Medicare Creates Experimental Pilot Incentive Program to Boost Medication Adherence


By Bill Hein, Payer/Provider Executive Lead

As a strong believer in harnessing the power of pharmacists as part of the patient care team, I’m pleased to see some critical national action being taken to further evaluate the impact they can have.  Medicare—the Nation’s biggest payer—is taking steps to close the medication adherence gap among beneficiaries.  The Centers for Medicare and Medicaid Services (CMS), the agency that oversees the program, is launching an experimental five-year pilot program to increase medication adherence for Medicare beneficiaries in Part D plans in five parts of the country.  

The new CMS initiative, known as the Enhanced Medication Therapy Management (MTM) model, will offer incentives to stand-alone Part D plans in five areas, through experimental pilots, to boost adherence. The areas are:  Arizona, Florida, Louisiana and Virginia, and a larger region that includes Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming.  The plans can design their own pilots and tailor them to their unique patient populations and geographic needs.

There are several drivers behind this initiative. Among elderly beneficiaries with four or more chronic conditions, medication non-adherence increased from 14.4% in 2009 to 17% in 2011, according to a 2014 Health Affairs analysis. The prevalence (among the sickest elderly) of forgoing basic needs to purchase medicines went from 6.8% in 2009 to 10.2% in 2011. The cost of nonadherence has been estimated at $100 billion to $300 billion annually, including expenditures for avoidable hospitalizations, nursing home admissions, and premature deaths. Chronic diseases are also on the rise, and older Americans are particularly vulnerable. Today, some 70 million Americans aged 50 and up suffer from 4-5 chronic conditions. Treating the chronically ill accounts for $3 out of every $4 spent on medical care, so reducing outlays for chronic disease management through improving medication adherence can result in significant savings to the U.S. healthcare system and improve quality of care.

CMS will accept applications for the Enhanced MTM model via a Request for Applications (RFA), to be released shortly.  Once released, application materials will be available at:  As experts in MTM and pilot management, Point-of-Care Partners offers subject matter expertise and a variety of technical assistance in proposal development and project management.  E-mail or call me if we can help.

More information about the Enhanced MTM model test can be found in the model announcement, available at  A webinar on the initiative will be held on October 21, 2015. Registration information will be available on the same site.



EHR Blamed for Ebola Death. REALLY?


By Michael Burger, Senior Consultant

Last week, a headline caught my eye:  “Report Finds EHR Contributed to Dallas Hospital’s 2014 Ebola Issues.”  The report is written by an independent panel convened by Texas Health Resources, which operates Texas Health Presbyterian Hospital Dallas. This is the hospital where patient Thomas Duncan received care, was not diagnosed with Ebola and subsequently passed away at his residence. 

The report illustrates the issues involving electronic health record (EHR) usability, including accusations that some EHR vendors have attested in the Meaningful Use certification process to use “user-centered design” or UCD. The events in Texas illuminate the challenge faced by EHR vendors regarding usability.

The report draws several interesting conclusions about what happened. It finds that the care team failed to monitor the patient’s clinical information as documented in the EHR and that the hospital seemed more concerned with patient satisfaction and less about outcomes. Moreover, the report concludes that the hospital was ill prepared to address Ebola by failing to get Ebola treatment information into the right hands quickly.

The comments related to electronic health records (EHRs) are particularly fascinating. The report concludes that there is “over reliance on the EHR to convey critical information,” that the “EHR configuration did not provide for automatic alerts related to travel history” and that “[the EHR had] no systems in place that would trigger a review or re-asking of critical travel information.” 

The report further notes that the sharing of travel history was not easily accessible to the physician, as viewing it “required extra and non-intuitive steps to be taken by the physician to access information highly relevant to clinical decision-making.” In the end, the hospital “[did not] optimally utilize the full capability of the EHR.”

It’s not surprising that Mr. Duncan’s death and the specter of Ebola elicited a post-mortem evaluation.  But is it right to blame EHRs for what happened in Texas?

We all agree that, used to their potential, EHRs can be a tremendous diagnostic tool, capable of detailed analysis of vast amounts of data in seconds. The challenge is how to make the analytical results useful in a life-or-death situation. EHR designers observe clinical workflows and build software to accommodate them. Smooth and efficient clinical workflow does not allow for “automatic alerts related to travel history” and certainly not “a review or re-asking of critical travel information.” Having observed clinical workflow more times than I can count, I can say for sure that nothing irks a doctor more than being interrupted by alerts.   Alert fatigue is a well-known phenomenon and barrier to EHR user satisfaction. I can only imagine a physician’s reaction if the EHR began prompting to re-ask questions! 

And what is the definition of smooth workflow? We have an expression in EHR product management: ask a group of 5 doctors for their opinion, and you’ll get 6 opinions. Consensus is difficult among physicians, particularly when it comes to EHR workflow.   It’s not a surprise then that the report concludes that the EHR “required extra and non-intuitive steps” to access relevant clinical information.  What is relevant to one physician is irrelevant and non-intuitive to another.  Plus, it varies across specialties and work environments, such as this particular hospital.  This means that EHR vendors must seek the middle of the road when it comes to workflow – to provide what is most relevant to most physicians. They also must trust that the physicians are relying on their medical training, not the EHR, to make their clinical decisions. Physicians wouldn’t have it any other way; they want to use EHRs as a resource, not a replacement for their training and medical judgment.

In a nod to our legal team’s advice at my former employer, we had a disclaimer that would display as users logged into the EHR. It contained a paragraph of “legalese,” which I’m sure that everyone clicked through without ever reading. Buried in it were important words: “This software contains logic including warnings and reminders meant to be used as reference material.  It is not designed and cannot be a substitute for the clinical decision making of a licensed healthcare professional.” While it’s tempting to blame the EHR for lapses in care quality, in the end it comes down to the caregivers. The best caregivers refer to the EHR as a reference, but rely on their diagnostic skills. Sometimes obscure diagnoses will be missed – to err is human.


I-STOP Legislation “Hall Pass” Given to New York Health Care Community


By Poojah Babbrah, Practice Lead, PBM Services

Providers, pharmacies and technology vendors in the state of New York are breathing a collective sigh of relief.  This afternoon, Governor Cuomo signed into law Bill S.2486 that delays, by one year, the implementation of the state’s I-STOP electronic prescribing mandate, which was adopted in 2012. The Governor has basically just given the collective New York health care community a “hall pass.”

I-STOP, which stands for Internet System for Tracking of Over Prescribing, was signed into law on August 27, 2012, by the New York State Legislature in order to help combat the rising issues around the misuse of prescription medication. The I-STOP legislation consists of five key components:

  1. Prescription Monitoring Program Registry
  2. Electronic Prescribing Mandate
  3. Controlled Substance Schedule Update
  4. Prescription Pain Medication Awareness Program
  5. Safe Disposal of Prescription Drugs

The one year delay specifically impacts the Electronic Prescribing Mandate requiring all providers in the state of New York to send all prescriptions (both controlled and non-controlled substances) electronically to the pharmacy; handwritten paper prescriptions will not be allowed. This mandate was supposed to go into effect on March 27, 2015, but it is now delayed by one year and will take effect on March 27, 2016.

For many, this “hall pass” has come just in time. Delays in vendor certifications, problems with identity proofing and even worse, delays in just purchasing a certified system, were all reasons given as to why the legislation should be delayed.  Those are all valid reasons, but what about those in the community who were able to meet the deadline? I liken it to spending hours and hours studying for an exam, just to come in the morning of the test to find out the teacher has delayed it because of a group of students who just weren’t ready. Frustrating?  Yes.  However, the other way to look at it is that you are all done and ready to go. No more prep needed!  Hat’s off to those of you who prepared and were ready for the deadline.  You are already making an impact on the real issue that the I-STOP legislation is meant to solve which is to reduce the abuse of controlled substances and improve patient safety as it relates to their prescription medications.

For providers and provider offices who are still not ready for electronic prescribing, you now have a pass valid for one year, but that does not mean you can relax. Choosing, implementing and enabling an EHR or stand-alone ePrescribing system takes time. If you prescribe controlled substances, there are added steps on top of the initial system implementation. One year may seem like a lot, but given the fact that this deadline was nearly 2.5 years after the initial approval of the legislation, the one year you now have to get up and running is comparatively short so get started now. 

Already have a certified system in place?  There is still plenty of work to do in your practice including making sure all providers have completed the identity-proofing process, obtained a two-factor authentication device that is compatible with the system and your providers are enabled to send EPCS prescriptions.  In addition, there are policies and procedures that must be followed by your practice to ensure you are meeting the DEA regulations outlined in the Interim Final Rule (IFR) for electronic prescribing of controlled substances. Many providers assume that they are all set once they have a certified system, however the regulations put much of the onus on the provider and the practice to ensure the system is being used and monitored correctly. 

IT Vendor Considerations

For the IT vendors who are in the midst of getting their systems ready for EPCS, I can’t stress enough the importance of getting through certification as quickly as possible.  Having been through it, I know that the auditing and certification process takes time and can be a challenge to navigate. Because there is no standard outline for the audit process, the DEA regulations are left to interpretation by the individual auditor and may vary widely from one auditing organization to another.  Also, ensuring that your system will meet all regulations outlined in the IFR can also be challenge for some vendors.

One year may seem like a lot of time, but keep in mind, it’s not just certification; you will also need time to ensure that 100% of your providers that use your system in the state of New York are enabled to sign and send EPCS prescriptions through your system.  This can also be a challenge as I mentioned above, primarily because the providers assume that the burden of implementation is on the IT vendor, when truly, the practice and the provider carry much of the burden themselves.

As Point-of Care Partners (POCP) recently wrote in HISTalk, “I-STOP may be the biggest health IT game changer of all.”  (You can read the blog here.)  This still holds true but keep in mind your 1-year hall pass WILL expire and when it does, you don’t want to be caught in the middle of the hallway with an expired pass and nowhere to turn. 

Point-of-Care Partners (POCP) has long been active in ePrescribing and EPCS. If you are an IT Vendor, POCP can help you efficiently transition your prescribers to EPCS in New York and in states that are expected to enact legislation similar to I-STOP.  Our ePrescribing State Law Review is the most succinct yet comprehensive analysis of federal and state rules, regulations and statutes governing electronic prescriptions, including EPCS. To learn more about the Law Review or subscribe to our complimentary ePrescribing State Law Capsule, visit our Regulatory Resource Center.

Pooja Babbrah is a health care information technology consultant with Point-of-Care Partners, a leading Health IT Management consulting firm. Pooja has spent more than 20 years in the health care industry and launched DrFirst’s EPCS Gold product, the health care industry’s first certified platform for e-prescribing of controlled substances.