Provider Status and the Electronic Health Record ––>
You are likely reading this well into the new year. With the new year, we want to start with what we have seen in 2014 and then look ahead for this year. 2014 was a critically important year for pharmacists, in the form of H.R. 4190, the legislation that is poised to bring provider status to pharmacists. As of this writing, there are 122 congressional cosponsors of the bill. We have no doubt that ComputerTalk’s readers are closely following this legislation, as well as participating in advocacy efforts to — hopefully — push it through to finally become the law of the land.
We recently spoke on the topic of the technology that is necessary to support pharmacists when provider status is achieved. This is an important topic for the future of pharmacy, so we are going to focus on it here. As is often the case with technology topics, an appreciation of the context in which the technology is to be used provides valuable insight into optimal use of the technology. Therefore, we will begin with developments in the larger domain of healthcare.
The Changing Landscape
Healthcare is undergoing significant change on many levels. Patients are increasingly being engaged as active participants in their own care. In this new, patient-centric model, patients receive greater information about their treatment options and engage with providers to select the treatment option that best fits their unique circumstances. On the provider side, reimbursement models previously based on volume and fees for services rendered are being replaced by models that reward quality. Insurance companies are also experiencing change, in the form of the star rating system for Part D plans, which largely focus on various aspects of medication-related quality. Another major shift is the focus on prevention and wellness, instead of the treatment of illnesses. This shift has been advanced by consumer electronic devices like the Fitbit and the Nike+ Fuelband activity monitors.
Another important change that we have previously written about is the government’s “meaningful use” program to advance the use of electronic health records (EHRs). Briefly, this program is based on the expectation that providers (and hospitals) that have EHRs will be able to provide better treatment by having access to patient-specific and knowledge-based information when it’s needed. The program also focuses on sharing information across locations of care through health information exchange (HIE), which is the electronic sharing of healthcare data or information. A third component of the program is EHR users’ reporting of quality metrics to demonstrate that patients are experiencing better care and, in some circumstances, outcomes. Recognizing the financial cost and changes in workflow that come with EHRs, those who adopt the technology are eligible for financial incentives — provided they meet certain criteria. The financial incentives are slated to change this year to include penalties for nonparticipation.
Since pharmacists are not currently recognized as providers under Medicare, they are not yet eligible for meaning-ful-use incentives. Looking specifically at provider status, it is important to know the three conditions of H.R. 4190. First, for services to be reimbursed, they must be provided in a medically underserved area (MUA), to a medically underserved population (MUP), or in a health professional shortage area (HPSA). Where are these? The good news is that you can find all MUAs, MUPs, and HPSAs near you by going to www.hrsa.gov/shortage and entering your specific geographic information. The second condition is that your specific state pharmacy practice act will govern the services you can provide. Third, reimbursement will be at 85% of the physician fee schedule, consistent with that of nurse practitioners and physician assistants.
Certainly pharmacists have the knowledge and expertise to provide valuable contributions to their patients’ care. Of course they do — they do it every day. And each day, they use a pharmacy management system that most likely isn’t designed to serve as a clinical documentation tool and does not share information electronically with local hospitals or providers (other than e-prescriptions). Recall that a major component of meaningful use is HIE. While we wait for pharmacy-specific EHRs (see below), the good news is that you can participate in HIE now, using Direct. Direct is a standards-based, encrypted messaging protocol. It is essentially a secure email exchange between parties that know each other. Direct addresses can be obtained through state, local, and regional health information service providers, or through entities involved in health information exchange. More on the Direct project can be found at http://www.healthit.gov/sites/default/files/directbasicsforprovidersqa_05092014.pdf. The good news is that your existing partners, like Surescripts and RelayHealth, have existing HIE services.
Much of the initial work leading up to vendors being able to offer EHRs for the meaningful-use program focused on determining the appropriate technical standards to support clinical practice. This initial work also looked at the functional requirements for the intended end users of the EHR. Unfortunately, pharmacy was not a target end user. The good news is that efforts to bring pharmacy more directly into the EHR discussion continue. The Pharmacy Health Information Technology Collaborative led the development of a pharmacy practitioner EHR functional profile. The profile is based on the widely accepted HL7 EHR-S profile and is intended to facilitate electronic documentation and sharing of medication-related data, specifically that which aligns with pharmacists’ activities. If you take the time to read it (http://www.hl7.org/implement/standards/product_brief.cfm?product _id=262), you will see that it is divided into three sections: direct care (functions to support provision of care to individual patients), supportive functions (support delivery of care but do not impact individual patients), and information infrastructure (the heuristics necessary for reliable and secure computing). The net effect is the existence of a standards-based guide for your vendor to create an EHR that aligns with your practice and is able to exchange information with partners external to your pharmacy.
Is this important? We believe it is, but so do others. In the last year, CVS and Walgreens announced partnerships with EHR vendors, health plans, and others in which they will share clinical data electronically. Will your pharmacy management system vendor think this is important to its business model? Honestly, we anticipate that you are going to have to educate your vendor to see the long-term value. We see it this way: Pharmacy needs to be able to electronically share clinical information — using industry standards — to remain viable in the emerging healthcare market. This aligns well with efforts toward provider status. Because it’s important to your future business success, it is also important to your vendor’s success. As of the writing of this column, the Pharmacy HIT Collaborative is in the process of developing a document to support you in your conversations with your vendor. We encourage you to watch for the document. We also continue to welcome your comments and questions. CT
Brent I. Fox, Pharm.D., Ph.D., is an associate professor and Bill G. Felkey, M.S., is professor emeritus, in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University. They can be reached at firstname.lastname@example.org and email@example.com.