The Top 10 Takeaways from the Surescripts 2015 National Progress Report

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By Tony Schueth

American healthcare continued to use technology at a record-breaking pace in 2015 to prescribe medications and improve patient care, according to Surescripts’ newly released 2015 National Progress Report. Here are our top 10 takeaways.

  1. ePrescribing adoption still grew in 2015. The Report indicates that regular electronic prescribing (ePrescribing) increased by roughly 10%, with 75% of non-controlled substance prescriptions being sent electronically. There were 1.41 billion such ePrescriptions routed through Surescripts in 2015.  In fact, these ePrescriptions nearly doubled since 2012 and increased 300% since 2010.
  2. Despite rumors to the contrary, ePrescribing is still alive. We think that the modest 2015 growth in ePrescribing is pretty good, especially since we are at the tail end of the ePrescribing adoption curve.  While the last mile may not be a cake walk, there are still many areas that can contribute to ePrescribing volume and adoption, such as prescriptions from laggards, dental care, discharge medications and long-term and post-acute care. Perhaps the biggest opportunities will come from increasing electronic prescriptions for controlled substances (EPCS) and specialty medications.
  3. EPCS adoption. EPCS grew substantially in 2015, fueled by the desire of all stakeholders to address the opioid epidemic and resulting state mandates. As a result, there was a 667% uptick in EPCS transactions—12.8 million in 2015, compared with 1.67 million in 2014. However, that growth was due mostly to New York’s I-STOP program, which mandates EPCS.
  4. EPCS Connectivity. About 80% of pharmacies (mostly chains) could receive ePrescriptions for controlled substances in 2015, which is slightly more than 2014. The number of providers who can electronically submit controlled substance prescriptions rose to 5.7% in 2015. While that’s a 359% increase over 2014, it’s still a disappointing overall connectivity rate. EPCS connectivity by pharmacies and physicians should rise as more states follow New York’s lead for mandatory EPCS. Legislation is a time-tested way to get folks off the starting blocks.
  5. Missing puzzle pieces. We were again surprised that we didn’t see anything about the formulary and benefit (F&B) file, which has been a major part of ePrescribing since back in the day and is critical for ePrior Authorization. There also was nothing about the real-time benefit check (RTBI). This up-and-coming transaction is a value add because of its potential for providing real-time, patient-specific formulary and benefits information at the point of care. Both the F&B and RTBI have implications for curbing costs and, arguably, improving health care by increasing formulary compliance and medication adherence. Research has shown that high out-of-pocket costs are a main reason why patients abandon prescriptions.
  6. Other transactions. In case you were unaware of what Surescripts has been up to, the Report highlights several newer products and services in the company’s portfolio. These include clinical messaging, electronic prior authorization (ePA) and medication history aimed at hospitals. Surescripts also is branching out into the realms of long-term and post-acute care (LTPAC). LTPAC is a huge growth area, which is ripe for ePrescribing and EPCS.
  7. Keep an eye out for specialty pharmacy. Specialty pharmacy was also missing. It’s important because specialty medications represent the fastest growing sector in the American healthcare system. Use of specialty medications is expected to jump by two-thirds in 2015 and account for half of all drug costs by 2016. Secondly, specialty pharmacies are just beginning to consider how to computerize their prescriptions and workflows.
  8. It’s a marketing brochure. The Report has evolved over the last decade or so from its humble beginnings as a yearly snapshot of ePrescribing adoption. Now it is slicker than ever. There are videos of providers, thought leaders and others, who comment on how Surescripts’ products improve patient care. There are interactive features, such as a return-on-investment calculator for physicians for ePA and an interactive map showing state rankings for EPCS enablement.
  9. The state ePrescribing adoption map isn’t quite what we expected. The Report contains a map indicating the estimated rate of ePrescribing use by state of medications in the five major therapeutic classes of drugs as defined by First DataBank. They are: heart and blood vessel, antibiotic and antiviral, brain and spinal cord, endocrine/hormonal and respiratory. This is a new approach that took us by surprise. If this format is kept, we hope other classes will be added.  Furthermore, the map could be done differently (or a second map added) to improve usability, for example by condition instead of therapeutic drug class.
  10. The presentation of data. The interactive map approach is easy on the eye and a pretty cool feature. It certainly is what many users expect in this digital age of data sound bites. However, this approach obscures how much information the Report really contains because the user must do a lot of digging and individual analysis to make meaningful comparisons across states and regions. Why? The user must click on each state, record data of interest, collate it and analyze it.  In the old days, much of this would be provided in chart form. Yes, charts are boring, but making users dig for the data could lead to less than fully optimal use of the Report.
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NCPDP Action Group Focused on Biologics and Biosimilars

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By Brian Bamberger, Practice Lead, Life Sciences

Biologics and biosimilars are starting to burst into the American market. Biosimilars are expected to quickly become mainstream in the near future because of their significant cost-savings and patient care implications. Recognizing their potential and patient safety implications, how can the unique challenges of biologics and biosimilars be addressed when folding them into the electronic health record landscape?

This was the focus of a July 21 Stakeholder Action Group (SAG) meeting of leaders of key industry stakeholders at the National Council for Prescription Drug Programs (NCPDP). Attendees included pharmacies, electronic health record (EHR) vendors, electronic prescribing infrastructure providers, pharmaceutical manufacturers, health care providers and other industry groups.

Unique challenges of biologics and biosimilars. Compared to traditional medications, biologics and biosimilars have unique properties—in terms of their manufacturing and the legal requirements related to their use. In addition, biologics and biosimilars are typically specialty medications, which as a whole still rely on antiquated phone-fax-paper methods for gaining payer approvals and engaging patients with specialty pharmacies.Those are among the reasons why changes will be needed when folding biologics and biosimilars information into the electronic health information ecosystem. The SAG discussed a number of these challenges, including:

  • Manufacturing variability. The composition of biologics and biosimilars vary among manufacturers and the lots they produce. This is important information that when captured in the electronic health record (EHR) may improve the reporting detail in adverse drug event (AE) reports.
  • Pharmacy substitution rules. States are leading the way in proposing and enacting substitution legislation for biosimilars. Most include a notification to the prescriber if an interchangeable biosimilar is available (even if there is no substitution). Not surprisingly, these requirements differ by state. How should these varying requirements be addressed in prescriber EHR systems to satisfy the needs of prescribers, pharmacies and states? The accuracy of the reported NDC numbers by pharmacies was also examined with an open question about NDC information in the EHR to identify drugs that were both prescribed and dispensed.
  • Adverse event reporting. Today, the Food and Drug Administration receives AE reports directly from healthcare professionals, consumers and manufacturers. Biologics and biosimilars are expected to generate a higher number of AE reports due to the complex conditions they treat. The reporting is typically based on the information a physician has available, which may be incomplete. For example, the EHR may contain information on which drug was prescribed, rather than the drug that actually was dispensed. As a result, the patient’s medication history may not be complete. This in turn causes the adverse event to be reported on the drug that was prescribed to the patent, rather than what was actually administered or dispensed.

Opportunities. The SAG discussed opportunities for reporting of biologics and biosimilar on current infrastructure and transactions. Two possibilities were identified for reporting administered or dispensed medications to patients. The first is RxFill, which is a Meaningful Use 3 requirement for EHR systems but isn’t used much today. The RxFill message tells the prescriber that the patient has picked up the medication from the pharmacy for each fill. The second is RxHistory, which also is available to the prescriber at the point of prescribing.  While very useful, the information may not be complete.

The SAG recommended that NCPDP convene a Task Group to develop use cases for biologics and biosimilars for both transactions. It also recommended the development of pilots to test the use of the transactions for biologics and biosimilars when an interchangeable biosimilar is available. A pilot can also be used to address the accuracy of NDC numbers in these messages.

Next steps.  The creation of the Task Group was just approved by NCPDP at the August Workgroup meetings.  Stay tuned for results of the Task Group’s deliberations and the development of pilots.

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Recent Regulations Continue Promotion of ePrescribing

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By Michael Burger, Senior Consultant

The federal government continues to keep its foot on the gas to further the adoption and effectiveness of electronic prescribing (ePrescribing) through the rulemaking process.  We have seen this modus operando from statutory requirements related to ePrescribing with Medicare Part D. We are seeing it again in two recent regulations. The first is the Notice of Proposed Rulemaking (NPRM), which explains requirements for implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The NPRM details the proposed future of the meaningful use (MU) program, including ePrescribing elements. The second regulation is last October’s final rule, which spells out the latest requirements of the electronic health record (EHR) certification program. ePrescribing is a core EHR functionality and the new regulation puts vendors in a tough spot.

ePrescribing and MACRA. Among its many features, MACRA creates a new program called the Merit-based Incentive Payment System (MIPS). MIPS is a carrot-and-stick incentive program in which physicians are measured on weighted metrics related to cost, quality, clinical practice improvement and a number of repurposed Meaningful Use measures. Results will be totaled to create a base score. The base score will be used by Medicare to increase or decrease a physician’s overall Medicare payments by certain percentages. Doctors can earn bonuses (or receive penalties) of up to 4% starting in 2019, a number that grows to 9% by 2022, depending on how well they perform. (For more information, see our article in this issue of HIT Perspectives.)

ePrescribing—along with other MU elements—is now contained in the Advancing Care Information (ACI) portion of MIPS (details start on page 208 of the NPRM). The ACI’s objectives count toward a quarter of the MIPS base score.

ACI’s criteria are essentially slightly tweaked versions of MU’s goals and objectives as spelled out in the EHR final certification rule. There are some slight differences in the measures, on which the government is seeking comment. MIPS eliminates the (MU) exclusion for low-volume users, so ePrescribing will be mandatory for all clinicians participating in MIPS. It remains to be seen how this will affect ePrescribing adoption, since an estimated 20% of physicians were not motivated by MU to adopt ePrescribing technology.

ePrescribing and EHR Certification.  The implementation of MACRA will continue in parallel with the previously established program for certifying EHRs run by the Office of the National Coordinator for Health Information Technology (ONC). In addition to the existing MU ePrescribing requirements, the 2015 version of the certification standards contains some new ePrescribing transactions. While these new transactions may not move the adoption needle, they will result in increased patient safety and provide additional clinical decision-making value. (Details begin on page 132 of the regulation.)

Going forward, EHRs will need to certify a new segment NCPDP SCRIPT v10.6 standard, Structured and Codified Sig. This segment will standardize dosing instructions for most prescriptions that are submitted electronically. Use of Structured and Codified Sig will improve productivity in physicians’ offices and pharmacies. The lack of a standardized way to electronically transmit Sig information to the pharmacy results in a volume of time consuming call-backs for clarification between providers and pharmacists. In addition, use of the Standardized and Codified Sig transaction will help eliminate the patient safety hazards caused the manual entry of this information in the free text field of the ePrescription and subsequent transcription by the pharmacist. This is a functionality that physicians can get behind and that has been requested by many provider groups to reduce telephone call-back volume.

EHRs also will have to handle three ePrescribing transactions that are seldom used today.  These are:

  • Change Prescription. This transaction is sent by the pharmacy to the prescriber when the pharmacy requests approval to switch from a drug originally prescribed to something different.
  • Cancel Prescription. This transaction is used by the prescriber to cancel an existing prescription.
  • Fill Status. This transaction is sent to the prescriber from the pharmacy and indicates the fill status of the prescription (dispensed, partially dispensed or not dispensed).

In addition to NewRx, Refill and Medication History, which were previously mandated for Meaningful Use, the government is clearly paving the way for the required use of these three new transactions by ensuring their availability in EHRS. More than likely, the government’s interest is in response to three patient safety-related issues: medication adherence compliance, biosimilar substitution and drug diversion.

Medication adherence has mushroomed to become a major concern to payers, providers and pharmacies. Some 3.8 billion prescriptions are written every year in the US, yet over half are taken incorrectly or not at all.  A study of over 75,000 commercially insured patients found that 30 percent failed to fill a new prescription, and new prescriptions for chronic conditions such as high blood pressure, diabetes, and high cholesterol were not filled 20-22 percent of the time. The result: rampant medication noncompliance creates an estimated 100,000 unnecessary fatalities and costs $200 billion each year in unnecessary hospital and doctor visits, lost productivity and premature deaths.

The use any of ePrescribing (and especially a Fill Status) can help physicians identify patients who are not filling their prescriptions or are not taking their medications as directed. This will enable the physician to have the necessary conversation with the patient and address the root causes of non-adherence.

Another issue is notifying physicians about a biosimilar substitution. Interest is growing in a technology solution now that nearly two-thirds of states have enacted — or are considering enacting — legislation requiring that physicians be notified when a biosimilar substitution is made.  (Our Regulatory Resource Center is tracking state and federal regulatory actions related to biosimilars.)  ePrescribing (and especially Change Prescription and Fill Status) could be used to indicate to a prescriber that a substitution was made and which biosimilar was dispensed. This is important information should an adverse event occur.  (Read more in HIT Perspectives.)

A third issue is that of diversion. Use of the Cancel Prescription transaction will alert the pharmacist that a therapy has been cancelled by the prescriber. This will prevent subsequent fills of cancelled prescriptions from being dispensed, and potentially be diverted. Cancel Prescription will not only enhance patient safety, but also reduce costs related to dispensing medications that have been discontinued.

Impact on EHRs.  The 2015 EHR certification regulation puts EHR vendors in a tough spot by requiring that EHRs support functionality for which there is little demand today.  Further, there is no MACRA/MIPS or Meaningful Use requirement that physicians use these new transactions. The If-EHRs-Build-It-Physicians-Will-Use-It approach has been unsuccessful in the past, unless coupled with rulemaking. For that reason, we see more regulations on the horizon—either in the next iteration of the EHR certification rule or additional MACRA regulations, not to mention those for Medicare Part D. In the meantime, EHR vendors are being asked to build (and certify) new features for which there is no corresponding requirement for physicians to use them.

I am a vocal advocate of introduction of features that leverage the power of information technology to make physicians’ jobs easier and aid in care quality improvement. Let’s hope that we get a legislative “nudge” to kick start the adoption of these new ePrescribing transactions.

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