Electronic prescription (e-prescribing) writing is defined by the eHealth Initiative as "the use of computing devices to enter, modify, review, and output or communicate drug prescriptions." Although the term e-prescribing implies the use of a computer for any type of prescribing action, a wide range of e-prescribing activities exist with varying levels of sophistication:
Level 1 - electronic reference handbook
Level 2 - stand alone prescription writer
Level 3 - patient-specific prescription creation or refilling
Level 4 - medication management (access to medication history, warnings, and alerts)
Level 5 - connectivity to dispensing site
Level 6 - integration with an electronic medical record
Adapted from Electronic Prescribing: Towards Maximum Value and Rapid Adoption, eHealth Initiative, 2004.
All levels of electronic prescription writing confer varying degrees of improvements in patient safety. Level 6, which is the most sophisticated, has been shown to confer the highest degree of patient safety and the largest return on the investment. Over the last 5 years, national interest in e-prescribing has increased as the Federal Government has enacted legislation, including the Medicare Modernization Act of 2003 (MMA), aimed at increasing the adoption of e-prescribing. The Centers for Medicare & Medicaid Services (CMS) released a report to Congress entitled Pilot Testing of Initial Electronic Prescribing Standards (PDF, 236 KB ). This report was mandated by the MMA, and it details the rigorous pilot testing of information standards by five leading e-prescribing organizations. AHRQ and the National Resource Center's evaluation report recommended that the medication history, formulary and benefits, and prescription fill status indicator standards were ready for implementation under Part D. Prior authorization, structured and codified signature (sig), and the RxNorm standards were not ready for implementation in their current state. In addition, the pilot projects evaluated key issues in e-prescribing such as reduction of adverse drug events, provider uptake, and potential gains in efficiency and effectiveness. Use of the proposed standards advances interoperability in the U.S. health care system and greatly enhances the ability of health IT to improve safety and quality. Such efforts are integral to AHRQ's mission to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.
Existing e-prescribing tools have begun to consider a variety of new uses for a medication history. Those uses include knowing what medications a patient has actually received from a pharmacist using data from Pharmacy Benefit Managers (PBMs). Services such as SureScripts provide this information to electronic prescription writing systems, allowing providers to see a complete view of the patient's medication history. Another current trend is transmission of electronic prescriptions using a standard known as NCPDP-SCRIPT. This standard supports interfaces to pharmacy information systems and is a foundation standard adopted by the U.S. Department of Health and Human Services (HHS) in 2005. A frequently used practice is to communicate via fax, which is often plagued by inaccurate fax numbers, poor management of faxes that are received by pharmacies, and poor systems to provide feedback about the status of fax delivery.
The Medicare Modernization Act of 2003 (MMA) requires that Part D plans support an electronic prescription program, should any of their providers and pharmacies voluntarily choose to e-prescribe. This program is required to provide for the electronic transmittal of prescription orders themselves; plan eligibility queries and responses; plan benefit information; drug interactions, warnings or cautions, and any dosage adjustments related to the drug being prescribed or dispensed; appropriate lower cost alternatives, if any, for a drug being prescribed; and the patient's medical history related to a covered Part D drug being prescribed or dispensed. For each requirement, HHS released the final ruling on e-prescribing and the foundation standards in November 2005 in the Federal Register. These standards are compatible with existing ones, especially the transactions specified in the administrative simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. MMA also required pilot projects during 2006 to test any standards for which there is not adequate industry experience. AHRQ and the Centers for Medicare & Medicaid Services (CMS) collaborated to issue grants and contracts for pilot testing e-prescribing standards. Results of these pilot projects were released in April 2007 in the form of an evaluation report from the AHRQ National Resource Center for Health Information Technology. Final e-prescribing standards were released in the Federal Register (PDF, 210 KB) on April 7, 2008, with implementation up to a year later. In the spring 2008 session of the U.S. Congress, the Medicare Improvements for Patients and Providers Act of 2008 was passed, offering physicians financial incentives for electronic prescribing. Under the new law, Medicare physicians who e-prescribe will receive a 2-percent payment bonus in 2009 and 2010, a 1-percent bonus in 2011 and 2012, and a 0.5-percent bonus in 2013. In addition, payments to Medicare physicians who do not e-prescribe will be reduced by 1 percent in 2012, 1.5 percent in 2013 and 2 percent in subsequent years.
In addition to the MMA, The Joint Commission for the Accreditation of Hospital Organizations (The Joint Commission) has recently endorsed medication reconciliation in 2006. Hospitals that are accredited by The Joint Commission need to demonstrate methods to verify that medication histories are reconciled and up-to-date with medication lists after each care transition (e.g., from outpatient to inpatient status; from inpatient ward to inpatient ICU; from outpatient hospital to nursing home facility). Medication reconciliation has been shown to be a time-intensive activity on the part of those people involved. E-prescribing tools may improve the process by providing more accurate and complete histories.
The Agency for Healthcare Research and Quality (AHRQ) has funded organizations across the country that are implementing and evaluating e-prescribing technologies. Selected projects include:
Title: Building an Implementation Toolset for E-Prescribing
Primary Investigator: Douglas Bell
Title: Effective Use of e-Prescribing in Physician Practices and Pharmacies
Primary Investigator: Joy Grossman
Title: Electronic Prescribing and Decision Support to Improve Rural Primary Care Quality
Primary Investigator: James Veline
Title: Electronic Prescribing and Electronic Transmission of Discharge Medication Lists
Primary Investigator: Rainu Kaushal
Title: Enabling Electronic Prescribing and Enhanced Management of Controlled Medications
Primary Investigator: Grant Carrow
Title: Impact of Office-Based e-Prescribing on Prescribing Processes and Outcomes
Primary Investigator: Michael Fischer
Title: Optimizing Medication History Value in Clinical Encounters with Elderly Patients
Primary Investigator: Kate Lapane
Title: Pharmaceutical Safety Tracking (PhaST): Managing Medications for Patient Safety
Primary Investigator: William Gardner
Title: RxSafe: Shared Medication Management and Decision Support for Rural Clinicians
Primary Investigator: Paul Gorman
Title: STEPStools: Developing Web Services for Safe Pediatric Dosing
Primary Investigator: Kevin Johnson
Title: Tailored DVD to Improve Medication Management for Low Literate Elderly Patients
Primary Investigator: Kate Lapane
Title: Using HIT to Improve Ambulatory Chronic Disease Care
Primary Investigator: David Mehr
Title: VA Integrated Medication Manager
Primary Investigator: Jonathan Nebeker
The following resources were selected from the Health IT Bibliography and represent peer-reviewed articles that describe best practices for the implementation and use of e-prescribing (eRx) systems.
Prescribers' Responses to Alerts During Medication Ordering in the Long Term Care Setting
Author(s): Judge J, Field TS, DeFlorio M, Laprino J, Auger J, Rochon P, Bates DW, Gurwitz JH
Source: J Am Med Inform Assoc (JAMIA). 2006 Jul-Aug;13(4):385-90 Epub 2006 Apr 18.
Summary: The objective of this study was to examine opportunities for improving medication safety in the long-term clinical care setting by determining medication orders that would generate a warning message to the prescriber via a computerized clinical decision support system (CDSS) and assessing which alerts would affect prescribers' actions. For this randomized controlled trial, prescribers ordering drugs for residents on three resident-care units of the facility were presented with alerts; these alerts were not displayed to prescribers in the four control units. During the 12 months of the study, the alert categories most often triggered were related to risks of central nervous system side-effects, such as over-sedation (20 percent). Alerts for risk of drug-associated constipation (13 percent) or renal insufficiency/electrolyte imbalance (12 percent) were also common. Overall, prescribers who received alerts were only slightly more likely to take an appropriate action (relative risk 1.11, 95 percent confidence interval 1.00, 1.22). Long-term care facilities must implement new system-level approaches with the potential to improve medication safety for their residents.
A Conceptual Framework for Evaluating Outpatient Electronic Prescribing Systems Based on Their Functional Capabilities
Author(s): Bell DS, Cretin S, Marken RS, Landman AB
Source: J Am Med Inform Assoc (JAMIA). 2004 Jan-Feb;11(1):60-70 Epub 2003 Oct 5.
Summary: Electronic prescribing (e-prescribing) may substantially improve health care quality and efficiency, but the available systems are complex and their heterogeneity makes comparing and evaluating them a challenge. Analyses of two commercial e-prescribing systems are presented as examples of applying the conceptual framework for anticipating the effects of alternative designs for outpatient e-prescribing systems. The proposed framework evaluated 14 e-prescribing functional capabilities within the medical management model. Evidence is identified to support eight specific effects for six of the functional capabilities. Applying the framework involves identifying an e-prescribing system's functional capabilities within the process model and then assessing the effects that could be expected from each capability in the proposed clinical environment. The proposed conceptual framework supports the integration of available evidence in considering the full range of effects from e-prescribing design alternatives. More research is needed into the effects of specific e-prescribing functional alternatives. Until more is known, e-prescribing initiatives should include provisions to monitor for unintended hazards.
Case Report: Activity Diagrams for Integrating Electronic Prescribing Tools into Clinical Workflow
Author(s): Johnson KB, Fitzhenry F.
Source: J Am Med Inform Assoc (JAMIA). 2006 Jul-Aug;13(4):391-395 Epub 2006 Apr 18.
Summary: To facilitate implementation of an electronic prescribing system, this case study modeled prescription management processes in various primary care settings. The Vanderbilt e-prescribing design team conducted initial interviews with 19 providers, including clinic managers, physicians and nurses, and then represented the sequences of steps carried out to complete prescriptions in activity diagrams (flowcharts). The diagrams covered outpatient prescribing for patients between clinic visits and while the patient was present in the clinic for either a scheduled or unscheduled visit. Practice size, practice setting, and practice specialty type influenced the prescribing processes used. This preliminary study does not address certain situations, including prescribing medications that are dispensed locally, and it ignores certain classes of medications, such as samples, alternative therapies, and dermatologic creams. The model developed may be useful to others engaged in building or tailoring an e-prescribing system to meet the specific workflows of various clinical settings.
Functional Characteristics of Commerical Ambulatory Electronic Prescribing Systems: A Field Study
Author(s): Wang CJ, Marken RS, Meili RC, Straus JB, Landman AB, Bell DS
Source: J Am Med Inform Assoc (JAMIA). 2005 May-Jun;12(3):346-56 Epub 2005 Jan 31.
Summary: This paper compares the functional capabilities being offered by commercial ambulatory electronic prescribing systems with a set of expert panel recommendations. The capabilities of 10 commercially available electronic prescribing systems were compared with 60 expert panel recommendations for capabilities that would improve patient safety, health outcomes, or patients' costs. On average, the systems fully implemented 50 percent of the recommended capabilities, with individual systems ranging from 26 percent to 64 percent implementation. Only 15 percent of the recommended capabilities were not implemented by any system. Prescribing systems that were part of electronic health records (EHRs) tended to implement more recommendations. Vendors' claims about their systems' capabilities had a 96 percent sensitivity and a 72 percent specificity when site visit findings were considered the gold standard. Electronic prescribing standards should include minimal functional capabilities, and certification of adherence to standards be needed where systems are installed and operating.