NCPA Comments to ONC: Definition of Meaningful Use
VIA Electronic Submission to MeaningfulUse@hhs.gov
June 26, 2009
Office of the National Coordinator for Health Information Technology
200 Independence Ave, SW
Suite 729D
Washington, DC 20201
Attention: HIT Policy Committee Meaningful Use Comments
Dear Sir or Madam:
Thank you for the opportunity to comment on the proposed definition of “meaningful use” as presented by the HIT Policy Committee on June 16, 2009. The National Community Pharmacists Association (NCPA) represents America’s independent community pharmacists, including the owners of more than 23,000 community pharmacies, pharmacy franchises, and chains. Together they employ over 300,000 full-time employees, and dispense nearly half of the nation’s retail prescription medicines.
NCPA appreciates the Meaningful Use Workgroup of the HIT Policy Committee for recognizing the need for appropriate quality measures that will make interoperable electronic health records (EHRs) meaningful for providers and patients and provide benefits to the health care system. Community pharmacies and pharmacists are an integral component of many of the objectives and measurements proposed in the matrix to achieve meaningful use. Pharmacists are a direct point of contact between patients and physicians, particularly in regard to the key elements of medication management envisioned to achieve the care goals of an interoperable EHR. In fact, improving medication management has been a common theme among various organizations and interested entities as they suggest definitions of meaningful use.1
In addition to dispensing prescriptions to patients, pharmacists also provide valuable clinical services, referred to as medication therapy management (MTM) services.2 MTM is distinct from medication dispensing and focuses on a patient-centered process of care, including comprehensive assessment and ongoing follow-up assessments to identify and resolve medication problems.3 Many of the objectives considered for inclusion in a meaningful use definition include elements of and outcomes associated with MTM services provided by pharmacists, such as implementing drug-drug checks, maintaining an active medication list, and exchanging key clinical information among providers of care. In addition, pharmacies often maintain records on drug allergies, patient use of over the counter medications, dietary, herbal and vitamin supplements and a record of all medications that are not filled through a third party, such as prescriptions that are paid for in cash. Third party payers, such as pharmacy benefit management (PBM) companies, do not have this complete data on patients. The data from a complete electronic medication list maintained by community pharmacies is an important means to achieve meaningful use that reinforces the need for a fully functional electronic medication management system.
Incorporating pharmacy-based measures into interoperable EHRs can provide patients and payers with better data and information on the overall contributions made by various providers to quality of care and health care outcomes. Like other health care providers, pharmacists’ contribution to overall quality should be based on a validated set of pharmacy outcomes measures. The Pharmacy Quality Alliance (PQA), which was initiated by CMS in 2006, has already taken the lead in developing validated pharmacy quality measures that help to determine whether a pharmacist made a difference in improving the use of prescription medications. Measures have been developed to determine whether pharmacists “improve medication adherence”, “enhance the care of individuals with diabetes”, and “improve medication safety.” These current and future PQA measures can and should be incorporated into an interoperable EHR system.
While NCPA members provide MTM services, integrating components of these services into an interoperable EHR system will require substantial changes and upgrades to existing electronic systems that may lag behind the aggressive timeline established in the matrix, particularly for 2011 measures and objectives. Electronic prescribing (e-rx) is an example of a currently operational system where the full functionality of the benefits has yet to be realized. In 2008, the Medicare Improvements for Patients and Providers Act (MIPPA) provided financial incentives for e-rx. While the uptake of e-rx has increased in 2009 by 61% over 2008 with the transmission of 134 million e-rx messages,i the full clinical functionality of e-rx is limited because information related to accessing medication history, formulary, and benefit information is often not routed despite being a requirement for eligibility to receive incentives under MIPPA.
Prescribers receive incentive payments by simply routing 50% of prescriptions electronically without the additional services that would really benefit providers and patients. This provides a concrete example of a shortcoming of developing a set of standards that do not really achieve the intended goal. NCPA recommends that one focus of meaningful use should be the utilization of an electronic medication management system that incorporates all the functionality of e-rx, such as medication history and formulary information, not simply transmission of prescription information that is an electronic substitute for a paper prescription and provides no additional clinical or cost benefit.
NCPA members are prepared to provide the services necessary to help achieve the goals of meaningful use of EHRs; however, as small business owners, their systems are often not prepared for interoperability. NCPA believes that given the role of pharmacists in an electronic health environment, incentives should be considered to ensure their connectivity, particularly in rural and urban communities with a number of underserved minority groups where community pharmacists often make the most difference and have a large presence.
Community pharmacies regularly maintain electronic patient records and transmit claims using electronic systems. In rural and underserved communities, pharmacies may be the only provider with experience in using electronic systems and thus could be a beneficial resource in connecting other health care providers electronically that would benefit many individuals and help to achieve the goals of meaningful use.
NCPA appreciates the opportunity to comment and looks forward to working with ONC as you address issues related to the definition of meaningful use . If you have any questions, please contact me at (703) 683-8200 or john.coster@ncpanet.org.
Sincerely,
John M. Coster, Ph.D., R.Ph.
Senior Vice President, Government Affairs
National Community Pharmacists Association
1 Achieving the Health IT objectives of the American Recovery and Reinvestment Act: A Framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR The Markle Foundation® Connecting for Health, April 2009
2 A full description of MTM services can be found in Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model. J Am Pharm Assoc. 2008; 48(3): 341-53.
3 Cipolle RJ. Strand LM, Morley PC. Pharmaceutical Care Practice: The Clinician’s Guide. New York: McGraw Hill; 2004.
i US achieves major milestone in e-prescribing [press release]. Alexandria, VA and St. Paul Minnesota: Surescripts. April 22, 2009. Available at http://www.surescripts.net/downloads/NPR_Announcement_Final.pdf. Accessed June 23, 2009.