Interoperability: Plugging Community Pharmacy into the Clinical Data Superhighway

In this age of emerging technology, it more important than ever for community pharmacists to get plugged into clinical data sharing. Community pharmacy system vendors are developing new ways to document clinical information, and the adoption and implementation of these interoperable health information technology (HIT) solutions will help in the collection, documentation, and exchange of data on pharmacist-provided patient care services with other health care providers, patients, and payers. Though these emerging solutions present a new set of challenges for community pharmacy, they have the potential to transform health care and benefit all stakeholders.

Electronic prescribing (e-prescribing) is the first step in creating interoperability between pharmacists and prescribers. As interoperable prescription information improves from a one-direction transaction to a bidirectional exchange of information, the prescription process will become more seamless. The ability to exchange clarification requests with prescribers in real time will save pharmacists’ time and may decrease the risk of medication errors.

It is important for community pharmacists to understand these process-improvement opportunities and changes to ensure that they will not be left behind. As payment models move away from fee-for-service toward a value-based model, interoperable HIT solutions are paramount to keeping the practice of pharmacy integral to patient care.

The Road to Interoperability

According to the Healthcare Information and Management Systems Society, “Interoperability describes the extent to which systems and devices can exchange data and interpret that shared data. For 2 systems to be interoperable, they must be able to exchange data and subsequently present that data such that it can be understood by a user.”¹

Interoperability is a term used in HIT to define ways computer systems communicate with each other. An example of interoperability outside of health care is e-mail: an individual with an e-mail account from one provider can seamlessly send and receive messages from someone who uses a different provider. This is the same type of interoperable exchange that occurs today in health care over secure networks.

In 2015, the Office of the National Coordinator for HIT (ONC) prioritized interoperability to drive HIT adoption.² In a letter in the ONC interoperability roadmap draft document, ONC National Coordinator for HIT Karen B. DeSalvo, MD, MPH, MSc, stated, “In the decade since ONC began its service to the nation, the United States has experienced remarkable progress in the digitization of the health experience. There has also been significant advancement of payment reform that is driving the need for better visibility of the care experience and demand for straightforward quality measurement. Consumers are increasingly expecting their electronic health data to be available when and where it matters to them, just as their data is in other sectors. And new technology is allowing for a more accessible, affordable, and innovative approach.”³

Although physicians and hospitals are receiving financial incentives for adopting HIT, community pharmacy is not part of the incentive program; ONC recognized pharmacists as providers in order to meet the driving factor of interoperability without providing financial incentives for their participation. However, whereas the incentives of HIT implementation are not monetary for community pharmacy, there are still important advantages for adopting HIT into the community pharmacy practice model.

The ONC’s draft interoperability roadmap document recognizes the value of pharmacists, especially in the community setting, for sharing clinical information with providers, patients, and payers.⁴ The pharmacist’s role as a health care provider is referenced throughout the 166-page document, which features an appendix on medication-therapy management (MTM). On April, 3, 2015, comments to the roadmap were submitted by the Pharmacy HIT Collaborative, which was formed in 2010 by 9 pharmacy professional associations and corporate stakeholders representing HIT initiatives for pharmacists providing patient care services in all practice settings.⁵ These comments reinforced ONC’s position on pharmacists’ relevance in the clinical exchange of information (eg, immunizations, e-prescribing, and MTM services). The interoperability roadmap identifies key process-improvement opportunities for community pharmacists who adopt HIT into their pharmacies. These mainly include interoperable solutions to e-prescribing, controlled substance abuse prevention, MTM services, and immunizations.

Plugging In: Challenges and Benefits

Community pharmacies today rely on their pharmacy management systems (PMS), which are designed with a dispensing work flow to fill prescriptions. E-prescribing is a key component of this interoperable work flow process for community pharmacies that have adopted HIT. The starting point in the PMS is the profile, which contains not only basic patient details and their medication list, but can also include clinical information such as lab results, diagnoses, allergies, and medication goals. Expanding the functionality of clinical information documentation starting with the patient profile can allow a more complete picture to be shared interoperably.

Figure 1: Prescription Fill Work Flow

The missing piece in community pharmacy is a consistent process for the documentation of clinical information (eg, MTM, immunizations, medication reconciliation). Currently, there is no set of standards that is widely used for collecting, documenting, and exchanging clinical information in the community pharmacy setting. As pharmacists begin to provide more clinical services, their PMSs will need to be capable of adopting a clinical work flow following the Joint Commission of Pharmacy Practitioners’ Pharmacists’ Patient Care Process.⁶

If information can be collected, documented, and exchanged in an electronic, standard, interoperable way, community pharmacies will have the potential to reduce staff and prevent medication errors, especially those related to transcription of information. In the future, community pharmacists may also play a more clinical role as care coordinators.

There are numerous challenges involved in adopting HIT solutions including, but not limited to, cost, limited value-based payment models that account for community pharmacists, quality measures, and lack of regulatory incentive. There has been limited published research showing the value of community pharmacists adopting electronic interoperable solutions; however, the interprofessional communication aspect of HIT solutions should be recognized as an added value not only to community pharmacists and payers, but, most importantly, to the patients they serve.

As reimbursement is increasingly tied to patient outcomes, payers and pharmacy benefit managers want to have high-performing pharmacies in their networks.⁷ The lack of interoperable technology solutions may keep high-performing pharmacies from appropriately documenting and reporting clinical services (eg, targeted invention programs, targeted medication reviews, comprehensive medication reviews). This lack of interoperability may lead to narrow payer networks and exclusion of these pharmacies from prescription dispensing and other service,s such as immunization.

There are 3 ways to drive HIT adoption: (1) regulatory requirements, (2) business need, and (3) quality measures. E-prescribing is an example of a regulatory requirement that is a nonfunded mandate for pharmacists; however, there are business benefits to adopting bidirectional e-prescribing solutions. Additional regulatory requirements, such as the adoption of electronic health records (EHRs), are frowned upon by community pharmacists because of nonfunded mandates. If we look at EHR adoption from a business perspective, it makes sense. Right now, payers are influenced by Medicare Part D Star Rating Quality Measures; HIT solutions will assist payers in meeting these quality measures and provide an opportunity for community pharmacists to show their value.

Currently, the major driving force for a community pharmacy to adopt HIT solutions is a business model, such as the accountable care organization (ACO). ACOs rely heavily on electronic clinical data using interoperable HIT solutions to demonstrate their reimbursement models. Community pharmacists have the potential to play a coordinating role in chronic care management and transitions of care, both key success factors for ACOs. The benefits outweigh the challenges for pharmacists to adopt EHR systems to collect, document, and exchange clinical information with other health care providers, patients, and payers.

E-Prescribing: A 2-Way Exchange

E-prescribing has been a way for community pharmacies to become early adopters in receiving electronic clinical information and has been a major reason for prescribers to adopt EHRs and other emerging technologies.

In terms of e-prescribing, exchanging electronic prescription information bidirectionally allows for a safer and more robust process that may include medication reconciliation and adherence. This exchange is needed for transitions of care and MTM services, prevention of drug abuse, and identification of doctor shopping. The Centers for Disease Control and Prevention and state public health departments are adopting electronic solutions for immunization administration. Adopting HIT in an interoperable way helps support these population health solutions.

Due to the increased regulatory requirements and higher physician adoption of e-prescribing, community pharmacies are seeing an increase in the volume of prescription information transmitted from the prescriber to the pharmacy; however, community pharmacists have been lacking a way to electronically communicate information back to the prescriber. The communication from the pharmacy to the physician has mostly been through phone and fax, which is a time-consuming process for the pharmacy and the prescriber.

As technology advances, we are now seeing the need for bidirectional exchange of prescription information. One of the first areas where this need is addressed is in the use of National Council for Prescription Drug Programs SCRIPT 10.6 Standard functions RxFILL, RxCHANGE, and RxCANCEL.⁸ These e-prescribing standards have not been used because the business need has not been there…until now. Each of these functions is meant to build a method to electronically exchange prescription information in an interoperable 2-way process:

• RxFILL is designed to let the prescriber know when the prescription was picked up for the patient.
• RxCHANGE is designed for the pharmacist to message the prescriber with changes to the prescription (eg, formulary changes, order clarifications, drug interactions).
• RxCANCEL is a function to allow the prescriber to cancel or discontinue a prescription.

With e-prescribing of controlled substances (EPCS), it is important for pharmacists and prescribers to securely communicate prescriptions that have the potential for diversion. State and federal regulations are driving expanded uses of data collected by prescription drug monitoring programs to prevent drug diversion. ECPS allows the pharmacist to be more engaged with the prescriber and to recognize drug abuse and doctor shopping. If pharmacists cannot achieve interoperability, especially with their documentation of clinical services (eg, transitions of care, chronic care management, and MTM), pharmacies could lose customers or be excluded from value-based payment models (eg, ACOs).

Enhancing Clinical Care

With physicians and hospitals being driven to adopt EHRs and to document clinical encounters, pharmacists have the opportunity to broaden their role in clinical care. Adopting pharmacist EHR systems will help to facilitate a more interprofessional approach to clinical care: pharmacist-provided patient care information that is electronically added into the physician work flow will be available to the physician for access during patient encounters. This is accomplished through a health information exchange utilizing interoperable standards for pharmacist and physician EHR systems.

The advantages of collecting, documenting, and exchanging clinical information interoperably are that it can improve patient care and facilitate pharmacists’ participation in a value-based payment model. These exchanges occur using interoperable standards that allow pharmacists to work in their own system and collect and exchange information using standard electronic structured documents for information such as discharge summary, lab results, patient care summary, immunization forms, medication action plans, and progress notes. These structured electronic documents can be viewed, downloaded, and transmitted in a process very similar to sending a secure e-mail.

Adapting for the Future

Community pharmacists using interoperable HIT solutions have the opportunity to play an integral role in the new wave of health care information exchange. The traditional practice of pharmacy is evolving into team-based care models driven by value-based payments. Community pharmacists who rethink their practice models to implement HIT documentation of patient care services will solidify their role as providers on the health care team. It is important for these HIT models to fit into the community pharmacy work flow and to be interoperable with other health care providers, patients, and payers (see Figure 2). New models are using HIT to engage the patients in their care.

If pharmacists do not begin to adopt interoperable clinical HIT solutions, they will be left behind or eventually go out of business. Even though community pharmacists are challenged by a lack of regulatory requirements and financial incentive to adopt HIT, there are significant benefits for pharmacies who participate. Who better than the community pharmacists, who have a trusted and influential relationship with their patients, to improve medication-related care?

Figure 2: Shared Nationwide Interoperability Roadmap: The Journey to Better Health and Care

Source: HealthIT.gov

Shelly Spiro, RPh, FASCP, is executive director of Pharmacy HIT Collaborative. The Collaborative is an organization of the major national pharmacy associations and associate members focused on advocating and educating key stakeholders regarding the meaningful use of health information technology (HIT) and the inclusion of pharmacists within a technology-enabled integrated health care system. Spiro is active in national pharmacy associations, standards development organizations (NCPDP, HL7, and X12), and is a leader in pharmacy HIT, with a 2014 appointment to the Federal Advisory Committee’s Health IT Policy Committee’s Interoperability and Health Information Exchange Workgroup. She is past president of the American Society of Consultant Pharmacists (ASCP), ASCP representative member of the Long-term and Post Acute Care HIT Collaborative, and 2014 Archambault Award recipient.Diana Quach, PharmD, CGP, is the executive vice president of Spiro Consulting, Inc, a national consulting company focusing on industry, HIT, long-term care, and hospital and ambulatory surgery center consulting. Her formal training involves a doctorate of pharmacy from Roseman University College of Pharmacy and an executive residency in association management from the American Society of Consultant Pharmacists. Dr. Quach currently practices in Nevada as a consultant pharmacist in long-term care and ambulatory surgery center clinical practice.

References

• What is interoperability? Healthcare Information and Management Systems Society website. www.himss.org/library/interoperability-standards/what-is. Published 2013. Accessed June 13, 2015.
• Interoperability. HealthIT.gov website. http://healthit.gov/policy-researchers-implementers/interoperability. Updated May 1, 2015. June 13, 2015.
• Office of the National Coordinator for Health Information Technology (ONC). Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. Washington, DC: ONC; 2014:4. www.healthit.gov/sites/default/files/nationwide-interoperability-roadmap-draft-version-1.0.pdf. Accessed June 13, 2015.
• Office of the National Coordinator for Health Information Technology (ONC). Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap, Draft Version 1.0. Washington, DC: ONC; 2014:4. www.healthit.gov/sites/default/files/nationwide-interoperability-roadmap-draft-version-1.0.pdf. Accessed June 13, 2015.
• Spiro S, Rosato E, Vlasses P, et al. Comments on connecting health and care for the nation: a shared nationwide interoperability roadmap draft version 1.0. Pharmacy Health Information Technology Collaborative website. www.pharmacyhit.org/pdfs/collaborative-outreach/Final%20Pharmacy%20HIT%20Coll%20ONC%20Roadmap%20Comments%204-3-15v1.pdf. Published April 3, 2015. Accessed June 13, 2015.
• Spiro S, Franz R, Anderegg S, et al. Workflow of pharmacist clinical documentation process in pharmacy practice settings. Pharmacy Health Information Technology Collaborative website. www.pharmacyhit.org/pdfs/workshop-documents/WG3-Post-2014-03.pdf. Published July 28, 2014. Accessed June 13, 2015.
• Connor K. Clinical performance: a prove-it moment for independent pharmacies. Smart Retailing Rx website. http://smartretailingrx.com/patient-care-counseling/clinical-performance-prove-moment-independent-pharmacies/. Published August 25, 2014. Accessed June 21, 2015.
• 2015 edition health information technology (Health IT) certification criteria, 2015 edition base electronic health record (EHR) definition, and ONC health IT certification program modifications: e-prescribing transactions or segments. Federal Register website. www.federalregister.gov/articles/2015/03/30/2015-06612/2015-edition-health-information-technology-health-it-certification-criteria-2015-edition-base#h-64. Published March 30, 2015. Accessed June 13, 2015.