HIT Perspectives – May 2023
Pharmacy Interoperability – The Next Frontier Advancing Patient Care
By Pooja Babbrah, Pharmacy & PBM Lead
Interoperability has been many things to many people and organizations over the years. Some think of it as a panacea for healthcare’s data-sharing ills. Others rely on it as a buzzword with which to fill their pitches, programs, and press releases. Still others, particularly those industry long-timers who’ve lived through the development, implementation, and use of first- and second-generation EHRs (electronic health records), know seamless data sharing among providers, patients, and payers continues to be a constantly evolving process, one helped along by those in government and the private sector who are doggedly determined to improve patient care through the elimination of those walled data gardens that once grew with abandon but are now slowly withering on the vine.
Within the past decade, regulatory frameworks like the 21st Century Cures Act have been developed to improve interoperability between provider EHRs and payer data-sharing capabilities. And while the state of interoperability has indeed evolved, there is still work to be done, particularly when it comes to looping in other members of the care team, such as pharmacists. These clinicians/frontline healthcare professionals have historically, for the most part, been left out of the interoperability conversation. There have been many regulatory actions advancing the use of pharmacy benefit standards, such as the passage of the HR6 Support Act and the most recent Notices of Proposed Rulemaking focused on moving to a newer version of the NCPDP (National Council for Prescription Drug Programs) SCRIPT standard and naming the NCPDP Real-time Prescription Benefit standard to advance data and patient cost transparency at the point of care, but there is still a lack of concerted effort to advance pharmacist clinical care and the interoperability needed to do so.
There is an expectation that these developments will inevitably speed up as patients continue to rely more heavily on their local pharmacies for expanded care services, especially in rural areas – a shift in frontline care made possible by the COVID-related public health emergency in early 2020. Pharmacists can now administer vaccines, offer point-of-care testing, monitor medications, and review therapy regimens – services they will continue to offer through the end of 2024 under the PREP (Public Readiness and Emergency Preparedness) Act.
Whether it be during the pandemic or today’s worsening healthcare staffing shortages, patients have come to rely on their local pharmacists for an increasing number of easily accessible healthcare services. And it’s no surprise, given that 90% of people in the United States live within five miles of a community pharmacy and visit those pharmacies a dozen times more often than their family doctors, according to research from Wolters Kluwer Health. That same research found that 61% of people believe pharmacies, retail clinics, or pharmacy clinics will provide the most primary care in the next five years. Just over half would trust a pharmacist to prescribe medications if it meant lower costs.
Patients … consumers … call them what you will, are on board with the idea of pharmacists being an integral part of their care team. To make that an operational reality, industry stakeholders must recognize that pharmacy interoperability is the next frontier in the world of healthcare access, use, and exchange.
The “Big Three” Retail Pharmacies Are Paving the Way
As the role of pharmacists has expanded, technology, for the most part, has kept pace. Even before the pandemic, pharmacists offered an easily accessible touchpoint for medication counseling and help with managing chronic conditions. The pandemic gave these clinicians increased responsibilities that came with technological upgrades, including vaccine appointment scheduling systems and other patient engagement capabilities. And as primary care practices and larger healthcare facilities scaled back in-person operations and ramped up virtual visits, the need for digital interactions with pharmacists increased, moving beyond ePrescribing and prescription data-monitoring programs to reveal the need for real-time pharmacy access to patient health histories, other provider notes, and care coordination alerts.
Amazon, CVS Health, and Walgreens (the latter two of which have a combined 20,000 locations across the country) have made their intentions to incorporate primary care with pharmacy services well known with high-profile acquisitions over the past several years. Amazon’s forays into patient care and pharmacy services are likely well known by industry insiders. Its $4 billion purchase of membership-based primary care provider One Medical, which uses a homegrown EHR and practice management system across its locations in 22 markets, combined with its online pharmacy service and relatively new clinic marketplace offering, make it a healthcare company almost akin to Kaiser, albeit with a heavy bent on virtual capabilities. Add in its Alexa/Echo-focused partnership with Teladoc Health and its interoperable capabilities – and the impact they could have on longitudinal patient care should the online retailer choose to connect with health information exchanges) and/or join/become QHINs (qualified health information networks) and other data-sharing organizations like CommonWell – are seemingly limitless.
CVS Health’s $11 billion acquisition of Medicare-focused, membership-based primary care provider Oak Street Health adds 169 locations to its roster of clinical facilities, which include MinuteClinics and Health Hubs. The retail pharmacy company will gain Oak Street’s proprietary Canopy clinical platform, which will no doubt interoperate at some point with CVS’ Epic system, installed across its 10,000-plus pharmacies and clinics. Epic, it should be noted, is one of six initial applicants approved by Office of National Coordinator for Health Information Technology (ONC) and Department of Health and Human Services as a QHIN under the Trusted Exchange Framework and Common Agreement.
Walgreens’ $5 billion investment in Village Medical, an athenahealth customer, will enable it to eventually co-locate 600 clinics alongside its retail pharmacies, making it the “first national pharmacy chain to offer full-service primary care practices with primary care physicians and pharmacists co-located at its stores all under one roof at a large scale.”
Combined, these three companies – should interoperable capabilities continue to evolve – have the ability to share, aggregate, and analyze patient health data on an unprecedented scale.
Community Pharmacies Aren’t Far Behind
Giant corporations aren’t the only entities interested in tighter integration of pharmacy and primary care. Many community pharmacists have seen the value-based writing on the wall and responded to this new, pandemic-induced level of patient interaction by moving beyond dispensing pills and counseling and shifting to a more value-based care approach. Pharmacies participating in the Flip the Pharmacy (FtP) practice transformation program, for example, are ahead of the curve when it comes to becoming more strategically embedded within care teams through new workflow technologies. Launched by the Community Pharmacy Foundation and the Community Pharmacy Enhanced Services Network, the program helps community pharmacies transform their care and business processes through two-year transformation projects modeled after similar Centers for Medicare and Medicaid Services programs for primary care. FtP ultimately aims to transform 1,000 community pharmacies into easily accessible, value-based care destinations focused on social determinants of health, opioid stewardship, immunizations, and other enhanced clinical services.
This transformation requires technological underpinnings that would be made more efficient by interoperable systems, such as those that could connect with those of the aforementioned “Big Three.” FtP Director of Practice Transformation Randy McDonough, PharmD, MS, BCGP, BCPS, FAPhA, noted as much in a recent FTP newsletter: There is a “need for pharmacists to become ‘interventionists,’ meaning that it is imperative that pharmacists identify and resolve medication-related problems and document their patient care activities. Documented interventions are the storylines behind patient outcomes. Without the interventions, the story is incomplete and the proof of our value within the healthcare system doubted. I say this because I have heard this repeated by multiple stakeholders, including payers, other providers, and even other pharmacists.”
Where better to document than in an interoperable, real-time patient health record that is shared by primary care doctors, health systems, payers, and social services organizations?
Pharmacy Interoperability Goes Beyond Technology
Bringing pharmacists into the interoperability fold of clinical care goes beyond go-lives and APIs (Application Programming Interfaces). Change management, governance structures, and cultural shifts are all part of the equation also. Team-based rather than proprietary care approaches must be embraced, in addition to modern technologies and workflows. North Dakota State Professor of Practice and Sanford Health Clinical Pharmacogenomics Clinical Program Director Natasha Petry, PharmD, MPH, BCACP, puts it this way: “It’s certainly a culture shift and there are potential difficulties with handoffs. It comes back to the sharing of information and knowing the whole story; and, historically, community pharmacists don’t have access to critical information … that might be in a siloed EHR.”
Reimbursement models must also flex to accommodate clinical services provided in a pharmacy setting. While pharmacists have increasingly gained the ability to be paid as providers for certain services, as seen during the pandemic, there are still inroads to be made. The National Association of Chain Drug Stores, for example, wants to establish a “reliable Medicare reimbursement pathway for pharmacy care services including vaccinations, testing, and therapeutics for COVID-19, flu, and other illnesses. Lack of this pathway today is generating real-world consequences – most notably, contributing to reduced access to life-saving therapeutics.”
Starting with Health Equity Strategies
Point-of-Care Partners (POCP) continues to work with payers to better understand the needs and opportunities for data exchange between payers and pharmacists, and the payment structures that accompany these evolving strategies. One area in which we have seen growing collaboration between payers and pharmacists is that of health equity strategies. As the number of family care physicians dwindles, particularly in rural areas, and the width of healthcare deserts grows, POCP has encouraged payers to integrate community pharmacies in rural areas into their health equity programs, which strive to increase care access for members in traditionally underserved and rural communities.
Payer efforts to better incorporate pharmacists into their care teams are happening in a community-based, grassroots fashion. In 2022, the Kentucky Association of Health Plans helped to launch pharmacist-directed colon cancer screenings. Kentucky Pharmacist Association Executive Director Benjamin Mudd, MD, told local news, “This is a part of a bigger picture to get more people screened, provide treatment, and reduce the number of patients who die from colon cancer. Pharmacists are uniquely positioned to touch those that may not have annual wellness visits. That is the population we are trying to catch.”
Payers have begun to see firsthand the valuable role pharmacists can play in ensuring patients are up to date on screenings and medications and identifying those in need of new medical devices and wearables, counseling patients on available social services, and taking advantage of other health plan benefits, including the evolving availability of digital therapeutics. Exchanging health equity data as part of these types of collaborations better enables both payers and pharmacists to realize the impact they have on care outcomes, costs, and quality. Interoperable systems are poised to make this health data exchange seamless and far less laborious, giving both parties more time to focus on more personal/timely member/patient interactions.
Policy and Standards Are Laying the Groundwork
As with all things related to interoperability, policy and standards are beginning to set healthcare stakeholders up for success in terms of onboarding pharmacists into interoperable care teams. It’s early days still for federal efforts, though national NCPDP data standards have supported real-time, bidirectional electronic exchange of data needed for prompt delivery and maintenance of safe and appropriate medication therapies for patients for some time now. NCPDP’s efforts have enabled a high level of interoperability among pharmacy entities, including pharmacies and pharmacists, drug benefit payers, and trading partners. Over time, use of NCPDP standards has been largely transactional. More recently, NCPDP standards have been developed and/or enhanced for exchange of some clinical as well as transactional data to support clinical decisions regarding prescribing and medication maintenance and adherence.
Work is also being done by the ONC, the Pharmacy HIT (Health Information Technology) Collaborative, the NCPDP, and other organizations to support payer, pharmacy, and provider data exchange and value-based agreements.
The ONC Health Information Technology Advisory Committee, for example, is beginning to look at ways in which standards can improve interoperability among pharmacy stakeholders for pharmacy-based clinical services and care coordination. HITAC’s initial efforts aim to:
- Identify critical standards and data needs for pharmacists and pharmacy stakeholders’ participation in emergency use interventions.
- Recommend ways to better integrate pharmacy systems and data for public health surveillance, reporting, and public health interventions.
- Identify standards needed to support prescribing and management of emerging therapies, including specialty medications, digital therapeutics, and gene therapies.
- Identify policy and technology needs and considerations for direct-to-consumer online prescribers.
Already identified challenges include information blocking, resistance to accommodating and incorporating Fast Healthcare Interoperability Resources (FHIR), non-standardized terminologies and value sets among codes already in use, limitations with the USCDI (United States Core Data for Interoperability) medication data class, and lack of enthusiasm around prioritizing EHR integration requests.
Federal efforts have also focused on highlighting the importance of integrating data found in the Pharmacist eCare Plan (developed and released in 2015 by NCPDP and HL7 (Health Level 7)) with data from EHRs and payer systems. The PeCP standard is used by thousands of pharmacies to document care using a standard language and format built on SNOMED and FHIR, both of which are widely accepted and already leveraged by other healthcare players for data exchange.
As POCP Regulatory Resource Center Lead and Senior Consultant Kim Boyd mentioned in a recent POCP blog, “Pharmacy system vendors must be able to translate current and emerging NCPDP standards to interact and be consumable within APIs and FHIR APIs, assuring consumption by EHRs and payer systems.” Movement in the pharmacy interoperability space at the state level has been happening for some time now. Most, if not all, states now have some form of Pharmacist Collaborative Practice Agreement in place. These are formal agreements in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform certain care functions. Nearly 20 states have even more robust agreements in place, giving pharmacists expanded care capabilities.
Payers Are Poised to Ensure Success
With so many different stakeholders already inching toward better incorporation of pharmacy into their care teams and technological workflows, the future of pharmacy interoperability is just around the corner. As OmniSYS Chief Pharmacy Officer David Pope recently told Drug Store News, “Success looks like purpose-built, pharmacy-first solutions, interoperability with disparate data sources, technology-facilitated new-provider relationships, and, above all, in-pharmacist workflow.”
Pope’s definition of pharmacy interoperability success may seem a bit pie-in-the-sky now, given the speed at which healthcare embraces change. However, if patients visiting the country’s nearly 30,000 pharmacies have their way, stakeholders will have to adapt and adopt pharmacy-friendly software and strategies. Members and patients “vote with their feet,” meaning they will inevitably patronize pharmacies and providers that offer easily accessible and affordable care of high quality. Those that don’t meet patients where they are – and aren’t able to share patient data with neighboring providers within the community – will soon find their patient panels dwindling. Payers have a key role to play in ensuring that their members and partners are firmly supported by interoperability developments. As Pope also stressed, “Payers are buying into pharmacists as providers, into retail pharmacy as the front door of healthcare. The time to get your technology platforms in place is now.”
If you need help understanding the current interoperability landscape or support in establishing a pharmacy component of your interoperability roadmap, contact email@example.com or firstname.lastname@example.org to set up time to discuss your needs and how POCP might be able to help.