Information Technology feature - Code warriors

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A new pilot project hopes to crack the language code of long-term care pharmacy. But the challenge is daunting.

We all know what it's like to be misunderstood. You think you are expressing yourself clearly only to find that the other person just doesn't get it.
Welcome to the world of electronic prescribing. As long-term care scrambles to transfer resident records and bedside reports at the push of a button, a critical element stands in the way: sending orders electronically to and from pharmacies.
Just as people need language to communicate, so, too, do pharmacies require languages to understand electronic prescriptions from facilities, and vice versa.
Some hopeful signs are emerging. Achieve Healthcare Technologies, of Eden Prairie, MN, received one of four grants from the Department of Health and Human Services to test three new communication standards specifically for long-term care. The pilot is scheduled for completion later this month.
The standards under scrutiny are: SCRIPT, for communication between the provider and the pharmacy; the Formulary Benefits and Eligibility Standard, for communication between the prescriber and payer; and the Prior Authorization Standard. (For more on these standards, see sidebar, page 28.)
The pilot represents a major breakthrough for long-term care, according to Rachelle F. Spiro, president of R. Spiro Consulting, a long-term care pharmacy and information systems consulting firm based in Alexandria, VA. Finally, long-term care has a seat at the table along with its healthcare kin – ambulatory care and acute care.
"What's unique with this pilot is we're right up front with everyone else," said Spiro who was instrumental in initiating the program. "They're testing the same thing we're testing. From that standpoint, that is a very unique pilot and very good for long-term care."

Medication communication
Standards (or standard means of communicating) are just the latest sign of the long-term care field's growing interest in the technology of medication. During the past year, several companies have introduced products that address the MAR (medication administration record) and e-prescribing.
American HealthTech, of Jackson, MS, for example, introduced a software package called eMAR, which allows nurses to review and deliver medication orders electronically at the point of care. Interactive prompts remind caregivers if they need to take additional steps before carrying out the order. Nurses also can view physician-guided acknowledgement of contraindications with documented instruction.
Still other companies have or plan to introduce systems with electronic prescribing components. ADL Data Systems, based in Dobbs Ferry, NY, recently brought to market a software system that allows nurses and doctors to input medication and other orders on a touch screen. The software then can transmit the order to a pharmacy electronically or via an electronic fax.
Another cutting-edge example involves Health Care Software, of Farmingdale, NJ. Next year, the firm plans to offer an integrated pharmacy solution for long-term care facilities that own institutional pharmacies. All prescription-related information will link into the electronic medical record of the resident.
"We feel it's beneficial for those providers to have a single system for long-term care, their electronic medical record and their pharmacy," said Thomas J. Fahey, HCS's vice president of sales and marketing.
PointClickCare, of Minneapolis, also has developed a system that incorporates electronic prescribing. Resident information links up with the MDS and the resident's electronic medical record. A piece that is expected to be available next year will allow the nurse to bar-code scan the shipping manifest from the pharmacy and, thereby, update the MAR.

A new frontier
Standards, in a sense, represent the next frontier, some experts say. While companies currently offer systems with electronic prescribing capabilities, current systems are proprietary and require separate interfaces.
"A pharmacy has a connection to a facility and a lot of vendors are working on those point-to-point connections," explains Michael Bordelon, formerly of Achieve, who was instrumental in the pilot project. "The problem is when you think of the 17,000 nursing homes and hundreds and hundreds of pharmacies. It's prohibitively expensive with these point-to-point connections."
Standards would open up the world of electronic prescribing so all facilities would be able to communicate with pharmacies electronically, Bordelon and others say.
"What standards have allowed us to do is make one connection to a switch," said Bordelon, who now works as executive vice president of long-term care development for Talyst, a pharmacy solutions provider in Bellevue, WA. "From that one connection they'll have access to all the pharmacies in the network and all the payers in the network."
Of course, it is important not to confuse messaging with functionality, experts point out. While standards would give facilities the ability to communicate with pharmacies, they still would need the appropriate vendor software to arrange and present the information.
Implementation obstacles
But most agree that widespread
e-prescribing in the long-term care market is still three to five years away. Several key challenges remain in the way.
Doctors are one. While physicians are adapting to inputting orders electronically in their practices, they are less than enthusiastic about doing it in the long-term care world, notes Doron Gutkind, chief software architect for Lintech, Fort Lee, NJ. They don't want to be "bothered," he said.
"It's one thing when the doctor is in his own office and wants an EMR and it's better for his business," Gutkind said. "It's another thing when the doctor comes to a nursing home every so often, gives orders and goes."
Facilities are another obstacle. Before operators can hope to implement e-prescribing, they must have a working electronic health record, notes Spiro, the consultant. Pharmacies are ready and software vendors have the capability, she added.
"It really has to come from the nursing home side," she said. "I would not want to promote an e-prescribing solution without having the facility adopt an electronic health record. You can do it, but you're not going to get the full benefits."
Also, surveyors must be on board with e-prescribing and how it works.
Providers are still relatively naïve about standards, said Zoe Bolton, vice president of business development for American HealthTech.
"I think they're aware of it, but they're not intimately involved in it," she said. "As the standard setting gets finalized and we start rolling out solutions, the provider base will be more educated about what it is and what is available to them."
And then there are skeptics of the creation of new long-term care standards. Andy Brigant, chief development officer for PointClickCare, doubts that many institutional pharmacies will switch standards for long-term care e-prescribing to accommodate the government.
"Everyone's talking about the SCRIPT standard, but the big pharmacies currently use HL7," he said, referring to a standard-setting organization similar to the organization that created SCRIPT. "The reality is that what the biggest companies are using will be the de-facto standards."
But Bordelon feels otherwise. While some people in the industry are aligned with HL7 and others are aligned with NCPDP, the Centers for Medicare & Medicaid Services has chosen NCPDP as the foundation standard for the ambulatory space, which, in terms of standards, is years ahead of long-term care.
"There are thousands of doctors and pharmacies that are using this every day," he said. "That's a lot of critical mass that's moving down the highway."

A "standard" scorecard

A glossary of standards:
SCRIPT: Developed by the National Council for Prescription Drug Programs (NCPDP). Named by the government as the initial foundation standard for e-prescribing for healthcare. The Achieve pilot is tweaking SCRIPT for long-term care.

Formulary Benefits and Eligibility Standard: This standard allows prescribers access to a prescription drug formulary to determine if a payer will cover a certain medication. Achieve is testing it for LTC.

Prior Authorization Standard: One of the least mature of all the standards. The third standard tested in the pilot.

HL7: A standards-setting organization like NCPDP. It was named by the government as the standard for the electronic health record. Stands for Health Level Seven.
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