E-prescribing makes it quick and easy for a doctor to prescribe a medication to a patient.  However, doctors need to take extra precautions to ensure that they are not prescribing unnecessary medications too quickly. 

Prescription drug abuse is a fast growing problem in America.  According to a study by the National Institute on Drug Abuse, approximately 7 million Americans abuse prescription drugs¹.  Furthermore, the CDC reported that in 2010, over 22,000 drug overdose deaths involved pharmaceutical drugs².  While the prescription medications can be obtained several unlawful ways (stealing someone else’s prescription or getting them through a drug dealer), a majority of them are obtained through prescriptions written directly for the drug abuser.  Drug seekers will “doctor shop” to find a doctor (or multiple doctors) who is willing to write them a prescription for their chosen drug. 

What Is Being Done?

49 states (all except Missouri) have put a Prescription Drug Monitoring Program (PDMP) in place.  These are electronic databases that prescribers can access to check a patient’s controlled substance prescription history within the state.  These are valuable tools that can help reduce prescription drug abuse.

Surescripts®, the nation’s largest e-Prescribing hub, also offers access to some Nationwide Pharmacy Fill History and Pharmacy Benefit Managers (PBM) claim history.  For e-Prescribing software systems that certify on this feature and prescribers that take advantage of it, this is an invaluable tool.

Is It Enough?

These tools can only help if they are actually used.  Checking these databases is voluntary in most states.  The Tampa Bay Times did an investigation in Florida on the actual use of their drug monitoring program.  They found that out of 48 million controlled substance prescriptions written, prescribers had only checked the database before writing 2 percent³.   There are only two states that have taken lead in making the use of these databases mandatory.  In August, New York put into effect the I-STOP law which requires prescribers to check their state database before prescribing controlled substances.  Tennessee also has a similar law in effect. 

In addition to actually using the databases, another key component to their effectiveness is that they provide current information.   One more significant part of New York’s I-STOP law is that it requires real-time reporting by pharmacists dispensing prescriptions.  The reporting requirements vary from state to state with only a couple requiring real-time reporting, some requiring reporting done within 24 hours and others only requiring monthly reporting. 

The PDMPs also vary from state to state as to which agency houses the database, which controlled substances are reported, who is required to submit data, and how noncompliance is enforced.  Some states are able to share data with other states while others are not.

And while e-Prescribing systems that offer access to the Surescripts® claims and fill history do allow for a nationwide accessible database, not all pharmacies and PMBs are in the network.  More importantly, not all prescribers take the time to pull the history even when they have the tool.

While Surescripts® and many states have taken a step in the right direction, in order to be as effective as possible in reducing prescription drug abuse, a database needs to:

• Be National – Each state having their own database is not the most effective model.  Drug abusers can easily cross state lines or even move to a new state to get more prescriptions.  The drug database information needs to be available nationwide.   An e-Prescribing Vendor wanting to give their prescribers access to all data would currently need to integrate with 49 PDMP systems and Surescripts®.

• Be Mandatory – Every prescriber should be required to check the drug database.  The information is of no use if it isn’t seen.

• Require pharmacy real-time reporting – Having the most current data available will prevent drug abusers from being able to get prescriptions from multiple pharmacies. 

• Include all prescriptions – Schedules of drugs can be changed and drugs that were once non-controlled substances become controlled substances.  A complete history of all prescriptions would be most beneficial to prescribers.  This information is not only helpful in fighting drug abuse, it can aid in the overall quality of patient care. 

• Be Standardized and Interoperable – Prescribers are much more likely to make use of the data if it is part of their normal workflow.  Having to login to a separate database in a new window is a hassle.  However, if the data is available in a standardized format that can be integrated with a prescriber’s current e-Prescribing solution it becomes much more effective.  While a Nationwide centralized database would allow for prescribers (and technology vendors) to be able to have one complete picture, interoperability between the PDMPs and Health Systems becomes important until that can happen.  Moving in that direction, the Office of the National Coordinator for Health Information Technology (ONC) just launched the PDMP & Health IT Initiative last week.  It aims to create standard methods for exchanging the data between PDMPs and health systems.  As described in the challenge statement, “There are a lack of common technical standards and vocabularies to enable PDMPs to share computable information with the EHR that providers can use to support clinical decision-making.”⁴

What Can Prescribers Do In The Mean Time?

Until there is one central database or interoperability between all e-Prescribing systems and PDMPs, prescribers should ensure they use their state systems and in addition, that they are using e-Rx programs that make national drug usage information available.  Programs like MDToolbox have access to the Surescripts® Nationwide Medication History through participating PBMs and pharmacies.   While this is still limited to the PBMs and pharmacies in the network and not mandated, it does give prescribers one more tool to stop abuse and prescription shoppers.  

1. "Topics in Brief: Prescription Drug Abuse" NIDA, December 2011.
2. “Opioids drive continued increase in drug overdose deaths,” CDC, February 2013.
3. Cox, John W. “Florida drug database intended to save lives is barely used by doctors.” Tampa Bay Times 6 Oct. 2012. http://www.tampabay.com/news/health/florida-drug-database-intended-to-save-lives-is-barely-used-by-doctors/1255062
4. Prescription Drug Monitoring Program (PDMP) & Health IT Integration Initiative, Office of the National Coordinator for Health IT http://wiki.siframework.org/PDMP+%26+Health+IT+Integration+Charter+and+Members

Keeping in line with our previous posts on the benefits of e-Prescribing software, this week we focus on the benefits of integrating e-Prescribing software with existing healthcare software programs like EHRs/EMRs (Electronic Health Record Systems and Electronic Medical Record Systems).  While several options exist for integration, here we concentrate on embedding certified e-Prescribing screens. 

5) Maintenance done for you

E-Prescribing requires a lot of data.  One of the main reasons to use an e-Prescribing vendor is so that the EHRs don’t have to worry about the data upkeep.  For example, MDToolbox provides a complete drug database that is updated monthly, a database for interactions, monographs and education materials that is also updated monthly, formulary information based on patients’ insurance plans that is updated weekly, and a pharmacy lookup that is updated nightly.  See more about MDToolbox’s e-Prescribing services. 

4) Additional Features through API

In addition to being able to add e-Prescribing to their product, there are often several other features available through the API that EHRs can add into their product.  These don’t have to be part of just e-Prescribing, they can be added wherever fits best in the EHR (by calling the API directly from EHR screens).  A few examples of some functions MDToolbox offers as part of e-Prescribing and also available to EHR screens include:

• Allergy Search
• Condition/Problem List Search
• Pharmacy Search
• Drug Research, Patient Education and Decision Support Materials

3) Meet Meaningful Use

E-Prescribing is a big part of certifying for Meaningful Use.  By adding an e-Prescribing system that already meets Meaningful Use, EHRs can focus their time on meeting the rest of the qualifications.  See which Meaningful Use criteria MDToolbox meets.

2) Faster

It can take countless development hours to design screens for e-Prescribing.  In order to electronically route prescriptions to pharmacies nationwide, you must connect to a hub.  The hubs have many rules and regulations that e-Prescribing screens must meet in order to connect.  Surescripts® (the nation’s largest hub) has strict certification requirements and the certification process can take a lot of time.  EHRs must register with Surescripts and take classes, as well as a series of tests, in order to get certified.  The process can take upwards of 4 months.  

An EHR will have a much faster time to market by embedding already certified screens.  Adding an eRx system like MDToolbox-Rx can be done in as quick as 2 weeks.  The system can be integrated and tested in one week and the next week a quick call (20 min or less) with Surescripts completes the process to go live. 

1) Cheaper

Obviously, less time spent on development equals money saved.  As mentioned above, in order to e-Prescribe, a lot of data is needed.  The cost to acquire and maintain this data can also be quite large and on-going. 

• Databases – MDToolbox maintains over 200 Gigabytes worth of data that needs to be continually updated from many sources.  As an example, according to the FDA¹, 5 new drug products were approved in October alone.  It is not only important to keep data updated to have the latest information available to prescribers, it is mandated to maintain status on the e-Prescribing Network.  In order to be certified through Surescripts, you must obtain approved vendor provided databases and update them regularly. 

• Federal, State and Hub Requirements and Regulations - The regulations are continually being updated and new rules put in place which requires constant product and coding updates.  E-Prescribing vendors keep up with the regulations and product updates, so EHRs who have integrated with them don’t have to worry about it.  These regulations include DEA rules and individual state rules.  For example, recently the State of New York passed the “I-STOP” Laws to help the state fight prescription drug abuse.  According to a posting at nysenate.gov², the new laws mandate medication history lookups for controlled substances, mandate ALL prescriptions be e-Sent by March 27, 2015, and updates the controlled substance schedules of many drugs to safer levels.  

In addition to the lower development and data costs, EHRs can also save big on certification costs. 

• Surescripts® Certifications - The Surescripts certification process not only takes time, it is an additional expense.  Thousands of dollars can be saved by embedding an e-Prescribing system that is already certified.   As Surescripts® (or other hubs) come out with new rules, changes, and updates, additional product certifications for the e-Prescribing system are required.  The process is an ongoing expense.

• EPCS Certification/Audits - If EHRs want to be able to electronically prescribe controlled substances, they must also go through a full DEA 1311 audit.  This can cost upwards of $15,000 dollars.  However, if an EHR adds an e-Prescribing system that has already been through the full audit, such as MDToolbox-Rx, this eliminates or greatly reduces the size and price of the audit (depending on type of integration).  Additionally, the DEA mandates that the audit be re-preformed every two years and re-audited any time the product is changed, equaling more ongoing costs.

Some EHRs may think the ability to create their own screens to match their system outweighs the above benefits.  However, a few e-Prescribing vendors allow customization with their screen integrations to allow for a seamless workflow.  Such things like the screen colors and fonts can be matched to the EHR's theme.  MDToolbox even allows private labeling, so an EHR can add e-Prescribing screens that completely match their current interface and their end users will have no idea that they used an e-Prescribing vendor.  So, we pose the question – With the many benefits of using already certified screens AND the ability to customize those screens, why would anyone want to go through the hard work of building and maintaining their own e-Prescribing system?

1. “New Drugs at FDA: CDER’s New Molecular Entities and New Therapeutic Biological Products of 2013.” U.S. Food and Drug Administration, Last Updated November 5, 2013. http://www.fda.gov/drugs/developmentapprovalprocess/druginnovation/default.htm
2. Montgomery, Velmanette. “New I-STOP Law To Help State Fight Prescription Drug Abuse.”  New York State Senate, September 6th, 2012 http://www.nysenate.gov/press-release/new-i-stop-law-help-state-fight-prescription-drug-abuse 

Our post last week covered the top 5 benefits of using e-Prescribing software for providers.  If you missed it, check it out here.  This week we focus on the benefits as they relate to patients.  

5) Patient Education Materials

Most e-Prescribing software includes drug reference information, including leaflets that can be printed and given to the patient (or electronic).  These leaflets are often available in several different languages, as well as adult and pediatric forms.  They include warnings, possible side effects, how to take the drug, and any other important information the patient needs to know about the drug.  Some products, including MDToolbox, also provide patient education information on patient conditions that can be printed and given to the patient as well.  

4) Compliance

An estimated 20% of all paper prescriptions are never filled ¹.  Eliminating the need to drop off the prescription at the pharmacy and reducing wait times aid in patient compliance.  Some providers may worry that the patient may forget to pick up a prescription that was e-Sent.  However, software like MDToolbox provides an auto print out of a “Prescription Receipt” that the prescriber can hand to the patient so they remember to go pick it up, as well as which pharmacy it was e-Sent to.  The print out also includes the prescription directions so that the patient is clear on how the prescription should be taken.

3) Saves Patients Time

Using e-Prescribing software significantly reduces the time the patient has to wait at the pharmacy and in most cases, the prescriptions are ready for the patient as soon as they get to the pharmacy.  Multiple trips to the pharmacy are eliminated and time spent waiting for physicians to reply to refill requests is reduced as well.

2) Saves Patients Money

Through most e-Prescribing programs, prescribers have access to a patient’s formulary information at the time of prescribing.  This allows the prescriber to view which drugs will be covered for the patient and which ones are not.  Many times co-pay information is also available.  This way the prescriber can pick the lowest cost drug available for the patient.  A study by Decision Resources found that 75% of the doctors surveyed said when they e-Prescribe they pay more attention to the costs for their patients².

1) Improves Patient Safety

We stated it last week, but it’s worth stating again (and again) because it is so important: e-Prescribing software greatly improves patient safety. 

Patients who see a provider who uses e-Prescribing do not have to worry about the pharmacist being able to interpret the prescriber’s handwriting.  They can be sure that the prescription the prescriber intended to write is readable in a standard, clear format by the pharmacist.  MDToolbox even uses tall man lettering, a way of distinguishing look-alike drug names, to maximize the amount of medication errors reduced. A survey by the Institute for Safe Medication Practices (ISMP) reported that 64% of all respondents stated that the use of tall man letters had prevented them from providing the wrong medication³.  

Through software systems like MDToolbox, prescribers can even access the patient’s medication history available from pharmacies and PBMs, so even if a patient forgets to report a medication they are currently taking, the prescriber will still have a record of it.  Having a complete, current medication list is important so prescribers can check for harmful and even possibly lethal drug interactions.  Prescribers can check against the patient’s records not only for drug-drug interactions, but also drug-allergy, drug-condition, duplicate therapy, body weight, age, and correct dosing. 

It’s clear from all of these benefits, e-Prescribing is a great tool to aid providers in giving patients the safe, affordable care they need.  

1. Koroneos, George, "Hard of (Ad)hering", Pharmaceutical Executive, August 1, 2008
2. Moore, Roy, “E-Prescribing and Electronic Health Records: Impact of Technology on Prescribing for Hypertension and Diabetes”, Decision Resources, February 2013
3. Institute for Safe Medication Practices (ISMP) Survey on tall man lettering to reduce drug name confusion. ISMP Med Saf Alert! 2008;13(10):4.

As an industry leader in e-Prescribing software, it seems appropriate that our first blog post would be about why using e-Prescribing software is so important.  The team here at MDToolbox is passionate about e-Prescribing, not just because it’s a “cool” project to work on, but because it’s revolutionizing the healthcare workflow and can literally save lives.

E-prescribing, or electronic prescribing, is the method of writing and sending a prescription using an electronic device.  Instead of handwriting  a prescription on paper, the provider electronically sends the prescription to the pharmacy.  It’s as easy as sending an e-mail. While there is a plethora of reasons providers should be using e-Prescribing software, we have narrowed it down to our top 5.

5) Use Anywhere, Any Time, on Any Device 

Most e-Prescribing software is web-based, allowing providers to log in and prescribe from anywhere they have access to the internet, on any device (iPads, tablets, smartphones, etc.) and at any time.  Patients’ medication records and e-prescribing can be accessed wherever prescribers need it – at the office, hospital, home, even the golf course.   

4) Secure

Using e-Prescribing software offers a more secure way of prescribing medications.  A study in the Journal of the American Medical Informatics Association¹, found that over 20% of prescribers had experienced prescription fraud in the past 6 months before the study.  These included the prescriptions being altered by the patients, counterfeited prescriptions, and stolen prescription pads.   By prescribers directly electronically sending prescriptions to pharmacies, this prescription fraud can be eliminated. 

3) Incentives/Penalties

The Centers for Medicare & Medicaid Services (CMS) created the Electronic Prescribing (eRx) Incentive Program in 2009 to encourage prescribers to use e-Prescribing software.  At that time they were giving incentive payments to eligible prescribers; however, they are now penalizing providers who do not use e-prescribing software with payment adjustments.  In 2013, the payment adjustment is 1.5% and in 2014 it will increase to 2.0%.

Meaningful Use, another CMS program, also provides incentives to providers for using certified electronic health record systems.  There are several core requirements and menu items that a provider must meet in order to attest to Meaningful Use.  Using e-Prescribing software will help meet many of these requirements.

2) Saves Time and Money   

Using e-Prescribing software allows providers and their staff to spend more time focused on patient care, and less time looking up drugs, on the phone with pharmacies, and writing out prescriptions.

 A complete drug database is available for prescriber to search.  Many e-Prescribing vendors offer several ways to search for drugs including common libraries, drug class, indication, supplies, and more.  Complete drug reference information, as well as recommended dosages is also often available.  MDToolbox even provides dosing recommendation and a dosing calculator right at the point of prescribing, so it’s easy to calculate the correct dosages. There is no need to go searching for calculators and through drug references books, everything needed for prescribing is available in one place. 

Physicians and their staff can spend hours on the phone a day responding to requests from pharmacies to clarify prescriptions, discuss formulary issues, and authorize refills.  A study by the Medical Group Management Association (MGMA) Center for Research, reported these calls can cost a practice almost $20,000 a year ².  Using e-Prescribing software reduces these callbacks and allows refill requests to be responded to electronically, rather than over the phone.  Refill requests are all stored in one place and can be approved or denied within a matter of seconds.  The prescriptions sent are clear, in a standard format, and the prescriber has access to the patient’s formulary information right at the time of prescribing, reducing the need to discuss them with the pharmacy.

 Another way prescribers can save time is by using favorite lists.  These allow the prescriber to save a favorite prescription, including directions and amounts, to a list.  The prescriber can then use this list to quickly pick and prescribe from and send the prescriptions to the pharmacy within seconds.  

1) Improves Patient Safety

The number one priority for providers and for the MDToolbox Team is patient safety.  Writing prescriptions by hand causes a significant amount of errors.  A study by professor of medical informatics at Weill Cornell Medical College, Rainu Kaushal and colleagues ³, found 37 errors for every 100 paper prescriptions.  The study also found a remarkable 88 legibility errors per 100 prescriptions.  Providers using e-Prescribing software cut the number of errors down to 7 for every 100 prescriptions and completely eliminated legibility errors. 

Using e-Prescribing software not only does away with handwriting errors, it also provides necessary alerts at the time of prescribing.  Prescribers can access a patient’s medication history, verify their medications, and in turn, receive a warning if they pick a drug to prescribe that could cause a possible adverse reaction (or even death).  These include drug-drug, drug-allergy, drug-condition, and duplicate therapy alerts.  With today’s available technology, there is no excuse for the possible harm that could come from these preventable medication errors. Every prescriber should be using e-Prescribing software.  

1.       Thomas CP, Kim M, McDonald A, Kreiner P, Kelleher SJ Jr, Blackman MB, Kaufman PN, & Carrow GM. Prescribers' expectations and barriers to electronic prescribing of controlled substances.  J Am Med Inform Assoc 2012;19:375-381.

2.       Medical Group Management Association (MGMA) Center for Research. Analyzing the Cost of Administrative Complexity. http://www.mgma.com/about/default.aspx?id=280

3.       Kaushal R, Kern LM, Barrón Y, Quaresimo J, Abramson EL. Electronic prescribing improves medication safety in community-based office practices. J Gen Intern Med. 2010 June; 25(6): 530–536.