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E-Prescribing and Ambulatory Medication Reconciliation

E-Prescribing and Ambulatory Medication Reconciliation. Douglas S. Bell, MD, PhD Assistant Professor, UCLA Department of Medicine Research Scientist, RAND Health. AHRQ Annual Conference September 27, 2007. Medication list  Safety Alerts. E-Prescribing Transactions. Eligibility

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E-Prescribing and Ambulatory Medication Reconciliation

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  1. E-Prescribing and Ambulatory Medication Reconciliation Douglas S. Bell, MD, PhD Assistant Professor, UCLA Department of MedicineResearch Scientist, RAND Health AHRQ Annual Conference September 27, 2007

  2. Medication list • Safety Alerts E-Prescribing Transactions • Eligibility • Formulary • Med History Mail-orderpharmacy Mail-orderpharmacy RxHub Caremark, Express Scripts, Medco, Wellpt NCPDP SCRIPT • Med History • Formulary Retailpharmacy Retailpharmacy Retailpharmacy SureScripts& others Retailpharmacy

  3. Study Objectives • To evaluate the technical adequacy and clinical effectiveness of: • NCPDP Formulary & Benefit Standard • Medication History function of NCPDP SCRIPT • Fill Status function of NCPDP SCRIPT • Prior Authorization (X12N 278, 275 w/ HL7 attachment) • RxNorm • Structured & Codified Sig In production today Completed, not in production Under development

  4. Medication History Standard • One function within the NCPCP SCRIPT standard • RXHREQ: send Patient ID, date range • RXHRES: return DRU segment for each claim • Drug identified by the NDC code, claim date Rx: Glucophage 850mg #90 [00087607010] on 9/10/2004 Core of the RX History RESponse DRU+D:SPRINTEC 28 DAY TABLET:ØØ5559Ø1658:ND+ØØ:28.Ø:87++LD:2ØØ41115:1Ø2*ZDS:28:8Ø4’ PVD+PC+3334444:ØB+++JONSON:TIM++++6518659191:TE’ PVD+P2+2234567:D3+++++FIRST STREET PHARMACY++6512219ØØØ:FX’ DRU+D:METFORMIN HCL 85Ø MG TABLET:ØØ378Ø24ØØ1:ND+ØØ:6Ø.Ø:87++LD:2ØØ41Ø21:1Ø2*ZDS:3Ø:8Ø4’ PVD+PC+3334444:ØB+++JONSON:TIM++++6518659191:TE’ PVD+P2+2234567:D3+++++FIRST STREET PHARMACY++6512219ØØØ:FX’

  5. Technical Expert Panel

  6. Medication History: Panel Results • Technical problems hinder reconciliation with prescriptions that the POC originated • No data available if patient can’t be identified through RxHub (270/271 Eligibility) • Matching dates can be challenging • Many fields are optional and often left empty • Prescriber ID, Sig, quantity dispensed • NDC Code may not match to POC’s drug DB

  7. Some vendors find reconciling Medication History too hard • Drive alerts only from prescriptions that they originated • All enthusiastically support developing RxNorm to solve NDC mapping problems

  8. The NDC Code Problem • NDC represents the package • metformin 850mg has >100 NDC codes 066267-*497-40 53489-468-88 062037-*675-01 051129-2460-*1 013411-*164-09 065243-*239-12 068115-*232-45 066267-*497-40 55111-430-01 062037-*675-05 051129-2610-*1 013411-*164-10 065243-*239-18 068115-*232-45 066267-*497-45 55111-430-05 062037-*675-10 051129-3594-*1 013668-*002-01 065243-*239-27 068115-*232-60 066267-*497-45 55111-430-30 062147-5001-*0 051129-3594-*2 013668-*002-05 065841-*029-01 068115-*232-60 066267-*497-60 55111-430-60 062318-0191-*0 051129-3943-*1 013668-*002-12 065841-*029-05 068382-*029-01 066267-*497-60 55111-430-78 062318-0191-*1 051129-3943-*2 013668-*002-30 065841-*029-10 068382-*029-05 066267-*497-90 55567-145-18 062584-*332-01 051655-*291-24 013668-*002-60 065862-*009-01 068382-*029-10 066267-*497-90 55567-145-25 063629-1396-*1 051655-*291-25 013668-*002-90 065862-*009-05 068788-0435-*3 066336-*883-60 57315-048-01 063629-1396-*2 051655-*291-52 020091-*533-01 065862-*009-26 068788-0435-*6 066689-*012-01 57315-048-04 063739-*300-10 051655-*291-53 020091-*533-05 065862-*009-50 0781-5051-01 066689-*012-30 57315-048-05 064679-*529-01 053489-*468-01 020091-*533-10 065862-*009-60 0781-5051-05 066689-*012-60 62037-675-01 064679-*529-02 053489-*468-03 0228-2715-10 065862-*009-90 20091-533-01 067090-*533-01 62037-675-05 064679-*529-03 053489-*468-05 0228-2715-11 066105-*601-10 20091-533-05 067090-*533-05 62037-675-10 064679-*529-04 053489-*468-10 0228-2715-50 066105-*744-23 20091-533-10 067090-*533-10 65862-009-01 064679-*529-05 054569-5353-*0 0228-2715-96 066267-*497-20 53489-468-01 067228-0268-*3 65862-009-05 064725-0209-*3 054569-5353-*3 023490-0898-*0 066267-*497-20 53489-468-03 067228-0268-*6 65862-009-50 064725-0209-*3 055045-2905-*0 023490-0898-*3 066267-*497-30 53489-468-05 067544-*107-53 65862-009-60 065243-*239-06 055045-2905-*0 023490-0898-*6 066267-*497-30 53489-468-10 • Each packager maintains their own codes • Changes aren’t always tracked at FDA

  9. RxNav RxNorm ID: 6809

  10. RxNav 2 RxNorm ID: 316257

  11. Dose Drug Dose Form RxNav 3 RxNormID: 311752 (SCD) Metformin 850 MG Oral Tablet

  12. Research Questions • How complete is RxNorm for representing a sample of actual prescriptions • What types of drugs are missing? • How consistently do independent attempts to represent the same prescription result in the same RxNorm concept being chosen?

  13. Methods • De-Identified • 10,000 SCRIPT New Rx’s • Transmitted to retail pharmacies by SureScripts • Representative NDC codes • 10,000 SCRIPT Renewal Requests • Transmitted to Allscripts by retail • Actual NDC codes • Three independent attempts to match NDC to the RxNorm generic clinical drug concept (SCD) • First DataBank, MediSpan, RAND

  14. RxNorm Lab Evaluation • Completeness • 19,824 non-device new prescriptions & renewal requests • 195 (0.98%) no matching SCD found; • 94% multi-vitamins, bowel preps, drugs packaged in a drug delivery device • 18,733 (94.5%) matched by 3 of 3 • Mismatches • 1003 of 19450 with 2+ SCD matches (6.2%) Root causes: • RxNorm errors • Synonymy already corrected as of Jan, 2007 (20%) • Previously unrecognized synonymy (30%) • Source errors • Bad NDC-to-SCD mappings used by one of the matchers

  15. Conclusions • Medication history • Technically adequate • Falling short due to NDC • Strong need for unique clinical drug identifier • RxNorm • Completeness very good (as of 11/2006) • Greatest need: Drug-device package • Some errors hinder reproducible use • RxNorm mapping errors being fixed • FDA’s Structured Product and Daily Med will help address source errors • Available and usable today

  16. Thanks • Point of Care Partners • Tony Schueth • Jack Guinan • SureScripts: Ajit Dhavle, Ken Whittemore • Allscripts: Jill Helm • First Databank: George Robinson, Tom Bizarro • MediSpan: Karen Eckert • NLM: John Kilbourne • RAND: Diane Schoeff, Shinyi Wu • All of our expert panelists • CMS and AHRQ

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