AHRQ Annual Conference September 27, 2007 Presenter – Michael Bordelon

1. New Approaches In Medication Management and Care Transitione-Prescribing and Remote Dispensingin Long Term Care AHRQ Annual ConferenceSeptember 27, 2007Presenter – Michael Bordelon

2. Long Term Care Background • Reimbursement Model: • Roughly 15% capitated Part A • 58% Medicaid/Part D • 27% Private Pay and Commercial Insurance • Typical Number of Beds: 90-120 • Pharmacies are almost never co-located with LTC facilities • Physicians per facility: 10-40 • Nurse Practitioners per facility: 1-2 • Nurses per facility: 50-80 • Med passes per day: 4-7 • Pharmacy trips to the facility: 2-3 • Admissions per week: 1-10 • Many facilities already manage their own orders in electronic systems

3. The Infamous LTC Prescribing Slide Physician Patient Allergies Order Update (Phone or fax) Clarify and update order with physician Start Decide on patient order Patient Orders Written order Physician signs copy of the order Physician writes order on Order Sheet Faxed order Verbal order Signed copy of order Copy of order (mail, on-site) Nursing Evaluate order, clarify if needed and file in Patient Record Evaluate order, clarify if needed Updated Order Sheet Patient Record File Signed copy in Pt. Record Patient Allergies Resident Status (phone call, fax, on-site) Notice updated Order Sheet, evaluate order and clarify if needed Write order on Physician Order Sheet Write order on Physician Order Sheet and send copy to physician Order Sheet Manage on-hand medications (Pt Meds, Stock and Emergency Kit) Start Patient MAR Resident Change in Condition; New admission Med Check patient choice for pharmacy Update the MAR Administer and Chart Med Resolve Discrepancy Follow pharmacy-specific procedure including after hours rules Receive and check medication (patient, med, doc) Clarify and update order with nursing Order Update (Phone or fax) Order (phone, fax, pickup by driver, auto-fax from SNF order management application) Pharmacy Order Question (phone or fax) Patient Allergies Consultant Pharmacist Patient Orders Drug Regimen Review or other Patient Status Review Receive new order Receive updated order Resolve issues with order (clinical, payor, etc.) Patient MAR Med MAR Update (optional) Order Exception Process order and dispense [includes payor verification and formulary compliance]

4. LTC Prescribing Nuances • Three way communication between • Prescriber – Nurse – Pharmacy • Most orders have no end date or quantity • Refill requests represent 80% of orders • No concept of Renewals • Need unique formulary and benefit information • Part A, Part D and Medicaid

5. e-Prescribing in Long Term Care • e-Prescribing is new to LTC • 2006 CMS Pilot Study was first official standards based e-prescribing study in Long Term Care • There are less than 5 standards based e-Prescribing installations today

6. LTC e-Rx Pilot Study Abstract • 2006 study focused on e-Rx standards most relevant to LTC • SCRIPT • Formulary Benefits • Electronic Prior Authorization • Other Capabilities Studied • Facility Managed Electronic Orders • Patient Safety Checks (DUR) • Electronic Signature • Automated Refill Requests • The study included two geographically diverse treatments facilities and two comparison facilities

7. Flow of Information RNA eRxRequest Refill Scanner

8. e-Rx Findings - Facility Impacts • Benefits • Facilities currently using electronic Physicians Orders will see modest change or disruption to current workflow • Ability to transmit orders directly to the pharmacy yielded benefits in reduced rework and callbacks • Management of Orders at the facility streamlines reconciliation processes • New Challenges • Prescriber adoption is vital • Integration with clinical systems (EHR) is critical • Nurses do not effectively use patient safety (DUR) tools • Even with Formulary Benefits data, managing complex Part D health plans is an ongoing challenge • Nursing staff now has to enter and manage data that the pharmacy once managed • Data entry errors can still happen

9. e-Rx Findings - Pharmacy Impacts • Benefits • Demographics pre-populated on new admissions • Straightforward new order processing • Discontinued orders • Readmissions streamlined • Do not have to manage MARs and Order Sheets • Refill requests streamlined • New challenges • Combination & Tapered Orders – Need codified SIG standard • Transcription accuracy • Timely transmission on admission orders • Fax mode for controlled substances leads to process inconsistencies

10. Standards Findings • NCPDP SCRIPT Standard works with new changes in Version 10.1 • NCPDP Formulary Benefits V1.0 technically works, but is dependent on greater prescriber adoption • Electronic Prior Authorization Technically works, but will require greater prescriber adoption • A Refill messaging standard is needed in LTC • An Admission, Discharge, Transfer (ADT) messaging standard is needed

11. What is Remote Dispensing? Automated oral solid dispensing in healthcare settings, such as nursing homes and correctional facilities, that have no onsite pharmacist Remote dispensing can work hand in hand with e-Prescribing

12. Oral Solid Packaging Medication Canister Remote Dispensing Packager

13. Process Overview

14. Process – Dispense Data From Central Pharmacy System

15. On Site Strip Packaging

16. On Site Strip Packaging • Daily Dispense • Med Pass/Resident Sort • Multi Dose Packing • PRN, New, Re-dispense

17. Process – Data Feedback Loop

18. Process – Inventory Monitoring

19. Process – Canister Fill at Pharmacy

20. Process – Canister Delivery

21. Value Proposition • Virtually eliminates drug waste • Significantly reduces delivery costs • Eliminates delay of first dose • Decreases administration time • Reduces medication errors • Eliminates the need for a refill process

22. Experience in early commercial pilots • High Adoption Rate with nursing staff • On demand PRNs and quick access to meds for new admissions are big wins • Will save a typical nursing facility more than $25K per year in Part A drug waste • May save $150K per year per facility for Part D drug waste savings • Robust canister logistics is the key to success

23. Medication ReconciliationinLong Term Care AHRQ Annual ConferenceSeptember 27, 2007Presenter – Michael Bordelon

24. Long Term Care Background • Reimbursement Model: • Roughly 15% capitated Part A • 58% Medicaid/Part D • 27% Private Pay and Commercial Insurance • Typical Number of Beds: 90-120 • Pharmacies are almost never co-located with LTC facilities • Physicians per facility: 10-40 • Nurse Practitioners per facility: 1-2 • Nurses per facility: 50-80 • Med passes per day: 4-7 • Pharmacy trips to the facility: 2-3 • Admissions per week: 1-10 • Many facilities already manage their own orders in electronic systems

25. The LTC Prescribing Slide Physician Patient Allergies Order Update (Phone or fax) Clarify and update order with physician Start Decide on patient order Patient Orders Written order Physician signs copy of the order Physician writes order on Order Sheet Faxed order Verbal order Signed copy of order Copy of order (mail, on-site) Nursing Evaluate order, clarify if needed and file in Patient Record Evaluate order, clarify if needed Updated Order Sheet Patient Record File Signed copy in Pt. Record Patient Allergies Resident Status (phone call, fax, on-site) Notice updated Order Sheet, evaluate order and clarify if needed Write order on Physician Order Sheet Write order on Physician Order Sheet and send copy to physician Order Sheet Manage on-hand medications (Pt Meds, Stock and Emergency Kit) Start Patient MAR Resident Change in Condition; New admission Med Check patient choice for pharmacy Update the MAR Administer and Chart Med Resolve Discrepancy Follow pharmacy-specific procedure including after hours rules Receive and check medication (patient, med, doc) Clarify and update order with nursing Order Update (Phone or fax) Order (phone, fax, pickup by driver, auto-fax from SNF order management application) Pharmacy Order Question (phone or fax) Patient Allergies Consultant Pharmacist Patient Orders Drug Regimen Review or other Patient Status Review Receive new order Receive updated order Resolve issues with order (clinical, payor, etc.) Patient MAR Med MAR Update (optional) Order Exception Process order and dispense [includes payor verification and formulary compliance]

26. Typical Admission in LTC • Most admissions in LTC are from a hospital setting • Most “residents” begin stay under Medicare Part A • Generally, discharge orders from the hospital are admission orders at the facility

27. Typical Order Management Process New Admission Pharmacy Fills Orders and Delivers Medications Resident Enters Nursing Home From Hospital with Discharge Orders Pharmacist Manually Enters Orders in PhIS with DUR Check Nurse Faxes Discharge Orders to Pharmacy Pharmacy Provides Paper Based MARs and Order Sheets

28. Typical Order Management Process New Admission Pharmacy Fills Orders and Delivers Medications Resident Enters Nursing Home From Hospital with Discharge Orders Pharmacist Manually Enters Orders in PhIS with DUR Check Nurse Faxes Discharge Orders to Pharmacy Pharmacy Provides Paper Based MARs and Order Sheets RISK: Physicians often do not review admission orders in a timely way RISK: Data entry errors can lead to inconsistencies RISK: Paper MARs and Order Sheets are “Stale” almost immediately

29. Typical Order Management Process During last 10 days of the month Pharmacy Delivers Final MARs Before Start of New Month Physician Reviews, Modifies and Signs Orders on Order Sheets Nursing Staff Faxes Handwritten MAR Updates to Pharmacy Pharmacy Sends Revised MAR to Facility Nurses Perform Secondary Review of MAR and Handwrite Corrections Nursing Staff Manually Reviews and Updates Orders on MARs

30. Typical Order Management Process During last 10 days of the month RISK: Is the Order Sheet Up to Date with MAR? RISK: Paper MARs and Order Sheets are “Stale” almost immediately Pharmacy Delivers Final MARs Before Start of New Month RISK: High Potential for Transcription Error Physician Reviews, Modifies and Signs Orders on Order Sheets Nursing Staff Faxes Handwritten MAR Updates to Pharmacy Pharmacy Sends Revised MAR to Facility Nurses Perform Secondary Review of MAR and Handwrite Corrections Nursing Staff Manually Reviews and Updates Orders on MARs RISK: Easy to Make Mistakes When Handwriting Changes to MAR RISK: New MAR May Be “Stale” due to New Admits and Order Changes RISK: Very Time Consuming and Often not Performed with Rigor

31. Typical MAR Flowsheet Blank Space To Handwrite New Orders During The Month

32. Medication Reconciliation withe-Prescribing • Facility “owns” all orders • Orders are managed in facility CPOE system • MARs are printed from the CPOE system • New orders are transmitted electronically to pharmacy • Discontinued and changed orders are Transmitted electronically to pharmacy Note: CPOE = Computerized Physician Order Entry

33. Order Management with e-Prescribing New Admission Pharmacy Fills Orders and Delivers Medications Resident Enters Nursing Home From Hospital with Discharge Orders Pharmacy Receives Order Electronically Physician Enters and Signs Orders in Facility CPOE System with DUR and Formulary Checks Facility Prints MARs and Order Sheets From CPOE System

34. Order Management with e-Prescribing New Admission BENFIT: Pharmacy Does Not Manage MARs or Order Sheets Pharmacy Fills Orders and Delivers Medications Resident Enters Nursing Home From Hospital with Discharge Orders Pharmacy Receives Order Electronically Physician Enters and Signs Orders in Facility CPOE System with DUR and Formulary Checks BENFIT: Physician Upfront Review of Orders and e-Signatures Facility Prints MARs and Order Sheets From CPOE System BENFIT: MARs and Order Sheets are Always Up to Date BENFIT: Reduction In Data Entry Errors

35. Order Management with e-Prescribing Ongoing Processes Pharmacy Receives Order Electronically and Resolves DUR Issues Physician Writes or DC's Orders In Facility CPOE System with e-Signature Nursing Staff Notified of Changes and Prints MAR Updates From CPOE System Nursing Staff can Print Entire Up to Date MAR and Order Sheet at Any Time

36. Order Management with e-Prescribing Ongoing Processes BENFIT: Reduction In Data Entry Errors BENFIT: Eliminates Monthly Review Because Orders are Always Up to Date Pharmacy Receives Order Electronically and Resolves DUR Issues Physician Writes or DC's Orders In Facility CPOE System with e-Signature BENFIT: Pharmacy System Always Up to Date BENFIT: No Handwritten Updates and MAR Always Up To Date Nursing Staff Notified of Changes and Prints MAR Updates From CPOE System Nursing Staff can Print Entire Up to Date MAR and Order Sheet at Any Time

37. e-Prescribing in Long Term Care • e-Prescribing is new to LTC • 2006 CMS Pilot Study was first official standards based e-prescribing study in Long Term Care • There are less than 5 standards based e-Prescribing installations today

38. LTC e-Rx Pilot Study Abstract • 2006 study focused on e-Rx standards most relevant to LTC • SCRIPT • Formulary Benefits • Electronic Prior Authorization • Other Capabilities Studied • Facility Managed Electronic Orders • Patient Safety Checks (DUR) • Electronic Signature • Automated Refill Requests • The study included two geographically diverse treatments facilities and two comparison facilities

39. e-Rx Findings - Facility Impacts • Benefits • Facilities currently using electronic Physicians Orders will see modest change or disruption to current workflow • Ability to transmit orders directly to the pharmacy yielded benefits in reduced rework and callbacks • Management of Orders at the facility streamlines reconciliation processes • New Challenges • Prescriber adoption is vital • Integration with clinical systems (EHR) is critical • Nurses do not effectively use patient safety (DUR) tools • Even with Formulary Benefits data, managing complex Part D health plans is an ongoing challenge • Nursing staff now has to enter and manage data that the pharmacy once managed • Data entry errors can still happen

40. e-Rx Findings - Pharmacy Impacts • Benefits • Demographics pre-populated on new admissions • Straightforward new order processing • Discontinued orders • Readmissions streamlined • Do not have to manage MARs and Order Sheets • Refill requests streamlined • New challenges • Combination & Tapered Orders – Need codified SIG standard • Transcription accuracy • Timely transmission on admission orders • Fax mode for controlled substances leads to process inconsistencies

41. Med Reconciliation Conclusions • e-Prescribing forces facilities to take ownership of their orders • Once a facility manages their own orders, they typically have up to date data for MARs and Order Sheets • e-Prescribing can significantly streamline processes and reduce reconciliation errors during new admissions from hospitals • e-Prescribing can reduce reconciliation errors between the nursing facility and the pharmacy • It is difficult to keep a facility managed CPOE system in sync with a pharmacy system without e-Prescribing