The last Meaningful Use Monday post detoured from the EHR incentives to ePrescribing under MIPPA—given its importance based on the impending schedule of penalties. Because I receive ePrescribing questions on a daily basis, I thought a quick recap of ePrescribing basics might be helpful:

• Incentives and penalties:

*Percent of provider’s total Medicare Part B FFS Allowable Charges. (Incentives assume provider does not receive EHR incentive for that year.)

**Based on 2011 ePrescribing activity

• Incentives are earned per provider, and each provider must individually meet the requirements. This means that some providers within a practice might qualify for an incentive, while others might incur a penalty. (Group reporting options exist, but they are limited and require qualification.)
• Reporting is by G-Code and there is only one: Use G-8553 on the Medicare claim to report that “at least one Rx was generated and transmitted using a qualified ePrescribing system during the patient encounter.”
• Surescripts certification qualifies an ePrescribing system. (This is distinct from the ONC-certification required for meaningful use.)
• Provider eligibility:
  • MD, NP, or PA with prescribing authority
  • At least 100 encounters with the specified CPT codes
  • Specified CPT codes must constitute at least 10% of the provider’s Medicare charges.
• To request exemption from penalties, use the following G-Codes on one Medicare claim before June 30, 2011:
  • Hardship Code G-8642: Rural area with limited high-speed internet access
  • Hardship Code G-8643: Limited pharmacies for ePrescribing
  • G-8664: Although an eligible provider, you do not have prescribing privileges

In a future post, Meaningful Use Monday will look at ePrescribing in the context of meaningful use.

Lynn Scheps is Vice President, Government Affairs at EMR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money.

No Matter What Else You Do in 2011, You’ve Got to ePrescribe

With all of the focus on meeting meaningful use, the requirements related to ePrescribing under the Medicare MIPPA program seem to be getting lost in the shuffle. Just as some practices didn’t get the message about the 2010 change in ePrescribing G-codes until late in the year, I am hearing that the communication hasn’t reached everyone about the importance of ePrescribing in 2011; so I thought I would post a reminder:

2011 ePrescribing activity will be the basis for the 2012 and 2013 ePrescribing Medicare penalties (AKA “adjustments”) under MIPPA. If you are not already ePrescribing, it’s important to start very soon. The following are the rules:

• ePrescribe on 10 Medicare encounters between now and June 30, 2011 to avoid a 1% reduction in 2012 Medicare rates.
• ePrescribe on 25 Medicare encounters between now and December 31, 2011 to avoid a 1.5% adjustment in 2013.
• By ePrescribing 25 times, you can also earn the 1% ePrescribing incentive in 2011.

Note, however, that the legislation does not allow providers to collect both the ePrescribing and EHR incentives (as a Medicare provider) in the same year, so you must make a choice: Collect the MIPPA incentive in 2011 and start pursuing meaningful use in 2012—a strategy discussed by Evan Steele in EMR Straight Talk—or forego the MIPPA incentive in 2011 and attest to meaningful use in 2011. In either case, you must continue to comply with MIPPA requirements to avoid the future penalties associated with that program.

Lynn Scheps is Vice President, Government Affairs at EMR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money.

Physicians who are eligible for both programs will likely find participation under Medicaid to be a preferable option because the incentives are higher, the first year rewards adoption/purchase, (without requiring demonstration of meaningful use depending on the state); and the program offers more flexibility in terms of time frames. To participate under Medicaid, a provider must have a practice that is 30% Medicaid (20% for pediatricians), based on number of patient encounters (as opposed to revenue). Some providers are only eligible under Medicaid—nurse practitioners; certified nurse-midwives; dentists; and physician assistants who practice in a Federally Qualified Health Center or rural health clinic that is led by a physician assistant.

Not all states have their EHR incentive programs ready to go yet. 14 states will launch in either January or February; others are expected later in the year.

The major differences between the Medicare and Medicaid incentive programs that providers should take into consideration when making their choice at registration include the following:

Next Monday’s post will highlight some other differences between the two programs that are interesting, but less influential.

Lynn Scheps is Vice President, Government Affairs at EMR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money.

In the weirdest news I’ve seen in a while, SureScripts has become an ONC-ATCB. Here’s the details from Health Data Management:

In a Dec. 23 announcement, the Office for the National Coordinator for Health IT said that Arlington, Va.-based Surescripts can verify that e-prescribing, privacy and security modules meet the standards laid out in the meaningful use requirements. Surescripts is the sixth authorizer to be approved by ONCHIT, but it’s the only one with limited certification abilities—the five others have ONCHIT’s blessing to certify Complete EHRs and EHR modules.

Doesn’t this scream conflict of interest? They run a nationwide e-Prescribing network, and yet they can certify ePrescribing for ONC. I guess you could make the argument that they know ePrescribing well and so they are qualified to do it. Although, it is just weird and awkward to consider them as an ATCB. I wonder which ePrescribing companies will actually use them. Why did SureScripts even go to the effort to become an ATCB?

I’m still really disturbed by the fact that we have so few practical meaningful use details. Sure, we have a lot of guidelines and a lot of prognosticators guessing at what they mean and how they’ll be measured. We even have a certifying body trying to guess what the EHR certification will be. Sadly, they’re all still guesses.

Let’s just take a simple example for a second and see some of the complexities.

Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

This certainly seems pretty straight forward. Probably about as straightforward as it comes as far as objectives. Basically, 75% of the prescriptions have to be ePrescribed using a certified EHR technology to meet the meaningful use guidelines.

Of course, the real question’s going to be around the word “permissible.” What’s considered a permissible prescription? I imagine this was added because currently you aren’t allowed to ePrescribe controlled substances. If I remember right, controlled substances make up about 15-20 percent of prescriptions. Certainly it wouldn’t be fair to include something that you’re not legally allowed to prescribe electronically in the requirements. Are there other exceptions under the “permissible” rule?

What’s going to happen once ePrescribing of controlled substances is allowed? Will doctors then be required to flip a switch and start sending controlled substance prescriptions electronically as well? Once they’re allowed, they’ll be considered permissible, no?

Let’s also not be surprised if the technology is built to do eprescribing in 2 systems (controlled vs not controlled). Of course, this adds a bit more complexity to measuring the 75% of prescriptions done electronically.

Also, does it give anyone else a bit of angst that the EHR software is basically going to spit out a report saying, “Yes, I ePrescribed 75% of my prescriptions.” I’m not sure how you scale a more sophisticated solution, but just taking some report from an EHR seems plenty gameable to me.

Will ONC be going around and doing some audits of the submissions to ensure that the data was actually good and not messed with? Can you imagine the challenge of having to audit some 300+ EMR vendors. Good luck with that.

I also love how the ePrescribing has to be done with a certified EHR system. A part of me really feels for those specialists that only write a few prescriptions a week. They get to learn the fun thing we call ePrescribing and they forget what they learned by the next time they have to ePrescribe.

UPDATE: Thanks to Russ in the comments, he pointed out the issue of calculating a percentage when your EMR won’t know if you just handed them a paper prescription instead of ePrescribing. I guess the criteria assumes they’re going to order the script and then print it out instead of sending it electronically? So, maybe the criteria should say 75% of scripts ordered in the EMR sent electronically. Just makes me laugh to think about it.

Lest ye think paper scripts don’t happen with an EMR, we can at least argue for them happening during EMR downtime (or printer or workstation or internet or…downtime). Although, they happen other times as well. How will an EMR calculate that percentage of prescriptions? Are they going to translate the freetext note that was entered into the EMR about the paper script that was given? Ideally the doctors will just enter in the script after the fact, but that’s not always the case.

I’m sure I’m missing other intricacies. My point is that there’s still a lot of unanswered questions around meaningful use. It would be nice to get some answers. It would be nice if ONC had a way to get and provide practical answers. You’d think they’d want that type of interaction as well.

I’ve been wanting to write about ePrescribing controlled substances since 9/13/09. In fact, I even did write post about the FDA approving a pilot to do electronic prescribing of controlled substances which I posted on that day. Turns out, it was a press release that was sent to me prematurely, so I hid it from view.

Well, a couple weeks ago, the Drug Enforcement Administration (DEA) released it’s interim final rule on ePrescribing of controlled substances (PDF). John Halamka described some of the most important details of this rule on his blog:

(a) To sign a controlled substance prescription, the electronic prescription application must require the practitioner to authenticate to the application using an authentication protocol that uses two of the following three factors:
(1) Something only the practitioner knows, such as a password or response to a challenge question.
(2) Something the practitioner is, biometric data such as a fingerprint or iris scan.
(3) Something the practitioner has, a device (hard token) separate from the computer to which the practitioner is gaining access.
(b) If one factor is a hard token, it must be separate from the computer to which it is gaining access and must meet at least the criteria of FIPS 140-2 Security Level 1, as incorporated by reference in § 1311.08, for cryptographic modules or one-time-password devices.
(c) If one factor is a biometric, the biometric subsystem must comply with the requirements of § 1311.116.

Halamka also suggests they’ll consider 3 approaches to support strong authentication:
*Fingerprints (Bio-Key software?)
*Hard Tokens (such as those provided by RSA)
*Cell Phones (As Gemalto talked about in this video)

I also recently heard someone tell me that the banking has a 6 percent failure rate for matching people. It’s hard for me to believe that it’s high and that the banking industry is willing to deal with that type of failure rate. Of course, that’s not good enough for controlled substances. So, they’re going to have to find some way to lower the patient matching failure rate. Although, I wonder what the failure rate is with the current model. Seems like electronic prescribing shouldn’t make it any worse than it currently is.

Many people are sitting their on the proverbial fence waiting to see what’s going to happen with the HITECH act and meaningful use before they actually go and implement an EMR. Now, I’m not going to let those people off the hook from evaluating and selecting an EMR. That should be done anyway. However, lately I’ve been thinking that many of these clinics shouldn’t be waiting to implement technology in their offices. Sure, EMR is a game changer and a major change for any office and has tremendous upside (regardless of stimulus money). However, for those of you in the wait for HITECH act money camp, there are still a number of IT projects that you can implement today that will benefit you once you actually implement an EMR. Here’s just a few of them:

Fax Server – This is a HUGE game changer for those that have an EMR. The medical world still revolves around the fax machine and will for a long time to come. Implementing a fax server in your office is a great first step to prepare your office for an EMR. Plus, it can save a lot of paper. For example, you can just delete all those “spam” faxes that you get. Fax servers are great and by having it installed and your users trained on how to use it so that when you implement your EMR you can just directly upload your faxes into your EMR without ever printing out the fax.

IM (Instant Messaging) – I’m amazed at how useful our clinic has found IM to be in our office. It’s a great way for the nurses to communicate with the clinicians, the clinical people with the front desk and the nurses with each other. You do have to manage when to IM versus a phone call versus an email (or secure EMR message once you have an EMR), but there’s sometimes that an IM is a perfect way to communicate in a clinic.

Shared Drives – Setting up a shared drive for your office is simple to do and can save a lot of time. I’m surprised how many offices don’t use this. It’s not the best thing for patient data, but there are hundreds of other office uses for a shared drive to prove beneficial. Ideally this would be setup on active directory, but even if you just manually map a shared drive it can work well in a clinic.

IT Infrastructure – Good IT companies will come and do an analysis of your current IT setup for free. They’ll also give you an idea of what things you could do now that will prepare you for your EMR implementation. Plus, even if you don’t do some of the things until you get closer to implementing an EMR, it’s good to know the weaknesses in your IT infrastructure early so that you can make that part of your plans.

Those are just a few examples. I’m sure some will also mention ePrescribing on this list. I’m not totally sold on that idea, but would love to hear people who disagree. What other technologies can clinics implement now regardless of their EMR purchase?

ePrescribing seems like the in vogue thing to do these days. It’s part of the proposed meaningful use matrix and so no doubt we’re going to hear a lot more about it (and we should). However, ePrescribing isn’t without its challenges. A little while ago I put the question to you my readers about the challenges associated with ePrescribing. The following are a couple of the responses that I received from people about their experience with ePrescribing.

Doctor’s advocate that I am, I’ll start off with a doctor’s experience…
E-Rx has been one of the best additions to our EHR. We have reduced paper use significantly, and rarely have problems with transmission. The problems mainly relate to the extra work of entering which pharmacy the patient ants to use.

Overall, e-rx has been a very positive experience – saving time, paper and money. Our e-rx with Dr. First integrates fully into the EHR making the documentation seamless.

From someone who use to work for an ePrescribing company…
(1) There was a saying “Free is not cheap enough” i.e. even if you give away the service, many, if not most doctors are not interested in it, because of the time and effort to implement e-prescribing (HW, networks, training etc). The MIPPA incentives definitely helped, but many doctors still felt that they were insubstantial compared to the cost (mostly their time) that they would have to invest in this.

I agree with you that e-prescribing is an area where there is almost universal agreement that this is a service that is much better than the traditional paper and pen method. All the doctors I have spoken to agree on this. Over time, it will become more and more popular, especially as EHRs penetrate the market. The last data I saw from SureScripts indicated that over 100,000 providers were now eprescribing, which is significantly higher than even just last year.

From the owner of an EMR company talking about integration with an ePrescribing solution and challenges associated with it…
One of the links I found on the AMA web site (several months ago) referred me to iScribe. This site is sponsored by Caremark. It has, in my opinion, a relatively simple to use interface.

Any practice can use the service and there is no need to even interface to existing EMR or practice management systems.

Some interesting information for those looking at ePrescribing. I’d love to hear more experiences in the comments.

I’ve heard a number of good and bad things about ePrescribing. I think that e-Prescribing is one of those things that people generally love, but has some major challenges that are still yet to be overcome. Those challenges can absolutely drive people nuts.

Since my readers are much smarter than me, let’s hear the challenges you’ve faced as you’ve used or implemented ePrescribing. Let it all hang out. If you have ideas or solutions to the problems you’ve faced, let us know those too.

Assuming I get enough responses, I’ll take your responses and do a summary post of people’s comments along with a link to your website (if you leave one).

I came across this blog post which had the actual definition of meaningful use as listed in the HITECH act itself. Check it out:

‘(2) MEANINGFUL EHR USER.— ‘‘(A) IN GENERAL.—For purposes of paragraph (1), an eligible professional shall be treated as a meaningful EHR user for an EHR reporting period for a payment year (or, for purposes of subsection (a)(7), for an EHR reporting period under such subsection for a year) if each of the following requirements is met: ‘‘(i) MEANINGFUL USE OF CERTIFIED EHR TECHNOLOGY.—The eligible professional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period the profes- sional is using certified EHR technology in a meaning- ful manner, which shall include the use of electronic prescribing as determined to be appropriate by the Secretary. ‘‘(ii) INFORMATIONEXCHANGE.—The eligible profes- sional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period such certified EHR technology is connected in a manner that provides, in accordance with law and standards applicable to the exchange of information, for the electronic exchange of health information to improve the quality of health care, such as pro- moting care coordination. ‘‘(iii) REPORTING ON MEASURES USINGE HR.—Subject to subparagraph (B)(ii) and using such certified EHR technology, the eligible professional submits information for such period, in a form and manner specified by the Secretary, on such clinical quality measures and such other measures as selected by the Secretary under subparagraph (B)(i).

Look at the definition. It defines a few simple things that should be required to show meaningful use:
* Electronic Prescribing
* Electronic Exchange of Health Information
* Reporting of Health Data

I’ve commented before that the meaningful use matrix was too much and this makes me wonder if HHS is being too ambitious as they look at this legislation. I think if the ARRA EHR stimulus money could achieve these three items it would be money well spent.