Medical E-Prescription Platform

Helping an independent medical software vendor beat the competition and retain key customers with a smart eRx module for their existing EHR system

Collaboration:

2017 - present

Business context

An independent healthcare software vendor from the US that provides highly customized electronic health record (EHR) solutions for hospitals, mental health facilities, and hospices.

The team already served four large healthcare delivery organizations who primarily used third-party eRx tools to prescribe medicine electronically.

The client wanted to extend their web-based EHR functionality by adding a computerized provider order entry module that would handle e-prescriptions for regular and controlled substances (Schedule II–V drugs) for end users of the EHR system (clinicians, nurses, etc.) as well as electronic orders for laboratory and radiology tests. By doing so, they intended to encourage clients to switch from competitors’ eRx products to their own and create a consolidated ecosystem of their own branded clinical applications that would smoothly interact with each other and provide instant, actionable insights for improving patient safety and quality of care.

Business challenges

Find a reliable technology partner who would take full responsibility for:
  • Stakeholder and technical workflow management to make sure that all business and functional requirements are properly prioritized and that product deliveries are made on time
  • Ensuring full HIPAA compliance for the eRx module in order to keep the whole EHR system HIPAA compliant
  • Making sure that the upgraded EHR system meets ONC Certification requirements to allow providers to apply for the Quality Payment Program
  • Setting up a delightful and easy training experience for clinical staff to enable a smooth transition from third-party eRx tools
Retain existing clients by increasing their satisfaction with the current EHR solution
Acquire new healthcare delivery organizations as loyal customers

Project details

Our client wanted to start with a minimum viable product (MVP) version of the digital health platform that would allow end users to create orders for Schedule I drugs and laboratory tests. These orders were expected to be delivered directly to a pharmacy or laboratory information system, which could help providers spend less time calling pharmacies and help labs clarify orders and spend more time with patients.

The eRx technology module was also expected to be equipped with at least basic clinical decision support functionality to automatically compare prescribed medications with a patient’s chart and treatment history, detect any potentially dangerous or fatal drug–drug or drug–allergy interactions, and instantly alert providers about potential interactions so providers can make informed decisions to improve patient safety.

Soon, however, the client realized this would not be enough to effectively compete with current third-party e-prescription tools used by healthcare establishments they served.

After several rounds of negotiations, our team of business analysts rolled out a plan for an extended MVP version that would be competitive enough to effectively cater to end users’ needs but still allow our client to stay within their planned budget and deadlines.

The final version of the eRx product is capable of the following:

Managing medication orders

Placing single prescription and multiple prescription orders

It’s possible to create a prescription for a single item or multiple items at once. Providers can search medications by typing the first few letters of a medication name or by typing the name of an active ingredient in the search field. When searching by active ingredient, providers can see and choose from both generic and brand name options. After choosing a medication, the provider needs to fill out a form by entering directions for use (called the “sig”) along with the duration for and frequency with which the medication should be taken. The dispense quantity is automatically calculated based on the two last parameters, with the ability for the prescriber to correct it if necessary. Information on the patient and prescriber is retrieved from the EHM system and populated automatically to avoid unnecessary typing. Prescribers can also add each prescribed medication to the Favorite Medication list to speed up refills and further orders.
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Sending orders to a preferred pharmacy

When sending a prescription, prescribers can choose from a patient’s preferred pharmacies (if specified by the patient) or search for the nearest pharmacy by ZIP code, pharmacy name, or address. Being location-aware, the application also lets prescribers filter pharmacies based on their proximity to either a healthcare facility or a patient’s home and check a pharmacy’s location on the map. Prescribers can add chosen pharmacies as patient defaults to simplify future orders.
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Refilling prescriptions

Prescribers can refill medications either from the Medication History or the Favorite Medication tab in a patient’s chart. After choosing to refill one or several medications, prescribers see a pre-populated form with all previously entered prescription details and can make any corrections as required.
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Tracking order statuses

It’s also possible to track the status of a prescribed medication order, which can be pending, rejected (by a pharmacy benefits manager, for instance), dispensed, started by the patient, and so on. By tracking these statuses, prescribers can quickly react to events that require an urgent response. For example, providers can follow up with patients by sending quick reminders if they see that a medication has been dispensed but the patient hasn’t started treatment.
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Implementing patient safety features

At the client’s request, we equipped the eRx module with clinical decision support (CDS) functionality to enable drug–drug and allergy alerts, which is aimed at reducing preventable adverse drug events (ADEs). The CDS-enabled eRx system is now capable of:
checking a prescribed medication against a patient’s medical data (age, weight, diagnoses, allergies, history of previous and current treatments)
alerting prescribers of possible contraindications, dangerous doses, potential adverse reactions, and duplicate therapies
providing clear instructions on how to provide better treatment
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To deliver the best possible experience with CDS functionality and to avoid desensitizing prescribers to drug–drug interactions, allergies, and overdose warnings, we removed alerts for patients with low levels of risk and modified alert rules so alerts are only shown when a patient belongs to a higher risk group such as elderly people, people with chronic diseases, and pregnant women.
It’s also possible to replace a medication with an alternative that is considered safer for a patient right at the point of order entry. Prescribers can also decide to proceed with the original medication by overriding alerts on possible interactions and side effects, which is why we gave them the opportunity to specify an override reason from a standard list of coded reasons together with a free-form explanation so prescribers can effectively log factors that may potentially contribute to an ADE.

Ordering lab and radiology tests

We also made it possible to send computerized laboratory and radiology test orders to a laboratory of a patient’s or provider’s choice and receive results right within the EHR system.
The laboratory test ordering functionality is also equipped with basic decision support to avoid duplication of test orders, which could be dangerous for a patient. Providers can also access patients’ test results and share them with patients and other providers. As with prescription orders, providers can save the most commonly used test patterns for a patient for more convenient and faster reordering.

Managing eligibility verification

Checking prescriptions against patients’ formularies

To meet ONC Health IT Certification Program requirements and help our client attain Certified EHR Technology (CEHRT) status, we needed to ensure that the eRx-enabled EHR system would successfully perform automatic checks of available drug formulary lists for a given patient and medication.
Every insurance payer maintains its own formulary database containing different types of medications assigned to specific formulary tiers that are covered by certain insurance policies. We had to enable integrations with both insurance formulary databases and pharmacy benefits management databases to ensure the platform has access to exhaustive formulary information.
By accessing a patient’s eligibility information, the benefit verification functionality in our eRx module is able to communicate the status for each medication prescribed. This helps prescribers determine the most clinically appropriate and cost-effective option for a patient. If a patient’s coverage information is not available, the prescribing provider can check a full list of alternative medications to find the best affordable treatment.

Electronic pre-authorization

The system also automatically notifies prescribers if a selected drug requires prior authorization (for example, if a desired medication is not on a patient’s benefit list but is still determined as medically necessary by the prescribing physician).
Providers can also instantly react to such alerts by submitting prior authorization requests via the EHR system to get instant feedback from payers or pharmacy benefit managers while still interacting with a patient at the point of care. This helps healthcare providers to:
increase patient satisfaction by saving time that would otherwise be spent on waiting for a drug to be approved and dispensed
increase employee satisfaction by eliminating back-and-forth communication with decision-makers for the prescription to be filled
increase patients’ well-being by allowing doctors to track pre-authorization request statuses and instantly react to any delays associated with prescription approvals that may delay care delivery

Ordering controlled substances

Our client requested that the eRx system be able to fill out electronic prescriptions for controlled substances in three US states – California, Texas, and Michigan (since two of the healthcare establishments served by our client operate in California, one operates in Texas, and the last is in Michigan).
We were tasked with creating a secure eRx system that would ensure integrity and authenticity for controlled substance prescriptions. By fully relying on the US Drug Enforcement Administration (DEA) Interim Final Rule requirements, we enabled the following:

Prescriber identity proofing

According to DEA requirements, prescribing providers must complete an identity proofing process to confirm they are authorized to e-prescribe controlled substances.
We partnered with a third-party digital identity service provider to enable frictionless identity proofing for providers who create e-prescriptions for regular and controlled substances with our eRx-enabled EHR system.
The process also requires other members on a provider’s team to confirm a provider’s identity. Using the EHR application, a provider who is undergoing verification can invite one or two already verified staff members to help them to finish the verification process through their accounts.
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Access control to give EPCS permissions to approved providers

We also set up a multi-level access control process according to DEA security requirements, where the system administrator can give permissions to allow verified users to e-sign prescriptions and download a mobile identity proofing application to complete the eRx registration process.
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Two-factor authentication when signing EPCS prescriptions

Upon choosing a regulated drug, the system instantly notifies the prescriber that this drug is a controlled substance and specifies its level. As controlled substances may require further authorization by a payer or a pharmacy benefit manager, prescribers can make such requests at the point of order entry to speed up the filling process.
When choosing a pharmacy to send an e-prescription order to, prescribers can also sort nearby pharmacies by their ability to accept controlled substance prescriptions to be sure their patients will receive the required medication.
After checking a drug against a patient’s formulary list, choosing a pharmacy, and reviewing the eRx order, a provider is prompted to complete two-factor authentication to authorize the transmission of sensitive information to the pharmacy. The authentication process is performed using an account password and the prescriber’s phone number, through which the prescriber gets a secure token, either by text message or phone call, to input in the main app.

Audit log

We also added audit log functionality for all EPCS-related events that take place in providers’ accounts to be able to track security incidents and identify their destinations and sources, thus demonstrating compliance with DEA rules.

Technical implementation

Taking into account the client’s requirements for the product’s security and interoperability, Yalantis has developed a fully HIPAA-compliant eRx software solution capable of not only meeting DEA EPCS requirements but also of obtaining ONC Health IT Certification.
Architecture
Considering the client–server nature of the solution, it was important to select the best cloud service provider and design the product’s architecture in a way that would allow us to use its responsive components. Amazon Web Services (AWS) was the best choice for us, as it’s a secure and proven HIPAA-compliant cloud service provider that offers robust tooling for developing, maintaining, and scaling the whole project ecosystem.
We used a microservices approach for decomposing the solution on the back end into smaller autonomous parts tightly coupled through APIs, each designed to cover a specific business need within the application.
Code quality and quality control
High code quality is crucial for all solutions produced within Yalantis, but enabling high-quality code is especially important when it comes to safety-critical systems like eRx apps, EHR apps, and other e-health products.
As part of eRx product execution, our team of developers did their best to deliver code that would be highly satisfactory in terms of its reliability, maintainability, testability, portability, and reusability.
Our team of manual and automation quality assurance engineers also worked to guarantee that the designed product would fully meet functional and non-functional requirements as well as fully satisfy the client’s quality expectations. Our QA team made sure to apply a mandatory set of testing techniques to deliver a smoothly operating product:
  • Functional testing
  • Smoke testing
  • UI testing
  • Unit testing
  • Performance testing
  • Compatibility testing
  • Compliance testing
  • Security testing
Technical implementation details
Prescriber identity proofing
To enable identity proofing for prescribers, we relied on Imprivata, which is a proven digital identity service provider for the US market. The Imprivata solution is fully synchronized with the EHR system and allows for verifying EPCS-eligible providers through checking their identities NPI and DEA databases upon registering to use the eRx functionality in the system.
EPCS two-factor authentication
Two-factor authentication was implemented through integration with Cisco’s DUO multi-factor authentication tool that is fully ECPS- and HIPAA-compliant. As a great bonus, DUO ​​natively integrates with applications, which helped us add a flexible and user-friendly level of security to our system.
Drug information retrieval
To check general drug-related information as well as drug schedule information and sig data for regular and controlled substances, we integrated with the DEA and openFDA databases.
Basic decision support (dosage and drug–drug interactions)
We used the FirstDataBank open API integration to check drug dosages. For retrieving information on drug–drug interactions, we used RxNav.

Value delivered

Together with our client, we’ve achieved the following results:
Three out of four partnering healthcare delivery establishments have successfully moved to the new integrated E-Prescribing solution.
Three new contracts were signed with our client in the first six months after rolling out the eRx solution.
We’ve continued our collaboration with the client to extend their CPOE functionality with more advanced features, including patient referrals, a dosage calculator, and integration with a Prescription Drug Monitoring Program (PDMP) solution to access patients’ PDMP reports right from their medical charts.

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