Five Technology Trends: Changing Pharmacy Practice Today and Tomorrow

AUGUST 20, 2015
Anthony Schueth, MS, William Hein, and Jeffrey Hull, RPh
The ways in which medications are prescribed, dispensed, and administered in the United States are rapidly changing. Health information technology (HIT) is central to this transformation and includes a broad array of tools used in managing and sharing patient information electronically, rather than through paper records and traditional phone and fax methods.

Reaching beyond real-time claims adjudication, HIT creates value for pharmacies and opportunities for pharmacists to use their professional skills in innovative ways in today’s evolving value-based care systems. The result: pharmacists will use HIT to positively affect patient care, improve patient outcomes, and reduce the cost of care. With that in mind, here are 5 technology-dependent trends that are increasingly making an impact on pharmacy.

Electronic Prior Authorization
Once seen as merely a possibility on the horizon for pharmacy, electronic prior authorization (ePA) is now being put into practice. According to CoverMyMeds’ National Adoption Scorecard, released in March 2015, 67% of pharmacies have a live solution for ePA.1 There are 2 types of prior authorization (PA) work flow, retrospective and prospective, which affect pharmacy in profound but different ways.

In the retrospective model, a pharmacy can obtain PA after an initial rejection of a claim. For example, if a pharmacy does not know that PA is required, it might submit the claim to the payer only to have it subsequently rejected. Using the pharmacy software system, the pharmacist can then either enter a code or hit an “easy” button that will result in a form being forwarded to the provider to obtain PA. The transaction, based on standards developed and maintained by the National Council for Prescription Drug Programs (NCPDP), results in a claim being subsequently submitted by the pharmacy and paid without getting a PA edit back from the payer. This model leverages the NCPDP Telecommunication and SCRIPT standards.

In the prospective model, ePA is prescriber-initiated. In this model, the prescriber is alerted by the software—either in the stand-alone electronic prescribing (e-prescribing) application or within the electronic health record (EHR)—that PA is required. The prescription is temporarily pended and a request is sent to the payer for the criteria. With some payers, that request might result in an immediate approval. In the vast majority of cases, however, questions are returned to the prescriber who, in turn, completes the request and may subsequently be given an approval. If the submitted claim goes through without edit, the pharmacy may not even know that the prescriber requested and received approval from the payer. This model also enables the pharmacy to submit a claim without receiving a PA edit in response. The prospective model leverages the NCPDP formulary and benefit flat file and SCRIPT transaction standard.

Whether prospective or retrospective, the new ePA framework allows questions to be customized, depending on the patient and the medication involved, and supports clinical attachments, such as subsets of the medical record. With the widespread adoption of EHR technology, much of the information to be exchanged can be system-driven, reducing the burden of manually entering and reviewing the data.

Ultimately, ePA at the point of prescribing will create value for pharmacies by eliminating many PAs from their work queues and freeing up valuable time, which will allow pharmacists to focus on patients and revenue-generating activities. This is borne out by the latest data from Surescripts, which estimates ePA can save 4 hours per pharmacist per week (or $11,000 per pharmacist per year).2 In addition, ePA helps speed the approval process, thus aiding in reducing abandoned prescriptions.

The new standard was created to address a need for a more efficient process because of the rise in PAs. At the same time, several states are mandating prior-authorization procedures, creating the potential for separate processes and standards for each state.

Implementing the new NCPDP ePA standard will add clarity and consistency across the health care continuum and the state regulatory process. It also represents an opportunity to improve the perceptions of lawmakers, patients, and physicians concerning important pharmacy outcomes management strategies, such as PA programs. ePAs have the potential to reduce costs, improve access, and improve outcomes by eliminating delays in treatment or prescription abandonment, which often occur with current processes and systems.

Medication Therapy Management
Pharmacists play a vital role in their organizations by leveraging technology to provide patient care services and medication therapy management (MTM). MTM is used to describe the broad range of health care services provided by pharmacists. These services include comprehensive medication reviews, medication reconciliation, drug use review, the ordering and review of lab tests, immunizations, drug dosage adjustments, and identification of gaps in care. Integrated systems of care, such as accountable care organizations (ACOs), already view MTM as essential to care delivery and to meeting ACO quality and cost targets. Such organizations also are heavily invested in HIT, including e-prescribing and EHRs. MTM can improve medication adherence and patient outcomes among patients suffering from chronic diseases, thus cutting costs and improving the quality of care and patient safety.

Pharmacists have been providing MTM services for Medicare patients for nearly a decade due to the requirement that Medicare Part D sponsors must have an established MTM program. Now many states require similar services for Medicaid patients and, in some cases, for those in institutional care. Commercial payers and drug chains also have come on board. The role of the pharmacist in MTM is broadening to include helping patients get involved in their health care decisions. The latter is crucial in ACOs and integrated delivery networks because it is a payment metric for Medicare and other payers. Pharmacists are also taking advantage of new technologies, such as telehealth and mobile health applications, to deliver personalized care and monitor outcomes and patient adherence.

As advanced MTM becomes more widespread, the MTM activities and interventions will require information obtained through health information exchanges (HIEs). HIEs will also provide the means to communicate pharmacy interventions to physicians and other members of the patient care team. For example, community pharmacists with HIE access could provide MTM and participate in ACO-like arrangements where they are also incentivized to improve population management and care quality. Instead of simply checking a box indicating that MTM was performed, they could contract to be measured and incented based upon cost and quality metrics achieved across certain patient panels, such as those with diabetes, high cholesterol, and hypertension.

Waging the War Against Substance Abuse
Prescription drug abuse—especially of opioids—is at epidemic levels. In 2010, 38,300 people in the United States died of drug overdose; 22,000 of these deaths were due to overdose from prescription medications, and 16,600 were from opioid pain relievers.3

State and the federal government agencies have recognized that technology has a role in addressing this serious problem. Electronic prescribing of controlled substances (EPCS) and prescription drug monitoring programs (PDMPs) are technologies currently being used in pharmacy, and their use will accelerate in the near future (see Sidebar).

EPCS now is gaining traction and should increase rapidly due to federal and state requirements. Some 1.6 million controlled-substances prescriptions were sent electronically in 2014 through the Surescripts network. Roughly three-quarters of pharmacies can receive electronic controlled-substance prescriptions, and 1.4% of providers are enabled to send them.2 EPCS is now legal in 49 states and the District of Columbia.2

Regular e-prescribing and EPCS can help clinicians recognize substance abuse through medication history checks, which show both controlled and noncontrolled medications that were paid for through the patient’s insurance. E-prescribing systems and pharmacy systems can also flag potentially deadly prescription errors and drug interactions related to opioid use, thus preventing accidental deaths and overdoses. Refill request monitoring can be used to help flag abuse and diversion.

Pharmacies should expect to see EPCS transaction volume start to take off due to mandatory use of EPCS by such programs as New York’s Internet System for Tracking Over-Prescribing (I-STOP), which requires e-prescribing for all prescriptions (the implementation date was moved back to March 2016). Physicians also will have to prescribe controlled substances electronically if they are to meet the federal government’s proposed higher e-prescribing threshold of 80%, which will be required for Meaningful Use (MU) stage 3, the federal incentive program that reduces Medicare payments for noncompliant physicians.

PDMPs, which collect state-specific controlled-substance prescription data, are operational or under development in most states. Checking the PDMP database before filling a controlled substance prescription is optional in most states, but highly encouraged. It is likely to become mandatory nationwide due to pressures to combat opioid abuse now that New York’s I-STOP has paved the way on the legislative front. The federal government and other entities are working to make PDMPs more accurate, interoperable, and easier to use. Real-time PDMP checks are on the horizon.

The Rise of Specialty Prescribing
Prescriptions are rapidly increasing for specialty medications, which are high-cost, complex therapies that require special handling, administration, and monitoring. Specialty medications account for less than 1% of prescriptions but more than 25% of prescription spending, which is expected to reach 50% by 2018.4 Outlays are expected to quadruple to $402 billion by 2020.5

The skyrocketing use and costs of specialty medications are due to several factors: increasing numbers of elderly and chronically ill patients need specialty medications. In addition, the federal government has a program encouraging development of “orphan drugs” for rare diseases or conditions. New specialty therapies are regularly coming onto the market, as well, including biosimilars (which are not to be confused with generics) and more effective drugs for such conditions as hepatitis C and cancer. As a result, specialty prescribing is on the radar of pharmacy stakeholders, who are looking to technology to help balance the high costs of specialty drugs versus their benefits. Moreover, specialty pharmacy is ripe for automation. Rather than a single transaction, specialty prescribing requires a series of transactions, which currently are done mostly by outmoded paper, phone, and fax. E-prescribing standards and infrastructure, however, are already available to handle the basic prescription process. Other necessary elements, such as ePA, are emerging and will facilitate increased automation of the specialty prescribing processes.

In the meantime, NCPDP has published guidance to improve the use of fields supported in the current version of the SCRIPT standard that would be of value to specialty pharmacies. NCPDP members recently voted to add fields to the SCRIPT standard to accommodate other information that will greatly enhance the utility and usability of specialty e-prescribing. This includes agency and service information, which will allow the provider to indicate the preferred agency and type of service; hospice eligibility indicators; IV administration information; additional patient demographic and clinical information; order-specific clinical information; and instructions related to delivery of the medication.

Real-Time Pharmacy Benefit
Real-time pharmacy benefit (RTPB) will not be widely available in the near future, although it is being pilot-tested today. There are 2 models: one using the NCPDP telecommunication (pharmacy claim) standard and the other using the NCPDP SCRIPT standard. Both hold promise to improve accuracy and clarity to the group-level formulary and benefit paradigm that is in use today, and have the potential to curb costs and, arguably, improve health care by increasing formulary compliance and medication adherence.

RTPB would replace or enhance the current process of linking an eligibility response with downloaded data files, which have limitations because of the latency of the update process and the inconsistent quantity and quality of the data. Real-time benefit verification will greatly improve the breadth, accuracy, and effectiveness of formulary data available to the prescriber at the point of care. This will address many prescribers’ perceptions that currently available formulary and benefit data are neither correct nor complete. Moreover, having real-time benefit information in the EHR will allow the prescriber to see other desired decision factors, such as co-pay amounts for individual patients at the point of prescribing. This will help with formulary compliance and medication adherence. Research has shown that high out-of-pocket costs are a main reason why patients abandon prescriptions.6

Conclusion
HIT has become essential to the pharmacy industry, dramatically changing the way medications are ordered and dispensed while creating value. It enables and supports transformational changes in pharmacists’ roles, both in traditional pharmacies and those associated with value-based care organizations. HIT facilitates increase pharmacist involvement for patient care, which will cut costs and improve outcomes. All of us—as pharmacists and as patients—can look forward to a brighter future enabled by technology.


Anthony Schueth, MS, is managing partner and CEO of Point-of-Care Partners, LLC.
William Hein is a former medication therapy management executive and the payer/provider executive lead at Point-of-Care Partners, LLC.
Jeffrey Hull, RPh, is a practicing retail pharmacist and a senior consultant at Point-of-Care Partners, LLC.



References
  1. National adoption scorecard: electronic prior authorization (ePA). CoverMyMeds website. https://epascorecard.covermymeds.com/. Published March 2015.
  2. 2014 national progress report: more connected than ever before. Surescripts website. http://surescripts.com/docs/default-source/national-progress-reports/surescripts-2014-national-progress-report.pdf. Published 2014.
  3. Centers for Disease Control and Prevention. National Vital Statistics System. 2010 Multiple Cause of Death File. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2012.
  4. Hirsch BR, Balu S, Schulman KA. The impact of specialty pharmaceuticals as drivers of health care costs. Health Affairs (Millwood). 2014;33(10):1714-1720. doi: 10.1377/hlthaff.2014.0558.
  5. The growth of specialty pharmacy: current trends and future opportunities. UnitedHealth Group website. www.unitedhealthgroup.com/~/media/UHG/PDF/2014/UNH-The-Growth-Of-Specialty-Pharmacy.ashx. Published April 2014.
  6. Gleason PP, Starner CI, Gunderson BW, Schafer JA, Sarran AS. Association of prescription abandonment with cost share for high-cost specialty medications. J Manag Care Pharm. 2009;15(8):648-658.

Sidebar: Electronic Prescribing of Controlled Substances: Ready to Take Off
Anthony Schueth, MS

Fasten your seat belts. Five years after becoming legal, electronic prescribing of controlled substances (EPCS) is on the runway, ready to take off. It has taken a massive industry effort to get EPCS to this point, especially considering that electronic prescribing (e-prescribing) has been available for decades. (The first such solution was created for the Veteran’s Administration in the late 1980s.) E-prescribing, one of the core capabilities of today’s electronic health records (EHRs), was initially deployed in acute care settings,1 but in the last 7 years, US physicians and hospitals have rapidly moved toward its adoption, in large part due to the EHR Incentive Program created and funded by the Health Information Technology for Economic and Clinical Health Act of 2009.

It is exciting to have witnessed and contributed to the metamorphosis of e-prescribing. Nearly 80% of ambulatory providers are e-prescribing, and most pharmacies accept electronic prescriptions. In comparison, almost 75% of pharmacies are capable of receiving controlled substances prescriptions while only 1.4% of prescribers can receive them—although that number is quickly growing.2 EPCS volume increased by 400% in 2014.2

The Legislative Landscape
Although the Interim Final Rule for Electronic Prescriptions made EPCS for schedules II through V controlled substances legal from a federal perspective on June 1, 2010, each state had to enact rules and legislation to make EPCS legal according to state law and in accordance with federal law. EPCS will soon be legal in all 50 states and Washington, DC. Missouri, the last state to allow EPCS, is expected to publish a rule revision this month.

Now that technology and infrastructure have advanced, state policy makers are taking advantage of e-prescribing’s potential to help address the nation’s drug abuse epidemic through such programs as New York’s State’s Internet System for Tracking Over-Prescribing (I-STOP). It mandates that all prescriptions be sent electronically by March 27, 2016, a 1-year delay from the original implementation date. I-STOP may be the biggest health information technology game changer of all because other states are likely to emulate New York.3

EPCS will also help physicians who prescribe controlled substances to meet the higher e-prescribing thresholds that will be required for meaningful use stage 3 of the EHR Incentive Program; the current proposal is 80%. Meeting this threshold will be of key importance for providers in certain specialties, such as oncology, who have many patients using controlled substances.

Role of EHRs
Most e-prescribing occurs within EHRs. Before EHR and e-prescribing vendors can extend EPCS to their users, a third-party certifying organization must audit their EHR application for compliance with Drug Enforcement Administration requirements Code of Federal Regulations 21 Part 1311. These requirements are involved, but many leading EHRs have already enabled their systems to handle EPCS. In the last 2 years, there has been a “popcorn effect” of EHR vendor solutions becoming certified for EPCS: In New York, for example, where I-STOP has mandated EPCS, 8 of the top 10 EHRs are certified for EPCS.4 As could be expected, I-STOP is also driving adoption of EPCS in new sectors, such as long-term care and the dental market.

Once certified for EPCS, EHR vendors must invest time to help their prescribers establish processes to meet identity proofing, access control, dual authentication, and digital signature requirements. Pharmacies must also verify their systems are certified for EPCS, set up access controls, create an e-prescription audit process, and adhere to record-keeping requirements.

Although no technology can take the place of health care providers’ professional judgment, EPCS has tremendous potential to help improve patients’ health due to the critical information it delivers to the point of care. It has the potential to reduce prescription drug abuse, unintended or intended, by giving prescribers access to medication history at the point of prescribing and by eliminating paper prescriptions that are prone to fraud. Now, it is a matter of equipping physicians for EPCS to match the capabilities of today’s pharmacies. Most of this responsibility is in the hands of EHR and e-prescribing vendors who undoubtedly have users lining up for EPCS.

References
  1. Hillblom D, Schueth A, Robertson SM, Topor L, Low G. The impact of information technology on managed care pharmacy: today and tomorrow. J Manag Care Spec Pharm. 2014;20(11):1073-1079.
  2. 2014 national progress report. Surescripts website. http://surescripts.com/docs/default-source/national-progress-reports/surescripts-2014-national-progress-report.pdf. Published 2014.
  3. Schueth T. Readers write: I-STOP may be the biggest health IT game-changer of all. HIStalk website. http://histalk2.com/2014/10/08/readers-write-i-stop-may-be-the-biggest-health-it-game-changer-of-all/. Published October 8, 2014.
  4. I-STOP deadline: March 27, 2016. CVS/caremark website. http://info.caremark.com/istop-compliance/are-you-compliant. Published 2014. Accessed July 6, 2015.


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