Hopes were high because e-prescribing was seen to provide immediate benefits that could greatly improve the delivery of quality health care and speed up the migration to electronic health records.

Although major progress has been made in improving the functionality and interoperability of e-prescribing, recent studies have pointed out that fewer than one in ten doctors have adopted the electronic system.

Several hurdles need to be tore down to make e-prescribing “truly interoperable” and produce the national-scale effects on prescription drug use that were originally envisioned,” health policy analysts reported in the recent issue of Health Affairs journal.

“If current trends continue, e-prescribing still represents a step toward reaping the benefits of IT and automated decision support in health care on a national scale,” they said.

The report was written by Maria Friedman and Anthony Schueth, executives of two separate e-health strategy and management firm in Maryland and Florida, and Douglas Bell, a RAND research scientist and associate professor in the David Geffen School of Medicine at the University of California, Los Angeles.

The trio recommended five policy points that will likely affect increased adoption and interoperability of e-prescribing: moving beyond incentive scheme, making a stronger business case, increasing stakeholders’ involvements, addressing issues of privacy and security, and pilot-testing and industry collaboration.

The current incentive scheme to adopt and use e-prescribing will “help get user adoption beyond its current nascent point,” researchers said, but pointed out that payments alone are not enough.

They cited the Southeastern Michigan e-Prescribing Initiative (SEMI), which suggested that for every $5 spent on incentives, $1 should be invested on user training and education.

Return on investment (ROI) should be clearly quantified for adopters, they said, but added that the value, as distinct from ROI, should also be made at it can be more convincing than ROI numbers alone.

For example, e-prescribing could improve nurses’ work life by eliminating after-hour prescription follow-up, while pharmacists can have more time to deal with patients instead of handling prescription callbacks.

“Value also can be created by adding clinical content or links to e-prescribing for data to improve the quality of patient care, such as laboratory tests or results,” the researchers said.

They also called for the increased involvement of stakeholders. For instance, independent pharmacies in rural areas tend to lack the ability to receive and process e-prescriptions, or if they do, they might not use all features because of concern over transaction fees.

Payers likewise need to make their formularies readily available for use in e-prescribing so doctors can choose less costly alternatives for their patients.

Meanwhile, privacy and security issues have slowed down efforts to expand the use and interoperability of health IT.

Policymakers have been debating whether to expand the 1996 Health Information Portability and Accountability Act to include other entities in the e-prescribing chain beyond prescribers, payers, and pharmacies

“Considerable attention continues to be paid to ensuring the authentication of users, the integrity of prescriptions, and the privacy and security of personal health information that passes through the e-prescribing networks,” the researchers said.

They also said that one of the most valuable lessons learned from HIPAA implementation is the need for pilot-testing before standards are made, saying that even small pilot studies yield valuable results in creating metrics or demonstrating value and ROI.

“The e-prescribing industry has been collaborative in pilot-testing e-prescribing implementations and tweaking standards. The expectation is that this will continue, along with federal funding for larger-scale endeavors,” they said.

For more information:
Friedman MA, Schueth A, Bell DS. Interoperable electronic prescribing in the United States: a progress report. Health Aff (Millwood). 2009 Mar-Apr;28(2):393-403.

The law mandated the use of “electronic prescription program” should any Part D plan providers and pharmacies voluntarily choose to prescribe using computer systems. It also called for the establishment of standards for the electronic transmission of prescriptions and certain other information for covered Part D drugs.

Health and Human Services Michael O. Leavitt reported in 2007 that Prescription Drug Plan (PDP) sponsors, Medicare Advantage (MA) Organizations offering Medicare Advantage-Prescription Drug (MA-PD) plans and other Part D sponsors “must support and comply with electronic prescribing standards when communicating with prescribers who want to use e-prescribing technology.”

Indeed, the importance of technical standards was underscored by a recent study, “Interoperable Electronic Prescribing In The United States: A Progress Report,” published by the Health Affairs journal last month.

“These standards are important because they are the key to systems’ interoperability and to achieving policy goals. They also create a level playing field among vendors’ offerings, so that purchasers can buy with confidence,” researchers wrote.

When the MMA was passed six years ago, the U.S. Department of Health and Human Services determined that “adequate experience existed for three basic e-prescribing standards,” the report said. These include the SCRIPT standard for transmitting electronic prescription requests between prescribers and pharmacies (please see Table below).

In 2006, the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) conducted pilot studies to include more standards, paving the way for the adoption of three additional standards for Part D e-prescribing, which took effect on
April 1, 2009.

The Health Affairs report summarized the three add-ons as follows:

• Formulary and benefit transaction standard. Use of this standard gives prescribers information about which drugs are covered by a beneficiary’s drug benefit plan.
• Medication history transaction standard. Use of this standard provides prescribers with information about the medications a beneficiary is already taking, including those prescribed by other providers, to help reduce the number of adverse drug events.
• Fill status notification. This allows prescribers to receive an electronic notice from the pharmacy telling them that a patient’s prescription has been picked up, has not been picked up, or has been partially filled. Its use is expected to improve the monitoring of medication adherence in patients with chronic conditions.

The report said the final rule also adopted the National Provider Identifier (NPI) for e-prescribing under Medicare Part D, and it retired National Council for Prescription Drug Programs (NCPDP) SCRIPT 5.0 in favor of the upgraded NCPDP SCRIPT 8.1.12.

Meanwhile, the pilot tests in 2006 also concluded that the following three standards were not yet ready for use. These are:

• RxNorm drug nomenclature. This standard—developed and maintained by the National Library of Medicine (NLM)—provides standard names for clinical drugs (active ingredient + strength + dose form).
• Structured and Codified Sig. This standard provides uniform and codified patient instructions for taking medicines (e.g., take one tablet twice a day)
• Transactions for electronic prior authorization (ePA) of medications. This set of standard-based transactions enable more efficient preapproval from health plans for certain medications and justification of those that are viewed as expensive.

Overview of Current E-Prescribing Functions and Standards

Source: Friedman M, Schueth A, & Bell D. (2009). “Interoperable Electronic Prescribing In The United States: A Progress Report.” Health Affairs, Mar-Apr;28(2):393–403.

A study based on e-prescribing in Massachusetts found that doctors who used e-prescribing systems could save $0.70 per patient per month, which translates to $845,000 annually per 100,000 insured patients filling prescriptions.

The savings were linked to one of the features of e-prescribing systems called formulary decision support, which prompts prescribers to prescribe lower-cost medications. Such feature increased the prescribing of generics and other lower-cost options, researchers reported in the Archives of Internal Medicine, one of the JAMA/Archives journals.

“The potential savings increase with more availability and use of e-prescribing; for complete e-prescribing use, the projected savings are $3.91 million per 100,000 patients per year,” said lead author Michael A. Fischer of Brigham and Women’s Hospital and Harvard Medical School in Boston.

Noting that prescription drug costs account for a significant proportion of medical spending, authors suggested that a tiered copayment system could lower the cost of medication.

In the study, insurers identified preferred medications, such as generic drugs, and classified them as first-tier with the lowest copayment. Moderately priced brand-name medications were categorized as second-tier while expensive brand-name medications were designated as third-tier.

More than 1.5 million patients filled 17.4 million prescriptions during the 18-month study period. After implementation of e-prescribing, tier 1 prescriptions increased by 3.3 percent and second- and third-tier prescriptions decreased accordingly, researchers reported.

“Our results suggest that there are important economic gains achievable through the broader use of e-prescribing with formulary decision support but that merely providing e-prescribing systems to clinicians will not necessarily achieve those savings,” they said.

Several health plans have been partnering with providers of e-prescribing programs, and they expect that the increased use of generic drugs will give them initial return on investment. The Health Alliance Plan of Michigan, for instance, estimated a five-year ROI of more than $14 million by improving its generic use rate.

The study “Interoperable Electronic Prescribing In The United States” published by the Health Affairs journal said the savings are significant for Medicare, which spent $42.2 billion in 2007 for beneficiaries’ prescription drugs.

“Such savings also could become increasingly important for private insurers that are facing decreasing investment earnings and enrollment because of the recent economic crisis,” the study noted.

For more information:

Fischer MA, Vogeli C, Stedman M, Ferris T, Brookhart MA, Weissman JS. (2008). Effect of Electronic Prescribing with Formulary Decision Support on Medication Use and Cost. Archives of Internal Medicine, Dec 8;168(22):2433-9.

Friedman M, Schueth A, & Bell D. (2009). Interoperable Electronic Prescribing In The United States: A Progress Report. Health Affairs, Mar-Apr;28(2):393–403.

For 2009, to be a “successful e-prescriber,” eligible professionals must report the e-prescribing quality measure through their Medicare Part B claims on at least 50 percent of applicable cases during the reporting year.

Under the Medicare E-prescribing Incentive Program, prescribers using a “qualified e-prescribing system” will receive incentive payments from Medicare beginning Jan. 1, 2009. The 2-percent reward will drop to 1 percent in 2011, then down further to 0.5 percent two years later, and go away after 2013.

The program, which is part of the Medicare Improvements for Patients and Providers Act of 2008, will slap those who do not adopt the electronic system with penalties – 1 percent in 2012, 1.5 percent in 2013, and 2 percent in 2014 and each subsequent year.

In addition, claimants should be an “eligible professional” whose estimated allowed Medicare Part B charges for the e-prescribing measure codes are at least 10% of their total Medicare Part B allowed charges. For more information, visit the CMS E-prescribing Incentive Program.

In general, an eligible professional is one of the following: physician, physical or occupational therapist, qualified speech-language pathologist, nurse practitioner, physician assistant, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical social worker, clinical psychologist, registered dietitian, nutrition professional and qualified audiologist.

According to CMS, the e-prescribing incentive is similar to the Physician Quality Reporting Initiative in that reporting periods are one year in length. The incentive is based on the covered professional services furnished by the eligible professional during the reporting year.

Meanwhile, the U.S. Department of Health and Human Services said that eligible professionals may be exempted from the reduction in payment “if it is determined that compliance with requirement for being a successful prescriber would result in significant hardship.

In a Medscape news report, Dr. David Brailer, chairman of Health Evolution Partners and and former National Coordinator for Health Information Technology, said that cost is barrier for many physicians to purchase and install electronic health systems.

“The incentives will turn that business case around. My expectation is that the payments will be in excess of what we anticipate physicians’ costs to be.”

The government said Medicare is expected to save up to $156 million over the five-year course of the program in avoided adverse drug events.

The HHS pointed out estimates that as many as 530,000 adverse drug events are reported every year by Medicare beneficiaries while the Institute of Medicine said that more than 1.5 million Americans are injured each year by drug errors.

The removal of an impediment to prescription writing was linked to the rise in Schedule II opioids and benzodiazepines prescriptions at the emergency department of the Good Samaritan Hospital Medical Center in New York, researchers claimed.

“Simple regulatory changes and lifting of barriers, such as the utilization of electronic prescriptions, can make significant changes to practice patterns and may change the way patients are treated,” the authors wrote in a study published recently by the Academy Emergency Medicine journal.

The study compared the changes in opioid and benzodiazepine prescriptions before and after the New York State implemented the “Official Prescription Program,” which was designed to reduce the amount of drugs diverted from legitimate medical use by preventing alterations, forgeries and counterfeiting of prescriptions.

The new system, implemented on April 19th, 2006, required all prescriptions to be computer-generated from the doctors’ stations and printed via a dedicated printer onto standardized prescription forms.

Before this, the hospital’s emergency department staff stored a specialized prescription form in a locked cabinet, and physicians had to handwrite and stamp the prescription.

A year before the program was enacted, a little over 2 percent of almost 27,000 charts reviewed in the study were for Schedule II controlled opioids, such as oxycodone. A year after regulatory changes were made, prescription for the same class of drugs increased to 13.6 percent. The same pattern was observed in benzodiazepines, which increased from 1.4 percent to 3.9 percent.

Meanwhile, the corresponding percentages for Schedule III-V opioids, which include hydrocodone and codeine, dropped from 29.9 percent to 18.1 percent during the same period, results showed.

Researchers said the change was attributed from a shift in the prescribing of hydrocodone to oxycodone. Both drugs have similar side effects but oxycodone is associated with less constipation than hydrocodone, giving patients better relief, they added.

“We have demonstrated that clinical practice may be significantly associated with the ease and convenience of prescribing medications,” the authors wrote.

Interestingly, the shift was observed as the result of technological improvements instituted to comply with a state regulation, rather than as a measure to directly address pain management, they said.

“As more EDs shift to electronic medical charting with linked prescription writing, a similar unanticipated change in prescribing patterns could occur,” they concluded.

For more information:

McGerald G, Dvorkin R, Levy D, Lovell-Rose S & Sharma A. (2009). “Prescriptions for schedule II opioids and benzodiazepines increase after the introduction of computer-generated prescriptions.” Acad Emerg Med. Jun;16(6):508-12. Read abstract

The agency had sought public comment on DEA’s draft rule #1117-AA61, titled “Electronic Prescriptions for Controlled Substances.” One year later, stakeholders are still waiting for DEA’s final decision to lift the e-prescribing moratorium on controlled substances.

In one of the recent developments, a bi-partisan group of senators has sent a letter in May to Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius asking for a final resolution on the proposal.

The 11 senators, who signed the letter, said, “E-prescribing is held back by the DEA,” which requires a parallel paper system for scheduled pharmaceuticals. “Obviously, having to run two systems compromises any savings from e-prescribing,” they wrote.

They said e-prescribing of controlled substances, which accounts for 10 percent to 20 percent of all prescriptions, is “an important piece of the puzzle” that could generate $20 billion per year in savings through reduced adverse drug events and patient adherence to prescription regimens.

“Crafting a final rule that advances both health care quality and efficiency, and reduces illegal prescription drug diversion, will require the cooperation, compromise and knowledge of experts at both the Department of Justice and the Department of Health and Human Services,” the senators said.

The DEA has said the proposal, seen by many as an adoption barrier, would equip pharmacies, hospitals, and practitioners with electronic prescribing capabilities while guarding the closed system of controls on controlled substances dispensing.

The American Journal of Health-System Pharmacy published in its July issue the report “Electronic prescribing of controlled substances,” which discussed elements of the proposed e-prescribing rule.

• In-person registration for e-prescribing authority.
  This is intended to ensure that only licensed personnel are registered. The licensee must present evidence from a credentialing authority to be licensed and receive electronic signature authority.
• Level 4 two-factor authentication.
  One factor must be a hardware token; the second may be a memorized pass code or a biometric identifier.
• Authentication at signature.
  This ensures that only the prescriber signs the prescription.
• Strict audit requirements.
  These help identify diversion at the pharmacy to ensure the security of the e-prescribing system.
• Verification of prescriber’s DEA number during prescription filling.
  This ensures that the prescriber is still authorized to issue prescriptions.
• Monthly review and approval of audit logs.
  This allows the prescriber the opportunity to identify problems.
• Archival of digitally signed prescriptions for five years.
  Such archival of records aids in retrospective auditing and investigation.

The Pharmacy Informatics and Technology section of the American Society of Health-System Pharmacists said stakeholders are waiting for a final rule “because it will largely determine whether the burden and costs associated with implementation outweigh the benefits.”

“Should the rule prove to be onerous, providers may opt to continue to prescribe controlled substances using the current paper process. Should the DEA promulgate a rule that is reasonable, many believe that the DEA’s rules will become the de facto requirements for all e-prescribing systems,” it added.

On the other hand, the Pharmaceutical Care Management Association, which represents the pharmacy benefit management firms, believed the proposed rule to permit e-prescribing is flawed.

In a five-page comment letter to DEA, the group said the proposed rule would create unnecessary burdens for doctors and pharmacists. Its president and CEO, Mark Merritt, pointed out the following issues:

• Ensuring generic substitution.
  The proposal is not clear whether changing a prescription to a generic would be allowed under this rule. PCMA recommends that pharmacists be allowed to change prescriptions according to state law and such action should not be considered “altering the prescription during transmission.”
• Verifying DEA registration.
  The proposed rule requires the pharmacy system to verify that the practitioner’s DEA registration is valid through the DEA CSA database. PCMA says such option is very costly, which could drive up costs for the service.
• Prescriber in-person identity proofing.
  The proposed rule requires prescribers to go verify in-person through a DEA registered hospital. PCMA says the process “creates a burden that is onerous and unnecessary and that does not result in the security and assurances that the DEA seeks to achieve.” PCMA recommends service providers be allowed to verify a prescriber’s identification in-person.
• Prescriber work-flow.
  The system requires reauthentication if the practitioner does not use the system for more than 2 minutes. PCMA says this is unreasonable and does not recognize the workflow demands of medical practice. It recommends that the time lapse for reauthentication be revised to 15 minutes.

The reality is that any transactions between your system and the pharmacy system will be handled by a third party delivery service.  This service company is Surescripts RxHub.  Some may be familiar with the history of the company, but for those not, in a nutshell they used to be two companies serving two very different user bases.  Surescripts worked with the retail pharmacies, while Rx Hub worked with the Pharmacy Benefit Managers (in other words, the insurers).   I’m sure Surescripts RxNorm are working towards a unified system, but until then you can still think of Surescripts RxHub as two different systems.

Implementing ePrescribing for the first time will be a lot of development work, so if you wanted to stage the development over time and get more bang for your buck it may be a good idea to start with one group rather than the whole kit and caboodle.

Fortunately, taking a look at the following CCHIT requirements makes this first decision pretty easy:

As you can see, CCHIT tries not to be partial for either group in the last two requirements but the simple truth is that the first requirement really points towards implementing a solution through the PBMs. Determining, the eligibility of drug insurance is definitely not a function of a pharmacy; and even if it was wouldn’t it be more efficient to go straight to the source – the insurer?

Stay Tuned

I started this post stating we’re really trying to just get a prescription from your existing EHR into the hands of the fulfiller.  Now, we’re talking about first getting not only the patient’s eligibility information but also changing your EHR to provide formulary information.  If that wasn’t enough, you’ll also be adding a view into the patient’s medication history.  In my next post, I plan on going into more detail just what all of this means and the things you should think about when you’re ready to implement this functionality.

I started by going to CCHIT and downloaded the final CCHIT Certified 08 Ambulatory EHR criteria and test scripts.  I then used the excel spreadsheet(CCHITCriteriaAMBULATORY08FINAL.xls)  and filtered by category “9. Medications / ePrescribing”.  For the sake of providing a foundational view of ePrescribing, I then further filtered my results to only include the 2008 provisions.  The list contained requirements that The table below illustrates my results:

I was initially confused by the first two entries.  It makes sense that EHRs be able to handle incoming and generate codified Allergy and Conditions to help in safely ordering medications, but I want to focus strictly on ordering the medication in my EHR and getting that prescription to the pharmacy electronically.  The Continuity of Care Document (CCD) is a subject worthy of its own series of posts.

Once I remove the CCD requirements, there are really only five requirements to satisfy in order to claim victory for the 2008 requirement set.  It may seem simple enough, but to satisfy these requirements you will find that the ordering system your granddaddy used (from paper to even existing electronic ordering) will need to be changed considerably.

Stay Tuned

Now that we’ve looked at all that is required to be a qualified e-prescribing system in 2008 according to CCHIT, I plan on detailing what exactly this entails per requirement.  Eventually, I plan on catching us up to the present year by doing the same with the 2009 requirements.  After that, get your flux capacitors fluxing and we’ll even check out what the future holds for us (2010 and beyond).

• E-prescribing makes sure that the prescriber is providing enough specific information for the pharmacist to fill the prescription, including the name of the drug, the dosage, its physical form, the route, and the physician’s instructions.
• Electronic prescribing software eliminates the time and effort of trying to understand the prescriber’s handwriting, as well as the chance of an error in that translation.
• E-prescribing significantly reduces the chance that the prescriber’s intentions are misinterpreted.
• E-prescribing is often used in conjuction with clinical decision support to ensure that any drug to drug interactions or drug to diagnosis issues are found and reported to the physician before the prescription order is completed.

Electronic prescribing is considered one of the most important areas of Healthcare IT, which is why Medicare created payment incentives for physicians who use a qualified e-prescribing system. In 2009, the incentives are an increase of 2% in revenue for each patient when e-prescribing is used. Due to the 2009 HITECH Act, electronic prescribing is required as part of any EMR (EHR) which qualifies for Medicare reimbursement in 2011.