MGMA partnered with Surescripts for a recent discussion on what’s changing in the technology behind medication reconciliation. The conversation, moderated by Daniel Williams, Sr. Editor and host of the MGMA Insights podcast, featured two experts from Surescripts – Andrew Borgschulte, principal product marketing manager, and Rachel Petersen, manager of product innovation, medication history and PDMP.
This interview has been lightly edited and condensed.
Williams: In today’s modern age of med rec, what do you mean at Surescripts when you say your medication history is “comprehensive?”
Petersen: Comprehensive, in our terms, means complete. So, all of the medications for that patient that you’re seeing in your office, all of the elements of the medication record that really support clinical decision-making: the name of the prescriber, their phone number, the pharmacy, where it was filled, the pharmacy’s phone number and any piece of data that’s going to help do that reconciliation.
Comprehensive data is really important, because it ensures that the therapy decisions made by your providers are made knowing those potential drug interactions but also the behaviors that the patient may exhibit, to really help ensure that the patients are getting that therapeutic benefit from the medication. These are really important elements in medical reconciliation.
Williams: Can you give us an example of a gap that might exist in medication history?
Borgschulte: If an organization isn’t using electronic med history, or if they’re using an electronic med history solution that isn’t truly comprehensive, they really might not be aware of some medications that a patient is taking outside of their four walls. Additionally, where we see a large gap is often those that were picked up from the pharmacy and paid with cash. Unfortunately, a lot of providers still rely on claims data, which can be a bit outdated and, by its nature, does not account for cash pay. This could be a significant portion of some maintenance meds. Pharmacies are starting to expand generic cash pay programs. Also, there are a lot of couponing programs and apps out there now in the world where it may make more sense for a patient – at least on their initial pickup dose – to pay cash. Having that blind spot could unfortunately be a big issue that could lead to an adverse drug event, or an area that that particular provider doesn’t have visibility into the full list of medications that the patient who’s in front of them either is on or has been taking recently.
Williams: When you get into the generics, what does that mean?
Borgschulte: A lot of these are maintenance medications, and these large pharmacies are offering these $4 generics. Because of that low cost, in a lot of cases, it’s either cheaper than the copay or, for some patients, not worth the hassle of worrying about getting their insurance card out and making sure they’re covered. So, again, if the claims data doesn’t exist or if that insurance claim in never made, then for providers who don’t have this comprehensive medication history solution, they just simply won’t see that data. Now, if they prescribe it themselves, that’s a different story.
But, as we know, patients are seeking care at more and more places, or disparate care. The common phrase now is that patients are hyper-mobile. But if you don’t need a referral, any of us can go sign up to see a specialist or check into something, a random ache or pain. Your primary care provider may not have visibility into those visits and into the medications that are prescribed. If any of these patients are on risk-based contracts or under some other value-based care agreement, it’s really crucial to have an understanding of what meds the patient is on and if they’re adhering properly.
Williams: We saw the distribution of vaccines everywhere, from pharmacies all the way to stadiums. But when we think about prescriptions, we see those in different places now. A lot of the groceries have pharmacies. When you’re talking about comprehensive medication history information, is all of this being distributed? Do you see this as helpful to the patients? Is it making it easier also with the providers? Is it filling some of those gaps there?
Borgschulte: One key thing when we say comprehensive is that Surescripts has direct relationships with pharmacy and PBM partners to power that medication history. Those relationships through our network alliance are what enable us to work on behalf of those that are doing the med history reconciliation or taking the med history for a new patient or patient data they haven’t seen in a while … the claims or insurance data but also the pharmacy fill data. That pharmacy fill data is almost always richer, so it includes the SIG, which are the patient instructions – take once daily, etc. It will often include the pharmacy name, the prescriber name. That’s really crucial to get your arms around all of that data.
Hear the entire interview with Petersen and Borgschulte in this episode of the MGMA Insights podcast:
Williams: Can you define dispensed medications and elaborate a little more on that?
Petersen: A dispensed medication is the actual record from the pharmacy or the claim that the patient has the medication in hand. It’s different than an e-prescription, because any prescription may be abandoned at the pharmacy, or the patient may choose not to pick it up. Dispensed medication means the patient actually has access and has paid for it, brought it home, has it in their medicine cabinet.
Williams: How are the data management and technology tools that Surescripts uses making medication history data easier to work with? How do they make it cleaner and more accurate for those providers and patients?
Petersen: While comprehensive data is important, making sure that it is clean is also critical. If you are filling a prescription at a pharmacy with your insurance, oftentimes there will be two records that are returned with the medication history. We are prioritizing improvements on our side to really create clean, non-duplicated records that are complete. Where possible, we are augmenting the records with information like the pharmacy’s phone number. If that record doesn’t contain it, we will add it from our scripts directory. Additionally, we are looking for other opportunities to add clinical intelligence. We’re looking for ways that we can improve the quality of those fields (pharmacy dataset) but also add structured elements to enable our EHR partners to automate more of the reconciliation process. We’re really looking to remove those barriers that can create and add time to the med rec, especially with the shift that’s happened over the last 15 months.
Williams: One term that caught my eye was clinical intelligence. Do you do any formal surveys or anecdotal information with nurses or providers to figure out what their pain points might be, so that data can be as comprehensive, clean and accurate as it needs to be?
Petersen: We receive feedback in several ways. First, we do an annual survey to understand the pain points and areas of medical reconciliation that aren’t working. We feed that information into our prioritization – where should we invest to ensure that the data is the most clean and usable? We also observe medication reconciliation in the wild, so to speak. We can get a lot of information from watching a patient and the nurse interact and go through their medication lists. What questions come up? What are the next steps that a nurse needs to take? And how can we inform those records so that the data is there in the first place? We’re looking to bring some of that knowledge from the clinical side to create standards that help us provide innovation that really preserves clinical intent.
Williams: Are there aspects around the timing and availability of data that helps providers and staff when reviewing medication history? Are there certain KPIs, metrics or other data you’re mining to make sure things are accurate?
Borgschulte: It’s crucial that our providers, EHR partners, their end clients, our health systems and everyone involved have access to the data at the right time. In most cases, that would be at the point of care … so that they can evaluate that med list right when the patient is there. This really turns the conversation about what medications the patient is on from an investigation into a validation. The other side is more of the standards and quality. We work extremely closely with the NCPDP, who sets the standards for how these things are displayed and what particular fields and elements need to be included. We are trying to lead the innovation to find that balance between complete and comprehensive data, but again, making it manageable and digestible.
There are over 200 fields in med history. Of course, every provider is not scanning all 200 of those fields. Depending on their EHR setup, they may not even have access to view those. It’s kind of what goes on behind the scenes to ensure that it’s accurate.
Williams: What have you seen happening differently over the last 15 years in this field? What’s better now?
Borgschulte: One thing we’ve seen in at least the last two to three years is the expectation is no longer just delivering the data where it’s supposed to be, securely, etc. Those are table stakes. What we’re really seeing now from our partners and clients is a desire for that next level of innovation. How can we make this data better, smarter, more digestible, more usable for those at the point of care? How can we reduce the administrative burden? How can we continue to keep the patient as our north star, meaning give our providers the time and energy needed to focus on the patient and not the technology? We provide what we like to call actionable intelligence, rather than just, ‘Hey, here’s a big spreadsheet. You figure it out.’ That doesn’t help anyone.”
Williams: What aspects of medication history and the reconciliation processes can make or break its effectiveness? What do workflows look like today? How do you continue to ratchet them up to make them more and more efficient?
Petersen: Workflow is really referring to how the provider interacts with data in general, within their EHR. You might have the best, cleanest, most comprehensive data. But if a doctor has to go to a website and break out of their flow to go and access that data and can’t be brought back into the patient’s record, it’s not very valuable. We are focused on ensuring that we’re bringing innovation and medication reconciliation data directly within the EHR, so that as the provider is stepping through their normal process for seeing a patient, the data’s just integrated, and it doesn’t feel like a break or pause or slow them down. The time to complete med rec, the analysis, switching back and forth between multiple screens really does contribute to burnout. Frankly, when you’re in front of the patient doing that, it can feel tense. What we’re trying to do is get the data in the hands of the clinicians that really need it – but in a way that doesn’t create extra time to do so.
Borgschulte: Transitions of care is the most common spot for data loss. Someone’s discharged from the hospital. Now what? Where does that data go? How does it get pulled in? How does it make its way to the next stop, whether that is post-acute care, a primary care provider visit, rehabilitation, whatever it might be? With the proliferation of specialties and subspecialties, there’s a lot of stops on that journey. If every member of the care team along the way has the most accurate and comprehensive data about the patient’s medication, it prevents things like adverse drug events and prevents duplicate prescriptions.
What it can do is potentially uncover things. One of our clients had a patient come in, and they couldn’t figure out why he was having issues with bleeding. There was nothing indicated in his chart that would show why that would be the case. And they pulled up our medication history and found from another provider that wasn’t in the records that this patient was prescribed a blood thinner. Well, that’s the missing puzzle piece, and that helped them to redirect the patient’s therapy. This is not trivial information; this is information that drives the course of treatment.
Williams: Where do we go from here? Are the major med history innovations already done, or are there new capabilities that will continue to improve the efficacy and outcomes of the med rec process?
Petersen: If 2020 has taught us anything, it’s that innovation is always happening. We have certainly invested a lot in the “what” for medications and medication reconciliation – what medications are a patient on? Which pharmacy did they fill at? While that’s really important, and it’s certainly critical for making that medication therapy decision, the next frontier I see as being the “why.” Why was the patient prescribed this new medication? If you are coming into a new doctor, “why” is something that’s often missing. Why are you on this blood thinner? Why are you taking that medication? Figuring out how to combine the data with that thinking and the reasoning is going to be really critical.
We’re looking at diagnosis and how we can combine diagnosis with the medication. We’re looking at how we can support cancellations. A patient may report that they’re not taking that medication anymore. If it’s been formally canceled by a provider, we want to include that and why it was canceled. That reasoning for why medication therapy changes is really the gap I see now.
This interview has been lightly edited and condensed.
Williams: In today’s modern age of med rec, what do you mean at Surescripts when you say your medication history is “comprehensive?”
Petersen: Comprehensive, in our terms, means complete. So, all of the medications for that patient that you’re seeing in your office, all of the elements of the medication record that really support clinical decision-making: the name of the prescriber, their phone number, the pharmacy, where it was filled, the pharmacy’s phone number and any piece of data that’s going to help do that reconciliation.
Comprehensive data is really important, because it ensures that the therapy decisions made by your providers are made knowing those potential drug interactions but also the behaviors that the patient may exhibit, to really help ensure that the patients are getting that therapeutic benefit from the medication. These are really important elements in medical reconciliation.
Williams: Can you give us an example of a gap that might exist in medication history?
Borgschulte: If an organization isn’t using electronic med history, or if they’re using an electronic med history solution that isn’t truly comprehensive, they really might not be aware of some medications that a patient is taking outside of their four walls. Additionally, where we see a large gap is often those that were picked up from the pharmacy and paid with cash. Unfortunately, a lot of providers still rely on claims data, which can be a bit outdated and, by its nature, does not account for cash pay. This could be a significant portion of some maintenance meds. Pharmacies are starting to expand generic cash pay programs. Also, there are a lot of couponing programs and apps out there now in the world where it may make more sense for a patient – at least on their initial pickup dose – to pay cash. Having that blind spot could unfortunately be a big issue that could lead to an adverse drug event, or an area that that particular provider doesn’t have visibility into the full list of medications that the patient who’s in front of them either is on or has been taking recently.
Williams: When you get into the generics, what does that mean?
Borgschulte: A lot of these are maintenance medications, and these large pharmacies are offering these $4 generics. Because of that low cost, in a lot of cases, it’s either cheaper than the copay or, for some patients, not worth the hassle of worrying about getting their insurance card out and making sure they’re covered. So, again, if the claims data doesn’t exist or if that insurance claim in never made, then for providers who don’t have this comprehensive medication history solution, they just simply won’t see that data. Now, if they prescribe it themselves, that’s a different story.
But, as we know, patients are seeking care at more and more places, or disparate care. The common phrase now is that patients are hyper-mobile. But if you don’t need a referral, any of us can go sign up to see a specialist or check into something, a random ache or pain. Your primary care provider may not have visibility into those visits and into the medications that are prescribed. If any of these patients are on risk-based contracts or under some other value-based care agreement, it’s really crucial to have an understanding of what meds the patient is on and if they’re adhering properly.
Williams: We saw the distribution of vaccines everywhere, from pharmacies all the way to stadiums. But when we think about prescriptions, we see those in different places now. A lot of the groceries have pharmacies. When you’re talking about comprehensive medication history information, is all of this being distributed? Do you see this as helpful to the patients? Is it making it easier also with the providers? Is it filling some of those gaps there?
Borgschulte: One key thing when we say comprehensive is that Surescripts has direct relationships with pharmacy and PBM partners to power that medication history. Those relationships through our network alliance are what enable us to work on behalf of those that are doing the med history reconciliation or taking the med history for a new patient or patient data they haven’t seen in a while … the claims or insurance data but also the pharmacy fill data. That pharmacy fill data is almost always richer, so it includes the SIG, which are the patient instructions – take once daily, etc. It will often include the pharmacy name, the prescriber name. That’s really crucial to get your arms around all of that data.
Hear the entire interview with Petersen and Borgschulte in this episode of the MGMA Insights podcast:
Williams: Can you define dispensed medications and elaborate a little more on that?
Petersen: A dispensed medication is the actual record from the pharmacy or the claim that the patient has the medication in hand. It’s different than an e-prescription, because any prescription may be abandoned at the pharmacy, or the patient may choose not to pick it up. Dispensed medication means the patient actually has access and has paid for it, brought it home, has it in their medicine cabinet.
Williams: How are the data management and technology tools that Surescripts uses making medication history data easier to work with? How do they make it cleaner and more accurate for those providers and patients?
Petersen: While comprehensive data is important, making sure that it is clean is also critical. If you are filling a prescription at a pharmacy with your insurance, oftentimes there will be two records that are returned with the medication history. We are prioritizing improvements on our side to really create clean, non-duplicated records that are complete. Where possible, we are augmenting the records with information like the pharmacy’s phone number. If that record doesn’t contain it, we will add it from our scripts directory. Additionally, we are looking for other opportunities to add clinical intelligence. We’re looking for ways that we can improve the quality of those fields (pharmacy dataset) but also add structured elements to enable our EHR partners to automate more of the reconciliation process. We’re really looking to remove those barriers that can create and add time to the med rec, especially with the shift that’s happened over the last 15 months.
Williams: One term that caught my eye was clinical intelligence. Do you do any formal surveys or anecdotal information with nurses or providers to figure out what their pain points might be, so that data can be as comprehensive, clean and accurate as it needs to be?
Petersen: We receive feedback in several ways. First, we do an annual survey to understand the pain points and areas of medical reconciliation that aren’t working. We feed that information into our prioritization – where should we invest to ensure that the data is the most clean and usable? We also observe medication reconciliation in the wild, so to speak. We can get a lot of information from watching a patient and the nurse interact and go through their medication lists. What questions come up? What are the next steps that a nurse needs to take? And how can we inform those records so that the data is there in the first place? We’re looking to bring some of that knowledge from the clinical side to create standards that help us provide innovation that really preserves clinical intent.
Williams: Are there aspects around the timing and availability of data that helps providers and staff when reviewing medication history? Are there certain KPIs, metrics or other data you’re mining to make sure things are accurate?
Borgschulte: It’s crucial that our providers, EHR partners, their end clients, our health systems and everyone involved have access to the data at the right time. In most cases, that would be at the point of care … so that they can evaluate that med list right when the patient is there. This really turns the conversation about what medications the patient is on from an investigation into a validation. The other side is more of the standards and quality. We work extremely closely with the NCPDP, who sets the standards for how these things are displayed and what particular fields and elements need to be included. We are trying to lead the innovation to find that balance between complete and comprehensive data, but again, making it manageable and digestible.
There are over 200 fields in med history. Of course, every provider is not scanning all 200 of those fields. Depending on their EHR setup, they may not even have access to view those. It’s kind of what goes on behind the scenes to ensure that it’s accurate.
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Williams: What have you seen happening differently over the last 15 years in this field? What’s better now?
Borgschulte: One thing we’ve seen in at least the last two to three years is the expectation is no longer just delivering the data where it’s supposed to be, securely, etc. Those are table stakes. What we’re really seeing now from our partners and clients is a desire for that next level of innovation. How can we make this data better, smarter, more digestible, more usable for those at the point of care? How can we reduce the administrative burden? How can we continue to keep the patient as our north star, meaning give our providers the time and energy needed to focus on the patient and not the technology? We provide what we like to call actionable intelligence, rather than just, ‘Hey, here’s a big spreadsheet. You figure it out.’ That doesn’t help anyone.”
Williams: What aspects of medication history and the reconciliation processes can make or break its effectiveness? What do workflows look like today? How do you continue to ratchet them up to make them more and more efficient?
Petersen: Workflow is really referring to how the provider interacts with data in general, within their EHR. You might have the best, cleanest, most comprehensive data. But if a doctor has to go to a website and break out of their flow to go and access that data and can’t be brought back into the patient’s record, it’s not very valuable. We are focused on ensuring that we’re bringing innovation and medication reconciliation data directly within the EHR, so that as the provider is stepping through their normal process for seeing a patient, the data’s just integrated, and it doesn’t feel like a break or pause or slow them down. The time to complete med rec, the analysis, switching back and forth between multiple screens really does contribute to burnout. Frankly, when you’re in front of the patient doing that, it can feel tense. What we’re trying to do is get the data in the hands of the clinicians that really need it – but in a way that doesn’t create extra time to do so.
Borgschulte: Transitions of care is the most common spot for data loss. Someone’s discharged from the hospital. Now what? Where does that data go? How does it get pulled in? How does it make its way to the next stop, whether that is post-acute care, a primary care provider visit, rehabilitation, whatever it might be? With the proliferation of specialties and subspecialties, there’s a lot of stops on that journey. If every member of the care team along the way has the most accurate and comprehensive data about the patient’s medication, it prevents things like adverse drug events and prevents duplicate prescriptions.
What it can do is potentially uncover things. One of our clients had a patient come in, and they couldn’t figure out why he was having issues with bleeding. There was nothing indicated in his chart that would show why that would be the case. And they pulled up our medication history and found from another provider that wasn’t in the records that this patient was prescribed a blood thinner. Well, that’s the missing puzzle piece, and that helped them to redirect the patient’s therapy. This is not trivial information; this is information that drives the course of treatment.
Williams: Where do we go from here? Are the major med history innovations already done, or are there new capabilities that will continue to improve the efficacy and outcomes of the med rec process?
Petersen: If 2020 has taught us anything, it’s that innovation is always happening. We have certainly invested a lot in the “what” for medications and medication reconciliation – what medications are a patient on? Which pharmacy did they fill at? While that’s really important, and it’s certainly critical for making that medication therapy decision, the next frontier I see as being the “why.” Why was the patient prescribed this new medication? If you are coming into a new doctor, “why” is something that’s often missing. Why are you on this blood thinner? Why are you taking that medication? Figuring out how to combine the data with that thinking and the reasoning is going to be really critical.
We’re looking at diagnosis and how we can combine diagnosis with the medication. We’re looking at how we can support cancellations. A patient may report that they’re not taking that medication anymore. If it’s been formally canceled by a provider, we want to include that and why it was canceled. That reasoning for why medication therapy changes is really the gap I see now.
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