6 Optimization Strategies for E-Prescribing

Section 6.1 Optimize

Optimization Strategies for e-Prescribing

E-prescribing (eRx) is used to communicate with pharmacies, and with the patient’s health plan pharmacy benefits manager (PBM). It supports the provider with reminders, alerts, and access to guidance. E-prescribing also enables checking against health plan formularies and transmission of prescriptions directly to the pharmacy of the patient’s choice.

Time needed: 12 - 14 hours
Suggested other tools: Section 2.4 Visioning, Goal Setting and Strategic Planning for EHR and HIE, Section 4.6 Workflow and Process Improvement for EHR and HIE

Introduction

E-prescribing is important for patient safety because of the ability to obtain a list of all prescriptions the patient has recently filled and the clinical decision support that, at a minimum, includes drug-allergy checking and drug-drug contraindication checking. A prescription cannot be sent until all components of the sig (description of how the medication is to be taken) are included, so there is no guessing or a need for follow-up phone calls to the provider concerning dose, route, etc. E-prescribing also a boon to productivity, especially for staff members handling refills.

Some providers have adopted standalone e-prescribing systems prior to adopting an electronic health record (EHR). For some, this was a means to quickly take advantage of incentives offered by commercial payers and the federal government. For others, eRx was viewed as part of a migration path toward EHR, allowing providers to ease into computer use. When the federal incentive program for meaningful use of EHR began in 2011, the incentive for using eRx alone was dropped. However, standalone eRx systems still exist and are used side by side with EHR.

How to Use

1.Review the comparison table to understand the differences between a standalone eRx and one that is incorporated into an EHR.

2.Carefully weigh the benefits of standalone systems vs. eRx as a part of an EHR. Some providers have found eRx to be the perfect way to become familiar with computer use and standardization. Others may find the workarounds necessitated by a standalone eRx (e.g., manual entry of patient demographics, updating medication lists) not worth the effort.

3.Monitor usage after go-live. Issues related to e-prescribing include the length of time it takes to enter an order, alert fatigue, keeping the drug knowledge base and formulary for e-prescribing up to date, training new or infrequent users, and monitoring the achievement of goals.

Comparison

Attribute / Standalone eRx / eRx with EHR
Definition / Use of computing devices to enter, modify, review, and output or communicate drug prescriptions to pharmacies. / Medication ordering automatically linked to the comprehensive health record. Includes access to lab results, problemlists, diagnoses, and other useful information that may be included in more sophisticated drug decision support.
Costs / □Hardware and software
□Interface to practice management system, if applicable
□Potential additional charges for customization, training, maintenance, upgrades
□Usually requires an upgrade in bandwidth to connect with the third party information providers / □Incremental cost if additional module (not always applicable).
□Costs of interfaces, customization, other services, and increase in bandwidth are usually an inherent part of the EHR.
Barriers to e-Rx in general / □Some independent pharmacies are not yet connected, although this is changing rapidly.
□Many Medicaid systems do not participate in supplying formulary information.
□Formulary information for commercial payers is somewhat “hit-or-miss;” with eligibility specific to a patient’s drug benefit plan often requiring a separate drug benefit plan identifier not generally collected by behavioral health facilities, and not often available on the standard insurance card. Formulary information is recognized as the “weak link” by the federal government in its incentive programs; users are not penalized for not using the functionality.
□All states allow eRx of all non-controlled substances. The Drug Enforcement Administration (DEA) approved for use of eRx for controlled substances in 2010. As of late 2013, 44 state boards of pharmacy had approved use of electronic prescribing for controlled substances (EPCS). It requires broadband Internet access.
Barriers to specific forms of e-Rx / □Information collected and stored in most standalone systems are not easily transferable to EHRs. / □Fully integrated functionality enables seamless population of prescription information from practice management system and to medication lists, etc., in EHR.
People challenges / □Change management requires adequate planning, training, support, and continuous quality improvement.
□Workflow changes may result in new roles and responsibilities, lost productivity during transition, and communication with local drug stores or pharmacies about upgrading their systems to accommodate eRx.
□Incentives require application of G codes to all claims, whether or not there is a prescription written through e-Rx. This workflow change is confusing to some providers.
□Some patients do not want to commit to a specific pharmacy. / □Change management issues are greater for EHR, although eRx component is often viewed as the “simpler” part.
□Workflow and patient issues are the same as for standalone eRx.
System challenges / □Drug benefit plan may be different than health insurance plan. If not captured, formulary information not available.
□Demographic information dependent upon manual entry or interface to practice management system.
□Medication history and medication reconciliation from payer/pharmacy benefits managers (PBM)may be incomplete or inaccurate. Initially requires manual entry to build medication list.
□Facility without an EHR must decide whether eRx system or paper chart is the “source of truth” for the medication list.
□Medical history information is not included. Desired information, such as allergies, must be entered manually. Problem list and lab alerting generally are not feasible.
□Prescribing from multiple office sites may not be accommodated.
□Updates for new medications, removed medications, formulary information, drug interaction information, and new pharmacy information must be available. / □Availability of demographic information is not an issue,except for drug benefit plan information.
□Medication history and medication reconciliation from payer/PBM may be incomplete or inaccurate. Depends on provider to obtain patient consent to capture this information. Initial medication list build should be part of overall EHR conversion.
□Medical history available from EHR to e-prescribing users, including ability for Drug-Dx and Drug-Lab checking, depending on EHR.
□Prescribing from multiple office sites should be more easily accommodated.
□Splitting prescriptions between pharmacies should be feasible.
Benefits / □Alerts to Drug-Drug, Drug-Allergy, and out-of-range-dosing contraindications improve patient safety.
□Can provide “Tall man” lettering (part of drug name in upper case letters) in look-alike drug names.
□Access to drug reference software.
□May offer formulary information, at least at the tier level, including alert for prior authorization.
□Can “learn” and display favorite drugs.
□Searchable pharmacy information.
□Stores prescription information or prints out copy for paper chart.
□Eliminates illegibility, oral communication, andpharmacy transcription errors.
□Reduces time spent on phone calls and call-backs to pharmacies.
□Reduces time spent faxing prescriptions to pharmacies.
□Automates renewal request and authorization process.
□Increases patient convenience and medication compliance.
□Improves formulary adherence.
□Permits mobile use if system includes handheld device.
□Improves drug surveillance/recall ability. / □In addition to standalone eRx benefits, adds Drug-Lab, Drug-Dosing (with height and weight parameters), Drug-Disease, and duplicate therapy alerts.
□Can set level of alerting to avoid alert fatigue.
□Reduces need to move to a separate device and eliminates manual data entry.
□Can “learn” and display for acceptance or modification favorite “sig” descriptions of how medications are to be taken.
□Stores prescription information in EHR.
□Enables printing of drug education materials for patients.
□Enables generation of complete medication list from EHR (whether prescribed by provider or not) and may contribute to medication reconciliation for patients sent to hospital.
□With a personal health record (PHR), patients can record information about their compliance and drug reactions/ sensitivities.
Incentives / □Basic software may be available free of charge on the Internet.
□Medicare will reduce payments for providers not using eRx starting in 2014.
□Favorable contracting may be awarded for increased use of generic drugs, / □Incentives the same as for standalone eRx, although workflow to document use of e-prescribing is simpler in an EHR.
Technical alternatives / □License to software downloaded to office computer or application service provider.
□Device may be handheld/personal digital assistant/smart phone, tablet, desktop, or other hardware. / □Same as for standalone eRx.
Summary / Pathway to an EHR that improves patient safety / Affords full scope of functionality for eRx

Prescription Drug Monitoring Program

Prescription drug abuse is one of the fastest growing health epidemics in the United States. A report issued by the Office of the National Coordinator for Health Information Technology (ONC) on September 26, 2013 ( notes that every day, 105 people die as a result of drug overdose, and another 6,748 are treated in emergency departments for the misuse or abuse of drugs. ONC further observed that prescription drug abuse is not only deadly, but costly. Prescription opioid abuse costs were about $55.7 billion in 2007. Of this, 46 percent were attributed to lost productivity in the workplace, 45 percent to abuse treatment, and 9 percent to criminal justice costs. The Agency for Healthcare Quality and Research (AHRQ) estimates that emergency department costs are two to five times higher than the same treatment delivered by a family physician or internist.

To address this problem, many states have established Prescription Drug Monitoring Programs (PDMPs) that use electronic databases to track the prescribing and dispensing of controlled prescription drugs. While many of these programs contain very useful information, there are no universal standards for exchanging such information between PDMPs and EHRs. The ONC—in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA), Centers for Disease Control (CDC), and the White House Office of National Drug Control Policy—launched a series of pilot studies to test various connections with state PDMPs and EHRs, health information exchange (HIE) organizations, and pharmacy dispensing systems. The result has been the creation of a “transitions of care” dataset that includes data elements involving behavioral and mental health, severe depression, bipolar disorder, and diabetes. These data elements have been added to the Consolidated-Clinical Document Architecture (C-CDA) standard (see Section 2.10 Exchange of Clinical Summaries via CCR, CCD, C-CDA). ONC plans to continue promoting HIE and interoperability among all providers of care.

E-prescribing Communication

This diagram illustrates how e-prescribing works, starting with the patient visit at the left:[1]

A patient visits a provider.
A provider enters a drug to be prescribed for a patient into a standalone eRx system or an EHR with eRx application.
A drug knowledge database, the intermediary, (connected to the eRx) checks the drug against information available in the eRx system, such as allergies, contraindications to drugs, needed lab studies (if eRx in EHR). The ordering provider is alerted and may make a change.

4.If available, the patient’s drug benefits (from companies that consolidate health plans’ pharmacy benefits managers (PBM) information, such as RxHub, InfoScan, and others) are checked to determine whether the drug is on formulary, and potentially in what expense tier. The ordering provider should consult with the patient about the cost of the drug and may change to generic, allow the pharmacy to change to generic, or set to “dispense as written” (DAW).

5. The ordering provider should ask the patient where to send the prescription, which is then converted into a standard prescription transaction (using the National Council for Prescription Drug Programs NCPDP standard) and sent to an e-Rx network. The network serves as a gateway to pharmacies, who receive prescriptions in their electronic pharmacy systems. The pharmacy goes through the same quality checks and submits a claim as soon as the patient picks up the prescribed drugs.

6.Controlled substances can be sent through the e-Rx network and accepted in states permitting this. If they are not accepted, the system will notify the prescriber to generate a printed prescription that can be signed by the provider and given to the patient or faxed to the pharmacy (if permitted). The DEA requires a two-factor authentication process that includes using a token for eRx of controlled substances and audit requirements.

7.If a local pharmacy is not yet connected to the e-prescribing network for electronic exchange of NCPDP transactions, the system will recognize this and automatically convert the transaction to a fax.

8.Patients should be directed to call their pharmacies to request refills. If a refill requires an approval to renew from the provider, the pharmacy will generate a renewal request transaction (in NCPDP format) and send it to the provider. The provider can use the eRx to process and return approval to the pharmacy.

Section 6 Optimize—Optimization Strategies for e-Prescribing- 1

[1] A Practical guide to Electronic Prescribing, Minnesota e-Health Initiative, June 2009