How Humana created a rules engine to screen patient prescriptions for potential adverse drug effects.
Name of Organization: Humana Pharmacy Solutions
Industry: Healthcare
Location: Louisville, KY USA
Opportunity or Challenge Encountered:
Adverse drug events currently account for 700,000 emergency room visits and 120,000 hospitalizations each year, while generating an additional $3.5 billion in medical costs, according to the Centers for Disease Control and Prevention. Up to 40 percent of these costs are avoidable through proper management of drug regimens.
Humana Pharmacy Solutions, which serves 11 million members within the Humana health insurance network, sought to better manage the problem of adverse drug events while also preventing the dispensing of unsafe combinations of medications, while providing better information on prescriptions. The service processes more than 240 million prescriptions per year, and has more than 500 pharmacists and 64,000 pharmacies in its network.
As documented in a recent case study, Humana needed to reduce the incidence of adverse drug events, automatically provide alternatives, improve customer and clinician experiences, and provide relevant information to all parties involved. The challenge for the service is that it did not have the ability to run the necessary analysis that incorporated each member’s prescriptions and medical history in real time to spot potentially unsafe prescriptions, avoid unnecessary prior authorizations, and identify alternative formulations for clinicians and pharmacists. The information was not uniformly present or current at the time of prescriptions.
There were also other challenges: Sometimes a prescription may be covered under insurance, but was potentially unsafe for the patient. A prescription may be covered, but due to high cost was denied by the patient, who was unaware of less-expensive alternatives. Another risk was that a prescription may not be covered or required prior authorization, prompting calls back to clinicians for clarification.
How This Opportunity or Challenge Was Met:
To provide these capabilities, Humana Pharmacy Solutions partnered with Transcend Insights, a population health management company, to help build an analytics engine called IntelligentRx that provides real-time clinical decision support for prescription drug benefits. The team built a rules engine that supported a full spectrum of pharmaceutical adjudication and clinical decision making. The analytics engine, once integrated into Humana’s infrastructure, was designed to provide real-time clinical decision support and safety alerts, tailored to patient health data.
The team expanded Humana’s IT infrastructure to support the massive data sets generated by Humana’s members. The IntelligentRx team also built out a system of clinical analytic rules surrounding patient safety and utilization management clinical policies, the case study states. The clinical rules engines was eventually expanded to incorporate advanced patient safety rules, and aid in Medicare Part D compliance. The advanced safety rules also flag for drug-to-disease interactions, and opioid overutilization. The analytics engine is now fully integrated within the Humana Pharmacy Solutions ecosystem.
Benefits From This Initiative:
This year, it is expected that IntelligentRx will be processing all pharmacy transactions for all of Humana’s 11 million members. With this analytics engine, Humana Pharmacy Solutions is now able to leverage real-time analytics that supports prescription decision making.
The analytics engine is delivering transaction response times that average less than 100 milliseconds, the case study reports. In addition, the system delivers drug alternatives where required, based on a member’s plan coverage and drug price –which is key to providing the lowest possible cost and reducing the chance of denial by a patient. The analytics engine also ranks alternatives with regard to safety and previously prescribed medications. The system also delivers real-time safety alerts on potential adverse drug effects to pharmacists and clinician’s.
(Source: Transcend Insights, Humana Pharmacy Solutions)
