Evolving the PDMP to Create A Powerful Medication Reconciliation - - PowerPoint PPT Presentation

Evolving the PDMP to Create A Powerful Medication Reconciliation Tool & PDMP Panel Discussion

• Marilee Benson, President of Zen Healthcare IT
• Kevin Borcher, Pharm.D, PDMP Program Director, NeHII
• Paula Weldon, Operations Manager, Reliance eHealth Collaborative
• Keith Parker, Chief Information Officer, Health Current

Introductions

Nebraska PDMP Initiative

• A prescription drug monitoring program (PDMP) is an

electronic database that tracks controlled substance prescriptions in a state. PDMPs can provide health authorities timely information about prescribing and patient behaviors that contribute to the epidemic and facilitate a nimble and targeted response.1

• Tool to allow healthcare professionals to make better

informed decisions relating to the treatment and safety of the patient

PDMP

• 1CDC. https://www.cdc.gov/drugoverdose/pdmp/states.html

Ø ASAP

Ø American Society for Automation in Pharmacy Ø Standard format for PDMP data submission

Ø NCPDP

Ø National Council for Prescription Drug Programs Ø ANSI-accredited standards Ø e-Prescribing, pharmacy claims adjudication

Ø HL7

Ø ANSI-accredited standards Ø Exchange, integration, sharing, retrieval of electronic health

information

ASAP and NCPDP and HL7, Oh My

Ø ASAP format Ø Patient

• Name
• Address
• Date of Birth
• Gender (optional)
• Phone Number (optional)
• ** No unique MRN or unique identifier

Ø Pharmacy

• Name
• Address
• Phone Number
• NPI/DEA

Data Availability

Ø Prescriber

• Name
• NPI/DEA

Ø Prescription

• Rx#
• Date written
• Date filled
• Date sold (optional)
• NDC
• Qty
• Days supply

Data Availability

PDMP Workflow Process

PDMP PDMP PDMP

Ø Operated by NE Department of Health and Human Services Ø In collaboration with Nebraska Health Information Initiative Ø Optum platform for user maintenance and access Ø PDMP Vendor – DrFirst Ø Dispensers (e.g., pharmacies) must report daily

Nebraska PDMP Highlights

Ø 2011 NeHII integrated the PDMP into the HIE

• First HIE to accomplish this
• Surescripts data feed
• 60-80+ % complete
• Missing Medicaid, much self-pay

Nebraska PDMP History

Ø 2016 – Legislation to enhance PDMP

• Mandatory collection of controlled substances January 1, 2017
• No opt out
• Prescribers and pharmacists may access at no cost
• Pharmacists may authorize designees
• Report ALL dispensed prescriptions by January 1, 2018

Ø 2017 – Prescribers may authorize designees

• Mandatory training

Ø 2018 – Exclude non-human non-controlled substances

Nebraska PDMP Legislation

Nebraska PDMP Reported Data

July 2017 – July 2018

User Queries

July 2017 – July 2018

9,008 9,844 7,169 7,741 8,160 9,088 12,461 15,431 20,315 24,939 29,528 31,328 34,444

• 5

,000 1 0,00 1 5,00 2 0,00 2 5,00 3 0,00 3 5,00 4 0,00 J ul-1 7 Aug

• 17 Sep
• 17

Oc t-1 7 Nov

• 17 Dec
• 17

J an-1 8 Fe b-18 M ar-18 Apr-1 8 M ay -1 8 J un-1 8 J ul-1 8

# Unique Queries per Month

Who Can Access?

PDMP users HIE Pathway Any HIE participant NeHII HIE users PDMP Pathway Prescribers (MD, PA, APRN, DDS) Dispensers (RP) Designees (RN, Pharm tech)

Patient PDMP Queries – Access through PDMP portal

MME Alert

Multiple Provider Episode Detail

Overlapping Opioid/Benzodiazepine Alert Detail

Reporting all dispensed prescriptions

Ø Required reporting as of January 1, 2018 Ø Comprehensive medication history

• 10 x more data than traditional PDMP’s that include

controlled substances only

Ø Patient safety tool Ø Allows clinicians to make better informed decisions Ø Identify medications from multiple prescribers and

pharmacies

Ø Identify potential drug interactions, allergies Ø Provides a valuable resource in the event of natural

disasters, system power interruptions

Ø Tool for medication reconciliation

Ø Only as accurate as the history obtained Ø Time-consuming Ø Distractions Ø Patient Ø Family/caregiver Ø Patient/family to bring in all medication bottles Ø Call pharmacies Ø Review EHR

Current Methods to Obtain Medication History

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital

Medication Reconciliation

Institute for Healthcare Improvement

• Medicare hospital readmissions (2003-2004) 1
• 19.6% within 30 days
• 34.0% within 90 days
• Longer rehospitalization length of stay
• Estimated cost of Medicare unplanned rehospitalizations in 2004 - $17.4 billion
• Readmissions
• 18.3-24.8% for HF, AMI, Pneumonia2
• 13.1-17.8% 3
• 23% suffered adverse event post-discharge4
• 12% considered avoidable
• 72% adverse drug events
• $$$
• Medicare Reimbursement/HRRP
• 2,597 hospitals penalized in FY 20175
• $528 million
• 0.73% average penalty
• 3% max penalty

Importance of Medication Reconciliation

• 2. Dharmarajan K, Hsieh AF, Lin Z, Bueno H, Ross JS, Horwitz LI, Barreto-Filho JA, Kim N, Bernheim SM, Suter LG, Drye

EE, Krumholz HM. Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia. JAMA. 2013;309(4):355-363.

• 3. Zuckerman RB, Sheingold SH et al. NEJM 2016; 374:1543-1551
• 1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med.

2009;360(14):1418-1428.

• 5. Kaiser Health News, 8/2/2016

Ø TJC 2005 National Patient Safety Goal #8

• “accurately and completely reconcile

medications across the continuum of care.“

Ø National Patient Safety Goal #3 (July, 2011)

• 03.06.01Obtain information on the medications the patient is currently

taking when he or she is admitted to the hospital or is seen in an outpatient

• setting. This information is documented in a list or other format that is useful

to those who manage medications. (Effective 1/1/15)

Importance of Medication Reconciliation

Ø Adverse Drug Events Ø Strategies for effective medication

reconciliation1

• Coordinated communication that includes

standardized medication lists, medication administration programs (MAP), interventions, and referrals;

• A foundation of automation and technology to

close the communication gap between health care professionals

Importance of Medication Reconciliation

• Pharmacy. 2014;49(2):112-114. doi:10.1310/hpj4902-112.

Ø Easy access

• Interoperability
• Workflow integration
• Directly access through health

information exchange, electronic health record or pharmacy software

• Single Sign-On
• Interstate data sharing

Opportunities for PDMPs

Ø MPI/Patient identifier Ø Specialized registry Ø Medication reconciliation Ø Data analytics Ø Quality improvement initiatives

• Opioid use
• Chronic Disease

Opportunities for PDMPs

Ø Support

• Professional associations
• Medical, Pharmacy, Hospital
• State government
• Health department
• PDMP administrators
• Legislators
• Attorney general
• Governor

Ø Federal/state legislation

Making it Work

Oregon PDMP Initiative

Problem statement

• We heard from providers that its outside of their workflow, its to

cumbersome, its too slow

• We wanted to provide a solution that allowed access through the HIE during

their normal community health record query

• In 2015 received an interoperability grant from the ONC through

the Oregon Health Authority

• Part of the funding was to pay for the connection between PDMP and

Reliance HIE

• Reliance contract with Appriss directly for this connection
• Changing vendors on our side caused delay in implementation

Reliance PDMP Connection

Oregon PDMP Legislation

2018

HB 4143 passes mandates all opioid prescribers to register for the PDMP

2017

HB 3440 passes allows interstate sharing and mandatory registration Allows Medical and Pharmacy Director PDMP Access

2016

HB 4124 passes allowing PDMP data access via Health IT systems Gives providers information at point of care

2009

PDMP program created to improve lives of Oregonians First state PDMP program to focus on public health aspects of data

Oregon PDMP Governance

• Increase use of PDMP data at the point of care
• Improved access and prescriber efficiency
• Minimized changes to current workflow
• Optimized prescribing practices

Oregon PDMP Goals

Contract:

• Statewide subscription with Appriss Health finalized June

2018

• Project kick-off with Appriss took place June 30, 2018

Implementation:

• Determine priority entities & EHR’s
• Set implementation goals & Metrics
• Draft reporting requirements

Oregon PDMP Project Status

Reliance User

Patient search includes Patient Name and DOB, and either their phone number or City, State, and Zip code. User Logs into Reliance, is taken to Universal Landing Page (ULP) and chooses to use the Community Health Record (CHR) Patient Record returned in CHR User searches CHR for patient data User Administration includes tracking of Provider level data (ie Medical License number) ensuring that they can access PDMP

Reliance User

User Selects the option to view the PDMP Data that displays after patient search is completed. Patient PDMP data pops up in a display

• window. User closes window to return

to chart. PDMP data is displayed only, not integrated into the patient record. End

Reliance PDMP Query Workflow

• Have conversations with state early about value of HIE --->

PDPM

§ Delegate access § If legislation changes are needed § Workflow of users in an HIE versus directly from EHR § Value of HIE for PDMP queries § Cost Savings (no direct Appriss connection needed) § Rural Providers with low-tech EHR § Providers with no EHR § Ability to reach all HIE participants (big-bang)

Challenges / Key Learnings

Arizona PDMP Initiative

Arizona’s PMP Mandate:

How Arizona and Health Current Users Are Able to Comply with the Controlled Substances PMP Mandate Keith Parker, Chief Information Officer

Arizona’s PDMP Mandate

• PMP legislative mandate signed by Governor Ducey March 2016
• Mandate delayed to allow EHR companies and statewide HIE to

integrate with PMP database

• Health Current written into mandate in that mandate is effective

60 days upon Health Current implementation with the board of pharmacies PDMP system

• Health Current informed the Board of Pharmacy that it had

integrated with PMP on August 17, 2017

• PMP Mandate went into effect on October 16, 2017

• 1. Prescriber must first register with Board of Pharmacy
• 2. Three options to comply:

a) Access via the Board of Pharmacy Website

• Manual log-in of prescriber, license & patient name; available now.

b) Access via an Electronic Health Record (EHR)

• Providers should check with vendor on availability, timing & costs.

c) Access via Health Current

• First need to be HIE participant; then need to be connected to HIE

portal.

OPTIONS FOR MEETING PMP MANDATE

• Workflow
• Costs
• Timing
• Functionality

CONSIDERATIONS FOR CHOOSING THE RIGHT OPTION

• Board of Pharmacy registration information
• Registration information is pre-loaded for a PMP connection through Health

Current and an EHR. Board of Pharmacy website requires manual entry.

• Ease of access
• Access to the PMP database is one or two clicks away for HIE portal users

and also with users of provider EHRs. Board of Pharmacy access requires a separate login via internet browser.

• Entry of patient and prescriber data
• For most patient searches, patient and prescriber fields are pre-populated

when searching from the HIE portal or from an EHR.

• Use of delegates
• Only licensed prescribers are able to access the PMP database through the

HIE Portal or an EHR. Delegates must use the Board of Pharmacy website.

WORKFLOW CONSIDERATIONS

• No cost for Board of Pharmacy website
• Free access to registered prescribers and their delegates.
• Health Current – No cost for community providers
• No HIE fees for community providers.
• EHR Costs – Check with EHR vendor
• There could be a cost for integrating an EHR with the PMP database.

Providers should check with their EHR vendor.

• Staff Time Costs – Short-term & long-term
• Access to the Board of Pharmacy website takes more time; connection

through Health Current or an EHR involves initial staff time for set-up, but longer term is more seamless and efficient.

COST CONSIDERATIONS

• Board of Pharmacy Website Available Now
• Access to the PMP database is available immediately for registered

prescribers and delegates.

• HIE Portal Users – Brief Set-up
• Users who have been set up for access to the HIE Portal have a brief set-

up process for access to the PMP database.

• Joining Health Current & HIE Portal Access – Variable
• Joining Health Current and initial HIE Portal access are processes with

variable timing.

• Access through EHR – Variable
• Check with EHR Vendor to determine availability, costs and timing.

TIMING CONSIDERATIONS

• Delegates Use
• Delegates are not able to access PMP data through Health Current or

through an EHR; delegates must use the Board of Pharmacy website.

• Search for PMP Data in Other States
• Only AZ controlled substance prescription data is available through Health

Current and an EHR. To search for controlled substance prescription data in other states, Board of Pharmacy website must be used.

• Accessing Other Patient Information
• Access through Health Current and an EHR allows users to also access
• ther patient information, such as recent hospitalizations or other patient

medical history.

FUNCTIONALITY CONSIDERATIONS

• Clinical data on more than 9.5 million unique patients
• More than 500 participating organizations
• More than 95% of Arizona inpatient discharges and emergency

department visits

• Integrated physical and behavioral health information
• Services:
• Alerts & Batch reports
• Multiple interface types
• HL7V2, HL7V3, IHE, EDI
• Direct mail
• Provider portal (Physical health, Part 2, PDMP)

BENEFITS OF ACCESS THROUGH HEALTH CURRENT

• Engage with key stakeholders:
• State (ensure appropriate mandates / legislation is in place)
• Board of pharmacy
• End users
• Simplify workflow and technical approach
• Worked with ZEN to build API within Health Current provider portal leveraging

provider username and patient demographics

• If you build it and mandate it will they come?
• Current PDMP rates are below 20%

Challenges / Lessons Learned

Audience Questions!

Marilee Benson, Zen Healthcare IT Marilee@consultzen.com Keith Parker Health Current (Arizona) Keith.Parker@healthcurrent.org Kevin Borcher, Pharm.D NeHII (Nebraska) Kborcher@NeHII.org Paula Weldon Reliance (Oregon) Paula.Weldon@Reliancehie.org

Contact Information