Retrospective Drug Utilization Review
Industry Challenge
When it comes to managing drug regimens, Medicaid administrators and healthcare program managers must control costs while producing positive patient outcomes. Without the ability to gather, manage and analyze data while providing a successful intervention method, they risk failing in this key area.
Solution
HID’s RxExplorer® retrospective drug utilization review (RDUR) application is the solution. RxExplorer can detect inappropriate drug use by evaluating pharmacy claims data, and medical claims data when available, against clinically-based therapeutic criteria. In use since 1976, RxExplorer is a best of breed data mining and reporting application that delivers proven results. Our product development team continually enhances this feature-rich application to provide additional benefits.
RxExplorer evaluates claims and patient data against the clinically sound, evidence-based criteria we have developed and refined over our more than 30 year history of working with criteria. HID’s full time pharmacists maintain our vast criteria database, the clinical engine that drives the DUR process.
A user-friendly data mining tool provides quick and easy access to standard reports, including provider report cards, drug/drug class utilization, and recipient histories and profiles. Users can create additional reports using powerful ad hoc reporting capabilities.
RxExplorer’s powerful processing engine performs the first step in clinical intervention by generating the Initial Criteria Exception Report (ICER™) using criteria selected by the client. One of the advantages of HID’s clinical intervention program is that clients can choose to use HID’s clinical staff rather than their own to select physicians for intervention.
Through RxExplorer, HID currently provides RDUR services to over 17 Medicaid agencies and a number of healthcare benefit management companies across the country.
Features
- Extensive catalog of criteria. RxExplorer’s catalog of clinical criteria is extensive, with over 100,000 possible permutations of the rules.
- Thorough review of all applicable data. For each RDUR cycle, RxExplorer thoroughly interrogates the database, looking for clinical exceptions for every claim. RxExplorer reports every exception on a Initial Criteria Exception Report (ICER).
- Comprehensive exception reporting. The ICER lists all found clinical criteria exceptions. These are stratified by risk for the reviewing clinician.
- RxExplorer Data Analysis and Decision Support System (DADS). RxExplorer includes an integrated DADS, a powerful data mining and ad hoc reporting tool.
- Targeted interventions. RxExplorer provides targeted interventions for clinicians from clinicians.
- Educational, not confrontational, interventions. RxExplorer’s interventions provide clinical professionals with useful information about the patient. The majority of feedback from physicians regarding the interventions is positive.
- Daily updates. RxExplorer receives daily updates from HID professionals who are knowledgeable about the latest clinical developments.
- Customizability. Criteria sets can be customized for each client. Intervention correspondence is developed and customized for each client.
- Scalability. RxPert can handle small to extremely large databases; one HID client maintains a database covering almost 5 million lives.
- Extensive reporting package. RxExplorer includes hundreds of standard reports, which can be customized for each client. In addition, each client can have its own set of unique reports.
- Risk scores. RxExplorer assigns a risk score to every criteria exception so the generated profiles are more likely to result in an intervention.
- Profile generation. RxExplorer can provide profiles of recipients, physicians, and pharmacists.
- Security and privacy. HID complies with all HIPAA regulations for protected health information.
- Web-enabled. RxExplorer’s sophisticated database organization allows the client to conduct RDUR operations over a Web-enabled browser.
Benefits
- Informed physicians
- Refined practice guidelines
- Improved overall healthcare and patient safety
- Improved therapy management for chronically ill patients
- Cost containment
For more information on how RxExplorer can help your organization, contact us. For a product brochure, click here.