Mariah Delaire June 7, 2016 HTM 520 Professor Mark Branning Electronic Prescribing Introduction It is estimated that more than one million Americans per year are negatively affected by medication errors, which are caused by mistakes in the prescription filling process (Office of the National Coordinator for Health Information Technology, 2015). Errors such as these can cost the health care industry billions of dollars every year, furthering the need for change to help lower costs and reduce medication errors. The resultant change is the use of electronic prescribing (eRx) facilitated through the use of electronic health care records (EHRs) and standalone software. Eprescribing enables prescribers to electronically send accurate and error free prescriptions to a pharmacy, and is a main component of improving the quality of patient care. The functions of eprescribing include messages regarding new prescriptions, prescription changes, refill requests, prescription fill status notifications, prescription cancellation, and medication history (National Council for Prescription Drug Programs, 2014). Initiatives such as the HITECH Act and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), helped to increase the adoption of e-prescribing systems. The adoption of the standards for e-prescribing was a key action in the government’s plan to expedite the process of widespread EHR adoption and implementation. As a result of this health information technology tool, patients in nearly all states can have their medications prescribed to them via e-prescriptions. During the e-prescribing process, a system user signs in where their identity is authenticated. The prescriber then identifies the patient records within the e-prescribing system. If the e-prescribing system is connected to that facility’s EHR system, it can recognize all patient records on that day’s schedule, making it easier for the prescriber to access information. The next step is to review any pertinent medical history on the patient, then enter and edit the prescription as needed. E-prescribing systems allow prescribers to send the information to the Transaction Hub where that information on the patient’s eligibility, formulary, and medication history/fill status is sent back for the prescriber to view. The transaction hub is the link between the prescriber, pharmacy, and the pharmacy benefits manager (PBM) (U.S. Department of Health and Human Services , 2016). As soon as the Transaction Hub receives the patient information from the prescriber, it verifies that information against the master patient index sending a message to the PBM. The PBM will then send information back to the transaction hub which is then sent back to the prescriber who can make the decision about the prescription based on the information. At that point, the prescriber can complete and authorize the prescription and is then able to send it to the preferred pharmacy. Benefits With the help of health information technology tools such as electronic prescribing, providers can safely and efficiently manage patient’s medications. In comparison to other tools such as paper or fax, eRx improves medication safety, prescribing accuracy, and health care quality and costs by
reducing adverse drug events (U.S. Department of Health and Human Services, 2016). The use of eprescribing is steadily increasing due to these may benefits. The growing complexity of patient’s needs in addition to the increasing volume of medications, marks an increased risk of error and adverse drug events. ERx can help to improve the safety of patients along with the quality of care they receive by eliminating illegible prescriptions and reducing oral miscommunications. ERx systems also have the ability to warn and alert prescribers if there are potential adverse events to other medications patients are taking and also allows providers access to a patient’s complete medication history. The use of e-prescribing systems has the ability to reduce time on phone calls to and from pharmacies while increasing patient convenience and medication compliance. In addition to the many benefits discussed, eRx systems can help to achieve direct cost savings for both the patients and the insurers. This can be done by pharmacy benefit managers (PBMs) and insurers providing detailed information to the prescriber about formularies and the benefits structure of a plan, enabling the provider to prescribe the most appropriate medication (U.S. Department of Health and Human Services, 2016). Overall, there are many benefits that e-prescribing has for providers, insurance companies, pharmacies and patients. Relationship to Meaningful Use Meaningful use is a set of criteria in which electronic heath care records (EHR) are used to improve overall patient care by healthcare providers. The ideas behind meaningful use is to improve population health, improve coordination of care, safety and patient engagement. Financial incentives have been approved for eligible providers and hospitals for the implementation of Meaningful Use, in hopes that more organizations will adopt EHRs. There are three stages of meaningful use with the plan of implementation over the course of five years. Stage one and two have already taken place, while stage three is planned to take place between the years 2016 and 2017. Electronic prescribing is one of the criteria set to achieve meaningful use. The main objective of eRx is to generate and transmit permissible prescriptions electronically. The stage one measure for e-prescribing focused on achieving more than 40 percent of prescriptions being transmitted electronically using certified EHR technology (CEHRT) (Centers for Medicare and Medicaid Services, 2014). The exclusions to this criterion are providers who write fewer than 100 prescriptions during the reporting period and any provider who does not have a pharmacy within their organization or a pharmacy within 10 miles that accept e-prescriptions. The objective of Stage two for e-prescribing remained the same, while the measure changed. The goal was to achieve more than 50 percent of permissible prescriptions written by the provider were to be queried for a drug formulary and transmitted electronically using a CEHRT (Centers for Medicare and Medicaid Services , 2014). It is important that the provider solely used a CEHRT to create the prescriptions and used standards adopted for the EHR technology certification to transmit. Exclusions for stage two remained the same as stage one. Stage three of eprescribing is proposed to maintain the objective and measure finalized in stage 2, with slight changes. The objective is still to generate and transmit permissible prescriptions electronically, however hospitals and critical access hospitals must also generate and transmit permissible discharge prescriptions electronically, meeting an 80 percent threshold (Centers for Medicare and Medicaid Services, 2015). Corresponding Standards Electronic prescribing standards is supported through the National Council for Prescription Drug Programs (NCPDP) who is an ANSI- accredited standards development organization. The
NCPDP is one of several Standards Development Organizations (SDOs) involved in Healthcare Information Technology and Standardization. Because so many different entities are involved in the prescription process, a set of standards are needed to ensure there is proper communication between all parties. One of the main electronic prescribing standards used is the XML-based NCPDP SCRIPT standard, which was created to help facilitate the transfer of prescription data between pharmacies, prescribers, intermediaries, facilities and payers in the outpatient setting (National Council for Prescription Drug Programs, 2014). SCRIPT enables communication of prescription information between the prescriber and the pharmacy in addition to medication history between all parties. This standard is essential in all transactions for new prescriptions, prescription changes, refill requests, prescription cancellation, medication history and prior authorization exchanges. Most inpatient settings who have adopted an EHR system use HL7 as part of their data standards. Because HL7 is being used, it needs to work alongside NCPDP SCRIPT to guide messages supporting the actions of new prescriptions, prescription changes, refill requests, prescription fill status notification, and prescription cancellations to and from the pharmacy. This HL7-NCPDP standard enables inpatient facilities using HL7 to electronically communicate prescriptions for patients that are discharged (HL7 Pharmacy Work Group, 2007). It also allows outpatient facilities using HL7 prescription tools to write prescriptions to be delivered to a pharmacy for dispensing. This system enables pharmacies to communicate refill or renewal requests to prescribers from NCPDP SCRIPT messages to HL7 messages as well. In addition, HL7-NCPDP allows prescription history messages in SCRIPT to be communicated between prescribers using either SCRIPT or HL7 standards. HL7-NCPDP works as a bridge to facilitate communication for providers using either standard. HL7 standards were not initially designed to manage the transactions of prescribers and retail pharmacies. It is important for inpatient settings to utilize the HL7-NCPDP standard to allow for the communication with ambulatory and retail pharmacies (HL7 Pharmacy Work Group, 2007). Another component of the NCPDP is the Formulary and Benefit Standard which provides patient benefits information to the physicians at the point of care. This enables physicians to make informed decisions during the prescribing process so he/she can choose the most appropriate drug for the patient (National Council for Prescription Drug Programs, 2014). Data for formulary and benefits can consist of formulary status, payer-specified alternatives, coverage information, copay information, and drug classifications. NCPDP Fill Status Notification is another component that notifies the prescriber after a patient has picked up a prescription at the pharmacy. This information is useful to track patients who appear to be non-compliant with their doctor’s advised course of treatment. ASC X12N 270/271 (Health Care Eligibility/Benefit Inquiry and Health Care Eligibility/Benefit Response), is another standard used for a prescriber to request eligibility information about a patient. This particular standard is maintained by the Accredited Standards Organization. The Structured and Codified Sig format for e-prescriptions includes instructions for the patient for taking medications at the end of the prescription. These instructions are called signtura and currently hold no standardized vocabulary (Liu, Burkhart, & Bell, 2011). An important component to standardization is standardized vocabulary, which is why RxNorm is used. RxNorm, a drug nomenclature from the National Library of Medicine, provides a vocabulary for name, dose, and form of available drugs (Bell, O'Neill, Reynolds, & Schoeff, 2011). Each drug in the database is distinct because it is assigned a unique identifier. This improves drug identification in e-prescribing
because it offers substantial efficiency for communicating health plan formulary information to prescribers. Data standards are an important component to any successful system because they not only ensure proper communication between multiple systems, but promote interoperability between those systems as well. E-prescribing gives providers the ability to securely and electronically exchange prescription information with pharmacies. It was observed that physicians using EHRs or eprescribing software are able to cut the amount of time in half on refilling authorizations when compared to non e-prescribing users (Hutchinson, 2007). With the amount of adverse drug events that occur each year along with the billions of dollars in added heath care costs, electronic prescriptions can help providers avoid these mistakes. Having patient medication information readily available, providers can prevent these adverse events by automatically checking for drug allergies, drug-drug interactions, and doses that are too high. It is essential to adopt e-prescribing because it reduces the large amount of adverse events and medication errors that occur every year while improving patient safety and quality of care. Cerner Electronic prescribing can come in a couple different forms. It could be integrated with an already functioning EHR system, or could be used as a software alone. However, with the HITECH act and Meaningful Use, most providers use an e-prescribing tool that is already a part of their existing EHR system. An example of an EHR vendor that has e-prescribe as a tool is Cerner. The eRx tool is a standalone and easy to use application that allows physicians to automate the prescriptions process. This type of tool is great to use alongside an existing EHR system because it can help providers increase reimbursement, decrease time and effort processing prescriptions, and ensure patient safety (Cerner, 2016). Cerner’s e-prescribing tool uses an electronic data interchange to transmit from prescriber to pharmacy and is partnered with SureScripts, a third party vendor, who supplies the network for the data transmission process. SureScripts is used because they have a relationship with close to 95 percent of the pharmacies around the country (Cerner, 2016). The use of a system such as Cerner ePrescribe helps providers to minimize re-entry of patient data, increases patient safety by reducing illegible prescriptions and adverse drug events, and displays formulary and benefits to ensure plan eligibility. Barriers and Challenges While e-prescribing is a valuable tool to improve patient safety and efficiency, it does come with some challenges. A large concern for hospitals and providers is the costs associated with implementing a eRx system. Many believe that the cost is too high to receive an appropriate return on investment. Change management and new workflow systems is another challenge because many practices are set in their ways of doing things. It also is timely for practices and hospitals to conduct training, planning and implementation of a new system. Another hurdle is selecting the proper hardware and software. It can especially be challenging if it is a smaller practice where they do not have IT staff for technical support. The connectivity of pharmacies poses a large challenge as well because while 97 percent of chain pharmacies are connected to an e-prescribing system, 73 percent of the independent pharmacies are not (U.S. Department of Health and Human Services, 2016). This means that the patient, formulary, eligibility, or medication history may not be current. Another challenge is security issues, such as the verification of electronic signatures and ensuring the medical
integrity of prescriptions. Therefore, it is essential that prescribers and pharmacies are protected with firewalls, have strict settings, and remain aware of signs of intrusion. With many challenges comes many opportunities for improvement; if these challenges can be addressed, widespread adoption and implementation of an e-prescribing tool can be accomplished. Future Trends It is no doubt that e-prescribing use has grown significantly over the last few years. Providers using e-prescribing tools via EHRs have increased from 7% in December 2008 to 54% in December 2012. Not only that, pharmacies utilizing e-prescribing software have gone from 70% in December 2008 to 94% in December 2012 (Gabriel, Furukawa, & Vaidya, 2013). Another trend that is expected to increase e-prescribing use is Meaningful Use Stage 3. It was seen that Stage 1 and Stage 2 showed a median performance of 89 percent and 92 percent, so it is expected that there will be continued expansion of pharmacy market acceptance and improved EHR use to facilitate e-prescribing (Centers for Medicare and Medicaid Services, 2015). The proposed measure for Stage 1 and 2 were 40 and 50 percent, and because of the seen trends, the proposed measure for Stage 3 is 80 percent. Eprescribing is expected to continue to enhance safety and medication compliance. E-prescribing will continue to prevent medication errors and increase patient safety along with saving large costs. Summary More than one million people every year are affected by medication errors, which contributes to billions of dollars in additional health care costs. The adoption of standalone or EHR e-prescribing systems can help to reduce these medication errors and associated costs. These systems improve patient safety, medication compliance, efficiency, quality of care, patient satisfaction and reduces costs. With the help of laws and bills such as the HITECH Act and Meaningful Use, widespread adoption is currently being taken place. Since the enactment of the HITECH Act, there has been a substantial increase in providers and pharmacies using e-prescribing technology. Through the use of data standards such as SCRIPT, HL7 and RxNorm, patient information can be easily exchanged between all associated systems. This ensures that the right medication is being prescribed for the right patient based on medication history, drug-drug interactions, allergies, among many other factors. Cerner is a great example of a vendor that works alongside a third part company to ensure that their e-prescribing software is efficient and up to date. Along with the many benefits of eRx, there are challenges such as the costs associated with adoption, user resistance to change, and the potential security issues. However, the future of e-prescribing is extremely positive because of all the benefits that are associated with the use of this system. The adoption of e-prescribing is only going to increase by providers, hospitals, and pharmacies because of how effective it is in preventing medical errors and reducing costs. Questions: 1) What is the common standard used for e-prescribing in the outpatient setting? XML- based NCDPD SCRIPT 2) What types of e-prescribing systems are there? Standalone and EHR based 3) Describe the major goal of eRx adoption. To prevent medical errors and reduce health care costs which improves patient safety, quality or care, and patient satisfaction.
References Bell, D., O'Neill, S., Reynolds, K., & Schoeff, D. (2011). Evaluation of RxNorm in Ambulatory Electronic Prescribing. RAND Health Quarterly. Centers for Medicare and Medicaid Services . (2014). Eligible Professional Meaningful Use Core Measure Stage 2. Baltimore: Centers for Medicare and Medicaid Services . Retrieved from https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_2_ePrescribing.pdf Centers for Medicare and Medicaid Services. (2014). Eligible Professional Meaningful Use Core Measure Stage 1. Baltimore: Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services. (2015). Federal Register: Meaningful Use Stage 3. Washington D.C.: Department of Health and Human Services. Cerner. (2016, May 7). EPrescribe. Retrieved from Cerner: http://www.cerner.com/solutions/Physician_Practices/Ambulatory_EMR_-_EHR/ePrescribe/ Gabriel, M., Furukawa, M., & Vaidya, V. (2013). Emerging and Encouraging Trends In EPrescribing. AJMC. Retrieved from http://www.ajmc.com/journals/issue/2013/2013-1-vol19-n9/emerging-andencouraging-trends-in-e-prescribing-adoption-among-providers-and-pharmacies HL7 Pharmacy Work Group. (2007, Janurary). HL7-NCPDP Electronic Prescribing Coordination Mapping Document, Release 1. Retrieved from Health Level Seven International: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=28 Hutchinson, K. (2007, April 20). Economics, Errors, and Emergencies: The Case for E-Prescribing and "Pharmacy Interoperability". Retrieved from MedScape: http://www.medscape.com/viewarticle/554617 Liu, H., Burkhart, Q., & Bell, D. (2011). Evaluation of the NCPDP Structured and Codified Sig Format for eprescriptions. Journal of American Medical Informatics Association, 645-651. National Council for Prescription Drug Programs. (2014). EPrescribing Fact Sheet. Scottsdale, AZ: NCPDP. Office of the National Coordinator for Health Information Technology. (2015, March 27). E-Prescribing. Retrieved from HIE Bright Spots: https://www.healthit.gov/policy-researchers-implementers/eprescribing). U.S. Department of Health and Human Services . (2016, May 5). How Does E-Prescribing Work? Retrieved from Health Information Technology and Quality Improvement: http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/ElectronicPrescribing/epreswork.html U.S. Department of Health and Human Services. (2016). What Are Some Challenges Associated with Eprescribe? Retrieved from Health Information Technology and Quality Improvement: http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/ElectronicPrescribing/challengesassoc .html U.S. Department of Health and Human Services. (2016, May 5). What Are Some of the Benefits of EPrescribing? Retrieved from Health Information Technology and Quality Improvement : http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/ElectronicPrescribing/benefitsepres.ht ml
