Electronic prescribing and federal policy

Successful electronic prescribing (eRx) has been a federal goal for several years. Numerous reasons for encouraging this migration away from handwritten prescriptions have been detailed, all pointing to improved health care quality. A recent talk by Don Berwick, the Administrator for the Centers for Medicare and Medicaid Services (CMS) underscored the federal push to get physicians e-prescribing.

Reduction in errors from illegible handwriting, such as wrong medications with similar-appearing names being dispensed and resulting in harm, are one important reason cited for moving to eRx. Reduction in call-backs from the pharmacy because the handwritten eRx has a wrong (or incomplete) dosage, directions or quantity are another workflow-hampering reason for eRx.

eRx systems are also more that simply legibility-correcting, and completeness-checking transcription tools. They also offer the ability to keep track of prescription histories for a patient, and to cross-check a medication for drug-drug and drug-allergy interactions. Reductions in these kinds of preventable errors has been a big driver in the move to incentivize eRx at the federal policy level.

eRx under different pieces of legislation stirs confusion
Encouragement of eRx has been captured in different pieces of legislation, which (unfortunately) has caused some confusion. As is generally the case for the federal government, administrative structure has been built around each piece of legislation, and such rules-based structures exist in relative silos that don’t necessarily talk to each other.

In 2008, the eRx Incentive Program was created as part of MIPPA legislation, which encouraged physicians to e-prescribe by giving increases in Medicare payments to physicians who could be identified as successful e-prescribers. Under this program, physicians needed to use a “qualified eRx system” that had certain features, but there was not a formal Certification program to identify specific eRx software – it was up to the prescriber to declare that the eRx system used was compliant (with the potential for audits, IRS-like).

The MIPPA eRx program identified “successful e-prescribers” by counting the number of specific zero-dollar G-codes submitted along with “qualifying events” (office visits, defined by their billing CPT codes) each year – if enough such G-codes were received, then the prescriber was deemed a “successful e-prescriber” and a bonus-adjustment of Medicare payments was made the following year. The G-codes have changed with each program year (there were multiple potential codes in previous years) – for 2011, there is only one G-code that CMS is using: G8553.

This approach has several implications: (1) only prescriptions generated during (or on the same day as) an in-office medical encounter are counted – refills that are done (electronically) on other days don’t count. Given that routine refill requests represent a significant work volume for a physician, and often exceed the volume of prescriptions created at the time of an office visit, this way of counting eRx will significantly understate true use of eRx technology. (2) Since a G8553 code needs to accompany an office visit billing code (e.g. 99212, 99213, etc.) submitted to Medicare, only eRx for Medicare fee-for-service patients are counted. Again, this may represent a minority of patients in a given practice, and therefore the measure understates the true use of eRx technology.

As with most federal programs, where there is encouragement (a bonus in Medicare payments) for an initial period of time, failure to adopt eRx after a few years will result in a penalty assessment. That time is now. Failure to demonstrate eRx use (i.e. submission of at least 10 G8553 codes in the first half of 2011) will result in a 1% reduction in Medicare payments in 2012. It takes CMS a long time to calculate all of this, so the 2012 penalties will look at January-June activity for 2011 in order to see who might be getting penalty-reductions next year.

Needless to say, this has many physicians worried. There is no neat tool offered by CMS to query and ask “do I have enough G-codes submitted yet?” A physician will need to review the billing history (from billing software, or from a billing service) and make sure that each Medicare-receiving clinician in the practice who has prescribing privileges has submitted at least 10 such G-codes for Medicare fee-for-service patients so far.

There is some flexibility here. Prescriptions for over-the-counter medications, if done by eRx to a pharmacy, as well as prescriptions for Durable Medical Equipment items (like diabetic supplies) all count as “valid e-prescriptions.” There are exception codes (G-codes which only need to be submitted once) for physicians who cannot, due to external circumstances, e-prescribe. CMS recently expanded the kinds of exceptions that would give a physician respite from the penalties, which will be finalized in August and available via a new portal on the CMS web site by October 1.

eRx under Meaningful Use
Separate from the 2008 MIPPA eRx Incentive, subsequent legislation in 2009 (ARRA) defined the EHR Incentive Program (“Meaningful Use”), which includes e-prescribing as one of its core features.

Electronic prescribing as defined by Meaningful Use is different than the MIPPA definition in several important ways:

(1) There is no counting of absolute numbers of G-codes. The eRx usage is a percentage of all prescriptions created (at least 40% of all prescriptions created in the EHR system need to be submitted electronically, excluding from the denominator prescriptions that cannot be e-prescribed, such as controlled substances). Prescriptions at the time of office-visits, as well as all routine refills done (regardless of whether it is at the time of a visit), all count. It is a percentage of all prescriptions that is measured.

(2) Meaningful Use applies to the entire practice, not just Medicare or Medicaid. The incentive is to encourage clinicians to adopt an entire EHR package (not just stand-alone eRx), and the measurement is from activity generated by the EHR for the whole practice. Even though bonus payments for EHR use are paid through Medicare or Medicaid, what is counted is overall practice activity.

(3) EHRs have a specific Certification process, so there is no ambiguity as to what qualifies. Using a Certified EHR qualifies for both the Meaningful Use program, as well as MIPPA eRx activity.

(4) Meaningful Use bonuses are paid as a single lump-sum, not as an adjustment of Medicare payments. If Meaningful Use bonuses are being sought, then a bonus adjustment of Medicare payments under MIPPA eRx cannot also be obtained (no double-dipping into both these programs, on the up-side). However, failure to provide the 10 G-codes might still result in penalties under the MIPPA program, while resulting in a bonus payment under the EHR Incentive Program – this absurdity will likely be resolved by the new exceptions for the MIPPA program being proposed by CMS.

The bottom line
Granted that there are 2 different pieces of federal legislation that encourage eRx use, and each program has different rules and administrative structures surrounding them (though CMS is trying to reconcile these differences), the bottom line for physicians is to use electronic prescribing everywhere possible. It results in better healthcare. The legibility issues go away. Complete and accurate prescriptions are sent the first time, without as many call-backs from pharmacies. Drug-drug and drug-allergy interaction checking becomes woven into the routine of prescribing (both for new prescriptions created at the time of a visit, as well as routine refills that are done very frequently every day). As the saying goes, “Just Do It” – and the time for doing it is now.