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ePrescribing Controlled Substances

Posted on August 3, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Back on September 13, 2009 I wrote a post titled, “FDA Approves Pilot Electronic Prescribing of Controlled Substances.” I’d link to the post, but unfortunately the news got sent to me prematurely and so I had to take the post down. It was unfortunate, since there was and still is a lot of interest in being able to ePrescribe controlled substances. In fact, I’d say that not being able to prescribe controlled substances electronically is the current Achilles heal of ePrescribing.

Fast forward to the recent announcement that DrFirst’s announcement of the Nationwide Launch of their ePrescribing Controlled Substances product. Their latest ePrescribing product for controlled substances is called EPCS Gold and is fully certified to meet the prescription processing requirements for Surescripts, the DEA’s requirements in the Interim final rule, and the Identify Proofing requirements set by NIST.

I’m really glad to see ePrescribing of controlled substances moving forward. This will make ePrescribing much more attractive to physicians. Especially physicians that regularly prescribe controlled substances like surgeons and pain doctors.

However, this controlled substance ePrescribing announcement does of course come with it’s limitations. I think they’re described well in this part of the press release:

Prescribers enrolling for EPCS Gold™ will be able to send controlled substance prescriptions electronically after a simple credentialing and identity-proofing process with DrFirst. After providers are certified, they can begin e-prescribing Schedule II-V drugs based on their individual state laws and the ability of the receiving pharmacy to meet the DEA’s requirements to process these prescriptions. To avoid any confusion and eliminate guesswork by providers, EPCS Gold™ automatically detects which substances can be sent electronically.

The two challenges are quite clear: state laws and pharmacy ability to meet the DEA’s requirements. I haven’t done any in depth research on either subject, but I have a feeling that both of these things will be major issues across the country. I’d like to think it won’t be, but knowing the pace of state legislation and pharmacy adoption of these standards I’m not hopeful that they’re ready to receive controlled substance prescriptions electronically.

However, the above step is an important one. You have to have all sides ready to handle the security required to make ePrescribing controlled substances a reality. This is the first step and a very good one.

Summary of ePrescribing Challenges

Posted on October 8, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

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.

Oftentimes patients decide to change from what they had requested previously and then you have to search the database for the correct pharmacy. If you live in a large city that can be cumbersome. Our clinical coordinator has entered cross streets into the database to make this easier.

Our state does not permit transmission of controlled substances which in a pediatric practice is primarily psychostimulant medications. Another minor issue is that you have to have the correct units before it will transmit – e.g. if you want 30 of a capsule you have to put 30 caps in the amount field even though you ordered capsules in the medication field. This is not the way most docs are accustomed to writing prescriptions but certainly more accurate.

If there are pharmacies that do not use E-Rx it goes by fax which can be very slow. Some pharmacies are better than others about keeping up with their -rxs coming in and it won’t be ready when the patient arrives. We tell the patient to call the pharmacy when leaving the office to let them know they are coming.

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.

(2) You still cannot prescribe Schedule drugs (primarily narcotics) via e-prescribing. This made it a tough sell to several specialties (pain, ortho, etc.). However, I have heard that is in the process of changing over time.

(3) Some of the clients that I dealt with did not want to implement eprescribing if it meant implementing another system to be integrated with whatever they had via HL7. They just wanted to wait until their existing vendor came out with a solid integrated solution.

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.

We’ve been able to figure out how to feed data into it (we recommend using Firefox for a web browser and a third-party app called iMacros – which is something developers should know about) and extract data out so that we can keep our systems in sync.

The price for iScribe is $0. There are some aspects that take more time on the part of the doctor/nursing staff, but then there are other things where life is greatly simplified. There is a learning curve and there are some quirks. Their phone support is superb, their e-mail support non-existent.

The first hurdle to overcome was to figure out a way to map their list of pharmacies with ours. Is it “Wal-mart” or “Walmart” or “Wal Mart”? Or, “Savon”, “Sav-on”, “Sav on”, “Albertsons”? It almost became a hand to hand combat to map.

The second hurdle was figuring out to map their list of drugs to ours. Tougher, because we had mis-spellings on our side.

Then there are the issues of dealing with controlled substances. Can’t send them electronically, so then the staff wonders why are we bothering with these extra steps? (Drug-drug interaction checking is the answer.)

In the beginning, the nurses would call the pharmacy. “Did you get our e-request?” The little pharmacies would always say yes. Early on, the big chains seemed to be hit and miss – which was odd.

The nurses have become a little bolder and have learned how to poke around in iScribe and now find reports to help them do their job more easily.

One interesting side note, I did an “edit” function on a patient we had sent prescriptions. On the iScribe side, they had ALL the insurance information on the individual. Which, btw, we had never provided. So in some method, the pharmacies already have all detail and have shared it all over the Caremark network.

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.

ePrescribing Challenges

Posted on October 4, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

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).

How Many Will Actually Collect ARRA EMR Stimulus Money?

Posted on September 19, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In my last post Michael Milne made the following comment that I think was worth discussing:

I firmly believe that less than 5% of all doctors who do buy a “certified” EMR are going to collect.

For example, how many here, or even heard of someone, have actually collected the e-prescribing incentive?

I think that 5% is a low estimate of who will collect on the EMR stimulus money. Although not that much lower. What do you think?

Reasons Why CCHIT Certification is an Inappropriate Standard for EHR Stimulus

Posted on March 15, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

An EMR and HIPAA reader, recently pointed me to a post on a Google Group called “Response to HIMSS ‘Call to Action’: Interoperability First.” The response starts with a short discussion of the need for government to promote and support some sort of interoperability standards. I’ve said a number of times before that interoperability should be a focus of government, because interoperability is more of a public health benefit than it is a benefit to doctors.

After discussing interoperability, the response discusses reasons why CCHIT certification is an inappropriate standard for the HITECH act to use to determine “certified EHR.” Take a look at the reasoning:

As it currently exists, CCHIT certification is an inappropriate standard for federal funding, authorization or endorsement of HIT systems:
*CCHIT 2009 certification has over 450 separate requirements, the collective effect of which tremendously increases the cost and complexity of IT solutions. Many of these requirements are “functional specifications” that should be determined by customer needs and priorities, rather than by committee. These requirements foster (if not mandate) the development of rigid, monolithic systems.

*The monolithic approach to certification taken by CCHIT does not reflect the current advances in information technology being leveraged by other industries where integrated solutions are used to support the complete “end-to-end” business process. Integration and interoperability are essential to leverage the potential of “cloud computing” and other service orientated delivery mechanisms.

*CCHIT works to the benefit of a small number of large EMR vendors that can command a high price from the relatively small segment of the market able to currently afford their products. It is essentially anti-competitive, and establishes a major barrier to entry by new vendors and open source projects (where the majority of innovation will take place).

*A quick count from the CCHIT website gives the following results for the number of systems certified for ambulatory EMR (including conditional certifications and multiple certified products from a single vendor):
i) 2006 = 93
ii) 2007 = 55
iii) 2008 = 14

*At this rate of attrition, the number of certified products will dwindle to the single digits.

*The shrinking number of vendors that are capable of meeting CCHIT certification exposes a fundamental flaw in its current organizational structure – CCHIT is funded by the very vendors it certifies. In order for it to maintain revenue, it needs to provide a reason for vendors to continue to either:
i) re-certify on a regular basis
ii) apply for new certifications

*The problem with this model is that, in order to justify ongoing re-certification, CCHIT must continue to add new certification requirements year-to-year. The driver for more requirements is not necessarily the needs of customers or the best interest of the healthcare system, but the need to have new requirements against which to certify vendors. This is illustrated by the fact that CCHIT has recently reduced the length of the certification from three to two years, and is adding numerous supplemental certifications in areas like child health, cardiovascular, etc. There is no end to the number of requirements to which this could lead, but there is no evidence it will serve anyone well in the long run, other than the few large vendors with the resources to keep up with this process, and CCHIT itself.

*Although in theory vendors can apply jointly for CCHIT certification, in practice the monolithic certification process will limit the ability for vendors to provide component solutions from which customers can choose to create best-of-breed, low cost solutions that best fit their needs. For instance, in the ambulatory arena, this might typically be a combination of Practice Management, EMR and e-Prescribing solutions.

*Certification of Practice Management systems in other markets (e.g., UK) has arguably reduced innovation and investment, increased the total cost of ownership and consolidated the market to such a point that there is limited choice and the barrier to entry for new entrants into the marketplace is unaffordable.

I think this is just the start of what could be said, but it raises some really important points about certification.