Saturday, June 28, 2008


On July 1, the public was informed that SureScripts and RxHub merged into a single entity called, for the present, SureScripts-RxHub.
This is exciting news for health care and for me personally. As an Express Scripts VP, I had the good fortune to be present through the planning for the formation of RxHub and, until the formation of the new company, was more recently a member of the SureScripts Board. So I've been a direct witness to the great efforts of both organizations. I add as well that the only facts in this posting are publicly available and that any conjecture on my part is simply that; I have not speculated in areas that I may have formally discussed with either entity.

RxHub was originally formed in 2001 by three pharmacy benefits managers (PBMs) - Advance/PCS (not yet acquired by CareMark), Express Scripts, and MedCo. With various acquisitions, the current owners of RxHub are Caremark, Express Scripts, and Medco. Other PBMs are planning participation. RxHub was formed primarily to simplify the task of e-prescribing for vendors. Since this organization (and SureScripts as well) were formed before standards were promulgated at a national level, these organizations were de facto standard setting bodies. RxHub derives its revenue from formulary eligibility checks and its costs are offset primarily by PBMs. Medication histories are based on medical claims. The first CEO of RxHub was Jim Bradley, now the Chairman of the Board of Prematics.

SureScripts was also established in 2001 by NACDS (National Association of Chain Drug Stores) and NCPA ( National Community Pharmacists Association) - the leading retail pharmacy associations. SureScripts derives its revenue from true e-prescribing messages (new scripts or refills) but not from fax messages; these costs are payed by pharmacies and additional funding is through various debt mechanisms. Medication histories and messaging is primarily through NCPDP SCRIPT. The founding CEO of SureScripts was Kevin Hutchinson, who now serves as CEO of Prematics under Jim Bradly.

Hence, over the past few years the charismatics founders of both RxHub and SureScripts are now working on the vendor end and hence working through the very organizations they created. Small, small, world.

From the outset, these two organizations both competed in some sectors and demonstrated remarkable collaboration in others. In principle, a direct connection between e-prescribing systems and PBMs through RxHub presented the theoretical opportunity to promote diversion of prescriptions from retail phramcies to PBM mail order pharmacies. An effort by the retail pharmacies to promote direct connectivity would mitigate this risk. Similarly, a direct connection with pharmacies without the presentation of formularly options would not simplify the process of PBM-based drug trend management. Both RxHub and SureScripts, no doubt, saw the need to simplify the process of e-prescribing. Both were committed absolutely to establishing national standards to simplify medication management and both actively participated in standards bodies long before the establishment of the HITSP structure created by the HHS Office of the Network Coordinator.

Standards were the easy part. Progress in medication management has been slow in coming. E-prescribing is a complex "dance" among the prescriber and staff, the pharmacy and staff, and the consumer. Each must re-think their activities and deviate from the norms set by fax-based or paper-based prescribing. In many areas, adoption of e-prescribing has been much slower than many of us would have expected. We underestimated the complexity of the system and the comprehensive effort required to provide incentives sufficient to change the behavior of prescriber, dispensing pharmacist, and consumer.

But recent progress is heartening. Where PBM coverage is high, medication histories are increasingly available through RxHub and eligibility checks are growing in frequency. Particularly where chain drugs stores are dominant, true e-prescribing (digital communications, not fax) is growing and fax is disappearing. Still less than 5% of prescriptions are at present sent in digital format.

The New Organization
The new organization will be governed 50:50 by the organizations that founded RxHub and SureScripts. Board composition will be 3 members from the PBM industry and 3 from the retail pharmacy. Management will be under to interim co-CEOs, J.P. Little and Rick Ratliff, who formerly were acting CEOs of RxHub and SureScripts, respectively.

The joint organization will maintain its prohibition of commercial messaging. Given the numerous tensions and differing business models, one can also reasonably assume that secondary sale or distribution of data will not be practiced (although each source PBM or pharmacy, one would assume, will continue whatever their current business practices are). In my personal view, the combined organization presents no new threat to the public through commercial intrusion or misuse of personal health information.

SureScripts-RxHub can be expected to emphasize the following practices in a more consistent and uniform way:
  • Prescription routing. One imagines that the SureScripts' capabilites will be enhanced to expedite digital messaging between prescribers and pharmacies to simplify the ordering, dispensing, refill requests, and medication fill status. Perhaps the PBM mail order pharmacies will be added to the SureScripts network.
  • Payor transactions. The RxHub eligibility checks will presumably continue to be developed to simplify coverage notification and formularies. (Suggestion to the PBM industry; a few hundred - or thousand fewer formulary and nuanced prior authorization rules would simply things immeasurably). Both SureScripts and RxHub supported various repositories of formulary and eligibility information; presumably there is some redundancy here and simplification will be a benefit to vendors and clinicians.
  • Rx history. This is perhaps the most exciting and uninished piece of work that can be addressed by the joint entity. Currently, historical data - if it is present at all - comes via the RxHub claims database or from SureScripts NCPDP script messages. But the RxHub database is claims-based and may suffer both from latency and incompleteness (if low cost-drugs are not entered into the claims database or if the individual is either self-pay or enrolled in a plan not currently connected to RxHub). Although virtually every chain drug store and the majority of independent pharmacies can communicate through e-presribing standards, many SureScripts member pharmacies have not completed medication history service agreements nationwide, but such agreements are anticipated in the next few months. Much work will have to be done. My guess (often wrong) is that prescribers will demand such a service at no cost as a quid pro quo for e-prescribing. Consumers will demand audit logs and various forms of authentication to ensure their medication histories are only accessed for appropriate reasons. As I have argued repeatedly, echoing the Commission for Systemic Interoperability Report of 2005. One of the major national health information technology priorities should be the creation of services that provide complete, reliable, and confidential prescription medication histories for every American. Sadly, although NHIN, ONC, HHS, and others have endorsed standards (often those emphasized by RxHub and SureScripts), follow-through has been disappointing and, to the best of my knowledge, the merger of these two entities is the result of a private-sector business need in the public interest, not the result of top-down regulatory pressure from the government. Fortunately members from both organizations have worked to simplify and advance the currently somewhat complex ONC medication management use case.
  • Pharmacy interoperability and care support. One can expect the combined entity to continue its enhancement of patient health information messaging among providers and dispensers to ensure better coordination and safer medication use.
  • Network support. The at times conflicting interests of the retail, chain, and PBM organizations (as well as the comepition within each sector) will necessitate contiuation of the tradition of neutrality, transparency, and efficiency currently critical to the success of each organizations. Again, the very tensions among the stake holders act, in my view, in the public interest here.
The announcement is great news for American consumers, health care organizations, intermediaries, and the health information management industries. Pressure for mandatory e-prescribing is mounting. The DEA has been under considerable congressional pressure to allow controlled-substances to be prescribed through digital devices and has issued a Notice of Proposed Rule Making (Federal Register June 27, 2008, volume 73, number 125).

At present, e-prescribing is still an incompletely practiced new form of coordination among prescriber, dispensing pharmacist, and the consumer. It is a system where everyone has to see benefit and change their behavior in some ways. There are many benefits in an ideal world, but in many instances, a lot of work must be done. Change is not easy.

The timing could not be better. Clinicians (both prescribers and dispensers), the staff working within clinical organizations, vendors, and the public are facing a complex array of challenges. In most instances, successful implementation of e-prescribing solutions for communities is the product of de facto collaboration among SureScripts, RxHub, pharmacies, payers, intermediaries, clinicians, and the public. Anything that simplifies the overall process should be applauded.

We are fortunate that the two organizations forming this new entity have complementary missions and have demonstrated a track-record of collaboration. Formalizing this relationship comes at a critical juncture. It is a unique and positive story.

Let us all wish them the best of luck.

Thursday, June 19, 2008

The Markle Foundations Connecting for Health Common Framework for Networked Personal Health Information

On Wednesday, June 25, the Markle Foundation's Connecting for Health Initiative will release a series of materials collectively entitled a "Common Framework for Networked Personal Health Information."
This work will be a follow-on to a much less detailed brief written in the context of the Connecting for Health Framework for Networked Personal Health Information. In this earlier phase, the attention was directed at providers and the means by which one assured trust was through contracts.

This very detailed and comprehensive set of documents will be based on a small set of common expectations; rules and protocols applicable to all exchange; the value of overcoming barriers to information sharing; and the improvement of the public trust. Without such an approach, many fear the policies will be monolithic and not sensitive to the variety of contexts in which health information is used. In lieu of a clear approach, piecmeal efforts may slow progress and innovation; implementation efforts may be disconnected from policies; and these approaches may place excessive reliance on consumer consent. Add to that, some approaches may simply not be practical.

What we are facing, many believe, is a "privacy gridlock" where too many parties are seeking the impossible perfect. The alternative is to show that extreme rhetoric is not necessary and that most efforts can rely on the enormous efforts that already have addressed some of the fundamental issues.

Three common expectations often articulated are:
  • Core privacy principles
  • Sound network design
  • Oversight and accountability
These are based on the broader set of guiding principles articulated in the Markle Comprehensive Framework. The three expectations have recently been discussed in Deven McGraw's June 4 testimony to the House Energey and Commerce Subcommittee, Health subcommittee.

The framework could be used as a set of guiding principles for a loose form of "certification" that defines attributes organizations, systems, or products must have to be included in federal health care initiatives, e-prescribing initiatives, health information exchanges, product development, consumer group activities, and other endeavors in which trusted use of health care information is necessary.

The new documents are impressive in scope. They are heavily-referenced and reflect the best thinking of some of the Nation's leaders. These are sound and comprehensive recommendations, but they are not necessarily prescriptive. They allow individuals and organizations to internalize and interpret recommendations in ways that seem most appropriate for their needs.

The Markle Connecting For Health Subcommittee on Quality and Cost Effectiveness

On June 19, 2008, the Markle Foundation Connecting for Health Steering Group met to discuss means of disseminating the Common Framework for Networked Personal Health Information and to discuss ongoing population health activities.

Now in its fifth year, the Markle Foundation has made remarkable contributions. Established in early 2004, the first public briefing on the Markle Agenda was held at the National Press Club on June 25, 2003.

Zoe Baird led the meeting discussing a meeting held last week by the Senate Finance Committee. Much was said about a universal health care financing vehicle and great attention was paid to costs. Although comprehensive legislation is not expected, incremental steps will be taken and information technology - wisely used - will enable better health care.

Some have lamented the lack of agreement that would allow the Government to use its market power as a payer for care. There is enough focus now with Congresional engagement and presidential campaigns that investments could be anticipated. One must make sure that the right kind of open markets are realized and, for this reason, both a consumer framework and a population health approach will be essential to the debate. There was significant discussion about the CBO report (2976) that pointed out where CBO believed additional congressional support could improve adoption and health.

Response to the CBO Report

Dr. Blackford Middleton noted the report gave a "reasonable review and summary of the literature on HIT value." Some CITL report aspects "were not represented well." These include:
  • A fundamentally different purpose for the report - the impact of funding
  • Value of un-standardized (level 3) vs standardized (level 4) interoperability.
  • They failed to note how CITL accounted for the current HIT context; CBO factored in existing provider-payer data exchanges, and existing lab and pharmacy integration
  • CBO treated costs of providers information systems but inadequately treated the internal benefits; their notion of data exchange was relatively restricted.
  • CITL differed with CBO on lab administration costs; phone call rates - but these were not key determinants of overall value
  • CBO's critique did not discuss some of the limitations of HIEI model limitations. The CITL model was more expansive and included realizing savings through quality improvements and the potential clinical benefit.
In the same discussion Zoe Baird noted that it isn't so much the report as how it is depicted to the public. Initial reports were rather unitarian in the view declaring that benefits are not there. CBO - recruiting a broad and talented array of health care economists - has emphasized a broader and more constructive mesage.

Subcommittee on Quality and Cost Effectiveness

One member of the committee expressed extreme frustration. After years of measurement, we haven't been able to "move the needle even one millimeter." People are "tired of it" and "it's time to move on." We need to measure something that counts and quite measuring for the sake of measuring. We do have measures that work - hospital infections, falls, and adverse events. There are very good programs on this focused primarily in hospitals - and this is done without "micro measurement" and by exploring different ways of including things into the processes.

To make an analogy, it is as if one measures the outcome of the Indianapolis 500 by measuring the piston characteristics, fuel injection performance, and, after adjusting for severity, develop an outcome metric!

It's time to re-think and move past the self-interest.

A second member empahsized the need to focus on a few simple things rather than continuing to expend energy as has been done over the past five years. Examples were providing a medication history for every American and better access to laboratory data.

One physician pointed out that "it isn't funny anymore" and spoke of an ongoing event concerning a relative where his personal presence was critical to pull together the various parties involved in the care of his hospitalized relative. Many providers stated "they really didn't have all the details" and depicted a number of clear outcomes that were the result of failures in the system. (The story rivalled that Regina Herzlinger tells in her recent book, "Who Killed Health Care.")

Five Potential High Impact Ideas

The Subcommittee currently is exploring five simple "high impact ideas"
for discusion as a sub-set of a more extensive list. They are:
  1. Measures that matter. Set big goals, like reducing cardiovascular events in the US over the next Y years by X%. Currently some measure for reporting rather than measure for improving. Measurement of "surrogate outcomes" should be abandon as "futile."

  2. Eliminate nosocomial blood stream infections in the US. This requires widespread adoption of evidence-based work flows involving every provider.

  3. Implement a national device registry. A simple correlation between surgeons and selected devices (e.g., hip prostheses, stents) would reveal variation.

  4. Make formularies on-line. (This writer would like to see no more than 50 formularies in the united states rather than thousands. In other words, "formularies that matter" not automating the thousand-plus variants of dubious value)

  5. Share a visit summary. Trials of interchange of CCR and CCD docments have been successful and hold great promise.
The overall approach is not to create another silo but rather to bridge with focus the gap between the many quality initiatives and the principles in policy and technology that are required to realize these objectives and improve them over time. The emphasis is on simplicity and evolution. Measures that matter, nosocomial infections, and visit summaries can be simplified by the maxim: "quit killing people" by focusing on a few systemic issues.

Some correctly point out that goals like elimination of nosocomial infections will result in part from the CMS regulations that prohibit payment for complications.

One strategy is to try to minimize rules that don't help. An example is the requirement for tamper-resistant prescriptions that require special paper and run counter to the technology imperatives expressed by this same government.

Rather than focus on delivery organizations, one should want to identify the four or five top diseases and measure what is required across the continuum of care. Instead, we get the "where do I fit in?" syndrome where roles are emphasized over results (e.g. "measures for anatomic pathologists").

These notes do not express the opinions of the Markle Foundation and may not accurately reflect the ongoing debate and discussions, but hopefully provide yet additional emphasis on why this vital organization's agenda should be supported.

Thursday, June 12, 2008

Two New e-Prescribing Reports

The Summer of 2008 will not be a time of rest for the e-prescribing and medication management industry. As part of what may be only an initial new round of industry and organizational activity, two reports have been released within the past week.

The CHT report provides an optimistic review with a highlight of many of the activities taking place across the country. The Southeast Michigan initiative, in particular, is worth note. The report emphasizes the value realized when medication management changes are implemented in a systematic and thoughtful way.

The eHI / CIMM report has a more thoughtful, cautionary tone.

The report identifies six issues that require additional work; none of these issues prohibits effective use, but each issue must be considered carefully as policy evolves:
  1. Financial cost
  2. Workflow change
  3. Change management
  4. Ban on transmitting prescriptions for controlled substances
  5. Hardware and software selection
  6. Pharmacy, payer/PBM, and mail order connectivity
  7. Remaining standards require approval: prior authorization, structured and codified SIG, and RxNorm.
  8. Unresolved challenges in medication reconciliation
The steering group also made five very important recommendations. Summarized, they are:
  1. The federal government must address the DEA prohibition on e-prescribing of controlled substances.
  2. Payers, employers, health plans, health systems, and federal and state governments should consider replicating and expanding successful incentive programs.
  3. Care providers across every setting of health care should adopt and effectively use e-prescribing.
  4. Create a public-private multi-stakeholder advisory body to monitor, assess, and make recommendations to accelerate the effective use of e-prescribing.
  5. All stakeholders should advance the e-prescribing infrastructure.The federal government and the private sector should continue, and accelerate, the development of standards for e-prescribing.
These are good reports, well worth the read before the rhetoric increases to an even greater extent.

Monday, June 2, 2008

NPI: Challenges Remain

In a May 29 Modern Healthcare Posting entitled "Claims processors see
rejections spike with NPI,
" Joseph Conn mentions the impact of NPI on claim rejection rates. Implemented around a holiday weekend, early "grim reports" suggest a massive increase in claims rejection rates. The lead paragraphs summarizes the posting:
"Healthcare industry claims processors and claims-flow watchers report at least fourfold increases in rejected Medicare claims, similar or even higher rejection rate spikes for Medicaid claims, and a doubling of rejection rates for claims processed by Blues plans on May 23, the first day a federally mandated National Provider Identifier was required."
A senior VP at Emdeon states “We’re seeing a rejection rate of 24%,” ......By Emdeon’s analysis, this individual reports, this represents "$25.8 million in claims that were turned down, which compares with an average rejection rate of 6% or $10.6 million before May 23." Medicaid rates published by Emdeon are similarly high. The rejection rate is 26% compared to a normal rate of 4%. Blue Cross claims however, saw less of a spike according to this authority, jumping from 3% to 6%.

For Medicaid claims processed by Emdeon, the rejection rate on May 23 was 26% compared with a normal rate of 4%; and for Blues claims, 6% were rejected that day compared with a norm of 3%. An industry trade group spokesperson mentioned a 42- physician practice group in which only 12 of the 42 physicians could submit claims without them being rejected. Another spokesperson mentioned a "state Medicaid official who said claims flow had fallen from a normal 100,000 a day to less than 20,000."

What does this mean for our preparedness for health IT? Time and again, there seems to be a disconnect between federal thinking and results on the ground. This disconnect seems to happen even even when the thinking is very sound and accepted by the majority of stakeholders.

What does this mean for e-prescribing? Presumably, problems with a mandate - even with plenty of lead time - might be of a similar magnitude. These possible problems should not deter our industry from pursuing these goals, but it should reinforce our commitment to ensure that transitions are effective. Rejected claims mean money and when money is to be had, people find solutions. Problems with e-prescribing may mean at least a temporary access to medications for those who take these medications to prevent far more serious illness.

These "frightening" reports on NPI should stimulate the medication management industry to ensure that authentication is reliable, authorization is valid, and that the entire process among prescriber/refiller, dispenser, and consumer runs smoothly. We can ill afford stories on e-prescribing similar to the NPI anecdotes provided by Modern Healthcare