Health Information Technology Needs of Pharmacists as Practitioners Sue Merk, R.Ph. EVP of Innovation, OneHealthPort

Conflict of Interest Statement  None today  Disclosure: OneHealthPort contracts with Office Alley for claims clearing for several payers in the NW. OneHealthPort does not receive any referral or other fees from Office Alley for any promotional services provided by OneHealthPort about Office Alley services.

For Pharmacists: At the completion of this program, the participant will be able to:  Identify software and service solutions for pharmacy professionals to collect information and submit claims.  Identify what pharmacy professionals should look for in different solutions.  Describe how the different software solutions fit together either incrementally and bundled together.  Describe best practices to succeed.

What does it mean to be a Medical Provider  Pharmacists must meet all the same requirements as other providers  Contracting  Credentialing  Meeting Prior authorization requirements  Checking eligibility and benefits  Billing payers and patients for services  Collecting copays and co-insurance  Documenting patient encounters  Sharing clinical information with other providers and health plans  Sharing clinical information with the patient or their family

Preparing to Care for Patients – Business Activities  In order to serve your patients under their Medical benefits, a pharmacist will need:  A Practice Management system or service to schedule appointments, capture billing information (payers and copays),output bills to payers electronically using a clearinghouse  A process to define/select codes and coding expertise to prep standard and non- standard visits  An Electronic Health Record to store patient clinical information and to appropriately document in accordance with industry standard  For community pharmacies – a process to get diagnosis and need from diagnosing physician – or share the clinical record

System Acquisition Approaches  Buy software and host it on your own servers – highest cost- highest risk  Variations include license software and use an IAAS to host and manage  You manage the application layer  Rent software – Software as a Service – hosted and managed by a vendor  Usually is the software vendor but not always – OCHIN host several products  Service bureau offers software and often other needed services like coding/billing/collections – Athena Health is an example  Free PMS based on claims submitted at fee to health plans – Office Alley, Practice Fusion  Partner with a health system with larger systems  Growing number of pharmacy chains and small practices doing this  Usually based on the health system wanting a close relationship with the provider

Sample systems  If you don’t have a Practice Management system (PMS) or Electronic Health Record (EMR/EHR), there are many options for renting versus buying software.  Software as a Service examples:  Office Alley – Practice Mate - free PMS – low rate EHR – free claims submissions to health plans  Practice Fusion – free EMR and PMS  Epic – hosted and managed by OCHIN

Practice Management System Supports Gap 1, 3, 4, and sometimes 5 solutions

Practice Management System

Practice Management System Features  Scheduling  Patient reminders  Billing - claims  Coding  Batch submissions to clearinghouses  AR management  Re-bills  Patient billing for balances or deductibles

Practice Management System Role  Pre-Visit Activities: Schedule appointments  Verify eligibility and benefits before a visit  Check on copay and pre-auth requirements for the scheduled service  Set date to send a patient reminder  If the copay or co-insurance is known for the scheduled visit – send the information to the patient with the appointment reminder – No Surprises  Send payment expectation rules disclaimer/reminder  Pre-Authorization  Check on websites and your contract for pre-auth requirements  Health Plan general rules collected on “One Stop Shop” on OneHealthPort website under – Administrative Simplification  THIS is the most important pre-visit workflow

Billing and collecting from Patients  A process to verify eligibility, benefits and pre-service requirements before the point of care  OneHealthPort websites for all health plans – good technician task - free  Subscribe to a service that charges by the patient to verify data for you –  Your Practice Management vendor may offer “value add” services for a fee  A process to Collect copays and coinsurance from patients before being treated  Check-in collection process  Credit card processing  A process to bill and collect any fees not collected at the time of care  Revenue Cycle Management vendors can assist with high deductibles or services outside the covered benefit – travel immunizations  Verify what your contract allows for “balance billing” to the patient

Billing and collecting from Payers  A process to verify eligibility (pre-service, date of service, at billing)  A process to bill the health plan using electronic claims submission  A process to code the claim before it is submitted  A process to reconcile payments and hunt down non-payments  A process to reconcile holdbacks and retro payment adjustments  A process to submit electronic attachments if request by the health plan for  Prior-authorization justifications  Claims submissions requiring more explanation  Request an extra-contractual benefit for a patient  Moving toward C-CDA electronic documents instead of fax of the chart

Coding of Claims  Stacey Olson has covered in depth the coding process  When looking for a vendor ask if they will support the Pharmacy codes  How does the vendor allow you to set up your code lists to simplify the coding workflow  Diagnosis code is ALWAYS required on all claims  Can be from the referring provider  Can be from the shared clinical record  Can request the patient Continuity of Care Document (CCD) from the provider practice electronically  If the patient is a Medicaid patient – check clinical record in the Clinical Data Repository opening in December via portal or query the record from your EMR

Electronic Health Record System Supports part of Gap 1, all of Gap 2, part of Gap 3

Electronic Health Record

Capturing the Clinical Record  The Electronic Health Record (EHR) is your documentation of the clinical visit and patient treatment plans.  There is no requirement that you use an EHR but it is becoming a necessity to meet contractual requirements for electronic clinical documents.  Systems and solutions can manage complex workflows and assist the practitioner to make sure best practices are performed and documented  Office of the National Coordinator (ONC) sets the certification criteria and authorizes certification organizations to test vendor products.  We have a log way to go on maturing the certified products for interoperability

What should you look for in a Clinical System  Certified Electronic Health Record that can output and receive a C-CDA  Low cost of entry  How many “connectivity” or interoperability options do you have to share data with other Providers, Payers or quality aggregators  Has the vendor worked with pharmacies or other small practice settings before  Are they willing to add visit types and codes specific for pharmacists?  Who are your top trading partners (practices) and what systems do they use  Do your major clinical trading partners have specific expectations for trading clinical records?

The growing importance of sharing clinical data  Required by health plans  Required by Health Care Authority (Medicaid) and PEBB (State Employees)  Required by ACOs  Dept. of Labor and Industries moving to replace custom forms with C-CDA  Must be able to “ask” for records from other practices - QUERY  Provide Clinical documents when requested by others – RESPOND to a QUERY  C-CDA document set is the new standard for attachments for appeals, claims clarifications and pre-auth documentation  Providing clinical data to the patient for their Patient Health Record

Interoperability – Sharing Across the Community  Direct – similar to but secure – individual address  Most vendors support – lowest rung on the ladder  May not have automated record selection to simplify sharing  No query  XDS.b – used to send clinical records to a Registry or Repository like the Immunization registry or the Medicaid Clinical Data Repository. Also has a query transaction to ask for records stored in the registry or repository  XCA – Cross Community Access to clinical records – a method to query another clinical organization and request records on a patient  FHIR – newer Fast Health Interoperability Resource – can support mobile and lighter weight queries across the community – not finalized but growing in vendor interest. This is web services or application programming interfaces (APIs) that make it easier for one system to query another for standard data.  Don’t settle for just one method – the future is all about data sharing

Tools to Help You in Selecting Systems

Don’t wing it – start your lists:  Put together your business requirements list – what services will you provide  Assign a Project Manager to lead your system search  Use consultants who know about a lot of systems – REC (Qualis) is a resource  Ask a lot of questions  Build a scorecard to compare different vendors and options  Make a list of your top trading partners and what systems they are using  Ask top trading partners about their interoperability choices  Know your budget – what can you afford  Know your primary billable transactions – if you don’t know, the vendor can’t verify how they will support you

Use Free Resources  Google “Selecting an EHR”  Selecthub  CMS Resources - implementation-steps/step-3-select-or-upgrade-certified-ehrhttps:// implementation-steps/step-3-select-or-upgrade-certified-ehr

Sample Evaluation Tool

Vendor Pricing Template Tool

Phone a Friend  Talk with other pharmacies who are in the search of tools  Talk with pharmacies who are already using PMS/EHR systems – what can they share  Talk with medical practices you trust about their systems  Ask for reference lists that you can contact if you are down to 1 or 2 finalists  Have a list of questions ready and then ask “what you didn’t ask” to grow your list  Ask the WSPA to host reference lists of who is willing to share information about their vendor selections

Questions  Contact Information for: Sue Merk OneHealthPort ext. 116