TELEDUR

     Before you learn why, let us review the background that explains the broad acceptance of DUR techniques today.

     Pharmaceuticals, when used properly, are cost- effective and help to reduce the need for more expensive hospitalization and, in some instances, surgical intervention. They also help to keep the elderly independent and out of nursing homes. Consequently, a growing number of healthcare professionals have placed heavy emphasis on drug therapy as the preferred option for patient care.

     Drug Utilization Review ("DUR") was an outgrowth of this paradigm shift. Its objective was, and is today, to enhance and improve therapeutic outcomes that are both clinically appropriate and economically sound. DUR, in its broad application, can be both prospective and retrospective with oversight and review of the dispensing process.

     When a professional asks "Is it appropriate to prescribe this drug?", the optimum answer is found in a fully informed assessment of multiple considerations instantaneously available from DUR. A number of issues need to be considered and each starts with the question: Is this drug,

• acceptable for the clinical situation?"
• the best drug? i. e. - the drug of choice, in the correct dose form, in the correct strength, etc. for the clinical situation.
• the least expensive acceptable drug for the clinical situation?
• clinically appropriate but not reimbursable? (in other words, the drug is the best and the least expensive, but the condition is cosmetic.)
• used excessively?
• significantly changing in its use with time?

     Concurrent DUR occurs before the medicine is dispensed to patients and involves a pharmacist's review of a physician's prescription. The focus of Concurrent and Prospective review is generally about potential adverse drug-to-drug/disease/age/pregnancy reactions, refills to soon, under/over utilization, min/max dosages, duplicate therapy, and the need for patient counseling.

     Clearly, Concurrent DUR is vital to the dispensing pharmacist because it enables early intervention for those rare instances of inappropriate prescribing. Healthcare professionals depend on DUR because they want to identify those situations and prevent or discourage them from recurring.

     Retrospective DUR involves evaluating pharmaceutical therapies after the medications have been dispensed and consumed by the patient. Patterns of dispensing can be analyzed. This capability is invaluable to the drug benefit sponsor's management. They are continually evaluating the feasibility of plan adjustments for improving member satisfaction while reducing costs.

     DP/Rx's TeleDUR is an expanded DUR model of current systems and is thoroughly integrated into the TeleClaim Drug Claims processor. The Concurrent DUR component is incorporated into the on-line, real- time adjudication process and the Retrospective DUR component is used in an off-line module of TeleClaim on an Ad Hoc or scheduled basis.

     TeleDUR allows you to analyze drug use in three ways.

     First, you define the circumstances under which it is inappropriate to use a given drug. This control and compliance regimen is the cornerstone of the system.

     For example, Premarin (estrogen) should not be dispensed to a male patient, The system compares each prescription to the appropriate set of circumstances to determine whether or not the order is acceptable. If not, the system transmits a message to the pharmacist advising of the condition. This is part of the adjudication process.

     Second, the system aggregates individual drug records into user-defined groups as a retrospective function. The reviewer can then see who is doing the most of something. For example, you can tell which physicians are prescribing the most narcotics and to what degree as shown below in Figure 1 .

     Third, the system includes a series of programs that let you retrospectively track trends in usage. These programs enable you to compare the prescribing, dispensing and/or consumption patterns of an individual (physician, pharmacy, patient) or group with the other members of that group, or with itself over time. An example would be an analysis of a recent period versus a comparable period in a previous year of controlled substances of the top prescribing physicians, as shown in Figure 2.

     All three system functions, described above, are created and controlled by the user. TeleDUR provides easy-to-use screen entry of the customizing parameters. Also, the system imports commercially available data and parameters that contribute immensely to the effectiveness Of TeleDUR.

Features and Functions

     Some drugs are used only to treat a specific disease. Some are used only in combination with other drugs and never by themselves . We give some drugs only to women and some only to men. Some drugs we give for a specific time period and no longer. The list of criteria that determine when a drug should be given is very long. Each drug has a unique collection of circumstances that justify its use. We call these circumstances the Compliance Criteria (aka: Absolute Criteria), and they embody a clinical judgment.

     A Compliance Criteria set is the group of individual control and compliance justifications for the use of a given drug,

     After the clinician establishes the Compliance Criteria set for a particular drug, the system compares a specific prescription to the set to see if it is justified. This comparison can be performed at various times in the process. If we compare before the prescription is written, then we call the DUR process Prospective. If we make the comparison after the doctor writes the prescription but before the drug is dispensed, the process is called Concurrent. If it is completed after the patient receives the medication, it is Retrospective.

     The TeleDUR user establishes these Compliance Criteria sets by data entry of the defining parameters to the system. The example, given below in Figure 3. , is the first screen, of two, for each set created. Each field location features "help" inquiry on demand for a more detailed definition so the novice user is never lost or stymied during entry.

     The individual drug checking function has three components. First, you create the sets themselves. TeleDUR allows you to define individual sets on-line or multiple sets in batch, using the values from the commercially available databases (i. e. First DataBank or MediSpan). Second, you specify when the set gets checked (during the order process or later in a retrospective mode.) Finally, you determine the type of response the system returns if a circumstance in the Compliance Criteria set is met (from a short warning message to pages of text called "monograms").

     Although an individual instance of drug use may be acceptable, sometimes we can ask other questions about overall drug usage. For example, "Is a physician prescribing substantially more of a particular drug than other physicians? Is a pharmacy dispensing more of a given brand than other pharmacies."

     The function that allows you to make this comparison is the HighlLow Criteria set. This function is the simplest. You read into the system a claims data file that contains all the medication records for every patient, sort it, and write out a report. An example was given earlier in Figure 1.

     Creation of a HighlLow Criteria set is necessary for each analysis report. The main menu of the system takes the user to a data entry screen that is similar to Figure 3. Three screens are created by the user for any one set. The entry screens provided are for (1) choosing the claims data to be selected in the process; (2) specifying how the selected records are to be sorted; and (3) designating what portion of the selected records you want printed. So, field by field the user defines and designs the report desired.

     For example, it may be desirable to review the most utilized generic drugs during a specific time period. The following Figure 4, shows, in bar chart graphics, those with the largest usage in ranked order. In this case, the selection was by class, time period and designation of the number of records having the greatest quantities of use.

     Sometimes delivery of quality healthcare is not a black and white process. "Should this drug be given now" is not the only question you can ask about usage. Changes in patterns of prescribing and consumption are also of interest.

     In the Comparative Trend Criteria set, you are looking at "trends" or patterns of usage over time. There are two possible comparisons. First, how does the group today compare to the group yesterday (for example, "Are there more or fewer class 2 prescriptions this year compared to last year?" as seen in Figure 2.). Second, how does the individual today compare to the individual yesterday (e. g. , "Has pharmacy XYZ filled more or fewer class 2 prescriptions this year as compared to last year?"). The Comparative Trend Criteria set allows you to make these comparisons in the simplest, most intuitive manner.

     There are three screens to be completed for a Comparative Trend Criteria set. First, you view a screen that lists all the data that comprise a patient medication order. You choose those data elements that you want to track by typing a X next to them. The second screen is used for specifying the sort order for the selected records. Finally, the third screen is used to designate the date ranges to be compared and selection of a limited number of line items (i.e. top 10%, bottom, etc.)

     Detecting instances of inappropriate therapy is only the first step in modifying physician behavior. You should also communicate with the physicians as the second step, since it is the physicians' prescribing habits that need to be modified. TeleDUR provides the preparation process for generating the letters with a word processor.

     First, you determine which physicians get the communication. Then, the system generates the letter file from the appropriate function.