Speeding Time to Therapy
on present-day ePA and the future
Creating value in today's
By Tony Schueth, Editor-in-Chief
By all accounts, 2017 was a busy year for health care organizations, health information technology vendors and others. We expect that hard work will continue — if not accelerate — in 2018 to address the myriad business and legislative requirements facing the health care system. With that in mind, here are a baker’s dozen trends to watch in 2018.
1. Biosimilars. The federal government and states will continue their efforts to establish the needed infrastructure for approval and adoption of biologics and biosimilars, which are gradually being approved for use in the United States. . The new changeover in names applies to both newly licensed biologics and biosimilars, and will also be applied retrospectively to biologics already on the market. Understandably, stakeholders are concerned about associated costs and burden of implementation and are raising their concerns to the FDA, which might tweak its guidance in response. There also is a need to capture patient information and outcomes in electronic health records (EHRs) for pharmacovigilance purposes as biologics come on stream.
2. Blockchain. Blockchain is health care’s latest bright, shiny object, meaning it will continue to attract attention in 2018. A data structure that can be time stamped and signed using a private key to prevent tampering, some people may know blockchain as the technology underlying the online currency Bitcoin. Payers are jumping in with both feet to implement blockchain,
Despite the apparent — and possibly premature — enthusiasm by payers, many questions surround the use of blockchain in health care. For example, it is too new to be well understood; infrastructure and interoperability requirements are unknown; and rules of the road will be needed for its implementation. Use cases must be developed.
3. EPCS. Electronic prescribing of controlled substances (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. Providers are finally beginning to invest in and use EPCS infrastructure because it’s time and it will help them meet required quality reporting targets for Medicare and other payers. Vendors are ready, so technology is no longer problematic.
Also, several states are requiring — or are poised to require — that all such prescriptions be sent electronically as a tool to fight the opioid epidemic. Along similar lines, a House bill (HR 3528) was introduced for mandatory EPCS in Medicare Part D. Such legislation at the federal level will jumpstart EPCS adoption because Medicare is a huge driver and nearly everyone else follows suit. That said, vendors will have to be nimble to adapt to such rapidly changing state requirements as controlled substance prescribing limits and new data elements like adding diagnosis onto prescriptions. In addition, there is no consistency in implementing these requirements across states, making implementation even more challenging for vendors. EHRs will need new forms of decision support to meet evolving state and federal requirements.
4. Electronic prior authorization (ePA). An increasing number of drugs — especially specialty medications needed for the rising number of chronic illnesses — require prior authorization (PA). The manual process has been a pain point for prescribers, pharmacies and patients alike. The industry responded with an ePA standard, which is being implemented. We believe that ePA is poised to take off in 2018. Why? Consider that we’re already seeing implementation involving the ability of many EHRs and pharmacy benefit managers to accept and exchange basic information for PAs. As another example, CoverMyMeds, a large ePA platform that uses the National Council for Prescription Drug Programs (NCPDP) ePA standard to help automate and accelerate PA requests and approvals, was recently bought for $1.4B by McKesson. This shows market recognition of the value and opportunities inherent in ePA. Pharmacists already have information to process PAs in that environment. As pharmacy moves to become instrumental in the care process in 2018, new use cases will arise, such as pharmacists becoming involved in ePA for long-term care patients.
5. Fast Healthcare Interoperability Resources (FHIR). FHIR is one of the latest in the Health Level 7 (HL7) family of standards. It underpins the accelerating movement toward open, standardized application programming interfaces (APIs), which are getting a further boost under the 21st Century Cures Act. Providers and pharmaceutical companies are considering how to use innovative APIs to communicate with patients and partners. Increased adoption of FHIR-based APIs is expected in 2018. FHIR also is becoming key to Internet-based information exchange networks. Its accelerating momentum continues with public backing. For example, Anthem joins Independence Blue Cross in using the FHIR standard to build out value-based data exchange work flows with providers. FHIR is also being considered for the transport of data for specialty pharmacy enrollment, which is part of efforts to automate specialty pharmacy (see below).
6. Information blocking. The 21st Century Cures Act requires the government to address perceived information blocking by EHRs. In addition to prohibiting the practice, the act bars certification of offending systems and permits such actions as decertification of noncompliant ones. This puts the ball squarely in the lap of the Office of the National Coordinator for Health Information Technology (ONC) and aligns with other ONC activities. To that end, ONC is expected to issue a regulation this spring defining information blocking, which is the first step in any enforcement process. The act allows financial penalties for noncompliance, and you can’t enforce something that isn’t spelled out in detail.
7. Interoperability. Interoperability is no longer a buzzword but a concept that is being put in place. Drivers for 2018 include requirements of ONC programs, the Medicare and CHIP Reauthorization Act and a downstream impetus from the 21st Century Cures Act. Health care stakeholders also are embracing the need for interoperability. , interoperability projects for health care organizations include connecting to external databases, such as health information exchanges (65%), connecting applications within the organization (58%), and adding connections from medical devices to existing systems (37%). Emphasis also will be placed on greater integration of EHRs and provider work flows.
8. Medication adherence. Poor medication adherence is partially responsible for avoidable hospital admissions, and 33% to 69% of all medication-related hospital admissions at a cost of about $100 billion per year. To be sure, medication noncompliance is a long-standing issue. Now we have reached an inflection point where technology, value-based care and concerns about the costs of chronic illness are converging to meaningfully address the problem. Medication adherence is becoming an outcomes measure in accountable care and performance-based contracting, including the Medicare Star Rating System. This will require the ability to mine EHR data to identify noncompliant patients and provide information about costs, gaps in care and outcomes. Health care organizations will continue to collaborate on strategies and tools to help patients adhere to their medication regimens. An example is the eHealth Initiative’s Electronic Medication Adherence Collaborative.
9. Patient identifier. Stakeholders will continue to focus on the need for a national patient identifier, which is a key to true interoperability. Because various technical and legislative constraints exist around the topic, stakeholders will continue to undertake various patient data and complicated algorithms to identify patients and try to link them correctly with their records. EHR vendors are aware that patient matching is an issue for their customers but a business case is needed. Even if a national patient identifier is created (which currently is prohibited by law), it is likely that individual stakeholders will request additional and varying data elements and formats. Such customization is expensive and time consuming. Moreover, EHR vendors are reluctant to make any changes without user demand, which traditionally has been driven by legislation. Meanwhile, correctly match patient data with the proper source. We expect to hear more about the patient matching issue from the Government Accountability Office, which was tasked to delve into the topic by the 21st Century Cures Act.
10.Prescription drug monitoring programs (PDMPs). Sadly, the opioid epidemic will show few signs of abating in 2018. In response, states will continue to enact legislation mandating that prescribers and pharmacists consult PDMPs before controlled substance prescriptions are written and the drugs dispensed. PDMPs are independent, state-run databases of controlled substance prescriptions that now exist in all states and the District of Columbia. In addition, states will increasingly demand that PDMPs become more interoperable due to the differences in states’ ability to exchange data. Efforts will accelerate to integrate PDMP data into EHRs, which also is a growing legislative requirement by states.
11.Real-time benefit check (RTBC). Intense interest will continue in 2018 around the RTBC. In contrast to current formulary and benefit information provided to electronic prescribers, the RTBC provides real-time information at the patient level, which is pulled directly from the payer. It allows the prescriber to see patient-specific condition management programs (such as PA and step therapy), true out-of-pocket costs for a medication (specific copay/coinsurance amount) and specific deductible information. This will prevent dispensing delays caused by inadvertent prescribing of a drug that is not covered by the patient’s insurance. RTBC can help the prescriber find affordable drugs for individual patients’ conditions. This, in turn, will increase medication adherence because patients will not take drugs they can’t afford. As evidence that RTBC is poised to take off in 2018, solutions already are in the market, including (for patients supported by the company), (which uses a modified NCPDP Telecommunications D.0 standard) and Surescripts (which uses a modified NCPDP SCRIPT standard). Meanwhile, an NCPDP task group will continue its work on use cases and standards development, including whether a new, hybrid standard is needed.
12.Specialty pharmacy automation. The industry will continue working on automating specialty prescribing in 2018, with focus on the specialty enrollment process. These efforts build on standards and implementations for electronic prescribing as well as complement the work under way to automate other aspects of specialty pharmacy. Stakeholders are coming together to identify additional or enhanced standards to support enrollment and other aspects of specialty pharmacy automation. HL7’s FHIR is likely to become the standard of choice to extract relevant patient administrative and clinical data from EHRs. NCPDP’s Specialty Electronic Prescribing Task Group is looking at how new data elements that are useful for the enrollment process can be incorporated into the SCRIPT standard. These include, for example, additional patient contact and demographic information, diagnosis, lab values, height and weight.
13.Virtual visits. Stakeholders will continue to jump on the virtual visit (aka telehealth) bandwagon in 2018. Myriad efforts are under way to implement and pay for such services by the Department of Veterans Affairs, Medicare, Medicaid and private payers. In fact, a majority of the nation’s health systems plan to expand virtual visit offerings or patient access based on early experience with the technology, . Pharmacies will ramp up use of virtual visits as part of a strategic move to offer more direct patient care. For example, New York-Presbyterian (NYP) and Walgreens are teaming up to provide remote access to NYP physicians on Walgreens’ website and kiosks at certain Duane Reade drugstores in New York City. for direct-to-consumer care through telehealth availability in its clinics and pharmacies. Despite the enthusiasm for virtual visits, critics (including the ) wonder if potential cost savings and consumer acceptance and satisfaction will actually materialize at expected levels. [Read more here about virtual visits in this issue of HIT Perspectives.]