies in long-term care

54. Recommendations 11-15 12. Support the development of longitudinal PHRs, PHR-related standards, and consumer-centric mechanisms for linking long-term care providers and other settings through PHRs 13. Support the foundational work required to create the standards, common tooling, and shared infrastructure necessary to support health information exchange and semantic interoperability 14. Promote information flow and outcomes transparency as a fundamental driver for transformation 15. Promote the use of open source software solutions to address some of long-term care�s technology needs?especially for infrastructure and shared requirements

55. ePrescribing CMS-AHRQ LTC e-prescribing pilot Modifications to NCPDP SCRIPT standard HL7 Continuity of Care Document (CCD) Standard for the exchange of clinical documents MDS PAC-PRD (Post-Acute Care Payment Reform Demonstration) HL7 EHR System (EHR-S) Functional Model The standard for the functions needed in an EHR-S CCHIT LTC roadmap � LTC EHR certification in 2010 55 LTC EHR Standards

57. Reduction in Adverse Drug Events Theoretically an integrated eMAR and EHR would help reduce adverse drug events (ADE) and medication errors July 2006 the Institute of Medicine�s report on �Preventing Medication Errors� concluded that of the 1.6 million nursing home population in the U.S., 800,000 preventable ADEs could occur each year 57

58. LTC industry is working on EHR-S standards to lead to CCHIT adoption in 2010 Additional research should be done on electronic prior authorization (ePA) Further standards of eMAR and inventory management is needed The pilot demonstrated a true computer to computer solution LTC ePrescribing can be supported with adopting NCPDP SCRPIT 10.1 or higher ePrescribing is ready for LTC implementation now and LTC should not be exempt from government mandated standards 58 Summary

59. Thank you Shelly Spiro President, Spiro Consulting 703-599-5051 www.spiroconsulting.net 59