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Opinions on Practice Management

Joseph S. Eastern, MD, FAAD

e-Prescribing: Is it Time to Take the Plunge?

Joseph S. Eastern, MD, FAAD

Tuesday, August 10, 2010

Years ago, experts and quasi-experts confidently predicted that electronic prescribing (e-prescribing) would be the standard operating procedure by now.

With all of the promised efficiencies and cost savings that would surely result from a switch to paperless prescribing, everyone took it as a given that most physicians and other "healthcare providers" would junk their prescription pads and adopt the new technology at first opportunity.

Obviously, that did not happen. The equipment was expensive; the obligatory open internet portal was frequently unreliable and, in some areas, not even available; and most pharmacies weren't equipped to receive electronic prescriptions anyway. Besides, it was hard to see where costs would decrease, as prescribing electronically often took longer than simply writing out a paper prescription. Most providers could see no real benefit, either for patients or for themselves, that would be worth the significant investment of money, time, and hassle.

Only third parties, it appeared, would see benefits - mostly cost savings as a result of a decreased number of prescribing errors and increased substitution of generics. The Center for Medicare and Medicaid Services (CMS) would save money too, but they also saw e-prescribing as a valuable data mine.

So why, providers said, should we be made to shoulder the entire cost of a system that would only increase our aggravation and primarily benefit third parties who will contribute nothing toward its creation? By 2008, barely 5% of prescriptions were written electronically.

The CMS tried to turn the tide in 2009 by adding a financial incentive: a 2% bonus on payment of only those Part B Medicare claims that included e-prescribing. The response was underwhelming; the bonus wouldn't begin to cover implementation costs, accessibility remained an issue, and the various "G" codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying. As 2009 ended, only about 10% of American physicians were e-prescribing. 

2010, however, may be the year in which to reconsider. The CMS has sweetened its financial carrot considerably, and made it much easier to collect, with a minimum of e-prescribing effort. The technology has improved significantly and, on top of this, a consortium of tech companies has made that technology readily accessible, and free, to anyone who wants it.

Over the course of 2010, if you document the use of a qualified e-prescribing program on only 25 Medicare claims during the entire year, you'll be paid the 2% bonus on every Medicare Part B claim that you file in 2010, whether e-prescribing was involved or not. 

In addition, the CMS has simplified the reporting process by eliminating all add-on codes except G8553 - the one that indicates that you used your e-prescribing set-up to write at least one prescription at the visit being billed. 

Of course, the CMS is hoping that you won't quit after only 25 claims; they're betting that you'll start to notice all of the purported advantages of e-prescribing. These, they claim, include decreased paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and simplified access to patients' medication histories. Because contraindications, drug interactions, and insurance coverage issues pop up on your screen as you prescribe, they also hope that you'll see decreases in the number of pharmacy phone calls, prior authorization nonsense, and treatment delays resulting from formulary issues. Furthermore, they hope that your patients will appreciate seeing their prescriptions filled faster, with fewer errors and coverage hassles.

But you still have to pay for the set-up yourself, right? Wrong. Many of the companies that will benefit financially from widespread e-prescribing have formed a coalition called the National e-Prescribing Patient Safety Initiative (NEPSI). The member companies include Allscripts, SureScripts, and NaviNet, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health. They have pooled $100 million to offer free e-prescribing technology to doctors and other providers nationwide.

You have a choice of a number of systems produced by various manufacturers. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate stand-alone system. Hardware and software details vary, but the concepts and requirements for all systems are generally similar, as they all must meet the same CMS criteria to qualify for the program.

In most cases, all you need to get started is an internet-enabled computer with a high-speed connection (not dial-up), and a database of patients.

Significant progress has also been made at the other end; approximately 70% of US pharmacies can now handle electronic prescriptions. 

Keep in mind that this will not be a complete transition for quite some time; you cannot eliminate paper prescriptions entirely from your practice at this juncture. In addition to the 30% of pharmacies not yet equipped for e-prescribing, Drug Enforcement Administration (DEA) rules prohibit sending controlled substance prescriptions electronically. However, the DEA recently announced a limited relaxation of those rules, effective June 1 2010. (For further details, go to http://www.deadiversion.usdoj.gov and select "ECPS" from the main page.)

You can learn more about the NEPSI, and sign up for their free, online-based prescribing software on their website (see http://www.nationalerx.com).

A list of other companies currently offering e-prescribing software, along with links to their respective websites, can be found at http://www.eprescribing.info/eprescribe/companylist.aspx.

A non-profit foundation called eHealthInitiative has released an excellent guide for physicians considering making the switch to e-prescribing, as well as for those who have already switched. You can find it at http://www.ehealthinitiative.org/basics-what-electronic-prescribing.html.

Details of the CMS incentive program are available at http://www.cms.hhs.gov/ERxIncentive. The 2% incentive will taper to 1% in 2011 and 2012, and then to 0.5% in 2013. However, beginning in 2012, there will be a 1% penalty for not e-prescribing, increasing to 1.5% in 2013 and 2% in 2014 and thereafter.

With most cost, accessibility, and hassle roadblocks removed, bureaucrats now hope that 75% of us will be prescribing electronically by 2014, and 90% by 2018. And that, they claim, will save the government $22 billion over the next decade owing to increased use of generic drugs and decreased prescribing errors. 

It will also allow governmental collection of detailed prescribing data, as previously mentioned. Whether that is in our long-term best interest is a whole other debate; however, it seems clear that e-prescribing will eventually become the standard, whether we like it or not. And with the downside minimized by free hardware and software, and only 25 e-prescriptions needed to collect the 2% bonus this year, this might just be the time to consider taking the plunge.

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