Back to faxing orders?

Not all providers switched to the new transmission system by Nov. 1.
Not all providers switched to the new transmission system by Nov. 1.

The first of November has come and gone, which was the deadline for long-term care providers to convert from HL7 to NCPDP SCRIPT 10.6 for pharmacy transmissions. For better or worse, not everyone has made the switch.

Information technology specialists are hoping for the best but bracing for the worst.

The transmission standards change for medication orders is part of a Centers for Medicare & Medicaid Services initiative aimed at long-term care providers that want to remain eligible for Medicare Part D reimbursement. 

Those that did not make the Nov. 1 deadline for electronic orders must revert to manual methods of transmission to continue their eligibility. In short, that means going back to faxing orders — something David Thompson, owner of Bellevue Rehab in Oklahoma City, didn't want to do.

“We worked very hard on HL7. We were used to doing things electronically and didn't want to go back in time,” he says. “Faxing is not nearly as secure — they get lost, they end up in the wrong hands, they are open for anyone to see and they get dropped on the floor.”

Thompson turned to VorroHealth to prepare for the deadline and said he made it with time to spare. The transition itself “was pretty seamless,” he says. “We didn't notice any changes and never had a hiccup.”

Maria Moen, vice president of care innovation for VorroHealth, says long-term care providers need to lean on their vendors for help — not just for NCPDP, but also for the upcoming transition to ICD-10 codes, and for issues related to interoperability and bundled payments.

“We have seen some pervasive technologies over the past five to seven years,” she says. “As we look at accountable care organizations and bundled payments, the emphasis is on the technology long-term care has. They want our help and we are committed to giving it to them.”

Specifically, NCPDP is “transitional because it is another unfunded mandate and everyone is working to meet the identified timelines,” Moen says. If some providers have not made the switch electronically, she maintains “it doesn't mean that they are being lackadaisical — it means they have not found it feasible.”

On the pharmacy end, they have to not only be able to accommodate the NCPDP 10.6 standard, but adjudicate the claims and determine potential negative interactions with each prescription, Moen says.

“Taking the new file format, absorbing the data and shooting it back out the door is not an easy task,” she says. “An electronic exchange of data is never easy — especially for medications.”

By Doc DeVore's estimate, about 20% of the electronic HL7 orders are now being faxed. Because eFax is not considered electronic ordering, he says all faxes must be manual, “which has been a little bumpy.” Even so, DeVore, director of clinical informatics and industry affairs for AOD Software, contends “the bumps haven't been so overwhelming.” He expects providers to be continually migrating to NCPDP 10.6.

Bridging gaps

One of the biggest challenges with the NCPDP conversion has been gaps and voids in the message standard, such as the length of narrative text fields and the lack of defined use, says Mark Welch, product manager for HealthMEDX.

“There have been a few issues with the standard's silence in some of our workflow and message use test cases, but by working closely with our pharmacy information systems partners we have bridged those gaps,” he says.

The format shift also has caused some deficits that are impacting workflows for clinicians, facilities and pharmacists. These deficits, Welch says, have resulted in a limited length of narrative and text fields.

“In the instance of compounded and IV medications, those issues are likely to increase the need for verbal communications between facilities and pharmacies,” he says.

Indeed, both the facility and pharmacy must be able to handle the NCPDP compliant prescription messages, agrees Kim Ross, senior director of marketing for MatrixCare. Certain EHR systems are unable to transmit an NCPDP 10.6 script and not all pharmacies are able to receive and process the standard message, she says, which means that the next challenge is to be able to implement the exchange of those messages.

“If the EHR vendor must develop individual, point-to-point integrations for each pharmacy software system, it can take months to complete new integrations,” Ross says. “However, if the EHR vendor has taken an API-oriented (application programming interface) approach, implementing new integrations goes much faster.”

Taking the plunge

Perhaps it was not “feasible” for all providers to make the format change by Nov. 1, but that should not discourage them from continuing to pursue the switch after the deadline, says Ross.

“Prior to the Nov. 1 change, fully 50 percent of skilled nursing facilities were aggressively moving toward a paperless environment,” she says. “SNFs using electronic health record platforms that were already NCPDP compliant, such as MatrixCare, transitioned smoothly. The obvious benefits in terms of reducing the error risk and increasing efficiencies for both the pharmacy and facility, in addition to regulatory pressures, will result in the majority of SNFs adopting e-prescribing solutions.”

Providers now reverting to sending manual faxes should consider several factors, including the risk of drug errors and the potential increase in the number of prescriptions processed by their facility, Ross says. Moreover, the possibility exists that even more stringent regulations may require facilities to transmit prescriptions electronically. New York is already planning to require all prescriptions to be sent electronically by March 2015.

“Providers currently have the opportunity to thoughtfully select and adopt technology that will yield higher efficiencies today, as opposed to being forced to do so should it become a regulatory requirement,” Ross says.

John Choi, EHR engineer from LG CNS, sees reverting to manual faxes as a pointless step backward.

“Faxing transmissions is very time-consuming — it is unnecessary to spend that much time processing medication,” he says. “As long as providers are using an EHR product that supports NCPDP, they should be able to electronically transfer orders to a pharmacy in the new format.”

Converting to NCPDP will require providers to adopt a technology that uses EHR or an order system that support the new standard, as well as prepare for changes in the clinical workflow and timeliness, says HealthMEDX's Welch.

“Provider staff education on pharmacy protocols for engaging in the electronic process and workflow is also important,” he says. “It's worth noting that the transition to electronic orders should not eliminate or diminish verbal or face-to-face communications between clinicians and pharmacies. Electronic communication doesn't mean we don't still need to talk to each other.”

‘Lazy data'

Whether they are known as electronic health records or electronic medical records, Moen says there is no reason that long-term care facilities should not be using them. Yet those that already have employed these systems may not be utilizing them to their fullest extent. As a result, these providers likely are saddled with what she calls “lazy data.”

In fact, energizing this lazy data is one of Moen's primary goals in the current, post-deadline landscape.

“When you are putting clinical information into an EHR and all you do is put it on the chart, that is lazy data,” she says. “When you actually use the clinical data and come up with the best possible outcome to drive your care organization and predict what will happen next, it becomes active data.”

VorroHealth will continue to help providers migrate from faxing to electronic information exchange with pharmacies. It will also work to assist in establishing portals for residents and their families to more actively engage in their care experience, Moen says.

“But we are not really focused on where we've been or where we are now,” Moen says. “We are looking two to four years down the road and what long-term care providers will need to be doing at that time.”