Quality Rounds
E-prescribing 101
Guidelines for the beginner.
By Scott D. Smith
There are a lot of reasons to begin e-prescribing now. Starting this year, Medicare is offering a 2 percent bonus to physicians who submit prescriptions to pharmacies electronically. (Those who don’t do so by 2012 will face a penalty.) In addition, Minnesota has mandated that all physicians e-prescribe by 2011. But those aren’t the only reasons for physicians to make the switch. Practitioners who are already e-prescribing say it saves them time doing refills, and it saves time for patients, as they don’t have to drop off a prescription and wait for it to be filled. It eliminates the chance of the patient losing a paper prescription, and it cuts down on the chance of pharmacists incorrectly interpreting hard-to-read handwriting. Also, e-prescribing systems can alert doctors to medication recalls and warn them about potential drug interactions. Clearly, it’s time to start e-prescribing. But where does one begin?
Getting Started
The first thing physicians need to know is that this is one change that does not have to be difficult or expensive. Pharmacies have already done a lot of the work needed to make e-prescribing happen.
In 2001, the trade associations representing drug store chains and pharmacists founded a company called SureScripts, which developed a network for allowing the secure transmission of electronic prescription information between computers at the pharmacy and computers at the physician’s office. Last year, SureScripts merged with a company called RxHub, which had developed a similar network that supplied patient formulary and eligibility information from large insurance databases. The merged company, SureScripts-RxHub, now offers a single network called the Pharmacy Health Information Exchange, through which all e-prescribing information can be transmitted. Today, 70 percent of the nation’s pharmacies are able to process prescriptions through the exchange, which is funded by transaction fees paid by pharmacies that receive electronic prescriptions and payers that deliver formulary and benefits information. Physicians pay nothing to use the exchange.
To do e-prescribing over that network, however, physicians need two things (assuming they already have access to computers): a high-speed Internet connection and an electronic prescribing application that has been certified to connect to the exchange.
E-prescribing software packages are either stand-alone systems or components of an electronic health record (EHR) system. Ideally, either should allow the physician to send new prescriptions directly to the pharmacy, enable pharmacies to send refill authorization requests directly to the prescriber so they can approve or deny them, provide prescribers with some or all information about a patient’s prescription history at the point of care, alert physicians to negative drug interactions, and give prescribers access to a patient’s drug coverage and formulary information during an office visit.
More than 90 stand-alone products are certified to connect with SureScripts-RxHub’s exchange, and they range in price from free to approximately $2,500 per prescriber per year. In order to compare products, go to www.surescripts.com/get-connected.aspx?ptype=physician. (SureScripts, which does not sell or develop electronic prescribing applications, acts as a neutral resource that certifies existing technologies that connect to the Pharmacy Health Information Exchange.)
A Tale of Two Systems
Charles Meyer, M.D., an internal medicine physician with Consultants Internal Medicine in Edina and editor in chief of Minnesota Medicine, says his group, which includes four physicians and a physician’s assistant, wasn’t ready to invest in an EHR system but wanted to start e-prescribing to qualify for the Medicare bonus. They chose Allscripts ePrescribe, a stand-alone web-based system offered free to physicians by the National ePrescribing Patient Safety Initiative (NEPSI), a coalition of organizations dedicated to reducing medical errors related to prescribing. Getting up and running was relatively painless, Meyer says. He started by registering at the NEPSI website, https://erxnowregistration.allscripts.com, providing identifying information such as his DEA and state license numbers. Allscripts created an account for him and asked him to generate five prescriptions for patients. “Those first five new prescriptions sort of turned on the whole system and then all the pharmacies on the [SureScripts-RxHub] system started sending me their refill requests,” Meyer says. His partners also registered and created their own e-prescribing accounts.
Paper Still Required for Narcotics
Physicians should keep in mind that e-prescribing cannot be done for Schedule 2 narcotics because the Drug Enforcement Administration prohibits the electronic prescription of controlled medications, which account for about 20 percent of prescriptions. The law requires physicians to sign a paper prescription that the patient then takes to the pharmacy. Therefore, providers can’t entirely eliminate paper prescriptions from their practices.
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Allscripts also offers two electronic prescribing products designed to work with EHR systems. St. Paul-based HealthEast Clinics, which employs about 126 clinicians, does e-prescribing through its Allscripts Enterprise EHR system. HealthEast clinicians started e-prescribing in 2007. As a first step, they entered their prescriptions into the EHR, and the system automatically sent computer-generated faxes to the pharmacies. That’s changed in the last year. Sending computer-generated faxes is no longer considered e-prescribing, and Medicare will no longer reimburse for faxed prescriptions starting in 2012.
By August of 2008, HealthEast had switched to doing computer-to-computer transmissions of both refills and new prescriptions over the SureScripts-RxHub network. Today, HealthEast clinicians send 75 percent of prescriptions digitally. They “write” their prescriptions on tablet computers that look like mini-laptops with keyboards and touch screens. Physicians can use either the keyboard or a stylus and handwriting-recognition software to enter information.
The biggest advantage to doing e-prescribing through an EHR system is that new prescriptions and refills are automatically entered in the patient’s medical record, says Linda Walling, M.D., medical director of clinical informatics for HealthEast Clinics. “The biggest improvement is that we now have an accurate medication list,” she says, explaining that SureScripts-RxHub can collect 18 months worth of claims information related to prescriptions and automatically load that onto the patient’s medication page.
At Meyer’s practice, where providers use a bank of desktop computers to access Allscripts ePrescribe, they still have to manually update the medication list in the patient’s paper chart. Allscripts ePrescribe allows Meyer to print a medication list, but it only includes the new prescriptions or recent refills that he has entered into the system. Because of this limitation, he sees his current stand-alone system as an interim step before moving to a full EHR.
“Stand-alone is not the final answer,” he says. “It is better if it helps our logistical things such as cutting down on faxes and pharmacy work; but one of the main reasons for a computerized record is to get everyone who deals with a patient’s medications—the hospital, pharmacy, doctor and patient—on the same page.”
E-prescribing systems integrated with an EHR have the power to access information already entered in the patient’s chart. For example, HealthEast’s system automatically alerts Walling to any patient allergies by cross-referencing the patient’s medical record. Meyer’s stand-alone system can do the same thing only if someone has manually entered allergy information into the patient’s record in the e-Prescribe database.
HealthEast’s system indicates that a particular drug is preferred by an insurer’s drug formulary. Meyer says his clinic’s stand-alone system is supposed to provide this information, when it is available from the SureScripts-RxHub network, but he has yet to see it.
Things to Think About
As they move toward e-prescribing, physicians should understand that it will affect the way they and their staffs do their jobs. Physicians say e-prescribing significantly reduces staff time needed to process refills, but it won’t necessarily save them time, especially if they use a stand-alone system for new prescriptions. That is because physicians may find themselves having to enter patient data as they write the script.
Meyer says this is fairly easy to do with Allscripts ePrescribe, as he only needs to enter basic information such as the patient’s name, gender, date of birth, and Zip code to fill a prescription. But he admits it is still time-consuming. His clinic is currently exploring whether Allscripts can import patient data from the clinic’s billing-management system.
Another issue to consider is how the e-prescribing system responds when a patient’s preferred pharmacy is not connected to the SureScripts-RxHub exchange. For example, HealthEast’s system automatically faxes the prescription to pharmacies that are not connected. But at Meyer’s clinic it’s up to the doctors to fax or provide a written prescription. About 90 percent of Minnesota pharmacies already have the capability to
e-prescribe. To find out whether a pharmacy is part of the SureScripts RxHub, go to www.rxsuccess.com.
Some clinics have found that it helps to contact frequently used pharmacies before making the switch to e-prescribing. Walling says HealthEast sent a letter to area pharmacies alerting them to the pending change and encouraging them to connect with the SureScripts-RxHub exchange. Also, HealthEast clinicians initially gave patients a note indicating that their prescription was sent electronically that they could take to their drug store. They also found that pharmacies that are used to receiving prescriptions by fax may need a reminder to check the computer instead.
Physicians should also be aware that eligibility and formulary information may not yet be available for all patients. Walling estimated that such information is available for only about 35 percent to 50 percent of HealthEast’s patients. She says that percentage may increase in 2009, as some of Minnesota’s large insurers switch to pharmacy benefit managers that feed information into the SureScripts-RxHub exchange.
Clinics also need to set up some type of coverage system for refills when a physician is out of the office. Meyer says when his colleague was on vacation, he was able to sign into that physician’s account and approve his refills. HealthEast has a shared-task screen in its EHR, where providers can see the refills that need to be made. Different team members are assigned to check it.
No Going Back
Although e-prescribing systems are still being perfected, both Meyer and Walling are seeing efficiencies as a result of using them. Meyer says the providers in his practice have found it especially helpful for ordering prescription refills. “Most of our activity is generated by refills, and this system is handy for that because it cuts down on the fax volume considerably,” he says. Meyer says the system allows him to log in and check to see if he has refills waiting for approval.
Walling has also found that e-prescribing saves staff time associated with refills, as they no longer need to track down the information to complete a patient’s refill request. In fact, HealthEast clinic staff are advised to tell patients to submit their refill requests directly to their pharmacies using the order number on the bottle. SureScripts-enrolled pharmacies will send an electronic refill request directly to the EHR. This procedure reduces the chance for transcription and communication errors, Walling says.
Walling admits she wouldn’t go back to handwriting prescriptions, and she wants to encourage other physicians to make the switch. “I really think this is where we need to go,” she says of e-prescribing. “If you look at the opportunity for harm to patients and what is available electronically, I think it’s just not supportable to continue handwriting
prescriptions.” MM
Scott Smith is a staff writer for the Minnesota Medical Association.