Using EHR Formulary Data to Provide Alternatives, Improve/Elevate Care, and Increase Patient Satisfaction

Better prescription choices result in savings for both payers and patients. Formulary data in the electronic health record (EHR) offers a frontline strategy for helping providers make prescription choices that yield savings while improving patient care, increasing patient satisfaction, and elevating payer star ratings.

Formulary data is a component of pharmacy benefits.  EHRs include formulary data automatically in the prescribing modules of more than 1.2 million providers, according to Surescripts.

Pharmacy benefit data at the point of care includes three core elements:

  • Eligibility information to identify the patient benefit
  • Formulary data including plan and group information to inform a prescriber’s drug selection
  • Real-time prescription benefit information (RTPB), providing patient-specific cost and deductible information. 

These three components work together to inform providers about drug coverage and cost at critical junctures in the prescription process.

According to a study published in the American Journal of Pharmacy Benefits, electronic prescribing paired with formulary information increased patient access to prescriptions and offered the information prescribers needed to make better drug selections. “Our findings suggest that provider adoption and use of e-prescribing applications with formulary decision support were associated with improvements in medication adherence in a nationally representative population.” While the study could not confirm a direct link between improved formulary information, higher adherence, and prescription savings for patients, the authors “suspect that prescriber use of the benefit information from e-prescribing, and patient knowledge that the prescription is likely to have lower co-pays (due to increased use of generic prescriptions and 90-day supply prescriptions), were also factors in the improved primary adherence numbers.”

A Surescripts 2019 survey of 300 healthcare professionals who have access to formulary data indicated that 90% of them use it routinely. Survey participants noted that formulary data boosts efficiency during the prescribing process, improves patient satisfaction and care, and reduces the administrative burden of prescription changes and rewrites due to integration within the prescription writing workflow.

In an earlier survey, Surescripts found that over 70% of prescribers trusted drug formulary information provided in their EHR.  Recent improvements in eligibility matching and efforts from formulary data experts like those on the Benmedica team and our partner Pharmacy Benefit Managers (PBMs) will continue to increase formulary data accuracy.

As part of the benefits information in the EHR, formulary data creates a foundation for subsequent steps in the prescribing process.  Even when real-time prescription benefit information is available, formulary data can prevent rework by offering prescribers the information needed to make an informed decision the first time. Because a real-time prescription benefit request requires a fully completed prescription with quantity, days’ supply, and patient instructions, prescribers must rework a prescription every time they want to switch drugs.

At the start of an encounter, eligibility and formulary information work together to automatically identify the patient's benefit, including plan or group formulary.  Eligibility linking to the formulary provides critical information to prescribers when selecting a new medication for a patient.  Formulary information can include the drug’s status on the formulary, prior authorization requirements, step therapy requirements, quantity limit and copay information based on pharmacy channel.  Some PBMs also include total drug costs to help prescribers who are part of risk-sharing agreements understand the drug's total expense.

Improving Patient Adherence and Reducing Abandonment

Reducing the number of abandoned prescriptions at the pharmacy counter improves the patient’s care received through the therapy they chose with the provider.  Also, selecting medications favored by the plan formulary lowers patient costs and increases satisfaction. These are both critical elements in improving patient outcomes.

The availability of eligibility and formulary benefits information to prescribers leads to an increase in the percentage of prescriptions patients pick up. In a recent data brief, Surescripts documented a 2.7% increase (from 69.3% to 72%) in prescription pickup rates when eligibility information was provided. This suggests that when prescribers have access to the right information in their EHR during the prescription-writing process, patients are more likely to start and remain on therapy.

There is not a direct measure of how often formulary data displays or what the direct impact of the formulary data might be. The best method for correlating the formulary display effect is to link it to EHR eligibility information before prescribing.  The eligibility information identifies the benefit along with the patient’s plan/group level formulary information.  Some users may have turned off formulary data, reducing the impact of formulary improvement measures.  Using eligibility as a proxy for formulary display will overestimate the number of prescriptions where formulary information appears and dilute any measured benefits over the total number of eligibility transactions instead of the lower number of formulary displays.  However, despite these limitations, there is still compelling evidence that providing formulary information increases medication adherence and patient outcomes.

Eligibility and formulary data can expand the use of mail pharmacies to improve adherence to drug therapies. A 2016 analysis of stroke survivors showed that of the 48,746 patients who refilled at least one medication, patients who used a mail-order achieved 74% of medication adherence, a 57% increase over the adherence in patients who used local pharmacies. The study also noted that, “[many] patients save money when ordering their medications by mail, and efforts to increase mail-order use among interested patients may be well accepted by patients and health systems.”

Researchers concluded that prescribers could help patients reduce drug costs and increase adherence by promoting the use of mail-order pharmacies. “Physicians, nurses, or clinic-based support staff may be able to improve adherence when a new medication is prescribed by ensuring that patients who have efficient access to a reliable mail-order pharmacy system consider using it to obtain their refills.” Using eligibility and formulary information is one significant way to ensure that prescribers know about savings opportunities and pass them on to their patients.

While selecting lower-cost prescriptions increases patient savings, plan sponsors also benefit.  An NCPDP Foundation-sponsored study by Johns Hopkins found an average saving of $21 when cost information on alternative drugs was available. Lower-cost medications reduce patient and plan expenditures, are more likely to be picked up at the pharmacy and support better adherence and patient satisfaction.

When Surescripts asked prescribers if they would switch a prescription to a comparable, more preferred drug on the formulary, 68% were likely or extremely likely to do so, and another 24% would switch half the time.  When prescribers saw an alternative that did not require prior authorization, they stated a similar inclination to accept the formulary data recommendation.

The same 2019 Surescripts brief included information on how prior authorization (PA) information in formulary data increased the number of prior authorizations submitted prospectively. Prospective prior authorization occurs when the EHR prompts the provider to start the PA process before transmitting the prescription to the pharmacy.  Prospective prior authorization informs the patient of a PA, eliminates potential confusion when they arrive at the pharmacy, reduces the delay for prior authorization approval, and increases patient satisfaction.

Star Rating Boost from Medication Adherence, Patient Satisfaction, and Use of Preferred Drugs 

Including and improving formulary data appearing in EHRs satisfies provider demand for key benefits information at the time of drug selection. Choosing the best drug based on formulary information helps patients afford medications, making it more likely that they will start and remain on therapy.  Using formulary information to avoid prior authorization required drugs or, when appropriate, completing the prior authorization before the patient arrives at the pharmacy also supports medication adherence and increases patient satisfaction.

Improving Formulary Data in EHRs to Increase the Benefits to Patients and the Plan

Plans and PBMs creating formulary data for use in EHRs can improve the information provided by:

  • Ensuring that relevant alternative drugs are included 
  • Providing data at the group level when group data differs from the plan
  • Adding copay and/or approximate cost to the formulary data to help providers assess their patients’ ability to pay
  • Improving the usage of formulary statuses that appear in EHRs to leverage the visibility of drug information
  • Including ingredient cost for providers on risk-sharing contacts 

Benmedica helps plan and PBM formulary implementers improve formulary data in EHRs with better messaging and enhanced alternatives.  Our SmartAlts™ service provides specific situations where alternatives in formulary data and real-time prescription benefit information can yield actionable information at the prescription decision point.  The result is increased savings for both patients and payers.

For more information on Benmedica and how we might help your organization improve formulary data to create added savings, contact us here.