Developing Recipient-Focused Software


HID was the first company to develop its own drug use review analysis software and has continued to augment, refine and extend its core software. This software contains therapeutic criteria that generate over 122,000 rules and comparisons against which each claim is evaluated. The criteria were written by HID’s Therapeutic Criteria Committee in partnership with many client DUR Boards as HID works with each client to modify the criteria to its unique desires.

HID has extensive experience providing outpatient-focused retrospective drug utilization review (RDUR) services to both public and private health care plans accumulated over the twenty-seven (27) years the company has been in the business of pharmacy service and drug utilization review. This includes working with state and local government agencies, presently including fourteen state Medicaid programs in Alabama, Arkansas, Kentucky, Maryland, Mississippi, Montana, Nevada, New York, North Dakota, Rhode Island, South Carolina, South Dakota, Wisconsin, and Wyoming. In addition, HID provides RDUR services to two large national pharmaceutical companies. These public and private sector programs encompass both patient-specific therapeutic RDUR and provider (physician/pharmacy) profiling and programs to educate providers by mail, telephone and face-to-face (counter detailing) discussions.

These recipient-focused programs generally involve three basic steps: (1) Computer-based analysis of patient-specific drug and medical claims histories using therapeutic criteria to identify high-risk drug therapy cases, (2) Review of 12-18 month drug-medical history “profiles” by trained clinicians to confirm the clinical significance of the computer-identified problems, and (3) Issuance of educational intervention packages to physicians and pharmacists involved in treating patients at high risk for drug-induced illness. These programs currently result in over 6,500 monthly alert letters being issued to physicians and pharmacists. HID-administered RDUR programs utilize the services of clinical monitors—specially trained pharmacists—who review high-risk patient profiles. For most RDUR programs, these clinical monitors perform this review function “in-house” at our Auburn, Alabama, facilities. For Kentucky, New York and Arkansas Medicaid RDUR programs, HID generates exception profiles and sends them to the state for profile review and issue of physician/pharmacy interventions. State Medicaid programs in Montana, South Dakota, Wyoming, and Wisconsin utilize HID’s RDUR software to manage their RDUR programs.

Ms. Pam DeRuiter, R.Ph., reviewing a profile.

HID develops and implements comprehensive provider profiling and education programs that complement HID’s patient-specific monitoring efforts. HID is now performing physician profiling on behalf of several Medicaid programs. These programs identify physicians and pharmacists whose prescribing habits may be substandard in terms of clinical appropriateness or cost effectiveness. Working with clinical experts from around the country, HID has developed clinical criteria and education materials that are used to profile and educate providers concerning selected classes of medications. For the Wisconsin and Mississippi Medicaid DUR programs, these physician/pharmacist educational interventions are carried out by physicians and pharmacists engaged and trained by HID, using three different methods: (1) Detailed mailed educational materials, (2) Mailed educational materials with a follow-up telephone call, (3) Face-to-face discussions. HID has also been engaged to perform physician and pharmacy profiling for the Kentucky Medicaid program. For this program, HID generates the physician profiles and ships them to the state for review and intervention.


Educating Physicians >