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NIST NCPDP Analysis – SCRIPT in Long-Term and Post-Acute Care 

August 31, 2011

Prepared by 1st American Systems and Services LLC

for 

National Institute of Standards and Technology

1

st American Systems and Services LLC
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1st American Systems and Services LLC

469 Township Road 1535

Proctorville, OH 45669 

www.1asas.com

Author

Frank McKinney

fm@frankmckinney.com
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Contents

Introduction ................................................................................................................................................4

Overview: Medication management in long-term and post-acute care settings...........................................4

LTPAC medication management steps and unique messaging needs ...........................................................6

Illustration: LTPAC medication order life cycle (skilled setting).................................................................6

Unique messaging needs during the LTPAC medication management process .........................................7

SCRIPT support for LTPAC medication management flows...........................................................................9

Summary of LTPAC messages: SCRIPT and other standards........................................................................10

Current adoption obstacles and future opportunities ................................................................................11
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Introduction

This document presents a high-level overview of e-prescribing in long-term and post-acute care (LTPAC) 

settings. It provides a background on the underlying medication management processes in those settings and 

a description of how e-prescribing fits in to the facility and pharmacy workflows—focusing on SCRIPT 

messages starting with version 10.1, when LTPAC support was introduced. Concluding the document is an 

informal assessment of current industry adoption, obstacles to electronic processes in theses settings, and 

opportunities for the future.

Document sections:

 Medication management in long-term and post-acute (LTPAC) settings

 Electronic prescribing workflows in LTPAC

 SCRIPT support for LTPAC 

 Current adoption obstacles and future opportunities

Overview: Medication management in long-term and post-acute care settings

John Derr, chief technology strategic officer and senior vice president for Golden Living—one of the largest 

providers of care for seniors in the US—describes long-term and post-acute care (LTPAC) as below:

“Unlike traditional acute and ambulatory healthcare settings—primarily hospitals and physician 

offices—LTPAC patients may be cared for in a wide variety of environments, depending on the 

individual patient's changing needs. LTPAC care sites include skilled nursing, nursing and assisted 

living facilities; home, independent and adult care environments; rehabilitation facilities; long-term 

acute care hospitals; and hospice.”

McKnight’s Long-Term Care News and Assisted Living (October, 2009)

Some important common characteristics among these settings related to medication management are...

 Resident patients. The patient resides in an environment that offers medication management 

services that include maintenance of a medication profile (“med list”), ordering and obtaining refills 

as needed, medication administration assistance (“med passes”), and independent review of their 

medication regime by a consultant pharmacist. These services may be offered “ala carte” (e.g., in an 

assisted living setting), or may be included in a full range of care in a skilled nursing facility.

The resident patient’s location in the care setting (unit, wing, floor, room, bed, etc.) is included in 

orders sent to the pharmacy, and frequently needed for packaging and delivery of medications to the 

setting. For example, the pharmacy may mark administration packaging with the resident’s unit, 

room and bed, and further may sequence medications in drug carts or other administration aids 

according to the patient’s facility location.

 Partner institutional pharmacy. The care setting has a relationship with an institutional pharmacy 

that offers specialized services for resident patients including delivery, packaging of medications into 
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special packaging to facilitate administration by facility staff, and consultant pharmacist services.

While patients have the option to use other pharmacies of their choice, the majority typically utilize 

the partner pharmacy—and certain services needed by residents are only offered by institutional 

pharmacies.

 Open-ended orders. For patients receiving more comprehensive care for longer periods of time, 

medication orders may be “open-ended”—stated in terms of daily doses rather than a fixed quantity 

of medication to be dispensed. The partner pharmacy takes responsibility for maintaining a sufficient 

supply of such medications at the facility, and may deliver weekly, daily monthly, or on some other 

time schedule. When the patient’s condition changes, the pharmacy receives a cancelation of the 

previous order and potentially a new order for an adjusted therapy.

 Cooperation between the prescriber, facility staff, and pharmacy. Especially in skilled care settings, 

the patient’s physician works closely with facility staff to set and manage treatment. Likewise, the 

pharmacy has responsibilities in the management of medication therapy for resident patients that 

goes beyond those in the ambulatory setting. These relationships result in additional communication 

needs in the medication management process, especially:

o review of patient orders by facility nursing staff prior to forwarding to the pharmacy and 

maintenance of a consolidated medication list containing drugs prescribed by all clinicians 

treating the patient

o annotation of medication orders by facility staff with care setting-specific information 

including patient location (unit/room/bed), facility administration times (“med passes”) and 

patient administration-related information such as tolerance for certain drug forms (e.g., 

patient meds are administered through a gastric tube)

o sharing of patient demographics, clinical “profile” information, and admission / discharge / 

transfer information with the partner pharmacy

o communication of the particular dispensed drug product from the pharmacy to facility, to aid 

in medication administration at the care setting and facility inventory management.

These characteristics drive the differences between e-prescribing in the ambulatory setting and LTPAC—

resulting in the need for additional message content and LTPAC-only message types. The next section 

outlines the steps in an LTPAC medication management process, reflecting these unique aspects, and relates 

it to NCPDP SCRIPT messaging.
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LTPAC medication management steps and unique messaging needs

Illustration: LTPAC medication order life cycle (skilled setting)

Prescriber – M.D. or Nurse Practitioner Nurse Agent for the Prescriber

Reviewing Nurse (Reviews, adds administration details) Pharmacy Administering Nurse (Administers Care) Medication Management Process – Long-Term Care (Skilled Nursing Facility) ** INITIAL DISCUSSION DRAFT **

Initiate / modify prescription order Enter order into system

Review / augment order (e.g., med pass times, admin directions)

Dispense

Sign Order Acknowledge conflict or revise prescription

* Conflicts include contraindications, formulary coverage limitations, or other conflicts identified by the CPOE system ** Pharmacy may dispense a provisional supply of the ordered medication as it works with the physician to resolve formulary / payment issues. Pharmacy notifies facility of dispensed medication. CPOE updates resident electronic medical record.

Consider safety alerts and formulary info

Transmit Order (EDI, fax)

Via Agent: handwritten, phone

Update med admin record (MAR)

Capture signature

Administer medication, document Request resupply if needed

Provide patient chart, medication info verbally

5/12/2008 Frank McKinney

Take vitals, labs Resolve claim issues **

Run drug utilization review / resolve potential safety conflicts

Dispense medication

Administer med

Resolve safety, formulary alerts**

Review chart Med Reconciliation at Admission, Change of LOC Review current meds (discharge, home meds) Change / discontinue med? Review chart Patient Encounter (exam, phone request) Review current meds (discharge, home meds) Change / discontinue med?

Review, counter- sign NP order

Direct prescriber order entry Add administration details

Review chart Review current meds Change med?

Resolve pharmacist safety, payment questions

Review chart Monitor / reauthorize patient meds Review current meds Change / stop med?

Facilitate, record adjustments

1 2

3 4

5

6

7 8

9 10

Sign Order Capture signature

Provide patient chart, medication info verbally

Provide patient chart, medication info verbally
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Unique messaging needs during the LTPAC medication management process 

Medication Reconciliation at Admission

 Resident intake / discharge and medication reconciliation. Resident transfer between hospital and 

LTPAC settings is commonplace, and involves special consideration regarding:

o Choice of hospital discharge medications and communication to the LTC facility and 

pharmacy

o Transfer of resident’s demographics and medical information (EHR) when the resident moves 

between the two settings.

Informed Prescribing Process

 Drug Utilization Review / safety checking. Certain patient safety checks are especially pertinent in LTC 

settings, e.g., geriatric alerts associated with certain medications (Beer’s list)

 Payer benefits / formulary / medication cost management. There are several unique LTC drivers that 

influence medication cost, reimbursement, and coverage approval:

o Medicare A periods

o Part D formularies and coverage rules, including prior authorization requirements

o Facility stock

o Pharmacy “formulary” reflecting negotiated pricing

Communication of Patient “Census” Information

 Resident information to the pharmacy. A key difference in LTPAC is that the “patient” is not present 

at the point of dispensing, and so is unable to provide information to the dispensing pharmacist. In 

this setting, medical information such as allergies and conditions, as well as insurance and delivery 

information, must be shared with the pharmacy, separate from a given medication order:

o Resident allergies, diagnoses

o Insurance information, responsible party

o Delivery information (facility, unit / room / bed)

o Special administration needs or tolerances

Because LTPAC orders are commonly open-ended, the need for up-to-date resident information is 

ongoing—to support dispensing / delivery of the medication past the initial dispensing. For example, 

it is critical that the partner pharmacy be notified of resident unit / room / bed transfers, updates to 

diagnoses and allergy information, etc.

Prescription Communication: Prescriber / Facility Staff Interaction

Facility nursing review of prescription orders. The LTPAC setting typically manages the full range of 

care for resident patients, and has the most complete view of therapies ordered by multiple 

clinicians—as reflected in the patient’s chart (in an electronic medical record system or other form). 

Therefore, it is critical that all medication orders are reviewed by facility staff in the context of the 

patient’s full set of care, to prevent conflicts and identify other potential care issues. In addition, 

facility staff may recognize additional patient needs not currently being addressed, which may result 

in changes to the patient’s medications after being communicated to the prescriber.
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Additional Care Setting-Related Annotations to the Medication Order

 Administration information to the pharmacy. An LTPAC pharmacy has unique responsibilities with 

respect to dispensing and delivery of medications in a manner that supports their directed 

administration. Prescription messaging must support administration-related elements such as the 

following:

o Stat orders

o Administration times

o Special administration directions (G-tube, half tablet, etc.)

o Patient location (unit, room, bed) information

o Multiple administration directions for a single “prescription,” e.g., tapered doses

 Open-ended orders. In long-term care settings, it is common for a physician to create open-ended 

orders for certain maintenance medications. These orders do not have a pre-defined end date, and 

are to be dispensed by the pharmacy until it is notified of the order’s discontinuation. Special 

communication requirements associated with open-ended orders include:

o Conventions for explicitly identifying an order as “open-ended,” with dispense quantity to be 

determined by the pharmacy according to protocol

o Message to communicate the discontinuation of an open-ended order

o Messaging conventions to communicate changes to open-ended orders

o Message to request “re-supply” or additional dispensing per an open-ended order

Dispensing Information

 Communication to the facility of actual dispensed medication information. Notification to the LTPAC 

setting of the actual dispensed medication is critical to medication administration and other facility 

processes. Further, dispensed medication details can potentially vary from delivery to delivery. In this 

setting, the dispensed medication may vary from that ordered due to several reasons, some unique 

to LTPAC:

o Generic substitution

o Therapeutic interchange resulting from consultation with the prescriber (“call back”)

o Therapeutic interchange per predetermined protocol agreed to by the prescriber, facility, 

and pharmacy

o Pharmacy inventory
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SCRIPT support for LTPAC medication management flows

The diagram below identifies the points in the LTPAC medication management process supported by NCPDP 

SCRIPT messages.

Prescriber Other Facility Staff SCRIPT Messaging LTC Pharmacy Electronic Information Source

SCRIPT 10.6 Support for LTC Medication Management Process – Skilled LTPAC Setting Clinician

Configure medication decision support Drug Knowledge Suppliers 3rd Party Formulary Supplier Perform eligibility and benefits checking Gather medication, diagnosis & allergy information 3rd Party Medication History Supplier Perform medication reconciliation at admission Write new medication order

Discontinue medication order Change medication order

Facility receives dispensing details and updates resident record

View medication, allergy, and other clinical information

Transfer resident. Update resident clinical, other info

Write new discharge prescriptions Provide info to the next provider of care and resident / surrogate

Verify order

Dispense new / changed med, or discontinue prescription

Medication Reconciliation at Admission

Order Medication Previous Care Setting (e.g., Hospital) Incorporate: Resident demographics and census events. Full diagnosis, allergy, and medication profiles Census Message

Resupply Medication

Fill Status Message

New Rx, Cancel Rx Messages

Census Message

Resupply Message Resident Transfer, Leave of Absence, Other Information Change

Discharge

Incorporate: - Eligibility - Medication and allergy - Demographics Perform medication reconciliation upon discharge

Review drug alerts and acknowledg-ments from prescriber

Process resupply (send add’l supply to Facility) Update resident record Request additional quantity of an active medication order 3rd Party Formulary Supplier Perform eligibility and benefits checking

Census Message Discharge resident Incorporate: - Demographics and census Retail Pharmacy: Dispense medication for patient pick-up New Rx Message (Discharge medications)

Fill Status Message

Review orders in the context of all patient care. Consult prescriber as needed. Provide pharmacy with setting- specific information such as patient location
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Summary of LTPAC messages: SCRIPT and other standards
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Current adoption obstacles and future opportunities

This section identifies some of the key obstacles impacting use of SCRIPT version 10.6 in LTPAC settings, and 

opportunities to address those in order to advance the use of e-prescribing there.

Inconsistency of SCRIPT implementation

Because the largest institutional pharmacies have added support for SCRIPT messaging in recent years, the 

majority pharmacies used by LTPAC facilities today have some level of support for electronic prescribing 

using SCRIPT version 10.1 or higher. However, the particular SCRIPT message types and versions supported 

vary by pharmacy, as well as implementation details, due to the fact that most facility-to-pharmacy 

messaging in the setting is accomplished using point-to-point connections negotiated separately between 

facility and pharmacy vendors rather than through networks such as Surescripts or Emdeon.

The lack of direction on LTPAC e-prescribing standards in the CMS e-prescribing standards for Medicare Part 

D has contributed to this inconsistency, by leaving a vacuum of guidance to vendors implementing eprescribing in this setting. CMS has indicated its intent to remove the LTPAC exemption in the Part D eprescribing standards, but not until SCRIPT version 8.1 is no longer allowed by those standards (because 8.1 

lacks support for the LTPAC workflow). Timing of LTPAC support has not been set, but removal of the 

exemption will likely not occur within the next 2-3 years.

Further, the system certification that has been required of ambulatory prescribing systems in conjunction 

with the MIPPA and HITECH incentive programs has not included LTPAC, since those incentive programs do 

not pertain to the LTPAC setting.

Limited LTPAC support by the major prescription routing network

The largest prescription routing network, Surescripts, has declined to fully support the LTPAC market—

instead focusing its attention and resources on the ambulatory setting. As noted above, this has led 

interested pharmacy and LTPAC facility system vendors to establish point-to-point network connections 

between themselves, resulting in a lack of consistency in standards implementation. Perhaps more 

importantly in the long term, this has also resulted in a lack of access by these stakeholders to the full set of 

healthcare providers and institutions participating in the larger networks. 

The transition to SCRIPT 10.6 offers another opportunity for the large prescribing networks to offer LTPAC 

support, since unlike previous SCRIPT versions, 10.6 provide robust support for LTPAC as well as ambulatory 

settings.

Full, convenient integration with community physician processes

Most LTPAC patients continue to receive care from the same community physicians they saw prior to 

entering into the setting. As a result, a considerable proportion of medication orders for these patients are 

initiated from outside the facility, via telephone or fax.

In order to address this issue, some facilities have implemented web-based or portal-accessible EHR/ eprescribing systems which can be accessed remotely by prescribers. Because the system is maintained by the 

facility, it includes complete medication, problem, allergy lists, reflecting care provided by all clinicians 

treating the patient.
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However, practitioners typically see the majority of their patients at their ambulatory clinic, while also 

treating their LTPAC patients. As such, these providers prefer to utilize the electronic medical record and 

prescribing systems they’ve implemented in their “home” clinics, rather than the systems present at the 

LTPAC facilities where their elderly or other patients are currently residing.

The NCPDP LTPAC E-Prescribing Task Group is currently developing a proposal for a messaging process that 

would enable such providers to use their ambulatory prescribing systems to create medication orders for 

their LTPAC patients and transmit them to the facility for review and addition of facility-specific details prior 

to routing to the pharmacy. The goal of this process is to accelerate the adoption of e-prescribing in the 

LTPAC setting by building on adoption in the ambulatory realm, while supporting the need for facility 

participation in the process.

Support for prescribing of controlled substance medications

A higher proportion of medications used in the LTPAC setting are controlled substances, as compared to the 

ambulatory setting. These medications present a further obstacle to LTPAC e-prescribing adoption due to the 

additional requirements established by the DEA in its interim final rule. Especially problematic are rules that 

would effectively require prescribers in this setting to have an uncommonly formal employment relationship 

with their patient’s LTPAC facilities in order to use the facilities’ prescribing systems to create electronic 

controlled substance prescriptions.

However, as a result of NCPDP comments to the initial DEA controlled substance rule, the interim final rule 

contains directional language supporting an electronic workflow by which a prescriber creates an electronic 

controlled substance prescription and routes it to an LTPAC facility for review and annotation, after which it is 

forwarded to the pharmacy. As noted above, the NCPDP LTPAC E-Prescribing Task Group is currently working 

on a messaging process that would enable that workflow—protecting the prescriber’s medication order while 

enabling the facility to review, annotate, and forward the order to the patient’s pharmacy.