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Although still a work underway, the shift to prescription automation in long-term care is inevitable.
Although still a work underway, the shift to prescription automation in long-term care is inevitable.

On Nov. 1, 2014, the Centers for Medicare & Medicaid Services lifted its electronic prescribing exemption for long-term care facilities.

CMS began requiring that LTC operators adhere to the National Council for Prescription Drug Programs SCRIPT v10.6 standard for electronic prescribing.

No longer allowed to use HL7 integrations and computer-generated faxes to communicate orders to pharmacies, skilled nursing and assisted living facilities were forced to either get on board with the new regulations or revert back to manual methods of prescription transmission, such as faxing orders. 

One year later, many industry experts say e-prescribing in long-term care is still a work on progress. 

“We're really still in the transition phase right now,” says Arnold Clayman, vice president of pharmacy practice & government affairs with the American Society of Consultant Pharmacists. “And all of the facilities, pharmacies and physicians are at different adoption and implementation points right now, which is leading to a lot of headaches and heartaches in the industry.”

As healthcare providers in New York gear up for a 2016 mandate requiring healthcare organizations of all kinds to engage in e-prescribing for both controlled and non-controlled substances, the shift to prescription automation in long-term care seems inevitable, says Steve Pacicco, CEO of SigmaCare. 

“Even though New York is the only state with an e-prescribing mandate on the books, organizations should be starting now to get themselves ready for compliance,” Pacicco says.

E-prescribing value

The use of e-prescribing has dramatically increased in the last decade, according to a study last year by the Office of the National Coordinator for Health Information Technology. Approximately 70% of physicians issued prescriptions through electronic health records in 2014 — 10 times the amount in 2008. Compared to manual paper faxing, the
NCPDP's bi-directional e-prescribing standard offers several benefits to long-term care, says Tim Quarberg, vice president of medication management for MatrixCare. These include the elimination of handwritten transcription errors, improved accuracy of order transmission, reduced data entry for pharmacists and fewer phone calls for clarification. 

E-prescribing technology also automatically evaluates prescriptions for potential drug interactions, further promoting patient safety while making the process more efficient, says Naushira Pandya, M.D., president of the board of directors for AMDA — the Society for Post-Acute and Long-Term Care Medicine. 

“Sometimes the systems are geared to be overly sensitive, which can cause fatigue among providers,” she says. “But there's several times where it's made me pause and reconsider the therapeutic regimen that the patient is on.”

E-prescribing also can help with care transitions, Pacicco says, noting that as patients move across the care continuum, sharing data — particularly medication data — can be critical.

“From acute care facilities to long-term care organizations, if data is not in electronic format, it's harder to share,” he says. “Automated solutions can seamlessly send information directly to another provider's EHR.”

‘Pain points' of e-prescribing

One of the biggest problems long-term care has faced in the switch to NCPDP regulations is that many of them are centered on the retail pharmacy environment, as opposed to the typical long-term care ordering and prescribing process, which often involves staff at skilled nursing facilities — not physicians — facilitating prescriber orders with the pharmacy, says Suresh Vishnubhatla, executive vice president of long-term care operations for PharMerica.

“It all comes back to workflow issues in how medications are ordered in the long-term care environment,” Vishnubhatla says. “Physicians use one set of software applications in their practice, while many facilities use a different EHR tool for electronic ordering. Keeping both parties and systems in sync is an issue most vendors haven't fully solved yet.”

The NCPDP standard also limits medication orders to 140 characters, which is a problem for patients on complex medication regimens such as sliding scale orders, which are common in long-term care, says Terri Weckle, senior vice president of strategic products for PointClickCare.

“That order ends up not being able to be sent electronically, and a fax has to be sent as a follow-up,” Weckle says. “So even though the standards are in place, there are still issues coming out as we put them into practice that need to be addressed.”

The industry also has to deal with the fact that right now, e-prescribing isn't set up as a three-way communication between the prescriber, the pharmacy and the LTC facility, says Lynn Connor, CEO of Senior Care Pharmacy.

“The physician can send one of our pharmacies an e-prescribed new order, refill request or dose change, but the nursing facility also needs to get that order, and by law, they're not allowed to take that from the pharmacy,” Connor says. And as the number of EHR software vendors in the marketplace continues to increase, solving this three-way communication problem becomes even more difficult, says Scott Walker, chief information officer at Remedi SeniorCare.

“There's too many players in the space, and a lot of them don't have the resources to develop and maintain software systems in a health care space — especially a pharmacy healthcare space,” Walker says.

For facilities caught in the middle of this e-prescribing mess, these technology “pain points” will continue to be felt until additional system updates and certifications are in place allowing the e-prescribing, EHR and pharmacy software to better communicate with one another, says Shelly Spiro, executive director of the Pharmacy HIT Collaborative.

“If facilities can't solve these communication problems related to e-prescribing, they can't get the prescriptions to their patients which can lead to survey problems around putting patients in immediate jeopardy for lack of access to medication,” Spiro says.

Solutions on the horizon?

In order to help close the gap between physicians, LTC facilities and pharmacies, physicians need anytime, anywhere access to e-prescribing, Connor says. Often, prescribers working in long-term care also have their own office practices or spend time at several skilled nursing facilities. They don't always have immediate access to electronic requests for medication refills or changes. 

“In one of our pharmacies, we actually send a fax to the physician's office to say, ‘We've sent you an e-request for a refill on a drug for one of your residents; please go look at your e-prescribing system,'” Connor says. “That defeats the whole purpose of e-prescribing and delays care for the resident.”

Weckle agrees, noting that as acuity gets pushed out of hospitals and into skilled nursing facilities and even back home, the physician must become more involved in patient care because there are more opportunities for changes in a resident's condition. In March, after months of discussions and testing with a physician advisory group, PointClickCare launched its Practitioner Engagement Solution, which allows physicians and nurse practitioners to electronically prescribe from a mobile device. Weckle says providing on-the-go access to patients' health records and the ability to discuss changes in resident conditions and care plans via secure, HIPAA-compliant text messages through the app is key to better engaging prescribers.

“It has to be easy and really tuned in to the practitioner's workflow,” Weckle says.

Making e-prescribing easier for physicians also will allow them to stay more engaged in their patient's care, Walker says. When physicians are in charge of entering the orders for a patient's medication themselves, they're notified of possible drug interaction issues, as well as whether the medication is not covered or a prior authorization is needed.

“That electronic dialogue needs to happen with the prescriber, not through a nurse who has to serve as an intermediary in the process,” Walker says.

He also notes that clinical consultant pharmacists need to work closely with facility nurses and administrators to make their tasks more efficient, enabling them to spend more time caring for residents and less time on tedious tasks. 

“The more we can get all of these entities — the pharmacy, the prescriber and the facility — to collaborate electronically in an easy way, the better off we'll be in terms of improving patient safety and reducing redundancies,” he says. “Maybe that's the silver lining in this very dark, stormy cloud: that there are good opportunities for us to do some things that help everyone collaborate."