Use of patient ID scanners

Patient ID scanners help with compliance with with the five patient rights in regards to drugs – the correct time, route, dose, medicine, and patient.  Off the shelf technology has usability problems therefore using a unified system works best in this situation.  Only 10% of hospitals use some form of patient identification.  The Parkview medical center and the New York Presperterian Center uses Intellidot CAREt system.  Safety and satisfaction increased at Parkview and errors dropped from 20% to 8%.  MDI hosipital used a bar code scanner but it did not work well on round wrists or medicine bottles.  They were contacted by Hand Held Products that uses uses 2D barcodes that resemble small dots.  The code is repeated so a good scan will be completed.  The Intellidot CAREt system uses a similar technology.  St. Luke’s Hospital implemented electronic medication administration and reporting system (eMAR) to improve services.  The Wythenshawe hospital uses the Datalogic Gryphon hand held scanner.  However there are still problems with hand held scanners if the wristband is wrong.

 

 

Summary of DEA’s Interim Final Rule on Controlled Substance E-Prescribing

The following highlights the IFR’s key requirements for controlled substance e-prescribing regarding physicians:

 

·         Option of e-prescribing controlled substances as of June 1, 2010, if they comply with specific requirements, as described below

·         Must first undergo a verification process (either in person or remotely) in order to receive authorization to e prescribe controlled substances

·         Set access controls in their office practice prior to e-prescribing controlled substances

·         Must use a two-factor credential to e-prescribe controlled substances

·         Can use their own digital certificate to sign e-prescriptions for controlled substances

·         Are not required to review their prescription logs

·         Must comply with notification requirements if they lose their hard token or if they discover that their security controls have been compromised

·         Must use a compliant e-prescribing application in order to e-prescribe controlled
substances

 

Identity proofing and access controls

 

Authentication must occur by a third party to verify the physician.  They must apply to certain federally approved credential service providers (CSPs) or certification authorities (CA).  Logical access controls can be user or role-based.  Access control must be handled by at least two people registered with the DEA within a practice.  An institutional practitioner (eg.  hospital) can conduct identity proofing in-house as part of their credentialing process.

 

Two-factor authentication

 

The DEA is allowing the use of a biometric as a substitute for a hard token or a password. 

 

Public key infrastructure (PKI) and digital certificates

 

The IFR allows a physician to use his or her own digital certificate to sign e-prescriptions for controlled substances.

 

Signature and transmission requirements

 

Only the physician may sign the prescription.  Signing and transmission does not need to occur at the same time.  The e-prescribing application will apply a digital signature to and archive the controlled substance prescription information when the physician completes the two-factor authentication protocol.  Some physicians may sign the prescription before office staff add pharmacy and insurance information.

 

Monthly e-prescribing logs

 

The IFR requires that the e-prescribing application automatically provide the physician with a monthly log of the physician’s controlled substance e-prescriptions and provide it on request.  A physician can specify a time period for log review for a minimum of to two years and display a patent’s drugs or general drugs.  This is a tool to help monitor and detect fraud or inappropriate activity.

 

Two year record keeping requirement

 

The IFR requires records related to controlled substance e-prescriptions to be retained for two years from the date of their creation or receipt.

 

E-prescribing controlled substances is an option

 

E-prescribing a controlled substances is an  addition to written and oral prescriptions for controlled substances.  Existing e-prescription applications and electronic health record systems that do not comply with the IFR rules can still use the old standards by using paper records.

E-Rx > What you need to know and do: Step-by-step

Steps 3, 4 & 5 – System costs and implementation

 

3.    Understanding costs and financing options

·         Planning

·         Identify a member(s) of the project team to research the costs and potential subsidies or reimbursement programs available, including health-care provider incentives

·         Identify any existing national and state initiatives for which the practice may qualify

·         Calculate your practice’s projected reimbursement under the new Medicare incentive legislation and research pay-for-performance programs

·         Technology

·         Document price differences between a stand-alone and EHR system and include associated costs

 

4.    Selecting a system

·         Planning

·         Involve the entire project team in system selection by defining specific evaluation criteria for comparison and facilitate open discussions about the pros and cons of each product and the rationale

·         Develop your own test scripts or scenarios reflecting your practice’s common workflows, and ask each vendor to demonstrate how their product would work in those scenarios

·         Contact other practices in your area that currently use the products you are evaluating

·         Evaluate usability features of each software vendor

·         Make sure you clearly understand what training is offered by the vendor and the costs

·         Technology

·         Ensure that the hardware required by the system supports your practice’s desired workflow, including efficiency, security, and hardware synchronization

·         Select Internet connectivity with a redundant Internet connection backup in place

 

5.    Deployment

·         Planning

·         Commit staff time during implementation for training and workflow integration

·         Ensure that all affected members of the practice receive appropriate training

·         Create an incremental approach to training over several days and schedule a few additional training sessions over the next few months

·         Ask your vendor if they provide access to learning materials

·         Technology

·         The project leader should keep your software vendor informed about any technical problems or usability issues

·         Log support cases with the technology provider

·         Set default routing to electronically send prescriptions to the pharmacy rather than faxing them because the feature will be under used

·         Utilize electronic prescription renewal functionality as this increases efficiency and improves patient service when they are able to get their prescriptions renewed more quickly

·         Integrate patient demographic information from the practice management system in advance of e-prescribing implementation

·         Designate a prescriber or staff person to retrieve and manage responses for renewal authorization requests that are sent electronically from pharmacies

·         Make sure you know how to select your patient’s pharmacy of choice using your e-prescribing application

·         Respond to electronic renewal requests as soon as possible, and always within 24 hours on business days to avoid duplicate renewal authorization requests

·         Avoid queuing or “batching” prescriptions before sending them to pharmacies electronically to provide pharmacies adequate time to receive and fill the prescription

·         Follow DEA regulations by refraining from electronic transmission of prescriptions for controlled substances until these regulations are changed to allow electronic transmission

·         Communications

·         Inform local pharmacies that you are getting ready to exchange prescription information electronically

·         Communicate with patients about electronic prescribing and its benefits and remind them to call the pharmacy rather than the practice when they need their prescriptions renewed

E-Rx > What you need to know and do: Step-by-step

Steps 1 & 2  – Your practice

1. Assessing your practice readiness 
   • Planning
     • Are your practice staff and leadership open to change?
     • Has your practice endured unsuccessful technology implementations or workflow
       changes in the past?
     • Are there other major projects on which your practice is currently focused?
     • Do your practice leadership and staff agree that e-prescribing can lead to clinical or operational improvements?
     • Have you discussed and planned for e
       known e-prescribing challenges?
   • Communication
     • Does your practice have a culture of open, honest communication?
     • In the past, have decisions been effectively communicated to the practice?
2. Defining your practice needs
   • Planning
     • Establish your vision and identify the specific objectives
     • Identify a project team experienced in the prescribing process and its workflow
     • Choose a project leader who is respected, knowledgeable of the practice, and is skilled at conflict resolution
     • Plan for known e-prescribing changes
   • Workflow and change management
     • Make a list of your practice’s specific medication management needs
     • Prioritize your practice needs to identify the trade-offs
     • Anticipate how your processes and workflow will change
   • Technology needs
     • Think about your computing needs
     • Consider hardware and network demands
     • Determine who will maintain your system
   • Communication
     • Describe the vision and objectives to the entire practice and their involvement in the project, especially input collection
     • Involve all parts of the practice when defining needs

Steps to create a prescription

1) Review patients’ current medication list and medication
       history information:

• Update medication history

• Correct medication history

• Reconcile with multiple history sources

 

2) Work with an existing medication:

• View details of a medication

• Discontinue or remove a medication

• Change dose, etc., for a medication

• Renew one or more medications

 

3) Prescribe or add new medication:

• Search for a medication

– From quick choices/favorites

– By name (generic or trade)

– By indication

– By formulary

• Display medications with prefilled, known, favorite,
              or standard dosing

• Select medication

• Review warnings

• Enter SIG and other parameters

• Automatically populate and update favorites list of drugs
                with prefilled known dosing based on frequency of
                utilization by clinician

 

4) Complete the prescription and authorize (electronically
        sign)

• One item

• Multiple items

• Items created by ancillary staff, residents, or others

 

5) Transmit prescriptions

• Choose print, fax, transmit options in real-time or batch
              mode

• Print formats and prescription information, conforming to
             state regulations

• Handle restrictions on certain medications (e.g., class II
                 controlled substances cannot presently be e-prescribed)

• Ensure prescription is sent to preferred patient pharmacy
                 (identified by practice staff prior to interaction with
                  prescriber)

A CLINICIAN’S GUIDE TO ELECTRONIC PRESCRIBING

Challenges to a E-prescribing

• Financial cost and return on investment (ROI)
• Hardware and software might need to be invested for stand-alone or EHR systems
• Larger practices can achieve ROI earlier
• Change management
• Difficulty changing to a new electronic system
• Workflow
• People need to adapt to the new system
• A full EHR system will take more time
• Controlled substances
• Electronic transmission of prescriptions for controlled substances is prohibited
• State regulatory restrictions
• All states allow electronic prescribing
• Medicaid in New York require a “dispense as written (DAW)” in a handwritten form
• Hardware and software selection
• This can be a daunting task
• Limitations on e-prescribing system remote access
• No easy remote access optimal
• Cell phone gaps for digital service and limitations of broadband internet service
• Pharmacy, payer/PBM and mail order connectivity
• Not all pharmacies are connected using certified software like SureScripts-RxHub
• Do not want to pay a fee
• Medication history information is not comprehensive
• Medication history and medication reconciliation
• Confidence cannot be placed in the completeness and currency of information
• Reconciliation from multiple sources must occur
• Doctor's must consult with patients on accuracy
• Medical history information
• Not all stand-alone systems include a history which could impact a medication decision
• Prescribing from multiple office sites
• Must accommodate this because there are differing registration numbers and passwords
• Must be able to work elsewhere, but that function is not always available
• Small and rural practice challenges
• Challenges are magnified
• Lack of access to broadband and to skilled information technology professionals
• Longer to achieve ROI
• Patient acceptance and usage issues
• Patients may fee uncomfortable with e-prescriptions and demand paper prescriptions
• Frequent travelers may feel prefer a written one

A CLINICIAN’S GUIDE TO ELECTRONIC PRESCRIBING

Choices for an e-prescribing system

Stand alone systems are less costly and complex, thus they can be implemented must faster than an EHR system.  Having a system is important in receiving a Medicare e-prescribing bonus.  Software is offered as a package that can be downloaded to a office computer system, or more commonly, though the internet using an application service provider (ASP) for a fee.  Multiple hardware devices can access this service.  A standalone system can be a gateway to an EHR service because prescribers can become more technologically proficient and comfortable with electronic systems

An EHR system with an integrated e-prescribing module has immediate access to all patient data in the system.  They have better quality and safety.  They also have a larger clinical decision support.  More EHR systems are now including e-prescribing.  Full automation and interoperability make an EHR system a better choice.  However, they are more costly and complex than stand alone.

 

A CLINICIAN’S GUIDE TO ELECTRONIC PRESCRIBING