# Presentation: 110130

## 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**

**Notes:**
Review our results related to each of the 6 standards
Part 1: Focus on the more-technical level related to evaluating the individual standards & how they’re being used.
Part 2 is slated for the next AHRQ Web conf., and it’ll cover more of our findings about e-prescribing adoption and outcomes.

## E-Prescribing Transactions

- RxHub

- SureScripts& others

- Mail-orderpharmacy

- Retailpharmacy

***Eligibility***
***Formulary***
***Med History***

***NCPDP SCRIPT***

***Med History***
***Formulary***

- Mail-orderpharmacy

- Caremark, Express Scripts, Medco, Wellpt

- Retailpharmacy

- Retailpharmacy

- Retailpharmacy

**Notes:**
POC – where you live
Prescribe – print or fax
Then along came RxHub, a joint venture of the 3 major PBMs: Caremark, Medco, ExpressScripts
Not only route prescriptions, but also provide additional information
Not to be outdone, the National Association of Chain Drugstores formed SureScripts
Your challenge is to select the right POC system for your medical group, and my job today is to help you learn what you need to know to make that choice

## 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***

## 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**

**Notes:**
Challenge is taking this

## Technical Expert Panel

| Category |  | Company |
| --- | --- | --- |
| Point of care software vendors | EHR | Allscripts |
|  | eRx | iScribe |
|  | eRx | InstantDx |
|  | EHR | MedPlus |
|  | eRx | ZixCorp |
| Content Providers |   | First DataBank |
|  |   | Wolters Kluwer |
| Intermediaries |   | RxHub |
|  |   | SureScripts |
|  |   | NDC |
| Pharmacies
 | Mail | Caremark Mail |
|  | Mail | Medco Mail |
|  | Large Chain | Walgreens |
|  | Independent | QS1 |
|  |   |   |

**Notes:**
representing organizations that have direct experience in implementing at the technical level, which means the data and fields. So this required a deep knowledge of what’s going on from the standpoint of all the participants in these transactions taking place between the POC and the pharmacy. We considered our expert panel to be composed of companies rather than individuals. A primary contact was charged with finding the appropriate expertise within the company to answer each discussion question.

## 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**

**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**

## The NDC Code Problem

**NDC represents the package**
**metformin 850mg has >100 NDC codes**

- 066267-*497-40	53489-468-88	062037-*675-01	051129-2460-*1	013411-*164-09	065243-*239-12	068115-*232-45
- 066267-*497-40	55111-430-01	062037-*675-05	051129-2610-*1	013411-*164-10	065243-*239-18	068115-*232-45
- 066267-*497-45	55111-430-05	062037-*675-10	051129-3594-*1	013668-*002-01	065243-*239-27	068115-*232-60
- 066267-*497-45	55111-430-30	062147-5001-*0	051129-3594-*2	013668-*002-05	065841-*029-01	068115-*232-60
- 066267-*497-60	55111-430-60	062318-0191-*0	051129-3943-*1	013668-*002-12	065841-*029-05	068382-*029-01
- 066267-*497-60	55111-430-78	062318-0191-*1	051129-3943-*2	013668-*002-30	065841-*029-10	068382-*029-05
- 066267-*497-90	55567-145-18	062584-*332-01	051655-*291-24	013668-*002-60	065862-*009-01	068382-*029-10
- 066267-*497-90	55567-145-25	063629-1396-*1	051655-*291-25	013668-*002-90	065862-*009-05	068788-0435-*3
- 066336-*883-60	57315-048-01	063629-1396-*2	051655-*291-52	020091-*533-01	065862-*009-26	068788-0435-*6
- 066689-*012-01	57315-048-04	063739-*300-10	051655-*291-53	020091-*533-05	065862-*009-50	0781-5051-01
- 066689-*012-30	57315-048-05	064679-*529-01	053489-*468-01	020091-*533-10	065862-*009-60	0781-5051-05
- 066689-*012-60	62037-675-01	064679-*529-02	053489-*468-03	0228-2715-10	065862-*009-90	20091-533-01
- 067090-*533-01	62037-675-05	064679-*529-03	053489-*468-05	0228-2715-11	066105-*601-10	20091-533-05
- 067090-*533-05	62037-675-10	064679-*529-04	053489-*468-10	0228-2715-50	066105-*744-23	20091-533-10
- 067090-*533-10	65862-009-01	064679-*529-05	054569-5353-*0	0228-2715-96	066267-*497-20	53489-468-01
- 067228-0268-*3	65862-009-05	064725-0209-*3	054569-5353-*3	023490-0898-*0	066267-*497-20	53489-468-03
- 067228-0268-*6	65862-009-50	064725-0209-*3	055045-2905-*0	023490-0898-*3	066267-*497-30	53489-468-05
- 067544-*107-53	65862-009-60	065243-*239-06	055045-2905-*0	023490-0898-*6	066267-*497-30	53489-468-10

**Each packager maintains their own codes**
**Changes aren’t always tracked at FDA**

## RxNav

**RxNorm ID: 6809**

## RxNav 2

**RxNorm ID: 316257**

## RxNav 3

***RxNav 3***

**Metformin  850 MG  Oral Tablet**

**RxNormID: 311752 (SCD)**

## 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?**

## 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**

## 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**

## 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**

## 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**