Mariah Delaire

June 7, 2016
HTM 520
Professor Mark Branning
Electronic Prescribing
Introduction
It is estimated that more than one million Americans per year are negatively affected by
medication errors, which are caused by mistakes in the prescription filling process (Office of the
National Coordinator for Health Information Technology, 2015). Errors such as these can cost the
health care industry billions of dollars every year, furthering the need for change to help lower costs
and reduce medication errors. The resultant change is the use of electronic prescribing (eRx)
facilitated through the use of electronic health care records (EHRs) and standalone software. Eprescribing enables prescribers to electronically send accurate and error free prescriptions to a
pharmacy, and is a main component of improving the quality of patient care. The functions of eprescribing include messages regarding new prescriptions, prescription changes, refill requests,
prescription fill status notifications, prescription cancellation, and medication history (National
Council for Prescription Drug Programs, 2014). Initiatives such as the HITECH Act and the
Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), helped to
increase the adoption of e-prescribing systems. The adoption of the standards for e-prescribing was a
key action in the governments plan to expedite the process of widespread EHR adoption and
implementation. As a result of this health information technology tool, patients in nearly all states can
have their medications prescribed to them via e-prescriptions.
During the e-prescribing process, a system user signs in where their identity is authenticated.
The prescriber then identifies the patient records within the e-prescribing system. If the e-prescribing
system is connected to that facilitys EHR system, it can recognize all patient records on that days
schedule, making it easier for the prescriber to access information. The next step is to review any
pertinent medical history on the patient, then enter and edit the prescription as needed. E-prescribing
systems allow prescribers to send the information to the Transaction Hub where that information on
the patients eligibility, formulary, and medication history/fill status is sent back for the prescriber to
view. The transaction hub is the link between the prescriber, pharmacy, and the pharmacy benefits
manager (PBM) (U.S. Department of Health and Human Services , 2016). As soon as the Transaction
Hub receives the patient information from the prescriber, it verifies that information against the
master patient index sending a message to the PBM. The PBM will then send information back to the
transaction hub which is then sent back to the prescriber who can make the decision about the
prescription based on the information. At that point, the prescriber can complete and authorize the
prescription and is then able to send it to the preferred pharmacy.
Benefits
With the help of health information technology tools such as electronic prescribing, providers
can safely and efficiently manage patients medications. In comparison to other tools such as paper or
fax, eRx improves medication safety, prescribing accuracy, and health care quality and costs by

reducing adverse drug events (U.S. Department of Health and Human Services, 2016). The use of eprescribing is steadily increasing due to these may benefits. The growing complexity of patients
needs in addition to the increasing volume of medications, marks an increased risk of error and
adverse drug events. ERx can help to improve the safety of patients along with the quality of care
they receive by eliminating illegible prescriptions and reducing oral miscommunications. ERx
systems also have the ability to warn and alert prescribers if there are potential adverse events to
other medications patients are taking and also allows providers access to a patients complete
medication history. The use of e-prescribing systems has the ability to reduce time on phone calls to
and from pharmacies while increasing patient convenience and medication compliance. In addition to
the many benefits discussed, eRx systems can help to achieve direct cost savings for both the patients
and the insurers. This can be done by pharmacy benefit managers (PBMs) and insurers providing
detailed information to the prescriber about formularies and the benefits structure of a plan, enabling
the provider to prescribe the most appropriate medication (U.S. Department of Health and Human
Services, 2016). Overall, there are many benefits that e-prescribing has for providers, insurance
companies, pharmacies and patients.
Relationship to Meaningful Use
Meaningful use is a set of criteria in which electronic heath care records (EHR) are used to
improve overall patient care by healthcare providers. The ideas behind meaningful use is to improve
population health, improve coordination of care, safety and patient engagement. Financial incentives
have been approved for eligible providers and hospitals for the implementation of Meaningful Use, in
hopes that more organizations will adopt EHRs. There are three stages of meaningful use with the
plan of implementation over the course of five years. Stage one and two have already taken place,
while stage three is planned to take place between the years 2016 and 2017. Electronic prescribing is
one of the criteria set to achieve meaningful use. The main objective of eRx is to generate and
transmit permissible prescriptions electronically. The stage one measure for e-prescribing focused on
achieving more than 40 percent of prescriptions being transmitted electronically using certified EHR
technology (CEHRT) (Centers for Medicare and Medicaid Services, 2014). The exclusions to this
criterion are providers who write fewer than 100 prescriptions during the reporting period and any
provider who does not have a pharmacy within their organization or a pharmacy within 10 miles that
accept e-prescriptions. The objective of Stage two for e-prescribing remained the same, while the
measure changed. The goal was to achieve more than 50 percent of permissible prescriptions written
by the provider were to be queried for a drug formulary and transmitted electronically using a
CEHRT (Centers for Medicare and Medicaid Services , 2014). It is important that the provider solely
used a CEHRT to create the prescriptions and used standards adopted for the EHR technology
certification to transmit. Exclusions for stage two remained the same as stage one. Stage three of eprescribing is proposed to maintain the objective and measure finalized in stage 2, with slight
changes. The objective is still to generate and transmit permissible prescriptions electronically,
however hospitals and critical access hospitals must also generate and transmit permissible discharge
prescriptions electronically, meeting an 80 percent threshold (Centers for Medicare and Medicaid
Services, 2015).
Corresponding Standards
Electronic prescribing standards is supported through the National Council for Prescription
Drug Programs (NCPDP) who is an ANSI- accredited standards development organization. The

NCPDP is one of several Standards Development Organizations (SDOs) involved in Healthcare

Information Technology and Standardization. Because so many different entities are involved in the
prescription process, a set of standards are needed to ensure there is proper communication between
all parties. One of the main electronic prescribing standards used is the XML-based NCPDP SCRIPT
standard, which was created to help facilitate the transfer of prescription data between pharmacies,
prescribers, intermediaries, facilities and payers in the outpatient setting (National Council for
Prescription Drug Programs, 2014). SCRIPT enables communication of prescription information
between the prescriber and the pharmacy in addition to medication history between all parties. This
standard is essential in all transactions for new prescriptions, prescription changes, refill requests,
prescription cancellation, medication history and prior authorization exchanges.
Most inpatient settings who have adopted an EHR system use HL7 as part of their data
standards. Because HL7 is being used, it needs to work alongside NCPDP SCRIPT to guide
messages supporting the actions of new prescriptions, prescription changes, refill requests,
prescription fill status notification, and prescription cancellations to and from the pharmacy. This
HL7-NCPDP standard enables inpatient facilities using HL7 to electronically communicate
prescriptions for patients that are discharged (HL7 Pharmacy Work Group, 2007). It also allows
outpatient facilities using HL7 prescription tools to write prescriptions to be delivered to a pharmacy
for dispensing. This system enables pharmacies to communicate refill or renewal requests to
prescribers from NCPDP SCRIPT messages to HL7 messages as well. In addition, HL7-NCPDP
allows prescription history messages in SCRIPT to be communicated between prescribers using
either SCRIPT or HL7 standards. HL7-NCPDP works as a bridge to facilitate communication for
providers using either standard. HL7 standards were not initially designed to manage the transactions
of prescribers and retail pharmacies. It is important for inpatient settings to utilize the HL7-NCPDP
standard to allow for the communication with ambulatory and retail pharmacies (HL7 Pharmacy
Work Group, 2007).
Another component of the NCPDP is the Formulary and Benefit Standard which provides
patient benefits information to the physicians at the point of care. This enables physicians to make
informed decisions during the prescribing process so he/she can choose the most appropriate drug for
the patient (National Council for Prescription Drug Programs, 2014). Data for formulary and benefits
can consist of formulary status, payer-specified alternatives, coverage information, copay
information, and drug classifications. NCPDP Fill Status Notification is another component that
notifies the prescriber after a patient has picked up a prescription at the pharmacy. This information is
useful to track patients who appear to be non-compliant with their doctors advised course of
treatment. ASC X12N 270/271 (Health Care Eligibility/Benefit Inquiry and Health Care
Eligibility/Benefit Response), is another standard used for a prescriber to request eligibility
information about a patient. This particular standard is maintained by the Accredited Standards
Organization. The Structured and Codified Sig format for e-prescriptions includes instructions for the
patient for taking medications at the end of the prescription. These instructions are called signtura
and currently hold no standardized vocabulary (Liu, Burkhart, & Bell, 2011). An important
component to standardization is standardized vocabulary, which is why RxNorm is used. RxNorm, a
drug nomenclature from the National Library of Medicine, provides a vocabulary for name, dose, and
form of available drugs (Bell, O'Neill, Reynolds, & Schoeff, 2011). Each drug in the database is
distinct because it is assigned a unique identifier. This improves drug identification in e-prescribing

because it offers substantial efficiency for communicating health plan formulary information to
prescribers.
Data standards are an important component to any successful system because they not only
ensure proper communication between multiple systems, but promote interoperability between those
systems as well. E-prescribing gives providers the ability to securely and electronically exchange
prescription information with pharmacies. It was observed that physicians using EHRs or eprescribing software are able to cut the amount of time in half on refilling authorizations when
compared to non e-prescribing users (Hutchinson, 2007). With the amount of adverse drug events
that occur each year along with the billions of dollars in added heath care costs, electronic
prescriptions can help providers avoid these mistakes. Having patient medication information readily
available, providers can prevent these adverse events by automatically checking for drug allergies,
drug-drug interactions, and doses that are too high. It is essential to adopt e-prescribing because it
reduces the large amount of adverse events and medication errors that occur every year while
improving patient safety and quality of care.
Cerner
Electronic prescribing can come in a couple different forms. It could be integrated with an
already functioning EHR system, or could be used as a software alone. However, with the HITECH
act and Meaningful Use, most providers use an e-prescribing tool that is already a part of their
existing EHR system. An example of an EHR vendor that has e-prescribe as a tool is Cerner. The eRx
tool is a standalone and easy to use application that allows physicians to automate the prescriptions
process. This type of tool is great to use alongside an existing EHR system because it can help
providers increase reimbursement, decrease time and effort processing prescriptions, and ensure
patient safety (Cerner, 2016). Cerners e-prescribing tool uses an electronic data interchange to
transmit from prescriber to pharmacy and is partnered with SureScripts, a third party vendor, who
supplies the network for the data transmission process. SureScripts is used because they have a
relationship with close to 95 percent of the pharmacies around the country (Cerner, 2016). The use of
a system such as Cerner ePrescribe helps providers to minimize re-entry of patient data, increases
patient safety by reducing illegible prescriptions and adverse drug events, and displays formulary and
benefits to ensure plan eligibility.
Barriers and Challenges
While e-prescribing is a valuable tool to improve patient safety and efficiency, it does come
with some challenges. A large concern for hospitals and providers is the costs associated with
implementing a eRx system. Many believe that the cost is too high to receive an appropriate return
on investment. Change management and new workflow systems is another challenge because many
practices are set in their ways of doing things. It also is timely for practices and hospitals to conduct
training, planning and implementation of a new system. Another hurdle is selecting the proper
hardware and software. It can especially be challenging if it is a smaller practice where they do not
have IT staff for technical support. The connectivity of pharmacies poses a large challenge as well
because while 97 percent of chain pharmacies are connected to an e-prescribing system, 73 percent
of the independent pharmacies are not (U.S. Department of Health and Human Services, 2016). This
means that the patient, formulary, eligibility, or medication history may not be current. Another
challenge is security issues, such as the verification of electronic signatures and ensuring the medical

integrity of prescriptions. Therefore, it is essential that prescribers and pharmacies are protected with
firewalls, have strict settings, and remain aware of signs of intrusion. With many challenges comes
many opportunities for improvement; if these challenges can be addressed, widespread adoption and
implementation of an e-prescribing tool can be accomplished.
Future Trends
It is no doubt that e-prescribing use has grown significantly over the last few years. Providers
using e-prescribing tools via EHRs have increased from 7% in December 2008 to 54% in December
2012. Not only that, pharmacies utilizing e-prescribing software have gone from 70% in December
2008 to 94% in December 2012 (Gabriel, Furukawa, & Vaidya, 2013). Another trend that is expected
to increase e-prescribing use is Meaningful Use Stage 3. It was seen that Stage 1 and Stage 2 showed
a median performance of 89 percent and 92 percent, so it is expected that there will be continued
expansion of pharmacy market acceptance and improved EHR use to facilitate e-prescribing (Centers
for Medicare and Medicaid Services, 2015). The proposed measure for Stage 1 and 2 were 40 and 50
percent, and because of the seen trends, the proposed measure for Stage 3 is 80 percent. Eprescribing is expected to continue to enhance safety and medication compliance. E-prescribing will
continue to prevent medication errors and increase patient safety along with saving large costs.
Summary
More than one million people every year are affected by medication errors, which contributes
to billions of dollars in additional health care costs. The adoption of standalone or EHR e-prescribing
systems can help to reduce these medication errors and associated costs. These systems improve
patient safety, medication compliance, efficiency, quality of care, patient satisfaction and reduces
costs. With the help of laws and bills such as the HITECH Act and Meaningful Use, widespread
adoption is currently being taken place. Since the enactment of the HITECH Act, there has been a
substantial increase in providers and pharmacies using e-prescribing technology. Through the use of
data standards such as SCRIPT, HL7 and RxNorm, patient information can be easily exchanged
between all associated systems. This ensures that the right medication is being prescribed for the
right patient based on medication history, drug-drug interactions, allergies, among many other
factors. Cerner is a great example of a vendor that works alongside a third part company to ensure
that their e-prescribing software is efficient and up to date. Along with the many benefits of eRx,
there are challenges such as the costs associated with adoption, user resistance to change, and the
potential security issues. However, the future of e-prescribing is extremely positive because of all the
benefits that are associated with the use of this system. The adoption of e-prescribing is only going to
increase by providers, hospitals, and pharmacies because of how effective it is in preventing medical
errors and reducing costs.
Questions:
1) What is the common standard used for e-prescribing in the outpatient setting? XML- based
NCDPD SCRIPT
2) What types of e-prescribing systems are there? Standalone and EHR based
3) Describe the major goal of eRx adoption. To prevent medical errors and reduce health
care costs which improves patient safety, quality or care, and patient satisfaction.

References
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