About Barbara Mullarky

Barbara has had a successful career in the healthcare industry, working for both vendors and healthcare provider organizations. She has held roles in sales, marketing, product management and professional services, working with EMR and department-focused solutions for the laboratory and imaging. Prior to becoming the Director of Product Management at SRS, Barbara was with GE Healthcare (now GE Digital), where she held the positions of Senior Product Marketing Manager for Centricity imaging products, Product Marketing Manager and Customer Collaboration Leader for what is now Caradigm, and Upstream Marketing Manager for Centricity Laboratory. Barbara also worked at the University of Arizona Medical Center, where she managed a team that was responsible for implementing and maintaining 27 departmental IT solutions, the ambulatory EMR and the patient safety initiatives. Originally from New Jersey, Barbara now lives with her husband in Tucson, AZ. She is a graduate of the West Virginia University College of Medicine and is a registered Medical Technologist. When not at work, she loves traveling, taking photographs, watching football and spending time with her two Brittanys.

The Opioid Crisis, PDMP, and Interoperability

opioid-blog-image-1The National Crisis

The opioid epidemic makes the news at least once a day in my neck of the woods.  Patients, providers and the government talk about the problem and how they’re going to solve it. Drug companies advertise Naloxone as something that you should have on hand as a first response to an overdose, just like having an Epi-pen on-hand is recommended to respond to severe allergic reactions. One of the most talked about solutions for physicians and eligible provides is the PDMP or Prescription Drug Monitoring Program.

What is a PDMP?

A PDMP is a state run system that records data on prescriptions for Schedule II to V narcotics. Currently, 49 states plus the District of Columbia have implemented a PDMP. Missouri is the only state without a statewide PDMP. The contents of each can vary based on the laws of the state, but generally the database is populated by pharmacies when a prescription is dispensed and, in some cases, by the dispensing physician or insurance claims. There are some holes in the databases. In some cases, federally operated pharmacies such as those on military bases, are not required to submit data. In other cases, prescriptions paid for in cash are not submitted. And they only contain the data for prescriptions written in your state. For those of you who live in towns that border neighboring states, your patients may have their prescriptions filled in a different state than where you practice.

While not perfect, PDMPs are one of the best tools available today to help practitioners understand their patient’s drug history and the patient’s potential to be an abuser.  There are documented successes with PDMPs. New York mandated the use of PDMPs in 2013, and in that first year, doctor shopping decreased by 75%, the number of opioid doses dispensed decreased by 10%, and the number of prescriptions for buprenorphine, a drug used to treat opioid addiction, increased by 15%.[1] In 2012, Kentucky became the first state in the nation to pass legislation mandating comprehensive PDMP use. That legislation led to a 13% decline in opioids dispensed, a 25% decline in prescription opioid deaths, and an almost 90% increase in prescriptions for buprenorphine, a medication to treat opioid addiction.[2]

Making connectivity difficult

Today, 39 states require a provider to check the state’s PDMP before they write a prescription for an opioid. Since not all states use the same software (some are homegrown), the ability for EHR vendors to connect to these databases is not easy or simple.  Some states, like New York, are simply not ready for EHRs to connect. This makes your workflow and the workflow of your staff difficult.opioid-blog-image-2

Figure 1 Information current as of January 2019

Is Your Prescribing Workflow Optimized?

Working with our partners at DrFirst, SRS Health now provides a seamless workflow to allow providers to check the PDMP for 35 states. Three other states are in process. With just one click, the patient’s medication history is displayed and the date that the PDMP check was performed is recorded in your state’s database and made available within the EHR’s prescribing application.

Interstate checking of PDMPs is also available for 47 participating states so practices in border towns can see not only their state PDMP data but that in neighboring states as well. Practices just need to request access to other states at implementation. If access is available across states, it will be set up as part of the installation.opioid-blog-image-3

Figure 2 Connectivity as of November 2018

What else will help?

PDMPs are one of the tools available for clinicians to help fight the opioid crisis. Utilizing electronic prescribing for controlled substances is another tool. EPCS prevents prescriptions from being altered or copied and refilled multiple times.  Pharmacists tell stories about how a 30-day supply has become a 130-day supply.

MYTH: Not many pharmacies accept electronic prescriptions for controlled substances. FALSE

According to Surescripts, > 95% of pharmacies in the US are EPCS enabled[3],[4] while physician and provider adoption remains low, with only 31% of providers using EPCS. New York leads the nation with 93.8% of controlled substances prescribe electronically. North Dakota, Maine, South Dakota and Minnesota round out the top five with 57%, 41.2%, 37.3% and 34.2%.[5]

While only 5 states require EPCS (Arizona joined the ranks as of January 1), ePrescribing of opioids is coming. Six more states have passed laws that go into effect from January 1, 2020 through January 1, 2022. In October, 2018, the federal government passed the Opioid Response Act[6]. A portion of the act called the “Every Prescription Conveyed Securely (EPCS) Act will require electronic prescribing for patients covered by Medicare and Medicare Advantage plans of all Schedule II-V narcotics beginning January 1, 2021. Earlier in the year, retail giants Walmart and Sam’s Club announced that they will require EPCS for all controlled substances by 1/1/2020 – less than 12 months from now!

How can you prepare?

For SRS Health EHR users, the answer is simple. We’re ready so you can be ready too. With our new Rx application, powered by DrFirst, we deliver an integrated eRx, EPCS, PMDP access and mobile application that allows you to meet all the state and federal mandates and help improve patient care. Just contact your account manager to learn more.

For non-SRS Health EHR users, check with your EHR vendor to see what capabilities they offer. Contact us if you’d like to learn more, our team is ready to help.

Citations:

[1]  Shatterproof, et al. “Prescription Drug Monitoring Programs: Critical Elements of Effective State Legislation.” March 2016.

[2]  Shatterproof, et al. “Prescription Drug Monitoring Programs: Critical Elements of Effective State Legislation.” March 2016.

[3] Electronic Prescribing for Controlled Substances, Surescripts

[4] E-Prescribing Pharmacies

[5] E-prescribing up more than 500% since 2015. Health Information Technology, May 8, 2018

[6] Senate easily passes sweeping opioids legislation, Washington Post, October 3, 2018

Are You Preparing for Appropriate Use Criteria Compliance?

auc-blogAppropriate Use Criteria (AUC) is a lesser-known government law that will affect everyone who orders advanced imaging procedures—a staple of orthopaedic practices. AUC is part of the Medicare Physician Fee Schedule regulations.

The law will impact the ordering, performing, and payment for advanced imaging procedures beginning January 1, 2020. The initial year (2020) will be an educational and testing year that will not affect payment.

Included in the advanced imaging procedure category are MRI, CT, PET, and nuclear studies. While certain specialties may not order many PET or nuclear studies, MRI and CT are staples in the diagnostic pathway and help determine care.

How does the law work?

The government is mandating that before any advanced imaging procedure is ordered, the ordering provider must consult an approved Clinical Decision Support Mechanism (CDSM). The CDSM will consider multiple factors on the patient and provide a recommendation as to whether or not the ordered procedure is appropriate or whether an alternative would be better.

At this point, providers have the choice to continue with the original order or to follow the CDSM recommendations. Information provided in the CDSM recommendation must be provided to the furnishing provider (imaging facility). The imaging facility must then include this information on the claim to the payer, and data on the choices made by the ordering provider will be stored in the CDSM for future auditing purposes.

Those who do their own in-house imaging will be impacted on the ordering and furnishing side. Your EHR, Radiology Information System (RIS), and claims management system will all need to be updated with new software to manage this.

We encourage you to speak with your EHR vendor to make the process of remaining compliant and meeting the requirements as seamless and minimally invasive as possible.

The Opioid Crisis

It’s not news that America is facing a crisis with opioids and narcotic abuse—public service announcements are running on every network; the president has declared it a health emergency; and an increasing number of Americans have had personal experiences with a family member or friend who has become addicted.

Laws have been put in place or are being considered at every level of the government to help address the problem. One approach to helping doctors continue to care for their legitimate patient requests while identifying drug seekers or “doctor shoppers” is the PDMP, or Prescription Drug Monitoring Program.state-of-market-041718-600px

1 Interstate Data Sharing: http://www.pdmpassist.org/pdf/Interstate_Data_Sharing_20170920.pdf
2 PDMP Hub-to-Hub Interoperability Updates: http://www.pdmpassist.org/pdf/Interstate_Data_Sharing_20170920.pdf
3 PMP Gateway: https://apprisshealth.com/solutions/pmp-gateway/

PDMPs are state-run databases containing patients’ prescription histories. PDMPs now exist in all states, and more than 40 states have laws making it mandatory to check the PDMP before prescribing a narcotic. Some states require documentation that the doctor not only checked the PDMP, but also counseled the patient. And some states are starting to identify doctors who prescribe high numbers of narcotics, and are putting programs in place to counsel those providers. The College of Healthcare Information Management Executives (CHIME), a branch of HIMSS, recently met and recommended that the Center for Medicare and Medicaid Services (CMS) include the use of Electronic Prescribing of Controlled Substances (EPCS) as part of the MIPS portion of the Quality Payment Program (QPP) in 2019. They also recommended that CMS and Office of the National Coordinator (ONC) focus on interoperability and removing the burden for clinicians.

Another method to help control the crisis is the use of EPCS. Unfortunately only 17 percent of physicians in the US are EPCS enabled. [1] While 90 percent of standard prescriptions are processed electronically, only 14 percent of controlled substance prescriptions are electronically delivered. [2]

Does your EHR offer PDMP connectivity? Does it allow for EPCS? The technology to automatically complete PDMP checking and documentation does exist—today—providing physicians with the option of making their prescribing and compliance workflows seamless. Providers who use EPCS with PDMP should automatically be presented with the patient’s prescription history any time they prescribe a narcotic. The system should also automatically connect to the state database, retrieve the history, display it to the physician, and record that the physician checked the PDMP. This can be up to a 67 percent time savings over the current process of logging into the PDMP directly. [3]

SRS has committed to joining the fight by being the first specialty EHR to offer PDMP checking and documentation integrated within the prescribing workflow. This is a great step in keeping our clients ahead of the curve.

What are you doing to address the opioid crisis?

 


Better Patient Reported Outcomes Lead to Better Outcomes

Outcomes is a hot topic in the healthcare industry. It is one of the criteria being used to define value-based reimbursement strategies and, more importantly, to drive better care for patients.

For some time now, payers and government agencies have been using traditional measures to evaluate outcomes, assessing the number of patients who were readmitted within 30 days, or how many post-surgical infections occurred. For the most part, this data was retrospectively analyzed; it was used to put process improvements into place, but it seldom took into account patients’ own opinions on how they were doing. Ultimately, how can we claim a successful outcome if the patient doesn’t subjectively experience an improvement in health and well-being?

outcomes-blog-v2Many EHRs provide some level of clinical decision support—reminding doctors of how long it has been since an osteoporosis patient’s last bone scan, or when it’s time to review an arthritis patient’s therapy and order blood tests for his or her medications. Some might put this in the category of outcomes, but to me, they are really alerts. Can they affect outcomes—of course! But do they really tell us how the patient is doing?

To change this paradigm, practices are moving toward collecting and measuring patient reported outcomes (PROs). The National Quality Forum defines PROs as, “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.” PROs provide data on what patients are able to do and how they feel by asking questions. They not only cover the clinical aspects of pain, swelling, and range of motion, they assess the patient’s reported status for physical, mental, and social well-being.

In orthopaedics, standardized surveys such as PROMIS, HOOS, and KOOS have been designed to collect patient-reported information before and after surgical procedures. This allows physicians to prospectively and retrospectively evaluate data provided by their patients.

Prospectively, the surveys can be used to determine the factors that will drive a better outcome for the patient. Using best practices standards, physicians can make a determination prior to taking action as to how successful the outcome will be. By discussing potential outcomes, lifestyle factors, and behavioral changes with the patient before surgery is scheduled, doctors can better predict the outcome and recommend the best path—all while controlling costs. For example, if a patient does not have reliable transportation to get to follow-up appointments and physical therapy, physicians might provide information on local transportation services or decide on inpatient versus outpatient rehab.

Retrospectively, if a patient reports unsatisfactory results, doctors can gauge the patient’s feedback against the original expectations of the treatment plan. It might be that the patient is meeting, or even surpassing, the predicted outcome. That little piece of information might change the patient’s outlook and get him or her back on the path to success. Alternately, doctors can determine what could have been done to either reach a better outcome, or develop a more accurate prediction. These learnings can be implemented as best practice to drive better outcomes for future patients.

PROs can also be used as a benchmarking tool, as a way to gauge success against others in the same practice or the same market.

Today, only 35% of orthopaedic practices are collecting outcomes data. Part of this is due to the complexity of managing the process—of collecting, analyzing, and making the data relevant. The most critical step is of course getting the patient to respond to surveys, but equally important is presenting that data in a way that orthopaedists can review it and share it with the patient at the point of care, during the appointment. This allows them to intervene quickly when a negative outcome is reported. Imagine a future when a patient reporting a pain level of 9, a knee that is red and swollen, and an inability to stand without assistance automatically triggers a message to your office to call and intervene. Not only can this save the patient an unnecessary trip to the emergency room, but it can potentially save the practice money if it is doing bundled payments.

At SRS, we believe that the process of collecting and acting on patient reported outcomes should be as automated as possible, and should all take place in the same system you work in, day in and day out—your EHR. That is why we have made this vision a reality with our integrated Outcomes solution.

Is Healthcare Hi-Tech Enough?

315x236-Devices-med-iconsThe answer to that question depends on what part of the healthcare continuum you look at. When it comes to the actual treatment of disease, few fields can compare with medicine in terms of developing and incorporating new technology. Think of cyber knives, genetically guided cancer therapies, complex new drugs for autoimmune diseases, and the way that surgery has become increasingly less invasive through its reliance on computer imaging and magnification for micro-, laparoscopic, and robot assisted surgery.

On the other hand, when it comes to the use of information technology, healthcare hasn’t been nearly as forward looking as, say, banking, or travel, or even the food industry. How often have you visited a highly respected doctor, located in state-of-the-art facilities, and had to spend half an hour filling out pages of badly xeroxed forms, asking redundant and often irrelevant questions about your personal health history? How often has a member of your doctor’s staff had to spend the time to call you to remind you of an appointment? How often have you wasted time trying to reach your doctor by phone to ask a simple question about your treatment?

Fortunately, the landscape is changing. The industry is starting to engage patients in new ways, using text messaging, video conferencing, and wearable devices to keep patients actively in the therapeutic loop rather than simply at the passive, receiving end. And it’s about time.

According to Pew research:

  • 88% of Americans use the Internet
  • 73% have broadband service at home
  • 95% of us carry a cell phone of some type
  • 62% of those have used their phone in the past year to look up information about a health condition.

Those numbers don’t surprise me. As I write this, I am sitting in O’Hare Airport and almost everyone in the departure lounge has a smart phone in his or her hand. Urban legend has it that people under 55 like to text while people over 60 prefer to make phone calls, but if O’Hare is any indication, the over-60 crowd is just as tech savvy as the younger generation. They’re checking the airline app—this happens to be a really bad travel day fraught with weather delays—so that they can text their families and friends with updates. In 2013, Exerpian Marketing found that adults over 55 send almost 500 text messages a month. I’m sure that number is much higher today.

So why not take advantage of this in your practice? Phones and texting allow you to engage with your patients in a whole new way. You can text them appointment reminders (my hair dresser has been doing it for years), let them know if your office is closed due to inclement weather, or notify them that it’s time to make an appointment to have their eyes checked.

Mobile devices can also be used as an electronic physician’s assistant, with apps to guide care and improve outcomes. Imagine if patients could log onto an app on their phones that reminded them of exercises they had to do that day, showed a video of how to do those exercises, recorded that the exercises had been done as well as the patient pain level and other progress indicators . . . and then automatically transmitted all of this information to the physician to become part of their charts. And that all this happened without the time and expense of the doctor’s staff having to make personal calls.

Even better, imagine that you, as the patient, could see your doctor without leaving your home or office. While video technology has been around for a long time, traditional physician practices have been slow to adopt teleservices. This is partly because state regulations and reimbursement policies have not encouraged it, outside of the few online physician services offering quick and relatively easy consults on a “pay now for service” basis. However, more and more states are passing legislation that allow doctors to establish provider-patient relationships through face-to-face interactive, two-way, real-time communication, or through store-and-forward technologies. In addition, some of the laws call out payment policies, and require that care provided via teleservices be billed the same as an in-office visit. I’d personally love it if my doctor adopted teleservices—it would save me the 30-minute drive to her office, the 10 minutes spent parking, the 20-minute delay because she is usually running late, and the 30-minute drive home. Instead, her office could text me when she’s ready and we could engage for 15 minutes via a telemedicine system. A lot better than the minimum 90+ minutes to do an in-person visit.

The final frontier is when healthcare manages to combine information technology with its existing drive for advanced treatment technology. One university research team is developing a tracking device that could be embedded in a pill; the device would activate when the patient took the medication, sending a message to a receiver app, which in turn would create a record for family members or physicians to review. This may initially sound a little too invasive, but think of the boon for families caring for an elder relative—they could verify that the correct meds were taken without having to hire an on-site care-giver or to make daily trips to ensure compliance.

What’s common to all these new technologies is that they recognize that the patient is at the center of the care team, and the information the patient provides must be incorporated into the therapeutic process in real time. The sooner we engage patients in their own care, the better outcomes we will all experience—and the technology that we are already using every day can help us get there. Is the healthcare you are providing hi-tech enough? What technology are you using now to advance your patient engagement?