CPESN FAQ

What is the CPESN pharmacy? 

The CPESN initiative is about the importance of targeting and channeling patients to high-performing pharmacies.  All pharmacies are not the same.  Some pharmacies are primarily focused on filling the prescription as quickly as possible, with minimal patient interaction.  Other pharmacies are heavily focused on the patient and his or her health care, with a clear focus on interventions that change and positively impact patient outcomes.  CPESN pharmacies that have strong relationships with the patient and members of the patient’s local care team.  They are pharmacies that provide enhanced services that have proven to improve the health of complex patients.

Who is the CPESN patient?

CPESN patients are those who are on many chronic medications who lack coordination of care and have many opportunities for gaps to occur in this care.  They don't necessarily need convenience, they need coordination, high touch, and enhanced services that will change their outcome.

Where did CPESN originate?

CPESN originated from Community Care of North Carolina (CCNC) and its progressive initiatives, working together to provide cooperative, coordinated care through the medical home model, with the underlying goal to improve quality and cost-effectiveness while enhancing the ability of the primary care physician to improve care outcomes for patients with chronic diseases. 

In September 2015, CCNC launched the Multi-State High-Performing Community Pharmacy Collaborative (MSPC) to facilitate the expansion of additional high-performing CPESN networks nationally.  The MSPC was developed to connect pharmacists and other pharmacy stakeholders who have an interest in the delivery of financially viable, patient-centered care that exceeds traditional pharmacy dispensing services.  The nationwide expansion is supported by joint collaboration between CCNC and the National Community Pharmacists Association (NCPA) and the formation of CPESN USA. 

What is the Pharmacist eCare Plan?

The Pharmacist Electronic Care Plan (or eCare Plan) is a standard, not a platform. Standards are a way to get everyone in a market to agree to a way of extracting and trading data. The claims transmission standard, for instance, that you use to submit a claim to get paid for a prescription is a time-tested and sturdy standard that has been used many tens of billions of times over nearly four decades so your pharmacy management system can talk to multiple other types of systems and payers.

The eCare Plan transmission standard contains nearly all your clinical data for the latest episode of care you engage in with a given patient. Data such as active medication list, drug therapy problems, laboratory results, patient goals, health concerns, and vitals make up your clinical record.  In addition, (conveniently) the eCare Plan standard contains a “payer sheet” and SNOMED CT codes that make it very useful for payment down the road when enhanced services are widely reimbursed.  

CPESN USA does not own the standard. The standard is the result of a collaboration between HL7 international standards group, NCPDP, and CMS’s innovations center, along with ONC (the technology office for CMS responsible for “meaningful use”). It is an open standard that anyone can use for multiple purposes.  

What does all of this mean? – it means that eCare Plan is the future of clinical documentation sharing, billing and quality assurance efforts for pharmacists and pharmacies. CPESN USA is steadfastly nondenominational to which clinical documentation system is used by participating pharmacies.

Who Owns and Directs the eCare Plan Data?

Unless you’ve agreed to otherwise with a vendor or payer, you own your own clinical data and you have the privilege of directing it where and how you like. This is important when considering clinical integration, which is the basis of the entire CPESN Networks construct. We have a responsibility – for antitrust reasons – to have a “shared investment in quality reporting and sharing of data” in order to maintain our ability to group together in the marketplace. 

When CPESN USA works with vendors to collect your eCare Plan data, it is doing so at your direction through your participation agreement and data attestation. The vendor is not “giving” CPESN USA the data, it is sharing your data as a custodian of your data with CPESN USA for quality assurance and program implementation (essentially the clinical integration functions of quality reporting and using it to implement programs).    

The data remains yours throughout unless you’ve given up your rights to own and direct your data.

Why is the eCare Plan Important in Expressing your Value?

Prior to the eCare Plan, there was no good way to determine the quality and depth of “MTM” or enhanced services you provide using clinical data because there was no way to properly bring together data from multiple payers and multiple MTM vendors to implement quality assurance and clinical performance measurement.   

Additionally, the biggest complaint we’ve heard over the four years of interacting with all of you goes something like this:“our pharmacy is ready from a care delivery perspective right now, but workflow and extra documentation for these programs is a nightmare”. Currently, pharmacies spend more time documenting for billing than we do caring for the patient. 

The eCare Plan, as a standard, gives you the choice of clinical documentation and workflows that meet your specific needs. It also allows you to group together (as with CPESN networks) to engage in clinical integration, payer and health system engagement without having to have identical workflows, data systems, and technical dependencies. In short, it gives you choice to work the way you want to, but provides for universal sharing and reporting. 

This allows all of you to stand together to differentiate yourselves from conventional pharmacies and show your quality and contract collectively, yet still keep your local autonomy and choice of system and workflow. 

What do participating pharmacies need to do to make sure they are following CPESN networks clinical integration standards?

The current, the CPESN USA standard for Quality Assurance Data Collection and Transmission states the following: 

“As functionality becomes available through HIT vendors in use in pharmacies participating in CPESN USA, initiate regular transmission of fill history to CPESN USA for quality assurance purposes.”   

If you have eCare Plan functionality available to you, your vendor should now be sending it to CPESN USA regularly. Importantly, if you do not have eCare Plan functionality, you have until 12/31/18 to obtain that functionality per the standard. Also, for any pharmacy new to the network there is a six-month grace period to obtain eCare Plan functionality. 

 

What is Network Adequacy?

 

Network Adequacy is a widely used and well-understood term in the insurance world that describes the coverage a provider network has in relation to a payer’s membership. It is often one of many criteria Medicaid MCOs and others are graded on when responding to a bid. It can be calculated different ways for different providers but is usually uses specific criteria and mathematical formula.