HIT Perspectives – November 2018
Looking Back at 2018 Predictions: How’d We Do?
By Tony Schueth, Editor-in-Chief
Every January for the past several years, we’ve made predictions about key trends that should affect health information technology (health IT), electronic prescribing (ePrescribing) and the exchange of various types of health data in the coming year. We thought it might be interesting to circle back and see how our predictions panned out. Here’s the rundown of predictions for 2018, where things landed and how we graded ourselves.
- Biosimilars. We got ahead of the curve on this one. Biosimilars are poised to take off because insurers, the government and other health care stakeholders believe biosimilars will offer comparable clinical utility at a lower cost versus reference drugs. Five biosimilars were approved by the Food and Drug Administration (FDA) in 2018, the same number as 2017. Regulatory and competitive barriers continue to be addressed. The FDA is working on one of the biggest remaining barriers: drug manufacturers’ extending patents to stifle competition on branded drugs. This is important because a number of drugs are scheduled to come off patent, opening the door for biosimilars.Grade: Way ahead of ourselves.
- Blockchain. A data structure of ordered “blocks” that cannot be changed, deleted or otherwise modified, blockchain was widely hyped as a trend in 2018. As we reported in January, just about every large health care organization reported actual and expected investment in blockchain technology.
That said, its use didn’t exactly trickle down to the health IT ecosystem as soon as we expected. However, startup applications are springing up like mushrooms. Examples include using blockchain in electronic health records (EHRs) to help track patients through their entire postacute care journey, health data analytics (using blockchain as a service) and managing personal health records.
Grade: Way ahead of ourselves.
- Electronic prescribing of controlled substances (EPCS). Earlier in the year, we predicted that EPCS will experience an accelerated uptick in adoption in 2018, along with the rapid increase in controlled substance prescription volume seen over the past couple years. That is coming to pass, according to unpublished Surescripts data. At the last National Council for Prescription Drug Programs (NCPDP) workgroup meeting, they showed new EPCS transactions jumped from 5 million in January to around 10 million at the end of the summer. About a quarter of prescribers using Surescripts’ network now are active EPCS users, growth that has increased by over 50% in just the past month. This is due to several factors. The first is state legislation. EPCS transaction volume initially was driven by mandates in four states (New York, Minnesota, Connecticut and Maine). Active EPCS prescribers jumped in response to mandates in Maine and Connecticut, whose requirements recently went live. They rose from virtually zero in January 2018 to nearly 50% by mid-September in Maine and 43% in Connecticut.
Volume will likely respond upward even more quickly in the next couple of years as 11 more states will require EPCS for some or all controlled substances within the next few years; five more have similar bills pending in their legislatures. This is putting pressure on providers to adopt EPCS in response to the opioid epidemic. Providers are finally beginning to invest in and use EPCS infrastructure because it’s time and, in part, it will help them meet required quality reporting targets for Medicare and other payers. Vendors are ready, so preparedness that is no longer problematic. The costs for prescriber adoption — a major barrier — are coming down.
However, EPCS will get a huge boost in the next couple of years from legislation that was unknown in January: the newly enacted SUPPORT for Patients and Communities Act (HR6). It requires that all scheduled drugs covered under Medicare Part D must be electronically prescribed beginning January 1, 2021. (Click here for our analysis of the legislation in this issue of HIT Perspectives.) We expect this, in turn, will push private payers and states to adopt similar requirements. It is likely that physicians who are required to use EPCS for Part D prescriptions will use EPCS for all prescriptions. The act’s regulatory mandates will push physicians to adopt EPCS sooner rather than later.
Grade: On target.
- ePA. We predicted in January wider adoption of electronic prior authorization (ePA) for pharmacy transactions. To be sure, progress was made but many unknowns still remain. For example, a couple dozen states require support of ePA, with many specifying use of the ePA standard from the NCPDP. Several other states are working on ePA legislation, but requirements vary across jurisdictions and are not all standards based. How that affects adoption has yet to be determined.
At the same time, progress was made by pharmacies and payers in terms of commitment to ePA implementation. According to CoverMyMeds, all pharmacies are committed to an ePA solution in 2018, as are 96% of payers and 80% of EHRs.
That said, adoption by health care providers is still not what it could be. For example, 70% do not know that prior authorization (PA) is needed when prescribing certain medications. That is because the field is frequently not populated by commercial payers in the formulary and benefit (F&B) files used for ePrescribing. The reasons for this omission are not fully understood. A workaround is on the way in terms of the real-time pharmacy benefit check (RTPBC). The RTPBC’s response to a prescriber’s inquiry will indicate if PA is needed. However, the RTPBC is a fairly new transaction. The breadth and depth of its adoption are unknown.
There also was continued movement in 2018 toward automation and standardization of electronic medical prior authorization. (Click here to read more about it.) There is growing interest in medical ePA because of the intensive paper-based process for PA on specialty drugs covered under the medical benefit.
Grade: Somewhat ahead of ourselves.
- FHIR. The health IT world is still, well, on fire due to the accelerating adoption of FHIR (the Fast Healthcare Interoperability Resource). This draft standard will be finalized as a standard by HL7 toward the end of this year. Widely deployed in draft standard format across EHRs, vendors and providers, FHIR provides normalized data formats and elements (known as “resources”) and application programming interface(s) (API) for exchanging data with EHRs. FHIR differs from previous standards because it uses existing common, modern, Web-based suites of API technology. A driving force for promoting payer adoption of FHIR is the DaVinci Project, which got off the ground midyear. DaVinci is a multistakeholder group that is developing value-based care use cases for data exchange that leverage the FHIR standard. We’re honored to be its program management organization.
Grade: On target.
- Information blocking. Information blocking has been all the buzz for the past couple of years. It resulted in requirements in the 21st Century Cures Act prohibiting the practice. We included it as a trend for 2018 because of an anticipated regulation spelling out the details. So far, that regulation has not been promulgated — we suspect, in part, because the government had difficulty defining it. Frankly, a lot of what some people call information blocking is really not so much a technology challenge as a business one. The competitive nature of health care delivery is primarily what prohibits the exchange of clinical information — competitors don’t want to make it easy for patients to seek care outside their networks.Grade: On target.
- Interoperability. As just about every item on this list indicates, interoperability is no longer just a buzzword. The public and private sectors both saw significant progress in exchanging clinical and administrative data in 2018. We noted in January that an emerging area of emphasis is improving patients’ access to their data. This is top-of-mind at the Centers for Medicare and Medicaid Services (CMS), which rolled out its MyHealthEData initiative and Blue Button 2.0. On the private side, Apple debuted its new ”Health” application (app) for users of newer iPhones and iPods. Users can download their records from a certain number of participating provider organizations such as Cleveland Clinic. While consumers are rapidly adopting the Apple app, beneficiary uptake of BlueButton 2.0 is minimal, although over 1,200 developers are interested. This captures the current state of interoperability: many are interested in various facets and progress has been made, but significant adoption challenges remain.
Grade: On target.
- Medication adherence. Medication adherence is a long-standing problem that emerged from the shadows in 2018. Payers, in particular, called it out as a driver of health care costs and poor patient outcomes, which resulted in growing demand for drug price transparency at the point of prescribing. We made progress in 2018 in better understanding the problem and creating new and improved solutions. Efforts also ramped up to better connect patients with the costs of their expensive specialty medications, thus reducing noncompliance, poor outcomes and unnecessary costs.
Grade: On target.
- Patient identifier. It seems as though everyone keeps talking about the need for a universal patient identifier, which is key for achieving interoperability. It is needed to accurately associate patients with their records among various providers and within and across payers and health systems. While many efforts are underway to develop a patient identifier, none have emerged a clear winner. Meanwhile, the government still is prohibited by statute from developing an individual patient identifier. Patient identification is one use case in which Blockchain makes sense for exchange of patient clinical information.
Grade: Slightly ahead of ourselves.
- PDMPs. Prescription drug monitoring programs (PDMPs) are state-run databases of prescriptions for opioids and other kinds of controlled substances, depending on the locality. As such, they are viewed as key to addressing the opioid crisis by preventing drug diversion, doctor shopping and opioid overprescribing. States worked in 2018 on legislation surrounding use and interoperability of PDMPs, including mandates to consult the PDMP before creating or filling prescriptions for all or some scheduled drugs; requiring better interstate data sharing; and removing barriers caused by varying state laws concerning who can access PDMP data and under what circumstances. Section 7162 of the newly enacted SUPPORT for Patients and Communities Act is devoted to improving PDMP interoperability. In the near future, this also will help drive interoperability, including better integration of PDMP data in the workflow.
Grade: On target.
- RTPBC. The real-time pharmacy benefit check provides more accurate information in real time to the health care provider directly from the pharmacy benefit manager, based on patient-level plan data. Work continued by NCPDP in 2018 on developing standard formats and one implementation guide for the real-time exchange of pharmacy benefit data. In the absence of a standard, several proprietary solutions have entered the market. Their transaction volume is rapidly increasing, indicating value. At the same time, the RTPBC is viewed as a method for creating drug pricing transparency at the point of prescribing. This should lead to improved patient satisfaction and medication adherence, which are key metrics for value-based care organizations. All these drivers indicate accelerating adoption and usefulness of the RTPBC in the near-term.
Grade: On target.
- Specialty pharmacy automation. Standardized specialty pharmacy automation continued to make progress in 2018. NCPDP created a specialty pharmacy workgroup, which will identify challenges to automated data exchange in specialty pharmacy and how they might be addressed through the NCPDP standards-setting process. A separate workgroup is working on an enrollment standard for specialty pharmacy — a needed building block for end-to-end automation. Stakeholders continue to push for specialty pharmacy automation to improve speed to therapy and better manage the use of high-cost specialty medications.
Grade: On target.
- Virtual visits. Telehealth continues to be one of the fastest growing segments of health care. In 2018, the virtual doctor was in — providing diagnosis, treatment and remote patient monitoring to patients all over the country, not just in rural areas. The percentage of health care organizations using telehealth rose from 63% in 2015 to 74% in 2018, a statistic that continues to increase daily. Usage barriers continued to be addressed, including cross-state licensing for doctors and reimbursement under Medicaid and Medicare. An example is the new provisions in the SUPPORT for Patients and Communities Act, which expands telehealth services in Medicare for substance abuse treatment. A new telehealth CPT code for remote patient monitoring (99091) was added in 2018 to facilitate Medicare payment and billing. CMS also is proposing to expand telehealth coverage for Medicare Advantage plans. Virtual visits skyrocketed by hospitals, physicians and pharmacies. Patients linked up through the Web and their smart phones.
Grade: On target.
Keep up with the trends at Point-of-Care Partners (POCP). Our Regulatory Resource Center (RRC) tracks state and federal legislation and regulations related to opioids, ePA and other topics of interest. Contact Keith Fisher (email@example.com), who is the center’s co-lead. POCP subject matter experts can update you on the health IT landscape, breaking developments and where things are heading in the future. Drop me a line (firstname.lastname@example.org) and I’d be happy to put you in touch.