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AHRQ Annual Conference September 27, 2007 E-Prescribing and Ambulatory Medication Reconciliation Douglas S. Bell, MD, PhD Assistant Professor, UCLA Department.

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Presentation on theme: "AHRQ Annual Conference September 27, 2007 E-Prescribing and Ambulatory Medication Reconciliation Douglas S. Bell, MD, PhD Assistant Professor, UCLA Department."— Presentation transcript:

1 AHRQ Annual Conference September 27, 2007 E-Prescribing and Ambulatory Medication Reconciliation Douglas S. Bell, MD, PhD Assistant Professor, UCLA Department of Medicine Research Scientist, RAND Health

2 Douglas S. Bell, 9/26/2007 E-Prescribing Transactions RxHub SureScripts & others Mail-order pharmacy Retail pharmacy Eligibility Formulary Med History NCPDP SCRIPT Med History Formulary Mail-order pharmacy Caremark, Express Scripts, Medco, Wellpt Retail pharmacy Medication list  Safety Alerts

3 Douglas S. Bell, 9/26/2007 Study Objectives To evaluate the technical adequacy and clinical effectiveness of: –NCPDP Formulary & Benefit Standard –Medication History function of NCPDP SCRIPT –Fill Status function of NCPDP SCRIPT –Prior Authorization (X12N 278, 275 w/ HL7 attachment) –RxNorm –Structured & Codified Sig In production today Completed, not in production Under development

4 Douglas S. Bell, 9/26/2007 Medication History Standard One function within the NCPCP SCRIPT standard –RXHREQ: send Patient ID, date range –RXHRES: return DRU segment for each claim Drug identified by the NDC code, claim date Core of the RX History RESponse DRU+D:SPRINTEC 28 DAY TABLET:ØØ5559Ø1658:ND+ØØ:28.Ø:87++LD:2ØØ41115:1Ø2*ZDS:28:8Ø4’ PVD+PC+3334444:ØB+++JONSON:TIM++++6518659191:TE’ PVD+P2+2234567:D3+++++FIRST STREET PHARMACY++6512219ØØØ:FX’ DRU+D:METFORMIN HCL 85Ø MG TABLET:ØØ378Ø24ØØ1:ND+ØØ:6Ø.Ø:87++LD:2ØØ41Ø21:1Ø2*ZDS:3Ø:8Ø4’ PVD+PC+3334444:ØB+++JONSON:TIM++++6518659191:TE’ PVD+P2+2234567:D3+++++FIRST STREET PHARMACY++6512219ØØØ:FX’ Rx: Glucophage 850mg #90 [00087607010] on 9/10/2004

5 Douglas S. Bell, 9/26/2007 Technical Expert Panel CategoryCompany Point of care software vendors EHRAllscripts eRxiScribe eRxInstantDx EHRMedPlus eRxZixCorp Content Providers First DataBank Wolters Kluwer Intermediaries RxHub SureScripts NDC Pharmacies MailCaremark Mail MailMedco Mail Large ChainWalgreens IndependentQS1

6 Douglas S. Bell, 9/26/2007 Medication History: Panel Results Technical problems hinder reconciliation with prescriptions that the POC originated –No data available if patient can’t be identified through RxHub (270/271 Eligibility) –Matching dates can be challenging –Many fields are optional and often left empty Prescriber ID, Sig, quantity dispensed –NDC Code may not match to POC’s drug DB

7 Douglas S. Bell, 9/26/2007 Some vendors find reconciling Medication History too hard –Drive alerts only from prescriptions that they originated All enthusiastically support developing RxNorm to solve NDC mapping problems

8 Douglas S. Bell, 9/26/2007 The NDC Code Problem NDC represents the package –metformin 850mg has >100 NDC codes 066267-*497-4053489-468-88062037-*675-01051129-2460-*1013411-*164-09065243-*239-12068115-*232-45 066267-*497-4055111-430-01062037-*675-05051129-2610-*1013411-*164-10065243-*239-18068115-*232-45 066267-*497-4555111-430-05062037-*675-10051129-3594-*1013668-*002-01065243-*239-27068115-*232-60 066267-*497-4555111-430-30062147-5001-*0051129-3594-*2013668-*002-05065841-*029-01068115-*232-60 066267-*497-6055111-430-60062318-0191-*0051129-3943-*1013668-*002-12065841-*029-05068382-*029-01 066267-*497-6055111-430-78062318-0191-*1051129-3943-*2013668-*002-30065841-*029-10068382-*029-05 066267-*497-9055567-145-18062584-*332-01051655-*291-24013668-*002-60065862-*009-01068382-*029-10 066267-*497-9055567-145-25063629-1396-*1051655-*291-25013668-*002-90065862-*009-05068788-0435-*3 066336-*883-6057315-048-01063629-1396-*2051655-*291-52020091-*533-01065862-*009-26068788-0435-*6 066689-*012-0157315-048-04063739-*300-10051655-*291-53020091-*533-05065862-*009-500781-5051-01 066689-*012-3057315-048-05064679-*529-01053489-*468-01020091-*533-10065862-*009-600781-5051-05 066689-*012-6062037-675-01064679-*529-02053489-*468-030228-2715-10065862-*009-9020091-533-01 067090-*533-0162037-675-05064679-*529-03053489-*468-050228-2715-11066105-*601-1020091-533-05 067090-*533-0562037-675-10064679-*529-04053489-*468-100228-2715-50066105-*744-2320091-533-10 067090-*533-1065862-009-01064679-*529-05054569-5353-*00228-2715-96066267-*497-2053489-468-01 067228-0268-*365862-009-05064725-0209-*3054569-5353-*3023490-0898-*0066267-*497-2053489-468-03 067228-0268-*665862-009-50064725-0209-*3055045-2905-*0023490-0898-*3066267-*497-3053489-468-05 067544-*107-5365862-009-60065243-*239-06055045-2905-*0023490-0898-*6066267-*497-3053489-468-10 –Each packager maintains their own codes –Changes aren’t always tracked at FDA

9 Douglas S. Bell, 9/26/2007 RxNav RxNorm ID: 6809

10 Douglas S. Bell, 9/26/2007 RxNav 2 RxNorm ID: 316257

11 Douglas S. Bell, 9/26/2007 RxNav 3 Metformin 850 MG Oral Tablet RxNormID: 311752 (SCD) Drug Dose Dose Form

12 Douglas S. Bell, 9/26/2007 Research Questions How complete is RxNorm for representing a sample of actual prescriptions What types of drugs are missing? How consistently do independent attempts to represent the same prescription result in the same RxNorm concept being chosen?

13 Douglas S. Bell, 9/26/2007 Methods De-Identified –10,000 SCRIPT New Rx’s Transmitted to retail pharmacies by SureScripts Representative NDC codes –10,000 SCRIPT Renewal Requests Transmitted to Allscripts by retail Actual NDC codes Three independent attempts to match NDC to the RxNorm generic clinical drug concept (SCD) –First DataBank, MediSpan, RAND

14 Douglas S. Bell, 9/26/2007 RxNorm Lab Evaluation Completeness –19,824 non-device new prescriptions & renewal requests 195 (0.98%) no matching SCD found; – 94% multi-vitamins, bowel preps, drugs packaged in a drug delivery device 18,733 (94.5%) matched by 3 of 3 Mismatches –1003 of 19450 with 2+ SCD matches (6.2%) Root causes: RxNorm errors – Synonymy already corrected as of Jan, 2007 (20%) – Previously unrecognized synonymy (30%) Source errors – Bad NDC-to-SCD mappings used by one of the matchers

15 Douglas S. Bell, 9/26/2007 Conclusions Medication history –Technically adequate –Falling short due to NDC –Strong need for unique clinical drug identifier RxNorm –Completeness very good (as of 11/2006) Greatest need: Drug-device package –Some errors hinder reproducible use RxNorm mapping errors being fixed FDA’s Structured Product and Daily Med will help address source errors –Available and usable today

16 Douglas S. Bell, 9/26/2007 Thanks Point of Care Partners –Tony Schueth –Jack Guinan SureScripts: Ajit Dhavle, Ken Whittemore Allscripts: Jill Helm First Databank: George Robinson, Tom Bizarro MediSpan: Karen Eckert NLM: John Kilbourne RAND: Diane Schoeff, Shinyi Wu All of our expert panelists CMS and AHRQ

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