Health Information Exchange: Slow Progress, Hopeful Deadlines

Monday, July 30, 2018
Author: 

Marsha K. Millonig, MBA, BPharm

Two years ago, I wrote a blog about health information exchange (HIE) and the role of the pharmacist in this important component of patient care. In that post, I reviewed the role of pharmacy in health information technology – always a leader – and identified key steps to ensure that pharmacists can exchange information appropriately to support the delivery of patient care. Understanding the priorities behind the decision to exchange data and determining what and how is to be exchanged were among those key steps.

We all intrinsically understand that the safe, timely exchange of relevant, appropriate health information is a necessity. So, why haven’t we made more progress, and why hasn’t HIE gained more momentum in the pharmacy sector?

Obstacles and Delays

In this day and age, we expect ease in our transactions. We have become accustomed to it in our personal lives – shopping, banking, transportation – yet we struggle for it professionally.

Progress has been slower than anticipated when I first examined the issue two years ago. Pharmacists are doing good work when it comes to checking their local prescription drug monitoring program (PDMP), which is a valuable tool in addressing the overuse and misuse of opioids. But exchanging other information – such as lab values, immunization administration records, allergy and adverse event reporting, and documentation of care provided – still does not routinely occur within workflow.

It is clear that exchanging information is important, so why has the industry not gained more momentum? There are likely quite a few reasons:

Resources and priorities

Data exchange partners have to agree on what information can and should be exchanged. Then resources have to be allocated to assess the exchange mechanisms (e.g., secure email such as DIRECT or sFTP) and if there is a standard or will a proprietary format be used.

Integration

Once those decisions are made, then planners must consider how to integrate the data exchanged into workflow. Exchanging the data only has value if it is available to end users when and where they need to see it. All the basics of project management then come into play – timelines, milestones, resources – in order to achieve the goal of exchanging information. And this process is likely to be repeated depending on the type of data or the exchange partners involved.

Standards

Another likely reason for the delay is that the industry has been waiting for a newer version of NCPDP’s SCRIPT Standard to more effectively exchange data, such as allergy or adverse events, prescription fill status, and prior authorization information. 

The Centers for Medicare and Medicaid Services (CMS) published a final rule in April 2018 that will drive the industry’s transition to a more current version. Compliance with this new version is required for those who are subject to the regulation by January 1, 2020.

What Comes Next?

So, in two more years when compliance is required, pharmacists and prescribers will have a more effective tool to exchange data. The challenge will be in seeing if there is interest and capacity in leveraging all that the SCRIPT Standard can support. Otherwise, we’ll be where we are today, exchanging the bare minimum on a prescription-related transaction. That minimum will only change either through regulation or through industry or patient demand.

And what about other trading partners, such as payers? The new version of the SCRIPT Standard includes enhancements to prior authorization transactions (generally exchanged between the prescriber and the payer/PA processor). It’s clear that use of electronic prior authorization improves efficiency and positively impacts patient care by reducing the time needed to process a prior authorization request. Proprietary solutions are available in the marketplace that allow a prescriber to check the pharmacy benefit in real-time before sending a prescription to the pharmacy.  This type of data exchange can lead to smarter prescribing decisions – selecting a product with the highest coverage level for the patient – that can help improve adherence and reduce inefficiencies in the prescribing process.

Yet adoption of these tools takes time, and many are waiting for either a standard transaction that will be used by all prescribers and payers, or they are waiting for a mandate before investing the time and effort to implement a new feature.

The primary data exchange between a pharmacist and payer involves claims transactions. On May 17, 2018, the National Committee on Vital and Health Statistics sent a letter to the Secretary of Health and Human Services recommending that the standard named for pharmacy claim billing be updated to a newer version. This occurred nearly nine years after the last SCRIPT version was named. As with the SCRIPT Standard, the Telecommunication Standard has seen dozens of changes included at the request of the industry. Moving to this new version will improve the ability of pharmacies and payers to exchange data.

No specific timeline for this transition has yet been announced.

As pharmacists continue to provide additional services, they need a way to document their work to support any associated billing. Pharmacy systems will need a way to capture care documentation and associated code systems so that claims can be promptly and efficiently submitted. Standards are available that can support the exchange of information; the greater challenge is extracting the data from whichever system stores it, if there even is a system to store it.

There are solutions available, whether embedded within current pharmacy management systems or as an add-on tool that can integrate with existing systems. These tools will be extremely valuable as pharmacists offer more services that are reimbursable.

Hopefully, when we evaluate HIE practices two years from now, we’ll be able to report on significant progress regarding health information exchange.

Marsha K. Millonig, MBA, BPharm, is president and CEO of Catalyst Enterprises, LLC, and an Associate Fellow at the University of Minnesota College of Pharmacy’s Center for Leading Healthcare Change.

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