I HAVE SPOKEN AT ASAP (American Society for Automation in Pharmacy) meetings in the past about health information exchange (HIE) and the role of the pharmacist in this important component of patient care. In those presentations, I reviewed pharmacy’s role in health information technology — always a leader — and identified key steps to ensure that pharmacists can exchange information appropriately to support the delivery of patient care. Understanding the priorities behind the decision to exchange data and determining what and how it is to be exchanged were among those key steps.
We all intrinsically understand that the safe, timely, and accurate exchange of health information is a necessity. In this day and age, we expect ease in our transactions. We have it in our personal lives — shopping, banking, transportation — yet struggle for it in our industry.
Progress has been slower than anticipated during the last two years. Pharmacists are doing good work when it comes to checking their local prescription drug monitoring program (PDMP), which is a valuable tool in addressing the overuse and misuse of opioids. But exchanging other information, such as lab values, immunization administration records, allergy and adverse event reporting, and documentation of care provided, still does not routinely occur within workflow.
It is clear that exchanging information is important, so why has the industry not gained more momentum? There are likely quite a few reasons. First is probably resources and priorities. Data exchange partners have to agree on what information can and should be exchanged. Then resources have to be allocated to assess the exchange mechanisms, e.g., secure email such as DIRECT or SFTP (secure file transfer protocol), and whether a standard or a proprietary format will be used. Once those decisions are made, then planners must consider how to integrate the data exchanged into the workflow. Exchanging the data only has value if it is available to the end users when and where they need to see it. All the basics of project management then come into play — timelines, milestones, resources — in order to achieve the goal of exchanging information. And this process is likely to be repeated depending on the type of data or the exchange partners involved.
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Another likely reason for the delay is that the industry has been waiting for a newer version of NCPDP’s SCRIPT Standard to more effectively exchange data such as allergy or adverse events, prescription fill status, and prior authorization information. The Centers for Medicare and Medicaid Services (CMS) published a final rule in April 2018 that will drive the industry’s transition to a more current version. Compliance with this new version is required for those who are subject to the regulation by Jan. 1, 2020.
So within the next two years, pharmacists and prescribers will have a more effective tool to exchange data. The challenge will be in seeing if there is interest and capacity in leveraging all that the SCRIPT Standard can support. Otherwise, we’ll be where we are today, exchanging the bare minimum on a prescription-related transaction. That minimum will change either through regulation or through industry, or patient demand.
And what about other trading partners, such as payers? The new version of the SCRIPT Standard includes enhancements to the prior authorization transactions (generally exchanged between the prescriber and the payer/PA processor). It’s clear that use of electronic prior authorization improves efficiency and positively impacts patient care by reducing the time needed to process a prior authorization request. Proprietary solutions are available in the marketplace that allow a prescriber to check the pharmacy benefit, in real time, before sending a prescription to the pharmacy. This type of data exchange can lead to smarter prescribing decisions — selecting a product with the highest coverage level for the patient — that can improve adherence and reduce inefficiencies in the prescribing process. Yet adoption of these tools takes time, and many are waiting for either a standard transaction that will be used by all prescribers and payers, or a mandate before investing the time and effort to implement a new feature.
The primary data exchange between a pharmacist and payer involves claims transactions. On May 17, 2018, the National Committee on Vital and Health Statistics sent a letter to the Secretary of Health and Human Services recommending that the standard named for pharmacy claim billing be updated to a newer version. This occurs nearly nine years after the last version was named. As with the SCRIPT Standard, the telecommunication standard has seen dozens of changes included at the request of the industry. Moving to this new version will improve the ability of pharmacies and payers to exchange data. No specific timeline for this transition has yet been announced.
As pharmacists continue to provide additional services, they need a way to document their work to support any associated billing. Pharmacy systems will need a way to capture care documentation and associated code systems so that claims can be promptly and efficiently submitted. Standards are available that can support the exchange of information; the greater challenge is extracting the data from whichever system stores it, if there even is a system to store it. There are solutions available, whether embedded within current pharmacy management systems or as an add-on tool that can integrate with existing systems. These tools will be extremely valuable as pharmacists offer more services that are reimbursable.
Hopefully, when we look back two years from now we’ll be able to report on significant progress regarding health information exchange. I’ll continue to keep readers updated on developments. CT
Marsha K. Millonig, B.Pharm., M.B.A., is president of Catalyst Enterprises LLC in Eagan, Minn. The firm provides consulting, research, and writing services to the healthcare industry. The author can be reached at firstname.lastname@example.org.