1. New Approaches In Medication Management and Care Transition e-Prescribing and Remote Dispensing in Long Term Care AHRQ Annual Conference September 27, 2007 Presenter – Michael Bordelon

2. Long Term Care Background Reimbursement Model:  Roughly 15% capitated Part A  58% Medicaid/Part D  27% Private Pay and Commercial Insurance Typical Number of Beds: 90-120 Pharmacies are almost never co-located with LTC facilities Physicians per facility: 10-40 Nurse Practitioners per facility: 1-2 Nurses per facility: 50-80 Med passes per day: 4-7 Pharmacy trips to the facility: 2-3 Admissions per week: 1-10 Many facilities already manage their own orders in electronic systems

3. Pharmacy Consultant Pharmacist The Infamous LTC Prescribing Slide Nursing Physician Decide on patient order Evaluate order, clarify if needed and file in Patient Record Faxed order Physician signs copy of the order Receive new order Check patient choice for pharmacy Process order and dispense [includes payor verification and formulary compliance] Process order and dispense [includes payor verification and formulary compliance] Resolve issues with order (clinical, payor, etc.) Clarify and update order with nursing Clarify and update order with physician Med Order Question (phone or fax) Verbal order Signed copy of order Patient MAR Patient Allergies Order Sheet Order Update (Phone or fax) Order Update (Phone or fax) Receive updated order Patient MAR Patient Allergies Patient Orders Patient Allergies Patient Orders MAR Update (optional) Start Physician writes order on Order Sheet Written order Update the MAR File Signed copy in Pt. Record Notice updated Order Sheet, evaluate order and clarify if needed Patient Record Updated Order Sheet Copy of order (mail, on-site) Order Exception Evaluate order, clarify if needed Receive and check medication (patient, med, doc) Write order on Physician Order Sheet Write order on Physician Order Sheet and send copy to physician Administer and Chart Manage on-hand medications (Pt Meds, Stock and Emergency Kit) Manage on-hand medications (Pt Meds, Stock and Emergency Kit) Med Resolve Discrepancy Drug Regimen Review or other Patient Status Review Resident Change in Condition; New admission Resident Change in Condition; New admission Start Order (phone, fax, pickup by driver, auto-fax from SNF order management application) Follow pharmacy-specific procedure including after hours rules Resident Status (phone call, fax, on-site)

4. LTC Prescribing Nuances Three way communication between  Prescriber – Nurse – Pharmacy Most orders have no end date or quantity Refill requests represent 80% of orders No concept of Renewals Need unique formulary and benefit information  Part A, Part D and Medicaid

5. e-Prescribing in Long Term Care e-Prescribing is new to LTC 2006 CMS Pilot Study was first official standards based e-prescribing study in Long Term Care There are less than 5 standards based e- Prescribing installations today

6. LTC e-Rx Pilot Study Abstract 2006 study focused on e-Rx standards most relevant to LTC  SCRIPT  Formulary Benefits  Electronic Prior Authorization Other Capabilities Studied  Facility Managed Electronic Orders  Patient Safety Checks (DUR)  Electronic Signature  Automated Refill Requests The study included two geographically diverse treatments facilities and two comparison facilities

7. Flow of Information RNA eRxRequest Refill Scanner

8. e-Rx Findings - Facility Impacts Benefits  Facilities currently using electronic Physicians Orders will see modest change or disruption to current workflow  Ability to transmit orders directly to the pharmacy yielded benefits in reduced rework and callbacks  Management of Orders at the facility streamlines reconciliation processes New Challenges  Prescriber adoption is vital  Integration with clinical systems (EHR) is critical  Nurses do not effectively use patient safety (DUR) tools  Even with Formulary Benefits data, managing complex Part D health plans is an ongoing challenge  Nursing staff now has to enter and manage data that the pharmacy once managed  Data entry errors can still happen

9. e-Rx Findings - Pharmacy Impacts Benefits  Demographics pre-populated on new admissions  Straightforward new order processing  Discontinued orders  Readmissions streamlined  Do not have to manage MARs and Order Sheets  Refill requests streamlined New challenges  Combination & Tapered Orders – Need codified SIG standard  Transcription accuracy  Timely transmission on admission orders  Fax mode for controlled substances leads to process inconsistencies

10. Standards Findings  NCPDP SCRIPT Standard works with new changes in Version 10.1  NCPDP Formulary Benefits V1.0 technically works, but is dependent on greater prescriber adoption  Electronic Prior Authorization Technically works, but will require greater prescriber adoption  A Refill messaging standard is needed in LTC  An Admission, Discharge, Transfer (ADT) messaging standard is needed

11. What is Remote Dispensing? Automated oral solid dispensing in healthcare settings, such as nursing homes and correctional facilities, that have no onsite pharmacist Remote dispensing can work hand in hand with e-Prescribing

12. Oral Solid Packaging Remote Dispensing Packager Medication Canister

13. Process Overview

14. Process – Dispense Data From Central Pharmacy System

15. On Site Strip Packaging

16. Daily Dispense Med Pass/Resident Sort Multi Dose Packing PRN, New, Re-dispense

17. Process – Data Feedback Loop

18. Process – Inventory Monitoring

19. Process – Canister Fill at Pharmacy

20. Process – Canister Delivery

21. Value Proposition Virtually eliminates drug waste Significantly reduces delivery costs Eliminates delay of first dose Decreases administration time Reduces medication errors Eliminates the need for a refill process

22. Experience in early commercial pilots High Adoption Rate with nursing staff On demand PRNs and quick access to meds for new admissions are big wins Will save a typical nursing facility more than $25K per year in Part A drug waste May save $150K per year per facility for Part D drug waste savings Robust canister logistics is the key to success

23. Medication Reconciliation in Long Term Care AHRQ Annual Conference September 27, 2007 Presenter – Michael Bordelon

24. Long Term Care Background Reimbursement Model:  Roughly 15% capitated Part A  58% Medicaid/Part D  27% Private Pay and Commercial Insurance Typical Number of Beds: 90-120 Pharmacies are almost never co-located with LTC facilities Physicians per facility: 10-40 Nurse Practitioners per facility: 1-2 Nurses per facility: 50-80 Med passes per day: 4-7 Pharmacy trips to the facility: 2-3 Admissions per week: 1-10 Many facilities already manage their own orders in electronic systems

25. Pharmacy Consultant Pharmacist The LTC Prescribing Slide Nursing Physician Decide on patient order Evaluate order, clarify if needed and file in Patient Record Faxed order Physician signs copy of the order Receive new order Check patient choice for pharmacy Process order and dispense [includes payor verification and formulary compliance] Process order and dispense [includes payor verification and formulary compliance] Resolve issues with order (clinical, payor, etc.) Clarify and update order with nursing Clarify and update order with physician Med Order Question (phone or fax) Verbal order Signed copy of order Patient MAR Patient Allergies Order Sheet Order Update (Phone or fax) Order Update (Phone or fax) Receive updated order Patient MAR Patient Allergies Patient Orders Patient Allergies Patient Orders MAR Update (optional) Start Physician writes order on Order Sheet Written order Update the MAR File Signed copy in Pt. Record Notice updated Order Sheet, evaluate order and clarify if needed Patient Record Updated Order Sheet Copy of order (mail, on-site) Order Exception Evaluate order, clarify if needed Receive and check medication (patient, med, doc) Write order on Physician Order Sheet Write order on Physician Order Sheet and send copy to physician Administer and Chart Manage on-hand medications (Pt Meds, Stock and Emergency Kit) Manage on-hand medications (Pt Meds, Stock and Emergency Kit) Med Resolve Discrepancy Drug Regimen Review or other Patient Status Review Resident Change in Condition; New admission Resident Change in Condition; New admission Start Order (phone, fax, pickup by driver, auto-fax from SNF order management application) Follow pharmacy-specific procedure including after hours rules Resident Status (phone call, fax, on-site)

26. Typical Admission in LTC Most admissions in LTC are from a hospital setting Most “residents” begin stay under Medicare Part A Generally, discharge orders from the hospital are admission orders at the facility

27. Resident Enters Nursing Home From Hospital with Discharge Orders Pharmacist Manually Enters Orders in PhIS with DUR Check Pharmacy Fills Orders and Delivers Medications Pharmacy Provides Paper Based MARs and Order Sheets Nurse Faxes Discharge Orders to Pharmacy Typical Order Management Process New Admission

28. Resident Enters Nursing Home From Hospital with Discharge Orders Pharmacist Manually Enters Orders in PhIS with DUR Check Pharmacy Fills Orders and Delivers Medications Pharmacy Provides Paper Based MARs and Order Sheets Nurse Faxes Discharge Orders to Pharmacy Typical Order Management Process New Admission RISK: Physicians often do not review admission orders in a timely way RISK: Data entry errors can lead to inconsistencies RISK: Paper MARs and Order Sheets are “Stale” almost immediately

29. Nursing Staff Manually Reviews and Updates Orders on MARs Physician Reviews, Modifies and Signs Orders on Order Sheets Nursing Staff Faxes Handwritten MAR Updates to Pharmacy Pharmacy Sends Revised MAR to Facility Nurses Perform Secondary Review of MAR and Handwrite Corrections Typical Order Management Process During last 10 days of the month Pharmacy Delivers Final MARs Before Start of New Month

30. Nursing Staff Manually Reviews and Updates Orders on MARs Physician Reviews, Modifies and Signs Orders on Order Sheets Nursing Staff Faxes Handwritten MAR Updates to Pharmacy Pharmacy Sends Revised MAR to Facility Nurses Perform Secondary Review of MAR and Handwrite Corrections Typical Order Management Process During last 10 days of the month RISK: Is the Order Sheet Up to Date with MAR? RISK: High Potential for Transcription Error RISK: New MAR May Be “Stale” due to New Admits and Order Changes RISK: Very Time Consuming and Often not Performed with Rigor RISK: Easy to Make Mistakes When Handwriting Changes to MAR Pharmacy Delivers Final MARs Before Start of New Month RISK: Paper MARs and Order Sheets are “Stale” almost immediately

31. Typical MAR Flowsheet Blank Space To Handwrite New Orders During The Month

32. Medication Reconciliation with e-Prescribing Facility “owns” all orders Orders are managed in facility CPOE system MARs are printed from the CPOE system New orders are transmitted electronically to pharmacy Discontinued and changed orders are Transmitted electronically to pharmacy Note: CPOE = Computerized Physician Order Entry

33. Resident Enters Nursing Home From Hospital with Discharge Orders Pharmacy Receives Order Electronically Pharmacy Fills Orders and Delivers Medications Physician Enters and Signs Orders in Facility CPOE System with DUR and Formulary Checks Facility Prints MARs and Order Sheets From CPOE System Order Management with e-Prescribing New Admission

34. Resident Enters Nursing Home From Hospital with Discharge Orders Pharmacy Receives Order Electronically Pharmacy Fills Orders and Delivers Medications Physician Enters and Signs Orders in Facility CPOE System with DUR and Formulary Checks Facility Prints MARs and Order Sheets From CPOE System BENFIT: Physician Upfront Review of Orders and e-Signatures BENFIT: MARs and Order Sheets are Always Up to Date BENFIT: Reduction In Data Entry Errors Order Management with e-Prescribing New Admission BENFIT: Pharmacy Does Not Manage MARs or Order Sheets

35. Nursing Staff Notified of Changes and Prints MAR Updates From CPOE System Physician Writes or DC's Orders In Facility CPOE System with e-Signature Nursing Staff can Print Entire Up to Date MAR and Order Sheet at Any Time Pharmacy Receives Order Electronically and Resolves DUR Issues Order Management with e-Prescribing Ongoing Processes

36. Nursing Staff Notified of Changes and Prints MAR Updates From CPOE System Physician Writes or DC's Orders In Facility CPOE System with e-Signature Nursing Staff can Print Entire Up to Date MAR and Order Sheet at Any Time Pharmacy Receives Order Electronically and Resolves DUR Issues BENFIT: Reduction In Data Entry Errors BENFIT: No Handwritten Updates and MAR Always Up To Date BENFIT: Pharmacy System Always Up to Date BENFIT: Eliminates Monthly Review Because Orders are Always Up to Date Order Management with e-Prescribing Ongoing Processes

37. e-Prescribing in Long Term Care e-Prescribing is new to LTC 2006 CMS Pilot Study was first official standards based e-prescribing study in Long Term Care There are less than 5 standards based e- Prescribing installations today

38. LTC e-Rx Pilot Study Abstract 2006 study focused on e-Rx standards most relevant to LTC  SCRIPT  Formulary Benefits  Electronic Prior Authorization Other Capabilities Studied  Facility Managed Electronic Orders  Patient Safety Checks (DUR)  Electronic Signature  Automated Refill Requests The study included two geographically diverse treatments facilities and two comparison facilities

39. e-Rx Findings - Facility Impacts Benefits  Facilities currently using electronic Physicians Orders will see modest change or disruption to current workflow  Ability to transmit orders directly to the pharmacy yielded benefits in reduced rework and callbacks  Management of Orders at the facility streamlines reconciliation processes New Challenges  Prescriber adoption is vital  Integration with clinical systems (EHR) is critical  Nurses do not effectively use patient safety (DUR) tools  Even with Formulary Benefits data, managing complex Part D health plans is an ongoing challenge  Nursing staff now has to enter and manage data that the pharmacy once managed  Data entry errors can still happen

40. e-Rx Findings - Pharmacy Impacts Benefits  Demographics pre-populated on new admissions  Straightforward new order processing  Discontinued orders  Readmissions streamlined  Do not have to manage MARs and Order Sheets  Refill requests streamlined New challenges  Combination & Tapered Orders – Need codified SIG standard  Transcription accuracy  Timely transmission on admission orders  Fax mode for controlled substances leads to process inconsistencies

41. Med Reconciliation Conclusions e-Prescribing forces facilities to take ownership of their orders Once a facility manages their own orders, they typically have up to date data for MARs and Order Sheets e-Prescribing can significantly streamline processes and reduce reconciliation errors during new admissions from hospitals e-Prescribing can reduce reconciliation errors between the nursing facility and the pharmacy It is difficult to keep a facility managed CPOE system in sync with a pharmacy system without e- Prescribing