April 17, 2013

Denied New To Follow Workflow

In the workflow for electronic prescription routing, there are two core message flows. The first deals with the routing of an entirely new prescription, called “NewRx” in the NCPDP standard. A new prescription may authorize one single dispensing, or more than one, depending on the therapeutic requirement specified by the prescriber. On a NewRx message, the prescriber can indicate how many additional dispensings are authorized beyond the one that is implicit in the new prescription message. The number of authorized dispensings can range from zero to ninety-nine, although the most common values are zero, two, and eleven. Two is typically used when each dispensing provides thirty days worth of medication. Therefore two authorized refills provides a total of three dispensings (slang in the industry is “1 + 2”) which would last a total of ninety days.

After the total number of authorized dispensings are exhausted, the pharmacy must contact the prescriber to seek further authorization before additional dispensings can be made. Before e-prescribing, renewal authorization communications was done by phone or fax (if permitted by state and federal law.)

With e-prescribing, the second core workflow deals with a renewal authorization requests and responses. These messages are called refill requests and refill responses, abbreviated as RefReq and RefRes respectively.

When the pharmacy needs to obtain further authorization to make another dispensing to a patient, they send an electronic RefReq message to the provider who issued the original prescription. The provider can reply with a response message back to the pharmacy. A RefRes message comes in one of four flavors. The straightforward “Approve” and “Deny” responses are self-explanatory. “Approved with Changes” allows the prescriber to indicate that the renewal is approved, but modest changes are being made to the request, usually the number of refills is being changed.

The fourth response type is “Denied New Prescription to Follow” (DNTF). This type of response indicates that the request that has been made is being denied, but that an entirely NewRx will be sent instead.

The DNTF response type was developed years ago, before e-prescribing was really active. The intent of that response type was to communicate to the pharmacy that a clinical change was required. Literally “Deny this one you asked for, and substitute it with this NewRx instead.”

The issue that we observed in practice is that the DNTF was being used for more than a clinical change. If a technical change was required, say something as benign as wanting to send a different NDC number, or a slightly different formatted drug name text string, the DNTF workflow was being used by many e-prescribing or electronic medical record (EMR) vendors. The reasons for needing to make a technical change are complex and intricate, based on some of the nuances of the NCPDP standard like the use of drug names as free text fields, the use of disparate drug reference database compendia, and a lack of standardization on improvements such as RxNorm (a new drug identification standard) and Structured and Codified SIG. This practice of using the DNTF for technical changes instead of clinical changes frustrates pharmacists, because they are getting a message that communicates “Deny this one you asked for, and substitute it with this NewRx instead.” The problem is that much too often the medication information being denied is IDENTICAL to the information that is in the NewRx. There are two problems with that in pharmacy:

  1. There is a different workflow for a DNTF compared to Approved. The DNTF workflow sometimes requires re-work which introduces inefficiency and the potential of an error.
  2. The pharmacy is paying for messages and is paying two fees, one for the DNTF and one for the NewRx, when the semantic meaning of the messages was in fact “Approved” and could have been relayed in one message that would only incur one fee.

NCPDP has recognized this issue and is in the process of redefining the DNTF response type. Once approved and ratified, we think there will be only one message going back to the pharmacy, that indicates both “Deny the request” and “Here’s the NewRx” within one message.

Instead of waiting for the industry to approve, adopt, and start using that new message, Surescripts has decided to change its billing practice in advance of the NCPDP change by eliminating the fee for DNTF. While there still is a percentage of DNTF messages that indicate valid clinical change, the numbers of DNTF with technical only content changes have been increasing, and we are taking this step in the best interests of the industry and the balance of the network.

The billing change does not change the current use of the DNTF, which still presents workflow and processing challenges at both ends of the network, but it does relieve a pain point which has been growing, and sets a path toward an NCPDP change that we think is going to help alleviate the problem in the long run. Surescripts will be performing additional analysis of DNTF usage to encourage the proper and optimal use of the message over time.

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