State HIE Technical Assistance:Preliminary Guidance for Program Participants on Electronic Prescribing

August 20th, 2010

ePrescribing encompasses many processes…

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• Checking pharmacy benefit eligibility• Reviewing a patient’s formulary and benefit information, including prior

authorization requirements, based upon eligibility status• Applying clinical decision support (CDS) tools such as dosing calculators or rules

to avoid errors or identify potential contraindications• Generating a medication prescription or a prescription renewal using a software

application that includes computerized provider order entry (CPOE) capabilities• Maintaining active medication and medication allergy lists• Completing prior authorization requirements and receiving prior authorization

approval • Obtaining and reviewing medication history and fill status information from

multiple sources• Receiving and responding to medication refill requests• Electronically transmitting a prescription to a pharmacy (and related bi-

directional information exchange)

1Program Information Notice (PIN) available at: http://www.healthit.hhs.gov/stateHIEOur primary focus today

2009 Data from Surescripts

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Source: Surescripts

As of 2009, Surescripts connects to:

•97% of chain pharmacies •62% of independent pharmacies•85% of all community (retail) pharmacies for eRx delivery to pharmacies5

Stage 1 Meaningful Use Definitions and Standards

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Stage 1 Meaningful Use definition2

• The concept of “permissible” prescriptions refers to restrictions on the electronic prescribing of controlled substances (EPCS).

• The eRx requirement does not apply to eligible hospitals or critical access hospitals (CAHs) as part of the 2011 Stage 1 objectives, though it will likely be a component of future stage objectives

A certified EHR (or eRx module) must… “generate and transmit permissible

prescriptions electronically . . . using certified EHR technology.”

Stage 1 Meaningful Use Definitions and Standards (cont.)

• The final rule on MU also requires CPOE by EPs, eligible hospitals and CAHs– CPOE is the provider's use of

computer assistance to directly enter medical orders from a computer or mobile device.

• The final rule limits the requirement for CPOE in Stage 1 to medication orders for both EPs and hospitals and distinguishes between CPOE and the electronic transmission of an order (for prescriptions, eRx).

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State or SDE Responsibilities for ePrescribing

• Initiate a transparent multi-stakeholder process to set goals and conduct gap analysis

• Monitor and track meaningful use HIE capabilities in the state, including the percent of pharmacies accepting electronic prescribing and refill requests

• Assure trust of information sharing through a privacy and security framework for HIE

• Set strategy to meet gaps in HIE capabilities for meaningful use

• Ensure consistency with national policies and standards

• Align with Medicaid and public health programs

Source: 2010 Program Information Notice

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Potential Roles for the State or SDE in ePrescribing

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• Conduct a gap analysis on ePrescribing capabilities within the state

• Actively track and monitor the adoption and use of ePrescribing

• Develop consumer and provider communication and educational campaigns through collaboration with healthcare stakeholders to build awareness and acceptance of ePrescribing

• Examine state regulations and statutes affecting electronic prescribing

• Use licensure and contracting vehicles to set requirements for ePrescribing

• Coordinate strategies for addressing barriers to adoption of ePrescribing with RECs, the State HIT Coordinator, broadband providers, professional associations and other HIT stakeholders

• Develop strategies to engage pharmacies that are not yet connected (mostly independents) to become eRx enabled

• Update state Medicaid systems to support e-prescribing

• Increase eligible provider awareness of EHR and eRx options, resources and incentives

• Facilitate the advancement of the electronic prescribing of controlled substances (EPCS) by conducting pilots and demonstration projects of authentication and by providing credentialing services to providers and pharmacies within the State

• Promote the use and further development of national messaging and terminology standards

• Monitor progress on issues that are still maturing and educate stakeholders on their status

Potential Roles for the State or SDE in ePrescribing

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Conduct a gap analysis on ePrescribing capabilities within the state

• The gap analysis is described in the Program Information Notice (PIN)

• The gap analysis covers any issues that impact the broad adoption and widespread use of ePrescribing

• Use the gap analysis to determine how the state or SDE needs to address these gaps to ensure Stage 1 eRx options are available to eligible providers

Potential Roles for the State or SDE in ePrescribing

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Actively track and monitor the adoption and use of ePrescribing

• Set public targets for adoption and use of ePrescribing

• Use the many levers available to move your state forward to those targets.

Potential Roles for the State or SDE in ePrescribing

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evelop consumer and provider communication and educational campaigns through collaboration with

healthcare stakeholders to build awareness and acceptance of ePrescribing

• Patients may be confused about how their medication is received at the pharmacy and not understand eRx benefits

• Most providers will have neither the time nor the detailed knowledge of the patient experience to explain the eRx process to patients

• Get Connected Campaign7 is an example eRx educational program

Potential Roles for the State or SDE in ePrescribing

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xamine state regulations and statutes affecting electronic prescribing

• States may enact more restrictive rules for the electronic prescribing of controlled substances (EPCS) as the rules for EPCS recently promulgated by the DOJ establish a floor, not a ceiling, for how controlled substances may be electronically prescribed

• Each State or SDE must understand any implications of State-specific statutes and educate healthcare stakeholders

• Develop consensus on optimal changes to state laws/regulations that address issues and advocate for making those changes

Potential Roles for the State or SDE in ePrescribing

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Use licensure and contracting vehicles to set requirements for ePrescribing

• State boards of pharmacy can play an influential role

• At least one state (Ohio) has developed their own certification process for ePrescribing applications to ensure that they comply with state regulations

• A certification process that is limited to reviewing the unique requirements of the State can help to ensure that vendors are in compliance with state-specific rules

• Consider collaborating to establish a standardized approach for articulating those unique requirements across states

State Example: Minnesota

Jennifer Fritz, MPHMinnesota Department of HealthOffice of Health Information TechnologyJennifer.Fritz@state.mn.us 651-201-3662

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Minnesota: Legislation Impacting eRx• 2011 e-Prescribing Mandate [Minnesota Statute 62J.497 (2008)]

– All providers, group purchasers, prescribers, and dispensers establish and maintain an electronic prescription drug program that complies with applicable standards by January 2011

• New Minnesota Law Governing HIE [Chapter 336 (SF 2974) signed May 13, 2010]

– Establishes certification requirements and oversight for organizations conducting Health Information Exchange in Minnesota

– Allows open, free market for provision of HIE services – Requires State certificate of authority to operate Health Information

Organizations (HIOs) or Health Data Intermediaries (HDIs) – Verifies financial sustainability of HIE service providers– Protects consumers– Protects providers

Minnesota Statewide Implementation Planand Companion Guides

A Prescription for Meeting Minnesota’s 2015 Interoperable Electronic Health Record Mandate: A Statewide Implementation Plan (2008 Edition)

Guide 1: Addressing Common Barriers to the Adoption of EHRs Released 2008

Guide 2: Standards Recommended to Achieve Interoperability in MN Released 2008, Updated June 2010

Guide 3: A Practical Guide to e-PrescribingReleased June 2009

Guide 4: A Practical Guide to Effective Use of EHR SystemsReleased June 2009

Potential Roles for the State or SDE in ePrescribing

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Coordinate strategies for addressing barriers to adoption of ePrescribing with RECs, the State HIT Coordinator, broadband providers, professional

associations and other HIT stakeholders

• Coordinate with stakeholders that are involved (or need to become involved) in ePrescribing

• Work closely with RECs to facilitate adoption, implementation and meaningful use of certified EHRs (including eRx capabilities) among eligible providers

Potential Roles for the State or SDE in ePrescribing

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Develop strategies to engage pharmacies that are not yet connected (mostly independents) to become eRx enabled—especially in areas where there are no local

pharmacies with the capability

• Only 62% of independent pharmacies had connected in 2009 • Use the gap analysis to identify areas where providers and patients

do not have reasonable expectation of finding a pharmacy that accepts prescriptions electronically

• Focus on areas of greatest need to create a critical mass of eRx-capable pharmacies

• Consider developing special incentives to support independent pharmacy adoption of ePrescribing

State Example: Rhode Island

Jennie ChillerDirector, REC Program Managementjchiller@riqi.org401-276-9141 ext 278

Rhode Island Quality Institutehttp://www.riqi.org

RI Regional Extension Centerhttp://www.DocEHRtalk.org

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E-Prescribing Utilization in RI

2007 2008 2009 % Growth

% of Total Prescriptions Routed Electronically

10.9% 23.3% 33.5% 241%

% of Prescribers using e-scripts for new or renewal prescriptions

39.0% 51.4% 67.5% 73%

% of pharmacies capable of accepting electronic scripts

88.6% 99.4% 100% 12%

E-Prescribing – Moving to an EHR

2007 2008 2009

% of e-prescribers using a stand-alone e-RX mechanism

54.9% 46.0% 41.4%

% of e-prescribers using an Electronic Health Record

45.1% 54.0% 58.6%

E-Prescribing Strategies

• High Prescribers Campaign– Target top 500 prescribers and understand their

barriers and drivers– Implement strategies based on results in 2011

• Education and Outreach – Spread knowledge around incentives, benefits, and

best practices via vendor meetings, office visits, payer-incentive matrix

• Leverage Physician Champions– Share local case studies, visit provider offices, utilize

DocEHRtalk.org• Legislation introduced by RI Department of Health

– requires all practitioners to have access to e-prescribing in the location(s) where they practice.

Potential Roles for the State or SDE in ePrescribing

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Update state Medicaid systems to support e-prescribing

• Define strategies and timetables for making medication history and formulary and benefit information available to providers

• Accurate and timely access to medication history and formulary data has been demonstrated to reduce duplicative and fraudulent prescriptions and help providers identify potential drug-drug interactions8

Potential Roles for the State or SDE in ePrescribing

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Increase eligible provider awareness of EHR and eRx options, resources and incentives

• Enable pathways to MU by offering or building awareness of certified products that meet the requirements for an eRx module– Markets where there is an opportunity for a certified eRx

module to be added to a certified EHR, since performance of MU requirements in the absence of a certified EHR is not sufficient to achieve MU

• States or SDEs could provide additional motivation to EPs by negotiating discounts or other incentives for full-featured certified EHRs that include eRx functionality on their behalf

State Example: Florida

Walt CulbertsonProgram DirectorThe Center for the Advancement of Health ITA Regional Extension Center serving Northern and Rural Florida

Office: 904-230-1336Cell: 904-651-1805walt.culbertson@advancehealthit.orghttp://www.advancehealthIT.org http://www.chcalliance.org

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ePrescribe Florida

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• ePrescribe Florida worked to increase patient safety and meet the needs of the Florida public by establishing a collaborative framework that helps achieve an understanding of the benefits of electronic prescribing, while fostering education and implementation efforts to accelerate physician adoption and cooperation among prescribing constituents.

• Collaborative Planning December 2006• Began Operations February 2007

– 1,274 active e-prescribers (4%) in 2005– 1,210 active e-prescribers (4%) in 2006– 2,331 active e-prescribers (7%) in 2007 – 4,497 active e-prescribers (14%) in 2008– 7,238 active e-prescribers (23%) in 2009

Source: Surescripts, June 2010

ePrescribe Florida MembersePrescribe Florida MembersSteering Committee and Advisory CouncilSteering Committee and Advisory Council

Medical and Pharmacy AssociationsMedical and Pharmacy Associations•Florida Academy of Family Physicians •Florida Hospital Association •Florida Chapter of the American College of Cardiology•Florida Chapter, American Society of Consultant Pharmacists •Florida Medical Association•Pharmacy Provider Services Corporation •Florida Pharmacy Association•Florida Osteopathic Medical Association Health PlansHealth Plans•Aetna •AvMed •Blue Cross and Blue Shield of Florida •CIGNA HealthCare •Humana•Health First Healthplans•UnitedHealthcare Pharmacies and Pharmaceuticals Pharmacies and Pharmaceuticals •Albertsons •AstraZeneca•CVS •Novartis•Publix •Walgreens •Wal-Mart•Winn-Dixie Electronic NetworksElectronic Networks•eRxNetwork •Surescripts•ScriptSaveState Agencies and ProgramsState Agencies and Programs•Agency for Health Care Administration (AHCA)•Florida Medicaid•Florida Drug Control Office of the Governor •FMQAI - Quality Assurance OrganizationOther Stakeholders Other Stakeholders •University of South Florida (USF)•Florida Chapters of HIMSS•Rural Health Partnership•WellFlorida

Steering Committee Members

ePrescribe Florida Approach

1. Provide Education– Prescribers– Stakeholders (Payers, PBMs, Pharmacies,

Patients)– Others (Media, Government, Law Enforcement,

Academic Medical, etc.)

2. Promote Consistency– Payer and PBM information delivery

• E&B• Med History• Formulary

– Pharmacy receipt and processing– Vendors

• Applications Functionality • Training and Implementation Support

– Prescribers• How to select an application• How to implement and make successful• How to seek funding and financing alternatives

3. Promote Incentives and Funding

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Potential Roles for the State or SDE in ePrescribing

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Facilitate the advancement of the electronic prescribing of controlled substances (EPCS) by conducting pilots and demonstration projects of

authentication and by providing credentialing services to providers and pharmacies within the State

• States or SDEs could choose to play a role in facilitating or offering services related to:– Identity proofing, – Issuance of authentication credentials such as digital certificates, – Certifying eRx applications and pharmacy information systems,– Conducting audits as required under the DoJ rule

Potential Roles for the State or SDE in ePrescribing

• MU final rule identified the Medicare Part D adopted standards as the required transaction standard for eRx12

• NCPDP SCRIPT 8.1 or NCPDP SCRIPT 10.6

• On July 1st, 2010, CMS issued an IFR that identifies NCPDP SCRIPT 10.6 as a backward compatible update of the previously adopted NCPDP SCRIPT 8.1 for Medicare Part D electronic prescribing. 13

• For terminology, ONC has adopted a standard that requires certified applications to use “any source vocabulary that is included in RxNorm”14

• Application providers use various code sets within their systems, while still promoting RxNorm as a crosswalk between the disparate code sets

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eRx Messaging eRx Terminology

Promote the use and further development of national messaging and terminology standards

Potential Roles for the State or SDE in ePrescribing

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Monitor progress on issues that are still maturing and educate stakeholders on their status

• Future work is needed on such issues as:– Creating a standardized, structured and codified sig (the ordering information that

is included as part of the prescription —e.g., “take two pills by mouth at bedtime”);

– Embedding prior authorization into the electronic prescribing process; and– Ensuring that hospital-based CPOE systems (that typically use HL7 messaging

to send prescriptions to inpatient pharmacy) are able to transmit prescriptions to community or mail order pharmacies during emergency department or outpatient clinic visits or following a patient’s discharge.

• Though the issues presented above are not required for meaningful use in 2011, they are needed to address current limitations in ePrescribing and, once addressed, will impact the quality and efficiency of care

State Example: Tennessee

Will RiceExecutive DirectorOffice of e-Health InitiativesState of Tennessee 310 Great Circle Road4th Floor, East WingNashville, TN 37243 Cell: (615) 584-2212Email: Will.Rice@tn.gov

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Impetus for Medication Management RFI

• Opportunity to improve care and lower costs through leveraging multi-state purchasing power/demand

• Driver for service: meaningful use criteria– Drug formulary checks– E-Prescribing requirements– Medication history and allergy lists

Goals for the RFI

• Needed to map out current technology and data connectivity landscape:– Other potentially comprehensive data sources

besides Surescripts?– Vendors that can gather and reconcile disparate

data sources to integrate into EHRs?– What technology and data can be provided at the

point of care?– Recognizing all states are different, what are the

types of services states can provide that will most dramatically lower costs and improve quality?

RFI Process

• Tennessee engaged other states through a variety of channels

• Participating states include:Alabama, California, Colorado, Georgia, Hawaii, Iowa, Maine, Missouri, New York, North Carolina, South Carolina, Tennessee, Utah

• 21 responses received, demos now complete, and preparing to discuss next steps

Initial Market Findings

• All vendors at least partly rely on Surescripts• Some vendors have already begun

assembling additional data networks• Med reconciliation technology is available

and capable – connecting data sources will be the main challenge

• Impressive decision support capabilities at point of care (including research-based alerts and patient cost-sharing)

• No one vendor can “do it all”

• States have enacted legislative powers to encourage or mandate the adoption of ePrescribing technology. • Arizona – A 2008 executive order was aimed at significantly increasing patient

safety through the use of e-prescribing in Arizona.• California – A 2006 executive order established a e-prescribing requirement by

all providers by 2010. • New Hampshire – A 2006 executive order mandated healthcare providers to

implement e-prescribing by October 2008. • Tennessee – The e-Prescribe Tennessee program to advise and support the

state as it implements a strategy for e-prescribing adoption. • Rhode Island – The “Anywhere, Anytime Health Information” platform set a goal

of 75 percent of all prescriptions be completed electronically. Rhode Islands medical professional associations developed policy supporting ePrescribing adoption.

• Minnesota – A 2007 bill provided $14M in assistance for rural providers to meet ePrescribing and other HIT mandates. State statute requires all hospitals and health care providers implement e-prescribing by January 1, 2011, and interoperable EHRs by January 1, 2015.

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Legislative or Regulatory Action

About the State HIE TA Program

• Who We Are: Our team is dedicated to providing up-to-date technical assistance to states and SDEs.– We are comprised of a team of subject matter experts (SMEs)

with deep expertise in several areas, including legal and policy, technical architecture, e-prescribing, etc. Our SMEs work directly with states in many capacities, including one-on-one consults.

• Services we provide: Funded by ONC and thus offered at no cost to your program, including:– One-on-one and group consultations – Specific guidance and recommended practices – Inter-state collaboration and mentoring opportunities – Informational webinars– Market analysis reports– Toolkit modules– Speaking engagements

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Appendix A: Resources and Tools

• Program Information Notice (PIN)http://www.statehieresources.org/wp-content/uploads/2010/07/Program-Information-Notice-to-States-for-HTML_7-6_1028AM.htm• Surescripts 2009 National Progress Report on E-Prescribing

http://www.surescripts.com/ downloads/npr/national-progress-report.pdf • MU Final Rule

http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf • MU Standards and Certification Criteria Final Rulehttp://edocket.access.gpo.gov/2010/pdf/2010-17210.pdf• ONC Overview of EHR Certification Process

http://www.healthit.hhs.gov/certification • MU Notice of Proposed Rule Making (NPRM)

http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf • MU Interim Final Rule (IFR)

http://edocket.access.gpo.gov/2010/pdf/E9-31216.pdf

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Appendix A: Resources and Tools (cont.)

• HIT Policy Workgroup Web Site http://www.healthit.hhs.gov/portal/server.pt?CommunityID=1474&spaceID=14&parentname=&control=SetCommunity&parentid=&in_hi_userid=11673&PageID=0&space=CommunityPage

• DOJ Electronic Prescriptions for Controlled Substance Web Site http://www.deadiversion.usdoj.gov/ecomm/e_rx/index.html

• National Council for Prescription Drug Programs Web Site http://www.ncpdp.org./

• National Library of Medicine RxNorm Release Documentation File for 11/02/2009 Full Release http://www.nlm.nih.gov/research/umls/rxnorm/docs/2009/rxnorm_doco_full11022009.html

• Electronic Prescribing Readiness Assessment – Sponsored by medical specialty organizations, practice associations and The Center for Improving Medication Management. Site includes a tool for querying by ZIP Code a database of pharmacies participating in ePrescribing. www.getrxconnected.com

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Appendix B: Acronyms

• CAHs: Critical Access Hospitals• CDS: Clinical Decision Support• CMS: Center for Medicare and Medicaid Services• CPOE: Computerized Provider Order Entry• DOJ: Department of Justice• EHR: Electronic Health Record• EP: Eligible Provider• EPCS: Electronic Prescribing of Controlled Substances• eRX: Electronic Prescribing• HDI: Health Data Intermediaries• HIE: Health Information Exchange• HIT: Health Information Technology• HIO: Health Information Organization• HITECH: Health Information Technology for Economic and Clinical Health

Act of 2009

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Appendix B: Acronyms (cont.)

• IFR: Interim Final Rule• ONC: Office of the National Coordinator for Health Information Technology• MIPPA: Medicare Improvements for Patients and Providers Act• MMA: Medicare Modernization Act of 2003• MU: Meaningful Use• NACDS: National Association of Chain Drug Stores• REC: Regional Extension Center• NPRM: Notice of Proposed Rule Making • ONC: Office of the National Coordinator for Health Information Technology• PBM: Pharmacy Benefit Manager• PIN: Program Information Notice• REC: Regional Extension Center• RFI: Request For Information • SDE: State Designated Entity

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