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E-Prescribing: Part II


E-prescribing Update

While the number of electronic prescription transactions has been increasing over the past several years, recent incentives from the Medication Modernization Act (MMA) have now infused this practice with new life.


Statistical Information

SureScripts, a company that is the result of a 2008 merger between the country’s two innovative health information networks, RxHub and Surescripts, estimates that there were over 100 million completed electronic prescription transactions in 2008.  In 2007, only 35 million electronic transactions occurred and even fewer occurred in 2006 with 13 million. 

Currently, there are more than 35,000 healthcare providers practicing e- prescribing, the majority of which are physicians in addition to nurse practitioners and physicians assistants.  This number is expected to increase to over 85,000 in 2008.  There are currently more than 40,000 pharmacies receiving e- prescriptions including both chain and independently owned and it is anticipated that an additional 5000 will be added to the list after 2008 data is collected and disseminated.1


Getting Started with E- prescribing

In order for a physician to be in contact with a pharmacy, it must be connected to the network, which is provided by technology vendors.  There are many different types of vendors, providing both stand-alone e-prescribing software and e-prescribing software integrated with electronic medical record (EMR) systems.  As technology advances and systems improve, some anticipate a shift to EMR system use1.

Technology vendors will need to work with healthcare professionals to ensure proper training and understanding of the software.   This training can be achieved by a variety of methods, including on-site education or phone sessions.


Initial Standards for E- prescribing

Developing the standards that will facilitate e-prescribing is one of the key action items in the government’s plan to expedite the adoption of electronic medical records and build a national electronic health information infrastructure in the United States. Recognizing the need for uniform standards in this process, Centers for Medicare and Medicaid Services (CMS) identified six initial standards.  These standards cover:


  1. Formulary and benefits information

This standard must provide a uniform means for pharmacy benefit payers to communicate a range of formulary and benefits information to prescribers via point-of-care (POC) systems2.

  1. Exchange of medication history

This provides a uniform means for prescribers and payers to communicate about the list of drugs that have been dispensed to a patient2.  It may also provide information that would help identify potential drug interactions2.

  1. Structured and Codified Sig

This standard provides a standard structured code set for expressing patient instructions for taking medications which analysis showed that NCPDP Structured and Codified Sig 1.0 was not able to meet the requisite objectives, functionality and criteria required by the MMA for use in the Medicare Part D e-prescribing program2.

  1. Fill status notification

This would enable a pharmacy to notify a prescriber when the prescription has been dispensed (picked up by patient), partially dispensed (partial amount of medication picked up by patient), or not dispensed (not picked up by patient resulting in the medication being returned to stock), however, this standard was met with some resistance due to the potential to unnecessary administrative burden on prescribers and dispensers2.

  1. Clinical drug terminology

This provides standard names for clinical drugs (active ingredient + strength + dose form) and for dose forms as administered to a patient2.  The program used, RxNorm, demonstrated potential but sometimes would erroneously linked some NDCs to lists of ingredients rather than to the drugs themselves and sometimes the NDCs liked by RxNorm did not match to the semantic clinical drug (SCD)2.  Due to these errors RxNorm was not able to meet the requisite objectives, functionality and criteria required by section 1860D-4(e)(3) of the Act for use for Medicare Part D e-prescribing2.

  1. Prior authorization

This standard would allow prescribers to obtain certification from a plan that a patient meets the coverage criteria for a given drug, however, modifications to the standard would need to be made prior to adoption as a final standard for the Medicare Part D e-prescribing program2.



The CMS have established three exemptions to the use of NCPDP (National Council for Prescription Drug Programs) SCRIPT foundation standard.  The first exemption provided for entities transmitting prescriptions or prescription-related information by means of computer-generated facsimile2.  The second exemption required the use of either HL7 (Health Level Seven) or the adopted NCPDP SCRIPT standards in electronic transmittals of prescriptions or prescription related information or prescription related information when the sender and recipient are part of the same legal entity (for example, within a staff model HMO)2.  The third exemption was when an entity is required by law to issue a prescription for a patient to a non- prescribing provider (such as a nursing facility) that in turn forwards the prescription to a dispenser2.



SureScripts has identified the following initiatives as activities that will assist in accommodating radical growth in this area.

  1. Work with Congress and the DEA to allow e-prescribing of controlled substances1.  Many physicians have stated this restriction requires them to keep written prescribing practices along with e- prescribing thereby increasing the burden of maintaining two prescribing processes.  Physicians report sticking with written prescription processes to keep things simple, which is underutilizing e-prescribing technology.
  1. Healthcare leaders must focus adoption programs and utilization based incentives on high prescribers1.  A long term goal of converting 100 percent of prescribers to e- prescribing should not be the primary focus, but rather, focusing on prescribers who generate the majority of prescriptions.  By implementing incentives, one would expect to see an increase in e-prescribing.  One example would be Medicare payment incentives of up to 2 percent.   It should be noted the sooner a prescriber adopts e-prescribing the better because there may be some negatives, such as payment reductions of up to 2 percent.

Harvard Medical School has researched errors associated with e-prescribing3.  They were able to identify and evaluate various factors (user, technology and environmental) contributing to errors3.  User factors include knowledge deficit about application features, knowledge deficit about the prescription, multi- tasking, improper use of shortcuts, and improper use of free text.  Technology factors can be defined by issues such as user interface design, medication dictionary, and data entry errors.  Environmental factors might include a lack of adequate time during visit and placement of computer equipment.

The type of errors mentioned include: drug product, dose, route, and frequency.   Drug product errors are those associated with an incorrect drug name, strength omission or error, incorrect drug selection or the manual alteration of a script.  Dose errors would include the omission of dose information, incorrect dose (overdose or underdose), ambiguity in sig field or incomplete dose information.  Examples of route errors include incorrect route, omitted/should be PO, and omitted/should be other route.  Frequency errors would include the failure to list frequency or alteration of frequency.

There is great potential with e- prescribing, however, additional progress is required if larger scale success is to be achieved.


New Additions in 2009

The American Recovery and Reinvestment Act has provided $19 billion toward health information technology (HIT) adoption.  A key element to the widespread adoption and use of HIT is the development of uniform electronic standards that allow various HIT systems to communicate with each other.  Medicare has also initiated e- prescribing incentives and Medicare D processors must now be compliant with CMS e-prescribing standards.


1 National Progress Reports on E-Prescribing, December 2007. Retrieved from Report-on-EPrescribing-1.pdf   & nloads/NPR/national-progress-report.pdf

2 Federal Register, Vol. 73, No. 67, April 7, 2008.

3 Errors Associated with the Use of E-Prescribing, Eric Poon MD, MPH, Harvard Medical School