0 enabling healthcare interoperability Webinar Series Sponsored by the HITSP Education, Communications and Outreach Committee Medication Management September 18, 2008 | 2:00 – 3:30 pm (Eastern) Presenter: Scott M. Robertson, PharmD Co-Chair, Consumer Perspective Technical Committee

Slide 1 HITSP – enabling healthcare interoperability  During this 90-minute webinar, participants will explore the medication management cycle, gaining a basic knowledge of: — the people, organizations and systems that comprise the medication management cycle; — the impact of fragmented medication and allergy information on patient care and safety; — sources of patient-specific medication and allergy information, their advantages and limitations; — electronic processes, e.g., eRx (electronic prescribing), that facilitate the medication management cycle and improve patient care and safety; and — similarities and differences between inpatient, ambulatory and long term care settings in the medication management cycle. Learning Objectives a webinar series on U.S. healthcare interoperability

Slide 2 HITSP – enabling healthcare interoperability Agenda  Steve’s Story  HITSP – a quick review  Medication Management — What is it? — Information Sources — For the Consumer — For the Prescriber — HITSP constructs — Fitting the pieces together  Conclusion  Questions and Answers / Open Dialogue a webinar series on U.S. healthcare interoperability

Slide 3 HITSP – enabling healthcare interoperability Introduction: Steve’s Story... part nine  Patient is a 26-year-old male coping with the long-term effects of a brain tumor that was removed during his childhood  Medications may change often in response to changes in medical conditions — Patient finds keeping track of those medication changes is challenging  Patient’s doctors are not aware of the over-the-counter (OTC) medications he is taking for allergies — Patient is worried about drug-to-drug reaction

Slide 4 HITSP – enabling healthcare interoperability  HITSP is a volunteer-driven, consensus-based organization that is funded through a contract from the Department of Health and Human Services  The HITSP Panel brings together public and private-sector experts from across the healthcare community to harmonize and recommend the technical standards that are necessary to assure the interoperability of electronic health records Overview

Slide 5 HITSP – enabling healthcare interoperability  The HITSP Standards Harmonization Framework — Identify a pool of standards for an AHIC (American Health Information Community) Use Case — Identify gaps and overlaps in the standards for this specific Use Case — Make recommendations for resolution of gaps and overlaps — Select standards using HITSP-approved Readiness Criteria — Develop Interoperability Specifications (IS) that use the selected standard(s) for the specific context — Test the IS Deliverables and Mode of Operation

Slide 6 HITSP – enabling healthcare interoperability  Each HITSP Interoperability Specification defines a set of “constructs” that: — specify how to integrate and constrain selected standards to meet the business needs of a Use Case; and — define a Roadmap to use emerging standards and to harmonize overlapping standards when resolved.  In essence, a HITSP IS represents a suite of documents that integrate and constrain existing standards to satisfy a Use Case Deliverables and Mode of Operation

Slide 7 HITSP – enabling healthcare interoperability  HITSP construct types, in decreasing breadth of scope, include: — Interoperability Specifications Integration of all constructs used to meet the business needs of a Use Case Interoperability Specifications — Transaction Packages Logical grouping of transactions Transaction Packages — Transactions Logical grouping of actions that use components and/or composite standards to realize the actions Transactions — Components Logical grouping of base standards that work together, such as messaging and terminology Components Deliverables and Mode of Operation

Slide 8 HITSP – enabling healthcare interoperability  IS Status = State in the acceptance process — Released Panel approved for submission to HHS — Accepted Secretary of HHS has accepted for a period of testing — Recognized Secretary of HHS has recognized the IS for immediate implementation  Revisions and updates may mean that multiple versions of some Interoperability Specifications exist with differing status levels Deliverables and Mode of Operation

Slide 9 HITSP – enabling healthcare interoperability IS 01 Electronic Health Record (EHR) Laboratory Results Reporting IS 02 Biosurveillance IS 03 Consumer Empowerment and Access to Clinical Information via Networks IS 04 Emergency Responder Electronic Health Record (ER-EHR) IS 05 Consumer Empowerment and Access to Clinical Information via Media IS 06 Quality IS 07 Medication Management Current Interoperability Specifications (IS)

Slide 10 HITSP – enabling healthcare interoperability IS 07Medication Management  This Interoperability Specification defines specific standards to facilitate access to necessary medication and allergy information for consumers, clinicians, pharmacists, health insurance agencies, inpatient and ambulatory care, etc. — Version: 1.0 Released (Panel Approved) — Version 1.0.1Panel Review

Slide 11 HITSP – enabling healthcare interoperability  Medication Management addresses the information surrounding the acts of prescribing, dispensing, and administering a medication — Communicating the information — Coordinating information from multiple sources — Provides the complete picture the prescriber needs to prescribe the most appropriate medication — Provides knowledge to the patient of what to take and when to take it  Note difference with Medication Therapy Management — i.e., managing medication(s) for a specific therapeutic outcome Medication Management Definition and explanation

Slide 12 HITSP – enabling healthcare interoperability Medication Management Definition and explanation (continued)  Whenever a change in medication may occur, there is potential for misunderstanding and errors — Patient / Clinician encounter (in person or remote) — Hospital admission or discharge — Transfer to other care facilities — Release to home — Instructions passed on to caregivers by the patient Caregiver help Patient at home Step-down & other care Hospital stay Clinic Visit

Slide 13 HITSP – enabling healthcare interoperability  Medication changes are made based upon, or require knowledge of: — changes in medical condition being treated — other medical conditions, active and resolved — current medication treatment — prior medication treatment — allergies — patient-specific factors Medication Therapy Medication Change Medication Therapy Medical Status Current Meds Prior Meds Allergies Patient Factors Medication Management Definition and explanation (continued)

Slide 14 HITSP – enabling healthcare interoperability Medication Management Information Sources  Many sources exist  Level of information varies  Coverage varies  Reliability

Slide 15 HITSP – enabling healthcare interoperability  PROBLEM: Many sources exist Medication Therapy Medication Change Medication Therapy Medical Status Current Meds Prior Meds Allergies Patient Factors Medical Status Current Meds Prior Meds Allergies Patient Factors Medical Status Current Meds Prior Meds Allergies Patient Factors Medical Status Current Meds Prior Meds Allergies Patient Factors Medical Status Current Meds Prior Meds Allergies Patient Factors Medication Management Information Sources (continued) For the PrescriberFor the Patient Need to coordinate information from multiple sources Needs to understand the new Medication Therapy (i.e., “what do I take, when, and why”)

Slide 16 HITSP – enabling healthcare interoperability  Many sources exist — Patient — Family / friends / others — Payors / Pharmacy Benefit Managers (PBMs) — Clinicians – multiple — Pharmacies – multiple — Electronic Health Records (EHRs) – multiple — Personal Health Records (PHRs) – multiple Medication Management Information Sources (continued)

Slide 17 HITSP – enabling healthcare interoperability  Level of information varies (not complete listings) — Patient drug name, how taken, other medications and supplements — Clinician drug name, how taken, reason for drug, when ordered, patient response to drug, related clinical values (labs) — Pharmacy drug name, lot, manufacturer, prescriber, date & time dispensed, quantity, cost — Pharmacy Benefit Manager (PBM) drug name, prescriber, date dispensed, quantity, pharmacy — Electronic Health Record (EHR) drug name, prescriber, date ordered, date administered(?), indication, how administered, related clinical values — Personal Health Record (PHR) patient-entered, see patient; system-to-system, see PBM or EHR Medication Management Information Sources (continued)

Slide 18 HITSP – enabling healthcare interoperability Medication Management Information Sources (continued)  Coverage varies — Patient potentially all medications, OTCs, supplements, herbals … — Clinicians probably limited to those medications they prescribed — Pharmacy medications, potentially OTCs, supplements purchased there — PBM covered and paid medications only — EHR all medications for encounters in that EHR — PHR potentially all medications, OTC, supplements, herbals …

Slide 19 HITSP – enabling healthcare interoperability  Reliability — Patient what they know and understand, can be the best source in some cases. Ranges from very good and complete to very poor and unreliable. — Clinician very reliable in most cases, best when they have chart/system available — Pharmacy very reliable – the source of most medications — PBM very reliable (people get paid from the transactions) — EHR very reliable for tracked encounters — PHR reliable but dependent on user input Medication Management Information Sources (continued)

Slide 20 HITSP – enabling healthcare interoperability Medication Management For the Consumer  Confidence — I know what I am taking (prescribed and otherwise) — My doctors know what I am taking — No confusion when instructions change  The right medication at the right time — What the prescriber wrote — What the pharmacy dispensed — What I am taking and how I’m taking it  The best result from the medication

Slide 21 HITSP – enabling healthcare interoperability  Complete medication picture — Medications by other clinicians — Medications self-prescribed by the patient (OTC, supplements, herbs, etc) — Prior medications — Allergies and Intolerances — Medical conditions and status — Drug Benefits, Formulary and related factors  Compliance information — Knowing when the patient filled/refilled the prescription  Improved workflow — Reliable exchange with pharmacy — Reduced need for call-backs Medication Management For the Prescriber

Slide 22 HITSP – enabling healthcare interoperability Medication Management For the Pharmacist  Complete medication picture — Medications by other clinicians, other pharmacies — Medications self-prescribed by the patient (OTC, supplements, herbs, etc) — Prior medications — Allergies and Intolerances — Medical conditions and status — Drug Benefits, Formulary and related factors  Improved workflow — Reliable exchange from prescriber — Reduced need for call-backs — All necessary information for therapeutic checking

Slide 23 HITSP – enabling healthcare interoperability CURRENT IS 07 ConstructsDescription Interoperability Specification IS 07Medication Management Interoperability Specification Transaction Packages TP 13Manage Sharing of Documents TP 20Access Control Transaction TP 22Patient ID Cross-Referencing TP 30Manage Consent Directives TP 43Medication Orders TP 46Medication Formulary and Benefits Information TransactionsT 15Collect and Communicate Security Audit Trail T 16Consistent Time T 17Secured Communication Channel T 23Patient Demographics Query T 40Patient Generic Health Plan Eligibility Verification T 42Medication Dispensing Status ComponentsC 19Entity Identity Assertion C 32Summary Documents Using HL7 Continuity of Care Document (CCD) TN 900Security and Privacy Technical Note IS 07 – Version 1.0 – Released (Panel Approved) HITSP Constructs

Slide 24 HITSP – enabling healthcare interoperability IS 07Medication Management Document Map SCRIPT HL7 Telecom Formulary and Benefit X12 HL7

Slide 25 HITSP – enabling healthcare interoperability IS 07 – Version 1.0 – Released (Panel Approved) Base Standards  Accredited Standards Committee (ASC) — X12N 270/271 Health Care Eligibility Benefit Inquiry and Response  National Council for Prescription Drug Programs (NCPDP) — Telecommunications Standard — SCRIPT Standard Implementation Guide — Formulary and Benefits Standard Implementation Guide  HL7 — Continuity of Care Document (CCD) — V2.5/v2.5.1 Pharmacy/Treatment Orders  Vocabularies — RxNorm / Federal Medication Terminologies — SNOMED-CT

Slide 26 HITSP – enabling healthcare interoperability IS 07 Medication Management Sharing Clinical / Operational Information Patient Generic Health Plan Eligibility Verification T 40 Medication Dispensing Status T 42 Medication Orders TP 43 Medication Formulary and Benefits Information TP 46 Summary Documents Using HL7 Continuity of Care Document (CCD) C 32

Slide 27 HITSP – enabling healthcare interoperability Manage Consent Directives TP 30 Collect & Communicate Security Audit Trail T 15 Entity Identity Assertion C 19 Secured Communication Channel T 17 Access Control TP 20 Consistent Time T 16 IS 07 Medication Management Privacy and Security Security and Privacy Technical Note TN 900

Slide 28 HITSP – enabling healthcare interoperability Manage Sharing of Documents T 13 Patient ID Cross-Referencing TP 22 IS 07 Medication Management Infrastructure Patient Demographics Query T 23

Slide 29 HITSP – enabling healthcare interoperability Codified SIG TBD IS 07 Medication Management Future Direction New Constructs Required Long-Term Care Requirements TBD Patient-oriented Information TBD Prior-Authorization TBD Terminology Harmonization TBD Medication Monitor/Devices TBD

Slide 30 HITSP – enabling healthcare interoperability Constructs (single purpose or reusable) Type 1: Base or Composite Standards  Re-Use Applying an existing construct to more than one IS  Re-Purpose Updating a construct to meet the needs of a new Use Case  Can extend or constrain when reusing or re-purposing — Specifications contain a common superset — Superset can be extended as new requirements are encountered — Superset can be constrained with use-specific constraints Units of Information Exchange HITSP IS Constructs - Re-Use and Re-Purpose

Slide 31 HITSP – enabling healthcare interoperability “local EHR” Medication Management Fitting the Pieces Together  “Simple” Clinic Visit Encounter Patient Clinician Evaluation Prescription Pharmacy Pt History PBM “other” EHR PHR eRx Rx History Allergies Insurance Info Rx History Allergies Rx History Formulary Benefits Eligibility Rx Claims C32 TP43 C32 SCRIPT HL7 Telecom C32 HL7 Formulary and Benefit Telecom HL7

Slide 32 HITSP – enabling healthcare interoperability “local EHR”  “Simple” Clinic Visit (continued) Encounter Patient Clinician Evaluation Prescription Pharmacy Pt History PBM “other” EHR PHR Rx Claims Rx Fill Medication Management Fitting the Pieces Together C32 T42 SCRIPT HL7 Telecom

Slide 33 HITSP – enabling healthcare interoperability EHR  Hospital Admission Admission Patient Clinician Admission Orders Pt History PBM “other” EHR PHR Rx History Allergies Insurance Info Rx History Allergies Rx History Formulary Benefits Eligibility Pharmacy Rx History Allergies Medication Management Fitting the Pieces Together C32 HL7 Formulary and Benefit

Slide 34 HITSP – enabling healthcare interoperability EHR Medication Management Fitting the Pieces Together  Hospital Discharge Discharge Patient Clinician Discharge Orders Prescription Pharmacy Pt History PBM “other” EHR PHR Rx Claims eRx C32 TP43 T42 SCRIPT HL7 Telecom C32 HL7 SCRIPT

35 enabling healthcare interoperability Webinar Series Sponsored by the HITSP Education, Communications and Outreach Committee Conclusion

Slide 36 HITSP – enabling healthcare interoperability Medication Management Benefits of Implementation...  for the Patient — eases burden to remember complicated information — the complete medication list can be available on a PHR, or can be printed out at the end of clinical encounters  for the Prescriber — assures complete information on the patient’s medication history, such as allergies and any drug benefit restrictions — prescriptions presented in a clear and unambiguous form  for the Pharmacy — provides complete medication and allergy information to evaluate and process the prescription — provides appropriate instruction to the patient

Slide 37 HITSP – enabling healthcare interoperability Future: Steve’s Story... part nine  All of Steve’s doctors, even new doctors, to have the same complete medication history and allergy information  His doctors can access his medication history knowing the limitations and reliability of the sources  The prescriber to be aware of all of his medications, permitting the prescriber to be very specific about what to stop and what to continue

Slide 38 HITSP – enabling healthcare interoperability  Use or specify HITSP Interoperability Specifications in your HIT efforts and in your Requests for Proposals (RFPs)  Ask for CCHIT certification  Leverage Health Information Exchanges to promote HITSP specifications to make connections easier in the future  Ask... Is there a HITSP standard we could be using?  Get involved in HITSP... Help shape the standards How YOU can become involved

Slide 39 HITSP – enabling healthcare interoperability Webinar 1 Standardizing How We Share Information in Healthcare: An Introduction to HITSP Thursday, June 5, 2008 — 2:00-3:30 pm EDT Webinar 6Quality New date Thursday, October 2, 2008 — 2:00-3:30 pm EDT Webinar 2HITSP Foundational Components Thursday, June 19, 2008 — 2:00-3:30 pm EDT Webinar 7Security, Privacy and Infrastructure Thursday, August 21, 2008 — 2:00-3:30 pm EDT Webinar 3Consumer Access to Clinical Information Thursday, June 26, 2008 — 2:00-3:30 pm EDT Webinar 8EHR and Emergency Response Thursday, September 4, 2008 — 2:00-3:30 pm EDT Webinar 4Biosurveillance Thursday, July 10, 2008 — 2:00-3:30 pm EDT Webinar 9Medication Management Thursday, September 18, 2008 — 2:00-3:30 pm EDT 2008 Webinar 5Electronic Health Record (EHR) and Lab Reporting Thursday, July 24, 2008 — 2:00-3:30 pm EDT Learn more about specific HITSP activities by accessing the webinar archive         How YOU can become involved

Slide 40 HITSP – enabling healthcare interoperability Jessica Kant, HIMSSTheresa Wisdom, HIMSS Re: HITSP Technical Committees Michelle Deane, ANSI Re: HITSP, its Board and Coordinating Committees Join HITSP in developing a safe and secure health information network for the United States. Visit or contact...

Slide 41 HITSP – enabling healthcare interoperability Sponsor Strategic Partners

42 enabling healthcare interoperability Webinar Series Sponsored by the HITSP Education, Communications and Outreach Committee Medication Management Questions and Answers