February 27, 2018

Physician Community Webinar Series

Leveraging Standards to Address Patient Safety Issues

John Klimek R.Ph.Senior Vice PresidentStandards and Industry ITNCPDP

Welcome to the Physician Community Webinar Series Sponsored by the HIMSS Physician Community

• A complimentary virtual event.

• Covers a wide range of topics on Medical Informatics,

HIEs (Health Information Exchange), Standards and

Interoperability, eMeasures and Quality Initiatives, and

how it affects, impacts and involves physicians.

• For more information, visit www.himss.org/physician or

contact Yvonne Patrick at ypatrick@himss.org.

Welcome to the Physician Community Webinar Series Sponsored by the HIMSS Physician Community

• Please insert all questions in the Q & A box located on

the bottom right of your screen.

• A copy of the recording and slide set will be available for

download within 5 business days on the Physician

Community Webinar Series Archive Page

www.himss.org/physician

Speaker:

John Klimek, R.Ph.

is SVP, Standards & Industry Information

Technology of NCPDP, the not-for-profit, ANSI-

accredited, SDO. Klimek leads the charge to

use standards to advance interoperability and

protect patient safety. He was recently Chair of

the Health Standards Collaborative (HSC), a

collaboration among SDOs working to

facilitate the industry-wide, interoperable

standards to support a sustainable HIT

infrastructure.

Learning Objectives

• Learn about NCPDP

• Identify two NCPDP standards that can be used to

detect potential fraud/abuse in the opioid epidemic

• Describe two patient safety use cases for the real-time

benefit check standard

• Illustrate the interoperable flow of data within providers’

practice workflows

NCPDP

Multi-stakeholder, Problem-solving Forum for Healthcare

• ANSI-accredited Standards Development Organization

• Standards for Electronic Exchange of Information

• Many of our standards are named in federal legislation,

including HIPAA, MMA, HITECH and Meaningful Use (MU)

• Best Practices for Patient Safety

• Advisor to Policymakers (EDvocacy)

• Founder & Past Chair of Standards Charter Organization

(SCO) now known as the HSC - Health Standards

Collaborative

NCPDP Member Representation (January 2018)

Producer/Provider (392)

• Client Service Oriented

• Includes pharmacies, manufacturers, in-patient/out-patient care centers

Payer/Processor (427)

• Financial oriented sector

• Includes HMOs, PBMs, government (CMS, HHS, ONC), health insurers

Vendor/General Interest (585)

• The link between Producer/Provider and Payer/Processor

• Includes health information exchanges, consulting, clinical programs, software and hardware vendors

NCPDP’s Standards Development Process

Standards are born of business needs and patient

safety issues raised by stakeholders participating in

an NCPDP problem-solving forum.

Prescription for Improving the Healthcare System

NCPDP Standards & Healthcare Experience

Work Groups

Best Practices – NCPDP’s Process

• Getting the right people in the room, engendering trust

• Consensus-based process, solutions

• Driven by business need, patient safety

• Workflow-enabled solutions for ease-of-use and adoption

NCPDP Standards-based Facilitator Model for Patient Safety, An

Interoperable Solution for PDMP

Leveraging Standards to Address Opioid Epidemic

Identify two NCPDP standards that can be used to detect potential fraud/abuse in the opioid epidemic

• NCPDP Telecommunication Standard - Pharmacy Claims billing

• NCPDP SCRIPT Standard - ePrescribing

Opioid Epidemic – Public Health Crisis

NCPDP Standards-based Facilitator Model for Patient Safety, An Interoperable Solution for PDMP

• Uses NCPDP’s Real-Time SCRIPT Standard for ePrescribing and Telecommunication Standard

– Eliminate data silos and promote interoperability

– Support clinical-decision making at point-of-care

– Detect/deter fraud and abuse and support access for patients with valid medical need

• Model also leverages an independent, third-party Facilitator, monitoring medication use across state lines

• Designed to add a risk identification enhancement to augment state PDMPs, NOT replace them

• Supports patient safety efforts to curb a public health crisis

Opioid Epidemic – Public Health Crisis

NCPDP Standards-based Facilitator Model for Patient Safety, An Interoperable Solution for PDMP

• Providers/Prescribers:

– Enables healthcare providers to deter prescription drug abuse before controlled substances are prescribed.

– Better informed clinical decision making at points-of-prescribing and dispensing

– Uses real-time reporting, alerts and responses

– Provides actionable and timely information within existing workflows

– Supports access for patients with a valid medical need

– Averts opioid misuse

PDMPs lack uniform best practices:

• Lack standards to share drug abuse information effectively

to address potential drug abuse and diversion, or evaluate

patient risk

• Process is systemically burdensome (e.g., outside provider

workflows)

• Does not effectively provide information in a timely manner

in order to make clinical decisions at point-of-care

PDMP Challenges

• Ability for web tools to access state PDMP data

• Help identify and deter or prevent drug abuse and

diversion

• Help decrease fraud and abuse

PDMP Benefits

Overcoming PDMP Barriers

• Share real-time information at the point of care through the use of existing, interoperable industry standards

• Reduce burden on providers by incorporating drug abuse information within pharmacy and prescriber workflows when risk exists

• With 1 billion prescriptions written/dispensed not possible or practical to manually check 100%

• Enable prescribers and pharmacists to make clinical decisions prior to writing and dispensing medications for proactive intervention

• Ensure access for patients with valid medical needs

NCPDP White Paper on PDMP

• Strategic Action Group meeting on PDMPs held in Baltimore, MD, on October 18, 2012.

• Goals and Objectives were to identify the current and future issues and needs regarding PDMPs.

• At the request of the PDMP Strategic Action Group, a PDMP Task Group was formed in November 2012, with the initial task of developing a White Paper to:

– Examine the problem;

– Identify future needs; and

– Recommend solutions for PDMP data access and role of NCPDP.

http://ncpdp.org/Education/Whitepaper

White paper: NCPDP’s Integrated, Interoperable Solution to Ensure

Patient Safe Use of Controlled Substances (Revised 2016)

NCPDP Interoperable Solution for PDMP

NCPDP Telecommunication Standard

Standard format for electronic submission of third party drug claims and other transactions between pharmacy providers, insurance carriers, third-party administrators, and other responsible parties

Transactions:

• Eligibility verification;

• Claim and service billing;

• Predetermination of benefits;

• Prior authorization;

• Information reporting; and

• Controlled substance (general and regulated) transaction exchanges

NCPDP SCRIPT Standard (ePrescribing)

• Transmits prescription/medication information between prescribers, pharmacies, payers, and other entities

• Functionality includes: New prescriptions, change, cancel, refill requests, prescription fill status notifications, relaying medication history, transactions for long-term care, controlled substances, compound Rx, electronic prior authorization and other transactions

• Patient safety features built into the standard (SIG)

• Providers access information at the point of care –and within their existing workflows

Underutilized functionality:

• Structured and Codified Sig - promotes greater consistency in specifying directions and for clinical review/analysis

• Support for patient observations - allows prescribers to supply Patient Height, Weight, Diastolic and Systolic Blood Pressure

• Support for scheduled medications - provides fields necessary to enable ePrescribing of controlled substances.

• Compound prescription support - support for multi-ingredient compound exchange.

• Adverse events/reactions - the NCPDP SCRIPT Standard supports the exchange of drug use review (DUR) fields.

• Support for electronic prior authorizations – provides the means to exchange information needed in prior authorization (PA) requirements, including access to information on covered medications at the point of care, information on PA approvals and denials.

NCPDP SCRIPT Standard (ePrescribing)

NCPDP’s Real-Time Prescription Benefit Transaction (RTPB)

Real-time exchange of data between providers and

processors/PBMs/adjudicators.

Meeting with ONC on limitations using the current NCPDP Formulary & Benefit Standard

• Batch Standard – Not Real-Time

• Formularies change – outdated information

• Variations on information provided

(i.e. $$$ or to represent approximate cost)

Real Time Prescription Benefit CheckHistory

Reasons for developing Real Time Benefit Check (RTBC)

• Gives provider/physician clear information on formulary information

• Provides information on drugs requiring PA

• Creates a personalized estimate of a patient’s payment responsibility

• Prevents sticker-shock at pharmacy

• Increases likelihood that patient will get the prescribed medication

• Goal: Standardize, reduce workarounds to enhance interoperability

• Prior Authorization information –

• Data shows 40% of patients abandon prescriptions waiting for PA

• Prescriber can start PA process or choose alternative

• Estimate of prescription cost –

• Patients know what to expect

• Alternatives can be chosen if becomes cost prohibitive

Safety Factors in RTPB

Physician flow of information Standards – and integral part

ONC Meaningful Use and ePrescribing

Pharmacy a small part – but plays a big role in healthcare

Critical Juncture Between Diagnosis and Outcomes

• Medication adherence

• Medication alternatives

• Drug Utilization Review

• Medication Therapy Management

• Specialty pharmacy

Standards - Essential component

• Standards are foundational, evolve based on need

• Enable interoperability, data exchange

• Provide actionable data at point-of-care

• Ease burden on providers, developed to conform to workflows

• Establish important point of communication between prescribers/pharmacists

HSC – Health Standards Collaborative

Standards Development Organizations (SDOs)

• AAMI (Association for the Advancement of Medical Instrumentation)

• ADA (American Dental Association)

• ASC X12 (Accredited Standards Committee)

• ASTM (American Society for Testing Materials)

• CDISC (Clinical Data Interchange Standards Consortium)

• HL7 (Health Level Seven)

• IAIABC (International Association of Industrial Accident Boards and

Commissions)

• ISO/TC215

• NCPDP (National Council for Prescription Drug Programs)

• Regenstrief

NCPDP Industry Guidance

Our best practices industry guidance white papers

are developed using our multi-stakeholder,

consensus-building process.

Thank you!

John Klimek, R.Ph.

Senior VP, Standards & Industry IT

NCPDP (National Council for Prescription Drug Programs)

www.ncpdp.org

Email: jklimek@ncpdp.org

LinkedIn: http://www.linkedin.com/in/jklimekncpdp

Office: 480-477-1000 ext. 136

Q&APlease insert all questions in the Q & A box located on

the bottom right of your screen.

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