Study of Real-Time Prescription Monitoring Program (PMP) Data
Collection for the Kentucky All Schedule Prescription Electronic
Reporting (KASPER) Program
KASPER Evaluation Team*
Institute for Pharmaceutical Outcomes and Policy
Department of Pharmacy Practice and Science
College of Pharmacy
University of Kentucky
Lexington, Kentucky
June 2011
*
Patricia R. Freeman, PhD, RPh
Karen Blumenschein, PharmD
Jeffery Talbert, PhD
Stacy Taylor, PharmD, MHA
Joseph L. Fink III, BSPharm, JD
CONTENTS
I.
Introduction …………………………………………………………….….3
II.
Scope of Work……………………………………………………….…….5
III.
State PMP Stakeholder Interview………………………………………..6
IV.
Independent Pharmacist Stakeholder Interview…………...…...……...7
V.
Chain Pharmacy Manager Interviews….………………………………11
VI.
Survey of Non-Pharmacy Dispensers of Controlled Substances…...14
VII.
Software Vendor Interviews…..….………………………………...…...17
VIII. Summary and Recommendations…………………………...…………19
IX.
Appendices …………………………………………………...………….25
2
I.
Introduction
Since the early 2000s, the mandate for and implementation of prescription drug
monitoring programs (PMPs) has become a national movement. As of May 16, 2011,
49 states have mandated programs and 35 of these states have implemented
operational PMPs. The common goal among these programs is to reduce prescription
drug abuse and diversion by discouraging ‘doctor shopping’, which occurs when
patients see multiple providers and pharmacies with the intent of obtaining controlled
substances for misuse and/or diversion. This goal should be accomplished without
causing a ‘chilling effect’ that compromises patient access to controlled substances
(CS) required for legitimate medical needs. However, there is wide variation in program
design, objectives, and operation across the states, including the mechanism and the
frequency with which CS prescription data are reported from dispensers to the PMP.
Currently in the majority of states, dispensers report CS prescription data to the PMPs
via electronic batch files. Aggregate data are collected on the CS prescriptions
dispensed within the dispensing system over a given time period and then a batch file is
created from the data and uploaded to the state PMP database. The common
procedure for processing and transmitting CS prescription data to PMPs is depicted in
Figure 1 below.
Figure 1: Controlled Substance Prescription Data Reporting Process
3
Kentucky’s PMP, the Kentucky All Schedule Prescription Electronic Reporting Program
(KASPER), has contracted with RelayHealth as the vendor for all CS data collection.
Currently, in addition to electronic batch file transmission as described above,
RelayHealth offers an option to automatically extract a pharmacy’s CS reporting
information directly from the adjudication transactions sent to the RelayHealth switching
network which eliminates the need for the pharmacy to submit batch files1.
The majority of states (32) mandate data reporting every 7–14 days (Figure 2), including
Kentucky which currently mandates reporting of CS data to the PMP every seven days.
Three states - Minnesota, North Dakota and Oklahoma - currently require dispensers of
CS to report data to the PMP daily. To date, only one state - Oklahoma - has mandated
‘real-time’ reporting to the PMP effective January 1, 2012. Currently, there is no
standard definition of ‘real-time.’ The Oklahoma legislature has defined real-time as at
the point-of-sale, i.e., at the point the CS prescription is purchased and placed in the
hands of the patient consumer2. Another view of real-time is at the point of CS
prescription filling and adjudication, i.e., at the time the CS prescription is entered into
the pharmacy dispensing systems and processed for third party payment through the
switch as described in the American Society for Automation in Pharmacy (ASAP)
Standard for Prescription Monitoring Programs3.
Figure 2: Mandated Frequency of Data Reporting to PMPs4
n=40
100%
90%
80%
70%
60%
50%
40%
30%
20%
Monthly
Biweekly
Weekly
Daily
10%
0%
__________________
1
Relay Health Prescription Monitoring Program Information, accessed May 24, 2011,
http://pmp.relayhealth.com/KY/Documents/Setup%20for%20Network%20KY%20PMP%20Submission.pdf
2
Oklahoma Bureau of Narcotics and Dangerous Drugs Control Prescription Monitoring Program, accessed May 24, 2011,
http://www.ok.gov/obndd/documents/Oklahoma%202009%20PMP%20Transmission%20Manual%20v5.0.pdf
3
Implementation Guide ASAP Standard Version 4 • Release 1 for Prescription Monitoring Programs, accessed June 11, 2011,
http://www.doh.wa.gov/bids/ASAP_PMP_V4-1_92010_Short.pdf
4
Alliance of States with Prescription Monitoring Programs, accessed May 24, 2011, http://pmpalliance.org/content/pmp-datacollectionfrequency?order=field_frequency_data_collected_value&sort=asc
4
Proponents of real-time CS prescription data reporting argue that healthcare providers
need current real-time data in PMP reports so they can make accurate CS prescribing
and dispensing treatment decisions. In contrast, opponents of real-time data reporting
have suggested that the costs associated with implementing the technological
enhancements required for real-time data reporting are too high to outweigh the benefits
gained by real-time transmission as compared to more frequent batch transmissions,
i.e. daily.
Accordingly, this present study sought to identify the barriers to real-time CS
prescription data submission to the KASPER program and to gather opinions on the
advantages and disadvantages of real-time reporting from KASPER stakeholders.
II.
Scope of Work
The KASPER Evaluation Team was engaged by Cabinet for Health and Family
Services (CHFS), Office of the Inspector General, to conduct a study to identify the
challenges and costs associated with implementing real time data collection within the
KASPER program. To accomplish this, the following study components were outlined in
the scope of work to be conducted by the Team:
1) Conduct a survey of state PMPs and identify and interview stakeholders in states
identified as moving quickly toward real-time PMP data collection.
2) Develop and provide a continuing education program on PMPs, including
approaches to and advantages of real-time reporting in terms of clinical decisionmaking at the point of care.
3) Conduct a stakeholder interview with independent pharmacy providers from
across the state to get input on real-time data collection.
4) Conduct stakeholder interviews with representatives from a minimum of five
major pharmacy chains servicing Kentucky.
5) Conduct a survey of a minimum of 10 non-pharmacy dispensers of CS, including
dispensing physicians, veterinarians and dentists.
6) Conduct a survey or interview with seven major pharmacy software vendors.
7) Identify policy issues related to real-time data collection within the KASPER
program and recommendations to address these issues.
5
III.
State PMP Stakeholder Interviews
The KASPER evaluation team participated in a project kick off meeting via
teleconference with KASPER and CHFS staff on July 1, 2010. Information provided by
CHFS staff indicated that Oklahoma is the only state moving toward real-time data
collection and provided contact information for the Oklahoma PMP manager.
The KASPER evaluation team conducted a phone interview with the Oklahoma PMP
manager on September 23, 2010 and posed the following questions:
1) How is OK defining real-time transmission?
2) What is OK’s approach to real-time transmission?
a. What is the platform for transmission?
b. Who is required to transmit real-time (all or just pharmacy dispensers)?
3) What is current timeline for implementation of real-time transmission?
4) What input did OK obtain from relevant groups (if any) before moving toward real
time? From whom did OK seek information? How was the information
solicited/collected?
5) What obstacles/challenges have been encountered along the way? How did
these impact the implementation timeline?
6) How were the obstacles/challenges addressed?
7) What is the best estimate of the cost to pharmacies and the state of OK for
moving to real time transmission?
Real time transmission in Oklahoma is defined as the point-of-sale i.e., within 5 minutes
of the actual time at which the CS prescription is put into the hands of the
patient/consumer and not at the point of processing and adjudication. All dispensers,
regardless of practice site, will be required to transmit real time to the Oklahoma PMP.
To get buy-in for the move to real-time data transmission, a planning committee was
created that included representatives from major chain pharmacy and dispensing
system software vendors. The planning committee worked with PMP staff to identify an
appropriate timeline for implementation that would allow for developing and
implementing the needed technological upgrades that would be compatible with realtime transmission at the point of sale. The planning committee’s work coincided with
the legislative initiative that would statutorily mandate real-time transmission by January
2012.
Although little resistance was encountered during the legislative process, as the
deadline for implementation (January 2012) grew nearer, some chain pharmacies
raised issues relative to their ability to meet the statutory requirements. Oklahoma PMP
utilizes software developed in-house as the platform for data transmission so there is no
vendor and therefore no external costs associated with implementation. A web form
has also been created for practitioners who dispense small volumes of CS so that CS
prescribing data can be entered manually instead of through direct electronic
transmission from dispensing system software.
6
IV. Continuing Education Program-Independent Pharmacist
Stakeholder Interviews
The KASPER Evaluation Team developed and conducted a 1.5 hour continuing
education (CE) program entitled “The Future of KASPER: Technology Enhancements”
at the 13th Annual American Pharmacy Services Corporation (APSC) Meeting for
Independent Pharmacy, on Friday, August 6, 2010 from 1:00 – 2:30 PM. The CE
program, presented by Dr. Patricia Freeman of the KASPER evaluation team, was
presented in two parts. Part I was designed to provide the participants with an
overview of prescription monitoring programs and to discuss the findings of the
pharmacist survey conducted as part of the recent KASPER evaluation conducted by
the KASPER evaluation team. Part 2 was designed to collect information relative to
pharmacists’ opinions on real-time transmission of CS data to the KASPER program
and served as the stakeholder interview component of this study. The stakeholder
interview protocol was approved by both CHFS and University of Kentucky (UK)
Institutional Review Boards. A full copy of the slides, which were distributed as a
handout to audience participants, can be found in Appendix 1. The learning objectives
for the program were as follows:
Part I:
- Describe the current status of prescription monitoring programs in the US
- Discuss findings from the recent evaluation of the KASPER program
Part II:
- Identify the advantages of real-time reporting of CS prescription data
- Discuss the technology enhancements needed to accomplish real-time data
reporting
- Identify obstacles and barriers to the implementation of real-time data
transmission
In addition to KASPER evaluation team members and APSC staff, 43 participants were
in the audience. Following the presentation of Part I, demographic information was
collected from the audience using the Turning Point Audience Response System.
Twenty-two percent identified themselves as a pharmacy owner, 48% identified
themselves as owner and pharmacist, 19% as pharmacist, and 11% as pharmacy
technician. The participants had been in practice an average of 27 (±14) years and
dispensed an average of 257 (±113) prescriptions per day. Of these 257 prescriptions,
the participants estimated they dispensed an average of 55 (±43) CS prescriptions daily.
The majority of participants were from the North Central region of Kentucky (48%) while
33% indicated they were from the eastern region, 11% from the western region and 7%
from the south-central region as depicted in the graphic depicted in Figure 3 below.
7
Figure 3: Geographic Regions of Kentucky
When asked, 77% of participants reported having registered for a KASPER account
while 19% did not have an account; 4% were unsure. Sixty-seven percent of
participants indicated they had personally transmitted CS prescription data to KASPER.
The majority of participants (79%) identified third-party insurance as the primary payer
for prescriptions in the pharmacy while 21% of participants indicated Medicaid as the
primary payer. Rx30 was the most commonly reported dispensing software with 50% of
participants indicating they used this system; other systems participants reported using
include QS1, HCC, HBS, Computer Rx, Renlar, RxKey and SRS. When asked if their
prescription dispensing system was capable of real-time data transmission at the point
of controlled substance dispensing, 46% indicated yes, 11% indicated no, while 43%
indicated they were not sure or did not know.
Seven distinct discussion questions were asked during Part II of the program which
generated much discussion. The participants were very engaged in the discussion,
sharing ideas and opinions freely. The major themes that emerged from each of the
questions are summarized below.
How is controlled substance prescription information currently transmitted
to KASPER from your pharmacy? Does this transmission require any
actions on your part (or by someone else in the pharmacy)?
Some participants reported using batch files as the mode of weekly transmission
while others expressed using the automatic extraction process previously offered
by RelayHealth. The general consensus of those that used batch reporting was
that the pharmacist had to remember to build/save/send the data report weekly.
In contrast, those that used the automatic extraction feature had to remember to
flag all CS prescriptions that are cash transactions rather than third-party
transactions so that they are transmitted to RelayHealth for automatic extraction.
[RelayHealth instructions for submitting electronic batch files and for automatic
CS data extraction accessed from the RelayHealth website on May 16, 2011 are
provided in Appendices 2 and 3 for reference].
8
Several participants voiced concern over the fact that automatic extraction of
data from claims by RelayHealth occurs at the point of adjudication and not at the
point of sale. Thus, claims for prescriptions that are adjudicated but never picked
up are still submitted to KASPER. This was specifically identified as a concern
with possible real-time transmission of data to KASPER at the point of
adjudication according to one participant who said “There needs to be a way to
pull (the prescription) off the KASPER report if you reverse a cash prescription.”
If your prescription dispensing system is not capable of real-time data
transmission at the point of controlled substance dispensing, what needs
to be changed in order to accommodate this?
Participants seemed to indicate this was more of an issue with the adjudication
‘switch’ companies e.g. RelayHealth rather than an individual software issue,
although as stated above some participants indicated the software they used was
not capable of real-time data transmission. Concern again was voiced regarding
transmission at point of dispensing (adjudication) vs. point of sale. Debate
ensued over the value of transmission at these two different points in the
dispensing process and no consensus was reached by the audience on the
benefits/merits of point of sale vs. point of dispensing transmission. Of interest to
note is that not all pharmacies currently have point-of-sale systems that are
integrated with their dispensing systems. When polled, approximately two-thirds
of the participants in the audience indicated they currently have point-of-sale
systems.
What costs do you incur under the current system that requires data
transmission to KASPER every seven days? How would these costs
change if KASPER moved to real-time data transmission?
Kentucky law mandates that KASPER must not charge a fee to use the system.
This mandate is included in all information provided by Kentucky’s data collection
vendor (RelayHealth) to dispensers of CS. It was clear from the discussion that
some pharmacist dispensers believe they are paying fees to the switch for CS
data reporting. Individual responses to this question included:
•
•
•
•
•
“For cash prescriptions we have to pay to go through the switch.”
“For real time we would have to pay for each cash prescription we
transmit and it is 5-7 cents for each one.”
“We pay 6 cents per transaction and we get billed for reversals.”
“It should be zero cost – why would the burden be on us (meaning
pharmacists)?”
“KASPER gets a free-ride because we are doing this stuff for other
payers.”
Only one participant offered the comment that “Right now it is free to KASPER.”
9
What do you see as the biggest obstacle to real-time data transmission at
the point of controlled substance dispensing?
The general consensus of participants in response to this question was the ability
to have and interface with the appropriate technology that would allow for realtime data transmission. Not being sure of the technology required to accomplish
real-time, one participant indicated that the potential cost associated with
implementing the required technology would be an obstacle.
An interesting comment relative to real-time transmission is that if it is going to be
implemented it should be interactive. The system should not just be designed to
gather data with no feedback to the pharmacists. As one participant stated: “You
can’t run a KASPER every time you fill a controlled substance so the system has
to be interactive.” By interactive, pharmacist participants meant that any
potential real-time requirement for CS data transmission to KASPER should
provide immediate feedback to pharmacists similar to the drug utilization review
(DUR) alerts pharmacists receive when adjudicating Medicaid claims.
An additional concern raised in response to this question centered around
pharmacists’ liability. “If they do this will that change our liability? Right now KY
has no liability – will that change?” “Will we get sued for cutting people off?”
What do you perceive as the advantages of real-time data transmission at
the point of controlled substance dispensing?
Responses to this question were varied. Some participants questioned the
advantage of real-time, “That’s what I want to know, what IS the advantage of
real- time? I don’t see it.” Others suggested that the real advantage would be if
the system were two-way – data were transmitted and information received back
from KASPER in real-time like a DUR alert as previously mentioned.
What do you perceive as the disadvantages of real-time data transmission
at the point of controlled substance dispensing?
Participants suggested that the main disadvantage of real-time data transmission
at the point of dispensing is related to the technological changes that would be
needed. “Some people may have to change software.” “Some will have to pay
$10K for a software upgrade.” Additionally, comments were made questioning
the role of the pharmacist vs. the prescriber in ensuring appropriate CS use.
“The state should tell prescribers to transmit KASPER data --- remove us
(meaning pharmacists) from being the middle man”
10
Do you have any suggestions regarding how KASPER could obtain
controlled substance data from Kentucky pharmacies in real time?
The specific responses provided by the participants did not really address the
question posed. Participants continued to question the value of the pharmacist
as the health care professional ‘policing’ this issue vs. the prescriber. “KASPER
should be run before prescribing – not dispensing.” “KASPER should be part of
the standard of care for chronic pain patients.”
V. Chain Pharmacy Manager Interviews
Six major chains which own and operate pharmacies in Kentucky were identified for
interviews. To gather input from chain pharmacy managers, the Kentucky Retail
Federation was approached for assistance in identifying appropriate individuals at the
corporate level for interviews. Contact information for chain pharmacy managers was
obtained and emails requesting participation in the telephone interviews were sent by
the KASPER evaluation team. Positive responses, implying consent to participate in
the study, were received from four of the six chains identified. Telephone interviews
with the chain pharmacy mangers were conducted during November 2010 - January
2011 by members of the KASPER evaluation team. A series of standard questions,
similar to those posed to the independent pharmacists during the APSC stakeholder
interview in August, were presented to the participants. The full set of questions is
included in Appendix 4. Combined, the four chains operated over 400 pharmacies
geographically dispersed across Kentucky which dispensed on average approximately
300 prescriptions per pharmacy daily.
As with the independent pharmacist stakeholder interviews, the responses to the
questions were documented and reviewed for themes that emerged across all four
interview sessions with the chain pharmacy managers. The major themes that emerged
from each of the questions are summarized below.
How is controlled substance prescription information currently transmitted
to KASPER from your pharmacy? Does this transmission require any
actions on your part (or by someone else in the pharmacy)?
Representatives from all four chain pharmacies indicated that CS prescription
information is transmitted via batch file through RelayHealth to the KASPER
program and that this process is done ‘behind the scenes’ with no action required
on the part of the pharmacist at the pharmacy level. Currently, Kentucky law
mandates transmission of CS data to the KASPER program every seven days,
two of the chains reported transmitting data to KASPER on a more frequent basis
(twice a week and daily).
Is your prescription dispensing system capable of real-time data
transmission at the point of controlled substance dispensing? If not, what
needs to be changed in order to accommodate this?
11
Representatives from all four chains answered this question with a resounding
“no”. When questioned further, all said while the technology is available that
would allow for real-time transmission of CS prescription data to KASPER,
changes to the dispensing system software would be required. “I can answer this
for the entire industry – NO. Obviously we could, I mean there are some triggers
we could add….but that would be a significant development effort and I’m not
sure what that gets us.” Another participant stated “We would have to make
changes to it. Most of the information we consider real-time today is
adjudication. Oklahoma is looking at it right now and we have to make changes.
I would question the reason why – I don’t understand why it would need to be
real-time versus a daily batch transmission.”
Additionally, much discussion on this question surrounded the definition of ‘realtime’ and the problems that would be encountered during the dispensing process
workflow should real-time be defined as the point-of-sale, rather than at the point
of prescription processing and adjudication. Clearly if real-time is defined as
point-of-sale vs. point-of-adjudication, then costs associated with purchasing and
using integrated point-of-sale systems would be incurred by those pharmacies
that currently do not utilize them. Concern was voiced regarding transmission of
data at the point of processing/adjudication, which then would be available
immediately to the provider via KASPER reports and could present misleading
information upon which a provider might take unnecessary action. “There are a
multitude of definitions of dispensing. The step of adjudication can be viewed as
‘real-time’ but when exactly is dispensing? When you hand it to the customer?
Which step in the process is real-time….at point of sale or when it’s
adjudicated?”
What costs do you incur under the current system that requires data
transmission to KASPER every seven days? How would these costs
change if KASPER moved to real-time data transmission?
All agreed there would be a cost associated with moving to a real-time or near
real-time model of CS prescription data transmission to KASPER. While
individual participants from the various chains estimated these costs differently,
the general consensus of this group of stakeholders was that the costs would be
associated with building the IT solutions to accomplish real-time, once built and
deployed, routine maintenance costs would not be that different than they are
currently. “There’s not so much of a cost once the infrastructure is there to
support it. The IT resources are a cost – not so much to get it deployed but to
build it…..I would say it would be north of $100,000 to build this.” Another
participant responded “The development work is what would be expensive. I
don’t think daily would be nearly as difficult as real-time. When we went from
weekly to twice a week it was relatively smooth.”
12
What do you see as the biggest obstacle to real-time data transmission at
the point of controlled substance dispensing?
In response to this question, a couple of participants first replied: “Why is it
needed?” “What is the rationale behind the move to real-time?” They went
further to express their concerns relative to the role of the pharmacist as a ‘law
enforcement’ official. “Is the pharmacist going to get information back in realtime so that they can act as a policeman…are they supposed to stop that
prescription that they catch from going through?” Additionally, one participant
questioned why the state was focusing on catching the “1% of the population that
attempt to get CS drugs” for non-medical needs.
What do you perceive as the advantages of real-time data transmission at
the point of controlled substance dispensing?
None of the four chain participants articulated any advantage to real-time data
transmission. “I don’t really see an advantage to real-time…we are health care
providers. Nowhere in the definition does it say we are law enforcement.”
Another participant stated “I don’t see an advantage the way that it is being
proposed.”
What do you perceive as the disadvantages of real-time data transmission
at the point of controlled substance dispensing?
Participants suggested cost and the IT resources it would take to develop a
system compatible with real-time reporting. Participants continued to question
the value of real-time over daily transmission. “It would help if we could
understand what the benefits of it are. Is someone going to be acting on this
real-time? Otherwise what’s the difference between real-time and nightly?”
“Real time sounds good but I am worried about the unintended consequences. A
legitimate patient could be denied care because of interpretation of what the
pharmacist sees in the data.” “What do you do with someone who has a reaction
with one drug and so goes back to the doctor the same day and it looks bad to
you on a KASPER report, but it’s really a normal situation.
Do you have any suggestions regarding how KASPER could obtain
controlled substance data from Kentucky pharmacies in real time?
The consensus of the participants again was related to understanding why realtime is advantageous over daily reporting. Additionally, participants indicated
that if the state were to mandate real-time reporting, it should be done in a way
that would not impact workflow. One participant stressed the need for ample
implementation time. “Once you define real-time, the implementation has got to
be a minimum of six months” Ultimately, although participants questioned the
13
value of real-time, the general consensus was that if it were mandated, it could
be done. “If the legislature says real-time has to be done then we will comply.”
VI. Survey of Non-Pharmacy Dispensers of Controlled Substances
The purpose of the survey was to gather information from non-pharmacy dispensers of
CS, including dispensing physicians, dentists and veterinarians, to identify the effort and
costs associated with providing data real-time to the KASPER program. The survey
questions were developed with input from KASPER and CHFS staff and copies of the
survey instruments are provided in Appendices 5 and 6. The survey protocol was
approved by both the CHFS Institutional Review Board (IRB) and the University of
Kentucky IRB.
A. Survey Methodology
The survey methodology followed a slightly modified version of the method described by
Dillman5. The sample of physician dispensers included all physicians reporting CS
dispensing to the eKASPER program through RelayHealth on July 14, 2010. A total of
24 unique physician dispensers were identified in the provided dataset. Due to the
small number of individuals in the sample, all identified physician dispensers were
mailed a survey packet containing a plain text survey form and a business reply
envelope with return postage. One week following the mailing of the survey packet, a
postcard was sent that thanked those who had returned the questionnaire and asked
those who had not to please do so. Anyone who had not responded after the postcard
wave was then sent a second copy of the questionnaire packet. This second mailing
occurred two weeks after the first survey was sent.
The veterinarian sample included all veterinarians reporting CS dispensing to the
eKASPER program through Relay-Health on July 13, 2010. A total of 47 unique
veterinarian dispensers were identified in the provided dataset and were mailed surveys
as described above.
Although the original scope of work called for the administration of a survey to
dispensing dentists, the KASPER program manager indicated that no dispensing
dentists were registered with KASPER to report CS dispensing as of July 14, 2010.
B. Survey Findings
1. Response Rates
Seven surveys sent to physician dispensers were returned due to invalid addresses,
decreasing the final number of physician dispensers in the sample from 24 to 17.
Four responses were received from dispensing physicians for a response rate of
approximately 24%.
_________________
5
Dillman DA. Mail and telephone surveys: the total design method. New York: John Wiley & Sons,1978.
14
Seven surveys sent to veterinarian dispensers also were returned due to invalid
addresses decreasing the final number of veterinarian dispensers in the sample from 47
to 40. Twenty-six responses were received for a response rate of approximately 65%.
Overall response rate from the two groups was 53% and is similar to response rates
reported for other surveys of health care providers. Complete summary tables of survey
responses by group (physician and veterinarians) are included in Appendices 7 - 8.
2. Dispensing Physician Responses
Four (75%) responding physicians reported dispensing CS prescriptions daily whereas
1 (25%) reported dispensing CS prescriptions one or more times per week. The
reported number of CS prescriptions dispensed per month ranged from 11 -25 to
greater than 100. All dispensing physicians that responded to the survey reported they
frequently (75%) or always (25%) requested a KASPER report of a patient’s CS
prescription history prior to dispensing.
All responding physicians indicated they currently submit CS dispensing information to
KASPER on a weekly basis and all report having internet access at the practice site via
desk-top and/or laptop computers. Two respondents (50%) indicated they submit data
electronically while one respondent (25%) listed completing the approved paper form
and submitting via fax to RelayHealth as the method of data reporting. One respondent
did not answer this question.
When asked about the costs associated with the current method utilized for data
reporting to KASPER, none indicated any costs incurred other than personnel time
required to complete and submit the data report. When asked how these costs would
change if KASPER changed to require real-time internet-based data submission of CS
prescription information, one physician indicated no change while three indicated
additional costs would be incurred relative to more personnel time and costs associated
with making the technological changes to make software capable of real-time
submission.
When asked to identify the biggest obstacle to real-time data transmission at the point
of CS dispensing, physician dispensers reported that setting up the program software to
transmit and the costs associated with those software changes. When asked regarding
suggestions on how KASPER could obtain CS data from the practice in real-time, one
respondent noted “It would work if the computer software people could make a link or
submission button for staff to use at check-out.”
Complete summary tables of survey responses are included in Appendix 7.
15
2. Dispensing Veterinarian Responses
The majority (61%) of responding veterinarians reported dispensing CS prescriptions
one or more times per week whereas nine (35%) respondents reported dispensing CS
prescriptions daily. The majority (42%) reported dispensing only between 0-10
CS prescriptions per month, while only 12% of respondents reported dispensing 51 –
100 CS prescriptions per month. The vast majority (89%) of dispensing veterinarians
that responded to the survey reported they do not request a KASPER report prior to
dispensing with only one respondent reporting that a KASPER report is requested prior
to each prescription dispensed.
Over two-thirds (73%) of dispensing veterinarians indicated they currently submit CS
dispensing information to KASPER on a weekly basis while the remaining 7 (27%)
indicated varying other time frames of submission, including every 8 – 10 days, every 9
days, biweekly, and monthly. When asked about internet access at the practice site, all
but 5 respondents indicated access is available via desk-top and/or laptop computers.
Most dispensing veterinarians submit data on dispensed CS prescriptions by completing
the approved paper from and submitting it via fax (65%) or mail (23%) to RelayHealth.
Only two (8%) indicated submitting CS data via electronic means. Thus, when asked
how workflow would be impacted if KASPER were to begin requiring real-time
submission of CS prescription information at the time of dispensing, not surprisingly 16
(62%) indicated it would have a major impact on workflow for a variety of reasons,
mainly related to internet access and software issues. A complete list of reasons cited
can be found in Appendix 8.
When asked about the costs (other than the personnel time required to complete and
submit the data) associated with the current method utilized for data reporting to
KASPER one-fourth (27%) reported incurring costs such as postage, cost of fax and
long-distance charges, paper to copy forms, etc. When asked how these costs would
change if KASPER changed to require real-time internet-based data submission of CS
prescription information, 10 (40%) of respondents indicated no change in costs would
occur whereas 15 (60%) indicated additional costs would be incurred relative to more
internet access, increased personnel time and costs associated with making the
technological changes to make software capable of real-time submission.
When asked to identify the biggest obstacle to real-time data transmission at the point
of CS dispensing, veterinarian dispensers reported a variety of obstacles including
incompatible software, lack of internet access, disruption of workflow, time, and training.
Complete summary tables of survey responses are included in Appendix 8.
16
VII.
Software Vendor Interviews
Seven major vendors providing dispensing system software to pharmacies in Kentucky
were identified for potential stakeholder interviews. Vendors were identified based on
feedback from the independent pharmacy stakeholder interview and from the chain
pharmacy managers’ interviews. Initial contact with software vendors was made via
company websites and through assistance from the ASAP. Once the contact
information for appropriate individuals to interview was obtained, emails requesting
participation in the telephone interviews were sent by the KASPER evaluation team.
Positive responses, implying consent to participate in the study, were received from 3 of
the 7 vendors identified, including one vendor who offers 9 unique pharmacy
management systems. Telephone interviews with the software vendors were
conducted during March and April 2011 by members of the KASPER evaluation team.
A series of standard questions were presented to the participants. The full set of
questions is included in Appendix 9. Combined, the 3 vendors represented 11
pharmacy management systems currently utilized in several hundred pharmacies
throughout Kentucky. In addition to the software vendors, a representative for ASAP,
which sets the current standard for PMP data transmission also was interviewed.
As described previously, the responses to the questions were documented and
reviewed for themes that emerged across the 3 interview sessions with the software
vendor representatives and the ASAP representative. The major themes that emerged
from each of the questions are summarized below.
How does your software transmit data to KASPER? Does this transmission
require any action on the part of the pharmacists or other person at the
individual store level?
According to the participants, this varies based on the individual management
system in question. Some of the newer systems conduct the reporting in the
background, mostly behind the scenes while other older systems require some
facilitation by the pharmacists to indicate that the batch file is ready to be submitted.
Other pharmacies may be using the automatic extraction process at the point of
adjudication through RelayHealth.
What changes have you made for other state PMPs? Ex, Oklahoma real-time
law? What were the costs associated with these changes? What were the
lessons learned?
Format changes to keep up with data standards such as those required by NCPDP,
ASAP, and individual state PMP requirements, are ongoing. According to one
participant the costs associated with keeping up with PMP program requirements
has increased. “In the past, PMP reporting has been a fairly minor piece of work so
it hasn’t been carved out separately from other parts of our programs. We are now
getting to the point where we are tracking the hours that it takes for functionality.”
When asked regarding lessons learned, having a national standard common across
17
all states’ PMPs so individual coding does not have to be done for each state and
timing were identified as two major lessons learned. “Having to individually code for
each and every state is very cumbersome and costly from a programming
standpoint.” Another participant stated “The most challenging part has been the
timing – it has been really bad but it’s not their (OK PMP) choice. They have a piece
of legislation they have to comply with. The new CMS standards for pharmacy
begins January 1, 2012, and this coincides with the deadline for OK’s PMP, so the
choice for us is between claims (for CMS deadline) and PMP stuff.”
If real-time transmission of dispensing information is defined as transmission
that occurs from the site of dispensing to the KASPER program at the point of
sale – when the prescription is picked up by the patient for whom it was
prescribed. With this definition in mind is your software capable of real time
data transmission at the point of controlled substance dispensing? If not, is it
capable of real-time transmission at the point of adjudication? How could it
be modified to support real time? How much effort or cost would this require?
How long would the conversion take?
The general consensus was that no software system is currently able to handle CS
data transmission to the PMP database real-time at the point of sale. “Right now we
can do it at the point of adjudication.” Another participant stated: “None of our
systems are currently able to handle it real-time at the point of sale.”
Issues regarding transmitting data at the point of adjudication or billing were raised.
“There are a lot of challenges to tying PMP reporting to billing. Those two things are
not meant to be done in one step, they are meant to be done in separate steps.”
“There are a lot of caveats of using the switch – cash prescriptions don’t go through
the switch, pharmacy off-line plans (like with a local employer) don’t go through,
partial fills and long-term-care cycle fills.”
When asked regarding the effort or cost associated with software modifications to
support real time data transmission participants replied “It would require significant
programming effort, not sure of the costs yet.” Another stated “I could try to get
some more precise cost estimates if needed, but my own gut feel estimate for a
given pharmacy system is on the order of the lower tens of thousands.” One
participant noted “We are spending considerably more (to ensure PMP compliance)
than in the past and have considered passing these costs along to the pharmacies.”
When asked how long it would take for conversion of software to support real-time
data transmission, participants were unsure. “Not sure, it’s a fairly big programming
effort.” Another stated: “Once Oklahoma is done we will have a lot of functionality
problems solved. OK has the most clear and current standard based on ASAP.
Moving to ASAP 4.1 would be even more clear. As long as you aren’t on something
before ASAP’95 it’s not a big deal.”
What is the greatest obstacle to real time data transmission?
All participants suggested time as the greatest obstacle. “If the timeline is really
short and aggressive it is a problem. It seems like you could require it by the latter
half of 2013 and that would be okay.” Another stated: “Just making the time for
18
(PMP) programming vs. the time needed to meet the other state/federal regulations
that are due later this year.”
If Kentucky moves to real time transmission, what do you perceive are the
pitfalls for the implementation at the pharmacy?
In response to this question, a participant questioned whether KASPER would
require point of sale for data transmission or if there would be a real-time process
outside of point of sale. Another participant stated: “Why real-time? Incomplete
data, etc may cause errors. You might make a mistake calling someone a doctor
shopper.” “If you go real time, then you have issues like clerk danger, putting
people in bad positions to deny a client a prescription.”
Any other issues we should consider?
Several interesting points were raised in response to this question. First, one
participant suggested that the logistics of going real-time would significantly impact
workflow. Would CS prescription data go to the PMP and then be ‘accepted’ by the
PMP before being sent to the payer for adjudication? To this individual, it seemed
the only advantage to real time is to stop the prescription transaction. If that is not
the intent then states can get close to real time by having nightly batches. No
special software development would be required and this would considerably reduce
the time lag in data for providers who request KASPER reports. “States are
truncating the time frame for submitting the files. They could send batch files every
hour, daily, etc. This is preferable to real time and could be very fast but would not
impact the transaction process and workflow.”
Vendor representatives also expressed appreciation for the outreach efforts being
made by CHFS and the KASPER program. “Bringing in the vendors like you are,
that really helps to make this stuff work. Ask these questions and get a good
assessment and give adequate time for the changes that have to occur in the
system. Try to keep the playing field as level as possible there has been some
concern in Oklahoma that mail order does not have to follow the same rules.”
VIII. Summary and Recommendations
PMPs have been implemented by states as a mechanism to address the growing public
health crisis of prescription drug abuse. PMP characteristics vary considerably among
the states, including the frequency with which CS prescription data is reported from
dispensers to the state PMP databases. While the majority of states require weekly or
biweekly reporting, three states require daily reporting (Minnesota, North Dakota and
Oklahoma) and one state - Oklahoma - has a mandate effective January 1, 2012 for
‘real-time’ reporting defined as within 5 minutes of the point-of-sale of a CS prescription
at a pharmacy or other dispenser6.
___________________
6
Oklahoma Bureau of Narcotics and Dangerous Drugs Control Prescription Monitoring Program, accessed May 24, 2011,
http://www.ok.gov/obndd/documents/Oklahoma%202009%20PMP%20Transmission%20Manual%20v5.0.pdf
19
Currently, dispensers of CS in Kentucky are required to report CS prescription data to
the KASPER program database weekly.
To identify the barriers to submission of CS prescription data to the KASPER program in
real-time and to gather opinions on the advantages and disadvantages of real-time
reporting, multiple approaches were taken, including an interview with the Oklahoma
PMP manager, a continuing education program and stakeholder interview with
independent pharmacy providers, stakeholder interviews with representatives from retail
pharmacy chains, surveys of non-pharmacy dispensers of CS and stakeholder
interviews with pharmacy software vendors. The information gleaned from these
approaches was used to inform the recommendations outlined herein.
At the onset of this study, Oklahoma was identified as the only state currently moving
toward real-time data transmission. Dispensers are required to report CS prescription
data to the PMP daily at the present time and within 5 minutes of the sale of CS (point
of delivery to the patient or patient representative) effective January 1, 2012. Overall, it
appears from the information gleaned from the Oklahoma PMP program manager that
the keys to success for implementing real-time data transmission to the PMP database
include involving all stakeholders in the implementation process and providing ample
time for planning and preparation before implementing a mandated change to real-time
reporting.
The continuing education program on KASPER and technology enhancements was well
received by the independent pharmacists in the audience who were engaged and
interested in providing feedback. Independent pharmacists questioned the definition of
real-time (point of sale vs. point of adjudication). Approximately one-third of
independent pharmacists in the audience reported not having an integrated point of sale
system at the present time. Thus, if KASPER were to define real-time reporting as at
the point of sale, the costs associated with purchasing and using integrated point-ofsale systems would be incurred by those pharmacies that currently do not utilize them.
Additionally, participants questioned the value of real-time. Specifically, they questioned
the role of the pharmacist as gatekeeper vs. the role of the prescriber. Finally, many
independent pharmacists who use automatic extraction through RelayHealth as the
current method for data reporting are under the misimpression that switching fees are
incurred for data submission. This clearly represents an educational opportunity for the
Cabinet and KASPER program officials.
Similar to the independent pharmacy stakeholders, chain pharmacy representatives
questioned the definition of real-time and raised significant issues relative to the impact
of real-time reporting at the point of sale on pharmacy workflow and the accuracy of
data if real-time reporting occurs at the point of adjudication. Additionally, because
chain pharmacies typically have their own proprietary pharmacy management software
20
systems, the chain pharmacy managers were also able to provide some perspectives
on the costs associated with making the technological changes needed to accomplish
real-time data transmission.
While the majority did not specifically state a cost, all agreed ‘significant costs’ would be
incurred and one company representative suggested the costs associated with
developing and implementing software changes needed for real-time transmission
would cost over $100,000.
Surveys of non-pharmacy dispensers of CS including physicians and veterinarians
gleaned similar information. According to respondents, significant costs would be
incurred if real-time data reporting were mandated. Although some currently submit
data electronically, the vast majority of non-pharmacy dispensers responding to the
survey indicated that data were currently submitted via the required paper form and
transmitted via facsimile to RelayHealth. Additionally, several non-pharmacy
dispensers reported having no internet access for web-based submission of data should
it be required in the future by the KASPER program. Notably, some non-pharmacy
dispensers report they currently submit CS prescription data to the KASPER program
every 14 days. Considering that current state law mandates that all dispensers of CS
report CS prescription information to KASPER every 7 days, it appears that this is an
additional educational opportunity for the Cabinet.
Finally, interviews with representatives from pharmacy management system software
vendors and a representative from the ASAP were conducted and, as with other
stakeholders, these participants questioned the value of real-time reporting. Although
all agreed the technology is available to implement real-time reporting, the general
consensus was that no software system is currently able to handle CS data
transmission to the PMP database real-time at the point of sale. Without extensive
programming changes, representatives indicated real-time transmission could occur
only at the point of adjudication.
When considering real-time vs. more frequent batch reporting, one must question the
rationale behind the desire for real-time. From a healthcare practitioner who requests
KASPER reports for treatment decisions viewpoint, what additional value is gained by
seeing real-time data vs. data that is 24 hours old for example? Is the desire of realtime reporting to stop the prescription from being written or is it to stop the prescription
from being dispensed? There appears to be differences in the need for and desire of
current information when viewed from a regulatory (legal) vs. healthcare provider
standpoint.
21
Data from an independent evaluation of the KASPER program7, as well as from the
2010 Satisfaction Survey8 conducted by KASPER indicate that nearly every user of
KASPER believes KASPER is effective at reducing doctor shopping and curbing the
abuse and diversion of CS prescriptions. Furthermore, data indicate that when utilized,
the information in a KASPER report impacts healthcare treatment decisions.
However, in 2009 only 27.5% of prescribers and 16% of dispensers were registered
KASPER users. This begs the question from a policy standpoint whether a more costeffective approach to enhancement of KASPER would be finding mechanisms by which
the use of KASPER for treatment decisions is increased.
The take home message from all stakeholders relative to the biggest obstacle in
KASPER moving to real-time was the need to understand why real-time reporting is
needed vs. implementing more frequent batch transmission (i.e., daily). Daily batch
transmission would serve to improve the currency of information available for
prescribers and dispensers to use for treatment decisions at the point of care but would
not be associated with any implementation costs for CS dispensers. The Cabinet
should consider whether daily transmission, coupled with strategies to increase the use
of KASPER by prescribers and dispensers, would be a more cost-effective mandate for
all involved than one for real-time reporting.
Considering the overall results from the study, one can look at the policy options to
reduce abuse and diversion as choices along a program-benefit/program-expense
continuum. One can view program expenses in a broad sense consisting of the actual
cost to operate the program, the ‘expense’ for providers and pharmacies, and the
‘expense’ to patients. Benefits are similar, with program benefits to patients, providers,
and the state/public. Ideally, any program should deliver the maximum benefit for the
lowest expense: an efficient program. When additional program expenses begin to
deliver fewer benefits per expense, policy makers use the term “flat-of-the-curve” to
denote diminishing marginal returns, or the point where additional program expense
yields very little increase in benefits.
Consider the following hypothetical graph (Figure 4) depicting policy options for the
reporting frequency for the KASPER program. The current program based on weekly
reporting produces benefits for the current expense. Based on survey data and
information from stakeholder interviews, it appears that moving to daily reporting would
incur little additional expense and likely yield additional program benefits.
______________________
7
Independent Evaluation of the Kentucky All Schedule Prescription Electronic Reporting (KASPER) Program, accessed June 11, 2011,
http://chfs.ky.gov/NR/rdonlyres/24493B2E-B1A1-4399-89AD-1625953BAD43/0/KASPEREvaluationFinalReport10152010.pdf
8
2010 KASPER Satisfaction Survey, accessed June 11,2011, http://chfs.ky.gov/NR/rdonlyres/BDC0DFC9-924B-4F11-A10A5EB17933FDDB/0/2010KASPERSatisfactionSurveyExecutiveSummary.pdf
22
Program Benefit
Figure 4: Benefit-Expense Continuum for PDMP Reporting Frequency
Daily Reporting
Real-Time Reporting
Weekly Reporting
No Program
Program Expense
Moving to real time reporting requires a much greater program expense and likely
produces few additional benefits over daily reporting.
Again, if the ideal point is locating where benefits of the program are greatest for the
lowest expense, our current analysis, taken from the information gleaned from
stakeholder interviews and dispenser survey, suggests that moving beyond daily
reporting requires considerable new program expense while likely only producing
modest gains in benefits.
As the Cabinet considers strategies to improve the KASPER program, a range of
options—beginning with simple program operational changes to increase the
effectiveness of the current program to more complex changes focused on increasing
use of KASPER reports prior to making prescribing decisions – should be considered.
The following potential policy modifications are proposed for consideration.
Policy Options for Improving the Effectiveness of KASPER to Reduce
Prescription Drug Abuse and Diversion:
•
Increase the effectiveness of the current program. Optimize CHFS policy
and statutes to allow review of program outliers. A recent review of the KASPER
program revealed considerable variation across providers in prescribing CS in
Kentucky9. Most providers issue very few CS prescriptions. For example, the
typical KASPER account holder issued an average of 1,665 CS prescriptions in
2009, compared to 250 CS prescriptions issued by non-account holders. Yet the
distribution of prescribing is highly skewed; in 2009, 90% of all CS prescribers
issued fewer than 2,500 CS prescriptions.
______________________
9
Independent Evaluation of the Kentucky All Schedule Prescription Electronic Reporting (KASPER) Program, accessed June 11, 2011,
http://chfs.ky.gov/NR/rdonlyres/24493B2E-B1A1-4399-89AD-1625953BAD43/0/KASPEREvaluationFinalReport10152010.pdf
23
•
•
If one defines the top and bottom 1% as outliers on either end of the CS
prescribing continuum, a review of the top 1% of CS prescribers shows that in
2009 the top prescribers in this bracket issued more than 40,000 CS
prescriptions. The Cabinet should work with the medical licensing boards to
establish a review process of outlier prescribers to ensure the safety of Kentucky
patients.
Encourage use of KASPER. From 2002 to 2009 CS prescribing in Kentucky
increased by 40% and KASPER system requests increased by 400%. Prescriber
use of the KASPER system is growing, but only about 27% of prescribers have
registered accounts. The Cabinet should consider options to increase prescriber
use of KASPER.
o Increase outreach and continuing education effort on the use of KASPER
and its usefulness in making informed CS prescribing decisions.
o Require all CS prescribers to have KASPER accounts.
o Require providers to review KASPER reports for all new CS prescriptions,
with mandatory review of KASPER reports every 6 months when
prescribing CS for long-term use.
o Implement proactive KASPER reporting, where potential outlier use of CS
by patients triggers a KASPER alert sent to prescribers.
Improve the operation of the current program. With more prescribers using
the KASPER program, the efficiency of the program could be improved by
moving from weekly reporting to daily reporting at little to no cost to dispensers.
24
Appendix 1: Slide Set for Continuing Education Program and Independent
Pharmacy Stakeholder Interview
25
26
27
28
29
30
31
32
Appendix 2: RelayHealth Instructions for Submitting Electronic Batch Files
33
34
Appendix 3: RelayHealth Instructions for Automatic Extraction of Prescription
Data
35
36
37
Appendix 4: Questions for Phone Interviews of Chain Pharmacy Managers
•
What is your role within the company?
•
How many individual pharmacies are operated by your company in Kentucky?
•
What is the geographic distribution of your company’s pharmacies in Kentucky?
•
What is the average volume of prescriptions dispensed daily in your company’s Kentucky
pharmacies?
o What percent of this volume is represented by controlled substances?
•
Are your pharmacists able to request KASPER reports for clinical decision-making at
point of dispensing?
o If so, any insight on how frequently KASPER reports are utilized?
•
How is CS data currently transmitted to KASPER from your company’s pharmacies in
Kentucky? Does this transmission require any actions on the part of the pharmacist or
other person at the individual store level? What is the frequency of transmission?
•
Are there any specific policies/procedures pertaining to KASPER e.g. who can transmit,
etc.?
•
Which prescription dispensing system does your company use?
•
Is your company’s prescription dispensing system capable of real-time data transmission
at the point of controlled substance dispensing?
o If your prescription dispensing system is not capable of real-time data
transmission at the point of controlled substance dispensing, what needs to be
fixed in order to accommodate this?
•
Under the current system that requires data transmission to KASPER every seven days,
what costs are incurred by your company?
o How would these costs change if KASPER moved to real-time data transmission?
•
What does your company see as the biggest obstacle to real-time data transmission at
point of CS dispensing?
38
•
What does your company perceive as the advantages of real-time data transmission at
point of CS dispensing?
•
What does your company perceive as the disadvantages of real-time data transmission at
point of CS dispensing?
•
Does your company have any suggestions regarding how KASPER could obtain CS data
from Kentucky pharmacies in real time?
39
Appendix 5: Dispensing Physician Survey
The Kentucky Cabinet for Health and Family Services has contracted with the University
of Kentucky to conduct a survey of non-pharmacy dispensers of controlled substances,
including physicians, dentists and veterinarians. The information will be used to improve
the Kentucky All Schedule Prescription Electronic Reporting (KASPER) Program so that it
better meets the needs of those who utilize it.
You may skip any question that you do not want to answer and may write comments next
to any question or on a separate page. Your answers are anonymous and your name will
not be used in any report.
Please return the survey using the postage paid envelope within the next two weeks.
If you have any questions about the survey please call Patricia Freeman at 859-323-1381. If
you have any questions about your rights as a volunteer in the research, contact the Office
of Research Integrity at the University of Kentucky at 1-866-400-9428. Thank you for your
assistance.
1) How frequently do you dispense controlled substances directly to patients? (Please do not
include instances when you write a prescription and send a patient to a local pharmacy to
obtain medication, only include instances when you dispense directly to the patient.)
a. Daily
b. Usually one or more times a week
c. Usually one or more times a month
d. Less than once per month
2) Approximately how many controlled substance prescriptions do you dispense directly to
patients per month on average?
a. 0-10
b. 11-25
c. 26-50
d. 51-100
e. >100
3) The KASPER program allows prescribers to request information about a patient’s controlled
substance prescription history. Do you (or does someone in your practice) typically request
a KASPER report of a patient’s controlled substance prescription history prior to dispensing
a controlled substance?
a. Yes, every time
b. Yes, frequently
c. Yes, rarely
d. No
4) How do you currently submit controlled substance dispensing information to the KASPER
data collection agent: RelayHealth?
a. Complete paper form by hand and FAX
b. Complete paper form by hand and Mail
c. Maintain a computer spreadsheet and submit via email, FAX, or mail
40
d. Electronic submission from practice management or other software system
e. Other_______________________
5) Who in your practice completes and submits the controlled substance dispensing
information to KASPER?
a. The prescriber completes and submits the information
b. A physician’s assistant completes and submits the information
c. A nurse completes and submits the information
d. A technician completes and submits the information
e. Other staff member (not listed above) completes and submits the information
6) How often do you currently submit controlled substance dispensing information to
KASPER?
a. Daily
b. Weekly
c. Other _________________
7) Does your primary practice site currently have Internet access?
a. Yes, via a desktop computer
b. Yes, via a laptop computer
c. Yes, via a “smart” phone
d. No
8) If the KASPER program started requiring data submission via the Internet at the time of
dispensing a controlled substance (in other words, in “real-time”), how do you anticipate
this would impact your work flow?
a. No impact
b. Slight impact
c. Major impact – please describe _______________________________________
9) Aside from personnel time, are there other costs that you incur under the current system
for submitting controlled substance information to KASPER?
a. No
b. Yes – please describe _______________________________________________
10) Would your costs change if KASPER moved to real-time Internet-based data submission?
a. No
b. Yes – please describe_______________________________________________
11) What do you see as the biggest obstacle to real-time data transmission at the point of
controlled substance dispensing?
12) What do you perceive as the advantages of real-time data transmission at the point of
controlled substance dispensing?
13) What do you perceive as the disadvantages of real-time data transmission at the point of
controlled substance dispensing?
14) Do you have any suggestions regarding how KASPER could obtain controlled substance data
from your practice in real time?
41
Appendix 6: Dispensing Veterinarian Survey
The Kentucky Cabinet for Health and Family Services has contracted with the University
of Kentucky to conduct a survey of non-pharmacy dispensers of controlled substances,
including physicians, dentists and veterinarians. The information will be used to improve
the Kentucky All Schedule Prescription Electronic Reporting (KASPER) Program so that it
better meets the needs of those who utilize it.
You may skip any question that you do not want to answer and may write comments next
to any question or on a separate page. Your answers are anonymous and your name will
not be used in any report.
Please return the survey using the postage paid envelope within the next two weeks.
If you have any questions about the survey please call Patricia Freeman at 859-323-1381. If
you have any questions about your rights as a volunteer in the research, contact the Office
of Research Integrity at the University of Kentucky at 1-866-400-9428. Thank you for your
assistance.
1) How frequently do you dispense controlled substances directly to pet owners? (Please do
not include instances when you write a prescription and send a pet owner to a local
pharmacy to obtain medication, only include instances when you dispense directly to the
pet owner.)
□ Daily
□ Usually one or more times a week
□ Usually one or more times a month
□ Less than once per month
2) Approximately how many controlled substance prescriptions do you dispense directly to
pet owners per month on average?
□ 0-10
□ 11-25
□ 26-50
□ 51-100
□ >100
3) The KASPER program allows prescribers to request information about a patient/pet’s
controlled substance prescription history. Do you (or does someone in your practice)
typically request a KASPER report of a patient/pet’s controlled substance prescription
history prior to dispensing a controlled substance?
□ Yes, every time
□ Yes, frequently
□ Yes, rarely
□ No
4) How do you currently submit controlled substance dispensing information to the KASPER
data collection agent: RelayHealth?
□ Complete paper form by hand and FAX
□ Complete paper form by hand and Mail
42
□
□
□
Maintain a computer spreadsheet and submit via email, FAX, or mail
Electronic submission from practice management or other software system
Other__________________________
5) Who in your practice completes and submits the controlled substance dispensing
information to KASPER?
□ The prescriber completes and submits the information
□ A nurse completes and submits the information
□ A technician completes and submits the information
□ Other staff member (not listed above) fills out and submits the information
6) When filling out the form, what does your practice site use for the “Patient (Owner) ID
Number”?
□ Pet owner’s social security number
□ Patient/pet’s medical record number
□ Other___________________________
7) How often do you currently submit controlled substance dispensing information to
KASPER?
□ Daily
□ Weekly
□ Other ___________________________
8) Does your primary practice site currently have Internet access?
□ Yes, via a desktop computer
□ Yes, via a laptop computer
□ Yes, via a “smart” phone
□ No
9) If the KASPER program started requiring data submission via the Internet at the time of
dispensing a controlled substance (in other words, in “real-time”), how do you anticipate
this would impact your work flow?
□ No impact
□ Slight impact
□ Major impact – please describe _______________________________________
10) Aside from personnel time, are there other costs that you incur under the current system
for submitting controlled substance information to KASPER?
□ No
□ Yes – please describe _______________________________________________
11) Would your costs change if KASPER moved to real-time Internet-based data submission?
□ No
□ Yes – please describe_______________________________________________
12) What do you see as the biggest obstacle to real-time data transmission at the point of
controlled substance dispensing?
43
13) What do you perceive as the advantages of real-time data transmission at the point of
controlled substance dispensing?
14) What do you perceive as the disadvantages of real-time data transmission at the point of
controlled substance dispensing?
15) Do you have any suggestions regarding how KASPER could obtain controlled substance data
from your practice in real time?
44
Appendix 7: Dispensing Physician Responses
Question 1: How frequently do you dispense controlled substances directly to patients? (Please
do not include instances when you write a prescription and send a patient to a local pharmacy
to obtain medication, only include instances when you dispense directly to the patient.)
Daily
3
Usually one or more times a week
1
Usually one or more times a month
0
Less than once per month
0
Total
4
Question 2: Approximately how many controlled substance prescriptions do you dispense
directly to patients per month on average?
0-10
11-25
26-50
51-100
>100
Total
0
1
1
1
1
4
Question 3: The KASPER program allows prescribers to request information about a patient’s
controlled substance prescription history. Do you (or does someone in your practice) typically
request a KASPER report of a patient’s controlled substance prescription history prior to
dispensing a controlled substance?
Yes, every time
Yes, frequently
Yes, rarely
No
Total
1
3
0
0
4
45
Question 4: How do you currently submit controlled substance dispensing information to the
KASPER data collection agent: RelayHealth?
Complete paper form by hand and FAX
Complete paper form by hand and Mail
Maintain a computer spreadsheet and submit via email, FAX,
or mail
Electronic submission from practice management or other
software system
Other__________________________
Total
1
0
0
2
0
3
Question 5: Who in your practice completes and submits the controlled substance dispensing
information to KASPER?
The prescriber completes and submits the
information
A physician’s assistant completes and submits
the information
A nurse completes and submits the information
A technician completes and submits the
information
Other staff member fills out and submits the
information
Total
1
2
0
0
1
4
Question 6: How often do you currently submit controlled substance dispensing information to
KASPER?
Daily
Weekly
Other
________________________
Total
0
4
0
4
46
Question 7: Does your primary practice site currently have Internet access?
Yes, via a desktop
computer
Yes, via a laptop
computer
Yes, via a “smart” phone
No
Total
4
1
0
0
5*
*One respondent selected more than one response.
Question 8: If the KASPER program started requiring data submission via the Internet at the
time of dispensing a controlled substance (in other words, in “real-time”), how do you
anticipate this would impact your work flow?
No impact
Slight impact
Major impact- please
describe______________
Total
0
2
1
3
Question 9: Aside from personnel time, are there other costs that you incur under the current
system for submitting controlled substance information to KASPER?
No
Yes- please describe
_________________
Total
4
0
4
Question 10: Would your costs change if KASPER moved to real-time Internet-based data
submission?
No
1
Yes- please describe
3
_________________
Total
4
“please describe” responses:



More personnel time
Increased cost, time depending on frequency for entry
Initially it would cost to change the software submission capabilities
47
Question 11: What do you see as the biggest obstacle to real-time data transmission at the
point of controlled substance dispensing?


Setting up the program for software to transmit may be costly.
Computer software changes
Question 12: What do you perceive as the advantages of real-time data transmission at the
point of controlled substance dispensing?


Reduce abuse of controlled substances.
Nothing for the office
Question 13: What do you perceive as the disadvantages of real-time data transmission at the
point of controlled substance dispensing?

time
Question 14: Do you have any suggestions regarding how KASPER could obtain controlled
substance data from your practice in real time?

It would work with the computer software people to make a link or submission
button for staff to use at check-out.
48
Appendix 8: Dispensing Veterinarian Responses
Question 1: How frequently do you dispense controlled substances directly to pet owners?
(Please do not include instances when you write a prescription and send a pet owner to a local
pharmacy to obtain medication, only include instances when you dispense directly to the pet
owner.)
Daily
9
Usually one or more times a week
16
Usually one or more times a month
1
Less than once per month
0
Total
26
Question 2: Approximately how many controlled substance prescriptions do you dispense
directly to pet owners per month on average?
0-10
11
11-25
9
26-50
3
51-100
3
>100
0
Total
26
Question 3: The KASPER program allows prescribers to request information about a
patient/pet’s controlled substance prescription history. Do you (or does someone in your
practice) typically request a KASPER report of a patient/pet’s controlled substance prescription
history prior to dispensing a controlled substance?
Yes, every time 1
Yes, frequently
0
Yes, rarely
1
No
23
Total
25
49
Question 4: How do you currently submit controlled substance dispensing information to the
KASPER data collection agent: RelayHealth?
Complete paper form by hand and FAX
17
Complete paper form by hand and Mail
6
Maintain a computer spreadsheet and submit via email, FAX,
or mail
1
Electronic submission from practice management or other
software system
2
Other__________________________
0
Total
26
Question 5: Who in your practice completes and submits the controlled substance dispensing
information to KASPER?
2
The prescriber completes and submits the
information
A nurse completes and submits the information
0
A technician completes and submits the
information
15
Other staff member fills out and submits the
information
9
Total
26
Question 6: When filling out the form, what does your practice site use for the “Patient (Owner)
ID Number”?
Pet owner’s social security number
5
Patient/pet’s medical record number
11
Other____________________________ 5
Total
21
“Other” responses:
•
•
Nothing
[also driver’s license]
50
•
•
•
•
[or DL #]
SSN or DL#
999--medical record- patient ID number
Question 7: How often do you currently submit controlled substance dispensing information to
KASPER?
Daily
0
Weekly
19
Other
________________________
7
Total
26
“Other” responses:
•
•
•
•
•
•
every 9 days
monthly
2x/month
Monthly
every 2 weeks
every 8-10 days
Question 8: Does your primary practice site currently have Internet access?
19
Yes, via a desktop
computer
Yes, via a laptop
computer
4
Yes, via a “smart” phone
1
No
5
Total
29*
*Some respondents reported having more than one of these devices for
accessing the Internet.
51
Question 9: If the KASPER program started requiring data submission via the Internet at the
time of dispensing a controlled substance (in other words, in “real-time”), how do you
anticipate this would impact your work flow?
No impact
1
Slight impact
9
Major impact- please
describe______________
16
Total
26
“Please describe” responses:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
would impact flow a lot, as 1 vet practice and vet fills out all controlled
drugs/kasper paperwork
Would be difficult to interupt work flow to access internet every time Rx is
filled, too busy and staff arrangements would not be conducive to this
method!
Time!
Computer with internet access is not connected to the main hospital
computer system and/or software.
Time problem when in middle of patient treatment having to stop to submit.
Dr. would always want or need technician available to do this job which is
not always possible. Would have to batch them and send at later time.
Linking our software with the internet not everyone in the practice as
control to the internet
It would be very hard to make time or assign a person to this task with
limited staff members on a busy day.
Since we do not have internet nor contemplate having it in the near future it
would be impossible to do so unless it would be impossible to do so unless
we phoned you at each time if a toll-free # was provided.
No direct internet hook-up
no internet
We would need to transmit batch fills in ASAP (American Society of
Automation in Pharmacy) as format. We do not have that capability.
No medical records computerized at this time- only internet and payroll on
computer
No internet access to the prescriber or other employees
1) Most controlled subs are connected to surgery- no computer in surgery
area. 2) Not all employees are proficient on computers- "real time" would
require a shift in responsibilites- may cause confusion- "I didn't do it- I
thought you were doing it," etc.
It takes a long time
I am the accountant and I send the report weekly. I am not here to send the
report on a real time basis.
52
Question 10: Aside from personnel time, are there other costs that you incur under the current
system for submitting controlled substance information to KASPER?
No
19
Yes- please describe
_________________
7
Total
26
“Please describe” responses:
•
•
•
•
•
•
•
faxes- long distances, copies of forms minimal
postage, paper to copy forms
Cost of phone call to fax
long-distance fax #
postage
A notebook and papers copied to put in the notebook and stamps to mail it!
Cost of computer, internet access
Question 11: Would your costs change if KASPER moved to real-time Internet-based data
submission?
No
10
Yes- please describe
_________________
Total
15
25
“Please describe” responses:
•
•
•
•
•
•
•
•
•
•
•
•
•
we would have to purchase different computer software
increase time of employees
integrating computer system
postage, paper to copy forms
no internet
No phone call expense
It would incur costs if we had to have internet connected or, if we had to
make long distance phone calls to report.
Would need direct internet hook-up
we don't have internet
We would have to install computers that have internet access!
Slow down services if we have to, add extra steps to the transactions
if have to hire add'l employees
If we are busy and checking a few people out then it could be longer for
check out time plus our accountant submits this and she is only here for 1-2
days a week.
53
Question 12: What do you see as the biggest obstacle to real-time data transmission at the
point of controlled substance dispensing?
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
we currently don't have the necessary software
Would not be practical in 1 vet practice
Having the time and availability to do so, training all staff for KASPER submission.
Little impact except having to access internet to report prescriptions.
Time
Interfering with work flow. Work stoppage.
Computer software update or add-on
1) Setting up the program to process a submission 2) Training employees and Dr's to use
the process 3) Failure to get all Rx's submitted properly due to various employees involved
in the process, and busy office peak seasons
Trouble setting up. Security. Open internet link.
time and computer/internet purchase
Training every staff member including doctors to do such, and on busy days having time to
complete this task.
I would need someone to explain what would be involved in "real-time data transmission."
Bottlenecking- the ability to get people in and out and all the info needed in to get the
people out
Again, for us #1 would be the fact that we do not have internet. Otherwise, the fact of getting
everyone into the routine of reporting in real-time would be one of the biggest obstacles
and remembering to do it each time.
Finding the time to submit the information.
Time, internet hook-up
Not all of our office computers have internet access so it would be problematic for us.
we don't have internet
Normally the information is gathered and submitted during "down time".
See question 9
Time! We are a small office with very little personnel and no extra money to hire extra help!
1) No easy access to a computer from our surgery 2) Person currently responsible for
reporting- not always available in real time 3) Extra steps to service for clients- stop what
you are doing and fill out form
ease of use
Time for receptionist or technician
Question 13: What do you perceive as the advantages of real-time data transmission at the
point of controlled substance dispensing?
•
•
•
•
•
•
•
•
•
•
•
None to me
More consistency in reporting if executed correctly.
It could actually decrease the amount of written paperwork.
no mailing
Less paperwork. Not many advantages.
better surveillance
Only advantage is not having to do the weekly submissions and not having to fill out
paperwork.
not having to fill out forms
NA
Not having to worry about remembering to sen din prescriptions weekly.
Not sure
54
•
•
•
•
•
•
•
•
•
•
•
NA
If it was an automatic submission and it also coincided with our record keeping it could be a
very good thing.
There would be less paperwork to fill out. It would be less likely to copy incorrect
information.
Faster records update
being current on inventory and able to be sure numbers are correct
Less paperwork although this is not a big issue for us
None
None for my purposes.
None
??
It will be available daily instead of weekly
Question 14: What do you perceive as the disadvantages of real-time data transmission at the
point of controlled substance dispensing?
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Time, training, tech issues
None
Time
Work stoppage- interrupts workflow
initial start-up and integration
Major problem would be not all submissions would get done! Dr's would want tech to do
the job and techs would forget, then the file would be filed away. This has even happened
with proper submissions we have now, but at least we have a slip in the file next time it
opened.
See #12
same as above- question 12- easy errors
Not sure, possibly taking more time when we are really busy.
Not enough staff trained well enough to get all the essential info needed.
Time issues may come into play; when rushed or pressed for time in clinic situation it may
be difficult to be able to report at the time of dispensing if an email or phone call had to be
made each time.
Time issues may come into play; when rushed or pressed for time in clinic situation it may
be difficult to be able to report at the time of dispensing if an email or phone call had to be
made each time.
Finding the time to enter and submit the information.
Internet failures, time to get online
unsure of what it entails
See above #12
it would be impossible
We function on a tight schedule. To have someone stop and submit data would throw the
schedule off.
Time and confusion
Finding someone in my office that has the time and knowledge to do real time reporting
if busy and treating lots of people out at once things not getting submitted or taking to long
to check out
The time it will take technician or secretaries to send. Especially if the clinic is busy! Plus as
a small business we can't hire someone to perform one job.
55
Question 15: Do you have any suggestions regarding how KASPER could obtain controlled
substance data from your practice in real time?
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Availability for remote access to database and records of controlled Rx's.
No
No, not necessary for my limited dispensing
weekly submission of reports online, not sure how we could do it in real time
Sorry, no.
provide computer and internet
An easy program/link to access and apply the proper information- a pop up to remind
whomever is doing the prescription.
No
Info submitted with 24 hrs
If KASPER could link up to the clinic's software or an automatic email submission could be
sent at the time of the transaction for the controlled substance it could easily be ensured
that records were sent/maintained. However, not sure how this could be done- especially
for those who do not have internet capabilities.
A very easy accessible site that is dummy proof.
FAX hard copy
I'm not sure that real-time transmission is necessary
no- see above- no internet
If the procedure was quick and simple
Reporting longer periods of time would be helpful (longer than 8 days)
Why do they need this! We rarely dispense anything now and it's not anything that needs all
this confusion!
Work with software company to collect data directly so a separate transaction would not be
necessary. Software company in this case is "Intravet”.
56
Appendix 9: Questions for Software Vendor Surveys
1. What is your title/role in the company?
2. How many pharmacies in Kentucky use your software?
a. What is the geographic distribution of the pharmacies?
3. How does your software transmit data to KASPER?
a. Does this transmission require any action on the part of the pharmacists or other
person at the individual store level?
4. What changes has your company made for the software to comply with KASPER data
transmission requirements?
5. What changes have you made for other state PMPs? Ex, Oklahoma real-time law?
a. What were the costs associated with these changes?
b. What were the lessons learned?
6. Real Time transmission of dispensing information is defined as transmission that occurs
from the site of dispensing to the KASPER program at the point of sale – when the
prescription is picked up by the patient for whom it was prescribed. With this definition
in mind:
a. Is your software capable of real time data transmission at the point of controlled
substance dispensing? If not, is it capable of real-time transmission at the point
of adjudication?
b. How could it be modified to support real time?
c. How much effort or cost would this require?
d. How long would the conversion take?
7. What is the greatest obstacle to real time data transmission?
8. If Kentucky moves to real time transmission, what do you perceive are the pitfalls for
the implementation at the pharmacy?
9. How does your software interface with RELAY Health?
10. Any other issues we should consider?
57
58