The Physician’s Corner
E-prescribing: It’s Time is Here

By Henry Tulgan, M.D., FACP

The CMS National E-Prescribing Conference and a number of other regional and local educational activities are helping make physicians and other prescribers aware of the value of e-prescribing. The impetus for e-prescribing, in part, is the Medicare Modernization Act of 2003, which created Medicare Part D, the voluntary Medicare prescription benefit.  As early as 2006, CMS created a number of proposed standards to be tested in pilot programs. In 2007, CMS chose three locations for the program, which will be required on April 1, 2009 for Part D plans.  As of December 2008, when this CME activity was published, e-prescribing remains optional for physicians and pharmacies.

The federal government hopes to make e-prescribing a requirement by 2011 or 2012, and just recently, Blue Cross Blue Shield of Massachusetts announced that it will require e-prescribing by 2011 to allow physicians to qualify for bonus payments.

The following are the three CMS mandated e-prescribing standards:

• Formulary and benefits information sharing between providers and Part D plan sponsors.
  The purpose is to alert prescribers instantly if a drug is not covered or if a similar one or a generic may be substituted.
• Medication history communication between providers.
  The advantage is to help to avoid potentially harmful drug interactions, polypharmacy and lack of compliance.
• Pharmacy to provider fill-status notification.
  This is another way to check for compliance.

One additional need is for prescribers to use their National Provider Identifier (NPI). For those who have not already obtained an NPI, it can be obtained from https://nppes.cms.hhs.gov. Although applicants are told that this is a 20-minute process, in reality it can be completed much more quickly. Also, in most instances the NPI will be issued by return e-mail.

Although the start up of required e-prescribing under Medicare is near, a number of issues persist. First, the absence of a standard and codified SIG (medication instruction) means there may still be prescribing errors due to the use of abbreviations and shorthand. Also, CMS has not yet adopted standards for drug terminology and prior authorization. To date there is still a ban on using e-prescribing for controlled substances, which instead must be written on special tamper-proof paper.

Additionally, there are IT considerations for prescribers.  The implementation of stand-alone and EMR-based e-prescribing systems varies in cost and features.  Small practices may lack the resources to fully evaluate them.  It helps that there are several systems that have been tested as part of SureScriptsRxHub’s vetting process.  All vendors who are listed on the SureScripts website (http://www.surescripts.com/getconnected.aspx?ptype=physician) meet the 2009 Part D standards for the functions they provide.

Fortunately, there are safe harbors for technology grants, and BCBS has suggested that it will help make it easier for these entities to implement e-prescribing systems. Whatever system is chosen, the Health Insurance Portability and Accountability Act (HIPAA) and state law must be obeyed.  In order to manage risk, the system must be secure – limiting who has access to it – and it must be backed up daily.

It’s important to note that attorneys have scrutinized e-prescribing carefully.  While they recognize its potential advantages, some wonder if the notification of fill status requirement could create a legal obligation for the physician to follow up with the patient.  As a result, additional e-prescribing standards may be added in the future.

Risk management strategies

• The transaction must be paperless at both ends to reap the full risk-management benefit,
• Make sure your e-prescribing system is password protected, especially if you are using a handheld for e-prescribing,
• Check for and use your e-prescribing system for intelligent features that check for drug interactions and drug allergies. 
• Be aware of relevant security and privacy provisions in both HIPAA and Massachusetts state law.

Next: CME Exam Instructions