ADVANCES IN PHARMACEUTICAL

PRACTICESNic Smith PharmDSmith Pharmacy

● E-Prescribing

● Innovative and Alternative Approaches to Affordable Medications

My Basic Info

• Reside in Freedom with wife Nikki and four girls (Marlee 8, Jovie 6, Luci 4 & Ro 1)

• Graduated from Freedom High School (1998) and University of Wisconsin-Madison with PharmD (2004)

• Pharmacist/Pharmacy Manager for Wal-Mart (2004-2013)

• Pharmacist for Omro Pharmacy (2010-2013)

• Pharmacy Preceptor for Concordia & UW-Madison (2006-current)

• Smith Pharmacy, an entirely independent pharmacy, established December 2013• Voted by Consumers the Post Crescent “Pharmacy of the Year” 2014-2015

Why does CMS push for E-Prescribing ?

• Incentive program 2009-2013 • Payment adjustments for prescribers who do not meet

qualifications

• Critical in the success of Electronic Health Records

E-Scribing- How does it come through on the pharmacy side?

• Simple analogy - similar to email in many aspects• Always a traceable footprint

• Most pharmacy systems have it wait in a “queue”• Links to patients in pharmacy database based on % match

• Links to prescribers in pharmacy database based on % match

• Watch for duplicates (ex: William Smith or Bill Smith, Dr. J. Bob Smith or Dr. Bob Smith, John Van Camp or John Vancamp)

E-Scribing Costs• Prescriber

• E-Prescription stand-alone system cost about $2,500/prescriber (studies show minimal benefits without integration)

• Integrated EHR systems cost $25,000-$45,000/prescriber

• EHR systems provide maximum benefits and reduce errors

• Typically one-time cost

• Subsidies are available

• No per claim fee on prescribing end

• Pharmacy• Start-up fees are minimal

• Averaged $0.215 per transmission in 2010, latest study estimates $0.36/claim

• Some argue that e-scripts can actually save pharmacy money, due to being less labor-intensive

Benefits of Electronic Prescribing

• Studies show significantly lower chance of errors (as compared to hand-written scripts) and increased adherence with first fill

• Decreased wait times

• Real-time DUR/screening review (dosings, interactions, cautions, etc)

• Formulary alerts • Still in infancy stages

• Reduces lag time with prior authorizations (PA’s)

• Increases cost efficiency

Benefits of Electronic Prescriptions (cont.)

• Reduces the reliance of paper charting

• Pre-populated data on rx’s very useful (examples: patient- address, allergies, insurance , etc. prescriber- address, DEA (controls), fax, NPI, phone, etc )• This data is often missing (or limited) from all other prescription sources

• Prescriber can write rx’s anywhere within secure wireless networks

• Reduces fraudulent rx’s with two-factor authentication and direct transmission• Patient fraud

• Pharmacy fraud

• Prescriber and prescriber office fraud

Controlled Meds and E-Scribing

• E-scribing of CII–CV’s were legalized federally on June 1, 2010

• E-scribing of CII–CV’s were legalized in Wisconsin since March 28, 2012

• Locally, controlled medications prescribed via e-scribing has become common practice just w/in the past 6 months

• Two factor authentication (for prescribers) must contain at least 2 of the following:• Something you know (a knowledge factor)

• Something you have (a hard token stored separately from the computer being accessed). The hard token, if used, must be a cryptographic device or a one-time-password device that meets Federal Information Processing Standard 140-2 Security Level 1

• Something you are (biometrics such as a fingerprint or eyescan)

Controlled Medications (cont)• Anyone can fill out the information for a controlled substance (such as patient name, drug, strength, quantity,

etc), but the prescriber MUST review and sign • “Signing” consists of: written / faxed must be in their own handwriting … or electronic signatures must use 2 point authentication

• All controls must always be quantifiable • example: “take one tablet as needed for anxiety” is not allowed… A corrected version could state “take one tablet every 8 hours

as needed for anxiety.” The latter example can thus justify a maximum of 3 tablets/day

• Schedule III-V prescriptions have max of 5 refills and expire in 6 months from date written

• Schedule II prescriptions (expire 60 days from date written)• Can NEVER surpass a 90 day supply

• Multiple Rx’s can be given to patient, as long as:

• Totaled quantity of all rx’s does not surpass 90 days

• example- John Doe was prescribed Adderall at his Nov. 6th appointment. He could be legally given three prescriptions of 30 days each (keep in mind the 60 day expiration)

• Date written is correct (post-dating is strictly forbidden). Future prescriptions must state the earliest date that the rx can be filled

• Pharmacy can partial fill a CII only if they do not have enough in stock. Balance must be given within 72 hours or it is voided.

Controlled Medications- CII(please note that hospice prescriptions and emergency prescriptions for schedule II prescriptions have different regulations than

below)

• Schedule II (CII) prescriptions

• Can NEVER surpass a 90 day supply

• Multiple CII prescriptions for same medication can be given to patient, as long as:

• Date written is correct (post-dating is strictly forbidden). Future prescriptions must also state the earliest date that the rx can be filled

• Totaled quantity of all rx’s does not surpass 90 days

• example- John Doe was prescribed Adderall at his Nov. 6th appointment. He could be legally given three prescriptions of 30 days each (keep in mind the 60 day expiration) . Due to situation described below, often advised to a max of two monthly prescriptions/time (if given in advance)

• Adderall 20mg tablets 1 tablet po BID #60 tablets (written 11/6/2015, filled 11/6/2015)

• Adderall 20mg tablets 1 tablet po BID . Fill on or after 12/6/15 #60 tablets (written 11/6/2015, filled 12/6/15)

• Adderall 20mg tablets 1 tablet po BID . Fill on or after 1/5/15 #60 tablets (written 11/6/2015, filled 1/5/15)

• Note- John Doe’s 3rd rx expires 1/5/15 (60 days from write date of 11/6/15).. thus the compliant patient has a very small window to get the 3rd rx filled

• Pharmacy can partial fill a CII only if they do not have enough in stock. Balance must be given w/in 72 hours or it is voided (= new rx)

Top 10 E-Scribing Pitfalls/Issues

• #1 Clicking Errors

• #2 Wrong Dosage Form

• #3 Transmission Issues

• #4 Communication Gaps

• #5 Old Notes Still on Rx

• #6 Wrong Quantities / Vague Quantities

• #7 Lack of Detail (Insurance Audits)

• #8 Controlled Substance Issues

• #9 DAW / Diagnosis Codes

• #10 Compounds (Customization Limited)

Downfalls to E-Scribing#1. “Clicking Errors”

• Wrong Patient• “Smith, Nichole” instead of “Smith, Nicholas”

• Wrong Drug or Drug Form• “Tramadol 50mg” is very close in the drop-down list to “Trazodone 50mg”

• Salt forms• Doxycycline: hyclate / monohydrate

• Metoprolol: tartrate / succinate

• Fluticasone nasal spray: furoate (Veramyst®) /propionate (Flonase®)

• Release Format (more details with these errors handout)

• Metformin 500mg or Metformin 500mg taber24h

• These poor abbreviations have dramatically improved by electronic software companies last few years

• Error reporting systems have helped (PEER PORTAL & ISMP)

Downfalls to E-Scribing#1. “Clicking Errors” (cont)

• Non-Existent Drug

• OTC drugs notorious (ex. zinc oxide cream 17.9% ??? )

• Multiple option drug listing; just generic ingredients listed (ex. Prenatal vitamins, oral contraceptives, etc)

• Wrong Sig / Dosing

• “tsp” or “tbsp” is a three-fold difference in dosing

• To reduce risks of errors such as these, put INDICATION in directions for use

• Trazodone 50mg take 1 tablet po q HS prn for insomnia …

• Tramadol 50mg take 1 tablet po q 6 hours prn pain (right knee pain)…

• Recent example: Jane Doe Hydralazine 25mg tablet take one tablet po q 6 hours prn itching

• We called prescriber and confirmed that this was intended to be “hydroxyzine 25mg” and not hydralazine. We had this issue fixed before the patient came to the pharmacy. If the prescriber simply did not put the indication on the rx, this would have raised little/no flags until consulting with patient – which could have resulted in dangerous hypotension

Downfalls to E-Scribing#2. “Wrong Dosage Form”

• This is the 2nd most common error/issue with e-scribing• Examples of these errors occur daily

• Many difficult to explain medications (some examples below and in handout)• Depakote DR (delayed release, twice daily typically) is different than Depakote ER

(extended release, once daily)

• Bupropion HCl (TID) vs bupropion SR (12 hour) vs bupropion XL (24 hour)

• Treatment dosings (careful to not underdose/overdose): nitrofurantoin macrocrystals/monohydrate 100mg BID and nitrofurantoin macrocrystals 100mg is dosed QID

• Timolol ophthalmic solution is dosed BID and timolol ophthalmic gel solution (XE) is dosed QD

Downfalls to E-Scribing#3. “Transmission Issues”

• Sending patient prescription to the wrong pharmacy• VERY COMMON ISSUE, 1 in 25 rx’s sent to wrong pharmacy (Source: Electronic prescription

errors in ambulatory pharmacy. J Manag Care Pharm 2011;9:71)

• “Batching” of prescriptions• Send rx’s after every appointment ideal (as compared to waiting to lunch to send several

patients at once)

• Server delay issues and server downtime possibility

• Duplications • Pharmacy might fax and e-request

• Patient requests and pharmacy request

Downfalls to E-Scribing#4. “Communication Gap”

• Scenario- John Smith comes in for yearly checkup. All 8 of his medications are renewed and e-scribed to pharmacy with refills to get to next scheduled annual appointment.• Pharmacy fills all medications. After 10 days, pharmacy goes through and calls patients to remind them that they have

medications at pharmacy. John tells pharmacy technician, “I don’t need any of my meds…. I told the nurse that at my appointment.”

• Scenario- Barb Smith is seen at Urgent Care for uncomplicated urinary tract infection. • Pharmacy receives a rx for “MacroBid 100mg po BID x 7 days #14 capsules ”

• 5 minutes later, pharmacy receives a rx for “SMZ/TMP 800/160mg take one tablet po BID x 3 days #6 tablets”

• Upon questioning Barb, pharmacy calls to confirm which medication is intended. Prescriber explains that MacroBid was cancelled due to concerns over her kidney function.

• Although neither of the above scenarios would be considered extreme, these are common situations that occur daily at pharmacies.

• Solution- please indicate in notes (or sig) any valuable information to relay to pharmacy• Using above examples, simply placing the statement “medications not needed at this time- hold until patient requests” or

“please cancel MacroBid rx, replaced by Bactrim due to kidney function concerns” would save time and effort on both sides.

Downfalls to E-Scribing#5. “Old Notes Still on Rx”

• Often overlooked• Can lead to two different set of directions

• Example- Rx for Ron Wolff Venlafaxine ER 75mg capsules 2 po BID #360

Notes from e-script state “take one capsule daily for 5 days, one capsule BID x 5 days, one capsule AM & 2 capsules PM x 5 days, then go to 2 capsules BID.” Upon looking at John’s profile, it is noted he has been on venlafaxine ER 75mg capsules 2 po BID for almost 2 years

Downfalls to E-Scribing#6. “Wrong Quantities and/or Vague Quantities”

• This is the most common error in e-scribing

• Common with items that are not tablets or capsules

• Pharmacies often put in difficult situation• Understand prescriber’s intent

• Need to clarify to meet insurance and/or legal requirements

• Often required to “quantify” a prescription

Downfalls to E-Scribing#6. “Wrong Quantities and/or Vague

Quantities” (cont)

• Common examples• Eye drops/Ear drops with multiple sizes (“1 each” or “1 bottle”)

• Creams / Ointments with multiple sizes (“1 each” or “1 tube”)

• Nebulizer treatments and inhalers (ea, mL or vials)

• Scenario: Aaron Rogers

Restasis® opth soln instill one drop in each eye BID qtty: 3 month supply

manufacturer states to “not reuse vials” thus resulting in 180 vials (6 x 30 vial boxes), although common practice to reuse vials w/in 24 hours thus giving patient a 6 month supply

Downfalls to E-Scribing#7. “Lack of Detail”

• This is becoming more of an issue with increasing costs of medications and increased scrutiny of insurance audits• Due to tremendous increases in opthalmic, otic and topical rx’s during the last 5

years, insurances audit pharmacies regularly on “easy target and expensive drugs”

• All prescriptions need to be quantifiable. “Use as directed” as sole directions should never be used.

• If written for “1 bottle” or “1 tube” – it is required to use smallest package size per insurance requirements. If a larger sized product is needed, please indicate a specified quantity

• Most drops typically contain 15-20 drops/mL

• Topical creams, gels, ointments, etc – helpful to state area of use if possible. (See Caremark Topical Usage

Downfalls to E-Scribing#8. “Controlled Substance Issues”

• Duplicates possible

• Send CII prescription to wrong pharmacy• Can’t be “transferred”

• E-Script is unique to that pharmacy

• Must be either “voided and resent” or filled at pharmacy where sent

Downfalls to E-Scribing#9. “DAW and Diagnosis Codes”

• DAW is selected in error often

• DAW-1= “Prescribing prescriber specifies the branded version of a drug on the hard copy prescription (or in the orally communicated instructions.”• If a branded drug (or a specified brand of a generic) is required / requested:

• Notify in sig or directions helps in clarification

• Examples) Brand name: “Synthroid Medically Necessary. Do Not Substitute.”

Specified manufacturer of a generic drug: “Taro Lamotrigine Medically Necessary- Do Not Substitute.”

Downfalls to E-Scribing#10. “Compounds”

• “How do we enter this compound?” This is our most common question with electronic prescriptions. Many aspects are system-specific.• Some systems allow for manual entry (but often these “drop out” after a specified

time period).

• Commercial drugs often picked as the agent, but notes / directions state alternatives

• Example: Ted Thompson Triamcinolone 0.1% cream Apply to affected areas on torso BID qtty: 1 pound jar (454 grams)

notes: mix 50:50 with Aquaphor

• Not ideal

• Typically best to fax rx or call rx into pharmacy

INNOVATIVE APPROACHES TO AFFORDABILITY

ALTERNATIVE OPTIONS

Innovative Approaches??

• The number of uninsured adults on decline since 2012

• The number of underinsured has risen during this time *• High deductible plans have been on the rise annually, resulting in higher

patient cost share

• Many customers forced to avoid or delay needed healthcare

• Decreased medication compliance directly correlated with costs of medications

*Collins, Rasmussen, Doty et al., Too High a Price, 2014.

Innovative Approaches- Where do patients go for help with their prescriptions?

• Financial assistance• WI Medicaid ( https://www.dhs.wisconsin.gov/contacts.htm )

• Disability / Medicare ( https://medicare.gov ) (https://www.ssa.gov )

• Various county / state programs

• What if you don’t qualify?

Innovative Approaches- Where do patients go for help?

• Brand Name Drugs (= Coupons or Manufacturer Assistance Programs)

• www.needymeds.org – Excellent & well maintained website for brand name drug assistance• Coupons can be VERY VALUABLE and often can be combined with commercial insurance (Medicare plans very

limited usage)

• Click on “Patient Savings” and “Brand Name Drugs”

• Links to both coupons and applications to qualify for obtaining med for little/no cost from manufacturer

• Generic Drugs (= Discount Cards)

• Careful with web searches- remember, the ONLY source that will help you pay for part of your brand name prescription is the manufacturer. There are thousands of misleading coupons / discount programs online – most have little/no value• Discount cards- thousands available – some promote large savings such as “save 75% on average”

• Discount cards typically profit from pharmacy transaction fees and/or selling personal information

• GoodRx- gives ballpark pricing idea for a consumer.. Prices not always accurate for many pharmacies!!

• Reputable discount card, but typically discount cards can’t be used with insurance

Alternative Ideas to Help Our Patients Afford Their Medications

• Many, many ideas & options. Sometimes need to “think outside the box”• Often ask yourself, “is a compliant patient with medication x

better off than a non-compliant patient on medication y?”

• Typically done on behalf of a patient request

• Some medications obviously not worth the risk

Alternative Ideas to Help Our Patients Afford Their Medications (cont.)

• Splitting tablets

• Look into insurance options• Different Medicare Part D plans. Often times pharmacies or patients can find their out of pocket estimates

amongst all available plans during open enrollment time.

• Wisconsin Senior Care (costs only $30 per individual per year)• Every Wisconsin citizen that is 65 years old qualifies. Income determines deductible / spend-down amounts (amount to pay before

insurance kicks in)

• Underutilized insurance that can be used alone or in combination with a Medicare D plan.

• Does have a very restrictive formulary

• Great option for patients of lower income that have expensive medications (can help dramatically if patient hits the donuthole)

• Price shop different pharmacies (especially for generics) - HUGE DIFFERENCES can exist on many meds

• Brand name drugs-- Does patient qualify for assistance through the manufacturer?? Are any manufacturer coupons available? Note: Medicare = not eligible usually

Alternative Ideas to Help Our Patients Afford Their Medications (cont.)

• Alternative form available?• Compounding? Many times alternatives can be made that are both

individualized and more affordable

• Miscellaneous• Only reasonable insulin option comes from Wal-Mart (Relion brand-

Novolin NPH & Novolin R … around $28/vial).

• Methotrexate- tablets are very expensive (often $60-$150/month, depending on dose). Injectable solution (preservative free) can be mixed orally for about $7-15/month.

Alternative Ideas to Help Our Patients Afford Their Medications (cont.)

• Miscellaneous• Vancomycin oral capsule (C. Difficile treatment) costs often $250-500/treatment. Since

vancomycin has no oral absorption, many prescribers opt to have the IV powder of vancomycin reconstituted and consumed orally by a compounding pharmacy (often $50-100/treatment using IV for reconstitution)

• Others- often take older proven ingredient(s) and reformulate and/or market a beneficial side effect of a particular drug. Hundreds of examples currently in marketplace.

• The patent-owning pharmaceutical company does perform beneficial studies with drugs at substantial costs on their behalf

• EXAMPLES- Intuniv® (guanfacine ER), Kapvay® (clonidine ER), Mirvaso® topical gel (brimonidine), Qualaquin® (quinine sulfate), Qsymia® (topiramate ER and phentermine), Quillivant XR® (liquid ER methylphenidate), Zyban® (bupropion SR)

QUESTIONS

• Thank you for this opportunity !!

Nic Smith, PharmD

Smith Pharmacy