April 30, 2010
Percent of ePrescribing for Meaningful Use
Written by: John
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.
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14 responses to "Percent of ePrescribing for Meaningful Use"
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I also wonder how the other 25% is accounted for. Does the objective imply that the other 25% are still entered with CPOE? If you are entering electronically and your certified system has e-Prescribing capability, why wouldn’t you ePrescribe? Shouldn’t the system just do that automatically because you entered it in the computer? Otherwise, if the prescriber is prescribing on paper, there is no way the computer can tell what the percentage is since the total prescriptions are not known to it. The computer would only be able to tell you a count of how many were e-Prescribed. This implies that, if the prescriber is creating some prescriptions with paper, they are keeping a running tally (yeah right) so they know what the total paper prescriptions are such that they can combine that number with what the EMR tells them and produce the percentage.
Russ,
Of course, I knew I was missing something. How will they be able to keep track of how many paper scripts were written? They can’t go to the pharmacies and get a report per doctor (except in Utah maybe). They’re not going to look through all the notes to find the free text where the doctor wrote that they gave the patient a paper script for “insert medication name.”
I’ll update the post with this too.
Likewise, the word “transmit” could be trouble. Not all pharmacies currently have the capabilities to receive a script electronically. For those that dont, most ERx software instead will send as a fax. Be a bit hard to generate 75% transmitted e-prescriptions is 50% of the pharmacies your patients use can’t accept them. Hopefully, they will let faxing count as “electronically transmitted” too, but you never know with the gov’t.
MSangston,
I considered talking about that too. At least they used electronically submitted as opposed to ePrescribed. Then, I think there would be more doubt. Fax seems to satisfy electronically submitted, but I guess you do never know. Goes back to the angst around the lack of details.
Too true to all points raised, especially Russ’s: I hadn’t even considered the percentage part in terms of tallying all paper prescriptions! It reminds me of an interview I heard way back (or so it seems) when the rules were first released. He talked about the fact that the idea of a percentages could be misleading; for example, a patient portal requires a certain amount of work, even if you open it up to only one patient. You may as well open it up to them all.
And thanks for bringing up audits, John, I’ve been wondering about that this whole time with the whole “attestation” business. How are we going to prove these things are happening? Of course, at this point I’d simply like to see a final version of the MU rules come out, with all revisions made. Then we can really nitpick and attempt to figure out what the requirements are.
What is being missed here is the eprescribing regulations are being written TO GIVE THE PHARMACISTS A MONOPOLY – IT IS A MOVE BY THE PHARMACISTS TO CONTROL THE PRESCRIPTION PAD.
The pharmacy associations have quietly been making agreements for all pharmacy associations to participate in Surescripts. To accomplish this they also had to get faxing re-defined as eprescribing because many pharmacies do not have adequate software. Probably 50% of all “eprescibing” through Surescripts is now faxing.But to keep the stranglehood on the Rx pad, at the same time as faxing was re-defined as a standard they got formulary checking and patient Rx history checking included in the definition of eprescibing. This effectively closes the hole created by allowing faxes. The Rx associations together will know what is prescrbed by what doctor for what patient.
The pharmacists are further trying to lock the doctors into their centralized control by making eprescribing a key to get stimulus funds. Therefore EMRs have to use Surescripts as part of their EMR or develop there own nationwide system.
What does this mean? It means the pharmacists can control prices and dispensing fees at a minimum as a start. This is a huge problem and only if a doctor dispenses themselves through a capable EMR can they avoid loss of control over the drugs they prescibe.
Medscribbler is the ONLY EMR that has an independent eprescribing function that meets the stimulus fund definitions. It is also the only EMR I know that can independently qualify if a physician dispenses themselves. We want to be independent and allow doctors to be independent in keeping control of the prescription pad. We will offer VALUE equal to or greater than the stimulus funds. To us stimulus funds are a crutch for bad design and value! In my opinion Medscribbler’s eprescribing is superior to Surescripts because it is doctor centered first and not pharmacist centered.
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CEOmike,
Are you offering your ePrescribing solution to other EMR vendors that want an alternative to SureScripts?
John,
At this point no. Soon we will have an option for every doctor to be able to use it (free) – and by extention linking by EMRs.
Problem here, is we are going to challenge those with a lot more money than us – so we have are actually holding off because there will be seriuos runs at us with marketing spend, lobbying and lawsuits – Think of it – what would you do if you had 10s of millions in investment and hundreds of employees and a little 10 man company threatened to destroy it all almost overnight! I have already fought off successfully two threats of lawsuits – I am not relishing being the Chinese in Viet Nam.
Yes, it’s definitely a challenge going up against the big boy EMR software companies. Let us know when it’s ready for public release. I’m sure that many of my readers will like to know that there’s other ePrescribing options out there.
Actually, if I had a partner with the last 70 or 80 thousand to finish it and who also had deep pockets so I could fight back at least legally and lobbying we could have it ready in about a month. Think of $1.00 for every prescription written paid by the pharmacists. Right now the doctors are giving away their services for free thinking they are getting some value from the pharmacists – I’d like to know what – they should pay for the service – without physicians we are in the witch brews and magic potions age!
If I print a print prescription from my EMR onto tapper proof paper, how is this different than submitting a scripts electronically through SureScripts only to have them turn around and fax it to the pharmacy.
When I print:
1.) I get DUR information
2.) I get formulary information
3.) I submit to the printer electronically
4.) The script prints on tamper proof paper, with secure printing, and legible hand writing.
It’s easy to make a case that scripts printed through an EMR qualify as “permissible”.
John2,
Sure, that’s an easy number to come up with. Assuming the EMR vendor is tracking it. However, what if they’re tracking isn’t quite right? Who’s going to audit that the software didn’t leave out reprints, etc. Also, this doesn’t take into account the print outs that aren’t “permissible” like controlled substances which currently have to be printed out. This is a simple concept that’s hard to measure when you try to do it at any scale.
Don’t forget about those scripts that you would have sent electronically BUT the drug names are too long or the SIG is too long (this can frequently happen). E-prescribing has limits on field sizes that are sent to their pharmacies. Gotta fax or print them. BUT we tried to send them Electronically. How do we count these?