Arnold Z' Balanoff, MD, FAAP

1

Centers for Medicare Medicaid Services
CMS Electronic Prescribing Incentive Program

• Arnold Z. Balanoff, MD, FAAP
• Robert L. Epps, MPA
• Region VII, CMS

2
What is E-Prescribing

• Computer-based electronic generation transmission
  and filling of a prescription
• New prescriptions and refills
• Takes place of paper or faxed prescriptions
• Stand-alone system vs. EHR with integrated
  e-prescribing module

3
Why E-Prescribing?

• Lower administrative costs
• Reduces verbal miscommunications
• Solves problem of hard-to-read prescriptions
• Reduces duplicate prescriptions
• Reduces drug-drug interactions
• Reduces confusion at transitions of care

4
Why E-Prescribing?

• Provides warnings and alert systems
• Provides access to patients medication history
  and allergies
• Reduces time on pharmacy phone calls and faxing
• Automation of renewals and authorizations
• Improves formulary adherence

5
Why E-Prescribing?

• 98,000 die from medical errors annually
• More than breast cancer, AIDS, or motor vehicle
  accidents
• 1.5 million preventable adverse drug events
  annually
• Hospitals, long-term care, outpatient encounters
• 530,000 among Medicare beneficiaries
• 877 million per year for Medicare beneficiaries
• Source Institute of Medicine 1999, 2000, 2003,
  2006

6
Barriers to Adoption

• Surveys consistently show adoption remains
  limited
• Financial cost and ROI
• Workflow
• Controlled substances
• Standards

7
Return on Investment for Practices

• MGMA (2004) estimated time spent managing
  administrative complexity related to
  prescriptions
• Valued at 15,700 per year per full time
  physician
• Manually processing refills, resolving patients
  formulary and coverage issues, and issues related
  to dosage and legibility
• Did not take measure time spent managing faxes
• Average time spent managing refills cut in half
  after eRx implemented (Brown University 2006)
• From 35 to 17 minutes a day for prescriber
• From 87 to 43 minutes a day for staff

8
E-Prescribing Incentives Reductions
9
E-Prescribing Measure

• Must have qualified e-prescribing system to
  report this measure
• The measure is intended to be reported for EVERY
  patient visit meeting the denominator criteria
• Successful reporting is defined as reporting on
  at least 50 of applicable cases
• Denominator codes for EM services billed in
  office or outpatient setting
• 90801, 90802, 90804, 90805, 90806, 90807, 90808,
  90809, 92002, 92004, 92012, 92014, 96150, 96151,
  96152, 99201, 99202, 99203, 99204, 99205, 99211,
  99212, 99213, 99214, 99215, 99241, 99242, 99243,
  99244, 99245, G0101, G0108, G0109
• psych visits, certain eye visits, consultations,
  pelvic exam, DM education
• does not include the ED, nursing home, home
  visits
• Part B charges for the denominator codes must
  make up at least 10 of total Part B charges

10
E-Prescribing Measure

• Reporting options (G-codes)
• All prescriptions created during the encounter
  were generated using a qualified e-prescribing
  system (G8443)
• E-prescribing system available, but no
  prescriptions were generated during the
  encounter. Provider does have access to a
  qualified e-prescribing system. (G8445)
• E-prescribing system available, but not used for
  one or more prescriptions due to patient/system
  reasons (G8446)
• required by state/federal law or regulations
• patient request
• qualified system temporarily inoperable
• pharmacy unable to receive electronic
  transmission

11
Qualified Systems

• Must be capable of ALL of the following
• Generating a complete active medication list
  incorporating electronic data received from
  pharmacies and pharmacy benefit managers if
  available
• Selecting medications, printing prescriptions,
  electronically transmitting prescriptions, and
  conducting all alerts
• Providing information related to lower cost,
  therapeutically appropriate alternatives (if
  any).
• Providing information on formulary or tiered
  formulary medications, patient eligibility, and
  authorization requirements received
  electronically from the patients drug plan (if
  available)

12
Selection of a System

• Strategic
• Stand-alone system (2,000 - 3,000) vs
  integrated into EHR (30,000 50,000)
• Locally installed vs web-based
• Desktop vs mobile (PDA/tablet)
• Functionality /Features
• Fully qualified system to obtain incentive
  payment
• User interface
• Interface with PMS (avoid double entry)
• Performance
• Scale
• Non-essential enhanced feature set
• links to external DSS tools
• create favorites med list
• create print patient information leaflets

13
Selection of a System

• Vendor services
• Training
• Ongoing support
• Cost
• Hardware, software
• System installation and maintenance
• Initial data extraction / upload from PMS
• Updates
• Free or almost free?

14
Stark Safe Harbor E-Prescribing Rules

• Stark exception and anti-kickback safe harbor
• permits hospitals to provide eRx technology to
  physicians
• Covers hardware, software, internet connectivity,
  training/support services to transmit and
  receive electronic prescription drug information
• Applies to hospitals, practices, Medicare
  Prescription Drug Plans and Medicare Advantage
  Plans
• No specific cap on value
• Restrictions on certain anti-competitive actions

15
How Do You Know a System is Qualified?

• Functionalities for a fully qualified system
• Compliance with Part D Standards
• NCPDP SCRIPT 8.1
• EHR vs. Stand-alone Systems
• EHR systems with built-in eRx are qualified if
  2008 CCHIT Certification
• CCHIT expects to review stand-alone systems for
  certification in 2009
• National Council for Prescription Drug
  Programs
• Certification Commission for Healthcare
  Information Technology

16
How Do You Know a System is Qualified?

• As part of SureScripts-RxHubs vetting process,
  all vendors who are listed on the SureScripts
  website http//www.surescripts.com/get-connected
  .aspx?ptypephysician meet the 2009 Part D
  standards for the functions they provide.
• If an eRx system is not on the SureScripts
  network, a potential customer should look at the
  Part D standards on the CMS website and check
  with the products vendor.

17
Other e-Prescribing Initiatives

• Medicaid
• CMS has provided gt 100 million in Transformation
  Grants to states
• many state Medicaid initiatives
• eRx integrated into MITA
• Multi-stakeholder collaboratives

18
Looking forward.

• MIPPA allows CMS to use ether Part D data or PQRI
  measure to determine if prescriber qualifies for
  incentive payments
• Part D Plans must submit a Prescription Drug
  Event (PDE) record to CMS for every adjudicated
  Part D claim
• Data infrastructure not ready for 2009

19
Resources

• CMS Website
• http//www.cms.hhs.gov/eprescribing/
• http//www.cms.hhs.gov/PQRI/
• Download reports, rules and policies
• Clinicians Guide to Electronic Prescribing
• http//ehealthinitiative.org/eRx/clinicians.mspx
• National E-prescribing Conference CME
• http//www.massmed.org
• ACP, AAFP, HIMSS websites
• Healthcare Information and Management Systems
  Society

20
Thank You

• Arnold Z. Balanoff, MD,
• Robert L. Epps, MPA
• Region VII, CMS