What is E-Prescribing?
Electronic prescribing, or e-prescribing as it is commonly called, is the use of an automated data entry system to generate a prescription that is then transmitted through a special network to the pharmacy in such a way that the data goes directly into the pharmacy’s computer system. It is not simply e-mailing or electronically faxing a prescription.
The Medicare Part D prescription drug program more formally defines e-prescribing as:
“E-prescribing means the transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager or health plan, either directly or through an intermediary, including an e-prescribing network.
For the prescriber, e-prescribing happens when a physician uses a computer or hand held device with software that allows him or her to—with a patient’s consent—electronically access information regarding a patient’s drug benefit coverage and medication history; electronically transmit the prescription to the patient’s choice of pharmacy; and, when the patient runs out of refills, his or her pharmacist can also electronically send a renewal request to the physician’s office for approval.
Benefits of E-Prescribing
By eliminating paper, e-prescribing creates a more efficient and safer process for patients to access their medications. This electronic process helps to prevent, and in some cases eliminate, the top reasons for prescription errors—including illegible hand-writing, incorrect dosing, and missed drug/allergy reactions—which improves patient safety and helps to control ever increasing medication costs due to medication errors.
Through electronic prescribing, all health care stakeholders—including providers, patients, pharmacies, and payors/PBMs—expect to see prescription related benefits such as:
Payors/PBMs: Increased generic/formulary usage, efficiency, Rx compliance and prevention of ADEs (reduced costs)
Patients: Increased safety, efficiency and compliance, lower co-pays
Providers: Increased efficiency, improved care, patient satisfaction and potential short and long-term incentives
Pharmacies: Increased efficiency, improved care, improved patient satisfaction
Key functionalities of an E-Prescribing System
E-prescribing involves far more than an electronic connection. In order to see an increase in both quality and efficiency that can be attributed to e-prescribing, the system must be capable of performing key functions related to:
Medication selection/decision support capabilities (e.g., diagnosis-based medication menus, evidence based information, drug interaction checking, safety-alerts, formulary checking, prescription renewal, and dosage calculation)
Patient-specific information capabilities (e.g., current patient medication list, access to patient historical data, patient identification)
System integration capabilities (e.g., connection with various databases, connection with pharmacy and pharmacy benefit manager systems)
Educational capabilities (e.g., patient education, provider feedback)
The Journey of an
The journey of an e-script begins when the patient and physician review history and discuss the current issue and treatment options. As the physician electronically writes the prescription, the
The physician then reviews clinical alerts, formulary, reference, prescription history, eligibility, and prior authorization information with the patient and selects therapy and verifies the patient’s preferred pharmacy.
Once the prescription is finalized, the e-script is generated and the physician routs it to the patient’s pharmacy of choice. The pharmacist fills the prescription and sends a fill notification to the physician.
If the pharmacy is online and has the ability to accept electronic prescriptions, the two-way connectivity provides for the transmission of new prescriptions, refill authorizations, and denials and change requests between the pharmacy and the provider’s office.
What Will This Look Like in My Office?
The Physician:
Signs onto the
e-prescribing system. The sign-on process maintains the security of the system and is required in order to prove identity and verify legal prescribing permissions.Selects the patient and reviews current patient data, including current and past medication data based on information from other providers and pharmacies.
Selects medication. He or she can either work with current medication (change dose, refill prescriptions, discontinue medication, etc.) or choose a new medication either by selecting from a predetermined list or searching for specific drugs based on search results, warnings, and/or favorites.
Signs the prescription and transmits it electronically to the patient’s preferred pharmacy.
Medicare E-Prescribing Incentive Program
In order to promote the adoption and use of e-prescribing systems, the "Medicare Improvements for Patients and Providers Act of 2008" authorized an e-prescribing incentive program beginning January 1, 2009.
In 2012, this program will provide the opportunity for financial incentives and financial penalties in 2013 and 2014. Eligible professionals who successfully e-prescribe will be eligible to receive an incentive of 1% of the total estimated allowed charges for professional services covered by Medicare Part B and furnished during 2012. Payment reductions for those who do not successfully meet e-prescribing reporting requirements will be applied in 2013 (1.5%) and 2014 (2%).
Eligible professionals for the e-prescribing program in 2012 include:
- physicians or other practitioners who have prescribing authority,
- who currently uses a qualified e-prescribing system, and
- whose estimated Part B charges for the e-prescribing measure codes are at least 10% of their total Part B allowed charges.
This could include:
- Audiologists
- Certified Nurse Midwife
- Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
- Clinical Nurse Specialist
- Clinical Psychologist
- Clinical Social Worker
- Nutrition Professional
- Nurse Practitioner
- Physician Assistant
- Registered Dietician
- Occupational Therapist
- Physical Therapist
- Qualified Speech-Language Therapist
According to CMS, EPs who are unsure whether relevant Part B charges will be at least 10% of total charges should err on the side of participation.
For more information on securing an electronic prescribing system or verifying that your current system is in compliance, click here.
+ Incentives
- Incentives
for further instruction on claims reporting and a sample claim.+ Penalties
- Penalties
+ Note for Nurse Practitioners, Physician Assistants, Physical Therapists and other providers in your practice
- Note for Nurse Practitioners, Physician Assistants, Physical Therapists and other providers in your practice
+ e-Prescribing and Meaningful Use
- e-Prescribing and Meaningful Use
+ Next Steps
- Next Steps
+ 2009 Incentive Payments
- 2009 Incentive Payments
Click here for 2010 e-prescribing information.
Click here for 2009 e-prescribing information.
How do I get started?
E-prescribing should be implemented with an understanding of both the potential benefits it brings as well and the needs and workflows of your practice. When fully adopted and merged into practice, e-prescribing will enhance patient safety, improve office efficiencies, and increase both provider and patient satisfaction.
Business case for e-prescribing
For the provider looking to adopt an e-prescribing system in clinical practice, the business case for acquiring and implementing the system will vary according to the:
Size of practice
Type of practice
Participation of health plans
Participation of local pharmacies
Practice setting
Availability of IT infrastructure and support
Stand alone e-prescribing vs. EHR
Availability of incentives and ability to take advantage of them
There is no one perfect system that will work for every practice, so it is important to identify your current practice prescribing workflow and needs.
A needs assessment is the core task in establishing your plan and should include the identification of practice requirements ( such as staffing, change management and training, and incentive benefits eligibility), hardware and software needs (such as PDA’s, software, and server and security requirements), and infrastructure needs (such as connectivity/interoperability).
Beginning your e-prescribing system selection process with these needs in mind will certainly reduce the time spent securing a system and increase the likelihood that you will find a system that is the right fit for your practice. With the right system, you can expect to realize the potential savings associated with increased practice efficiency handling medication renewal requests and increased prescriber accuracy resulting in fewer call-backs from pharmacies for legibility issues, drug incompatibility or ineligibility.
You should anticipate initial costs to include software licensing fees, hardware, network and internet access and training and technical support. Additional expenses that may add to your complete costs to include temporary decreases in productivity resulting from training and workflow redesign; practice management, lab and other interfaces; customization for practice specialty and other factors; maintenance of system; upgrades; and data conversion (from different practice management system or from stand alone e-prescribing system to EHR).
Several resources have been developed to help providers navigate their way to e-prescribing success. For more information on developing your business case for securing and implementing the right system for your practice, visit the ACR’s e-prescribing resources page for links to sites that will help you in creating your customized e-prescribing action plan. These sites will help you narrow the vendor field and provide you with a buying guide that includes questions to ask and functionalities to identify.
Is There Financial Assistance Available to Help Me Secure an E-Prescribing System?
Many incentives and assistance opportunities are available to help physicians in securing an e-prescribing system and to recoup the expense associated with e-prescribing adoption. Active programs include grant and loan programs, reimbursement for utilization, pay for performance, malpractice insurance premium reductions, and health care IT suppliers discounts.
Beginning January 1, 2009, Medicare will offer physician payment incentives of 2 percent for using e-prescribing in 2009 and 2010 – with this amount declining slightly over the next three years. For more information on this program, visit the CMS E-Prescribing Incentive page found under the ACR’s Electronic Prescribing site.
A number of national and state level incentive programs that provide for everything from software and/or hardware to direct incentive payments for e-prescribing are open to physicians across the U.S. For more information of the opportunities available, a listing of prescribing initiatives can be found on the SureScripts Web site at http://www.surescripts.com/about-e-prescribing/incentive-programs.aspx.
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There are parameters for technology donations so that, under certain conditions, providers can accept free donations of e-prescribing hardware, software, and related services without violating the Stark law or Anti-Kickback Statute. Check with your local hospital or health care system to see what opportunities may be available. For more information about the Stark law and Anti-Kickback Statute, please visit either of the two Web sites below:
www.cms.hhs.gov/PhysicianSelfReferral/01_overview.asp
www.oig.hhs.gov/fraud/safeharborregulations.asp There are a number of free web-based e-prescribing systems available to every provider.
Stand-alone vs. EHR
E-prescribing systems can be implemented as either a stand-alone system, or as a system embedded within an EHR. Stand-alone systems are significantly less costly than full EHRs and do not force your office to change as many of its work patterns (making it much faster to implement), but for your office to see the full benefit of e-prescribing in terms of safety, quality and efficiency, the ultimate goal should be movement toward or integration with an EHR.
Stand-alone systems store and manage patient data specific to the prescribing process. They are available either as a software package downloaded to your office computer, or as an application hosted through the Internet. Stand-alone systems allow providers to order medication electronically, but are limited in decision support as they have limited patient data available. These systems can be enhanced through integration with practice management systems, billing systems, and scheduling software. Without this integration, your practice will face redundant data entry which may slow productivity. Successful implementation of a stand-alone e-prescribing system will require that your practice develop a parallel workflow that makes use of both the e-prescribing system and paper chart.
To maximize patient safety and quality through electronic prescribing, the system should be truly integrated into the practice workflow and should host more information than just patient prescription history. This can only be accomplished through integration with an EHR system, which will combine prescription drug information with immediate access to patient demographics, clinical notes, problem lists, allergies, side effects, lab results and other elements of the patient’s medical history.
How do I know what pharmacies in my area are connected for e-prescribing?
Many e-prescribing programs provide you with an up to date list of those pharmacies in your area that have the ability to receive electronic prescriptions. It is important to verify that this list is current so that you are not faxing prescriptions to those pharmacies that are not connected for e-prescribing. Your e-prescribing/EHR software vendor is responsible for maintaining your pharmacy directory and keeping it up to date. Contact your vendor for more information on their processes.
You can also identify the pharmacies that are connected in your area by visiting GetRxConnected or the SureScripts Web site. Both sites will allow you enter your location by state or zip code to view a listing of pharmacies connected for electronic prescribing.
For more information on securing an electronic prescribing system, contact Itara Barnes at .
E-Prescribing With an EHR
Do you really know what happens to that prescription after you click “send?”
E-prescribing is the electronic transmission of a prescription to the pharmacy in such a way that the data goes directly into the pharmacy’s computer system. In many cases, a physician clicks “send” to disburse prescriptions to the assigned pharmacy, and thinks that he or she is electronically prescribing, but the physician may actually be sending a computer generated fax.
In other practices, the physician who clicks “send” avoids sending the prescription directly altogether and fires it to his or her in office printer to be handed to the patient or manually faxed to the pharmacy.
Why does it matter if I prescribe electronically or via fax?
Sending a computer generated fax prescription, is just that, a faxed prescription. The faxed prescription must then be entered into the pharmacy’s computer system manually, increasing the chance for drug error.
Additionally, starting January 1, 2009, CMS, under the “Medicare Modernization Act,” will require all Medicare Part D computer generated prescriptions to comply with NCPDP Script standard, and thus be transmitted electronically and not via fax1. Lack in understanding of your system and being unsure as to whether you prescribe electronically does not place you in compliance.
In addition to the safety and efficiency associated with electronic prescribing, two-way connectivity is available with most chain and independent pharmacies. Two-way connectivity can assist in completely automating your prescribing system through fast and efficient communication. New prescriptions will immediately transmit to the pharmacies system and refill requests can be sent directly to your EHR. Some pharmacies even notify you when the patient picks up a prescription and gives a list of medications prescribed by other doctors and filled at that pharmacy.
How do I know if I am properly e-prescribing?
Your e-prescription software or EHR vendor will be able to work with you to confirm that your system is enabled to prescribe electronically to those pharmacies accepting electronic prescriptions. You can also verify whether your practice can establish an e-prescribing connection with pharmacies by visiting GetRxConnected and taking the readiness assessment. This site also contains a list of connected pharmacies by state.
You can also contact your vendor and request your connection to the “Pharmacy Health Information Exchange.” Be sure to explain that you want to receive refill requests electronically from local pharmacies, not by fax. You may also want to ask the following questions: Is a system upgrade required? Are there any additional costs involved? What kind of training will be provided? When can I get connected?
E-Prescribing Resources
Get Rx Connected
www.getrxconnected.com
Get Rx Connected is a special resource page that allows prescribers to determine if technologies used within their practices are certified for connectivity to the Pharmacy Health Information Exchange, operated by SureScripts.
Through filling out an online response form, prescribers and/or their staff receive instant, customized reports that confirm certification status of technologies used, provide a listing of connected pharmacies in their area, and estimate the value of time they currently spend managing refill requests by fax and phone.
This site will also generate a customized action guide for those practices seeking to adopt e-prescribing technology and includes a listing of certified e-prescribing systems that may meet the individual prescriber’s needs, with the option of contacting the vendors directly to obtain a system demonstration.
A Clinician’s Guide to E-Prescribing
www.ehealthinitiative.org
A Clinician’s Guide to Electronic Prescribing is a “how-to” guide to help clinicians make informed decisions about how and when to transition from paper to electronic prescribing systems.
Developed by the eHealth Initiative—with the strategic guidance of a multi-stakeholder steering group comprised of clinicians, consumers, employers, health plans, and pharmacies, and in partnership with four major medical associations—the guide is designed to meet the needs of two target audiences:
The first section of the guide targets office-based clinicians who are new to the concept of e-prescribing and who seek a basic understanding of what e-prescribing is, how it works, what its benefits and challenges are, and the current environment impacting its widespread adoption.
The second section of the guide targets office-based clinicians who are ready to move forward and bring e-prescribing into their practices. It presents fundamental questions and steps to follow in planning for, selecting and implementing an e-prescribing system.
The guide also provides a list of key references and resources readers may consult to help make the transition to e-prescribing as smooth as possible.
Click here 
for the full prescriber guide.
SureScripts
http://www.surescripts.com/
SureScripts, operator of the Pharmacy Health Information Exchange, provides resources and programs to prescribers and pharmacists relating to e-prescribing adoption and utilization.
The tools and communications available include an e-prescribing connectivity guide, SureScripts physician-certified solution provider list, buyers guide, state/national e-prescribing initiatives, and prescriber peer perspectives.
Rx for Success
www.RxSuccess.com
Rx for Success has been developed as a comprehensive area where prescribers can access resources to help with initial, and continue the ongoing implementation of, electronic prescribing. Tools available include:
Best practices guide: E-prescribing best practices guide separated into those sections that apply during implementation of electronic prescribing and those that may apply post implementation.
Support protocol sheet: A troubleshooting sheet that outlines steps practices should take if they encounter issues with the ways in which prescription information is exchanged electronically with pharmacists.
Reporting site-faxed refill request: This page allows practices to diagnose and, when necessary, report potential issues with EDI enabled pharmacies that send refill requests both electronically and by fax.
Find a connected pharmacy tool: This tool allows prescribers to see which pharmacies in their states are able to exchange prescription information with them electronically.
MD to pharmacy letter: A letter that can be used by practices to let pharmacies in their area know that their practice is enabled for e-prescribing. The letter encourages non-connected pharmacies to contact their vendors to establish their connection to the Pharmacy Health Information Exchange.
Patient notification cards: These cards can be given to patients to inform them that their prescription was sent electronically. They also serve as a reminder for the pharmacist that the prescription was sent electronically and to check their computer (or fax machine if the pharmacy has not been enabled for electronic prescribing).
Patient flyer: A flyer to educate patients that their prescriber manages prescriptions electronically and the benefits of doing so.
The National E-Prescribing Patient Safety Initiative
www.nationalerx.com
The National E-Prescribing Patient Safety Initiative is a new coalition of the nation’s most prominent technology companies and health care organizations dedicated to improving patient safety and reducing harmful medication errors. To accelerate the adoption of electronic prescribing, NEPSI will make web-based electronic prescribing software available free to every physician in America. The NEPSI offering, eRx NOW™, is web-based software from Allscripts.
AMA Electronic Prescribing Toolkit
http://www.ama-assn.org/ama/pub/category/20298.html
To help with inquiries that may arise, the AMA created "Understanding the basics of Medicare’s electronic prescribing incentive program." This new guide covers the fundamental basics of the program, including such topics as what the program is, incentive amounts for using the program, eligibility criteria to receive incentive payments and reporting and system requirements.
Ask a Coding Question through ACR Discussion Forums.
Electronic Prescribing of Controlled Substances
DEA rule gives providers the option of writing prescriptions for controlled substances electronically.
On June 1, 2010, the “Electronic Prescriptions for Controlled Substances” [Docket No. DEA-218, RIN 1117-AA61] rule became effective providing provide pharmacies, hospitals, and practitioners with the ability to use modern technology for controlled substance prescriptions while maintaining the closed system of controls on controlled substances. The regulations also permit pharmacies to receive, dispense, and archive these electronic prescriptions.
The DEA has been moving in this direction for about 15 years, but the pace has been very slow as controlled substances carry a much higher risk of diversion and requires increased safeguards to prevent misuse and abuse in comparison to non-controlled substances. This risk and previously immature technology slowed progress as the DEA felt that paper prescriptions would be easier to prosecute than electronic prescriptions.
The renewed push for e-prescribing of controlled substances began in 2008 when the agency announced its intention to create an alternative to manual prescriptions. The resulting rule was a step in the right direction, but was widely viewed as too burdensome and inflexible by most stakeholders. As a result, it failed to be adopted by providers and the e-health industry.
More recently, with the February 2009 passage of the HITECH Act which created incentives for increased use of HIT by physicians, pressure on the DEA to develop a reasonable process for e-prescribing controlled substances increased leading to the development of the current interim rule which effectively addresses the diversion issue and facilitates the prosecution of violators while being more responsive to provider and pharmacy burden and workflow issues.
This is welcome news to providers who are currently e-prescribing and will now be able to stream line their prescribing practices by instituting one single electronic prescribing workflow.
To make e-prescribing of controlled substances secure, the new DEA rule requires that physicians provide 2 of the following to log into the system and generate an electronic prescription:
- Something the person knows (such as a password)
- Something the person has (such as a 'hard token' device that generates a random number to be typed into the computer)
- Something the person 'is' (such as a retina scan or fingerprint)
With the new regulations in effect, e-prescribing of controlled substances is permitted in the US, but it could be awhile before we see widespread electronic prescribing of controlled substances. The rule creates new technical demands that must be addressed in order to make the process feasible. Software developers may need a year or more to get up to speed with the programming needed to manage the hard tokens and biometrics in addition to making updates to computer systems that will allow prescribers to transmit scheduled medication orders, intermediary networks to process the prescriptions, and pharmacies to receive them. Pharmacies will also have to reprogram and have their systems certified by an entity approved by the DEA.
Additional legal and policy barriers will need to be tackled in order for these prescriptions to move electronically. CMS will need to issue its own new electronic prescribing standard under Medicare or grant a waiver to its current standards in order to allow physicians to meet the DEA requirements and state Boards of Pharmacy and other state agencies will need to modify any outdated state regulations that are barriers to e-prescribing of controlled substances.
The ACR will work to keep the membership current as the e-health environment matures to facilitate electronic prescribing of controlled substances. Check back frequently for updates and guidance on working with your system vendor, DEA, and local pharmacies on e-prescribing of controlled substances.
E-Prescribing and Medicaid Tamper Resistance
Update on Tamper-Resistant Prescription Pads: Micro printing or a printed void pantograph will now satisfy Category 1 copy resistance and enable practices to avoid the high cost of acquiring special tamper-proof prescription paper.
As of October 1, 2008, all fee-for-service Medicaid prescriptions that are either handwritten or printed from an EHR/e-prescribing application will be required to have a minimum of 1 feature from all three Centers for Medicare & Medicaid Services categories of tamper-resistant features.
CMS has now clarified those requirements for printed prescriptions generated via EHR or e-prescribing systems and has determined that compliance for these prescriptions within Category 1 (copy resistance) can be achieved without using special paper. Special paper can still be used for printing, but the overall guidance from the NCPDP and CMS to State Medicaid Directors is that copy resistance can be met with using micro printing or a printed void pantograph. These features enable practices to avoid the high cost of acquiring special tamper-proof prescription paper.
Review of Centers for Medicare & Medicaid Services Requirements
By October 1, 2008 handwritten or printed prescriptions must contain a feature within all three categories. While the law specifies the term, “prescription pad,” the CMS stated that these requirements also apply to computer-generated prescriptions that are printed using paper inserted into the printer:
One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form
One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber
One or more industry-recognized features designed to prevent the use of counterfeit prescription forms
Review the updated summary of features that could be used on a tamper-resistant pad/paper in compliance with the CMS guidelines. Click here for sample tamper resistant scripts.
Exemptions
The following exemptions have been defined by the CMS in the letter issued to State Medicaid Directors on August 17, 2007.
The tamper-resistant requirement does not apply to the following:
Written prescription refills presented to a pharmacy before April 1, 2008.
Prescription orders transmitted to a pharmacy electronically, by telephone, or by fax.
Prescriptions for patients in nursing homes and other facilities, where the patient does not handle the prescription directly.
Compliance
Although CMS guidance is clear, the enforcement, definition, and interpretation of this legislation have been left up to each individual state and states have the right to issue their own guidance, as long as it is not less restrictive than the CMS guidance. If you or your practice does not meet the exemptions listed above, you must understand your state's interpretation of this law by reviewing the Tamper-Resistant Prescription Pad Security Features Required by States Prior to April 1, 2008 .
Some states may have issued guidance without full comprehension of the changed CMS position, and without understanding the implications of their decision for EHR users. While CMS will attempt to have states understand this clarified guidance, it may be necessary to work with your own state, if its current guidance is not in keeping with the clarified CMS guidance, to help them to revise its guidance.
Suggested next steps:
Contact your EHR vendor and/or health system or practice administrator to make sure that your EHR will be able print prescriptions that are tamper resistant, as defined by the CMS rules. Many EHR and e-prescribing systems already allow for micro printing of a signature line that satisfies the Category 1 requirement. Micro printing produces a very small font which is legible when viewed at a 5x magnification or greater, but illegible when copied. For micro printing to be effective, this feature must be printed in a 0.5 font or less.
Contact your State Medicaid director's office to make sure that they have received the new advisory from the NCPDP-CMS and are either accepting it as the October 1 rule for their jurisdiction or creating their own guidance informed by this advisory. If there is an existing rule that does not take into account this new advisory, appeal the advisory. While states certainly have the choice to create a rule that is more conservative than the CMS advisory, it should be informed by this updated advisory, and should not make printing a tamper resistant prescription from an EHR impossible because of the exorbitant costs of special paper or printers.
Contact the pharmacies you prescribe to, and make sure they are aware of this new advisory, and give them voided samples of your new October 1 compliant prescriptions.
If you have any additional questions or concerns regarding Tamper Resistant Prescriptions or e-prescribing, please contact Itara Barnes at or (404)633-3777.
