einteract /eprescribing What you need to know and do. einteract Learning Objectives 1. Understand the issues, regulations and impacts facing hospital and LTPAC facilities regarding rehospitalizations 2. Understand the INTERACT and it s electronica cousin, einteract program, including the clinical and educational tools and strategies for use in everyday practice in LTPAC facilities 3. Understand the impact of the new eprescribing rules for NY and how they affect workflow for LTC facilities. 1
The Problem Readmissions In 2011, nearly 25% of Medicare recipients were hospitalized within 30 days of discharge... 90% classified as unplanned Annual Cost $14.3 BILLION OIG Report, November 2013, Daniel R Levinson, Medicare Nursing Home Resident Hospitalization Rates Merit additional Monitoring 2
Hospitalization Statistics Close to 1 in 4 people admitted to a SNF from a hospital are readmitted within 30 days Approx. 60% of potentially preventable hospitalizations involved individuals age 65+ About 40% of hospitalizations for dually eligible Medicare/Medicaid beneficiaries were for conditions that could be managed at lower levels of care One chronic illness 7x more likely Four or more chronic illness 99x more likely These nursing home resident hospitalizations cost Medicare an average of $11,255, which was 33.2 percent above the average cost ($8,447) of hospitalizations for all Medicare residents. Maslow & Ouslander, 2012 Factors Influencing Decisions Medicare reimbursement policies Patient and family preferences Legal liability and regulatory sanctions Lack of advance directives for Palliative Care or Hospice Emergency Department time pressures Availability of trained staff Availability of Lab and Pharmacy services Maslow & Ouslander, 2012 3
Impact on Residents Disruption in continuity of care and care giver Emotional and physical trauma of transfer Hospital acquired conditions Delirium Polypharmacy Infections Falls Immobility and deconditioning Pressure ulcers Other issues Maslow & Ouslander, 2012 Impact on LTPAC Providers Potential loss of referral sources/marketshare Increased workload associated with discharge and readmissions Decreased revenue Increased legal liability Regulatory sanctions Future financial incentives and penalties (2018) 4
Introduction to INTERACT INTERACT INTERACT (Interventions to Reduce Acute Care Transfers), is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in care facilities. INTERACT uses a standardized, evidence based set of tools to promote timely assessments, appropriate and timely communication to practitioners and the communication tools to make sure the right information is conveyed to practitioners to prevent transfer and hospitals in the event the resident is transferred. 5
Overview Program was developed with support of CMS and The Commonwealth Fund Input from a wide variety of health professionals The INTERACT program is the intellectual property of Florida Atlantic University Results Average cost to implement was $7,700 Facilities that participated reduced rates by 17% Those that implemented more components reduced rates by 24% Projected savings for Medicare Part A were approximately $125,000 per year Ouslander et al 2011 6
Goals for Inclusion in HIT Ensure compliance of program and tools Eliminate duplication of static information Increase access to all resident information Proactively address issues and concerns Reduce time spent on manual tasks Higher likelihood of success of the program Introduction to einteract 7
What is einteract? Joint initiative between Florida Atlantic University s INTERACT project team and PointClickCare What is einteract? Industry s first and only software design effort to embed the updated INTERACT process and tools directly into an EHR framework 8
What is einteract? Not an adaptation or integration of paperbased templates einteract einteract is the industry s first initiative designed to reduce unnecessary hospital readmissions by bringing the significant quality improvements of the INTERACT program to Electronic Health Record (EHR) software platforms. The same evidence based tool set used in INTERACT is streamlined, automatic and seamlessly integrated within the EHR. 9
Objectives of einteract Improve quality of care Proactively address resident issues and concerns Gain workflow efficiencies Eliminate duplication of work Improve adherence to program and tools Increase access to all resident information Higher likelihood of success of the INTERACT program einteract Medication Reconciliation Tools Medication Reconciliation is the process of verifying resident medication lists at a point of care transition, to identify which medications have been added, discontinued, or changed relative to pre admission medication lists Facility from home Hospital from Facility Facility From Hospital Critical to successful discharge transition Most studies included in a 2012 systematic review showed that medication reconciliation was associated with a decrease in actual and potential adverse drug events The first step is having an accurate medication list at hospital discharge, which depends on the following: Having an accurate pre admission medication list. Having an accurate list of medications being taken by the resident at the time of discharge. Having knowledge of what medication changes were made during hospitalization and the reasons for the changes. 10
einteract Advanced Care Planning Tools Physicians must communicate with residents and families about advance directives, but all staff need to be able to communicate about goals of care, preferences, and end of life care Advance Directives such as a Durable Power of Attorney for Health Care document, Living Will, and POLST and other similar directives Plans for care when a sudden, life threatening condition is diagnosed such as a stroke, heart attack, pneumonia, or cancer Plans for care when a resident s health is gradually deteriorating such as progression of Alzheimer s disease or other dementia; weight loss without an obvious medical cause; and worsening of congestive heart failure, kidney failure, or chronic lung disease Considering a palliative or comfort care plan or enrolling in a hospice program Completed and attached to the record and automatically transferred to receiving facilities in transitions of care. einteract Early Warning Tools STOPANDWATCH alerts through POC leveraging the bedside worker to provide timely notice of changes in condition through kiosk or app Known that the earlier we can identify symptoms of change, the more likely we can manage in the home OR transfer when the transfer is necessary CNAs play the most important role in this aspect if the program 11
Early Warning Tool Seems different than usual Talks or communicates less Overall needs more help Pain New or Worsening; Participated less in activities Ate less No bowel movement in 3 days; or diarrhea Drank less Weight change Agitated or nervous more than usual Tired, weak confused or drowsy Change in skin color or condition Help with walking, transferring, toileting more than usual einteract Decision Support Tools einteract Change in Condition Evaluation embedded form which automates data collection by auto populating data from the EHR. The change in condition form will have the greatest impact on streamlining and program success as it is the combination of the tool set most poorly used within INTERACT SBAR, Care Paths and Change in Condition cards. Dynamic form assessment changes as data is entered in the form prompting for the right data elements to be collected so that nothing is missed. Completion of the form creates the appropriate Progress Note automatically. Provides both change in condition alerts as well as notifications directing immediate notification of physician or appropriate suggestions to manage the client in house. 12
einteract Communication Tools einteract NH to Hospital Transfer Form also tied to census management so that transfers and discharges initiate the form so it doesn t get missed. EHR autopopulation reduces time it takes to complete and can be sent through Integration (HIE, ACO) or direct messaging. CCD or continuity of care document captures a 92 day summary of the residents documented care on discharge or transfer to acute which can also be sent electronically with the above form. einteract Quality Improvement Tools einteract Hospital Transfers Rate Tracker tied to census activity so that it isn t additional data capture but is automatically captured with each ADT to/from acute care. einteract Quality Improvement Worksheet for Review of Acute Care Transfers allows the analytical review of a specific transfer in order to determine where process improvement can occur personally at the resident level and identify trends that require attention at the corporation/facility level einteract QI Analysis of Acute Care Transfers automates data collection and review by aggregating and displaying data captured in the worksheet and presenting it in graphs for trending and further analysis. 13
Key Benefits Save Time & Money Eliminate multiple systems and/or paper charts; no need for multiple disparate solutions; reduces time spent on manual tasks; no additional software or training costs for separate system Ensure Compliance Embeds INTERACT protocols directly within the workflow of the EHR; ensures compliance with INTERACT tools and protocols; higher likelihood of success through sustainable usage in core EHR Resident Safety Instant access to INTERACT information with rest of the resident charge for entire care team; proactively address issues and concerns with automated alerts in real time Key Takeaways Adopt a program now Determine your baseline and gaps Leverage HIT tools where possible Monitor for results and adjust Communicate results 14
eprescribing What is eprescribing? An electronic prescription is: Created, recorded, transmitted or stored by electronic means; Issued and validated with the prescriber s electronic signature; Electronically encrypted to prevent unauthorized access, alteration or use of the prescription; and, Transmitted electronically directly from the prescriber to a pharmacy or pharmacist. 15
What is eprescribing? Two sets of regs: The DEA regulations (as stated in the final rule 21 CFR 1311) The state board of pharmacy regulations for the state in which they practice DEA manages certifications for eprescribing of Controlled Substances through EPCS (Electronic Prescriptions for Controlled Substances) docket No. DEA 218, RIN 1117 AA61. Benefits of eprescribing Reduced medication errors Reduced call volume for clarification orders A more complete prescription history in the medical record longitudinal record Improved service times real time prescription transfer to pharmacy Improved medication safety Reduced pharmacy call backs No need to stock state specific eprescribing paper 16
What will change with eprescribing? Prescription will no longer be valid if: Printed directly from the EHR It is a paper version signed by the prescriber Manually faxed to the pharmacy Electronically faxed to the pharmacy from within an EHR It is called into pharmacy by prescriber It is a telephone order created and only signed by the nurse for dispense. Key eprescribing Dates November 1 st, 2014 Required all electronic medication information exchange to meet the NCPDP standard. Until that time, HL7 has been the standard in LTC March 27 th, 2015 All electronic prescriptions (Controlled and non controlled) must be electronically signed and sent to pharmacy by the practitioner before being dispensed by the pharmacy 17
NCPDP National Council for Prescription Drug Programs Accredited standard for the exchange of information related to medication supplies, and services within the healthcare system Includes all necessary information to dispense the electronic prescription Meets the CMS eprescribing rules for Med Part D Affects prescribers, pharmacies, LTC Facilities, EHR and Pharmacy software vendors, intermediaries NCPDP The following transactions need to be in NCPDP to be valid: New Prescription Change of Prescription Prescription Cancellation New supply Fill status notifications Med history exchange Only Exception may use HL7 if facility and pharmacy are part of the same entity 18
Workflow Changes for LTC Currently, between 80 90% of all orders are phoned in by Prescriber, entered by the nurse and sent to pharmacy, either by fax or through an integration. Orders were usually signed after the dispense Orders for Controlled substances were both entered by the nurse and signed on paper by physician and sent to the pharmacy As of March 27 th, the prescriber must approve the order and send that order to the pharmacy Current Practice.. Nurse receives medication order Dispensed info sent to emar Medication delivered to the facility Nurse enters in EHR Pharmacy Dispenses the Medication Nurse Administers Medication to the Resident Controlled Substances Dr Additionally writes and signs prescription which is sent to pharmacy Order sent to pharmacy Prescriber or attending signs off uncontrolled orders within 48 hours 19
Future Workflow.. Nurse receives medication order Dispensed info sent to emar Medication delivered to the facility Nurse enters in EHR Pharmacy Dispenses the Medication Nurse Administers Medication to the Resident Prescriber Approves Medication Order in the EHR (Controlled requires 2 factor) Prescription sent electronically to pharmacy NY State Exceptions to Workflow The following list describes the only exceptions to the new workflow: 1. System down so can t electronically add an order 2. When eprescribing creates impracticality for the patient can t get the prescription in a timely manner and delay could be detrimental to patient 3. Dispensed medication is from Out of State Pharmacy 4. Prescriber has a waiver 20
Waivers Time limited If granted they have a 1 year limit from the requirement to electronically prescribe Proven Circumstances Economic hardship Technological limitations outside of the control of the practitioner Granted to Physicians and NOT Facilities What You Should be Doing. Make sure your vendor is working to meet the standard and timelines established and is working towards EPCS certification before March 27, 2015 Register with NY BNE EPCS, once the vendor is certified. Understand how your workflows will need to change policy and procedure changes Educate staff Have the right equipment on hand i.e. access to EHR to write/approve orders, tokens for controlled substances for practitioners Capturing the right Practitioner Information DEA/NPI in the EHR/CPOE software 21
Questions & Answers Contact Information Jayne Warwick, RN, HBScN Solutions Specialist www.pointclickcare.com Jayne.w@pointclickcare.com Twitter: @nerd_e_nurse 800.277.5889 einteract Resources Maslow, K., & Ouslander, MD, J. G. (2012). Measurement of potentially preventable hospitalizations. Prepared for the Long Term Quality Alliance. Washington, DC: Long Term Quality Alliance. Wyman, PhD, J. F., & Hassard, MD, W. R. (2012). Preventing avoidable hospitalizations of nursing home residents: a multipronged approach to a perennial problem. Journal of the American Geriatrics Society (58), 760 761. Centers for Medicare and Medicaid Services. (2012, April 24). Readsmissions Reduction Program. Retrieved July 31, 2012, from Centers for Medicare and Medicaid Services: http://cms.gov/medicare/medicare Fee for Service Payment/AcuteInpatientPPS/Readmissions Reduction Program.html/ Hospital based medication reconciliation practices: a systematic review. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL Arch Intern Med. 2012;172(14):1057. Florida Atlantic University. (2011, February 07). INTERACT II Home. Retrieved July 31, 2012, from INTERACT Interventions to Reduce Acute Care Transfers: interact2.net/index.aspx Ouslander et al, (2011). Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project. Journal of The American Geriatrics Society, 59, 745 753. Handler, MD, PhD, CMD, S. M., Sharkey, MBA, S. S., Hudak, RN, MS, S., & Ouslander, MD, J. G. (2011). Incorporating INTERACT II Clinical Decision Support Tools into Nursing Home Health Information Technology. Annals of Long Term Care: Clinical Care and Aging, 19 (11), 23 26. 22
eprescribing Resources New York's e prescribing mandate: Are prescribers and pharmacies ready? Cohen, Laurie T, Lane, Brooke A, September 11, 2014 http://www.nixonpeabody.com/nys_practitioners_electronic_prescription_mandate National Council for Prescription Drug Programs (NCPDP): Industry lnformation and Resources. http://www.ncpdp.org/resources/eprescribing Centers for Medicare and Medicaid Services (CMS): eprescribing and lts lmportance. http://www.cms.gov/medicare/ehealth/eprescribing/index.htmi DEA lnterim Final Rule for EPCS http://www.deadiversion.usdoj.gov/ecomm/erx Imprivata: A Planning Guide for Electronic Prescriptions for Controlled Substances (EPCS) http://www.imprivata.com/sites/default/files/resource files/epcs Whitepaper.pdf New York EPCS Regulations http://www. health.ny.gov/regulations/recently adopted/docs/2013 02 13 electronic_prescribing_dispensing_and_record_keeping_of_controlled_substances.pdf New York DOH EPCS FAQ http://www.health.ny.qov/professionals/narcotic/electronic_prescribing/docs/epcs_faqs.pdf New York Practitioner EPCS Registration http://www.health.ny.gov/forms/doh 5121.Pdf 23