• JANUARY 2008 FEATURE ARTICLES •
Health Plans and Technology
Take Me To The Pilot
A pilot project from Mississippi Medicaid gives providers handheld access to beneficiary medication information saving millions of dollars.
By E. Victor Brown, Senior Editor
While the promise of health information technology is to improve and simplify our lives, it is usually only through its transparency-of-use coupled with its ability to work in the ways that humans think, that the promise can be fulfilled. When the state of Mississippi's Division of Medicaid began to look at e-prescribing as a clear way to move the ' physicians and their Medicaid patients towards that promise, the organization's intent was to do so for those both at the beginning and further down the path of health IT adoption.
Over the last two years, Mississippi Medicaid has been conducting a pilot project whereby 225 of the ' physicians with the greatest number of Medicaid beneficiaries have moved to e-prescribing via PDA. The project is intended to provide point-of-care access to critical drug information, interaction screening tools, current medication histories, preferred drug lists and clinical decision support tools affecting thousands of beneficiaries. To date, the project has not only increased patient safety, reduced prescriptions and saved millions of dollars but also meets the organization's primary goal of improved health for beneficiaries.
The Concept
For any such project to take flight, it must have internal champions willing to learn from successful examples, create innovative approaches and build internal and external support. Phyllis Williams—deputy administrator of health services for the division of Medicaid in Mississippi—has been with Medicaid for 19 years, 17 of which have been spent on the health services side of Medicaid. It was she and Pharmacy Director Judy Clark who began the project at a time of great change for the state and the region. "At the time that we started this, I was the acting deputy and Haley Barbour had just come into the governor's office," says Williams. "It was really just Judy and I working together who initially sold the idea to our executive director who gave us the go-ahead to make it happen."
The concept of the project was to put a wireless patient care solution with 100 days worth of pharmacy claims of each physician's Medicaid patients in the hands of the ' busiest Medicaid prescribers via a hand-held device. This would allow physicians to not only facilitate electronic prescribing but also allow them to see if patients weren't getting prescriptions filled, eliminate duplication and abuse as well as adverse drug/drug interactions.
According to Williams, it was the summer of 2004 when she and Clark began looking at various programs to help prescribers make better decisions. "In the course of looking at this, Judy learned about Informed Decision's eMPOWERx software that would allow our agency to not only combine clinical info and indications but also combine it with our up-and-coming preferred drug list and our claims history," explains Williams.
Having witnessed and then made contact with Florida Medicaid regarding their pilot program (Florida Medicaid attributed a savings of more than $26 million to their program in 2006), the two began mapping out a plan specific to Mississippi's needs. While Florida's program rolled out in urban areas of the state, Williams and Clark had a broader scope in mind. "For total buy-in we would have to reach prescribers from the northern and southern part of the state rather than just one geographical area," says Clark.
The organization had to start at the northern part of the state and go south rather than the other way around due to Hurricane Katrina wiping out half the ' infrastructure. Ultimately, Mississippi Medicaid would find a partner in Informed Decisions towards a long-term solution to disaster preparedness communications (See sidebar).
Challenges To Progress
After further research of potential vendors, only Informed Decisions had the current capability of providing Mississippi Medicaid with support on the device itself. They also had a relationship with a wireless carrier in the state that gave them the broadest coverage, as well as the Web and database support critical to success. "We ultimately chose Informed Decisions' eMPOWERx software due to the fact that they could put everything together as well as letting physicians know if mandated state benefit limits had been met with a patient," says Clark.
As a governmental organization, the biggest challenge for Mississippi Medicaid would be the ' procurement rules, which demand that state funded contracts go through a competitive process. Fortunately, the rules also state that a vendor with a unique one-of-a-kind product and service that meets the stated needs can trump the competitive clause.
To fund the program, Williams and Clark looked to the Mississippi Academy of Family Physicians Foundation, which provided the project with $250,000 in grant funds. "This allowed us to start the program even without direct state funding because we could match that through our normal federal matching rate, giving us a $500,000 program that could be funded for two years through December 2007," says Williams.
Trial Participants
In order to identify potential trial participants, Mississippi Medicaid ran a report to identify the top prescribers while simultaneously determining the wireless carrier and potential areas without service. Top prescribers located in areas without service, were removed from the list. With the project coming on the heels of Hurricane Katrina, wireless coverage was less than ideal in the lower half of the state. "We identified the top 500 prescribers and rather than give out multiple devices to doctors in the same practice, we wanted to spread it out more, so that we were covering all areas of the state with the trial numbers," explains Williams.
One of those physicians based in a more urban and technology-heavy scenario was Michael O'Dell, M.D., family medicine residency director and QC officer at North Mississippi Medical Center (NMMC), the primary care center of the much larger North Mississippi Health System (NMHS). The 650-bed NMMC is the largest hospital in Mississippi and the largest non-metropolitan hospital in America. The Level II trauma center serves more than 650,000 people in 22 counties in north Mississippi, northwest Alabama and portions of Tennessee. NMMC has been designated the most wired hospital for the past seven years with the entire NMHS enterprise on a single unified IT system.
O'Dell's offices on the NMMC campus are a residency training program for family physicians with seven faculty positions, 20 residents-in-training and a staff of 15. "In our clinic operations we have over 450,000 patients in our database and 11,000 of them just in my clinic," says O'Dell. "Thirty-two percent of all of NMHS' patients are Medicaid, so the ability to track them is an enormous undertaking unless you have some sort of computerized automation ability."
The project's importance to physicians without EMRs cannot be understated as it provides them with the first component of health IT infrastructure towards an eventual wired health organization. Another physician that is part of the project is Kurt Bruckmeier, M.D., who cares for approximately 200 Medicaid beneficiaries through Hattiesburg, Miss.-based Pacific Physicians Services. "I've been a Medicaid provider since I've been in private practice which has been 21 years," says Bruckmeier. "Prior to getting this system, the patient or the pharmacy would call for medication refills and my nurse would have to stop what she was doing or call back, so it considerably slowed down the nurse's workflow."
Rollout and Training
Once the vendor had provided the wireless specifications, Williams and Clark included them in the RFP. They then purchased the Siemens cellular phones that would be used in the project from Cingular Wireless, the carrier that met the network specifications. In an unrelated but highly beneficial turn of events, Cingular invested more than $85 million in Mississippi on network improvements in late 2005. The next step was rollout of the prepared phones by an Informed Decisions subcontractor who went to each of the physicians' offices to install the software on office PCs as well as train them on the device. The trainer showed them how to download the patient info, access all of the features and use the device. Due to Katrina, the process wasn't completed until February 2006.
The whole process of installation and training took less than an hour for all project participants. According to O'Dell, he was also serving on the Medicaid pharmacy and therapeutics committee while a faculty colleague served on the Medicaid drug utilization committee. "Both of us began using the hand-held device fairly quickly as we knew that we would be getting questions from our peers," says O'Dell.
In Practice
The process of prescribing with the device is a simple one of just selecting the patient, then the pharmacy and electronically sending the prescription. Prescribers can log onto the system via the hand-held unit from anywhere but also have the option of using an office PC with the software. Physicians without an EMR or EHR can print out a paper form when the device is docked and enter the info in the patients' charts. The same information is available online to those prescribers without a hand-held device.
"Although the system came preloaded with my full Medicaid patient roster, which includes their demographics and prescriptions from me and other physicians, this platform is not just for Medicaid patients because we can load any patient into the system," says Bruckmeier.
One year after putting the wireless patient care program into the hands of its providers, Mississippi Medicaid has realized a savings in prescription drug costs of more than $1.2 million per month. An estimated savings of approximately $922,000 was realized in hospital costs during 2006 from the system's "high" and "very high" drug interaction alerts. An estimated savings of more than $14.4 million was realized in 2006 due to the ability to prescribe fewer and less costly medications. Prescribers using the system write 20 percent fewer prescriptions than prescribers who do not, due to increased knowledge of duplications in therapy and fraud. This system also meets the guidelines of the new CMS tamper-resistant initiative.
According to Williams, the next challenge towards greater rollout of the solution in Mississippi is covering the rural parts of the state with no access to the wireless network and devising a way for physicians utilizing their own PDA devices to incorporate this software and system access via a Web portal. Ultimately, Williams, Clark and Mississippi Medicaid in general are ready and willing to do what they can to improve patient care for both physicians and patients. "Rather than being viewed as just a claims payment agency that sets restrictions and limits, Medicaid is trying to be proactive," says Williams. "We not only want to show that we are very concerned with the quality of care that our Medicaid beneficiaries are receiving, but also do whatever we can to improve that process."
Mississippi Medicaid and Disaster Preparedness: A Case Study
By Phyllis Williams
In the aftermath of Hurricane Katrina, with thousands of Mississippi residents forced into shelters, public health workers were hampered by a lack of access to critical evacuee medication information. Mississippi Medicaid immediately recognized the serious threat this medication interruption posed to our approximately 622,000 beneficiaries. Within three days of the disaster, Florida-based Informed Decisions had rolled out a Web interface that gave our shelter personnel—as well as the pharmacies and healthcare facilities that remained operational—online access to critical medication information of our Medicaid evacuees.
To reach out to non-Medicaid evacuees and to our neighbors in Louisiana, we joined forces with a collaborative of private companies, public agencies and national organizations (listed below) to re-purpose the eMPOWERx infrastructure. The front-end Web interface was built out to be more intuitive, the data fields were broadened and prescriber information was expanded to accommodate use by non-Medicaid providers and for non-Medicaid patients in Mississippi and in Louisiana. The end result was KatrinaHealth.org, which could be accessed by any authorized provider caring for a Hurricane Katrina evacuee anywhere in the country.
The system provided a 90-day snapshot of evacuee prescription histories, alerted users to patient allergies and provided a medication identification component that allowed providers to identify tablets and capsules by querying the database using unique characteristics such as color, shape and imprints/markings.
By the end of September 2005, KatrinaHealth.org users had performed nearly 4,000 information searches on patients, with independent and retail pharmacists performing 84 percent of the searches. In all, more than 6,000 patient information searches were performed between September 2005 and February 2006.
While KatrinaHealth.org was a successful one-time response to a single emergency situation, we know that other disasters will strike somewhere. That is why we joined together with the American Medical Association, Informed Decisions, the National Association of Chain Drug Stores, the National Community Pharmacy Association, SureScripts and Rx Hub to develop a similar, but greatly expanded system, that can be activated in response to any disaster anywhere in the country.
The resultant ICERx.org, is based upon a simple, but potentially lifesaving idea conceived by a paramedic after the London terrorist bombings in July 2005 that killed 56 and injured hundreds. The idea was for mobile phone users to place an "In Case of Emergency" (ICE) entry in their phone that identifies an emergency contact that can provide first responders with vital medical information about the victim. Should another hurricane make landfall in Mississippi, or should we be crippled by any natural or man-made disaster, we simply put the call out to the ICERx.org collaborators to activate the system.
At that time, the data flow is turned on and ICERx.org channels information securely between information providers (including Medicaid) and the authorized providers who are caring for evacuees in disaster zones, shelters, or anywhere in the country they may go.
Only licensed prescribers and pharmacists who have registered on the system and whose identities have been properly authenticated will be allowed to login. Once inside the system, they can access a 100-day snapshot of comprehensive medication information for the evacuees in their care. This includes prescription history information, including drug name, dosage, quantity, day supply, the name of the provider who wrote the prescription and the pharmacy that filled it; available patient clinical alerts, including drug interaction, therapeutic duplication and elderly alerts; and, clinical pharmacology drug reference information including drug monographs, interaction reports and the drug identifier tool.
While we have not yet had to activate ICERx.org, we know the time will come when it will be needed. Evacuees will have access to the information they need to replace and refill their prescription medications, regardless of where they are or how they got there. Furthermore, the clinical decision support tools and clinical alerts will help prevent errors and potential drug interactions, whether medications are being given in an emergency shelter or at a doctor's office or pharmacy. Having this system in place means our first responders, prescribers and pharmacists can provider better, faster and safer care to evacuees.
Contributing organizations to KatrinaHealth.org:
American Medical Association, Gold Standard, The International Rescue Committee, Manatt Phelps and Phillips, The Markle Foundation, National Association of Chain Drug Stores, National Community Pharmacists Association, RxHub, the State of Louisiana, the State of Mississippi, SureScripts, Swandive, U.S. Department of Commerce, U.S. Department of Defense, U.S. Department of Health and Human Services, U.S. Department of Homeland Security, and the U.S. Department of Veterans Affairs.