Presented by NCPDP and HIMSS for the Pharmacy Informatics Community The Impact of Standards & Pharmacy Informatics September 20, 2012 Lisa Ashton, Pharm.D. Office of Health Information Integrity, California Health and Human Services. Lynne Gilbertson NCPDP Stephen C. Mullenix, R.Ph. NCPDP
Objectives Explain how pharmacy computer applications/systems communicate with each other and the differences between messaging standards, terminology standards, and functionality standards. Explain the role of NCPDP and how NCPDP brings together the pharmacy industry to create standards for sharing information about medications, supplies and services within the healthcare systems. Describe why prospective pharmacy informaticists and pharmacy schools should be prepared for optimal communication in healthcare. 2
A Pharmacy World Without Standards A physician would be handwriting a prescription for a patient to take to a pharmacy. The patient would pay cash and then submit a claim to the insurance that would be reimbursed or not. There would be as many types of claims forms as there are insurance companies. Allergies, drug interactions and duplicate meds would occur frequently. Medicare Part D would be impossible to administer. 3
Harmonization and Interoperability Standards contribute to a harmonized use of health information technology and exchange in pharmacy industry. The primary aim of standardization is to enable interoperability in a multi-vendor, multi-network, multi-disciplinary healthcare system. A standard is only one part of the design phase of an eventual product, but it is a critical part. 4
What s a One? Dose Form Proper Unit of Measurement Tablet (including convenience packs or oral contraceptive packs) Capsule (including convenience packs) Transdermal Patch Suppository Non-filled Hypodermic Syringe Kit Powder Packet Vial with Powder Non-drug Products (test strips, swabs, alcohol wipes) Tape Liquid (elixir, syrup, ophthalmic/otic liquids, bulk liquids, etc.) Reconstitutables (the volume in the container after the powder has been reconstituted into a liquid) Liquid Pre-filled Syringes EA Tablet EA Capsule EA Transdermal Patch EA Suppository EA Non-filled Hypodermic Syringe EA Kit EA Powder Packet EA Vial with Powder EA actual non-drug item in the container EA Tape ML or CC (in the exact metric quantity, not rounded off) Vial/Ampule with Liquid Inhalers, Nebulized Solutions (when labeled as ml on product) Solid (ointment, cream, bulk powder, etc.) Inhalers (when labeled as mcg, mg or gm on product) GM (in the exact metric quantity, not rounded off to whole numbers) (mcg is converted to gm) 5
Examples from E-Prescribing 6
What s a one? 7
What the heck? 8
NCPDP Standards 9
What is NCPDP? 10 An ANSI-accredited standards development organization. Provides a forum and marketplace for a diverse membership focused on health care and pharmacy business solutions. A member driven organization that has been named in various government legislation and rulings, such as HIPAA and the Medicare Part D Regulation. One of several Standards Development Organizations (SDOs) involved in Healthcare Information Technology and Standardization. Focus on pharmacy services, and has the highest member representation from the pharmacy services sector of healthcare. NCPDP standards are used in pharmacy processes, payer processes, electronic prescribing, rebates, and more. NCPDP dataq - provides healthcare stakeholders with up-to-date, comprehensive, and in-depth pharmacy information. NCPDP Online - enumerator of the NCPDP Provider ID number. HCIdea - NCPDP s relational healthcare prescriber database of over 2.1 million prescribers created for the industry, by the industry. RxReconn TM - NCPDP s legislative tracking product.
SCRIPT Standard Exchange between prescribers, pharmacies, intermediaries, payers New prescription request Change of new prescription Cancel of prescription Refill/renewals request/response or Resupply in long term care Fill Status notification Medication history exchange Drug Administration exchange in long term care Prescriber-reported samples for more robust medication history Query functions for new prescription requests Provides standardized, electronic exchanges in patient care reducing manual errors 11
Structured and Codified Sig Standard Standardizes the portion of an electronic prescription containing the directions for use using existing, accepted electronic transmission standards. To facilitate communication between prescribers and pharmacists, to improve the efficiency of the prescribing and dispensing activities and to help reduce the opportunity for errors. SCRIPT 10.6 and above support. Provides standardized, electronic exchanges in patient care reducing manual errors 12
Formulary and Benefit Standard Pharmacy benefit payers (including health plans and Pharmacy Benefit Managers) communicate formulary and benefit information to prescriber systems. Information for the prescriber to consider for the most appropriate drug choice for the patient. Which drugs are considered to be on formulary, and alternative medications for those drugs not on formulary Limitations that may impact whether the patient s benefit will cover a drug being considered (such as age limits, gender limits, step therapy rules, benefit-specific coverage exclusions, etc.) The cost to the patient for one drug option versus another Enables the physician to consider information during the prescribing process, so that he/she can make the most appropriate drug choice for the patient 13
Specialized Standard Exchange between prescribers, pharmacies, intermediaries, payers PHARMACY Respond to a request for census events initiate a request for clinical information initiate a response for clinical information Provides standardized, electronic exchanges in patient care reducing manual errors PRESCRIBER notify a pharmacy or other entity of drug administration events such as suspending administration initiate a request for clinical information initiate a response for clinical information ENTITIES (pharmacy, prescriber, intermediary, payer/health plan) initiate a request by the facility in a long term care environment to notify the pharmacy about census events initiate a request for clinical information initiate a response for clinical information 14
Functional Profiles To facilitate the capture and sharing of point of care prescription and medication related clinical data by Electronic Health Record (EHR) systems in a standard manner. EHR-S Standalone Electronic Prescribing Functional Profile and Pharmacy/Pharmacist Provider Functional Profile and Standalone Electronic Prescription EHR-S Functional Profile Developed jointly by NCPDP and HL7. These profiles indicate which functions are required, desired or implemented for certain EHR systems, Health Care Delivery settings, or other purposes. The profiles detail functions of systems and are used to support the development of interoperable EHR systems and the certification of those systems by the Certification Commission for Health Information Technology (CCHIT). 15
Telecommunication Standard Supports the following processes (and others) 1. Eligibility Verification 2. Claim billing 3. Service billing 4. Information Reporting 5. Prior Authorization 6. Controlled Substance Reporting 7. Predetermination of Benefits 16
Batch Standard A batch wrapper for the Telecommunication Standard Implementation Guide The same parsing routines can be used for the batch detail records as the real-time transactions. 17
Medicaid Subrogation Standard Medicaid Subrogation is a process whereby Medicaid is the payer of last resort. The state has reimbursed the pharmacy provider for covered claims and now is pursuing reimbursement from other payers for these claims. Some states may choose to Pay all claims in full, through a federal waiver, at the point of receipt and Chase reimbursements from responsible third parties after the fact. The Medicaid Subrogation transactions use the Telecommunication Standard Implementation Guide transactions wrapped in the Batch Standard Implementation Guide (The same parsing routines can be used for the batch detail records.) 18
Pharmacy and/or Combination ID Card Reduce consumer time caused by the lack of necessary information Minimum necessary information on front and back of card Legislated usage or discussion stage in most states Based on INCITS Provides a consistent implementation for the industry reducing frustration, lack of information, workflow interruptions 19
Billing Unit Standard A common billing unit language for the submission of prescription claims. New products are given a common identifier (each, ml, gram) for billing purposes. Provides a consistent and well-defined billing unit for use in pharmacy transactions for accurate reimbursement and drug utilization review 20
Audit Standard Defines the record layout for batch audit transactions between Auditors and Providers. Supports two types of audit functions: Desk Top Audit - the Auditor presents a list of prescriptions to a Provider. The Auditor asks for specific details about the prescriptions and the Provider must return those items to the Auditor by the date specified. For Desk Top audits, a detail record is required for each prescription that is to be part of the audit. In-Store Audits - the Auditor physically goes to the Provider s location and reviews records associated with prescriptions. For in-store audit requests, a detail record must present a range of information (e.g. prescription numbers) that the Provider will prepare for the Auditor prior to arrival. Piloting underway Provides standard method to support the business functions 21
Post Adjudication Standard Client Groups, Pharmacy Benefit Managers (PBMs), Payers, Fiscal Agents, Vendors, and Administrative Oversight Organizations will use this format to share post-adjudicated pharmacy claim data. The data is used to support: 1. Auditing of services 2. Retrospective DUR review 3. Statistical reporting 4. Evaluate Health Care 5. Evaluate Contractor performance 6. Develop and evaluate Capitation rates 7. Pay reinsurance (stop loss) to contractors 8. Develop fee for service payment rates. Provides standard method to share this data 22
Financial Information Reporting Standard A process whereby a patient, under one plan sponsor, has changed from one benefit plan Pharmacy Benefit Manager (PBM) to another benefit plan PBM and point-in-time financial information is moved from the previous PBM to the new PBM. Used in Medicare Part D processing now Facilitates the standardized exchange of information 23
Manufacturers Rebate Standard Rebate information from Pharmacy Management Organizations (PMOs) to Pharmaceutical Industry Contracting Organizations (PICOs). File Standard for submission of product utilization, plan membership, formulary information, market definitions, and reconciliation. Provides standard electronic format to adjudicate claims rebate processes 24
Medical Rebate Standard Provides a standardized format for health plans rebate submissions to multiple manufacturers throughout the industry. Implementation of the medical rebate exchange also eliminates the need for manufacturers to create internal mapping processes to standardize unique data formats from each health plan or third party administrator. Provides standard electronic format for rebate processes 25
Prior Authorization Transfer Standard Transferring prior authorizations between Pharmacy Benefit Managers (PBM) when clients (plans) change PBMs and request that their prior authorization data transfer from their previous to their new PBM. Provides standard methods that entities can use to share this data 26
Prescription Transfer Standard Transfer of prescriptions from one pharmacy to another (historical or open refills), or within a pharmacy when converting software systems. Allows compliance with regulatory requirements for the transfer of a prescription while introducing economies of scale 27
Retiree Drug Subsidy Standard Assists in the automation of summarized drug cost and related data transfer from one processor/pharmacy benefit manager to another processor/pharmacy benefit manager. Allows for the continuation of CMS Retiree Drug Subsidy (RDS) cost data reporting by the receiving entity for a given application ID plan year. Provides standard methods that entities can use to share this data 28
Uniform Healthcare Payer Data Standard Used by Client Groups, Pharmacy Benefit Managers (PBMs), Fiscal Agents, Vendors, and Administrative Oversight Organizations and State entities to share pharmacy claim data that is used to support statistical reporting, evaluation of healthcare, and State or regional reporting requirements. Used for data submission to a state agency or to a statesponsored healthcare payer data collection initiative. Provides standard methods that entities can use to share this data 29
Operating Rules for Connectivity Provides for consistent implementation of necessary business rules and guidelines for the electronic exchange of information used in pharmacy and electronic prescribing industry exchanges for NCPDP standards and the ASC X12 Standards transactions that are not defined by a standard or its implementation specifications as adopted. Provides standard method for connectivity in pharmacy industry functions. 30
Universal Claim Forms Paper forms for Standard Claim Billing Workers Compensation Billing Information at http://www.ncpdp.org/products.aspx 31
Data Dictionaries With all NCPDP standards, NCPDP Data Dictionaries and External Code Lists are available. Data Dictionaries contain names, definitions and other information on all of the data elements used in all NCPDP Standards. One Data Dictionary publication is applicable to one version of a standard. The Standards Matrix shows these tables. 32
External Code Lists External Code Lists (ECL) are a list of value codes with descriptions for data elements used within specified NCPDP Standards. Approved data element values contained in the External Code List document may be added to, modified, and/or deleted and result in a new publication of the ECL document and will not require a version/release change to applicable NCPDP Standards. ECL entries will point to non-ncpdp code lists used (ISO, ICD, SNOMED, FMT, etc) ECL allows support for fluid business needs for values. Emergency Telecommunication External Code List Value Addendum applies strictly to the Telecommunication Standard Version D.Ø and above to facilitate consistent adoption of the approved ECL versions within a reasonable, workable timeframe, across all industry participants. An annual implementation is recommended. Consideration of expedited implementation of regulatory-required values provided. The most current Addendum publication is available on the NCPDP website with the Data Dictionary and ECL publications. This allows support for fluid business needs and updates based on regulatory needs for values. 33
Pharmacy Informatics Training: Where we ve been and where we are going 34
Historical Perspective 1970s & 80s Pharmacy Informaticists Self-made On-the-job training Acute-care emphasis 35
Historical Perspective 1980s & 1990s Pharmacy Informaticists Ambulatory Expansion TEFRA/DRG s Real-time electronic Adjudication Pharmacy Informaticists largely self-made 36
Historical Perspective 2000 to present Pharmacy Informaticists Importance of Pharmacy Informatics/HIT welldocumented Multiple organizations weigh in (IOM, IMIA, APhA, AMIA, HIMSS, ASHP, AACP, etc.) E-HIT Collaborative Roadmap (2011) Pharmacy HIT Strategic Plan ACPE Standards 37
Historical Perspective 38
39 Questions?
Thank You! Lynne Gilbertson VP, Standards Development NCPDP lgilbertson@ncpdp.org www.ncpdp.org Stephen C. Mullenix, R.Ph. SVP, Public Policy & Industry Relations NCPDP smullenix@ncpdp.org www.ncpdp.org Lisa Ashton, Pharm.D. Office of Health Information Integrity, California Health and Human Services EAshton@ohi.ca.gov 40
Save the Dates! Pharmacy Informatics Town Hall Series: Thursday, October 18 12:00pm CT/1:00pm ET: eprescribing Fundamentals Thursday, November 15 12:00pm CT /1:00pm ET: Improving Medication Reconciliation with Standards http://www.himss.org/asp/topics_pharmacyinformatics.asp 41