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The importance of the fine printing

July 28, 2008
by David Raths
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CMS says “microprinting” technology can be used in place of tamper-resistant prescription pads

William Bria, MD, says he can’t recall anyone receiving a standing ovation before at a symposium of the Association of Medical Directors of Information Systems (AMDIS). But that’s what happened in July when Peter Basch, MD, explained his successful efforts to help the Centers for Medicare and Medicaid Services (CMS) expand its guidelines for tamper-resistant prescriptions to include “microprinting” technology. The change may ultimately save health systems and smaller providers that use e-prescribing millions of dollars in unnecessary expense.

Dr. Bria, chief medical information officer at Shriners Hospital for Children and chairman of AMDIS’s board, explains that a new federal law that takes effect October 1 requires tamper-resistant prescription pads for scripts written for Medicaid patients, but the law failed to address the needs of e-prescribing and electronic medical record (EMR) systems. In instances when e-prescribing organizations would need to print prescriptions, such as for controlled substances (see sidebar), the new law would require them to switch back to using prescription pads using new types of paper and two-drawer printers.

AMDIS saw the law as creating a new barrier to e-prescribing, which is exactly the opposite of CMS policy. The 2,000-member organization wrote a white paper and contacted legislators, but Dr. Bria says that Dr. Basch went one step further by getting himself appointed to a National Council for Prescription Drug Programs focus group helping CMS define standards.

Controlled substances prescribed by behavioral healthcare providers include:
  • Alprazolam (Xanax)
  • Amphetamine (Dexedrine)
  • Buprenorphine (Suboxone, Subutex)
  • Clonazepam (Klonopin)
  • Lorazepam (Ativan)
  • Methadone
  • Methylphenidate (Ritalin)

Dr. Bria

“After explaining these issues, we got the CMS people to rethink what tamper resistance means in an electronic environment,” explains Dr. Basch, medical director of ambulatory clinical systems for

MedStar Health in Columbia, Maryland. “We got them to focus on the functional process we could achieve with software and a laser printer. If we could embed these features into templates of EMRs or firmware of the printer, we could accomplish the same thing.”

The result is that in July CMS ruled that both microprinting and a technology called void pantograph may be used by computer-generated prescribing systems to achieve compliance with the new law.

By adding to the background of a document—in this case, a prescription—very fine text that can't be reproduced on conventional copying equipment, microprinting gives pharmacists the means to authenticate a prescription. Void pantograph systems, still an emerging technology, cause a word such as “void,” “illegal,” or “copy” to appear when a document is photocopied.

Now it is up to EMR vendors to incorporate the microprinting capability into their templates by the October 1 deadline set by the law, Dr. Basch says, noting, “We may see a struggle to meet that deadline and people using other stopgap measures for a few months.”

Dr. Basch

No one was more surprised than Dr. Basch about the standing ovation he received at the AMDIS meeting. But, he adds, “Every large healthcare organization across the country was thinking, ‘How are we going to afford to do this?’ I know that in my organization, it would have cost something like $1 million to $1.5 million to implement.”

Even relatively smaller behavioral healthcare organizations stand to save from this technology, as they prescribe many controlled drugs.

The good news, Dr. Basch says, is that all the stakeholder groups came together to improve the regulations in a way that doesn’t provide a disincentive to using EMRs and yet achieves the objective of working to reduce prescription fraud.

The DEA recently published proposed regulations to allow e-prescribing of controlled substances. For more details, click here.
David Raths is a freelance writer and frequent contributor to

Healthcare Informatics.