Medication Reconsiliation Pharmacy Informatics TownHall December2012

7/27/2019 Medication Reconsiliation Pharmacy Informatics TownHall December2012

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Presented by NCPDP and HIMSS for the Pharmacy Informatics Community

IMPROVING MEDICATIONRECONCILIATION WITH STANDARDS

Rick Sage, Sr. Vice President,Pharmacy Services, Emdeon

December 13, 2012

Keith Shuster, Manager, Acute

Pharmacy Services, Norwalk

Hospital


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Todays Speakers

Keith Shuster, R.Ph, M.B.A., has over 25 years of clinical and

management experience. As Manager of acute care pharmacy services

at Norwalk Hospital, Keith is currently responsible for pharmacy

operations. Norwalk Hospital is a 328 bed community teaching hospital

located in lower Fairfield county Connecticut. The pharmacy

department is staffed 24/7 by 11 pharmacist, 4 clinical specialists, and

12 technicians. The inpatient pharmacy follows a centralizeddistribution model including robotic dispensing, medication carousel,

and bar code ready inventory. The Hospital staff maintains at least 98%

computerized prescriber order entry and 90% bedside barcode

compliance rates.

Rick Sage has over 25 years experience in the pharmacy industry. As Sr.

Vice President of Pharmacy Services for Emdeon, Rick Sage directs thecompanys pharmacy initiatives with a focus on developing programs,

standards and partnerships to improve patient outcomes and reduce

healthcare costs. Building the IT infrastructure to support Emdeon

Clinical Exchange eRx Network has been a priority of Ricks for the last

eight years.


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Agenda/Objectives

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Discuss medication management trends today

by exploring progress and barriers that have

been identified.

Explore new trends and available resources onthe medication reconciliation process.

Explain current standards and regulatory

requirements in place today including:

Meaningful Use, Joint Commission PatientSafety Goals and available NCPDP resources.


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A process for documenting a complete list of the

patients current medications upon admission to the

organization AND compare/reconcile the

medications the organization provides, upon...

A complete list of the patients medications is

communicated to the next provider of service

A Joint Commission National Patient Safety Goal

Medication Reconciliation


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Objective

Maintain and communicate accurate patient medicationinformation

Elements of Performance

Compare the medication information the patient brought to the

organization, with the medications ordered for the patient by theorganization,in order to identify and resolve discrepancies

Provide the patient with written information on the medications

the patient should be taking at the end of the episode of care

Explain the importance of managing medication information to the

patient at the end of the episode of care

Spotlights critical risk points

Admission, transfers, and discharge

National Patient Safety Goal*: Medication Reconciliation

*Reference: Joint Commission


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Hospital Drivers

Hospitals are now financially penalized forreadmissions

Ineffective medication reconciliation upon hospital admission:

Up to 50% of medication errors

Up to 20% of future Adverse Drug Events (ADEs)

More than one-third of patients had at least one discrepancy in one

study

According to the AHRQ, unintended medication discrepancies occur in

14% of patients upon discharge

Medication Reconciliation is a Joint Commission Accreditation

requirement for hospitals

6 Sources: American Academy of Pediatrics, Journal of General Internal Medicine,AHRQ


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Automated medication reconciliation can help

accomplish NPSG.06.03.01 requirements by:

Reducing manual and redundant processes needed to

achieve NPSG accreditation

Increasing accuracy, thereby decreasing unintentional

medication discrepancies

Improving the accuracy associated with assessments formedication appropriateness

Increasing the speed by which valuable medication

reconciliation information is delivered

Automation and Medication Reconciliation


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Accurate/Timely medication history

Complete medication history

Medication name, dose, frequency

All medications from all sources (cash, OTCetc.)

Discussion with patient/family

Process for admission, transfer, and discharge

What not to take upon discharge

Keys to medication reconciliation


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Paper solution

Retrospective comparison upon admission

Hospital vendor solutions

Medication Reconciliation Trends


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Pharmacy prescription data

Pharmacy Benefits Management (PBMs)

Data

Interfaced to hospital systems

Nurse documents as medication history

Prescriber can document a medication as

history OR convert to inpatient order

Pharmacist discharge phone calls and Medical

home

Latest Trend - Automation


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PBM look up dependent onaccurate/matching name and DOB

Some 3rd party insurers do not participate

Staff role confusion Nurse, physician, and/or pharmacy

personnel

Timely arrival, data gathering, and exchangeof information

Trusting the information

Automation automatic

Barriers


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Key Drivers

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Evolution of HIT

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25 Years Now


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Recent Drivers

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ARRA

HITECH

MEANINGFUL USE

INTEROPERABILITY

MEDICAL HOME / ACOs


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Convergence

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Administrative

Clinical

Connect Capture Normalize ShareAnalyze &

Report


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Meaningful Use


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Critically important to

81% of surveyedproviders*

*Source: HEALTHCARE INSIGHTS 2012: SMALL PRACTICE RESULTS, EMDEON, 2012.


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But only 42% have

already fullyimplemented an EMR*

*Source: HEALTHCARE INSIGHTS 2012: SMALL PRACTICE RESULTS, EMDEON, 2012.


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Closer Look at Stage 2: Electronic Exchange*

Stage 2 focuses on actual use cases of electronic

information exchange:

Stage 2 requires that a provider send a summary

of care record for more than 50% of transitions of

care and referrals

The rule also requires that a provider electronically

transmit a summary of care for more than 10% of

transitions of care and referrals

At least one summary of care document sent

electronically to recipient with different EHR

vendor or to CMS test EHR19 *HIMSS 2012 presentation by Robert Anthony


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Closer Look at Stage 2: Med Reconciliation*

Core requirement for Stage 2:

Eligible Professional (EP), Eligible Hospital (EH) or

Critical Access Hospital (CAH) must perform

medication reconciliation for more than 50

percent of transitions in care

To an eligible professional

Admission to an eligible hospital or CAHs

inpatient or emergency department

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*Page 175 of MU Stage 2 final rule


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Key Considerations


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Hospital/Acute Care

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Hospital inpatient care

Number of discharges annually:

36.1 million

Average length of stay in days: 4.9

Hospital outpatient department care Number of annual outpatient

department visits: 96.1 million

Hospital emergency department

care

Number of annual emergency

department visits: 136.1 million

Number of emergency

department visits resulting in

hospital admission: 17.1 million

Number of emergency

department visits resulting in

admission to critical care unit: 2.2

million

This results in approximately 268 million medication reconciliations annually

Source: http://www.cdc.gov/nchs/fastats/hospital.htm


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Requires Additional Data & Collaboration

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Many medications are used for multiple conditions; all diagnoses not readilyavailable

Patients use multiple physicians

Primary Care Providers (PCPs) often do not have time to work with clinicalpharmacists to reconcile medications

Patients use multiple pharmacies or pay cash, creating lack of visibility

Patients may not remember what they are taking

Lack of awareness of medications in patient home

Disparate health systems make data sharing difficult

Hospital and emergency events create frequent misalignments in establishedmedication therapy


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Patient Authorization (HIPAA)

Patient authorizes to their

provider/physician or healthcare

provider either verbally or written, to

access any medical data, including

medication history

The requesting provider is responsible

to ensure that any request for

medication history information is madefor an authorized purpose, as defined by

HIPAA (meaning for, continuity of care,

avoidance of medication errors and

other treatment)24


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Supporting Standards


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NCPDP SCRIPT Medication History Overview

Real-time exchange between prescribing systems, pharmacy systems,payer/processor systems, or other entities involved in healthcare

Populates medication history on prescriber and pharmacy systems

Medication history information delivered in the NCPDP 8.1 SCRIPT

XML format Request message = RXHREQ

Response message = RXHRES

Will be supported with the NCPDP 10.6 SCRIPT XML format

Accessible via existing ePrescribing workflows

Can include third party claims submitted to payers/processors andcash claims stored on pharmacy systems including OTC if submitted asa prescription

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A Real-Time Solution

Endpoints obtain pharmacy-sourced medication historythrough a single real-time inquiry accessed via anePrescribing application or web portal

Identifies a unique patient using person-matchingalgorithms based on several criteria including patient firstand last name, gender, date of birth and zip code

Applies edits and rules to eliminate duplicate records &

limit time period in which history is searched

Filters to remove any drugs based on state and/or otherlegal requirements from the results

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Medication History Request/Response

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Entity

Entity

Medication History RequestMessage - RXHREQ

Medication History ResponseMessage - RXHRES

1. Requesting entity supplies enough information to uniquely identifypatient.

2. Prescriptions returned in the order of the most recent date filledfirst.

3. Requesting entity must evaluate the Patient Consent for accuratereporting.


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Medication History Patient Consent

Patient Consent flag required as part of obtaining successful

medication history

Consent is the responsibility of each healthcare provider

Pharmacy receives consent prior to submitting claim to

payer/PBM

Provider receives consent prior to requesting medication

history

Providers application sends a flag in the medication history

request indicating that the provider has obtained theappropriate consent

The lack of consent will return a rejected response

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Comprehensive Medication Reviews

Required by Medicare once per year starting January 1, 2013

Supported by CDA Release 2 Medication Therapy Management (MTM)Part D Implementation Guide that is a joint Release between NCPDP andHL7 based on the HL7 Clinical Document Architecture (CDA)

Generates Medication Action Plan and Medication List

May be used by pharmacists to conduct MTM medication reviewsanytime and can include non-prescription medications

Designed to help eligible providers (EPs) and eligible hospitals (EHs)meet MU medication reconciliation requirements

Uses RxNorm and specific MTM SNOMED CT codes for EP and EH tointegrate the active medication list and care plan into EHR

DERF approved during August 2012 WG10 meeting; Task Groupreconciling HL7 ballot comments; final ANSI approved versionexpected to be published May 2013

Key Contacts See Resource section

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Putting it All Together


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Name:Arthur DoeDOB: 01/01/1940Gender: Male

Notes:Has a primary care physician Sees 2-3 specialists per year Is on maintenance medications for

- Hypertension- Diabetes

Our Patient


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?

PCP

Specialist

Hospital

Pharmacy

Lab

Payer

101010001011

110011

101010001011110011

101010001011

110011

101010001011

110011

101010001011

110011

101010001011110011

Payer

Problems

Allergies

Active Medications

Results

Medicare 999999999BBCBST Z999999999

DiabetesHypertensionHyperlcholesterolemia

SulfaPenicillin

Metformin 500 MGLisinopril 10 MGLipitor 20 MG

HbA1c 6.2%Triglycerides 302 mg/dLTotal Cholest. 240 mg/dLHDL 70 mg/dLLDL 135 mg/dL

Arthurs data is

siloed on information islands.

Care is less coordinated.Quality is reduced.Payment and delivery are less efficient.

How do we bring it together?

HIEVisualized

Health InformationExchange

Patient Centric

Interoperable


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Medication Reconciliation (MR)

Improving Care

Transitions: Optimizing

Medication

Reconciliation: March2012

http://www.ashp.org

/DocLibrary/Policy/P

atientSafety/Optimizing-Med-

Reconciliation.aspx

CDA Release 2 Medication Therapy Management
http://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspxhttp://www.ashp.org/DocLibrary/Policy/PatientSafety/Optimizing-Med-Reconciliation.aspx


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CDA Release 2 Medication Therapy Management

(MTM) Part D IG

Information on the MTM CDA can be obtained from

Sue Thompson with NCPDP, [email protected]

Interested pilot participants should contact Shelly Spirowith Pharmacy e-HIT Collaborative,

[email protected]

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mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Thank You!

Rick Sage

SrVP, Pharmacy Services

Emdeon

[email protected]

Keith Shuster

Manager of Acute Care

Pharmacy Services

Norwalk Hospital

[email protected]

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mailto:[email protected]:[email protected]:[email protected]:[email protected]

Medication Reconsiliation Pharmacy Informatics TownHall December2012

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