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.
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Comparison
Attribute
Standalone eRx
eRx with EHR
Definition
Use of computing devices to enter, modify, review, and
output or communicate drug prescriptions to pharmacies.
Costs
Medication ordering automatically linked to the comprehensive
health record. Includes access to lab results, problem lists,
diagnoses, and other useful information that may be included in
more sophisticated drug decision support.
□ Incremental cost if additional module (not always applicable).
□ Hardware and software
□ Interface to practice management system, if applicable
□ Potential additional charges for customization, training,
□ Costs of interfaces, customization, other services, and increase in
maintenance, upgrades
bandwidth are usually an inherent part of the EHR.
□ Usually requires an upgrade in bandwidth to connect
with the third party information providers
□ 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.
□ Information collected and stored in most standalone
□ Fully integrated functionality enables seamless population of
systems are not easily transferable to EHRs.
prescription information from practice management system and to
medication lists, etc., in EHR.
□ Change management requires adequate planning,
□ Change management issues are greater for EHR, although eRx
training, support, and continuous quality improvement.
component is often viewed as the “simpler” part.
□ Workflow changes may result in new roles and
□ Workflow and patient issues are the same as for standalone eRx.
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 eRx. This workflow change is confusing to some
providers.
□ Some patients do not want to commit to a specific
pharmacy.
Barriers to eRx in general
Barriers to
specific
forms of e-Rx
People
challenges
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Attribute
Standalone eRx
eRx with EHR
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.
□ Alerts to Drug-Drug, Drug-Allergy, and out-of-rangedosing 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, and
pharmacy 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.
□ 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
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□ In addition to standalone eRx benefits, adds Drug-Lab, DrugDosing (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.
Attribute
Incentives
Technical
alternatives
Summary
Standalone eRx
□ Improves drug surveillance/recall ability.
□ 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,
□ 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.
Pathway to an EHR that improves patient safety
eRx with EHR
□ Incentives the same as for standalone eRx, although workflow to
document use of e-prescribing is simpler in an EHR.
□ Same as for standalone eRx.
Affords full scope of functionality for eRx
Copyright © 2014, Margret\A Consulting, LLC. Used with permission of author
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
(http://www.healthit.gov/sites/default/files/bhandhit_issue_brief.pdf) 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.
Section 6 Optimize—Optimization Strategies for e-Prescribing - 4
E-prescribing Communication
This diagram illustrates how e-prescribing works, starting with the patient visit at the left:1
1. A patient visits a provider.
2. A provider enters a drug to be prescribed for a patient into a standalone eRx system or an EHR with eRx application.
3. 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).
1
A Practical guide to Electronic Prescribing, Minnesota e-Health Initiative, June 2009 www.health.state.mn.us/ehealth/summit/g3e-prescribing2009.pdf
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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.
Copyright © 2014 Stratis Health.
Section 6 Optimize—Optimization Strategies for e-Prescribing - 6
Updated 03-18-14