According to the Centers for Medicare & Medicaid Services (CMS), e-prescribing is the “ability to send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care.” While e-prescribing is now required only for drug plans participating in Medicare Part D, it continues to grow rapidly nationwide as an all-but-essential feature in many pharmacies and a growing number of physician offices.
E-prescribing is also prominent among the criteria needed to demonstrate “meaningful use” of electronic health records (EHRs) and qualify for EHR incentive funding under the ARRA HITECH Act (see “ARRA HITECH ‘meaningful use’ criteria for e-prescribing”). While e-prescribing is essential for those who intend to pursue EHR incentive funding in the near term, at least some of its benefits may be realized if it is used separate from or as a stepping stone to an EHR system.
Elements of an e-prescribing system
Under the “foundation standards” in Medicare Part D regulations, an e-prescribing system must provide four basic functions to prescribers (see “Required EHR functionality”). These functions, along with access to a major e-prescribing network, are typically part of any e-prescribing software package purchased from an e-prescribing vendor.
And, though it's possible for major software developers, health plans, or other entities to develop and certify their own e-prescribing software against Medicare Part D requirements, “most e-prescribing systems have a core set of functionality certified by Surescripts,” says Charles Klein, PhD, of Netsmart Technologies.
Klein points out that the context in which the e-prescribing takes place, the number and type of prescriptions involved, and the information required by the prescriber to make the right decision can differ significantly between general medicine and behavioral healthcare.
He says: “The major difference between e-prescribing for general medicine and psychiatry, especially in community mental health settings, is that the psychiatrists are treating long-time patients with serious and persistent mental illness. That changes the workflow, because prescribing to a chronically ill person is different from prescribing for a patient who goes to primary care for a one-time prescription. Doctors see these patients, often when they come in to reorder meds, and the workflow needs to match up with the needs of a chronic condition. Doctors have to be able to reorder quickly, pull up a history of how the patient has been doing on that med, and understand all of the meds they're taking very quickly.”
He adds that often, the dosing recommended by psychiatrists varies due to the use of titrations and tapers. “It's common, for example when starting a medication like Paxil, for a psychiatrist to prescribe a 10 mg dose for one week, then bump up to 20 mg.” Based on patient response, dosages may titrate up or down over time. Or, if a medication is ineffective, the dosage may be tapered down and discontinued. “When a psychiatrist is trying to see whether one medication is working or not, it may be important to have a system that can show cross-titrations and tapers and illustrate the actual dosage that the patient is on (or should be on) at the present time.”
How e-prescribing relates to the EHR
In most medical sub-specialties, “the primary purpose of EHRs is to support the physician,” says Mike Morris, president and CEO of Anasazi Software. “In behavioral health, physicians are five percent or less of EHR users. The other 95 percent of users, including clinical and administrative staff, are non-physicians who support the chronic care treatment model.”
In this scenario, it's important to ask, “Are the docs using the EHR?” says Klein. Understanding the degree to which a job role-psychiatrist or physician vs. clinician or staff-depends on the EHR is important to the selection and implementation of e-prescribing.
In many behavioral health situations, clinicians are the dominant users of the EHR, creating and updating patient histories, diagnoses, treatment plans, and progress notes. Yet, says Morris, “to truly prescribe, a doctor needs not only this diagnostic information, but other information-medication history, psychosocial assessment, height and weight, lab results, and other data.” So, a significant level of integration, or data sharing, between the EHR and the e-prescribing systems is essential.
There are multiple ways to achieve integration (see “Adding e-prescribing to an existing EHR system”). The simplest way, says Morris, is to acquire an EHR with an integral e-prescribing module, or to add on such a module to your EHR system later on.
“I believe that the greatest value that doctors derive from the EHR is to have all of the patient information and prescriptions integrated and presented to them in a single place,” Morris says. “They feel more confident that they're making better medical decisions.” He adds that adding an e-prescribing module to an existing EHR is “easy if you've already done the planning, training, and support necessary to support an EHR.”
Like the federal meaningful use criteria, Morris views integration of e-prescribing and EHRs as a given. He asserts that while “standalone” e-prescribing systems may offer “an incremental benefit,” it's not much.