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HIT Perspectives: Value Based Care

HIT Perspectives – February 2015

Interoperability, Value-Based Care and the War on Painkillers to Drive E-Prescribing for Controlled Substances

By Tony Schueth, Editor-in-Chief

E-prescribing for controlled substances (EPCS) has been slow to take off but will gain renewed traction due to policy and legislative changes at the federal and state levels that have created new drivers expected to hasten the adoption of EPCS beginning in 2015.

Controlled substances account for roughly 13% of all prescriptions each year. EPCS has long been approved by the Drug Enforcement Administration (DEA), providing certain requirements are met. It is legal in 49 states, whose requirements must meet or exceed those put in place by the DEA. According to Surescripts, nearly all physicians who electronically prescribe (ePrescribe) also prescribe controlled substances. However, the vast majority of controlled substance prescriptions are still handled via traditional phone/paper/fax methods. It is estimated that only 1% of controlled substance prescriptions are transmitted electronically.

This percentage is expected to rise quickly because the federal government, in particular, has added policy levers in terms of increased interoperability of health information technology (healthIT). Movement by Medicare and private payers toward value-based care also will require greater EPCS adoption. Finally, states are looking to enact legislation requiring EPCS as a tool to combat the war against abuse of prescription painkillers.

Improved interoperability. EPCS is included in a federal interoperability initiative to improve care through increased, interoperable exchange of clinical and prescription data. Created by the Office of the National Coordinator for Heath Information Technology (ONC), the draft Shared Nationwide Interoperability Roadmap has an overall goal to achieve basic electronic health data interoperability by 2017. EPCS, with concurrent availability of data from state prescription drug monitoring programs (PDMPs), is featured among the Roadmap’s 2015 to 2017 calls to action — specifically, for providers to routinely leverage standards-based healthIT to support priorities and work flows. The combination of the ONC throwing its considerable clout behind this recommendation and its two-year implementation horizon are sure to be short-term drivers for increased EPCS adoption.

PDMPs are secure, state-administered electronic databases that track the prescribing and dispensing of controlled substances and other prescription drugs of concern. Both the federal and state governments recognize PDMPs as effective tools toward reducing prescription fraud and abuse of controlled substances. Currently, 49 states and Guam have an operational PDMP, which collects data from dispensers and reports information from its database to authorized users. (Click here for an in-depth overview of PDMP programs.)

Despite the promise of PDMPs, more work needs to be done to enable the exchange of EPCS data and their integration into EHRs and the ePrescribing work flow. The ability of PDMPs to exchange data across state lines is presently suboptimal. As of November 2014, 29 state PDMPs can share data with other state databases.

To address those concerns, ONC has sponsored a stakeholder-driven Standards and Interoperability (S&I) Workgroup. It is looking at harmonizing standards for PDMP data exchange, facilitating pilots and creating an implementation guide. (Click here to learn more about this S&I initiative.)

More standards interoperability. Another piece of ONC’s impetus for interoperability is its 2015 Interoperability Standards Advisory (Advisory). This represents a framework and process going forward by which ONC will coordinate functionality-specific standards recommendations with stakeholder input. The result, according to ONC, will be the identification, assessment, and determination of the best available interoperability standards and implementation specifications for industry use toward specific health care purposes. The 2015 Advisory is basically a set of lists of best practices for standards in four broad categories: vocabulary/code sets/terminologies, content/structure, transport and services. These are broken down to indicate which standards are appropriate for specific uses. Recommended standards for ePrescribing (and EPCS by extension) include SCRIPT v.10.6 and Formulary and Benefits v3.0, both created and maintained by the National Council for Prescription Drug Programs (NCPDP). ONC’s clout behind this standards-focused project will raise all boats, including EPCS.

Rise in value-based care. Public and private payers are renewing efforts to move toward value-based care, which, among other requirements, will rely on more EPCS to provide better medication and cost data. Medicare recently announced a plan to move away from fee-for-service (FFS) medicine within four years toward reimbursement through such “alternative” models as bundled payments, patient-centered medical homes and accountable care organizations. At the same time, nearly all remaining Medicare FFS payments are expected to be tied to quality or value by 2018. The result will be a renewed emphasis on pay for performance by linking reimbursement to quality measures and patient outcomes. This will require better data and better, interoperable data exchange.

Similar goals have been enunciated by a coalition of private insurers and health systems that have partnered to accelerate the transition to value-based care. Members of the Health Care Transformation Task Force intend to move 75% of their business to value-based contracts that prioritize quality and cost effectiveness by 2020. Stakeholders include Aetna, Health Care Service Corp. and major employer groups, including the Pacific Business Group on Health.

With those goals in mind, increased EPCS will be a necessary requirement in this new environment.  Currently, lack of EPCS creates major data holes in a patient’s electronic medical record, medication history and treatment plans. The resulting gaps in treatment and difficulties in medication therapy management and medication reconciliation represent major quality concerns. Lack of EPCS also contributes to costly and dangerous adverse drug events because drug-drug and drug-allergy interactions with controlled substances are unknown at the point of prescribing. In addition, the lack of EPCS data results in an incomplete cost profile — both for the patient and particular drugs on a payer’s formulary. A complete picture of a patient’s medications and their costs will be necessary in alternative reimbursement models and value-based payment. For those reasons, the transition of payers to value-based care on a short-term horizon will spur increased EPCS adoption.

State legislation. States are considering using policy levers to further EPCS adoption as a tool against prescription drug abuse. New York is leading the way with enactment of the Internet System for Tracking Over-Prescribing Act in 2013, also known as the I-STOP bill. I-STOP has two parts. The first was creation of the Prescription Monitoring Program (PMP) Registry, which is essentially a PDMP as described above. Prescribers in New York must consult with the PMP before creating a prescription for Schedule II-IV controlled substances. The second part of the bill requires ePrescribing of all medications (both controlled substances and non-controlled substances) beginning March 27, 2015 (although that date may slip in response to concerns about stakeholder readiness).

The federal government, states and stakeholders (such as physician groups) are watching I-STOP with interest. Several states (including California, Illinois, Oklahoma, Texas and Utah) are considering passing similar legislation.

We expect EPCS will come out of the shadows in 2015 and emerge as a major source of quality and cost data for public and private payers, as well as a tool to fight prescription drug abuse. Point-of-Care Partners (POCP) has long been active in ePrescribing and EPCS. Let us put our expertise to work and help keep you up-to-date with the transition to EPCS. Our ePrescribing State Law Review is the most succinct yet comprehensive analysis of federal and state rules, regulations and statutes governing electronic prescriptions, including EPCS. We are closely monitoring the progress of the I-STOP Program in New York and interest in similar programs by other states, which we would be happy to share with you. Finally, POCP can help draft stakeholder comments regarding ONC’s draft Roadmap, which are due April 3, and its 2015 Advisory, due May 1.