hitpc - information exchange work group meaningful use stage 3 subgroup 1: quality and efficiency...
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HITPC - Information Exchange Work GroupMeaningful Use Stage 3
Subgroup 1: Quality and Efficiency
Chair: Dave GoetzMembers: Cris Ross, Chris Tashjian, Steve Stack
Agenda
• Controlled substance e-prescribing– Presentation from Ken Whittemore, Surescripts
• Medication history– Presentation from Jon D. Duke, Regenstrief
Institute• Review lab orders language
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IE Workgroup TimelineDate Topic
Tuesday, September 4th, 12:30-1:30pm ET
Goals and Objectives for stage 3 • Medication history• Controlled substance e-rx• finalize recommendations to IE WG for all areas
IE WG Call - Wednesday , September 5th, 3:00-4:00pm ET
Review SubWG recommendations
IE WG Call - Week of September 10th Finalize recommendations
September 18th MU WG meeting
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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
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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
PRIVILEGED & CONFIDENTIAL 5
General EPCS Issues
PRIVILEGED & CONFIDENTIAL 6
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.)
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Surescripts support of EPCS Beyond what is required by the DEA EPCS IFR:
– Restrict EPCS messaging to applications that have passed DEA Part 1311 audit as 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)
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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.
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EPCS Limited Availability (LA) process
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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
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 11
State EPCS Issues
PRIVILEGED & CONFIDENTIAL 12
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 13
State EPCS Status Map (see website for latest information)
PRIVILEGED & CONFIDENTIAL 14
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 15
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 17
Improving Drug Adherence through Advanced Clinical Decision Support
Jon D. Duke, MD, MSRegenstrief Institute
Background
• Communicating drug adherence information effectively to providers remains a challenge
• Reviewing dispensing histories is not practical within the time constraints of typical visit
Enhanced medication history
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 Nonadherence Associated With Diabetes, Hypertension, and Dyslipidemia. Am J Pharm Benefi ts. 2012;4(2):e41-e47.
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
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
1984 - 2010
1984 2010
Regenstrief’s New Platform: G3
Clinical Decision Support in G3
PhysicianContext
PatientContext
InstitutionalContext
Final Alert
Context-Aware AlertingOriginal Alert
Alerting Zones
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
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
Intervention 1
Intervention 1
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’
Intervention 2
Intervention 2
Intervention 2
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
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
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: 1. improvement in patient adherence / HbA1c (patient health outcomes measure)2. increase in frequency of provider conversations with patients (process measure)3. ability of the system to engage physicians (user acceptability measure)
Study Status
• Study launching 9/15/2012• Final results expected Fall 2013
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
Questions?
Thank you to Paul Dexter, Heather Black, Kim Heithoff, Linas Simonaitis
HITPC: MU Workgroup Stage 3 Recommendations
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Medication History
• MU WG recommendation
• Does the IE WG have any suggestions or does the group concur?
ID Stage 2 NPRM Stage 3 Recommendations Stage 4 Placeholder HITPC Comments
SGRP125
Placeholder for Stage 4
Placeholder for Stage 4 Medication reconciliation: create ability to accept data feed from PBM (Retrieve external medication fill history for medication adherence monitoring)
No changes suggested.
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?
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Next Steps
• Finalize recommendation language to present on the IE WG call tomorrow.
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