How E-Prescribing Is Fostering Collaboration Between Payers and Providers

PDF File: 

HCT2_wp_stember_scott.pdf

NCPDP

We absolutely are where health care and other segments of this industryon the medical side want to be.

HCT: What do you see as the state of collaboration in the health care industry today?

Phillip Scott: I’ve seen a significant outreach in our area of responsibility, which is standards development. We have several initiatives under way, driven by other standards development organizations, to try to bring collaboration, common language, and understanding together among the various service delivery organizations. And while that happens fairly sporadically, I think that these are actually recent examples that are really kind of new for us. The National Council for Prescription Drug Programs (NCPDP) historically has reached out to other organizations because of the way our membership is made up of virtually every segment of the health care industry that deals with the pharmacy services sector. We have always had to reach out to different organizations and everything we do is built on consensus and collaboration among our diverse membership. Our membership is far reaching so we’ve been very open to collaboration and are starting to have some success in this arena now.

HCT: What role is the NCPDP playing in fostering those collaborations?

PS: Just on the basis of the way we are made up. Let me give you a brief background on our organization and what our goals are. We’re made up of six different segments that include everything from payers and processors to manufacturers, retailers, software vendors, wholesalers, consultants, and those of general interest. We meet four times a year in a very open environment in which every individual member has as much opportunity and influence as anyone else in the organization. If you have a business need, you bring it to the organization and within 90 days you’ll know whether we’re able to move forward on your initiative or not. So our organization is very reactive to an individual or an individual company’s business needs as well as the needs of the industry as a whole.

Lee Ann Stember: NCPDP is an American National Standards Institute-accredited standards organization and we have certain procedures and policies that we have to adhere to in order to maintain that accreditation. Talking about the business needs of the industry – one doesn’t have to be a member of NCPDP to bring forward any type of business request to the organization. That individual does not have to become a member to participate in the workgroup meetings. However, they’re not allowed to vote during that period. We encourage everyone from all aspects of health care to bring their initiatives forward so that we can address the needs of the industry.

HCT: Give us an overview of how pharmacy standards are evolving.

LS: NCPDP was founded in 1977 because there was a need to standardize a universal prescription claim form. In August of 1988 the industry had embraced that form to the point that NCPDP had distributed, in a six-month period, over 1 billion paper claim forms and that was more than MasterCard, Visa, and American Express combined. So that was really the first initiative of NCPDP, standardizing prescription claim forms. It moved into tape and it moved into diskette. Then, very rapidly, in 1988, a movement began to start submitting claims electronically. Today all of the pharmacy claims that are traveling electronically are on NCPDP standards and over 4 million claims are actually submitted in less than a seven-second time period.

HCT: How is the e-prescribing standard format evolving?

LS: That’s moving along very nicely. That standard is called our SCRIPT standard and that became accredited about four years ago. It’s been slow but now there’s been such a huge initiative to start motivating and educating physicians that it’s just not the hard dollars they have to invest, it’s also the investment of time for their employees to better understand what the standard is all about.

PS: It has eliminated the need for a company to have proprietary systems on both ends, both at the physician and at the retail pharmacy. So the standards now allow for open communication across these systems. Now with the advent of PDAs and some other technologies, we’re going to see it move rapidly. The Drug Enforcement Association’s (DEA’s) initiative of electronic prescribing has helped significantly but I think we’re actually on the cusp of seeing this break loose. In my opinion, e-prescribing could be as big of an influence over the next couple of years as HIPAA was – for different reasons.

HCT: How is e-prescribing fostering collaboration between payers and providers?

PS: Well, you’re coming at it from a medical side. E-Prescribing is really more community based, meaning the physician’s practice setting and the retail environment as opposed to hospitals and insurers. Cost savings on the retailers’ side is fostering collaboration. Significant time and energy is spent trying to verify the written prescription and by the pharmacists and the physicians’ staff answering telephones and responding to faxes between themselves and many pharmacies. If you think about it, a doctor has a very heavy patient load. A busy dermatologist will see as many as 100+ patients a day in a really active practice. If each one of those patients is going to a different pharmacy, there’s a potential for communications from 100 pharmacies faxing that doctor’s office. If you pull that over to an electronic environment, you could do everything you can do with a paper claim, but you can do it in a matter of seconds instead of a matter of hours. Just the ease of the workload and the improved safety factors will be enough economic stimulus to foster this collaboration. We’re seeing the physicians’ offices really becoming quite interested in this. It will still be a challenge making that leap from the medical environment to the pharmacy until the physicians’ office management systems become as sophisticated as the pharmacy management systems.

HCT: What process and technology changes are required?

PS: At the risk of oversimplifying, it’s a matter of programming. For example, you’re a medical systems vendor and you’re writing to SureScripts programming or you’re writing to RxHub programming to be certified as a vendor, and you’re writing to portions of the NCPDP SCRIPT standard. For $650, you could have bought those standards anytime since 1997 when you were building the systems; you could have just programmed for it as it went in. So this is fairly new to a lot of folks. It’s not like what happens with us on the pharmacy side when, for example, the Telecom Standard version 5.1 was put into place in legislation and everybody was at 3.2. Our standards have historically been adopted voluntarily and, as a result, people move to them as per demand or as it meets their needs. So 5.1 (being HIPAA legislated) forced the industry to move involuntarily to that and that created a huge dip. It becomes a matter of really establishing your priorities, putting it into the workflow process, and then programming for it.

HCT: What’s involved for the providers?

LS: Number one, investing in the technology, and then the education portion is the other component.

HCT: How about on the payer side – are they all ready to go with this?

PS: The payers have really been ready for this for a long time. I saw a quote that ProxiMed, for example, has more than 300,000 electronic prescription transactions a month and has processed more than 17 million transactions since they came in to work with their network of people, which is made up of pharmacies and physicians. And ProxiMed is one who will probably win big, I think, because they were pioneers in this arena. They were also hampered by the need to be proprietary on both ends just to complete the network. Now they don’t run into the same set of circumstances because more and more people are programming for this – certainly on the retailers’ side.

HCT: What would you say is the benefit to the quality of care ratio with the patients who are involved with doctors and companies that are using this system?

LS: I would think that the patient would be elated to be in a physician’s office and have this type of service available. Especially if you have a child who has, for example, an ear infection. The last thing that a mother wants to do is go and wait in a pharmacy for 45 minutes for her prescription to get filled for this sick child. The physician is submitting that prescription electronically to that patient’s pharmacy of choice and they can find out if that prescription is on the formulary and then they will be told that that prescription will be ready in 10, 20, or 30 minutes. So the mother ultimately has that choice either to get to that pharmacy right away or go later.

PS: They also know what the copay is.

LS: Exactly. Everything is being verified right there while the patient is consulting with the physician.

HCT: How is the physician identification standard evolving?

PS: The HCIdea Provider Lookup utility is not a standard. And we have intentionally left it out of the standards development arena because our standards evolve based on business needs. It takes sometimes as much as two or three years for a standard to be worked through, passed, and evolved. We chose to approach this like anyone else would as it relates to any business initiatives. So to answer your question – how it’s evolving – it’s doing quite well actually. We have more than 1 million records that have been standardized and tagged with a unique identifier, which is the HCID number. So there’s a little difference there. Most standards, with the exception of 5.1, move along as a result of actions that have been taken between business partners, and they decide that this business practice is beneficial to the industry and move it into the standards process. It is our intent to obtain momentum with HCID before filing or going through the standards development process.

HCT: Will this help the payer and provider to be able to share information with each other more easily and is that going to help toward this fostering of collaboration?

LS: Ultimately, yes. That’s the goal. But I think with all of the privacy laws, etc., that’s going to be one of our greatest challenges. I mean, patients are not really open to tell their gynecologist – as an example – that they are diabetic or that they have got some disease – AIDS as an example. Patients don’t want that shared. So that is going to be one of the hurdles that we’re going to have to overcome.

HCT: A single doctor in a solo practice might have some difficulty getting up to speed – maybe buying the hardware or software. Would the larger health care providers already be in a position to take advantage of what you are offering?

PS: You know, I think we need to step back a second and just do a point of clarification. If you are relating to HCID – the HC identifier at HCIdea – that is a database product. That product has the sole purpose of eliminating the use of the DEA number for the purpose of prescription claims adjudication. It is to give each physician a unique identifier that cross-references him to his multiple locations and multiple DEA numbers. Today the problem is twofold: When a physician writes a prescription, a DEA number must be included in the claim in order for it to be processed. That means that a lot of numbers get made up. A lot of stores put their own DEA numbers in, and because it’s just a mechanical function, that would only allow the claim to flow if that space is filled in. So in order to eliminate that and get the DEA back to its intent, which is to track the dispensing and distribution of controlled substances, we have created the HCIdea number. We know that in Southern California, for example, we have one doctor whom we’ve identified with 24 different practice locations and DEA numbers. So in the HCID database you will get one unique identifier – that physician has one identifier that essentially cross-references to the other 23 locations – his primary and his other 23 as well as his DEA number. So now, while you may have 24 records, you only have one physician and it’s standardized. When you look at the records like the DEA file, city, county, and state are not always in the same place. There’s the first address and the second address. Sometimes when you look at the file when it should be in the primary or first address it’s down as the second. So we’ve taken all that information and made it consistent, much like we did with the universal claim form.

HCT: Sounds like a great simplification process.

PS: And so that’s the purpose of HCID and the HCIdea project. And we felt comfortable in doing that because – 25 years ago, or maybe less – we created a provider file that enumerated every pharmacy in the United States. That enumerator ultimately became the de facto identifier for all pharmacies to the point that they can’t do any business without an NCPDP provider ID number. Will communications improve and will information flow be enhanced? Absolutely. Because now you know that who you’re referring to is actually who you’re referring to. And that’s huge because all the health systems are required to certify that this provider is in fact the person that they think they’re getting the prescriptions from.

HCT: The barriers in payer-provider collaboration still need to be addressed. Just like HL7 and HIPAA, people were at first a little resistant but now they’re actually seeing a lot of pluses in improving the quality of patient care through standard information that can be shared going in both directions. What do you think is going to happen with the work that you’re doing along that line?

PS: We are the standard bearer as it relates to communication moving in both directions around pharmacy transactions, claims, etc. That includes everything from drug utilization reviews to prospective payment for professional services to drug-drug interactions, allergies, and contraindicated drugs. All this information flow occurs in a seven-second timeframe when a prescription is being processed. Everything is reviewed at the same time to see if that patient’s taking that drug from a different pharmacy and for a different purpose. It’s reviewed to make sure that there’s no contraindication or drug-drug interactions that are in place with any other prescription that has been identified. It’s reviewed to make sure that a drug is not contraindicated for a condition that the patient may have, but the physician wasn’t aware of. And the pharmacy is paid in real time for that transaction and the financial transactions are bundled and checks paid to them once a week. We absolutely are where health care and other segments of this industry on the medical side want to be.

HCT: What does the future hold for pharmacy standards? And what changes do you anticipate in the next few years?

LS: Actually, what I see in the next couple of years, and we’ve been talking about it here today, is the ultimate embracing of the SCRIPT standard by the prescriber and understanding the value that this is going to bring to the industry. We’re talking about NCPDP and how fast these transactions are traveling in real time online – ultimately, that’s our goal – to have that happening on the prescriber side. Phillip talked briefly about our role in identifying the tip of the brick which is the NCPDP provider number, but HCIdea, which is the tip of the nose for each of the prescibers, I think is going to enhance and bring all of this together. This is something that we’ve been working on since the early ’90s, but seeing that come to fruition is going to help the industry embrace the SCRIPT Standard. I don’t believe it’s just the expense of buying the hardware or the software. Some of these plans are offering to give all of this equipment to the physicians, but until they get their staff educated and understand the value of what this can bring to them, ultimately nothing is really going to happen. I don’t believe it’s the cost of the equipment that is holding up this project.

PS: In the next level of communications between providers and payers and processors, it’s vital that all of the standards translate and can cross-communicate from one environment to another. Under HIPAA, NCPDP has been mapping the X12 standards so that it becomes electronic as opposed to having to go from an electronic world to a paper world. Our industry works watching silos. And that silo is divided into pharmacy and into the medical side. It’s also community, hospital and patient, long-term care, and back to the community. The only way that information moves from the silos, from one to another, boils down to a big brown envelope and a little brown sack. Today they tell a patient, “You’re going into the hospital. Be sure to put all of your medications into a brown sack and bring them with you, and the big brown envelope is your medical records and X-rays.” What happens today in a hospital environment happens in a cocoon and when that patient is released in the community and comes back home, the community pharmacist has no idea what transpired in the hospital unless the patient tells them. And the need is collaboration – for us to be able to move it out of the medical environment, back into the community environment with the same speed and efficiency that has been happening with pharmacy for 20 years. So if there’s anything that I see that’s going to happen, it’s that we’re ultimately going to get rid of the little brown sack and the big brown envelope. And when that happens, we won’t have to be concerned that three of the prescriptions that grandma was taking were left in the medicine cabinet because the person picking those up didn’t know where to look.