Charting the next steps for e-prescribing policy

When e-prescribing first figured in the health policy scene in 2003, policymakers viewed it as a “low-hanging fruit” among myriad IT initiatives aimed at pushing doctors to convert their charts to electronic formats.

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.
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Progress of electronic prescribing standards

The shift to e-prescribing systems was formalized in 2003 with the passage of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA). One of its features is an outpatient prescription drug benefit for Medicare beneficiaries, or what is commonly referred to as Part D, which began in 2006.

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.”

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E-prescribing promises quick ROI, lower medication costs

One of the barriers in the swift adoption of electronic prescribing is the high switching cost associated with migrating from paper to e-format, but several studies have shown the investment is worth the potential savings in the future.

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.

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Incentive payments for e-prescribers

In its bid to entice more providers to shift to electronic prescribing, the Centers for Medicare and Medicaid Services (CMS) has started this year incentive payments of up to 2 percent to physicians and other eligible professionals who use the technology

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.

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E-prescribing triggers more prescription of controlled substances

A shift from handwritten to computer-generated prescriptions was associated with a substantial increase in the proportion of controlled substances prescribed out in a New York hospital.

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.

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Stakeholders await final DEA rule to lift E-prescription ban for controlled substances

The U.S. Drug Enforcement Agency (DEA) unveiled last year proposed regulations that would provide physicians and authorized prescribers with the option of issuing electronic prescriptions for controlled substances.

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.

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A CCHIT Based Guide to Qualified E-prescribing System – The First decision

Now that we’ve taken a look at the whole of what is deemed a qualified e-prescribing system in the eyes of CCHIT, I think its time to get into the weeds a bit and see what those high level requirements really mean.  Just as we have to crawl before we walk, I’m going to address the primary goal of getting a prescription order from your EHR to the pharmacy for fulfillment.  It’s a straightforward requirement, but there are a lot of things you must think about before being ready to e-prescribe.

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.

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A CCHIT Based Guide to a Qualified E-prescribing System – Part I (The 2008 requirements)

As I mentioned briefly in my previous post, Medicare is providing incentives for practices to implement a “qualified” e-prescribing solution.  The Medicare Improvement for Patients and Providers Act of 2008 (referred to lovingly as MIPPA) describes in detail the schedule of payments for practices (found here), but it falls short on detailing what a qualified system is.  Instead, the Center for Medicare and Medicaid Services (CMS) points to certification authorities to provide the guidance of qualifying a practice’s system. As the Certification Commission for Healthcare Information Technology(CCHIT) will be the basis for the EHR incentives that come with the healthcare stimulus package, I thought it might be a good exercise to see what they had to say about e-prescribing.

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E-Prescribing 101

Electronic prescribing is not just the ability to send prescriptions electronically to pharmacies. E-Prescribing can also increase care quality in a number of ways:

• 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.