Worth the Work, E-prescribing Will Have the Most Value for LTC Patients

May 13th, 2013 by Rod Baird

Is it worth the effort to create an e-prescribing system for long-term care (LTC)?

After 13 years of LTC physician practice management, I can say unequivocally that e-prescribing will diminish the occurrence of life-threatening, serious and moderately complex medication problems. This observation is backed up by multiple case studies.

Arguably, e-prescribing should show its greatest per patient value in LTC.  Because You’re dealing with a patient population that’s incredibly frail, often disoriented, and on 10-15 prescriptions. Statistical studies demonstrate that the probability of medication errors/interactions is almost 100% with this number of medications.


So where are we in regards to e-prescribing for LTC, and what additional steps are needed?

In my last blog, I pointed out that the federal government had proposed that when the LTC industry does start to e-prescribe, it must follow a new standard. That standard is identified as NCPDP 10.6 (National Council of Prescription Drug Programs).

Earlier this year NCPDP members and staff recognized a need beyond the  standard; that is to actually define a workflow specifically for e-prescribing in LTC.

E-prescribing in the physician’s office is a long-standing practice. The workflow is simple and relatively straightforward; orders go directly from the physician’s office to the pharmacy. When the first LTC e-prescribing models were built, the office based model was used as the base case. This ignored the regulatory requirement that affects most LTC facilities – they are the custodians of the official record and all of the orders have to be in their medical record – whether it’s paper or electronic. That means the initial communication has to occur between the physician and the facility nursing staff. Nothing prevents the order from going to the pharmacy simultaneously, but you can’t ignore the facility.

So that means you don’t just have the provider and the pharmacy involved. The LTC pharmacy – which almost universally is separate from the LTC facility – must be included, too.

You can see how with LTC, you’ll have a multiplicity of different workflows, depending on where the medication order is first entered. If software developers create order entry and send them to different locations, they need to have a roadmap showing how orders flow among the physician, the LTC facility and the pharmacy.

In LTC, you could have multiple workflows for managing any patient’s drug list, including:

  • A discharge med list from the hospital physician sent to the nursing home
  • The LTC physician making on-site rounds
  • An LTC nurse initiated phone call to an office based physician, or call center
  • Verbal orders created by the physician during a telephone call from the nurse
  • Physicians managing patients in adult care homes with no nursing staff

The NCPDP LTPAC e-prescribing task force came up with a set of models that describes the various methods of prescribing in LTC – and then five possible permutations of the electronic order entry system.

The group is building a visual model of the particular workflow cases. there are potentially three different electronic record-keeping systems that should be speaking to each other.

The system developers have to understand which one of these business models they’re working in and what communication standard is appropriate.

This is all part of a work in process. And it’s being revised and plowed through by a number of people who are intimately involved with this, trying to define what these different tasks are.

It’s still a long way to being a perfected model, but at least now we have a conversation among physician groups, the LTC pharmacy providers, as well as, their electronic providers.

The November 2013 adoption date for this standard is published in a draft notice as part of the 2013 Medicare Physicians’ Fee Schedule. If this date holds up, my work group’s efforts will continue to try to define the set of recommended protocols that people are actually going to use when they communicate.

Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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