Texas Department of Public Safety Guidelines for EPCS

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The recent rescheduling of hydrocodone combination products and the requirement to use special approved prescription paper for Schedule II drugs in Texas, has caused many prescribers to turn to e-Prescribing as an alternative. As prescribers look to this electronic alternative, there are several questions that come up as the Texas Department of Public Safety (Texas DPS) has given out some state specific guidelines. Here’s what prescribers need to know:

Is e-Sending Schedule II drugs allowed in Texas?

In October of 2013 the Texas DPS accepted the same requirements, with a few updates of their own, as the DEA in regards to sending Schedule II controlled substances electronically. 1

What are the Texas State Guidelines?

In order to comply with the Texas DPS guidelines, there are several things prescribers must be aware of and know before they start using an EPCS program. Prescribers must make sure that their vendor is certified by the DEA, meaning that they passed the required third party audit. Prescribers will also want to be sure that the vendor has EPCS capability activated for their state. Prescribers must also make sure that all their necessary credentials are included when e-Sending a prescription.

DPS, DEA and APN Numbers

The numbers prescribers now put down for paper prescriptions, their DPS, DEA and APN numbers for advanced practice nurses must also be on their electronic prescriptions as well. When prescribers are setting up their e-prescribing account they want to make sure that this information can be entered in the appropriate fields.

APNs will also enter their prescriptive authority identification number for all prescriptions written.  APNs and physicians assistants with prescriptive authority should also keep in mind they must include the DEA and DPS number of their supervising practitioner on all prescriptions schedules III-V.2

Control Numbers

Paper prescriptions written in the state of Texas for schedule II drugs require that each prescription be printed on DPS required paper that has a unique Control Number listed for the pharmacy to record. With e-prescribing all control number information, locating, and documenting is now handled entirely on the pharmacies end electronically.

What Does This Mean Now?

Texas DPS completed their beta testing of EPCS March 1, 2014. The purpose of which was to monitor Schedule II prescriptions for abuse, prescribing patterns, patients attempting to get prescriptions from multiple doctors, and fraudulent prescriptions. Also, to make sure all reporting on both the provider’s end and the pharmacy’s end was done accurately and in a timely manner.

After the results of the testing came back, the outcome was clear. Provider’s information was safer, as their DPS and DEA numbers were no longer floating around on written prescriptions for people to try to forge prescriptions with. The DPS information is also now easier and faster to track with everything being electronic. Patients’ information was also safer and relayed faster as there was no longer the constant need to rely on a phone or fax for patient information that may or may not have made it to the desired party on the other end.

Electronically prescribing controlled substances has proven to not only be a viable alternative to paper prescriptions in Texas, but an improvement. To get more information on EPCS or to start sending controlled substance electronically contact us at info@mdtoolbox.com or visit our EPCS page.

  1. https://www.pharmacy.texas.gov/EPCS.asp
  2. http://www.dps.texas.gov/RSD/ControlledSubstances/News/index.htm.

Top 5 Mistakes in Writing Quality E-Prescriptions

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Electronic prescribing (e-Prescribing) has been praised for increasing patient safety by providing clearer prescriptions and reducing medication errors.  Pharmacists no longer have to worry about interpreting the prescriber’s handwriting.  However, it has been found that even with e-Prescribing, more than 10% of prescriptions still contain an error1.  These errors can be highly dangerous, or even deadly.  Here we list out our top 5 mistakes found in electronic prescriptions (e-prescriptions) and solutions to prevent them.

    1.  Wrong Drug Name or Strength

One of the most dangerous medication errors is prescribing the wrong drug or strength.  E-Prescribing prevents errors that occur from illegible writing, but incorrect medication errors can still occur.  In many e-Prescribing systems, the prescriber selects the drug to prescribe from a lookup.  It is easy to see how a rushed prescriber could make a mis-click and pick the wrong drug or strength.  Additionally, several drugs have similar names.  If prescribers are not careful, they can easily confuse them with each other.  Of all medication errors, the FDA reports that about 10% come from drug name confusion2.  Several drugs have different strengths and some have different dosage routes as well.  For example, Ofloxacin is available in both a 0.3% opthamalic solution and a 0.3% otic solution.  Choosing the wrong route could have serious effects.  Selecting the wrong drug, strength, or route could even be fatal.  This is why it is critical that prescribers double check these fields when selecting a drug to e-prescribe. 

A good way to prevent picking the wrong drug name is to use e-Prescribing software that includes tall man lettering to help in selecting look-alike drug names.  These drug names include both lower and upper case letters in order to draw attention to the differences in their names.  For example, two similarly named insulins are listed as NovoLOG and NovoLIN to differentiate between them.

2.  Unclear Directions

The most important part of a prescription for the patient is the directions.  If the patient does not understand how to take/use the prescription, they will not get the intended results and it could be potentially harmful.  A common mistake in e-prescriptions is to write directions that include abbreviations, are incomplete, or that say something generic like “Take as directed.”

The directions must be written out fully in terms that the patient will understand.  They should not include any abbreviations or anything that the pharmacist would need to interpret or rewrite.   While pharmacists may understand the abbreviations, the reality is the busy pharmacist (or rather pharmacist assistant) will quickly re-write it or a computer program will re-write it for them and the translation is many times incorrect.   These mistakes can be fatal.  For example, the FDA reported a patient died when 20 units of insulin was abbreviated as "20 U," and the "U" was mistaken for a "zero"3.  The patient received an incorrect dose of 200 units as a result.

Prescribers must also not assume the patient will remember the directions they gave them orally – Including the full directions in the electronic message to the pharmacist gives the patient written clear directions they can check if they cannot remember what the prescriber told them.  Directions should always include when, how often, and how to take the medication

It is also important to make sure any numbers written in the directions are safely written.  Decimal points can be easily missed.  For example, 1.0 could be quickly read as 10 or .1 could be read as 1.  Prescribers should never include a decimal point and a trailing zero (X.0mg) but should always include a leading zero before a decimal point (0.Xmg).  It is recommended to try to avoid the use of zeroes by using alternative units of measure – for example use “50 micrograms” instead of “0.05 milligrams.” 

3.  Including Directions in the Wrong Place

Another common mistake in e-prescriptions is including direction information in a note or comment field.  The note field is a helpful field that allows prescribers to add additional free text information that is not part of the prescription.  However, this field should never be used for drug name, directions, the number of days, or any important information.  Many prescribers feel the need to include direction information in the note field because their e-Prescribing software does not allow them to enter custom directions.  It is quite challenging to prescribe medications that require tapering or titrations if the prescriber can only enter pre-structured directions.  The problem is most of the pharmacy software does not show the note information on the main dispensing screen and this makes it easy for the pharmacist to miss it.  This can then cause the pharmacist to include incorrect or incomplete directions.  Prescribers sometimes include conflicting direction information in the pharmacy note box as well.  For example a conflict might look like:

Directions:   3 times a day

Free Text Note:  1 GTT Q4 OD – patient has a coupon 

If the pharmacist fills based on directions, they have no idea how much the patient should take three times a day.  If the pharmacist happens to check the free text note field, they now know how much but have conflicting “how often”.  This causes the pharmacist to have to contact the prescriber for clarification and slows down the entire process of e-Prescribing.  This is why it is critical for prescribers to include the full directions in the directions box and only use the pharmacy note field for additional information.  A proper prescription might look like:

Directions:   1 drop in the right ear every  4 hours daily

Free Text Note:  Patient has a coupon

Using e-Prescribing software that allows prescribers to easily free text any custom directions needed, as well as customize their sig and direction lookups, is a great solution for preventing information being placed in the wrong field.  Using these solutions, as opposed to solutions where prescribers can only select pre-structured directions or have to complete complicated extra steps to have detailed directions, is an ideal way to avoid this information from being unseen or conflicting. 

4.  Incorrect Dosage

Another highly dangerous medication error is prescribing the wrong dosage.  It is easy for a prescriber to make a mistake when converting units of measurement or calculating a dose.  These mistakes can result in doses 10 or 100 times the intended amount.  For example, an infant recently died after receiving an overdose of morphine when a 3.5mg dose was given rather than what should have been a 0.35mg dose.  There have been many other cases where these kinds of mistakes have led to fatalities as well.  This is why it is important for prescribers to check and double check the dose they are prescribing. 

A great solution for prescribers is to use an e-Prescribing system that includes dosing references and a dosing calculator at the point of prescribing.   These calculators help prevent calculation errors and give warnings if the calculated doses are too high.  These are especially useful for pediatrics per weight based dosing.  In some systems, like MDToolbox, it will even convert mg per kg to mL automatically if needed for prescribers.  

5.  Wrong Quantity

Prescribers also make the mistake of including a quantity for either the number of days the prescription is for or the amount to be dispensed that is wrong in e-prescriptions.  Prescribing more or less of a medication than intended can have serious effects.   This is why it is important for prescribers to double check the dispense amount and the number of days it should last.  It is important that these amounts do not contradict each other or the directions, otherwise the pharmacist will not know which is the correct amount.

An example of a contradicting prescription:    

Directions:  Take 1 Tablet Daily for 5 days by Mouth

Days Supply:   5

Dispense #:  20

How many should the pharmacist dispense?   Does the patient need to take 20 pills over the next five days?   Or, do they only need to take one daily for five days and thus, only five tablets should be dispensed?  A patient could have serious adverse effects if they take the wrong amount of a prescription.  To ensure safe prescribing, a quality prescription should look like:

Directions:  Take 1 Tablet Daily by Mouth

Days Supply:   5

Dispense #:  5

To further prevent quantity errors, prescribers can use software (like MDToolbox) that helps them with auto calculating these amounts based on the directions and either the selected number of days or dispense number.

In addition to avoiding these mistakes, there are further steps prescribers should take to prevent medication errors.  They should always take the time to double check the complete prescription information before hitting e-Send.  Taking this small extra step can help catch a lot of unnecessary errors.  Prescribers should also make sure that the patient is clear about which prescription they are prescribing for them and the proper way to take/use it.  This way the patient can double check they are receiving the right prescription from the pharmacy and be able to use it as intended.  Prescribers should also use e-Prescribing software that allows them to print patient leaflets, as well as a medication summary that lists the prescriptions to give to the patient.  Medication summaries are a good way to remind the patient which medications were prescribed, how often to take them and which pharmacy they were e-Sent to. 

E-Prescribing continues to improve prescription safety.   We can take patient safety to the next level and minimize medication errors even further with a combination of prescribers following a few simple guidelines, double checking their prescriptions and using patient safety focused e-Prescribing software.   

If you have comments or suggestions for our blog or would like to learn more about MDToolbox’s e-Prescribing solutions we would love to hear from you!  Please leave a comment below, use our contact form or email us any time at info@mdtoolbox.com

 

  1. Nanji KC, et al "Errors associated with outpatient computerized prescribing systems" J Am Med Inform Assoc 2011; DOI:10.1136/amiajnl-2011-000205.
  2. Rados C. “Drug name confusion: preventing medication errors.” FDA Consumer Magazine. 2005;39. www.fda.gov/fdac.
  3. "Strategies to Reduce Medication Errors: Working to Improve Medication Safety." U.S. Food and Drug Administration, 12 Apr. 2013. Web. 09 Jan. 2014.

e-Prescribing Software: Top 5 Benefits for EHRs/EMRs

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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 

e-Prescribing Software: Top 5 Benefits for Patients

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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.

 

 

 

e-Prescribing Software: Top 5 Benefits for Providers

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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.