The Role of Interoperability in Enabling Prescription Drug Price Transparency

By Kelly Bundy, senior product analyst, Surescripts; part of the HIMSS Interoperability Showcase™ initiative

HIMSS Interoperability Showcase

The HIMSS Interoperability Showcase, part of the HIMSS Global Conference & Exhibition, demonstrates interoperability – the ability for different technology systems to communicate – in real-time with actual products in the marketplace. The following guest post shares the impact seamless data exchange can have on patients, providers and caregivers.

Warranted or not, the frustration a patient feels when paying out of pocket for an expensive medication reflects back on their care provider.

Can we make price transparency a reality in prescribing?

Yes. The industry has the tools that we need to achieve price transparency and to automate the cumbersome prior authorization process. These tools deliver actionable insights at the point of care and encourage meaningful conversations between clinicians and patients within health systems across the nation.

The key is a nationwide health information network with standards-based interoperability as its centerpiece.

Meet Patient Angela Davis

Our fictional patient, Angela Davis, is 52 and suffers from a variety of health conditions, including diabetes and rheumatoid arthritis. Like many patients, she cares about the quality of her medical treatment. She also cares about cost. And like many patients with significant medical histories, Angela sees multiple clinicians in a variety of care settings, including one of the largest health systems in her area. This complicates both quality and cost.

How do we improve quality and manage costs for our fictional patient?

What Matters to Angela (and Angela’s Clinicians)

With actionable insights at the point of prescribing – face to face with Angela in the clinic – Angela’s treatment outcome does not hinge on the clinician’s access to relevant information; rather, Angela would get the most affordable medication that meets her therapeutic need, no more and no less, regardless of care setting and location.

The solution is to deliver the actionable insights the clinician needs to make the best possible treatment decision under the circumstances. In the context of health IT, quality of care and costs, this is what matters.

The Role of Interoperability: Better Prescribing

When Angela moves cross country for a new job, she has much on her to-do list, including familiarizing herself with a new health system for routine primary care and finding specialists to help manage her diabetes and rheumatoid arthritis. Angela’s new job also means a new health plan, complete with its own drug formulary and benefits.

How can Angela avoid the kind of scenario in which she pays $1,000 out of pocket for her prescribed medication, for example, rather than $5 for a covered therapeutic alternative?

It starts and ends with the health system and the clinician at the point of care.

  • Clinic first, pharmacy second: When Angela’s clinician makes a prescribing decision, that decision should be based on all of the data, not some of it, such as real-time prescription benefit coverage (patient-specific information on deductible and out-of-pocket costs), and whether or not the prescription requires prior authorization. This helps to eliminate suboptimal decisions and outcomes before – not after – any prescription orders are sent to Angela’s pharmacy in the first place.
  • Embedded in the health system’s EHR: The best place to deliver actionable insights is in the EHR software, where Angela’s clinician is familiar with the normal prescribing workflow. Easy, intuitive access to data during the care encounter means that the clinician can have a meaningful conversation with Angela at the point of prescribing.
  • Updated and relevant: Price transparency means patient-specific information based on Angela’s new pharmacy benefit plan, including data straight from pharmacy benefits managers (PBMs). This information ecosystem includes benefits data on formulary restrictions, therapeutic alternatives (brand and generic), utilization management criteria and relevant clinical documents from prior care encounters, even those that took place in Angela’s former home state.

A nationwide network that connects pharmacies, PBMs and health systems will help us to deliver actionable insights to any clinician in any health system nationwide, in the EHR at the point of care, with data that is relevant to the patient and his or her health plan. As we move toward realizing the promise of value-based care, patients like Angela are already saving thousands of dollars on drugs, and interoperability and price transparency are fundamental to achieving it.

To learn more, visit our Clinical Exchange & Price Transparency vignette in the Interoperability Showcase, open throughout exhibit hours on Tuesday through Thursday, and come to our panel discussion in the Interoperability Showcase Education Theater on Tuesday, Feb. 12, from 12:30 to 1:30 pm.

Sponsored content. The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.


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