Quality Matters Newsletter



Electronic Prescribing (e-Prescribing) & MGO Physicians (Fall 2008)
Robert Thompson, MD FACP, Associate Medical Director/Medical Director of Clinical Quality Improvement


The topic of electronic prescribing has gotten much attention over the past few years and is garnering even more attention now that CMS has indicated the intent of financial rewards for usage (and eventual penalties for non implementation). This article will explore e-prescribing and the implications of adoption of e-prescribing for MGO physicians.


Physicians in the United States write more than 4 billion prescriptions per year. The great majority of these prescriptions are paper based (HiMSS estimates that 80% of US prescriptions are handwritten). Moreover, between 1.4% and 4% are erroneous, adding to what some experts estimate as 7000 deaths annually secondary to medication errors (EMR consultant). The Institute of Medicine estimates that 1.5 million Americans are injured by medication errors each year.

The problem of medication errors continues to increase, at least in part due to the aging American population (with 65% of the population using a prescription medication each year). The elderly are at the greatest risk, with co-morbidities, poly-pharmacy, and multiple physicians per patient all adding to this increased risk.

Recently, CMS has announced that physicians using e-prescribing will receive increased re-imbursement. Professionals who use e-prescribing in 2009 and 2010 will receive a 2% incentive payment, a 1% incentive payment in 2011 and 2012, and a 0.5% incentive payment in 2013. There will be a penalty in the form of a reduction in payment beginning in 2012 for those eligible practitioners who are not successful electronic prescribers.

Why e-prescribing?  

Error reduction: Prescriptions that are handwritten and then given to the patient or faxed to the pharmacy are notorious for the development of medication errors. Physician legibility problems, poor communication (by telephone or fax), multiple intermediaries, and inability to check for drug interactions all add to the problem.

Cost containment: Medicare expects to save $156 million over the course of the 5 year program previously described by avoiding adverse drug events. Physician’s offices spend much wasted time with telephone conversations and faxing prescriptions using a paper based system (estimated to be 3 hours per day). Increased malpractice risk is also an important consideration for physicians. Pharmacies are estimated to spend more than 4 hours per day handling prescription issues.

Legislation: The Medicare Modernization Act includes specific language regarding electronic prescribing and the implementation of electronic prescribing standards (initial standards approved in 2005), pilot programs (initiated in 2006), and finalized standards required for 2009.                                                                 

What is e-Prescribing?

Electronic prescribing is “an electronic way to generate prescriptions through an automated data-entry process utilizing e-prescribing software and a transmission network which links to participating pharmacies.” (EMR consultant). 

CMS definition: “ E-prescribing means the transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager, or health plan, either directly or through an intermediary, including an e-prescribing network. E-prescribing includes, but is not limited to, two-way transmissions between the point of care and the dispenser.”

Note that the use of fax machines for transmitting a hand written prescription does not meet the criteria for electronic prescribing. The CMS Final Rule for this program encompasses clinical decision support, including access to information on drug-drug interactions, drug-allergy interactions, patient medication history, pharmacy eligibility, formulary, and benefits information.

Benefits for physicians:

·         Improved patient safety & quality of care

·         Reduction of phone calls & call-backs to pharmacies

·         Eliminates faxes to pharmacies

·         Streamlines refill requests & authorization processes

·         Increases patient compliance

·         Improves formulary adherence

·         Increases patient convenience

·         Offers mobility to the provider

·         Improves reporting ability

How & How Much?

Electronic prescribing can be instituted whether a physician’s office has an EMR or not. Many EMRs now offer interoperable electronic prescribing within their systems. E-prescribing functionality is not specific to particular hardware or software and, stand-alone e-prescribing systems are readily available. Electronic connectivity through an internet connection is necessary, with high speed internet highly recommended.

How to proceed can seem daunting. However, there are many sources to help develop electronic prescribing in a particular office.   The resource listing with this article includes many sources of information. Of particular interest is the American Association of Family Practitioners website (, which includes a questionnaire that allows the user to confirm if the practice’s EMR technology is certified and compliant for e-prescribing, provides contact with technology vendors to request the connectivity, and provides mechanisms to contact & communicate with a vendor for acquiring new software. If the practice does not have an EMR, directions for connecting with e-prescribing vendors is supplied.

Another significant opportunity to allow participation in e-prescribing has been developed by OhioHealth. The article in this issue of Quality Matters provides necessary information about this innovative (and cost-saving) program.

Cost is always a significant consideration. The resources listed included cost descriptions and helpful clues for ways to reduce the start-up costs. Certainly, upgrading an EMR may be less expensive that adding a stand alone e-prescribing product. Estimates ranging from $3000 upward have been published (the AAFP website also includes a tool to calculate the cost of paper based systems to a practice----thus allowing for comparative information).

Other Considerations:

Controlled substances: Historically, CMS has not allowed the electronic transmission of prescriptions for controlled substances. However, current indications are that this prohibition will be lifted in the near future and that essentially all prescriptions will be included in e-prescribing programs.

Office challenges: 

  •         Workflow changes
  •         Change management
  •         Hardware & software selection
  •         Pharmacy, payer, & mail order connectivity
  •         Medical history & medication reconciliation 
  •         Completion of standards by CMS

 Clinical Integration: Clinically integrated systems often require the use of e-prescribing for continued participation (EMRs are not routinely required). It is anticipated that the clinically integrated system being developed by OhioHealth, the MGO, and Ohio Health Group will strongly recommend that participants use e-prescribing. 

Resources:     “The Physician’s Guide to EMR Solutions” Press release....”HHS Takes New Steps to Accelerate Adoption of Electronic Prescribing”   July 21, 2008 American Association of Family Practitioners...Get Connected program Healthcare Information & Management Systems Society
 Electronic Prescribing Update    Sept. 10, 2007
.....New England Journal of Medicine “The (Slowly) Vanishing Prescription Pad” Steinbrook, R. pp115-117, July 10, 2008 National e-prescribing Patient Safety Initiative (NEPSI) E-Health Initiative     
Electronic Prescribing: Becoming Mainstream Practice   June, 2008 (68 page document)
OhioHealth Physician IT Services   566-1067

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