Sharing Records

MICHAEL GARRY

As part of its effort to reform the nation's health care system, one of the signal goals of the Obama administration is to promote the development of a national network of electronic health records (EHRs) shared by doctors, hospitals, labs and retail pharmacies.

Under this network, all of a patient's health care providers would be privy to critical health data, from diagnoses and test results to medications and allergies; it would build on electronic medical records that some physicians use internally.

Retail pharmacists, for example, “would have access to diagnostic data that they don't have now,” said Bill Lockwood, executive director, American Society for Automation in Pharmacy, Blue Bell, Pa. “That would make pharmacists more effective health care providers of medication therapy management [MTM].”

While health care reform has its share of critics, few would dispute the need for an electronic health record system, part of a secure, interoperable, national health-information-technology (HIT) infrastructure that would bring efficiency, accuracy and cost-savings as well as medicinal benefits to millions. The question simply is how to move cost-averse health care providers into the digital age.

Government funding is one way. The American Recovery and Reinvestment Act of 2009 (ARRA) — the so-called stimulus bill — which was signed into law by President Obama in February, allocated $19 billion toward the modernization of the nation's HIT infrastructure and toward Medicare and Medicaid incentives for doctors and hospitals to electronically exchange patients' health information.

The HIT part of ARRA is significant enough to have its own act — the Health Information Technology for Economic and Clinical Health (HITECH) Act — and its own government department — the Office of the National Coordinator (ONC) for HIT.

Where do food retailers and their pharmacies fit into this bureaucratic maze? For one thing, retail pharmacies are part of the network of health care providers that is being asked to communicate electronically in support of patient care. In fact, pharmacies, which have been using technology to support communications with insurers since the 1980s, and have spearheaded the development of e-prescribing, are well ahead of the HIT game. More than 90% of pharmacies are able to receive e-prescriptions while less than half of physicians are sending them, according to industry estimates.

Still, retailers will need to keep up with the momentum gathering around HIT, making sure they are up to speed with e-prescribing as well as federal standards and policies that are being concocted to ensure an interoperable HIT infrastructure. For now, though, food retailers and other retail pharmacies appear to be waiting for new directives to be announced, or following their software vendor's lead, before committing time and resources to the issue.

“Our participation will be linked to what our [dispensing] software provider PDX can do,” said Randy Heiser, vice president of pharmacy, Giant Eagle, Pittsburgh, which has been receiving e-prescriptions for a few years. “The data starts with the dispensing system, which would then interface with the holder of the electronic health record.”

“Electronic health records are a ways down the road,” said Bob Egeland, vice president of pharmacy, Hy-Vee, West Des Moines, Iowa. “There are quite a few security issues unanswered, and many physicians still can't electronically transmit prescriptions. They are a long way from sharing important health care readings and data.”

In the meantime, retail pharmacy trade groups see the federal government's unprecedented emphasis on HIT as an opportunity for the retail pharmacy to gain a higher profile in the health care continuum and possibly garner some of the dollars earmarked for HIT development.

But at a minimum, industry groups want to ensure that pharmacy will be part of the overall network. “The key for retail pharmacy is [network] interoperability,” said Cathy Polley, vice president, pharmacy services, Food Marketing Institute, Arlington, Va. That would enable pharmacies to “have access to all pieces of the electronic health record.

MAKING THE CASE

The National Association of Chain Drug Stores, Alexandria, Va., regards chain pharmacies as part of the group “potentially eligible” to receive part of $2 billion allocated to ONC to expand the use of EHRs, said Kevin Nicholson, vice president, government affairs. “We've been making the case to Congress and the Office of the National Coordinator that pharmacies should be eligible for some of the money.”

Part of NACDS' case is that since doctors are being offered incentives (both positive and negative) to implement e-prescribing as a step toward adopting EHRs, pharmacies — as the recipient of those electronically sent prescriptions — need support to keep pace. Many large chains are set up for e-prescribing, but many smaller chains and independents are not, said Nicholson.

“Smaller pharmacies, especially, need assistance, and all pharmacies will need assistance moving to electronic health records,” he said. “So as physicians move to electronic health records, unless pharmacies receive similar financial support, they'll be left out of the electronic health record adoption.”

NACDS is also pursuing funding to help pharmacies comply with the privacy provisions of ARRA, such as the breach notification requirement, accounting of disclosures and patient-requested restrictions on disclosures.

But some observers question whether pharmacies will receive federal funding. “I don't see where pharmacy is part of the funding mechanism,” said John Klimek, senior vice president of industry information technology for the National Council for Prescription Drug Programs (NCPDP), Scottsdale, Ariz., and a former manager of pharmacy claims processing for Supervalu.

E-prescribing is viewed as the “gateway” toward more detailed electronic health records, said Nicholson. “The more pharmacists and doctors talk to each other electronically, the more robust the interaction that will lead to electronic health records.” In 2008, 68 million prescriptions were routed electronically, compared with 27 million in 2007, according to NACDS.

The federal government shares this view of e-prescribing, said Klimek. “The ONC sees electronic pharmacy information as a strong piece of electronic health records,” he said. “It is hoped that almost everything will be e-prescribed by 2013-2015, and all of that information will be electronically available.”

Though EHR data will be shared among multiple entities, it's not clear yet where the data will reside, noted Klimek. “It will be in some environment shared by all teams.”

MEANINGFUL USE

Two committees have been established by the ONC, the HIT Policy Committee and the HIT Standards Committee, which includes Klimek and former Wal-Mart technology executive Linda Dillman (now with Hewlett-Packard). In December, the HIT Policy Committee is expected to issue a definition of “meaningful use” as the term will apply to the use of HIT by physicians in 2011; unless they use the technology “meaningfully,” they won't qualify for financial incentives from Medicare, for example.

Already, it's clear that physicians won't meet the meaningful use standard unless they e-prescribe by 2011. “That means pharmacies will be helping doctors to be meaningful users, which is also why it's important to get funding for pharmacists,” said Afton Yurkon, manager of federal government affairs for NACDS.

NACDS would like the definition of meaningful use to view e-prescribing as not just the transmission of prescription information but also the ability to access medication history and formulary and benefits information, said Yurkon.

Also in December, the ONC is expected to issue an “interim final rule” on the standards needed for different health care providers to share EHRs via an interoperable network in the 2011 to 2015 time frame; privacy requirements will also be addressed.

For example, a certain version of the Script standard that governs e-prescribing will be named. In addition, the committee plans to name RxNorm, the codes that identify a drug and its strength, as the standard for EHRs, said Klimek, adding that SNOMED codes will be named as the standard for diagnoses instead of ICD9 and ICD10 codes. “You're going to see pharmacy software systems having to convert from NDC numbers to RxNorm codes, as well as using SNOMED codes.”