Top 5 Benefits of Direct Messaging

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Last week we covered the basics of what Direct messaging is in the healthcare field.  This week we focus on some of the biggest benefits of using Direct messaging. 

1.     Improves Care Coordination

By eliminating the need for outdated communication methods, such as faxing and mailing, and enabling electronic health information exchange with Direct messaging, communication is greatly improved between health care providers. Protected Health Information (PHI) is not only easier to send and receive electronically, but faster.  Instead of waiting for a fax or even worse, snail mail, Direct messaging allows for sending and receiving information almost instantaneously, increasing the efficiency and effectiveness of care coordination. 

2.     Secure

Faxes and envelopes could fall into the wrong hands.  Direct messaging increases the security of sending PHI information by encrypting messages and files and ensuring they are only accessible by the intended recipient.   

3.     Increases Workflow

When a patient’s information is sent by mail or fax, it still needs to be manually entered into the provider’s EHR.  By sending the information electronically, Direct messaging eliminates the need for this data entry and reduces the administrative workload.  Providers can spend more time with their patients, and less time on paper charts. 

Some Direct messaging systems, like MDToolbox-Direct, can also be integrated right into an EHR's workflow.  This increases the workflow even further by allowing providers to send and receive Direct messages in their EHR without having to log into a separate system, as well as incorporate any received information into the patient’s chart right at the time of receiving it. 

4.     Saves Money

In addition to the time saved with Direct messaging, providers can also save money by not having to pay for faxing or postage.  Furthermore, with the improved communication between providers that Direct messaging provides, duplicate procedures and tests can be avoided. 

5.     Reduces Errors

Direct messaging ensures clear and more complete information reaches the correct locations. Illegibility issues due to faxing or handwriting are eliminated by sending the information electronically and providers can be confident the information they send and receive is accurate.

Another huge benefit (and a main factor in the growth of Direct messaging) that we left off this list is that using Direct messaging meets Meaningful Use Stage 2 requirements.  We want to feature this benefit and so in our next Direct messaging blog series post, we delve into this topic in great detail.  Here’s a look at what other topics we have in our series:

5 Part Direct Messaging Blog Series: 

  1. Direct Messaging 101
  2. Top 5 Benefits of Direct Messaging (this article)
  3. Direct Messaging and Meaningful Use Stage 2 – Transition of Care
  4. How does Direct Messaging work – Details on how PHI stays secure
  5. Direct Messaging and Data Exchange:  What types of files and data can EHRs exchange?

Direct Messaging 101

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At MDToolbox, we focus on providing easy-to-integrate Meaningful Use tools.  We recently expanded our product offerings to include MDToolbox-Direct, a Direct Messaging Module that meets Meaningful Use Stage 2 criteria.  With our flagship product, MDToolbox-Rx, we focus on sending and receiving e-Prescribing messages between providers and pharmacies.  We are excited now to be able to facilitate a different type of messaging - Direct messaging.  So, what exactly is Direct messaging?

What is Direct Messaging?

Direct Messaging is a secure way for healthcare providers and organizations to send clinical messages and exchange Protected Health Information (PHI).  Providers and organizations can send secure electronic messages to each other, including attachments such as Continuity of Care Documents (CCD) files, Referral Documents, images such as X-rays, and other types of medical files.  This eliminates the need for using less secure methods that can put patient data at risk such as faxing, e-mailing, phoning, or standard mail. 

How is Direct Messaging different than email?

Direct messaging sounds very similar to regular email, and generally speaking, it is.  Providers and organizations have a Direct address (just like an email address) that they send and receive messages to/from.  However, there are some very important differences.  Direct messaging requires all users to have a designated Direct address that can send and receive authenticated, encrypted messages.   All messages and attachments sent must meet certain encryption standards that allow only the intended recipient(s) to decrypt and read the messages and attachments.  These standards were developed by the Office of the National Coordinator for Health Information Technology (ONC) as part of the Direct Project.

What is the Direct Project?

The Direct Project is an open government initiative that was started in 2010.  The purpose of the Direct Project is to create a set of technical standards, protocols, and services for secure, point-to-point electronic healthcare messaging.  The ultimate goal is to create advanced levels of interoperability by having all healthcare systems use the same Direct standards and protocols. This will make it is easy for healthcare providers and organizations to directly exchange information, no matter what software system they are using.  For further information on the Direct Project and the specific technical requirements, check out http://directproject.org/ 

How do I get Direct Messaging?

Organizations called Health Information Services Providers (HISP) provide the Direct addresses to providers and organizations and facilitate the encrypted messaging.  So instead of an email provider like Google or Outlook handling the message exchange, a HISP is responsible for securely routing and encrypting/decrypting the messages.  MDToolbox has partnered with Surescripts, a trusted industry leader, to provide HISP services and our MDToolbox-Direct module can be utilized stand alone for providers and organizations or easily integrated with EHRs and other Health IT systems. To find out more contact us at info@mdtoolbox.com or use our contact page

 Stay tuned for more posts in our 5 Part Direct Messaging Blog Series:

  1. Direct Messaging 101 (this article)
  2. Top 5 Benefits of Direct Messaging
  3. Direct Messaging and Meaningful Use Stage 2 – Transition of Care
  4. How does Direct Messaging work – Details on how PHI stays secure
  5. Direct Messaging and Data Exchange:  What types of files and data can EHRs exchange?

Meaningful Use Stage 2 Status

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Meaningful Use Stage 2 started at the beginning of the year and it has been off to a slow start. A report from CMS last month showed that only 50 eligible professionals (EPs) had attested to Stage 21.  While the latest numbers given have increased to 447 EPs that have attested to Stage 2, this is still a relatively small number.2  Such low numbers point towards a lack of certified products. 

A review of the ONC HIT’s Certified Health IT Product List shows that there were over 3,500 products certified for Ambulatory Stage 1 and only a little over 700 are certified for Ambulatory Stage 2.  It is also interesting to note that out of 988 developers who certified products for Stage 1 (many had several different products, even hundreds), there are only 312 vendors with Stage 2 products.  Of those vendors with Stage 2 products, only 140 have complete EHRs that meet all of the criteria for attesting to Stage 2.  

 

Only a fraction of products, complete EHRs, vendors, and complete EHR vendors have certified for Meaningful Use Stage 2 compared to those that certified for Stage 1 as of June 13, 2014

 

CMS has proposed a potential delay in the requirement of all providers to use a 2014 Stage 2 certified product this year.3  If the pending rule passes, then providers will have one more year to use their stage 1 product.  This would also give EHRs extra time to get their product certified for the harder Stage 2 criteria.  The proposed rule is only for 2014, EPs would be required to use 2014 Edition CEHRT for the EHR reporting periods in 2015.  The rule is open for comments until July 21. 

If the rule passes this gives EHRs more time to meet the new criteria of stage 2 and get their product certified.   If it doesn’t pass, providers wanting to attest this year that do not have a Stage 2 certified product may be out of luck.  In order to attest to Stage 2 this year, physicians must report for 90 days.  As it is now, those attesting to Stage 1 for the first time need to report for 90 days before October 1st, 2014 in order to avoid the 1% Medicare penalty next year.  This means they would need to start by July 1st, only a little over a week away and before the proposed rule could be finalized. 

As a vendor who recently achieved ONC HIT 2014 Edition Modular EHR certification for our e-Prescribing product, MDToolbox-Rx, we understand how challenging meeting the Stage 2 requirements can be.  Because of this, we hope that the pending CMS rule is approved to give other vendors and providers the extra time they need to meet the criteria. 

MDToolbox offers meaningful use tools to help vendors quickly and easily meet some of the most challenging criteria.  EHRs who integrate our meaningful use certified e-Prescribing module can cross 9 criteria off their list and inherit our certification number towards their Complete EHR.   MDToolbox has also added a new MU2 Direct Messaging Module, MDToolbox-Direct, to our product line.  The Direct messaging module allows sending secure clinical messages via the Surescripts network that meet Meaningful Use Transition of Care and View, Download, Transmit criteria.   Contact us today to find out more about how we can help you get Stage 2 certified.

 

 

  1.  http://www.healthit.gov/FACAS/sites/faca/files/HITPC_CMS_Update_2014-05-06.pdf
  2.  http://www.healthit.gov/facas/sites/faca/files/HITPC_CMSUpdate_2014-06-10.pptx
  3. CMS rule to help providers make use of Certified EHR Technology http://www.cms.gov/newsroom/mediareleasedatabase/press-releases/2014-press-releases-items/2014-05-20.html

Top 8 Acronyms You Need to Know for Meaningful Use

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Previously we covered important Meaningful Use Terms you need to know.  But, as it seems to be with any topic, there are several acronyms you need to know to understand Meaningful Use and the requirements as well.  To help you get started, here are our top 8:

 

ONC - Office of the National Coordinator for Health Information Technology

The ONC is the department within the U.S. Department of Health and Human Services that is in charge of Meaningful Use and promoting EHR use. 

 

NIST - National Institute for Standards and Technology

NIST is the agency within the U.S. Commerce Department that is in charge of creating the Meaningful Use test methods that EHRs use to certify on.  The agency creates standards for several other areas as well, including the Security Controls and ID Proofing needed for Electronic Prescribing of Controlled Substances (EPCS).

 

HITECH Act - Health Information Technology for Economic and Clinical Health Act

The HITECH act was signed into law in 2009 and is the act stipulating incentive payments be paid for Meaningful Use to eligible providers.

 

EP - Eligible Provider

EPs are healthcare providers that are eligible to attest to Meaningful Use.  The Medicare and Medicaid programs have different types of EPs:

Eligible Medicare EPs include:

  • Doctors of Medicine or Osteopathy
  • Doctors of Dental Surgery or Dental Medicine
  • Doctors of Podiatric Medicine
  • Doctors of Optometry
  • Chiropractors

Eligible Medicaid EPs include:

  • Physicians
  • Nurse Practitioners
  • Certified Nurse - Midwife
  • Dentists
  • Physicians Assistants who practice in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) that is led by a Physician Assistant

 

CDS - Clinical Decision Support

CDS can be a number of different tools in an EHR that offer healthcare providers patient-specific information to aid in their clinical decisions and is one of the requirements for attesting to Meaningful Use.  A good example of CDS is showing a drug-drug or drug-allergy alert when a provider selects a drug that could have an interaction for the patient.

 

CPOE - Computerized Physician Order Entry

CPOE is the process of electronically entering medical orders, instead of on paper charts, and is also a requirement for attesting to Meaningful Use.  A prime example is electronically entering a prescription, instead of writing it out by hand on a prescription pad. 

 

HIE - Health Information Exchange

HIE is the electronic exchange of health information.  It allows health care providers and patients to access and share a patient’s health records electronically.  One of the main goals of Meaningful Use Stage 2 is to increase HIE between providers in order to increase care coordination and patient outcomes.

 

C-CDA – Consolidated-Clinical Document Architecture

The C-CDA format is a specific format standard that allows EHRs to exchange patient data with each other.  

Top 4 Terms for Meeting Meaningful Use

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In our last post, we covered why Meaningful Use is so big in 2014.  When talking about Meaningful Use, there are a lot of terms and requirements that are thrown around and it can get quite confusing.  This week we delve a little deeper into some of the main terms and requirements for meeting Meaningful Use.

1.       Attestation

Meaningful use attestation is the process of demonstrating that an individual or organization is meeting the requirements in order to qualify for the federal government payments.  They must prove (attest to) that they are meaningfully using a certified EHR.  Providers are required to register and attest using the Centers for Medicare & Medicaid Services (CMS) website.  As we mentioned last week, there are three different stages to Meaningful Use and providers must attest annually to whichever stage they are on.  There are three sets of requirements providers must attest to at each stage:  core objectives, menu objectives, and clinical quality measures.

2.       Core Objectives

Each stage of Meaningful Use has its own set of Core Objectives that a provider must meet and attest to.  All Core Objectives are required and have a specific measurement for each objective that must be achieved.  For Stage 1 there are 15 Core Objectives and for Stage 2 there are 17 Core Objectives.  As providers move on to the next stage, the measures get higher and/or include more requirements. 

Here’s an example:

            Core Objective:   Generate and transmit permissible prescriptions electronically (eRx)

Stage 1 Measure:  More than 40% of all permissible prescriptions written by the EP (Eligible Provider) are transmitted electronically

Stage 2 Measure: More than 50% of all permissible prescriptions, or all prescriptions, written by the EP are queried for a drug formulary and transmitted electronically using CEHRT.

3.       Menu Objectives

In addition to the Core Objectives, providers also have to meet and attest to a set of Menu Objectives.  Not all Menu Objectives are required, and providers are allowed to choose a certain number from the set.  In Stage 1, providers must attest to 5 out of 10 Menu Objectives, with at least 1 public health objective selected.  In Stage 2, providers must attest to 3 out of 6 Menu Objectives. 

Here’s an example:

            Stage 1 Menu Objective: Medication reconciliation

Measure:  The EP performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP.

Stage 2 Menu Objective: Record electronic notes in patient records.

Measure: Enter at least one electronic progress note created, edited and signed by an EP for more than 30 percent of unique patients with at least one office visit during the EHR reporting period.

 4.       Clinical Quality Measures

Lastly, providers must attest to a set of Clinical Quality Measures (CQMs).   CQMs look at how well a provider delivers appropriate clinical services to their patients, or the quality of care.  They assess everything from treatments to experiences to outcomes.  As stated on the CMS website, “CQMs help identify areas that require improvement in care delivery, identify differences in care among various populations, and may improve care coordination between health care providers.” 

As of 2014, all providers have to report on the same CQMs regardless of what stage they are on.  There are 64 CQMs categorized into six National Quality Strategy domains which include: (1) Patient and Family Engagement (2) Patient Safety (3) Care Coordination (4) Population/Public Health (5) Efficient Use of Healthcare Resources and (6) Clinical Process/Effectiveness.  Providers must report on 9 of the 64 CQMs and they must cover at least three of the National Quality Strategy domains.  Providers are only allowed to attest to CQMs that their EHR vendor has certified on, so some providers might have a lot less than 64 to pick from. 

Here’s an example:

Clinical Quality Measure: Documentation of Current Medications in the Medical Record

Measure Description: Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability

Domain: Patient Safety

 

Source:

www.cms.gov

Meaningful Use in 2014 – What’s All the Fuss About?

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“Meaningful Use” is one of the biggest healthcare buzz terms in 2014, so what’s all the fuss about? Our next series of blog posts is dedicated to answering this, and other questions, about Meaningful Use.

Meaningful Use - The Basics

Meaningful Use was established by the Centers for Medicare & Medicaid Services (CMS) in 2011 as an incentive payment program to encourage the appropriate use of electronic health records (EHR).  The goal of the program is to improve patient care by “meaningfully using” EHRs to meet the following five priorities:

    1. Improving quality, safety, efficiency, and reducing health disparities
    2. Engaging patients and families in their health
    3. Improving care coordination
    4. Improving population and public health
    5. Ensuring adequate privacy and security protection for personal health information

 

Meaningful Use Stages

CMS has established certain objectives that healthcare providers must meet in order to receive incentive payments (and avoid penalties).  There are 3 stages to the program, with increasing requirements for participating:

  • Stage 1

Providers begin by meeting Stage 1 requirements for a 90 day period within the first year.  Then, depending on the year they started, they must demonstrate 3 months or a year of Meaningful Use in their second year.

The focus of Stage 1 is data capture and sharing, with five main areas:

  1. Electronically capturing health information in a standardized format
  2. Using that information to track key clinical conditions
  3. Communicating that information for care coordination processes
  4. Initiating the reporting of clinical quality measures and public health information
  5. Using information to engage patients and their families in their care
  • Stage 2

Once a provider has achieved Meaningful Use under the Stage 1 criteria, they move on to Stage 2 for two years.

The focus of Stage 2 is advanced clinical processes, with four main areas:

  1. More rigorous health information exchange (HIE)
  2. Increased requirements for e-prescribing and incorporating lab results
  3. Electronic transmission of patient care summaries across multiple settings
  4. More patient-controlled data
  • Stage 3

The focus of Stage 3 is improved outcomes, with five main areas:

  1. Improving quality, safety, and efficiency, leading to improved health outcomes
  2. Decision support for national high-priority conditions
  3. Patient access to self-management tools
  4. Access to comprehensive patient data through patient-centered HIE
  5. Improving population health

 

Why is 2014 Such a Big Year for Meaningful Use?  

  • Stage 2 Began

2014 is the first year that Stage 2 criteria have been effective and any providers who began Stage 1 in 2011 or 2012 are now required to begin Stage 2. 

  • Last Year to Start Earning Incentives

2014 is the last year that a provider can start participating and earn any EHR incentives.  If a provider starts participating in 2014, they can still earn up to $24,000 in incentives.  In addition, providers must successfully demonstrate meaningful use by October 1, 2014 to avoid a 1% Medicare penalty in 2015.  In 2016, the penalty increases to 2% and then increases again to 3% in 2017.   

  • 2014 Certified EHR Technology Required

In 2014, all providers are required to attest to meaningful use using only 2014 Certified EHR Technology, regardless of what stage they are on.  Because of this, all providers are only required to demonstrate meaningful use for a 3-month EHR reporting period.  This is to allow providers sufficient time to upgrade their systems to the necessary technology. 

This also means that all EHRs being used for Meaningful Use have to be recertified using the 2014 criteria by July 1, 2014 in order to allow providers to attest by the October 1st deadline.

 

Sources:

www.cms.gov

www.healthit.gov

EPCS Status Update

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With only three states left to approve EPCS and a few others working on their final requirements, EPCS is gaining great traction in 2014.  As more and more pharmacies come online every day, MDToolbox is excited to be at the forefront of helping HIT vendors and physicians take the next step – and send ALL prescriptions electronically.     

What states are we still watching? 

And then there were 3 - Arkansas, Montana, and Rhode Island

Arkansas, Montana, and Rhode Island are the three states where EPCS still remains unavailable as their state governments sort out the differences in the State Laws versus the DEA rulings.  Arkansas made progress by passing Act 1331 in April of 2013 to clarify that electronic prescribing of controlled substances is permitted.  Furthermore, the Arkansas State Board of Pharmacy had a public hearing scheduled to discuss the changes in February 2014, but it was postponed until March due to poor weather conditions.  Rhode Island also passed a similar bill, SB 647, in June of 2013 which states, “A practitioner may sign and transmit electronic prescriptions for controlled substances.”  However, further clarification is still needed from all three states before EPCS is allowed.  Stay tuned as we will post any updates as soon as we get them!   

Oregon

While Oregon is listed as allowing Schedule II-V substances to be sent electronically on the Surescripts map, Schedule II substances can actually only be legally e-Prescribed in emergency situations.    A bill was introduced on February 3, 2014, that if approved would allow all controlled substances including Schedule II drugs to be electronically sent in non-emergency situations as well.

New York

All eyes are on New York as they are leading the way by being the first state to mandate that all prescriptions be sent electronically.  It was almost a year ago that EPCS became legal in the state of New York.  As of March 27, 2013, amendments to Title 10 NYCRR Part 80 Rules and Regulations on Controlled Substances went into effect, technically allowing providers in New York to electronically prescribe Schedule II-V drugs1.  However, the actual implementation of EPCS has been slower than expected as the state of New York was overdue finalizing its registration process.  Pharmacies and providers are still currently struggling to meet all the requirements. 

It was not until January 23, 2014 that Surescripts was able to turn on EPCS functionality for the State of New York.  Currently, out of 5,579 registered New York pharmacies there are only about 850 listed as being able to receive electronic controlled substance prescriptions on the Surescripts network.  As we mentioned in our post about the Evolution of EPCS, pharmacy software must go through a DEA Certification or third-party audit to verify they comply with the strict regulations put in place by the DEA and through a Surescripts certification.  In addition, pharmacies in New York are also required to submit dispensing data for controlled substances using the American Society for Automation in Pharmacy (ASAP) format Version 4.2 or greater2

It is not only the pharmacies in New York that have to go through extra steps to use EPCS, the prescribers do as well.  The New York State Department of Health, Bureau of Narcotic Enforcement (BNE) recently released registration packets that are required for each prescriber who would like to transmit electronic prescriptions for controlled substances.  All prescribers must register their electronic prescribing software and be able to provide proof of a DEA certification or third party audit verifying the software meets the federal security requirements for transmitting controlled substance prescriptions electronically.  The DEA requires that all prescribers go through strict identity proofing and receive two-factor authentication credentials for EPCS.  Prescribers must attest that they have personally met these federal requirements when registering with the BNE as well. 

With the New York I-STOP Law mandating that ALL prescriptions be electronically sent by March 27, 2015 with limited exceptions, providers only have a little over a year to register and begin using EPCS certified software.

MDToolbox is prepared and ready to help any providers meet this fast approaching deadline.   We are currently offering free EPCS software tokens for a year to any providers that sign up.  Check out our EPCS page and contact us at info@mdtoolbox.com for more information. 

 

  1. https://www.health.ny.gov/regulations/recently_adopted/docs/2013-02-13_electronic_prescribing_dispensing_and_recordkeeping_of_controlled_substances.pdf
  2. https://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

 

The Evolution of EPCS

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Electronic prescribing of controlled substances (EPCS) is just starting to gain ground.  The Drug Enforcement Agency (DEA) rule allowing prescribers to electronically write prescriptions for controlled substances actually went into effect over three years ago.  However, its adoption has been slow. 

The need to be able to send controlled substances electronically is definitely there.  Approximately 11% of all prescriptions written are for controlled substances and 90% of prescribers write prescriptions for such drugs1.  If these prescriptions can’t be sent electronically, prescribers must handwrite or print them.  This can be a big interruption and slowdown in a prescriber’s workflow.  In addition, EPCS increases safety and decreases fraud.  So why is it taking so long for EPCS to become a norm? 

The DEA’s Interim Final Rule (IFR) first approved electronic sending and receiving of controlled substances in March 2010, and it went into effect on June 1, 2010.  Though in order to actually use EPCS, prescribers, e-Prescribing software, and pharmacy software must meet strict regulations.  Prescribers are required to go through stringent identity proofing and receive two-factor authentication credentials.  Each time they send a controlled substance, prescribers must use their two-factor authentication.  The two-factor has to be two of the following three items:

1) Something only the prescriber KNOWS, like a password or an answer to a challenge question

2) Something the prescriber IS, biometric data such as a fingerprint or 

3) Something the prescriber HAS like a device or token separate from the computer he is prescribing on.   

E-Prescribing software and pharmacy software must go through a DEA Certification or third-party audit to verify they comply with the regulations.  The IFR requires e-Prescribing software to have a two-factor authentication protocol, have access controls so only prescribers with the proper permissions can send controlled substance prescriptions, and put extra security and auditing measures in place.  Pharmacy software is also required to have access controls and stricter security measures, as well as additional features to be able to receive electronic controlled substance prescription orders.

In addition to the Federal DEA requirements, each state has their own laws and regulations concerning EPCS.  While 47 states have approved EPCS, there is still a small percentage of pharmacies in each of these states that are able to receive electronic prescriptions for controlled substances. 

It is clear that meeting all of these requirements can be challenging and takes ample time and money for all involved.  This has caused the progression to be quite slow.  Here’s how it looks on a year-by-year basis:

2010: DEA IFR goes into effect and states begin aligning their rules with those of the DEA.

2011: Software vendors working to meet requirements.

2012: First e-Prescribing and pharmacy software vendors certified.  Surescripts® reports a “modest number of EPCSs” transmitted in eight states as of May 2012.   

2013: About 14,000 pharmacy stores signed up for EPCS in 44 states, but only about 1,000 prescribers nationwide using EPCS as of Mid-2013.

2014: About 20,000 pharmacy stores signed up for EPCS in 47 states.  However, only 14 e-Prescribing systems certified for EPCS out of over 600 prescribing applications on the Surescripts® network. 2

 

Out of almost 70,000 total pharmacies and more than half a million e-Prescribing prescribers, the numbers of those using EPCS are still small.  However, that’s changing as EPCS growth takes off.

As one of the 14 certified Prescriber EPCS systems, MDToolbox is at the forefront of the EPCS movement.  We see now as the time that EPCS is going to take off.  MDToolbox is offering both standalone EPCS for prescribers and EPCS plug-in modules for EHRs looking for a quick and inexpensive way to get on-board with the movement.  With laws like New York’s I-STOP mandating ALL prescriptions be sent by March 27, 2015, we believe EPCS will see huge growth in 2014. 

What do you think?  We would love to hear from you and get your feedback, comments and questions. Leave a comment below or feel free to contact us at info@mdtoolbox.com.     

 

  1. Rannazzisi JT. A Prescription for Waste: Controlled Substance Abuse in Medicaid. Drug Enforcement Administration (DEA). September 30, 2009. www.justice.gov/dea/pr/speeches-testimony/2012-2009/ct093009.pdf. Accessed January 27,2014.
  2. Surescripts - http://www.surescripts.com/medication-network-services/e-prescribing-of-controlled-substances/regulatory-status-map

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.

Alerts No Longer Alerting

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One of the biggest draws of e-Prescribing is increasing safety by providing alerts for adverse reactions.  E-Prescribing systems can show warnings to prescribers for drug-drug, drug-allergy, drug-condition, and many other potential interactions.  However, these alerts actually become a problem if they are shown too often.  Prescribers start to have what is known as Alert Fatigue and completely ignore some or all of these warnings.  If messages are constantly popping up, a prescriber is likely to pay less attention to them and simply override them to continue with their workflow.  Studies have even shown as much as 95 percent of drug interaction alerts and 77 percent of drug allergy alerts are disregarded by doctors. 

This would not be such a huge issue if prescribers were only overriding low priority alerts.  However, they are overriding high priority alerts as well.  The problem comes from too many low priority and irrelevant alerts being shown.  Imagine a doctor first receiving a low priority alert, then an alert irrelevant to the patient, then another lower priority alert, and so on.  Doctors become so overwhelmed with alerts that they simply override all of them without taking notice of what they are, including those with the potential to prevent serious harm to patients.  A recent study published in the Journal of the American Medical Informatics Association looked at the appropriateness of overridden alerts.  Appropriate was defined as having the potential to prevent serious harm.  The study found that 53% of all overridden alerts were appropriate1

 

Reducing Alert Fatigue

It seems like a simple concept: To reduce alert fatigue, the number of alerts needs to be minimized. With so much alert information available, the challenge comes from deciding which alerts should be shown and which are less important.  E-Prescribing vendors are also faced with solving how to display the important alerts in a manner that doesn’t diminish work-flow. 

Drug-drug and drug-allergy interaction checking is a criterion in both Meaningful Use Stage 1 and Stage 2.  The 2014 Meaningful Use HIT Certification Program, approved by the Office of the National Coordinator for Health Information Technology (ONC), defines that drug-drug and drug-allergy alerts must both be automatically shown at the point of prescribing.  The drug-drug alerts shown must also be adjustable by severity level2.   

This means that certified products should, at a minimum, be including the ability to minimalize minor drug-drug interaction alerts.   This, however, does not cover severity level per drug-condition or drug-allergy alerts.  A minor intolerance allergy alert should be treated different than a major interaction that can cause serious harm or even death. 

The ONC has also created a list of the most critical drug-drug interactions (separate from the Meaningful Use program).  It has recommended that this list of 15 interactions be included in all prescribing systems and always generate an alert that cannot be turned off.  Some have suggested that these alerts should also require more to override them then the standard alerts, such as a required written reason.  It was also suggested that including these 15 alerts be a criterion for Meaningful Use of drug-drug interaction alerting.  However, this list is said to only be responsible for less than 1 percent of drug interaction alerts in some systems.  What about the rest of the alerts? 

 

Taking it a step further - Eliminating Alert Fatigue

In order to maximize patient safety and prescriber workflow, e-Prescribing systems need to go above and beyond the Meaningful Use Criteria.  There are 3 main points that need to be addressed to work towards the ultimate goal of eliminating alert fatigue:

 

      1. Selecting the Important Alerts

The importance of alert types varies from specialty to specialty and even from doctor to doctor.  This is why it is important for e-Prescribing vendors to have the ability to allow each prescriber to set their own customizable alert levels.  Each prescriber should be able to select for each alert type (not just drug-drug) whether they want to see all of the available alerts, only the highest alerts, or somewhere in between in order to maximize the effectiveness of the alerts. 

 

       2.  Displaying Alerts Without Causing “Fatigue”  

It is important to categorize all alerts by their severity level and display this information in a clear and easy to understand format.  If a prescriber has selected to see all alerts, it is still significant for them to know which are the highest alerts.  Color-coding alerts so that for example, red is the highest, is a good way to make each alert level clear to the user.  Alert fatigue can also be reduced by including all alerts for a given prescribing event together.  Instead of having several individual alerts popup one after another, all alerts should be displayed in one window with the highest level alert displayed at the top.   Review, overriding, or re-evaluation should never involve more than one or two clicks to continue with prescribing workflow.

 

3.  Creating Smarter Alerts 

A lot of e-Prescribing systems categorize each alert by level of risk per one drug interacting with another drug, but what about interaction concerns per age, weight, or condition that increase the risk?  At MDToolbox, we have taken it a step further and allow prescribers to create decision support interventions at the point of prescribing that can take into account other factors (like age, weight) when determining alert display.  We also include optional dosing references, alerts and calculators to further aid in “smart alerts”. 

 

Instead of being viewed as a hindrance in the prescribing workflow, alerts should be viewed as an important safety aid.  We hope that by reducing alert fatigue, the true effectiveness of prescribing medications with an alert system will be realized. 

 

 

  1. Nanji KC, Slight SP, Seger DL, et al. Overrides of medication-related clinical decision support alerts in outpatientsJ Am Med Inform Assoc Published Online First: 28 October 2013. doi:10.1136/amiajnl-2013-001813
  2. Office of the National Coordinator for Health Information Technology (ONC) - Test Procedure for §170.314 (a)(2) Drug-drug, drug-allergy interaction checks:   14  December, 2012.  http://www.healthit.gov/sites/default/files/170.314a2drug_interaction_checks_2014_tp_approvedv1.2.pdf