Effici ientInt tegratio onofM Medica ations mentin ntoanOutpatientC ClinicEH HR Managem

MedicationsManage ementGroup pKerryHei ineke,Nancy yCelmins,EdwardFlam MMI405 5HITIntegration,Inter roperability, andStanda rdsSumm mer2011 NicholasBertram

Contents
Introduction..................................................................................................................................................1 StakeholderIdentification............................................................................................................................1 BusinessCase................................................................................................................................................2 BusinessIssue...........................................................................................................................................2 BusinessProblem..................................................................................................................................2 People,ProcessesandProductsImpacted...........................................................................................2 BusinessJustification................................................................................................................................3 FinancialAnalysis..................................................................................................................................3 RegulatoryConcerns.............................................................................................................................4 HowtheSolutionFitstheStrategyofourOrganization.......................................................................5 GoalsandObjectives ................................................................................................................................6 . CriteriaforPatientCenteredCareSuccess ..........................................................................................6 . CriteriaforStaffCenteredSuccess.......................................................................................................7 CriteriaforFinancialSuccess................................................................................................................8 CriteriaforRegulatorySuccess.............................................................................................................9 WorkflowandWorkflowDiagrams ............................................................................................................10 . Currentworkflow....................................................................................................................................10 Improvedworkflow.................................................................................................................................14 . UtilizationofStandards ..............................................................................................................................18 StandardsSchematic...................................................................................................................................19 InformationSystemFunctionalRequirements...........................................................................................19 DiagramofInformationArchitecture.........................................................................................................22 DefiningOriginofDataElements ...............................................................................................................23 . FlowofDatasetsbetweenSystems............................................................................................................24 Conclusion...................................................................................................................................................24 Bibliography................................................................................................................................................25

Introduction
Nohealthcarebusinessplancanbefullyimplementedwithoutindicatingawelldescribedvision ofthemissions,goalsandobjectives.Thesemeasuresmustbewelldefined,withthespecificoutcomes describedanddeterminationofvaluesexplained.Thebusinessplanneedstoaddressthesuccessofthe endeavorfromfourseparatebutinterconnectedvantagepoints.Eachaspectshouldbeassessedforits ownweight,aswellasbyitsimportancetothebusinessplanasawhole.

Stakeholder Identification
Thestakeholdersforintegratingpharmacyprescriptioninformationwithaclinicselectronic healthrecord(EHR)aredescribedbelow.Includedaretheneedsofeachstakeholder. PrescribingCliniciansneedtoensuretheirpatientsaretakingcorrectmedicationsatthecorrectdose. Withoutacknowledgementbackfromthepharmacythatthepatientpickeduptheprescription,they arelefttoassumepatientcomplianceandfuturecaredecisionsmaybebasedontheinaccurate medicationslistfoundintheEHR.Inaddition,beforeaproviderprescribesamedication,itwouldbe prudenttocheckforothersimilarprescriptionsalreadyfilledfromotherproviders.Thiswillprevent duplicationofprescriptionsandpotentialabuseofdrugs. PharmaciesWithoutnotificationfromtheprovider,thepharmacydoesnotknowwhentodiscontinue medicationsduetoadosechangeorsubstitutemedication.Patientsmayenduprefillingthewrong prescription,whichmayresultinmedicationbeingreturnedtopharmacyand/orundesiredpatient outcomes.Inaddition,afteraproviderelectronicallysendsaprescriptiontothepharmacy,theyare oftenlefttoreshelfprescriptionswhenpatientsdonotpickthemup. ThirdPartyPayersbypreventingduplicateprescriptionsandlettingthepharmacyknowwhenthe providerhasdiscontinuedmedicationswillallowfordecreasedhealthcarecosts.Insurancemaybe payingtwiceforthesameorsimilarprescriptionalreadyfilledatanotherpharmacyorbyanother provider.Inaddition,whenthepharmacyknowsthataproviderhasdiscontinuedamedication,the payerwillnotkeeppayingforfuturerefillsrequestedbythepatient.

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Business Case
Ourprojectproposesthecreationofabidirectionalcommunicationprocessbetweenthe providerandpharmacy,integratingthecareprovidedinanoutpatientclinicwiththecareprovidedina retailpharmacy,inordertoreducehealthcarecostsandimprovepatientoutcomesformedicationnon compliantcases.

Business Issue
Business Problem Whenapatientdoesnotpickuptheirprescription(orpickitupdaysorweekslater)atthe pharmacy,theprovidersEHRisinaccuratesinceitshowsthepatientisactivelytakingthemedication (Shrank,etal.,2010). Thereisapotentialpatienthealthissueifthepatientisnottakingmedicationthatisneededfor theircondition(Shrank,etal.,2010). Whenproviderschangemedications,whetheritisadifferentdrugoradifferentdoseofthe samedrug,bynotupdatingthedispensingpharmacy,thepatientmayinadvertentlyrefilltheincorrect medicationinthefuture.Pleaserefertothetwoscenariosbelow. People, Processes and Products Impacted Providerswhenpatientsdonottakethecorrectprescription,providershavetoassumepatient complianceperwhatisdocumentedintheEHR.Futurecaredecisionsmaybebasedontheinaccurate medicationslistfoundintheEHR. Pharmaciesthepharmacywastestimeandresourcesbyfillingprescriptionsthatarenotpickedupby thepatientandthenreshelvingthedrug(Shrank,etal.,2010).Inaddition,thepharmacydoesnotknow whentodiscontinuemedicationsduetoadosechangeorwhenamedicationissubstitutedforanother. Patientsmayenduprefillingthewrongprescription,whichmayresultinmedicationbeingreturnedto pharmacyand/orundesiredpatientoutcomes. Patientswhenprescriptionsaregiventothepatient,thepatientmaydecidethattheycannotaffordit anddecidetonotfillit.Theimpactistwofold:1)continuityofcaremayhaveundesiredoutcomes.For example,thepatientmaypresenttotheclinicforanencounterwithadifferentproviderwhobases treatmentplansonthecurrentmedicationslistintheEHR.2)Thepatientshealthmaysufferduetonot takingthemedication. Insurance/ThirdPartyPayersinsurancecompaniesmayenduppayingformedicationsthatarenot takenduetothepatientrefillingthewrongdose.
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Business Justification
Financial Analysis Thisprojectexaminesthefactorssurroundingmedicationcompliance,alsoknownasmedication adherence,andoffersaninnovativesolutiontoaddresstheproblemandjustifythefinancial expenditurerequiredtoincreasemedicationcompliance(primarilysoftwaredevelopmentandsystems integration).Theprimaryareawhereanalysishasbeendoneinrelationtomedicationcomplianceisthe assessmentofthehealthriskposedbypatientsnotcontinuingtheirdrugtherapybetweenclinicvisits andthefinancialimpactonthehealthsystemandthepatientoverallbymedicationnoncompliance. Thissectionwillreviewtheresearchperformedbasedonliteraturepublishedoverthelast20years frombothphysicianprovidersandtheretailpharmaceuticalindustry.Theresearchhasbeenusedto supportmandatesinthePatientProtectionandAffordableCareAct(PPACA)legislationpassedin2010, inparticularimprovingqualityandcareoutcomesaswellasenhancinghealthcareinformation technologys(HIT)MeaningfulUsemandates.Inaddition,thissectionwillsummarizewhatsomelarge retailpharmaciesarealreadydoingtohelpbridgetheproviderpatientpharmacydisconnectthathas ledtomedicationnoncompliance. Asoutpatientproceduresandtreatmentgrow(asapercentageofoverallhealthcarespending) attheexpenseofinpatienttreatment(Kimbuende,2010)andmaintainsthepositionofthemajorityof clinicaltreatment,itisanaturalprogressiontoconsidertheincreasingamountofresourcesspenton prescriptions.IntheU.S.alone,prescriptionsfilledandrefilled,accountedfor6%and8%ofhealthcare spendin1994and1998respectively(Chawla,2001)growingto10%ofhealthcarespendin2008 (Kimbuende,2010).Forthepurposesofthisproject,werevieweddatathatindicatedmedicationnon compliancewasestimatedtoincreaseoverallhealthcarecostsfrom$170billion(Fischer,2009)to$280 billionintheUnitedStatesalone(NationalAssociationofChainDrugStores(NACDS),2011).Ithasbeen notedthatdespitetheknowledgeofhowmuchmedicationnoncompliancereallycoststhehealth system,onlywhengovernmentsponsoredhealthinsurancelosesenoughmoneywillsomethingtrulybe done(Mitka,2010).Theimplicationisthatuntilalargeenoughblockofpayers(theU.S.Governments sponsorshipofMedicareandMedicaidfundingforexample)stepinandmandateimprovement,our healthsystemwillcontinuetoseeavoidablelossoflifeandincreasedhealthcarecosts.Enoughanalysis hasbeenperformedtoknowthattargetingthemajorchronicconditions(Diabetes,Cholesterol, Hypertension,BehavioralHealth,Parkinsonsdisease,Respiratoryillness,HeartFailure,Osteoporosis, andEnlargedProstate(BPH))withmedicationcompliancetechniqueswillleadtoahealthierpopulation overallastheseconditionswillremainincheckwithpropermedicationtherapies(CVSCaremark,2011). Inadditiontothehundredsofbillionsofavoidablespendingenumeratedabove,over$100billion dollars(NationalAssociationofChainDrugStores(NACDS),2011)isspentannuallybytheretail pharmaciesforprescriptionswhicharefilledbutneverpickedupbythepatient.Theobviousdriverfora pharmacyretailoperationistoreducetheleakageamountsignificantlywhichcontributesdirectlyto thepharmacysprofitabilityaswellasimprovedpatienthealth.Anadditionalfinancialdriverfor integratingtheproviderandpharmacyfurtheristhattherewillbefinallyanopportunityforboth organizationstominetheirownprescriptiondatanotonlyfromwhatisbeingprescribedbuthowwell
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thepatientstoleratetheirmedicationaidinginutilizationreportingforthepharmaceuticalindustry.The analysisofcompliancehasbeendoneattheresearchstudylevelbutdespitetheevidencethat medicationcomplianceleadstobetterhealth,therehavenotbeenanysignificantstudiestoreportthis (Gellad,2010).Byintegratingprescribedmedicationstowhatisactuallyfilledattheretailleveland trackingthatperformanceagainstabodyofpatientsbackthroughanEHR,theconnectioniseffectively bridged. Regulatory Concerns IncludedinthepassageofPPACAin2010weremandatesnecessitatingtheimprovementofcare bypayingbasedonimprovedhealthoutcomeandmandatedtheexpansionofHIT.Amongthe MeaningfulUseguidelinesreleasedwastheadditionofeprescribingtechnologiesallowingaprovider toseamlesslycommunicatewithapatientpharmacy.Theintentwastoreducethechancethatthe patientwouldforgettofillordroptheirprescribedpharmaceuticaltherapyattheconclusionofaclinical officevisitaswellasintendedintegrationoftwocriticalpartsofthehealthcareindustry.Inaddition, otherproviderorganizationshaveappliednewmethodstoimprovemedicationcompliance.For example,aspartofanexpandedmedicalhomemodelofcontinuedcare,GeisingerHealthSystemhas deployedtheuseofamedicationspreferencesurveytobecompletedpriortoaphysicianofficevisit. Nursesreviewthesurveyandactivelyfollowupconcerningmedicationquestions.Thesurveyuse combinedwithadjustmentsinpricingofcertainchronicconditionmedicationshasprovidedGeisinger withacostreductionoffivetosevenpercent(Cutler,2010).Inadditiontohealthsystemsactively engagingpatientsdirectlywiththeirmedicationscompliance,largeretailoperationsalsoactively engagepatientstohelpensurethatprescriptionsarefilledappropriatelyandthatthemedicationis actuallyusedaspartofthecontinuedtherapyafteraphysiciansofficevisit.Caremark,aleading retailer,activelyengagesinseveralactivitiesaspartoftheirongoingefforttoimprovemedication compliance.Inparticular,Caremarkmaintainssixseparateactivitiesdesignedtopromotebetterhealth throughmedicationcompliance.Promotingmedicationcompliancecontributestothereductionin healthcarecostsbutCaremarkalsoprovidesdirectsavingstoapatient.Theactivitieswhichproduce financialsavingsinclude: FirstFillCounseling:Designedtobreakthecycleoftheoneinthreepatientswhodecideto discontinuetheirmedicationbeforetheirfirstrefill AdherenceOutreach:Designedtobreakthecycleofthethreeinfourpatientswhostoptakingtheir medicationbeforetheendoftheirprescribedtimeperiod InteractiveVoiceResponse(IVR)RefillReminders:Designedtoautomaticallynotifypatientswhen theirprescriptionisreadyforarefill ConsolidationCounseling:Designedtoguidepatientsthatusemultiplepharmaciestoasingle pharmacysincemultiplepharmacyusersarefivetimesmorelikelytobecomenoncompliant NewPrescriptionPickup:Designedtobreakthecycleofthetwointhreefirsttimeprescriptionsthat arefilledatthepharmacybutnotpickedupbythepatient OutofPocketCostReduction:Patientoutofpocketcostsarealoneamajorreasonwhymedication compliancebreaksdown;Caremarkresearcheslowercostalternativestohelpimprovecompliance
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Inaddition ntoPPACA,w whichhasbee enusedtohe lpproviderorganizationsbecomeinvolved inme edicationcom mpliance,thep primarylegisl lationinvolve edinmedicationcomplian nceistheMed dicare PrescriptionDrug,Improvemen nt,andModer rnizationAct of2003whic chactivelyde efinedmedica ation TheActassign nedfivekeya areasforMTM Mallofwhicharetheba asis therapymanagement(MTM).T rogramssuchastheonein nusebyCaremarkdescrib edabove.Thefiveareasid dentifiedinclude: forpr Condu uctingamedicationtherap pyreviewbet tweenthepa atientandpha armacist Devel lopmentofapersonalmed dicationrecordforpatie entmedicatio onhistory sstracking Devel lopmentofamedicationrelatedaction nplanforpa atientprogres Interv ventionorref ferraltowork kwithapresc cribingphysic cianorotherh healthcarepr rofessionalto o resolv vemedication nrelatedprob blems Docum mentationcre eationandtracking

How the Solution Fit ts the Strate egy of our Or rganization n

Beforeproceedingtodiscus sstheworkflo owswhichwiillelaboratef furtherhowo oursolutionf fits intotheg generalstrategyofreducin ngmedication nnoncomplia ance,thefollo owingchartd depictstheex xtent atwhicht thedisconnec ctpresentlye existsbetweenprescribing gprovidersan ndtheretailp pharmacy.All lfour criteriadisplayedwillb beaddressedbyoursoluti ion.Ourfocus sonmedicationcomplianceaimstobr reak meofthereas sonsbehindn noncomplian nceandtosho owwithminimalchangestoexisting downsom infrastruc cture,provide erscanbenot tifiedandactappropriatellywhentheir rpatientseith hertakethew wrong dosageof fprescribedd drugtherapyo ordonotfillo orpickupthe eirprescribed ddrugtherapy y.Asdiscusse edin theworkf flow,theadde edcommunic cationbetwee entheretailp pharmacyandproviderwillworktowards diminishin ngtheneedle essexpenseo ofpatientsconsumingmor rehealthcareservicestocorrectsomet thing whichwasavoidableattheirstarto oftheirtreatm ment.

Fig gurecitedfromPharmacies:Improv vingHealthReduc cingCost:(Nationa alAssociationofC ChainDrugStores( (NACDS),2011) EfficientIntegrationofMedication nsManagementin ntoanOutpatient tClinicEHR MMI405HITIntegratio on,Interoperabilit ty,andStandards Page5

Goals and Objectives

Criteria for PatientCentered Care Success PatientSafety: Theprimarycriteriaforpatientcaresuccessshouldbepatientsafety.TheInstituteforSafeMedication PracticespublishedImprovingMedicationSafetyincommunityPharmacy:assessingRiskand OpportunitiesforChangewiththefollowingsafetyprocesses: PatientInformation: o Routinelyaskfordiagnosisandcomorbidconditions,includingpregnancy o Whentranscribingtelephoneorders,usetwopatientidentifiers,utilizeaprescriptionpad thatpromptsforallergies,weightforchildrenunder6yearsofage,anddrugindication o Names:Theprocedureforenteringnamesshouldensurethatthereisonlyonenameper individual.Processshouldallowfornamesuffixes.First/Lastnameinterchangesshouldbe carefullyassessed.Ifpossible,ascannedcopyofaninsuranceorIDcardcanaccompanytext data. o DateofBirthshouldbeoneveryprescriptionhardcopyandreceipt o Children6yearsandundershouldhavedocumentedrecentweight o Patientdemographicsshouldbeupdatedyearly OrderEntry: o Systemdesignedtopreventdispensingifthereisnoallergyinformationontheprofile DrugUtilizationReview: o Updatemedicationprofilewitheachvisitincluding: Prescriptiondrugs Nonprescriptiondrugs Herbalremedies Dietarysupplements Othermedicationsfilledatotherpharmacies o Comparedrugwithclinicalindicationsanddruginteractions o DOBshouldbehighlightedforchildrensixyearsandunder: Incomputersystem Onreceipt Onprescriptionhardcopy o IdentifypatientseligibleforMedicationTherapyManagementServices(MTMS)(Institute forSafeMedicationPractices,2009)(U.S.GovernmentCenterforMedicare&Medicaid Services,2011) PickUpStage: o Usetwouniquepatientidentifiersatpointofsale o Confirmallergiesatpickup o Providepatientwithupdatedmedicationlistannually,&confirmlistwithpatient o Knowpatientslanguageofpreference,education,orreadingability,ifthereareanyvisual orauditoryimpairmenttoensurethattheircounselingisappropriatetotheirneeds
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 PatientSatisfaction: TheHospitalConsumerAssessmentofHealthcareProvidersandSystems(HCAHPS)isastandardized inpatientsurveythatassessespatientsatisfactionregardingtheirhospitalizationexperience(U.S. GovernmentCenterforMedicare&MedicaidServices,2011).Wecanadoptseveralofthesequestions toaddressPatientSatisfactioninouroutpatientpharmacysystemincluding: 1. Wereyougivenanymedicinethatyouhadnottakenbefore? YesNo 2. Didthestafftellyouwhatthemedicinewasfor? NeverSome mesUsuallyAlways 3. Didthestaffexplaintoyoupossiblesideeffectsinawayyoucouldunderstand? NeverSome mesUsuallyAlways PatientQualityofCare: Qualityofcarecanbemeasuredbycompilingscoresforthemetricsalreadydescribed,andthenadding additionaldatapointsappropriateforthelocalpopulation,forexample: Scoresforstateinspectionsurveys ScoresforselfassessmentfromtheInstituteforSafeMedicationPractice Scoresforpatientsatisfaction o Waittimes Scoresforpatientvaccinationrates Scoresforpercentageofprescriptionspickedup Scoresforpercentageofappropriateprescribingoflessexpensivealternatives Criteria for StaffCentered Success Beginninginthemid1990sthepharmacistprofessiondevelopedashortage.Thiswasattributedto severalissuesincluding: Increasedprescriptiondruguse Increasedscopeofpractice Shiftinfieldfromoutpatientcommunitypharmaciestoinpatientandclinicalvenues Lowerthananticipateduseofautomationandpharmacyparaprofessionals Inefficienciesinstandardprocesses,thatwerethenmagnifiedbytheabovementionedissues (Cooksey,Knapp,Walton,&Cultice,2002) Pharmacistrecruitmentandretentionthereforeisofgreatimportance.Ensuringsafety,jobsatisfaction andreliableproductivityforthestaffwilllikelyresultinhigherpatientsatisfactionscoresaswell. Becausecustomersatisfactionistiedtotheperceivedfriendlinessandhelpfulnessofthepharmacist,as wellaswaittimes(Arthur,2005),pharmacistsatisfactionandefficiencyisimportant.
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Clinicianswhoarewritingtheprescriptionsarealsopartofthestaffnecessarytoprovidesafecare,and theirsatisfactionwillpositivelyimpactproductivity.Indeed,thesethreefactors,safety,satisfactionand productivity,aresolidlylinked. StaffSafety: Carefulworkstationdesignisvital.Propertraininginergonomicscanhelptoavoidissuesrelatedto repetitivemotioninjuriesorworkstationpostureandvisualcomfort(U.S.GovernmentDepartmentof Labor,2007). StaffSatisfaction: Properlydesigned,acomputerizedproviderorderentryanddocumentationsystemwillbeeasytouse, saferandassistivetotheprovider.Developmentofaneasytoread,easytouse,intuitivesystemthat allowsthephysicianornursepractitionertospendmoretimewiththepatientandresultsinacoherent, organizeddocumentwillimprovesatisfactiononbothsides.Clinicaldecisionsupportcanassistwith differentialdiagnosis.Automaticalertsremindstaffofimportantallergies,sensitivitiesandother reminders.Computerizedorderentrysavestime,andallowsforinstantcomparisonwiththeprovider prescriptionstothepatientsinsuranceplanformularyaswellasinformationregardingallergiesordrug interactions.BetterpatientcareandaneasytoimplementCPOEwillimproveprovidersatisfaction. StaffProductivity: Cooksey,etalcitesphysical,organizationalandinformationalseparationofmanypharmacistsand pharmaciesfromotherhealthcareprovidersthatcreatesmajorstructuralandprocessbarriers: Insufficientormissingpatientmedicalinformation Inadequatepatientprivacyandconfidentiality Incompleteorineffectiveprofessionalcommunication Toomanyapprovedformularies (Cooksey,Knapp,Walton,&Cultice,2002)

Whilethearticleisdirectedspecificallytowardspharmacies,thepractitionerswritingtheprescriptions willnodoubtaffirmtheseconcerns.AwelldesignedanduserfriendlyPHRwillimproveproductivityand communicationbetweencliniciansandpharmacists. Criteria for Financial Success Financialsuccesswillbemeasuredbothdirectlyandindirectly.Abusinessplanthatearnestly addressestheneedsofthepatient,withafocusonaccuracyofthepatientsEHR,consistentmedication reconciliationandeducation,andspecialattentiontoensuringthatmedicationsareaffordableand effectivewilldrivepatientsatisfaction.Thiswillimproveadherencetoscheduledvisitsandmedication regimes,andthereforemaintainpatientvolumeandloyalty.Itwilldecreasenoshowsandpatientloss, andimprovethehealthofindividualsandthepublic.Medicationcompliancealsoaffectsthequalityand lengthoflifeleadingtobetterpublichealth,areductionofemployeeabsenteeismandimprovementof overallworkerproductivity(Cutler,2010).
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Criteria for Regulatory Success Thebusinessplanmustfirstcomplywithanyregulatoryspecifications.Exceptfortheregulation ofdrugsthemselves,mostgovernmentregulationsconcerningpharmaciesareaddressedatthestate level.TheU.S.FoodandDrugAdministration(FDA)isabranchoftheDepartmentofHealthandHuman Services(HHS).TheresponsibilityoftheFDAistoensurethatpublichealthissafeguardedbyensuring thatdrugsavailableintheU.S.arereliable,unadulteratedandreasonablysafetouse(U.S.Government Food&DrugAdministration,2011).Thestatelevelisresponsibleforlicensureandregulationof pharmacies,wheredrugsaresoldeitherwithorwithoutprescriptiontothegeneralpublic.Forexample, theStateofIllinoisBoardofPharmacyisresponsibleforregulationofcommunitypharmaciesandthe pharmaciststhatstaffthem.IncludedintheIllinoisPharmacyPracticeActaresubpartsregulatingTypes ofPharmacies,PharmacyStandards,andPharmacyOperations(StateofIllinois,2011). MostimportanttoourdiscussionareSubpartsE:RemotePrescription/MedicationOrderProcessing, SubpartF:ElectronicEquipmentRequirementsandSubpartG:ElectronicTransmissionofPrescriptions. Regardingtheprovidingofremoteprescription/medicationorderprocessing,thestateofIllinois requires: Thatthepharmacyberegisteredinitsstate ThatanelectroniccommunicationmethodbeHIPAAcompliantandsecure Thatthesystemallowsremoteaccesstoallrelevantpatientdatarequiredbythepharmacistfilling theprescription(i.e.medicationprofile,currentlabvalues,etc) Thattheelectronicsystembemaintaineddaily Inaddition,therearespecificrequirementsregardingthecapabilitiesoftheelectronicequipment: Thepharmacymusthaveacomputer,scanner,faxandprinter Allprescriptionsmustbefaxedandsequentiallynumbered.Theprescriptionlabelsmustbe producedatthefillingpharmacybutviewableatthehomepharmacy(iftwopharmaciesare involved). Scannedprescriptionsmustbeviewedatbothpharmacies(again,ifmorethanonepharmacyis involved.Thisisdiscouragedbutinthecaseofvacationsorothermitigatingfactors,canoccur). Allpatientdemographicandprescriptioninformationmustbeviewableatboththehomeand remotepharmaciesinrealtime Inthecaseofmultiplepharmacies,itmustbeeasilydiscerniblewhichpharmacyfilledaprescription Theoriginalprescription(oranexact,unalterableimage)mustbekeptonfile Finally,regardingelectronictransmissionofaprescription: Thetransmissionmaybedirectorthroughanintermediary.Buttheprescriptioncannotbealtered. Anelectronicprescriptionmustincludeallofthenormallyrecognizedrequirementsregardingform, content,recordkeepingandprocessing o Inaddition,itshouldalsoinclude: Thefacsimilenumber,ifappropriate Thedateandtimeofthetransmission
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Theidentityofthepersontransmitting,aswellasthecontactinformationand addressofthatperson Theelectronicequipmentmustbeinthepharmacyarea Ifafacsimile,itmustbenonfading.Aspreviouslydiscussed,thefacsimileisalegalrecordofthe prescription. Electronicrecordsareallowed,aslongastheyarereadilyretrievableandproperlysecured Thepharmacistandpractitionercannotmakeanysortofagreementthatwouldrestrictthe patientsabilitytochooseapharmacy PrescriptionsforcontrolledsubstancesmustmeetFederalregulations(U.S.Government DepartmentofJustice,2010)

Workflow and Workflow Diagrams

Thefollowingscenariosdescribecommonworkflowsofaproviderprescribinganewmedication forapatientwithsubsequentdosechangesandrefillsrequestedbythepatient.Thiswillthenbe followedbyanimprovedworkflowofeachscenariobasedontheproposedintegratedsolution.A flowchartfollowseachscenario.

Current workflow
Newprescription: Aproviderseesapatient(neworestablished)anddecidestoorderLevoxyl125mcg.The patienttellstheproviderherpreferredpharmacyisWalMartpharmacyandtheproviderfaxesit(or sendsitviaelectronicdatainterchange)tothepharmacy.Theelectronichealthrecordnowindicates thatthepatientisactivelytakingLevoxylat125mcgandthattheprescriptionwassenttothepatients preferredwhichisstoredasWalMart. WalMartfillstheorderandwaitsforthepatienttopickitup.Ifthepatientdecidesnottopick itup,thepharmacyreshelvestheprescriptionbutdoesnottelltheproviderthatthepatientfailedto pickitup.TheprovidersEHRstillshowsthepatientisactivelytakingthemedicationwhentheyarenot. Ifthepatientdoespickitup,thereisnocommunicationbacktotheproviderthatthepatienthas complied.Inthiscase,itispresumedthatthepatientistakingthemedicationasprescribed.

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 Revisiont topreviousp prescription: Continuingthe esamescenarioasabove,thepatientr returnsforaf followupvisi it.Becauseth he ThyroidStimu ulatingHormone(TSH)lab btestistoolo ow,theprovid dermakesan nadjustmentto patientsT thestreng gthoftheme edicationbyw writinganewprescription foralowerd dose,100mcg g.Thephysician faxesoverthenewpre escriptionbut tdoesnottellthepharma acytodiscont tinuetheprev viousprescrip ption. WalMartfillst W theneworde erandwaitsf forthepatien nttopickitup p.Assumingt thepatientpicksit up,theph harmacydoes sntremindth hepatienttostoptakingt theolddose.Inaddition,t thepharmacy y doesntse endacknowle edgementbac cktotheprov viderthatthe epatientpick kedupthepre escription.Ift the

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patientdoesntpickupthemedication,againtheEHRisinaccurateasitshowsthepatientistaking100 mcgbutshemaybetaking125mcgsinceshedidntpickupthenewprescription. Whenitistimetorefilltheprescription,thepatientcallstheprescriptionautomatedrefillline andispromptedtoentertheprescriptionnumber.Ifthepatiententersthewrongprescriptionnumber, thesystemwillacceptitandthepharmacywillfilltheincorrectprescription.Whenthepatientpicksit up,shemaynotremembertocheckthestrength.TheEHRisshowingtheincorrectstrength.An alternativeworkflowisthattheproviderfaxestheprescriptiontoamailorderpharmacysuchasMedco. Inthiscase,whenitstimetorefilltheprescription,thepatientisgiventhechoiceoftwodifferent strengthstoselect.Thepatientmaypickthewrongoneandthereisnoedittopreventthisfrom happening. Implication:Whilethepatientistakingtheincorrectdoseinbothcases,theEHRisincorrectlyshowing that100mcgisthecurrentdose.Patientcaredecisionsarebasedonthecurrentmedicationslistshown intheEHR.Labteststakenduringfutureofficevisitsmaynotpresentaclearpicturetotheprovider (e.g.,theprovidermaywonderwhyTSHisnothigheriftheLevoxyldoseislower). Alternateworkflow:Theprovidercouldhandtheprescriptiontothepatientiftheyprefertotakeitto theirpharmacyofchoice.Thepatientmayormaynottaketheprescriptiontoapharmacyandmayor maynottakethemedication.Thereisnochecktoverifythatthepatienthasfilledtheprescription.

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Improved workflow
Newprescription: Aproviderseesapatient(neworestablished)anddecidestoorderLevoxyl125mcg.The patienttellstheproviderherpreferredpharmacyisWalMartpharmacyandtheproviderfaxesit(or sendsitviaelectronicdatainterchange)tothepharmacy.Theelectronichealthrecordnowindicates thatthepatientisactivelytakingLevoxylat125mcgandthattheprescriptionwassenttothepatients preferredwhichisstoredasWalMart. WalMartfillstheorderandwaitsforthepatienttopickitup.Ifthepatientdecidesnottopick itup,thepharmacyreshelvestheprescriptionandtellstheproviderthatthepatientfailedtopickitup. ThepatientsmedicationlistintheEHRisupdatedwithanotethatthepatientdidntpickupthe prescription.Ifthepatientdoespickitup,thepharmacistwillcounselthepatientontheimportanceof continuingtheirmedication(CVSCaremark,2011).Inaddition,thepharmacysendscommunicationback totheproviderthatthepatientpickeditup.Thecommunicationautomaticallyupdatesthemedication listbynotingthatthepatientpickeduptheprescription.Itispresumedthatthepatientistakingthe medicationasprescribed. Alternateworkflow:Theprovidercouldhandtheprescriptiontothepatientiftheyprefertotakeitto theirpharmacyofchoice.Thepatientmayormaynottaketheprescriptiontoapharmacyandmayor maynottakethemedication.TheEHRcouldbesetuptoautomaticallynotifytheprescribingprovider that,afterapredeterminedamountoftimehaspassedwithoutreceivingnotificationbackfromthe pharmacy,thepatienthasnotcompliedwithobtainingandtakingtheprescription.Theprovidersoffice couldthencontactthepatienttoremindhertopickuptheprescriptionandmakeanoteinthe medicationlistthatthepatientmaynotbetakingtheirprescription.

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Revisiontopreviousprescription: Continuingthesamescenarioasabove,thepatientreturnsforafollowupvisit.Becausethe patientsThyroidStimulatingHormone(TSH)labtestistoolow,theprovidermakesanadjustmentto thestrengthofthemedicationbywritinganewprescriptionforalowerdose,100mcg.Thephysician faxesoverthenewprescriptionandsendsacommunicationtothepharmacytodiscontinuethe previousprescription. WalMartdiscontinuestheoldprescriptionandfillstheneworder,waitingforthepatientto pickitup.Assumingthepatientpicksitup,thepharmacyremindsthepatienttostoptakingtheold dose.Inaddition,thepharmacysendsacknowledgementbacktotheproviderthatthepatientpickedup theprescription.Ifthepatientdoesntpickupthemedication,thepharmacysendsacommunication backtotheproviderindicatingthatthepatientdidntpickuptheprescription.Also,thepharmacy attemptstocontactthepatientandgiveherareminderthatthephysicianhaschangedherdoseand sheneedstocomeinforthenewprescription. Whenitistimetorefilltheprescription,thepatientcallstheautomatedprescriptionrefillline andispromptedtoentertheprescriptionnumber.Ifthepatiententersthewrongprescriptionnumber, thesystemtellsthepatientthattheprescriptionhasbeendiscontinued.Thesystemgivesthepatient twochoices:thepatientmayenterthecorrectprescriptionnumberorthepatientcanspeakwitha pharmacyassistant.Whenthepatientpickstheprescriptionup,thepharmacistcounselsthepatientto stoptakingtheolddoseandbeginthenewone.Analternativeworkflowisthattheproviderfaxesthe prescriptiontoamailorderpharmacysuchasMedcoandtellsMedcothatthepreviousprescriptionhas beendiscontinued.Inthiscase,whenitstimetorefilltheprescription,thepatientisonlypresented withthecorrectprescriptionastheoldonehasbeeninactivatedandisnotabletobeselectedbythe patient.

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Utilization of Standards
Standardizationisnecessarytoensurethatdatatransmissionssentbetweenapplicationsare completeandcontainallessentialinformation.Wellconstructedandproperlyarrayeddatatransfers ensurethattheinformationtheycontainisproperlyinterpretedandprocessed. Ouroutpatientclinichousesanelectronichealthrecord(EHR)systemforourpatients.In addition,wehaveanoutpatientpharmacywithapharmacydatawarehousethatisspecificallydesigned toaddressthemanyaspectsofpharmacologicalcareforourpatientpopulationandourpharmacyasa business.Also,wehavedatasharingcapabilitieswithothercommunitypharmaciesinourtown,andwe areabletotransmitdataconcerningourpatientsandtheircarebackandforthfromthedifferent entitiesasneeded. CommunicationbetweenourADTsystem,thecliniciansworkstations,andthecentralEHR repositoryisconductedusingstandardHealthLevel7(HL7).HL7isalsousedtotransmitdatafromthe ADTandEHRsystemstothePharmacyDataWarehouse(PDW).However,thePDWaddsanother standard,theNationalCouncilforPrescriptionDrugPrograms(NCPDP).Thisisnecessarytoutilizethe datadictionarythatNCPDPhasdevelopedtoproperlyaddresstheissuesrelatedtoamedicationrelated datasystem(NationalCouncilforPrescriptionDrugPrograms,2011).InformationfromthePDWflows upanddowntheline,tothecliniciansworkstationsandouttothecommunitypharmacies. Inthefuture,wehopetoimprovethedataavailabilitytoourEHRfromotherfacilitiesandeven thepatientshomes.WedonotyethaveDigitalImagingandCommunicationsinMedicine(DICOM) capabilitiesforviewingvisualtestsdoneatthelocalhospital.Wealsowouldliketoimplementadata transmissionapplicationcapableofIEEEtransmissions,aswellasHL7forbloodpressurereadings, capillarybloodglucosereportsandotherhomemonitoringdevices.

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Standards Schematic

OutpatientFacility OutpatientFacilityPharmacyDataWarehouseMainframehouses HL7toandfromWorkstations multiplepayerformularies andTabletstoEHRon HL7/NCPDPServerhousesdruginteractiondatabase Mainframe NCPDPPCallowsPharmacisttoreview/approvereports

Legend
Legend Subtitle Symbol Count 3 2 1 3 2 2 5 2 3 Description User Mainframe Server Multi-function device Firewall Tablet computer PC Comm-link Ethernet

DatafromPharmacytoProviders regardingallergies/interactions/formulary NCPDPSNOMED

PatientPreferredPharmaciesdatasentfromOutpatientFacility NCPDP

Information System Functional Requirements

Basedontheimprovedworkflowsdepictedinthisproject,belowaretheinformationsystemfunctional requirementsneededtosupportabidirectionalcommunicationbetweentheoutpatientclinicEHRand anappropriatelyconnectedPharmacyManagementSystem. ClinicEHRPharmacyPrescribingModule: Thesystemshallacceptallrequireddataelements Thesystemshallvalidatealldataelements Thesystemshallperformdruglookupagainstformularybasedondiagnosis/protocol Thesystemshallperformadruginteractioncomparisonwithpatientsactiveprescriptionlist
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Thesystemshallperformadrugallergycomparisonwithpatientsdrugallergyhistory Thesystemshallperformathirdpartyprescriptioninsurancevalidationtodeterminewhether patientsplanspecifiesgeneric(ifanoptionfortreatment) Thesystemshallperformathirdpartyprescriptioninsurancevalidationtodeterminewhether patientsplanrequiresmailorderforallmaintenancemedication. Thesystemshallvalidatethepatientspreferredretailpharmacylocation ThesystemshallgenerateaneprescriptionandstoretherecordonthepatientsEHR Thesystemshallgenerateeitheraneprescriptionforelectronictransmissiontothepharmacyor paperprescriptionforfacsimiletransmissionifeprescribingisnotenabledatthepreferred pharmacy

EHRMedicationComplianceModule: PharmacyInformationManagementSystemModuleNewPrescription: Thesystemshallreceiveeitherelectronicallyorbyfacsimiletheeprescriptiontransmissionfrom theproviderlocation Thesystemshallreceivethepaperprescriptionfromthepatient Thesystemshallvalidatetheprescriptionandrejectstomanualworkflowanyinconsistent informationformanualprocessing/followup Thesystemshallprocessthevalidatedeprescription

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Thesystemshallreceiveprescriptionfilledtransaction Thesystemshallvalidatetheprescriptionfilledtransaction ThesystemshallupdatethepatientsEHRwiththeprescriptionfilledinformation Thesystemshallreceiveprescriptionpickeduptransaction Thesystemshallvalidatetheprescriptionpickeduptransaction ThesystemshallupdatethepatientsEHRwiththeprescriptionmedicationcomplianceflag Thesystemshallreceiveprescriptionnotpickeduptransaction Thesystemshallvalidatetheprescriptionnotpickeduptransaction ThesystemshallupdatethepatientsEHRwiththeprescriptionmedicationnoncomplianceflag Thesystemshallreceiveprescriptionrefilledtransaction Thesystemshallvalidatetheprescriptionrefilledtransaction ThesystemshallupdatethepatientsEHRwiththeprescriptionrefilledinformation Thesystemshallreceiveprescriptionrefillpickeduptransaction Thesystemshallvalidatetheprescriptionrefillpickeduptransaction ThesystemshallupdatethepatientsEHRwiththeprescriptionmedicationcomplianceflag Thesystemshallreceiveprescriptionrefillnotpickeduptransaction Thesystemshallvalidatetheprescriptionrefillnotpickeduptransaction ThesystemshallupdatethepatientsEHRwiththeprescriptionmedicationnoncomplianceflag

ThesystemshallcreateaprescriptionfilledtransactionandtransmitsbacktothesendingEHR MedicationComplianceModule Thesystemshallnotifythepatientifprescriptionisnotpickedupinasetnumberofdays Thesystemshallpromptthepharmacisttoofferprescriptioncounselingtothepatient Thesystemshallcreateaprescriptionpickeduptransactionandtransmitsbacktothesending EHRMedicationComplianceModule Thesystemcreatesaprescriptionnotpickeduptransactionandtransmitsbacktothesending EHRMedicationComplianceModule

PharmacyInformationManagementSystemModulePrescriptionRefill: Thesystemshallreceiveeitherelectronicallyorinpersonaprescriptionrefill Thesystemshallvalidatetheprescriptionrefillandrejectstomanualworkflowanyinconsistent informationformanualprocessing/followup Thesystemshallprocessthevalidatedprescriptionrefill Thesystemshallcreateaprescriptionrefillfilledtransactionandtransmitsbacktothesending EHRMedicationComplianceModule Thesystemshallnotifythepatientifprescriptionrefillisnotpickedupinasetnumberofdays Thesystemshallpromptthepharmacisttoofferprescriptioncounselingtothepatient Thesystemshallcreateaprescriptionrefillpickeduptransactionandtransmitsbacktothe sendingEHRMedicationComplianceModule Thesystemcreatesaprescriptionrefillnotpickeduptransactionandtransmitsbacktothe sendingEHRMedicationComplianceModule

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Diagram of Information Architecture

EfficientIntegrationofMedicationsManagementintoanOutpatientClinicEHR MMI405HITIntegration,Interoperability,andStandards Page22

Defining Origin of Data Elements

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Flow of Datasets between Systems

ADT Admission Discharge Transfer

PTDEMO EHR

EHR Electronic Health Record

EHR

ClinicianEntered Data

PharmacyDataWarehouse
PTDEMO PHARMDATA

PTDEMO PHARMDATA PTDEMO PHARMDATA Patient Preferred Pharmacy C PTDEMO

PHARMDATA Patient Preferred Pharmacy A Patient Preferred Pharmacy B

Conclusion
Justasanarchyisaninefficientformofgovernance,multipleapplicationsthatcannot communicateareaninefficientwaytomanagehealthcare.Programsthatcaninterfaceandsharedata thatisaccuratelyportrayedandinterpretedleadstoknowledgeableclinicians,andpatientsthatfeel valuedbecausetheirdoctorsandnursesunderstandandcanknowledgablydiscusstheirmedical histories,currentmedicationsandotherimportantinformation.Theuseofstandardsisinvaluablefor thispurpose,maintainingthestructureandsettingtherulesthatarerequiredforaccuracyand completeness.

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