Using Technology to Support MTM Steven T. Simenson, BPharm, FAPhA Managing Partner Goodrich Pharmacies Kenneth P. Whittemore, Jr., RPh, MBA Senior Vice President, Clinical Practice Integration SureScripts Financial Disclosures Steven T. Simenson, BPharm, FAPhA, Goodrich Pharmacies declares no conflicts of interest or financial interests in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, or honoraria. Kenneth P. Whittemore, Jr., RPh, MBA, SureScripts is employed by SureScripts, LLC, where he is involved in the service described in this program; he declares no conflicts of interest or financial interests in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, or honoraria. Electronic Medical Records and MTM Steven T. Simenson, BPharm, FAPhA Managing Partner Goodrich Pharmacies Goodrich Pharmacy, Inc. • 5 independent community pharmacies • Suburban to suburban/rural demographics • Professional 850 to 1400 sq ft pharmacies • 3 in clinic, 1 stand alone next to clinic, and 1 supermarket pharmacy • Established in 1864; stores added in 1991, 1997, 2002, and 2005 Prelude to MTM in Our Practice • 1980s: Generic substitution protocols for products with patent expirations – Save physician phone calls – With clinic remodeling gained direct phone access to physicians’ workspace and offices • 1990s: Therapeutic substitution protocols for PBM formulary mandates • We became indispensable resource for PAs and NPs as they entered clinic practice environment Pharmaceutical Care to MTM Timeline • 1990s: Disease state management – APhA Project IMPACT – LIPID panel in-store monitoring • Blood pressure monitoring for referred patients • Diabetes and A1c monitoring • Pharmacy student rotations • Actively recruiting pharmaceutical care patients through physician referral • On-site clinic medication therapy presentations to providers always with some MTM tie-in or focus • Collaborative Practice Agreements • Active MTM practice with Health Plan contracting Early Pharmacy Technology and Pharmacist Documentation • Paper Word and Excel forms, filed in folders in filing cabinets • Encouraged pharmacy software companies to add Note fields to Patient Profiles • Lipid, A1c, and other CLIA-waived testing devices appeared and were utilized • First Pharmaceutical Care documentation and billing systems appeared and utilized Electronic Medical Record Access and Contracted Pharmacist Services • Refill approval per standing order criteria and payment for consultation – Refill request • Patient medication chart review – Re-order medications – Order labs – Communicate with care team – Document and communicate patient consultation – Document immunizations Sharing Patient Information • Electronic Medical Record Systems offer a clear illumination of patient records that pharmacists seldom see • Shared information may improve MTM assessments and patient outcomes Integration With Other Systems • Different systems in other health care organizations and hospitals • Lack of systems • Long-term care systems • Insurance changes mandate provider changes • Importation and mail order systems Using EMR to Provide MTM • Preparation … pre-appointment – Check most recent labs with known medications • Look at kidney (SCr & GFR), liver function (AST/ALT), electrolytes, lipids, A1c, TSH/T4 – Check health care provider goals and plan – Check visit compliance – Prepare bulk of PMR and substantiate with patient at visit MTM Medication Therapy Review With Patient • Check EMR when necessary during MTM consult to answer new patient questions • Check for problem resolution or problem status with patient (provider goals) • Have draft MAP for discussion and questions with patient Post MTM Visit • Communication to care pool or provider of interventions, recommendations, and referrals per Core Elements of MTM services • Re-order medications • Order labs if necessary • Same-day feedback through provider work queue Benefits of Using EMR in Providing MTM • More accurate and complete patient information to assess medication AND care goals • Coordination with Physician Care Plan • Timeliness addressing concerns and problems • Pharmacist documentation in patient chart Benefits of Patient MTM • Pharmacist confidence level in patient medical information • Working in the same workflow patterns and system as other health care providers • Better patient acceptance and closer working relationships with other health care providers Effectively and Appropriately Using the EMR • System legal requirements and staff training • Access terminal in private yet convenient area • Signing on and OFF regularly • All areas when “touched” are labeled with individual accessing • Zero tolerance to breaches in security Current Barriers EMR Access • Health system employee or external consultant/business partner • Allies in system to help advocate access • HIPAA and confidentiality issues – Timeliness and barriers of HIPAA request – Not read only…two-way communication necessary Current EMR Shortcomings • Incomplete patient information – Multiple clinics and prescribers (specialists) • Competing EMR systems – OTCs – Herbals – Mail Order – Samples -- Changes by providers made when “On Call” and not documented Future Efficiencies • Billing capabilities through EMR system for MTM • Access and conversion to a single Universal Electronic Medical Record for all patients WITH appropriate pharmacist access and MTM documentation and charting capabilities • Include billing capabilities MTM Future Technology • I know what I think I would optimally like for MTM technology • I think I know what we need for MTM • Universal access to EMRs for all pharmacists • Ken? How and when will we get there? Using Technology to Support MTM: A Future Vision for Interoperability Ken Whittemore, Jr., RPh, MBA Senior Vice President, Clinical Practice Integration SureScripts In the Beginning… • It came down to money – No one liked the inefficiencies and inaccuracies associated with paper billing – So following widespread community pharmacy practice automation came: • Pin-fed computer-printed claim forms • Tape and diskette billing • And then the “Holy Grail”… Online, real-time claims adjudication Fast Forward About 5 Years… • Some in the profession began to ask: – “What other community pharmacy processes can we automate?” – One answer was: “How about the prescribing process itself?” • Paper-based, somewhat prone to error, inefficient, and costly • This made good sense to many in the profession – So down that road went most of the same players who had automated the community pharmacy billing process Why Did Automating the Prescribing Process Make Sense? E-Prescribing in the Early Days • Electronic prescriptions • Refill renewal requests and responses • And their lesser-known cousins – Change and cancel messages – Prescription fill messages And Not Much Happened Until… • 2001 – RxHub formed by the three largest PBMs (at that time) – SureScripts formed by NACDS and NCPA • Both were created to automate and improve the prescribing and medication-use processes – Since then, their roles and emphases have diverged Which Brings Us to Today • Over time, new needs were realized and are now being met – Medication history (Rx History) – Eligibility verification – Formulary information/lookup While We Were Focused on Our Piece of the Health Care Pie, Other Forces Were at Work Demand Supply • Clinical history for physician • Community pharmacy EMR/E-Rx prescription history • Better information for pay-for- • Clinical laboratory orders and performance results • Acute care medication • Payer clinical claims reconciliation information • Regional Health Information • PBM prescription history Organization (RHIO) • Physician-entered EMR collaboration information • Federal and state health • Patient-entered family history information technology policy • Clinical history for consumer personal health record (PHR) Eventually, the Professions Began Thinking in Terms of “Interoperability” • Many different types of health care information • Being shared electronically by a wide variety of caregivers • When appropriate to facilitate the provision of care to their patients Leading to the Notion of a National Health Information Network (NHIN) Lab Rx Hospital Radiology Payer RHIO NHIN Ingredients • Conceptual design • System architecture • Standards • Certification • Security and privacy • Patient matching • Authentication NHIN • End user applications • Pilot programs • Business model • Adoption programs Application Vendors • Best practices (E-Rx, EMR, HIS, PBHR, PHR, etc.) • Incentives alignment Member Physician Nurse Patient Employee Lab Tech Pharmacist Family Community Pharmacy Is More Prepared for Interoperability Than Are Others Ingredients Pharmacy Other Verticals Conceptual design System architecture Standards Certification Security and privacy Patient matching Authentication End user applications Pilot programs Business model Adoption programs Best practices Incentives alignment Pharmacy Health Information Exchange: Stakeholders and Infrastructure Inpatient Pharmacy In-store HIS Pharmacy Practice Rx History Clinics EMR Management Emergency MTM & Department Electronic Care Mgmt Prescribing Pharmacies Hospitals Physicians Patients Home Care Monitoring Intelligent PHR Dosing Payers / PBMs Payer-based P4P Health Rec. Prescription Formulary Predictive RHIOs History & Guides Modeling Integration Government Platform Patient Information CDC DEA Locators Policies Pharmacy Health Information Exchange As It Is Now Unfolding Inpatient Pharmacy In-store HIS Pharmacy Practice Rx History Clinics EMR Management Emergency MTM & Department Electronic Care Mgmt Prescribing Hospitals Pharmacies $ Physicians Patients Home Care Monitoring Intelligent PHR Dosing $ Payers / PBMs Payer-based P4P Health Rec. $ Prescription Formulary Predictive RHIOs History & Guides Modeling Integration Government Platform Patient Information CDC DEA Locators Policies Questions?
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