New Approaches In Medication Management and Care Transition

e-Prescribing and Remote Dispensingin Long Term Care

AHRQ Annual ConferenceSeptember 27, 2007

Presenter – Michael Bordelon

Long Term Care Background Reimbursement Model:

Roughly 15% capitated Part A 58% Medicaid/Part D 27% Private Pay and Commercial Insurance

Typical Number of Beds: 90-120 Pharmacies are almost never co-located with LTC facilities Physicians per facility: 10-40 Nurse Practitioners per facility: 1-2 Nurses per facility: 50-80 Med passes per day: 4-7 Pharmacy trips to the facility: 2-3 Admissions per week: 1-10 Many facilities already manage their own orders in electronic

systems

Pharmacy

ConsultantPharmacist

The Infamous LTC Prescribing Slide

Nursing

PhysicianDecide on

patient orderDecide on

patient order

Evaluate order, clarify if needed and file in Patient Record

Evaluate order, clarify if needed and file in Patient Record

Faxed order

Physician signs copy of the orderPhysician signs

copy of the order

Receive new orderReceive

new order

Check patient choice for pharmacy

Check patient choice for pharmacy

Process order and dispense[includes payor verification and formulary compliance]

Process order and dispense[includes payor verification and formulary compliance]

Resolve issues with order (clinical, payor, etc.)

Resolve issues with order (clinical, payor, etc.)

Clarify and update order with nursingClarify and update order with nursing

Clarify and update order with physicianClarify and update

order with physician

Med

Order Question(phone or fax)

Verbal orderSigned copy

of order

Patient MAR

Patient Allergies

Order Sheet

Order Update(Phone or fax)

Order Update(Phone or fax)

Receive updated order

Receive updated order

Patient MAR

Patient Allergies

Patient Orders

Patient Allergies

Patient Orders

MAR Update(optional)

Start

Physician writes order on Order Sheet

Physician writes order on Order Sheet

Written order

Update the MAR

Update the MAR

File Signed copy in Pt. Record

File Signed copy in Pt. Record

Notice updated Order Sheet, evaluate order and clarify if needed

Notice updated Order Sheet, evaluate order and clarify if needed

Patient RecordUpdated Order Sheet

Copy of order (mail, on-site)

Order Exception

Evaluate order, clarify if neededEvaluate order, clarify if needed

Receive and check medication (patient,

med, doc)

Receive and check medication (patient,

med, doc)

Write order on Physician Order Sheet

Write order on Physician Order Sheet

Write order on Physician Order Sheet and send

copy to physician

Write order on Physician Order Sheet and send

copy to physician

Administer and Chart

Administer and Chart

Manage on-hand medications

(Pt Meds, Stock and Emergency Kit)

Manage on-hand medications

(Pt Meds, Stock and Emergency Kit)

Med

Med

Resolve Discrepancy

Resolve Discrepancy

Drug Regimen Review or other Patient Status

Review

Drug Regimen Review or other Patient Status

Review

Resident Change in Condition;

New admission

Resident Change in Condition;

New admissionStart

Order (phone, fax, pickup by driver, auto-fax from SNF order

management application)

Follow pharmacy-specific procedure including after hours rules

Follow pharmacy-specific procedure including after hours rules

Resident Status(phone call, fax, on-site)

LTC Prescribing Nuances Three way communication between

Prescriber – Nurse – Pharmacy Most orders have no end date or

quantity Refill requests represent 80% of orders No concept of Renewals Need unique formulary and benefit

information Part A, Part D and Medicaid

e-Prescribing in Long Term Care

e-Prescribing is new to LTC

2006 CMS Pilot Study was first official standards based e-prescribing study in Long Term Care

There are less than 5 standards based e-Prescribing installations today

LTC e-Rx Pilot Study Abstract 2006 study focused on e-Rx standards most relevant to LTC

SCRIPT Formulary Benefits Electronic Prior Authorization

Other Capabilities Studied Facility Managed Electronic Orders Patient Safety Checks (DUR) Electronic Signature Automated Refill Requests

The study included two geographically diverse treatments facilities and two comparison facilities

Flow of Information

CPOE/EHR System(Achieve Matrix)

RxHUBSCRIPTSwitch

CPOE Client

Nursing Station

Browser HTTPS

PDPMed History

Formulary BenefitEligibility

Prior AuthorizationBrowser HTTPS

AchieveHostingServcies

RxHubHostingServices

FACILITYSYSTEMS

(BHS)

Pharmacy Billiing

Pharmacist DUR

PHARMACY TOOLS(Preferred Choice)

Browser HTTPS/ Citrix

Browser HTTPS/ Citrix

Dispensing System (RNA)

RxHUBFormularyBenefitsSwitch

PAYER COVERAGE

DATA

SCRIPT Web Service

Pharmacy Dispensing

System

X12 EDI

SCRIPT Web Service

NCPDP 5.1 E1/B1

PHYSICIAN TOOLS

RNA Refill Barcode Scanner

FTP

RNA eRxRequest Refill Scanner

e-Rx Findings - Facility Impacts Benefits

Facilities currently using electronic Physicians Orders will see modest change or disruption to current workflow

Ability to transmit orders directly to the pharmacy yielded benefits in reduced rework and callbacks

Management of Orders at the facility streamlines reconciliation processes

New Challenges Prescriber adoption is vital Integration with clinical systems (EHR) is critical Nurses do not effectively use patient safety (DUR) tools Even with Formulary Benefits data, managing complex Part D

health plans is an ongoing challenge Nursing staff now has to enter and manage data that the

pharmacy once managed Data entry errors can still happen

e-Rx Findings - Pharmacy Impacts Benefits

Demographics pre-populated on new admissions Straightforward new order processing Discontinued orders Readmissions streamlined Do not have to manage MARs and Order Sheets Refill requests streamlined

New challenges Combination & Tapered Orders – Need codified SIG

standard Transcription accuracy Timely transmission on admission orders Fax mode for controlled substances leads to process

inconsistencies

Standards Findings NCPDP SCRIPT Standard works with new

changes in Version 10.1 NCPDP Formulary Benefits V1.0 technically

works, but is dependent on greater prescriber adoption

Electronic Prior Authorization Technically works, but will require greater prescriber adoption

A Refill messaging standard is needed in LTC An Admission, Discharge, Transfer (ADT)

messaging standard is needed

What is Remote Dispensing?

Automated oral solid dispensing in healthcare settings, such as nursing homes and correctional facilities, that

have no onsite pharmacist

Remote dispensing can work hand in hand with e-Prescribing

Oral Solid Packaging

Remote Dispensing Packager

Medication Canister

Process Overview

Process – Dispense Data From Central Pharmacy System

On Site Strip Packaging

On Site Strip Packaging

•Daily Dispense•Med Pass/Resident Sort•Multi Dose Packing•PRN, New, Re-dispense

Process – Data Feedback Loop

Process – Inventory Monitoring

Process – Canister Fill at Pharmacy

Process – Canister Delivery

Value Proposition

Virtually eliminates drug waste

Significantly reduces delivery costs

Eliminates delay of first dose

Decreases administration time

Reduces medication errors

Eliminates the need for a refill process

Experience in early commercial pilots

High Adoption Rate with nursing staff On demand PRNs and quick access to meds for

new admissions are big wins Will save a typical nursing facility more than

$25K per year in Part A drug waste May save $150K per year per facility for Part D

drug waste savings Robust canister logistics is the key to success

Medication Reconciliationin

Long Term Care

AHRQ Annual ConferenceSeptember 27, 2007

Presenter – Michael Bordelon

Long Term Care Background Reimbursement Model:

Roughly 15% capitated Part A 58% Medicaid/Part D 27% Private Pay and Commercial Insurance

Typical Number of Beds: 90-120 Pharmacies are almost never co-located with LTC facilities Physicians per facility: 10-40 Nurse Practitioners per facility: 1-2 Nurses per facility: 50-80 Med passes per day: 4-7 Pharmacy trips to the facility: 2-3 Admissions per week: 1-10 Many facilities already manage their own orders in electronic

systems

Pharmacy

ConsultantPharmacist

The LTC Prescribing Slide

Nursing

PhysicianDecide on

patient orderDecide on

patient order

Evaluate order, clarify if needed and file in Patient Record

Evaluate order, clarify if needed and file in Patient Record

Faxed order

Physician signs copy of the orderPhysician signs

copy of the order

Receive new orderReceive

new order

Check patient choice for pharmacy

Check patient choice for pharmacy

Process order and dispense[includes payor verification and formulary compliance]

Process order and dispense[includes payor verification and formulary compliance]

Resolve issues with order (clinical, payor, etc.)

Resolve issues with order (clinical, payor, etc.)

Clarify and update order with nursingClarify and update order with nursing

Clarify and update order with physicianClarify and update

order with physician

Med

Order Question(phone or fax)

Verbal orderSigned copy

of order

Patient MAR

Patient Allergies

Order Sheet

Order Update(Phone or fax)

Order Update(Phone or fax)

Receive updated order

Receive updated order

Patient MAR

Patient Allergies

Patient Orders

Patient Allergies

Patient Orders

MAR Update(optional)

Start

Physician writes order on Order Sheet

Physician writes order on Order Sheet

Written order

Update the MAR

Update the MAR

File Signed copy in Pt. Record

File Signed copy in Pt. Record

Notice updated Order Sheet, evaluate order and clarify if needed

Notice updated Order Sheet, evaluate order and clarify if needed

Patient RecordUpdated Order Sheet

Copy of order (mail, on-site)

Order Exception

Evaluate order, clarify if neededEvaluate order, clarify if needed

Receive and check medication (patient,

med, doc)

Receive and check medication (patient,

med, doc)

Write order on Physician Order Sheet

Write order on Physician Order Sheet

Write order on Physician Order Sheet and send

copy to physician

Write order on Physician Order Sheet and send

copy to physician

Administer and Chart

Administer and Chart

Manage on-hand medications

(Pt Meds, Stock and Emergency Kit)

Manage on-hand medications

(Pt Meds, Stock and Emergency Kit)

Med

Med

Resolve Discrepancy

Resolve Discrepancy

Drug Regimen Review or other Patient Status

Review

Drug Regimen Review or other Patient Status

Review

Resident Change in Condition;

New admission

Resident Change in Condition;

New admissionStart

Order (phone, fax, pickup by driver, auto-fax from SNF order

management application)

Follow pharmacy-specific procedure including after hours rules

Follow pharmacy-specific procedure including after hours rules

Resident Status(phone call, fax, on-site)

Typical Admission in LTC

Most admissions in LTC are from a hospital setting

Most “residents” begin stay under Medicare Part A

Generally, discharge orders from the hospital are admission orders at the facility

Resident EntersNursing HomeFrom Hospital

with Discharge Orders

PharmacistManually Enters

Orders in PhIS withDUR Check

PharmacyFills Orders and

Delivers Medications

Pharmacy ProvidesPaper Based MARs

andOrder Sheets

Nurse FaxesDischarge Orders

to Pharmacy

Typical Order Management ProcessNew Admission

Resident EntersNursing HomeFrom Hospital

with Discharge Orders

PharmacistManually Enters

Orders in PhIS withDUR Check

PharmacyFills Orders and

Delivers Medications

Pharmacy ProvidesPaper Based MARs

andOrder Sheets

Nurse FaxesDischarge Orders

to Pharmacy

Typical Order Management ProcessNew Admission

RISK:Physicians

often do not review

admission orders in a timely way

RISK:Data entry

errorscan lead to

inconsistencies

RISK:Paper MARs and Order Sheets are

“Stale” almost

immediately

Nursing StaffManually Reviews

and UpdatesOrders on MARs

Physician Reviews,Modifies and Signs

Orders on Order Sheets

Nursing Staff FaxesHandwritten MAR

Updatesto Pharmacy

Pharmacy Sends Revised MAR

to Facility

Nurses PerformSecondary Review

of MAR andHandwrite Corrections

Typical Order Management ProcessDuring last 10 days of the month

Pharmacy DeliversFinal MARs

Before Start ofNew Month

Nursing StaffManually Reviews

and UpdatesOrders on MARs

Physician Reviews,Modifies and Signs

Orders on Order Sheets

Nursing Staff FaxesHandwritten MAR

Updatesto Pharmacy

Pharmacy Sends Revised MAR

to Facility

Nurses PerformSecondary Review

of MAR andHandwrite Corrections

Typical Order Management ProcessDuring last 10 days of the month

RISK:Is the Order

SheetUp to Date with

MAR? RISK:High Potential

for Transcription Error

RISK:New MAR May Be “Stale” due

to NewAdmits and

Order Changes

RISK:Very Time

Consuming and Often not

Performed with Rigor

RISK:Easy to Make

Mistakes WhenHandwriting

Changes to MAR

Pharmacy DeliversFinal MARs

Before Start ofNew Month

RISK:Paper MARs and Order Sheets are

“Stale” almost

immediately

Typical MAR Flowsheet

Blank Space To

Handwrite New Orders During The

Month

Medication Reconciliation withe-Prescribing Facility “owns” all orders Orders are managed in facility CPOE system MARs are printed from the CPOE system New orders are transmitted electronically to

pharmacy Discontinued and changed orders are

Transmitted electronically to pharmacyNote:

CPOE = Computerized Physician Order Entry

Resident EntersNursing HomeFrom Hospital

with Discharge Orders

Pharmacy ReceivesOrder Electronically

PharmacyFills Orders and

Delivers Medications

Physician Enters andSigns Orders in

Facility CPOE Systemwith DUR and Formulary

Checks

Facility PrintsMARs and Order Sheets

From CPOE System

Order Management with e-PrescribingNew Admission

Resident EntersNursing HomeFrom Hospital

with Discharge Orders

Pharmacy ReceivesOrder Electronically

PharmacyFills Orders and

Delivers Medications

Physician Enters andSigns Orders in

Facility CPOE Systemwith DUR and Formulary

Checks

Facility PrintsMARs and Order Sheets

From CPOE System

BENFIT:Physician Upfront Review

of Orders ande-Signatures

BENFIT:MARs and

Order Sheets are AlwaysUp to Date BENFIT:

Reduction InData Entry

Errors

Order Management with e-PrescribingNew Admission

BENFIT:Pharmacy Does Not

Manage MARs or Order Sheets

Nursing StaffNotified of Changes

andPrints MAR UpdatesFrom CPOE System

Physician Writes or DC'sOrders In Facility CPOE

System withe-Signature

Nursing Staff canPrint Entire Up to DateMAR and Order Sheet

at Any Time

Pharmacy ReceivesOrder Electronicallyand Resolves DUR

Issues

Order Management with e-PrescribingOngoing Processes

Nursing StaffNotified of Changes

andPrints MAR UpdatesFrom CPOE System

Physician Writes or DC'sOrders In Facility CPOE

System withe-Signature

Nursing Staff canPrint Entire Up to DateMAR and Order Sheet

at Any Time

Pharmacy ReceivesOrder Electronicallyand Resolves DUR

Issues

BENFIT:Reduction InData Entry

Errors

BENFIT:No

Handwritten Updates and MAR Always Up To Date

BENFIT:Pharmacy System

Always Up to Date

BENFIT:Eliminates Monthly ReviewBecause

Orders are Always Up to

Date

Order Management with e-PrescribingOngoing Processes

e-Prescribing in Long Term Care

e-Prescribing is new to LTC

2006 CMS Pilot Study was first official standards based e-prescribing study in Long Term Care

There are less than 5 standards based e-Prescribing installations today

LTC e-Rx Pilot Study Abstract 2006 study focused on e-Rx standards most relevant to LTC

SCRIPT Formulary Benefits Electronic Prior Authorization

Other Capabilities Studied Facility Managed Electronic Orders Patient Safety Checks (DUR) Electronic Signature Automated Refill Requests

The study included two geographically diverse treatments facilities and two comparison facilities

e-Rx Findings - Facility Impacts Benefits

Facilities currently using electronic Physicians Orders will see modest change or disruption to current workflow

Ability to transmit orders directly to the pharmacy yielded benefits in reduced rework and callbacks

Management of Orders at the facility streamlines reconciliation processes

New Challenges Prescriber adoption is vital Integration with clinical systems (EHR) is critical Nurses do not effectively use patient safety (DUR) tools Even with Formulary Benefits data, managing complex Part D

health plans is an ongoing challenge Nursing staff now has to enter and manage data that the

pharmacy once managed Data entry errors can still happen

e-Rx Findings - Pharmacy Impacts Benefits

Demographics pre-populated on new admissions Straightforward new order processing Discontinued orders Readmissions streamlined Do not have to manage MARs and Order Sheets Refill requests streamlined

New challenges Combination & Tapered Orders – Need codified SIG

standard Transcription accuracy Timely transmission on admission orders Fax mode for controlled substances leads to process

inconsistencies

Med Reconciliation Conclusions e-Prescribing forces facilities to take ownership of their

orders Once a facility manages their own orders, they

typically have up to date data for MARs and Order Sheets

e-Prescribing can significantly streamline processes and reduce reconciliation errors during new admissions from hospitals

e-Prescribing can reduce reconciliation errors between the nursing facility and the pharmacy

It is difficult to keep a facility managed CPOE system in sync with a pharmacy system without e-Prescribing