Epic Systems Corporation (Madison, WI) develops integrated inpatient, ambulatory, and payor information systems for large healthcare organizations, academic medical centers, and children’s healthcare systems. Epic provides the information backbone for many of the largest, most progressive healthcare organizations in the United States. All Epic applications incorporate the safety net of embedded clinical and financial decision support throughout the care continuum, helping organizations transform clinical care, streamline patient access, and manage revenue cycles.
We have provided customers with the ability to send ambulatory medication orders in electronic format to pharmacies since 1995. We have also implemented electronic refill authorization functionality throughout our applications. Based on these experiences, we offer the following observations.
Our customers which use e-prescribing functionality are usually organizations with their own pharmacies. Under these circumstances, e-prescribing is simply an interface added to the CPOE functionality in our systems. This improves patient safety in that drug interaction checking and other decision support is part of the process, the electronic transfer eliminates the possibilities of misreading the prescription, and clinically relevant information is shared between the pharmacy and EMR. In order to achieve these benefits, the interfaces we built had to have a shared format, with the capability to send the required information, and shared nomenclature.
The format we have used for sending of prescription information, receiving the dispense information, and handling of refill requests/authorizations is HL7 (spanning versions 2.2 through 2.5). This format satisfies the requirements outlined above - it has the ability to send detailed drug information, detailed patient information, detailed insurance information, and important clinical information like an allergy list. Historically, the HL7 format for pharmacy related data interchange has its roots in hospital settings, but it has evolved much beyond that and recent versions of the standard contain comprehensive set of messages able to handle the complexities of ambulatory settings and commercial pharmacies.
An additional advantage with using HL7 as the format for pharmacy data exchange is that it is an international standard, adopted in many countries in Europe, Canada, Japan, Australia, and others.
Our experience had the advantage of one organization controlling the nomenclature (provider identifiers, medication codes, etc.) This significantly contributed to the success of the implementations. When expanding to cases including commercial pharmacies, the following key areas need to be addressed:
We would like to note that NDC codes also play an important role in the communications between the pharmacy and the physician’s system. When sending the prescription information to the pharmacy the specificity of NDC codes is usually not needed, however, when the pharmacy sends the dispense information back to the physician’s system this specificity becomes useful, as it conveys the exact form, brand, packaging, etc., of the medication dispensed to the patient.
It is our hope that the observations presented here are found useful by the Commission. We believe that e-prescribing should not be considered in isolation and separate from ambulatory CPOE. It is important to choose standards that provide the capabilities outlined above so that the full benefits of e-prescribing can be achieved. It is also important to consider the overall infrastructure that can enable the communications between physician offices and retail pharmacies.