Download Summary of Findings: DrFirst Trial of Interconnection to the Michigan

Summary of Findings:
DrFirst Trial of Interconnection to the Michigan State PMP
for Mitre Corporation on Behalf of
National Coordinator for health IT (ONC)
and
Substance Abuse and Mental Health Service Administration (SAMHSA)
August 31, 2012
Background
The Mitre Corporation on behalf of the Office of the National Coordinator for health IT (ONC) and the
Substance Abuse and Mental Health Service Administration (SAMHSA) subcontracted with DrFirst to test
the feasibility of connecting a PDMP to DrFirst’s existing health IT system in order to enhance the
timeliness and completeness of information on dispensed controlled substances to providers, ED
physicians and pharmacists. For the purposes of the trial, it was determined that DrFirst would connect
its Rcopia Electronic prescription Management system to the Michigan state PMP via the PMP
interchange operated by Appriss. DrFirst would then make the Michigan data available to the 125
physicians of the Huron Valley Physician’s association in Southern Michigan toThe trial was scheduled to
take place starting on August 1, 2012 with data gathering to be completed on August 21, 2012 in
support of the provision of findings on August 31, 2012
Methodology
DrFirst operates a health information service platform called Rcopia that allows physicians to perform
several functions via a web interface.
1) Obtain medication history information from a number of sources to help the physician derive
the most complete medical history possible in support of their treatment of the patient
2) Medication reconciliation to support ongoing management of medications
3) Electronic Prescription Services, including the provision of alerts based on clinical criteria,
including documented allergies, drug on drug interactions with other documented medications
and duplicate therapy instances with other documented medications.
DrFirst also operates a separate platform element that it calls the Payor Engine. This platform allows
DrFirst to integrate additional sources of medication history into the feed for its customers, making the
medication history more complete for physicians. To complete this feasibility assessment, DrFirst
integrated the Michigan State PMP data feed into the Payor Engine’s data sources by configuring a
specific query to the Michigan PMP via the PMPi interchange operated by Appriss, Inc. A listing of the
system changes made to execute this trial is attached as Exhibit A.
Because of the nature of the Interaction of the Payor Engine and DrFirst’s Rcopia systems, the addition
of the incremental data source was completely transparent to the physicians of the Huron Valley
Physician’s Association. There were no changes whatsoever to the visual interface that the physicians
used from day to day and no training was required.
Implementation
In the weeks preceding the activation, DrFirst sent a presentation to the administrator of the Huron
Valley Physicians Association and attempted to schedule an orientation meeting with them. The Huron
Valley representative was not available, so DrFirst forwarded an overview description of the trial that
was going to take place through the month of August. The materials were meant as orientation since
there was no training or specific action required of the Huron Valley medical staff leading into or during
the course of the trial.
DrFirst prepared its solution and completed a demonstration for representatives of Mitre Corporation
on July 30, 2012. The Implementation launch and onset of data gathering was scheduled to take place
on August 1, based on dependencies with the getting test and production information from the State of
Michigan as well as DrFirst dependencies on its internal systems. After the original production launch
on August 1, DrFirst staff members discovered that the queries to the Michigan PMP were failing despite
the fact that identical queries succeeded during system testing. It was determined that the Michigan
state PMP production database was configured to respond to a different query structure than the test
database, so the DrFirst systems had to be rolled back from production and re-programmed to
accommodate the different production environment. The subsequent programming, combined with
recertification of the solution through DrFirst’s customer and partner ecosystem certification, delayed
the onset of data gathering until August 11, 2012. Because of this delay, DrFirst extended its data
gathering until August 24, 2012 to provide a reasonable sample. The relative patterns of usage are
consistent enough to support the overall findings of the study.
Results
Validating increased PMP activity
The trial consisted of 14 days of activity for the 125 physicians of the Huron Valley Physicians
association. These included 10 week days and 4 weekend days. Medication history query levels ranged
from 855-1505 queries on weekdays to approximately 30-90 on weekend days:
Huron Valley Physicians Association
Queries to PMPi and Responses
Date
8/11/2012
8/12/2012
8/13/2012
8/14/2012
8/15/2012
8/16/2012
8/17/2012
8/18/2012
8/19/2012
8/20/2012
8/21/2012
8/22/2012
8/23/2012
8/24/2012
Total Requests from
Requests that
pmp practices
found a pmp drug
60
9
91
7
1490
335
1270
184
962
56
1194
59
814
231
33
2
44
11
1505
440
1228
339
855
236
978
282
878
247
11402
2438
Percentage
0.15
7.7%
22.5%
14.5%
5.8%
4.9%
28.4%
6.1%
25.0%
29.2%
27.6%
27.6%
28.8%
28.1%
21.4%
Adding the PMPi data source to the Rcopia interface clearly increased the utilization of the Michigan
PMPi. Assuming all of the 125 physicians were continuously active with patients, each would have
submitted an additional 11 queries to the PMP on an average business day.
Increasing Physician Awareness of Potential Drug Seeking Behavior
Though DrFirst’s clinical systems are not focused specifically on attempting to identify and deter drug
seeking behavior, they do have certain safeguards in place to assist the physicians in their management
of prescriptions that can support deterrence. Specifically, DrFirst allows physicians to electronically
search data sources like the Michigan (and other) PMPs to obtain medication history information that a
patient might be unable (because they are incapacitated) or unwilling to provide. DrFirst integrated the
drug responses that it received from the Michigan PMP into its drug history. An example of a drug
history for a patient in the Rcopia interface is listed below:
DrFirst’s queries to the Michigan PMP generated positive responded and incremental elements to the
medication histories of approximately 21% of the queries submitted, giving the physicians a richer sense
of their patient’s use of controlled substances.
Additionally, DrFirst makes use of the medication history information to give the physicians a more
complete picture of the patients’ background to help avoid dangerous drug to drug interactions and
other complications when prescribing additional medications. It is also meant to identify duplicate
therapies that could place the patient at risk. DrFirst implements this in the form of clinical alerts that
are triggered by comparing prescriptions that physicians write against the patient’s aforementioned
medication history.
An example of Examples a clinical alert that a physician receives when writing a prescription that
provides duplicate therapy is listed below:
Additionally, physicians viewing a list of pending prescriptions for patients will see a warning indicating
duplicate therapy. Note the warning for the pending prescription for Lunesta below:
In the course of the 14 days of trial period with the Huron Valley Physican’s Association. DrFirst’s Rcopia
system provided 3281 Duplicate Therapy alerts to physicians. Of these alerts, 231, or 7% were informed
by Medication History elements from the Michigan PMP. Overall, the integration of the PMP data has
notably increased visibility to prescription drug acquisition. Whether this acquisition was part of valid
recurring therapy cannot be determined given only the raw data. Additional research would be
necessary to research the specific circumstances of the duplicate therapy alerts.
Exhibit A: System changes to support trial functionality
1)
2)
3)
4)
5)
6)
Configured query to align with PMP API
Configured query structure to align with Michigan State Test database API
Configured query structure to align with Michigan State production database API
Integrated Michigan PMPi data into the source for Rcopia software
Configured Rcopia software to allow access to Michigan state PMPi data only to HVPA physicians
Configured Duplicate Therapy Clinical Alerts in DrFirst’s electronic Prescribing systems based on
the Michigan PMP data source
7) Developed logging and reporting for new activities
8) Installed Certificate to validate DrFirst system Identity with the PMPi
9) Updated DrFirst Payor Engine to create a Medhistory request to be securely routed to the
Michigan PMPi.