Prescription Medication Histories - an Approach

There has been a growing awareness of the value of a prescription drug history in every care setting. Increasingly at least one vendor (SureScripts-RxHub) is collecting such information from the majority of America's pharmacies and a growing number of PBMs. These data are both claims (from PBMs) and dispensed meds in SCRIPT format (from the SureScripts side).

If one uses a certified e-prescribing device, it is said, one will get formulary information (particularly from participating PMBs) and medication histories "for free." This makes sense. After all, despite the prevalent rhetoric on the potential of these technologies to increase the safet of presribing, benefits also accrue the PBMs (through formulary compliance, automated prior authorization, and mail order pharmacy coordination; this was a rationale for the PBM investment) and at least the large pharmacies (through lower labor costs that can be offset by reducing personnel; the latter reductions are the justification for the fees pharmacies are charged when they receive a digital prescription).

But what of all of the other clinical settings in which prescription medication histories are vital? Were I taking medications that could critically influence my care, I'd want that history available in a secure way to anyont authorized to care for me. How will this be done?

One way is simly to charge money for the transaction fee. Prices evidently range from $0.50 per transaction to $3 per transaction. Prescribers ask: "I changed my processes to help PBMs and pharmacies out; the marginal cost to provide a prescription drug history from the service is almost zero (the care facility could incur the cost of authorization and certification); so why do you charge me again for something that I've already contributed to?

At the same time we as individuals are seeking answers to these questions, each state government has developed one or more databases to house prescription drug information for regulatory purposes. The most common example is databases for controlled substances. In most instances, these databases collect batch files of separate fees from pharmacies and, with the help of a lot of often expensive technology consultants (they have to love it), develop their own ad hoc approach. 50 states - possibly 50 different proposals.

So this writer wonders if one can save the states money and serve the public at the same time by taking a more progressive and real-time approach to state needs and setting certain conditions on what the vendor meeting these needs must do in return for the public. The proposal has two parts.

ONE: The States use a uniform approach to data representation and all contract with a vendor like SureScripts-RxHub for real-time feeds.
Among the constraints:

• The development of these databases would follow a national architcture and would be funded through the economic recovery legislation
• The states would pay a small - and I mean small - annual per capita fee to the vendor (like SureScripts-RxHub). The cost of this fee should be less than the cost of maintaining their current infrastructureus.
• The state database would only be used for authorized state purposes; the database would not be used as a "hub" for secondary distribution for clinical purposes
• The states get out of the "one off" approach; that's the only way they will save significant sums
• The states could also begin, informally, to converge on best practices for use of these data (i.e. narcotics databases, adherence reporting for public health

TWO: The same vendor must gurantee to provide the same feed "for free" to all certified care settings under reasonable authorization and authentication provisions.
This means:

• All medication histories are made available from a point-to-point, SCRIPT standard-based "utility."
• States stay out of the secondary distribution business
• Everyone else more or less stays clear as well of the secondary distribution businessunless they can provide all of the prescription history service to a states' citizens
• National standards would be used for "certification." I would think the ones used for e-prescribing today ought to suffice for other care settings. If the don't then perhaps our e-prescribing authentication and authorization methods are too lax

Who won't like this:

• Vendors to states databases - they become less critical to software development but have opportunities by making the data more useful to their state clients
• Some health plans - perhaps some plans enjoy some advantage by sitting in the middle of the transactions; but claims are the wrong way to present medication histories when dispensed data in SCRIPT format is avilalable
• Vendors. Who would not want to get a dollar a transaction and see these mythical revenue forcastes disappear. But the reality, in my view, is that prescribers should not adopt the current e-prescribing approaches unless rules are simplified (e.g., formularies, prior authorization), and unless neither their patients nor their care delivery organizations are forced to pay onerous prices for something that has both been financed and which is a vital public good

Just an idea. But it would seem to this writer that such an approach would help our states do their job, contribute to a national care (e.g., NHIN) infrastructure, reduce complexity, eliminar costly intermediaries, and improve care.