This post was authored by James Fasules, MD, FACC, Senior Vice President of Advocacy.

E-prescribing has been shown to improve safety and convenience for patients and clinicians, while also saving clinicians and pharmacists time and money. In an effort to encourage e-prescribing use, the Centers for Medicare and Medicaid Services in 2009 launched the E-Prescribing Incentive Program. As part of the program, providers that met the program criteria are able to earn an incentive payment on top of their Medicare Part B earnings.

Three years later, the program is still moving forward. Providers who e-prescribe 25 times between Jan. 1 and Dec. 31, 2012 will receive a one percent bonus – a definite incentive in this time of declining reimbursement. (Other restrictions apply and can be found here.) The newest addition, however, is that all eligible providers not participating in the program are subject to gradually increasing penalties. While it’s too late to avoid the 2012 penalty, there is still time to avoid the 1.5 percent penalty for 2013 … although the June 30 deadline is fast approaching.

According to CMS, individual eligible professionals and group practices can avoid the penalty by meeting the following six-month reporting requirements between now and the end of June:

• Individual eligible professionals: 10 e-prescribing events via claims
• Small e-prescribing group using the group practice reporting option (GPRO): 625 e-prescribing events via claims
• Large e-prescribing group using the GPRO: 2,500 e-prescribing events via claims

More information is also available here.

In addition, individual eligible professionals and group practices can also avoid the penalty by filing for a significant hardship exemption. Hardships exemptions are available to providers who are unable to electronically prescribe due to local, state, or federal law or regulation; have or will prescribe fewer than 100 prescriptions during a six-month reporting period (Jan. 1 – June 30); practice in a rural area without sufficient high-speed Internet access; or practice in an area without sufficient available pharmacies for e-prescribing. Hardship exemptions must be submitted through the Quality Reporting Communication Support Page no later than June 30. These requests are granted on a case-by-case basis and all decisions are final. Given the issues experienced last year by providers trying to request exemptions via the website, CMS has developed two documents outlining how to navigate the support page (Quality Reporting Communication Support Page User Guide and Tips for Using the Quality Reporting Communication Support Page). The College urges members not to wait until the deadline to file for an exemption!

For more information on health IT visit CardioSource.org/HealthIT.

Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule on e-Prescribing last week. The final rule establishes the requirements for successful reporting of the e-prescribing measure, while also finalizing additional hardship exemptions for avoiding the 2012 e-prescribing penalty that begins on Jan. 1, 2012.

The ACC, along with the AMA and others, have had significant concerns regarding the implementation of the 2012 penalty and have urged CMS to reconsider the details and timing and to thoroughly consider the effects of this position on specialists such as cardiologists. Although the final rule does not extend the reporting time, it makes it easier for physicians to be eligible for hardship exemptions and addresses many of the concerns the ACC raised.

Under the rule, final hardship exemption categories for eligible physicians are as follows:

• Practitioners who have registered to participate in the Medicare or Medicaid EHR Incentive Program and have adopted certified EHR technology.
• Practitioners who are unable to e-prescribe due to local, state or federal law or regulation. (This proposed exemption is designed to address practitioners who primarily prescribe controlled substances.)
• Practitioners who infrequently prescribe. (For 2012, this means a practitioner must not have had the opportunity to e-prescribe at least 10 times between January and the end of June 2011.)
• Practitioners who provide services that are not included in the e-prescribing measures (e.g. does not provide office visits).
• Practitioners with practices located in rural areas without high-speed Internet access.
• Practitioners with a practice located in an area without sufficient available pharmacies for e-prescribing. (This includes natural disaster-caused disruptions.)
  

This post is written by Denise Milestone, RN, of Parkview Health in Fort Wayne, Ind.

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In the last two years that e-prescribing has been used in my health system, Parkview Health in Fort Wayne, Ind., we’ve seen some major benefits, as well as overcome some challenges. The implementation process at Parkview was fairly straightforward. We started with a small group of physicians and nurses who were required to e-prescribe, and then we slowly added more practitioners to this group. We put out statistics on who was e-prescribing and how much and shared that with staff, so that physicians and nurses could see how they were doing compared to their peers. This did a lot to encourage adoption. Our staff seemed to pick it up most easily if they were younger and more computer savvy, but it was pretty simple for everyone to adopt. I would say it took about a month or two for everyone to get the hang of it.

I see the top three benefits of e-prescribing at Parkview as the following:

#3: E-prescribing cuts down on Parkview’s faxes and phone calls, both for the original prescription and for e-refills. We save on a lot of paper.

#2: Younger patients love it. It’s very convenient for them and they like not having to keep track of the prescription paper. But, it does seem like older patients miss having paper prescriptions and aren’t as comfortable with the idea of e-prescribing. We really have to educate not only the physicians and Parkview staff, but also the patients on the benefits of e-prescribing.

#1: Patient safety has improved. Not only is legibility addressed, but pharmacies are able to see in the system what drugs a patient is being prescribed and can make sure there aren’t any adverse events.

This is not to say e-prescribing is without challenges. In particular, we’ve had trouble adjusting prescriptions that start at one dose (like prescribing a patient a 20mg tablet twice/day) but then after a set period of time increase (like to a 40mg tablet once/day). Previously we have noted this clearly in the prescription area. Now, we have to add a comment in the notes section with instructions for the pharmacist, which occasionally causes confusion.

Also, because not all pharmacies are able to accept e-prescribing, there still some manual work that has to happen. Fortunately, our e-prescribing system knows which pharmacies cannot accept e-prescribing and will then revert to the old-fashioned way of faxing the prescription. This has definitely improved over the two years we’ve been e-prescribing -- more pharmacies than ever accept e-prescribing -- but there are still some that do not. It gets easier each year to e-prescribe.

Overall, the e-prescribing process was very easy to implement and its benefits have outweighed the minimal downsides we’ve experienced. We’re extremely happy e-prescribing, and so are our patients.

Has anyone else experienced the challenge with noting the dosages? How have you addressed?

But most likely you still won’t be, even though the Centers for Medicare and Medicaid Services (CMS) last week released a proposal that would add new hardship exemptions to the program. The proposal would exempt some practitioners from the 2012 Medicare penalty that will be levied against those who are not e-prescribing by June 30. The proposal would create new categories for hardship exemptions, making the total list of exemptions as follows:

• Individual practices in rural areas without high speed internet access
• Individual practices in areas without sufficient available pharmacies for electronic prescribing
• Practitioners who have registered to participate in the Medicare or Medicaid EHR Incentive Program and have adopted certified EHR technology
• Practitioners who are unable to electronically prescribe due to local, state, or federal law or regulation. (This proposed exemption is designed to address practitioners who prescribe controlled substances.)
• Practitioners who infrequently prescribe. (For 2012, this means a practitioner must not have had the opportunity to e-prescribe at least 10 times between January and the end of June 2011 in order to qualify for the exemption.)
• Practitioners who have had insufficient opportunities to report the e-prescribing measure due to program limitations

Under the proposal, practitioners would have until Oct. 1 to claim a hardship exemption. This new proposal comes after months of pressure from the ACC, AMA and other physician organizations. The College will be commenting on the proposal, particularly on the provisions of the e-prescribing program the new proposal does not address, such as the June 30 deadline and the narrowness of the proposed infrequent prescriber exemption.

In sum, while this is good news for some providers who qualify under the new hardship exemptions, most are still going to need to demonstrate that they are e-prescribing by June 30 to miss getting a 1% penalty in their Medicare payments.

More detailed information is posted at CardioSource.org/healthIT.

As part of ACC’s ongoing series on e-prescribing, ACC staff interviewed South Denver Cardiology CEO Brenda Lambert, RN, AACC, and Amy Hurley, RN, Director of Clinical Services at South Denver, about their experiences with e-prescribing and how it has affected their practice. The deadline to demonstrate successful e-prescribing under the Medicare E-Prescribing Incentive Program is June 30, 2011. Health care providers who cannot demonstrate successful e-prescribing by June 30 will have their 2012 Medicare payments penalized by 1 percent.

1.      What does e-prescribing mean to you? What are some of the benefits you’ve seen?

Lambert: We embraced e-prescribing as soon as we could with our electronic medical record (EMR) system. It’s been up for a year and was quite easy to do. So for us it was an easy implementation.

Some important things it’s meant to us: We always had a difficult time when patient called in for a prescription to make sure they had been seen in our office in the past year. We now know when their last visit was and if we can go ahead and e-prescribe or need to have them make an appointment.  If a patient or pharmacy contacts us we know if they’ve been seen all in the matter of less than a minute. We’ve increased efficiency and maximized patient care.

It has also help with legibility – I’ve personally experienced poor signatures or poor writing and the pharmacy would have to call back and double check what the prescription says. With e-prescribing it does improve patient safety as well.

We’d like to see a bidirectional piece added where we can see if the patient hasn’t picked up the prescription yet so we can do some follow-up, but that’s not in place at this time.

Hurley: It is also very convenient for the patient; if they’re in the office their prescriptions are ready for them at the pharmacy by the time they get there. Also, there’s a large database in our e-prescribing system that allows us to have access to all of the pharmacies in our area, so if the patient doesn’t know the information, we have it.

2.      Are there any downsides? What challenges have you had to overcome to implement e-prescribing?

Lambert:  More on our EMR side, there are times when meds aren’t used as much as others and you have to tweak dosages but it’s just a matter of identifying that and having it changed. Just like any system there are things that have to be improved.

We have had some problems for in-person pharmacy pick-up in terms of liability for payment. For example, if we e-prescribe to Walgreens and the patient decides between here and there they don’t want the medication, then that’s the end of it – they haven’t paid anything.

With mail in, once we click that button, the patient is liable for paying for the meds and can’t return it. Because of e-prescribing we’ve had multiple problems with patients saying they don’t want to take the medication anymore and wondering who will pay for what was delivered. We tell them they do.

3.      Are there any stories or reasons why e-prescribing has worked for you and your practice?

Lambert: There are many comments from patients saying how nice it is that they don’t have to wait at the pharmacy when they get there: once they arrive, the prescription is there and it’s correct. It’s been a huge patient-pleaser. It’s funny how you get used to it – I went to the doctor and he didn’t e-prescribe and I was surprised. I thought our physicians would resist, but it went as smooth as silk. Our physicians took to it immediately.  

Hurley: It’s a lot more efficient and more organized and cuts down on paper. We all know patients who lose a piece of paper no matter what it is – this is a slick, efficient way of doing things.

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Resources are available at cardiosource.org/HealthIT to help ACC members learn more about e-prescribing.  

Thirty-four percent of all office-based prescribers were using e-prescribing by the end of 2010. Cardiologists had the highest adoption rates (49%) followed by family physicians (47%). Providers created 326 million e-prescriptions in 2010, up from 190 million in 2009. Wow!

If 49% of cardiologists ARE e-prescribing, that means that 51% still AREN’T e-prescribing. Since we’re just a month and a half away from providers being penalized for not e-prescribing, this is not good. If you aren’t e-prescribing by June 30, your Medicare professional fee reimbursements will be cut by 1% in 2012. This requirement applies to ALL health providers participating in Medicare who are eligible for billing numbers: physicians, nurse practitioners, physician assistants, etc.

There’s still time to get an e-prescribing system set up and complete the requisite number of e-prescriptions before the deadline. Check out http://www.cardiosource.org/healthIT for more resources on how to get started. Also, check out the other posts on this blog about e-prescribing. This deadline is real and quickly approaching. If you don’t want to take the 1% cut in pay, you’ll need to get started now.

By David May, MD, PhD, FACC, senior physician and founder of Cardiovascular Specialists, PA, in Coppell, Texas, president of the Texas Chapter of the ACC and a member of the Board of Governors’ Steering Committee.

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Like a Sergio Leone western, e-prescribing (e-Rx) has been viewed by many as a dark and foreboding landscape in which physicians must have a broad, sweeping view of the electronic health care vista alternating with intimate, close-up reflections on each patient encounter. In reality, e-Rx accomplishes neither of these things perfectly. It is, however, here to stay.

The concept of e-Rx is quite simple.  The ability to submit an accurate, understandable, legible prescription without typographical mistakes from the point of care to the pharmacy is a vitally important part of any safe health care system.  Because of how important it is, the development and facilitation of the e-Rx process is one of the key elements in the overall plan for the further advancement of the electronic health infrastructure for the U.S.

Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 provides the guidelines for the incentive program we now define as the e-Prescribing Incentive Program. It was implemented in 2009 as a stand-alone program in addition to the Physician Quality Reporting System (PQRS). Providers who wished to participate in the e-Rx program could but did not have to participate in the PQRS incentive program.

Two years post-implementation, where does the program stand? Let’s review the good, the bad and the ugly.

The Good
The electronic submission of a prescription from the point of care to the pharmacy reduces errors by providing accurate, dose-correct prescriptions without illegible handwriting in a timely fashion. It benefits providers and pharmacies by allowing 24-hour submission and its asynchronous communication eliminates the “phone tag” delay associated with telephone submission and the twisted, often illegible faxed-in prescription. For patients, medicines are available in a timely and expeditious fashion with accurate tracking available. In my private practice, we’ve seen fewer mistakes in prescriptions, faster turnaround time in the pharmacy, and incentive payments in 2009 and 2010 of 2% of our Medicare Part B professional reimbursement through the e-Prescribing Program.

The Bad
The implementation of e-Rx submission requires providers to alter their normal work flow and develop additional skills. In addition, the enhancing and maintaining staff training is mandatory. For example, in my practice, the nurses are responsible for making sure the prescriptions make it to the right pharmacy for the patient. We had to devote a lot of resources to training to make sure this happens for every prescription. With a little creativity though, we were able to make this a more enjoyable experience by implementing the training as a game.

In addition, e-Rx requires great attention to detail, in that if your Internet access is not reliable, electronic submission can be problematic. Due diligence is necessary to be certain that submission has “gone through” successfully, and this is a departure from handing a patient a prescription and being done with it.

The Ugly
Like the PQRS incentive program, e-Rx incentive “carrot” is rapidly changing to an incentive “stick.” The 2012 payment adjustment reporting period is Jan. 1 to June 30, 2011. Practices that have not submitted 10 e-Rx submissions per provider by June 30, 2011, will be penalized 1% of their Medicare professional fee reimbursement for 2012. In addition, registry submission of the e-Rx information is not allowed for this time frame. The e-Rx information must be submitted by claim with the appropriate G code and evaluation and management code.

The E-Prescribing Program may not be perfect, but unlike a Sergio Leone western, it’s a reality. In order to avoid a one percent (1%) decrease in the covered professional Medicare reimbursement for 2012, you must be e-prescribing before June 30 of this year. See www.cardiosource.org/HealthIT for more resources to get started.

Did you know experts estimate that there are at least 1.5 million adverse drug events per year in the U.S.? Or that at least one-quarter of medication errors are believed to be preventable? Or that on average, hospital patients are subject to at least one medication error per day? Or that, at their most conservative estimates, experts projected 530,000 preventable adverse drug events among outpatient Medicare patients alone in 2003, excluding direct patient contact? These statistics from the 2006 Institute of Medicine (IOM) report, entitled, Preventing Medication Errors: Quality Chasm Series, highlight the grave need to reduce preventable medication errors and adverse drug events.

We’ve known medication errors to be a problem since at least the publication of the IOM report five years ago. In fact, some of the data cited in the IOM report are from studies published as early as 1995. So why are we still struggling to adopt proven methods of reducing these preventable harms?

One of these proven methods that reduces medication errors is e-prescribing. Congress has attempted to incentivize practitioners to adopt e-prescribing as part of the Medicare Improvements for Patients and Providers Act of 2008. For those who used e-prescribing systems to generate and transmit electronic prescriptions in 2009 and 2010, there was a 2 percent bonus for Medicare providers. Not a lot of money to be sure, but enough to more than justify the expense of an e-prescribing system. The bonus begins to phase out in 2011, so those who e-prescribe in 2011 will receive a 1 percent incentive payment. Less money than before, but still more than enough to cover the cost of an e-prescribing system.

So if 1 and 2 percent bonus payments aren’t enough to incentivize clinicians, what will be? How about an upcoming 1 percent Medicare penalty in 2012 for those who do not e-prescribe. Yes, if you are not e-prescribing in 2012, your Medicare payments for an entire year will be docked 1 percent. It’s fairly simple to qualify: clinicians must generate and transmit at least 10 e-prescriptions at the time of an office visit. However, the kicker is you must do this before June 30, 2011. June 30th is very, very soon, so it’s important you get started right away if you don’t want to be subject to the Medicare penalty.

For those of you who do not yet have an e-prescribing system in your office, I encourage you to visit www.cardiosource.org/healthit for recommendations on what to look for in an e-prescribing system and other resources available to ACC members. For those of you who do have an e-prescribing system in your office but are unfamiliar with the Medicare E-Prescribing Incentive Program, you will also find resources on www.cardiosource.org/healthit. Also, I encourage you to check back here on the ACC in Touch blog for the next 5 weeks to hear more about e-prescribing from the perspectives of our colleagues practicing in a variety of settings.

The ACC wants to hear from you about e-prescribing! Are you participating in the program? If so, what do you think of it?