E-prescribing grows up

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E-prescribing is gaining traction but many long-term care providers and physicians still go the paper route.
E-prescribing is gaining traction but many long-term care providers and physicians still go the paper route.

As far as new technology goes, e-prescribing is old hat.

But in a cash-strapped industry inundated by regulatory change and data-collection efforts, it's not necessarily a familiar one.

That may be changing thanks to compliance and reporting demands.

“I get a chuckle whenever I hear anyone call e-prescribing new,” says Chuck Klein, director of medication management for NetSmart. “For senior care and long-term care, if providers in these industries haven't already started e-prescribing, they should be scrambling.”

There appears to be no clear consensus as to how many long- term care providers currently have — or use — e-prescribing software that allows physicians to start new treatments without scribbling onto a prescription pad or sending an outdated e-fax.

Often, it depends whether facilities have comprehensive electronic records and analytic programs. Those vendors typically offer e-prescription services now, and many are specially certified to handle controlled substances.

Even that isn't enough to encourage full adoption.

At PharMerica, the number of long-term care clients using e-prescribing has doubled over the last year, but executive vice president Suresh Vishnubhatla says the overall number is still fairly small compared to the 30% to 35% who use e-ordering.

E-prescribing, however, is gaining traction.

“I think controlled [substance] prescriptions is some of what has driven it — the enforcement and the compliance,” Vishnubhatla says. “Going and chasing down paper all the time to stay compliant isn't that easy.”

Despite that, many long-term care settings or their consulting physicians still opt to handle prescriptions the traditional way. That can lead to time-consuming follow-up calls or potential patient harm due to errors.

“We are probably seeing about 15 to 20 percent of our orders coming over electronically,” says Joel Noped, operational support manager at Southern Pharmacy Services, a partner of Guardian Pharmacy. “This number has increased significantly over the last few years as more of our facilities have moved toward electronic systems. However, there is still a strong presence of the ‘traditional' methods for order transmission in LTC. I think that providers are starting to get a feel for the opportunities that are there, but it has not been overwhelming in the LTC community.”

Remaining obstacles include cost, differing state standards and misconceptions about the limitations of e-prescribing systems.

But Tim Quarberg, R.Ph., vice president of medication management for MatrixCare, says his company has at least 5,000 facilities using the e-prescribing tool within its clinical suite. Those that haven't ever looked at e-prescribing options or have not done so in years should reconsider, he says.

“Initially, it was just a matter of getting prescriptions to the pharmacy or getting orders filled. Over the years, that has really evolved,” he says. “Now we offer clinical decision support, safety through decreased drug errors, reduced duplicate therapies and notify when there are contraindications.”

Slow build

Quarberg says much of the customer growth came in 2014, with the adoption of a new standard — the NCPDP SCRIPT 10.6.

That's when the Centers for Medicare & Medicaid Services started requiring Medicare Part D participants communicating with independent pharmacies via computer-generated faxes to upgrade to a platform with the new standard (or convert back to manual processing).

At the time, 72% of facilities surveyed by LeadingAge's Center for Aging Services Technologies said they weren't ready for the new rules. Fewer than 10% were able to use the NCPDP SCRIPT 10.6 standard for e-prescribing.

Almost half of long-term care pharmacies also said they were not ready, but vendors such as Omni- care and PharMerica worked ahead of the new CMS rules to make adoption more plausible. More EHR providers also flowed prescribing into existing solutions.

“The integration of e-prescribing into EHR platforms, and the desire for facilities to have an interface with the pharmacy, has been the biggest shift in recent years, especially since the NCPDP SCRIPT requirements went into effect,” Noped says. Meanwhile, some states and provider partnerships offered incentives that made the shift to e-prescribing more appealing. But as with many technology incentives, those programs often left skilled nursing out of the loop.

More than 10 years ago, the Agency for Healthcare Research and Quality piloted an electronic prescribing software program — and only one of five grants included a long-term care provider.

CMS acknowledges that e-pre- scribing had “been largely ignored in the LTC environment.” When some states required other health- care providers to move forward with e-prescribing, skilled nursing facilities were often exempted.

In New York, for example, acute care providers must use e-prescriptions for any controlled substances (say, hydrocodone as a cough suppressant). But the state has issued a blanket waiver for skilled nursing facilities.

Klein says the expected end of that waiver in March will usher in a new wave of implementation as vendors rush to meet demands of the state's 600-plus certified nursing facilities.

Unaware, without a care

Ironically, some providers still don't realize their states allow e-prescribing by all physicians. EHR providers are busy promoting their capabilities and the potential efficiencies nursing homes might create through adoption of an electronic system.

SureScripts estimates e-pre- scribing will save the U.S. health- care system $140 billion to $240 billion through 2022, largely by preventing medication errors and improving efficiency.

But Noped cautions long-term care providers against making big assumptions about cost savings, noting that those who are new to software systems often have to adapt to new issues, such as resolving interface problems.

He says it's critical to under- stand how work will ow between all parties involved, and not assume that a pharmacy is able to troubleshoot all issues.

In a white paper for Matrix- Care, Megan Lenthe, RN, BSN, senior product manager, looked at efficiencies created when Fair- view Manor nursing home in Nebraska started using Matrix- Care e-prescribing to interact with its existing long-term care pharmacy.

The pharmacy reported a 35% decrease in efficiency and a 4% increase in errors with other vendors, but said systems like Matrix- Care's that are built to work with existing processes don't trigger the same kinds of problems.

Fairview reported a 40%

reduction in time spent communicating with the pharmacy over data-entry errors and a 70% reduction in medication errors thanks to features like barcode scanning, auto-review and inventory control.

Those benefits — even more than saving money — should be a major draw, Noped says.

“I think the advantage comes from the reporting and security options,” he says. “There are some potential opportunities to save time (or) steps by utilizing the other functionality of the inter- faces, so it is definitely in the best interest of the pharmacy to under- stand what those are.”

Vishnubhatla says PharMerica has focused on building systems that talk to multiple EHRs and pharmacy systems. The company has “developed the glue that holds those two programs together to make it easier for our clients.”

Well-designed systems can also streamline data collection efforts, providing color and context about what drugs are being prescribed at a high frequency or allowing facilities to share metrics with executives or partners.

“If we can populate that data, we have the possibility of eliminating transcription errors, reducing data entry and making medication reconciliation that much easier,” says Hannah Patterson, Netsmart's director of long-term care.

But an industry-wide lack of standardization can still make it tough to find a simple solution that works across state lines and discourages doctors who support multiple facilities from learning the intricacies of each system.

PharMerica is beta-testing a system that codifies sigs, or labeling instructions, which would address one common issue. Doctors might enter the same patient instructions in three different ways and systems that don't require consistency may confuse the process — or send pharmacy techs to the phone to sort out orders.

Several pharmacy experts pre- dict regulatory pressure will soon be around standardization.

Staffing implications

The industry's high-turnover rate complicates matters, Vishnubhatla says, because nurses may not have time to become e-prescribing experts before they have to enter new orders.

But Patterson adds e-prescribing also can provide safeguards. “The population of nurses in early career is high in skilled nursing facilities; they don't have years of experience to know contraindications,” she says.

Today's systems can provide administrators with live feedback, including compliance alerts. Additionally, some facilities that use de facto doctors, haven't been able to reap the benefits of e-prescribing.

But newer systems allow prescriptions to be entered either by a physician's assistant, nurse practitioner or nurse fielding a physician's call, then automatically remind staff to get the doctor's official sign-off into the system within a required timeframe. The next frontier will be to let doctors to send a prescription via secure smartphone.