Tuesday, August 26, 2008

Pharmacy Initiated Renewals

I've written extensively about e-Prescribing and have summarized the transactions as

Check health plan eligibility
Enforce formulary rules
Check dispensed/reimbursed drug history for drug/drug interactions
Route the prescription to a retail or mail order pharmacy

I have not discussed the refill/renewal process.

One of the clear return on investment cases for e-Prescribing is the notion that a pharmacy can initiate a renewal request rather than requiring the clinician's office's to process a patient call.

A patient simply walks into a pharmacy and asks for a renewal. If no refills are available, the pharmacy system autogenerates a renewal transaction which is sent to the original prescribing physician's electronic medical record system. Once there, it appears in a Task or "To Do list" for physician approval. Once approved, the prescription is sent back to the pharmacy to be filled. Refill requests can also be generated via the pharmacy’s web page or for a maintenance medication, via a chain’s web site, a patient can setup automatic dispensing of refills every 30 days (or whatever frequency) and then the patient receives a call and/or email when the prescription is ready. If there are no refills left, then the pharmacy will initiate the refill request so that the prescription will be ready when the previous dispensing is used up.

There are a few tricky informatics and workflow issues such as

1. How do you match the renewal and the original prescription?

If the original new prescription was sent electronically, the EMR or e-prescribing system can insert a unique identifier for the patient / med into the prescription. This identifier is stored in the pharmacy system and echoed in the NCPDP standard refill request transaction. There is a 100% match if the EMR / e-prescribing system has been coded correctly.

Thus all EMR vendors and EMR self builders should create and send prescriptions electronically with this unique identifier. Then, as refill requests begin to flow, they will be easily matched in the EMR workflow.

If a new prescription was not sent electronically, it will be matched based on the prescriber's physician identifier. If the physician is registered with a SureScripts Prescriber ID (SPI), then the pharmacy will send a refill request automatically at any time a patient calls into the pharmacy and there is a need for physician approval to continue the therapy. This is completely automated in the pharmacy system and applies to any prescription in the system prescribed by that doctor.

When a refill request comes in without the unique matching identifier, it can still be matched automatically in many cases. The refill request will have the patient demographic information, especially the last name and birth date, and will have the NDC of the dispensed medication. By finding the patient using last name and birth date and then using the NDC to identify the therapeutic class by using the EMR’s drug file and then matching that class against the patient’s active med history list, the EMR can provide an exact match or narrow down to a couple medications for the prescriber to select for the refill approval or denial.

2. What do you do if the original prescribing physician is out of the office?

In our all our various workflow implementations that create physician work queues, we need to think about coverage patterns. Typically, we enable covering physicians to examine the work queues of other physicians or enable support staff to monitor queues so they can escalate pharmaceutical renewals and other time sensitive notifications.

Here's the current status of Pharmacy Initiated renewals in the US and Massachusetts:

Surescripts/RxHub currently has over 50,000 active physicians in the network across the country. Approximately 60% of these clinicians are using a certified EMR system (i.e. Allscripts (Touchworks and Healthmatics), NextGen, eClinicalWorks, Kryptiq/GE, Epic etc.). In July 2008 over 35% of the 6.5 million e-prescription transactions processed were refill requests and refill responses. Half of these transactions were processed by EMR users via pharmacy initiated electronic refill transactions and the corresponding electronic refill responses (using NCPDP Refill Request and Refill Response standard transactions and not New Prescriptions).

In July 2008 in Massachusetts there were about 25,000 pharmacy generated electronic prescription renewal requests going into EMR systems and being responded to (approved or denied) by clinicians and sent back to pharmacies electronically.

Historically, Pharmacy Initiated Renewals were supported mostly by stand alone eRx applications, but now, this transaction is supported by EMRs. Over the next year, the large academic systems in Massachusetts will plan to include these transactions and this workflow in their EMRs. The end result will be a further decrease in the administrative burden of medication management on physician offices, reducing costs and enhancing patient service.


Jim Bresee said...

Hi John,

Another problem with pharmacy initiated renewals is with physicians that practice at multiple locations. The current Surescripts model routes prescriptions to the doc back at the prescribing location. Many physicians practice at multiple locations, making routing of renewals challenging. A model that sends the renewal to all possible prescriber locations, and then 'cancels' the renewal request at all locations after it receives a renewal successfully from one location.

Jim Bresee

John Halamka said...

Jim - here's the response from Bob Beckley, SVP Alliances & Product Strategy at Surescripts/RxHub:

Jim’s suggestion would work if the prescriber uses the same technology platform at all locations. That is not always the case. The prescriber might have one application at the hospital and a stand alone at his/her private practice. So, how do the other refill requests get cancelled? There is also the issue of the staff taking care of the “normal” every day maintenance medication refill requests. You could easily have the staff at two locations respond to the pharmacy, with potentially different messages, before a cancel message could be delivered. Finally there is no message within the standards right now to accomplish this. Also we have had concerns from prescribers that they do not want PHI information being delivered to an incorrect location. If a prescriber works at a clinic and also has a private practice, the prescriber does not want PHI from their private practice being sent to a location that does not have a relationship with the patient.

This is a challenge; we continue to work on ways to resolve this issue. A few steps we have taken are listed below:

If a prescriber uses one application, the application should show all messages regardless of location (hospital, clinic, private practice). This will ensure the prescriber gets the message regardless where they are seeing patients that day and if staff from another location handles the request, the request is removed from the global queue.
The pharmacy is supposed to send the refill to the location where the original prescription was written (where the patient encounter occurred). This way, especially for stand alone e-prescribing applications, the request is at the location where the charts are located. This does cause a delay if the prescriber is only in that location 2 days a week.
We continue to work with pharmacies to ensure they keep their directory of prescribers current so that the refill request is delivered to the proper location.

At this time, we have not found one solution that fits everyone’s need for this issue. We continue to work on this issue with our pharmacy and prescribing partners at our Tech Workshops and advisory councils.