1. 1 Florida Medicaid Program: Impact of ePrescribing Christopher B. Sullivan, Ph.D. - AHCA Kathy Mosbaugh, Exec V.P. - Informed Decisions, LLC Tad Davis, PharmD - AHCA

2. 2 www.ePrescribeFlorida.com Florida Medicaid Wireless Handheld Clinical Pharmacology Drug Information Database and E-Prescribing Christopher B. Sullivan, Ph.D. Agency for Health Care Administration

3. 3 www.ePrescribeFlorida.com Wireless Handheld PDA - the Opportunity for Change In 2003, the Agency for Health Care Administration was authorized to implement its wireless handheld PDA program in the Pharmacy program. AHCA developed a model in which clinical outcomes and Medicaid “ over-prescribing ” could be positively impacted at the point of care. Florida, under the direction of AHCA, is at the forefront in using healthcare technology.

4. 4 www.ePrescribeFlorida.com Wireless Handheld PDA - About the Program Florida uses wireless technology to make 100 days of our recipients’ prescription drug history available to practitioners. This medication history:  is available at the point of service;  permits immediate utilization and compliance review;  provides information about coverage and restrictions;  incorporates an e-prescribing function that permits immediate transmission of prescription authorization to the patient’s pharmacy.

5. 5 www.ePrescribeFlorida.com Wireless Handheld PDA - About the Program The prescription program allows physician participation in prospective drug utilization review to:  Minimize adverse drug reactions.  Detect overuse or under use of drugs.  Detect duplicate therapies.  Detect potential allergic responses.  Screen for appropriate dosage.

6. 6 www.ePrescribeFlorida.com Wireless Handheld PDA - About the Program Phase 1:  1000 high-volume participating Medicaid providers  Medicaid preferred drug list (PDL)  60-day patient specific prescription drug history  Drug utilization reports (i.e. interaction alerts, etc.) Phase 2:  Expanded to 3000 total participating Medicaid providers  100-day patient specific prescription drug history  Included electronic prescribing (e-prescribing)

7. 7 www.ePrescribeFlorida.com Wireless Handheld PDA Factors to Optimizing Utilization Three Components of the Wireless Handheld PDA Program:  Drug Information  Patient Information  Fraud and Abuse Detection Wireless Handheld PDA - About the Program

8. 8 www.ePrescribeFlorida.com Wireless Handheld PDA - About the Program The PDA program provides clinical benefits by alerting the provider to potential drug-drug interactions and providing electronic prescribing to avoid costly medication errors. This Prescribing System provides:  comprehensive recipient drug histories,  PDL status information,  clinical drug information,  drug-drug and drug-food interaction alerts and  recommendations for alternative medications.

9. 9 www.ePrescribeFlorida.com Ideal Electronic Prescription Available for any patient group Not an e-mail from electronic medical record  NCPDP 5.1 compatible transmission  Only requires pharmacist to: Confirm NDC selection Confirm the patient’s payor information Includes Controlled Substances, CIII - CV Wireless Handheld PDA - About the Program

10. 10 www.ePrescribeFlorida.com E-Prescribing - General Overview The system is supported through a Web-based, real-time prescribing system:  Allows providers to “write” prescriptions from a desktop computer or PDA – prompts for patient’s last pharmacy.  Allows electronic prescription submission to any pharmacy for dispensing and adjudication.  Is integrated with a clinical information database, which includes screening tools to reduce the potential for medication errors before they occur.  Employs Clinical Pharmacology and clinical report tools, empowering clinicians to screen a prescription for adverse effects.

11. 11 www.ePrescribeFlorida.com E-Prescribing - General Overview The Prescribing System is capable of tracking:  who wrote the prescription,  for which recipient,  what was ordered,  when it was ordered,  where it was sent and  what time it was filled. If the recipient does not pick up the prescription, the Prescribing System is capable of notifying the doctor.

12. 12 www.ePrescribeFlorida.com E-Prescribing - Data Tracking Capabilities Doctors can:  Track individual patients.  Track prescription status – compliance, fraud and abuse. Pharmacies can:  Track patient’s drug profiles – clinical review, fraud and abuse monitoring.  Track incoming prescription – improve workflow, minimize wait times.

13. 13 www.ePrescribeFlorida.com E-Prescribing - Data Tracking Capabilities AHCA can:  Track prescriptions at the recipient, doctor, pharmacy or NDC level.  Monitor outcomes resulting from drug therapy.

14. 14 www.ePrescribeFlorida.com 14 GSM’s User Interface 100-day Manifest PDL, Clinical PA, Drug Information Prescription Writing and Tracking Desktop PC Wireless PDA Medicaid Provider 1 2 3 4 5 ACS Wireless Handheld PDA Project Approach

15. 15 www.ePrescribeFlorida.com E-Prescribing Results Florida providers have sent 361,586 electronic prescriptions since the inception of the e-prescribing system. Anecdotal feedback from users continues to be positive.

16. 16 www.ePrescribeFlorida.com Medicaid Cost Per Member Per Month Impact of e-Prescribing – Number of Claims

17. 17 www.ePrescribeFlorida.com Medicaid Cost Per Member Per Month Impact of e-Prescribing - Savings

18. 18 www.ePrescribeFlorida.com Integrated Drug Data Technologies For Florida Medicaid Service Providers Kathy Mosbaugh, Exec Vice President Informed Decisions, LLC

19. 19 www.ePrescribeFlorida.com The History of Rx History ProDUR Possible with Point of Sale Claims in 1993 Pharmacies Got the Message / Physicians In the Dark  Prescribers would help if they had the information  No “Real time connection” was available  Internet connections were rare in physician offices Medicaid Fiscal Agent Website with Rx History – 2000  Did not have DUR / Pharmacology information  Unpredictable Access

20. 20 www.ePrescribeFlorida.com Prescriber Needs at the Point of Care Reference to Florida Medicaid PDL Constantly updated clinical pharmacology information Reference to best practice guidelines Specific, up-to-date patient medication history Elimination of errors in the prescribing/dispensing process due to:  Legibility issues  Lost paper prescriptions  Patient non-compliance  Assignment of prescription claim to incorrect prescriber

21. 21 www.ePrescribeFlorida.com Application of Health Information In 2002, Florida Legislature directed Agency to develop wireless handheld drug information application for prescribers to use at point of care The system was to provide:  Continuously updated clinical pharmacology information for prescriber reference  Reference to the Florida Medicaid PDL  Individual Medicaid patient medication history  Ongoing education and support for prescribers

22. 22 www.ePrescribeFlorida.com Impacting Utilization Through Technology The wireless handheld drug information application was developed with expectations of creating value-added services by:  Applying Patient Information  Improving Outcomes  Saving Money

23. 23 www.ePrescribeFlorida.com Point of care clinical decision support Coupling Clinical Pharmacology with real time patient data Delivering data for use on a variety of platforms Received National awards eMPOWERx

24. 24 www.ePrescribeFlorida.com Impacting the Delivery System Accurate medication history  Coordination of care – identify duplications  Record of therapeutic failure Formulary verification  Avoid formulary disruption Therapeutic fulfillment  Impact on silent disease Legible & complete prescriptions

25. 25 www.ePrescribeFlorida.com Overall Impact for Florida Medicaid Savings calculations- prescription utilization and cost avoidance 5:1 Return on Investment  2006 PEW Report noted $50 million savings for Florida in previous two years  AHCA currently reports $1.8 - $2 million in monthly savings  $4 million in savings quarterly by avoiding severe drug interactions

26. 26 www.ePrescribeFlorida.com Overall Impact for Florida Medicaid Savings realized by eliminating waste and reducing medication errors  Minimize duplication of therapy - Inefficiencies of a disconnected system  Minimize fraud and abuse - Real-time, proactive identification  Reduce medication errors – Preventing severe drug interactions

27. 27 www.ePrescribeFlorida.com Drug Interaction Alerts by Severity Ranking July-September 2006 Overall Impact for Florida Medicaid

28. 28 www.ePrescribeFlorida.com About the Program - Florida Launched (2003):  1000 high volume Medicaid providers  Providee Medicaid PDL  Providee 60-day patient specific Rx history  Drug utilization reports (interaction reports, etc.) Expanded (2004):  Expanded to 3000 total providers  Provided 100-day patient specific Rx history  Included electronic prescribing

29. 29 www.ePrescribeFlorida.com About the Program - Florida Currently:  Renewal of service for providers using PDAs  Open online access for all Medicaid providers  Increase ePrescribing  eMPOWERx Office

30. 30 www.ePrescribeFlorida.com CMS Acknowledgement

31. 31 www.ePrescribeFlorida.com Independent Review

32. 32 www.ePrescribeFlorida.com The eMPOWERx Program and the Provider

33. 33 www.ePrescribeFlorida.com Proof is in the Pudding “…I also use it as a teaching tool to let patients know how computers can make our lives easier and teach them and myself about medication side effects. Once they see the whole list of medications they are on, many of them realize they may be overmedicated by too many prescribing physicians.” Dr. Pedro Carballo

34. 34 www.ePrescribeFlorida.com Patient Specific Information ME0xxxx25RISPERDAL 3MG TABLET10/27/20036030 ME0xxxx61ZYPREXA 10MG TABLET10/27/20036030 ME0xxxx90KU-ZYME CAPSULE10/29/20039030 ME0xxxx90ZITHROMAX 250MG Z-PAK TAB10/29/200364 ME0xxxx90IBUPROFEN 800MG TABLET10/29/20033015 ME0xxxx90ALBUTEROL 90MCG INHALER10/29/20031730 ME0xxxx47CEFTIN 500MG TABLET10/31/20032010 ME0xxxx60SEROQUEL 300MG TABLET10/31/20036030 ME0xxxx47ADVAIR 500/50 DISKUS10/31/20036030 ME0xxxx47VIOXX 50MG TABLET10/31/200330 100 Day Medication History List

35. 35 www.ePrescribeFlorida.com Duplications of Therapy ME0xxxx25RISPERDAL 3MG TABLET10/27/20036030 ME0xxxx61ZYPREXA 10MG TABLET10/27/20036030 ME0xxxx90KU-ZYME CAPSULE10/29/20039030 ME0xxxx90ZITHROMAX 250MG Z-PAK TAB10/29/200364 ME0xxxx90IBUPROFEN 800MG TABLET10/29/20033015 ME0xxxx90ALBUTEROL 90MCG INHALER10/29/20031730 ME0xxxx47CEFTIN 500MG TABLET10/31/20032010 ME0xxxx60SEROQUEL 300MG TABLET10/31/20036030 ME0xxxx47ADVAIR 500/50 DISKUS10/31/20036030 ME0xxxx47VIOXX 50MG TABLET10/31/200330 Medication History List Identifies Duplicate Drugs

36. 36 www.ePrescribeFlorida.com Duplications of Therapy ME0xxxx25RISPERDAL 3MG TABLET10/27/20036030 ME0xxxx61ZYPREXA 10MG TABLET10/27/20036030 ME0xxxx90KU-ZYME CAPSULE10/29/20039030 ME0xxxx90ZITHROMAX 250MG Z-PAK TAB10/29/200364 ME0xxxx90IBUPROFEN 800MG TABLET10/29/20033015 ME0xxxx90ALBUTEROL 90MCG INHALER10/29/20031730 ME0xxxx47CEFTIN 500MG TABLET10/31/20032010 ME0xxxx60SEROQUEL 300MG TABLET10/31/20036030 ME0xxxx47ADVAIR 500/50 DISKUS10/31/20036030 ME0xxxx47VIOXX 50MG TABLET10/31/200330 Medication History List Identifies Duplicate Drugs

37. 37 www.ePrescribeFlorida.com Duplications of Therapy ME0xxxx25RISPERDAL 3MG TABLET10/27/20036030 ME0xxxx61ZYPREXA 10MG TABLET10/27/20036030 ME0xxxx90KU-ZYME CAPSULE10/29/20039030 ME0xxxx90ZITHROMAX 250MG Z-PAK TAB10/29/200364 ME0xxxx90IBUPROFEN 800MG TABLET10/29/20033015 ME0xxxx90ALBUTEROL 90MCG INHALER10/29/20031730 ME0xxxx47CEFTIN 500MG TABLET10/31/20032010 ME0xxxx60SEROQUEL 300MG TABLET10/31/20036030 ME0xxxx47ADVAIR 500/50 DISKUS10/31/20036030 ME0xxxx47VIOXX 50MG TABLET10/31/200330 Medication History List Identifies Duplicate Drugs

38. 38 www.ePrescribeFlorida.com Duplications of Therapy ME0xxxx25RISPERDAL 3MG TABLET10/27/20036030 ME0xxxx61ZYPREXA 10MG TABLET10/27/20036030 ME0xxxx90KU-ZYME CAPSULE10/29/20039030 ME0xxxx90ZITHROMAX 250MG Z-PAK TAB10/29/200364 ME0xxxx90IBUPROFEN 800MG TABLET10/29/20033015 ME0xxxx90ALBUTEROL 90MCG INHALER10/29/20031730 ME0xxxx47CEFTIN 500MG TABLET10/31/20032010 ME0xxxx60SEROQUEL 300MG TABLET10/31/20036030 ME0xxxx47ADVAIR 500/50 DISKUS10/31/20036030 ME0xxxx47VIOXX 50MG TABLET10/31/200330 Medication History List Identifies Duplicate Drugs

39. 39 www.ePrescribeFlorida.com Identifying Doctor Shoppers OS0xxxx68HYDROCODONE/APAP 10/650 TAB9/19/2003317 OS0xxxx68METHADOSE 10MG TABLET9/26/2003307 OS0xxxx68METHADOSE 10MG TABLET10/15/2003307 OS0xxxx68OXYCODONE W/APAP 5/325 TAB10/15/2003307 OS0xxxx68OXYCODONE W/APAP 5/325 TAB10/27/2003305 OS0xxxx68METHADOSE 10MG TABLET10/27/2003307 OS0xxxx68OXYCODONE W/APAP 5/325 TAB10/30/2003305 ME0xxxx42OXYCODONE W/APAP 5/325 TAB9/22/20036020 ME0xxxx42HYDROCODONE/APAP 10/650 TAB10/6/20036015 ME0xxxx42HYDROCODONE/APAP 10/650 TAB11/6/20034010 ME0xxxx42HYDROCODONE/APAP 10/650 TAB11/17/2003205 ME0xxxx18ACETAMINOPHEN/COD #3 TABLET10/21/20034013 ME0xxxx18ACETAMINOPHEN/COD #3 TABLET11/19/200310025 Medication History List Identifies Doctor Shopping

40. 40 www.ePrescribeFlorida.com Identifying Doctor Shoppers OS0xxxx68HYDROCODONE/APAP 10/650 TAB9/19/2003317 OS0xxxx68METHADOSE 10MG TABLET9/26/2003307 OS0xxxx68METHADOSE 10MG TABLET10/15/2003307 OS0xxxx68OXYCODONE W/APAP 5/325 TAB10/15/2003307 OS0xxxx68OXYCODONE W/APAP 5/325 TAB10/27/2003305 OS0xxxx68METHADOSE 10MG TABLET10/27/2003307 OS0xxxx68OXYCODONE W/APAP 5/325 TAB10/30/2003305 ME0xxxx42OXYCODONE W/APAP 5/325 TAB9/22/20036020 ME0xxxx42HYDROCODONE/APAP 10/650 TAB10/6/20036015 ME0xxxx42HYDROCODONE/APAP 10/650 TAB11/6/20034010 ME0xxxx42HYDROCODONE/APAP 10/650 TAB11/17/2003205 ME0xxxx18ACETAMINOPHEN/COD #3 TABLET10/21/20034013 ME0xxxx18ACETAMINOPHEN/COD #3 TABLET11/19/200310025 Medication History List Identifies Doctor Shopping

41. 41 www.ePrescribeFlorida.com eMPOWERx Solution The eMPOWERx Solution

42. 42 www.ePrescribeFlorida.com Refill Compliance Indicator Date of Last Fill Improve Adherence by… Benefits of eMPOWERx Solution

43. 43 www.ePrescribeFlorida.com Automatic Clinical Reports Enhance Safety by… Supported by Clinical Content Benefits of eMPOWERx Solution

44. 44 www.ePrescribeFlorida.com Lower Drug Costs by… Comprehensive medication history providing information for more informed therapeutic decisions Therapeutic duplications flagged for further review Benefits of eMPOWERx Solution

45. 45 www.ePrescribeFlorida.com eMPOWERx Ideals Empower the provider  Quality clinical decision support at the point of care  Provide efficiency throughout the process Enhance patient safety  Optimal information  Point-of-care access  Better outcomes  Eliminate waste

46. 46 www.ePrescribeFlorida.com Results of eMPOWERx Pilot Project Prescribers who use the PDA write fewer prescriptions on average Significantly lower cost per patient for prescriptions compared to non-PDA prescribers Florida providers have sent over 850,000 electronic prescriptions to date eMPOWERx users receive more than 5,000 drug interaction alerts each week; more than 1,000 of these are of high or very high severity Savings from avoided hospitalizations due to preventable drug interactions and reduced Rx cost is estimated at more than $16 million annually

47. 47 www.ePrescribeFlorida.com Going Forward e-Prescribing options used for only 7% of eligible Rx’s  Outreach to physicians and pharmacies is ongoing  New technology and platforms experience a learning curve Medicaid wireless handheld users prescribe 10%-16% fewer Rxs than control group physicians Wireless handheld and desktop prescribing and reference access moves system toward total electronic records

48. 48 www.ePrescribeFlorida.com Tad Davis, PharmD – AHCA Agency for Health Care Administration CMS Transformation Grant GenR x Expansion Project

49. 49 www.ePrescribeFlorida.com Medicaid Transformation Grant July 2006 CMS announces grant funding for projects to “Transform” healthcare  Emphasis on increasing generic drug utilization  Enhancing patient safety through the use of technology (e-prescribing, EMR … etc. ) October 1, 2006 Florida Medicaid submits GenR x Expansion Proposal January 25 th, 2007 CMS Awards Florida Medicaid 2 year $ 1.73 million for GenR x Expansion Project

50. 50 www.ePrescribeFlorida.com GenRx Vision Promote e-prescribing via Provide 10 day generic starter pak Increase utilization of generic medications Promote recruitment and retention of Medicaid Providers Improve patient outcomes by having with more direct contact with clinical pharmacists

51. 51 www.ePrescribeFlorida.com Goals of GenRx Pilot Project Enroll 300 to 600 dispensing practitioners as Florida Medicaid Pharmacy providers Establish over 100 practice sites as Medicaid Pharmacy Providers Train office staff and medical personnel in appropriate dispensing practices Increase e-prescriptions from 2% to 10% Increase average generic utilization in select drug categories from 27% to 50%

52. 52 www.ePrescribeFlorida.com Why GenRx? Providers using e-prescribing use fewer medications Compensate the prescriber for extra effort of electronic prescribing Enhance Medication Compliance  Eliminates some transportation issues  Minimizes unfilled prescriptions Patient satisfaction – One stop shopping Provides alternative to Brand name samples

53. 53 www.ePrescribeFlorida.com Year One

54. 54 www.ePrescribeFlorida.com Initial Encounter Creation of Face Sheet  Patient Demographics  Medication History past 6 months  Procedures & ICD-9 Codes 2 years Patient Eligible for Office Dispensing

55. 55 www.ePrescribeFlorida.com Prescribing Encounter Review medication profile & compliance issues New medication needed  Clinical Pharmacology Assistance  Florida Medicaid Formulary/Plan Limits Patient desires 10 day Starter Pak

56. 56 www.ePrescribeFlorida.com Prescribing Encounter Prescriber enters drug selection once  Enters a 10 day SIG & Quantity  Enters 30 day Quantity & Refill Instructions  Confirms Both Prescriptions

57. 57 www.ePrescribeFlorida.com Heritage Hand-off eMPOWERx sends transaction to Heritage Info Sys  Validates Prescriber’s own inventory  Sends claim to ACS for payment  Sends Label back to Prescriber’s Office

58. 58 www.ePrescribeFlorida.com Back at the Office Duplicate Prescription Labels Printed  Staff build prescription Duplicate Label becomes script to be signed Script added to daily dispensing log

59. 59 www.ePrescribeFlorida.com Prescription Building Pre-packed medications have duplicate labels  Tear-off label attached to script  OBRA 90 medication instructions selected  Meds/Script/Instructions back to prescriber

60. 60 www.ePrescribeFlorida.com Prescriber Hand-off Prescriber’s Role  Checks medication label against script  Hands medication/instructions to patient  Offers to counsel

61. 61 www.ePrescribeFlorida.com Patient Follow-up Patient stops at front desk  Obtains new appointment  Receives discharge instructions Rx Online Assistance Program (ROAP)

62. 62 www.ePrescribeFlorida.com Questions Questions Anyone?

63. 63 www.ePrescribeFlorida.com Christopher B. Sullivan, Ph.D. Agency for Health Care Administration sullivac@ahca.myflorida.com Kathy Mosbaugh, Exec Vice President Informed Decisions, LLC kmosbaugh@gmail.com Tad Davis, PharmD Agency for Health Care Administration davisj@ahca.myflorida.com