Optometry - Journal of the American Optometric Association
Volume 79, Issue 11 , Pages 692-701, November 2008

E-prescribing in the optometric practice

Article Outline

 

New Medicare e-prescribing regulations take effect January 1, 2009. Optometric practices should be taking steps now to ensure they are ready. The AOA Health Information Technology and Telehealth Committee offers a step-by-step plan to implement e-prescribing in an optometric practice.

Electronic pharmaceutical prescribing (e-prescribing) is rapidly becoming “mainstream practice,” a recent report by the influential eHealth Initiative notes. Long touted by health care experts in both the public and private sector as an important part of an overall effort to reduce medical errors and make the health care system more cost effective, pharmaceutical e-prescribing has been adopted as part of the government's plan to expedite the adoption of electronic medical records and build a national electronic health information infrastructure in the United States. And there is good reason. E-prescribing can hold numerous benefits for patients, health care providers, and the health care system as a whole.

E-prescribing was developed primarily in an effort to prevent adverse drug events. It was designed specifically to help prevent the type of medication errors that can occur as the result of illegible handwritten prescriptions or even miscommunication in the preparation of typed prescriptions. However, it can also help to prevent adverse drug interactions by offering access to patient medication histories and even automatic alerts to warn against potentially dangerous drug combinations. Government officials note that e-prescriptions can reduce potential for prescription fraud or tampering.

For patients, e-prescribing can offer the ability to fill and refill pharmaceutical prescriptions with greater convenience and fewer trips to the pharmacy. For health care practitioners, e-prescribing can provide practice efficiency and subsequent cost savings. It can make it faster and easier to issue prescriptions. Formularies, templates, and medical records access, included in many e-prescribing software programs today, help practitioners order the best pharmaceutical for the patient (with greater assurance the pharmaceutical will be covered under the patient's insurance plan) and make the ordering process easier. In particular, e-prescribing can make pharmaceutical prescription refill authorization—a process that often requires time-consuming telephone calls or faxes between pharmacies and practitioners and the checking of patient records—considerably easier and more efficient for both practitioner and staff. The medical history and other common e-prescribing features can also be used to help encourage proper patient compliance with care regimens.

Over the coming years, e-prescribing will become mandatory for health care providers. However, now is an ideal time for health providers—including optometrists—to implement e-prescribing in their practices. Starting January 1, 2009, Medicare will offer payment bonuses to health care providers who issue pharmaceutical prescriptions electronically and report this on their claims submissions. And that means, as the message on the American Optometric Association (AOA) Web site Health Information Technology page (www.aoa.org/HIT.xml) warns (see Figure 1), practitioners should now be asking themselves if they are ready to begin prescribing electronically. Under the recently enacted federal Medicare Improvement for Patients and Providers Act (MIPPA), Medicare will provide a 2% bonus to eligible health care providers (including optometrists) who e-prescribe in 2009 and 2010. The bonus will be reduced to 1% in 2011 and 0.5% in 2012. It will be phased out by 2013. At that point, Congress has authorized Medicare to penalize eligible doctors who do not e-prescribe with payment reductions of 1.0% in 2012, 1.5% in 2013, and 2.0% in 2014 and beyond.

Other public and private insurance plans are likely to also begin offering incentives or requirements for e-prescribing over the coming months and years. Medicaid does not now offer financial incentives for pharmaceutical e-prescribing; however, the program requires all paper pharmaceutical prescriptions to be written on tamper-proof pads, a requirement that can make e-prescribing more attractive.

Although optometrists might not realize the same savings as medical doctors, a cost calculation on the GetRxConnected Web site estimates a solo optometric practice responding to an average of just 1 pharmaceutical prescription refill reauthorization request each day, entailing 15 minutes of practitioner and staff time, could save 65 hours of time on 261 refill requests over the course of a year. That would amount to $25 per day in practitioner time ($6,525 per year) and $4 per day in staff time ($946 per year).

“All prescribers should adopt e-prescribing as it becomes mainstream practice,” the eHealth Initiative noted in its June 2008 report, Electronic Prescribing: Becoming Mainstream Practice. Optometric practices are no exception. Optometrists now play an important role in the diagnosis and treatment of eye health conditions. An optometrist will need to have e-prescribing capability to be a full-scope primary eye and vision care provider as well as to remain an important part of a patient's team of health care providers. And although the new Medicare e-prescribing program covers only pharmaceutical prescriptions, not vision correction prescriptions, electronic ordering of durable medical equipment such as eyewear under Medicare may not be far away.

“Small practices … in particular will need incentives, resources, and support, as well as high-quality, well-designed application products to begin transforming the way they prescribe and manage medications. There is a significant amount of work to be done in (such practices) including developing a better understanding of the impact that e-prescribing has on their workflow and care processes, as well as creating model practices for adoption and effective use,” the e-Health Initiative report acknowledges. The Medicare bonus program provides financial incentive for practitioners to adopt e-prescribing. The technical resources necessary for e-prescribing in an optometric practice are also available. A number of e-prescribing software systems—or electronic medical records (EMR) systems with e-prescribing capability—are already widely available. Over the last decade, at least 3 national e-prescribing networks have been developed. Earlier this year, the 2 major surviving networks merged to form the SureScripts-RxHub, providing a widely accepted national e-prescribing network with virtually all of the nation's major drug store chains accepting prescriptions through the system.

To support the implementation of e-prescribing in optometric practices, the AOA Health Information Technology and Telemedicine Committee (AOA-HITTC) has developed several new documents and a new interactive Web site feature, all of which can be accessed through a new e-prescribing section on the AOA Web site Health Information Technology page (www.aoa.org/HIT.xml). E-Prescribing: What Optometrists Need to Know, a new AOA White Paper, which will appear in the December issue of Optometry, outlines the basics of e-prescribing for optometrists. The new interactive GetRxConnected.com/Optometric Web site, developed as part of an AOA partnership with SureScripts-RxHub, provides an “Electronic Prescribing Readiness Assessment” specifically for optometric practices. The site offers 2 separate tracks: one for practices that already have e-prescribing or electronic health records (EHR) software in place to access the adequacy of existing systems and one to help practices that do not already have e-prescribing/EHR software to select a program that will meet both the needs of their practices and applicable standards. The GetRxConnected Web site also provides an overview of the benefits of e-prescribing and a state-by-state listing of pharmacies that already accept prescriptions electronically. For a more detailed look at e-prescribing, a link to the eHealth Initiative's Electronic Prescribing: Becoming Mainstream Practice report offers an in-depth history and analysis of electronic prescribing as well as step-by-step methodology for implementing e-prescribing in a health care practice. The AOA HIT Web page also provides links to the U.S. Centers for Medicare & Medicaid Services Web site, with requirements for participation in the new Medicare e-prescribing bonus program, and the SureScripts-RxHub Web site, which offers information on the e-prescribing network.

The AOA-HITTC strongly encourages optometrists to initiate e-prescribing in their practices. However, before doing so, it is important to understand what e-prescribing really means (see Box 1). Contrary to popular opinion, e-prescribing is not just the use of a computer to issue a prescription; it provides a number of capabilities beyond the simple transmission of a prescription—all of which government officials and system developers strongly encourage health care providers to utilize. The process of issuing a prescription electronically—taking advantage of all system capabilities—can be somewhat different than issuing a prescription on paper (see Box 2).

Box 1.
What is e-prescribing?

E-prescribing is the electronic generation of prescriptions through an automated data entry process utilizing e-prescribing software and a transmission network that links prescribers to participating pharmacies. It is intended to replace handwritten prescriptions, computer-printed prescriptions, and computer-faxed prescriptions. It should be emphasized that e-prescribing is not simply e-mailing prescriptions or faxing prescriptions to the pharmacist. To help ensure the privacy of patient information, e-prescriptions are transmitted through a private, secure, and closed electronic network established specifically for the purpose of e-prescribing. Prescription information is not transmitted in the form of an e-mail over the Internet. It should also be emphasized that e-prescribing does not include prescriptions that are transmitted to pharmacies in the form of computer-generated faxes. Final Medicare e-prescribing regulations published by the U.S. Centers for Medicare & Medicaid Services in the Federal Register in April 2008, allowing health care providers the ability to issue pharmaceutical prescriptions electronically, require e-prescribing systems meet National Council for Prescription Drug Programs standards. Those standards specifically prohibit the use of computer-generated fax prescriptions because such prescriptions do not facilitate use of other features that are now included in many e-prescribing systems and that can provide highly useful information to the prescriber. They include:

•Formulary and benefit transactions, which provide prescribers information about which drugs are covered under a Medicare beneficiary's prescription drug benefit plan.

•Medication history transactions, which provide prescribers with information regarding the medications a beneficiary is already taking—including those prescribed by other providers—to help reduce the number of adverse drug events.

•Fill status notifications, which allow prescribers to receive electronic notices from pharmacies indicating that prescriptions have been picked up, not picked up, or been partially filled. The feature is designed to help monitor medication adherence in patients with chronic conditions. (For additional information on these standards, log on to www.cms.hhs.gov/EPrescribing/.)

Box 2.
The e-prescribing process

The e-prescribing process overall is much more complex than simply writing a prescription and dispensing the prescribed medication for a patient. E-prescribing systems use a variety of devices and methods; among the most popular are handheld devices, tablet computers, and desktop computers. System infrastructure may be based entirely on the device, or on a server located in the local environment, or remotely through an application service provider environment. Each of these technologies brings its own benefits and challenges to the e-prescribing process.

Creation and management of electronic prescriptions in the clinician's office involve several steps. By looking at each of these steps, a health care provider can analyze many specific features, concerns, and needs that are important to the optimal design of electronic prescribing systems. This list outlines certain expectations and considerations involving several of the steps.

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Process for creating and managing prescriptions electronically 

Signing on 

A user of the system—clinician, staff, etc.—signs in by performing some sort of authentication to prove identity. Typical authentication is by username and password, although other technologies such as random-number cards (SecureID™), digital certificates, or fingerprint readers are used as well. Once authentication is complete, the system should know the user's role and type of authorization to use in the prescribing system. As described below, different types of clinicians may have different legal permissions to enter, review, or modify prescriptions.

Identifying the patient 

For the e-prescribing process to begin, the clinician needs to identify the patient within the e-prescribing system. Clear and seamless communication between patient registration data, clinical records, and the actual e-prescribing system are critical to this process. There are a number of elements that are key to successful identification of the patient:

•Ideally, patient demographic information should only need to be entered once (or not at all if provided by an electronic interface) at the clinician's office. Some of the best examples include a master patient index that links administrative and clinical systems in the clinician's office.

•Effective methods to update and transmit changes in demographic information, especially insurance and patient contact information, should be implemented. This may require query capabilities with external organizations, particularly health insurance company databases.

•Patient identification information should include information about the patient's health insurance coverage and drug benefit. For example:
-Name of insurance company or pharmaceutical benefit manager that handles the drug benefit

-Link to correct formulary for the patient

-Patient-specific benefit information


•The e-prescribing system should offer different ways to list patients. Some effective methods in current practice include locating the patients by:
-Clinician's daily schedule

-Patient's name

-Clinician's overall panel of patients


•Systems should have methods for dealing with potential mismatches or similar names. Effective methods currently include:
-Use of a Soundexa system or probabilistic matching, which does not require the system to identify an exact match on a full name

-Mapping alternative representations of patient names (or aliases) to the same person. This is useful when calls are received from patients or pharmacies and when a patient commonly goes by something other than his or her full legal name


•Patient registration information should be smoothly updated and coordinated across multiple information systems (e.g., practice management system, e-prescribing system, EHR). Note: Although this may be an implementation issue, it is important that a practice determine early on (1) who can update patient information and (2) whether the changes can be made on any information system with an update to the master patient index or whether the master patient index should be the only updated source.

•To provide for patient privacy while satisfying HIPAA privacy regulations, a patient's data should only be viewed by someone with a documented need to know that data for clinical or billing purposes. This implies that a documented relationship should have been established between the practice and/or clinician and the patient. Relationships can be created in the booking-scheduling-registration process, or they can be automatically created from other information, e.g., the existence of a prior visit or the patient's selection of the clinician as primary care provider. Where a relationship is not established in advance, the system may need to block access. In practical use, under certain circumstances, the policy may allow the user to gain access immediately by documenting the immediate need-to-know right on the screen (known as a challenge or a break-the-glass access). Where this is allowed, this access should be recorded in an audit trail and reviewed frequently for possible violations.

•Current health plan information should be available at all times, and patient-specific formulary information should be updated and accurate.

Selecting the drug, entering parameters, signing 

Many of the steps in the process map correspond to the actual work of reviewing the medical history and entering and editing a prescription. Many specific tasks fall within this process; e-prescribing systems should allow clinicians to perform a number of functions, including the following:

1.Review patients' current medication list and medication history information
•Update medication history

•Correct medication history

•Reconcile with multiple history sources


2.Work with an existing medication
•View details of a medication

•Discontinue or remove a medication

•Change dose for a medication

•Renew 1 or more medications


3.Prescribe or add new medication by:
•Choosing a medication from quick choices/favorites
-By name (generic or trade)

-By indication

-By formulary


•Displaying search results of drugs with prefilled, known, favorite, or standard dosing

•Selecting drug from the results

•Reviewing warnings

•Entering the instructions and other parameters

•Automatically populating and updating favorites list of drugs with pre-filled known dosing based on frequency of utilization by clinician


4.Complete the prescription
•Sign one item

•Sign multiple items

•Co-sign items created by ancillary staff, residents, or others


5.Output prescriptions
•Choose print, fax, or transmit options in real-time or batch mode

•Print formats and prescription information, conforming to state regulations

•Handle restrictions on certain medications (e.g., class II)


6.Other functions
•Enter/view/delete current allergies or intolerances

•Enter pre-existing medications

•Recognize limited prescribing authorization for some clinicians (e.g., midlevel clinicians in some states cannot sign class II prescriptions)

•Cosign prescriptions written by such persons

•Other “prescriptions,” e.g., durable equipment


Important functionality of electronic prescribing systems/modules 

Research and best practice experiences have suggested that electronic prescribing systems can successfully increase the efficiency of the prescription entry and/or editing process. For this to happen, the following must be done:

•Minimal key strokes or clicks should be needed to create a prescription.

•The drug dictionary (from which medications and doses are selected) should be tailored for optimal clinician use. Some databases may be too detailed or have too much information for practical use at the point of care. Applications that require specifying drugs at the National Drug Code level, for example, are likely to be difficult for most clinicians. In general, clinicians using an e-prescribing system should be able to enter drug names and prescribing information using the same level of specificity and detail that they currently utilize when handwriting a prescription.

•A Soundex or similar matching algorithm should be used to look up drugs even when spelling is incorrect.

•Common abbreviations and synonyms should be mapped to drugs to simplify typing (e.g., HCTZ for hydrochlorothiazide).

•The amount of detail that must be entered about the prescription should be similar to what is customary in the paper-prescribing world; requests for new types of data and fields that make the prescriber's work harder should be avoided.

•Formulary on/off status should be displayed during the drug selection or search process. Applications should prepopulate data fields automatically when answers are obvious (e.g., drug strength/form when only one exists).

•Complex but common dosing (such as prednisone tapers, alternate-day dosing, etc.) should be supported in an efficient, easy-to-use manner. For the major unusual doses (taper, titrate, alternate-day, variable-dose, sliding scale), special templates or on-screen forms may be needed.

•Clinical decision support warnings should advise but not force the clinician to take a particular course of action.

•Discontinuing, renewing, and modifying a medication should be simple and straightforward.

•Renewals of multiple medications can be done in a single, rapid operation.

•It must be easy to acquire the patient's current medication list, even when a patient uses multiple pharmacies or when a patient uses a variety of health plans.

•The patient must select preferred patient pharmacy with assistance from practice staff before the interaction with the prescriber.

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Summary 

The prescribing process is complex and involves many steps, including signing on to the system, identifying the patient, reviewing current patient information, writing the prescription (medication, dosage, form, instructions), signing off on the prescription, and printing or transmitting it to the pharmacy of the patient's choice. E-prescribing should support those steps and offer additional information and functionality that help make prescribing safer and more efficient while also streamlining communication with pharmacies and payers/pharmaceutical benefit managers.

(Adapted from Section II: The Prescribing Process, Electronic Prescribing: Becoming Mainstream Practice, June 2008, The eHealth Initiative and The Center for Improving Medication Management.)

aThe Soundex algorithm is a very popular phonetic matching algorithm, based on consonant sounds, that is designed to help find names that are misspelled in common ways.

The successful implementation of electronic pharmaceutical prescribing requires leadership, commitment, and a clear vision regarding how e-prescribing will be integrated into a practice, the eHealth Initiative notes. It also requires careful planning and proper selection of an e-prescribing system, a thorough understanding of the e-prescribing system's capabilities, the successful integration of the system into the practice workflow, good change management and communications, proper deployment and effective use, as well as adequate training and support.

The eHealth Initiative report includes a list of “best practices” and “lessons learned,” which were developed by the initiative on the basis of “four years of observing e-prescribing start-ups” in health care practices. Based on the eHealth Initiative report and measures recommended on the GetRxConnected Web site, the following are some suggested steps for the implementation of e-prescribing in an optometric practice.

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Implementing e-prescribing 

Essential to the successful implementation of e-prescribing in a practice is a firm understanding of what practitioners and staff can expect and what problems are likely to occur, according to the eHealth Initiative's Electronic Prescribing: Becoming Mainstream Practice report. “In the past, some early adopters of e-prescribing took a ‘try it and see’ approach. When they encountered unexpected challenges, they were quick to completely stop using the technology. In practices where a few prescribers were using e-prescribing and others were not, they often also stopped e-prescribing or used it at a persistently low level. Barriers to success include a low level of commitment to start with, poor choice in software and hardware, disappointment in functionality, lack of an interface with practice management system (so the prescriber has to enter each patient one by one), implementation of electronic new prescriptions but not electronic renewals, and inadequate training and support.”

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Vision and commitment 

There should be a clear understanding of the functionality and benefits of an e-prescribing system and a realistic vision of what the practice can accomplish through e-prescribing. A plan for implementation of e-prescribing for all practitioners and patients in the practice should be developed. Practitioners and staff should be informed of the potential benefits of the system. Practice workflow should be altered to take full advantage of e-prescribing features. Potential problems in the implementation should be discussed and addressed. If possible, optometrists should consult with fellow practitioners who have successfully implemented e-prescribing to gain understanding of the benefits and drawbacks of the various e-prescribing programs available—including their functionalities and impact on workflow—and determine the types of questions that should be asked of vendors.

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Selecting and implementing a system 

Once a practitioner determines what will be expected of an e-prescribing system, the GetRxConnected Web site offers a methodology for systematically selecting an e-prescribing software system that will meet the needs of the practice. GetRxConnected offers a “Buyer's Guide,” with a list of 20 features and factors that health care providers should check on when selecting an e-prescribing system (see Box 3). GetRxConnected also emphasizes that with Medicare's new e-prescribing program imminent, it is important to make sure any e-prescribing software meets all of the technical specifications required by the government health plan. Medicare specifically requires e-prescribing software to meet the latest National Council for Prescription Drug Programs (NCPDP) standards. Those standards require prescriptions be transmitted by prescribers and received by pharmacies in the form of electronic messages. They specifically prohibit the use of computer-generated faxes. Many of the “e-prescribing” programs now installed in optometric offices and other health care practices today actually transmit prescriptions in the form of faxes. Such faxed prescriptions do not allow pharmacists or prescribers to take advantage of the error safeguards or the time-saving efficiencies that e-prescribing is intended to provide. Computer-generated faxes are therefore not allowable under the NCPDP standards or the new Medicare e-prescribing program. Eventually, computer-generated fax prescriptions will not be allowable for any e-prescribing provider.

Box 3.
20 questions

GetRxConnected recommends optometrists look into the following 20 features or factors when assessing the readiness of their current e-prescribing system or shopping for a new one:

1.New prescription online filing capability

2.Capability to accept and authorize refill requests from pharmacy online

3.Two-way electronic communications capability with pharmacy

4.Access to patient prescription history

5.User tools to enhance practice workflow

6.Drug interaction checking

7.Formulary information

8.Special modules on lab results, charge capture, etc.

9.Complete electronic health records within the system

10.Mobile access mobile access capability

11.Desktop access capability

12.Remote access capability

13.Availability of initial training

14.Availability of ongoing support

15.Required system interfaces

16.Availability of updates

17.Hardware requirements

18.Initial and ongoing costs for software, training, interfacing

19.Special offers (discounts, etc.)

20.Compliance with National Council for Prescription Drug Programs standards and other applicable regulations.

To use the GetRxConnected Web site to find an e-prescribing system, practitioners should enter the Web site's “Guide to Selecting Technology” section. The interactive Web site feature assists in selecting e-prescribing systems that are appropriate, given the number of practitioners in the practice, the other uses of technology (online lab orders, electronic medical records) desired in the practice, the prescribing volume in the practice, and other factors. It will instantly return a list of the top 3 EMR systems and the top 3 stand-alone e-prescribing systems appropriate for the practice based on a system of certification and benchmarking. The e-prescribing programs are selected from among the more than 100 that have been certified to connect to the Pharmacy Health Information Exchange. The top 3 selections will represent the systems with the highest level of certification based on benchmarks for vendor and product performance across a number of categories including customer education, proven pharmacy interoperability, advanced medication management (including the ability to receive medication history from community pharmacies), workflow enhancements, and demonstrable expertise.

Practitioners can then download a copy of the “buyer's guide” worksheet and personally contact those 3 suggested software providers, using the worksheet to carefully compare the systems and determine which is best for the practice.

Once a system has been selected, the eHealth Initiative recommends the practice execute a formal agreement with the e-prescribing software system provider. Costs, timeframes, and milestones should be documented in planning documents that clarify functionality, implementation process, service and support expectations, purpose, and benefits. The practice should then put into action its formal plan for implementation of the e-prescribing system, allowing time for training and workflow integration. A project leader should be appointed.

Input from practitioners and staff should be considered during both the system selection and planning phases. Optometrists should also be sure to let their local pharmacies know they are preparing to begin e-prescribing and should work with the pharmacy to understand the e-prescribing process.

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System set-up and integration into the practice 

When installing the software, the practitioner (or project leader) should be certain to activate and become familiar with a number of product capabilities that can be important for successful e-prescribing:

•AutoFill to provide for minimal keystrokes when writing, renewing, or sending prescriptions

•Easy patient retrieval process

•Connection with current patient management systems to integrate patient demographics into the e-prescribing application quickly and easily

•Access to medication history information—with multiple history sources reconciled to a single view

•Ability to renew multiple prescriptions for a patient at once

•Favorite medication list feature

•Easy medication search (including trade names)

•Prefilled default fields

•Ability to provide instructions on the use of medications through templates (like sliding scales, tapers, etc.)

•Ability to order health care supplies

•Incorporation of alternative and nonprescribed medications in the medication list

•Clinical decision support warnings such as drug–drug interaction and drug–allergy alerts. Drug–lab result interaction and drug–problem checking are also desirable functions.

•Inclusion of reasons for prescribing (match to problem list or diagnosis)

•Easy signing and co-signing

•Easy pharmacy selection

•Easy and most efficient output

•Ability to receive delivery confirmation or failure notice once prescription reaches pharmacy

•Ability to handle callbacks/renewal requests (from patient or pharmacy)

When installing the software, the project leaders may find that some e-prescribing programs provide prescribers the option to fax, print, or electronically send prescriptions. On such systems, the default routing should be set for electronic transmission.

The practitioner or project leader should give considerable thought to the placement of computer hardware around the practice. The eHealth Initiative recommends practices have hardware conveniently located in examination rooms and throughout the practice to facilitate maximum use of e-prescribing and EHRs. The exact placement will depend on workflow in the practice. Some practices provide tablet computers, which the prescribers carry around with them. Others mount laptops on carts that can be wheeled around the practice. Some put a desktop in the examination room. The idea, according to the eHealth Initiative, is to keep prescribers from having to write prescriptions manually and later enter them in the e-prescribing system—a very inefficient process. Devices need to be efficient and secure (in line with federal Health Insurance Portability and Accountability Act [HIPAA] Security Regulation) while allowing rapid synchronization with other electronic systems in the office as well as communication with printers and other devices or networks.

To implement the e-prescribing system, of course, the practice must first have Internet connectivity—with a redundant Internet connection backup in place to help ensure access as required under the HIPAA Security Regulation.

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Workflow and change management 

Determining how prescribing workflow should change with e-prescribing is critical to success. Once the prescribing optometrist has written or edited a prescription, various other tasks must be performed to complete the work. Overall prescribing workflow considerations include:

•The role of the front desk and/or paraoptometrics in the prescribing process

•The role of practitioners in the prescribing process

•How to effectively incorporate frequently prescribed pharmaceuticals into the programming

•Hardware requirements

•Given roles and responsibilities of the practitioners and staff in the practice

•How to communicate patients about electronic prescribing

•How error logs are maintained and monitored

•How to monitor electronic renewal requests from the pharmacy

•How to best engage local pharmacies in mutual problem solving

The office policies on workflow should include a procedure for responding to a patient's or pharmacy's requests for renewals by phone, direct system linkages, secure e-mail, or Web-based secure messaging. When the office staff receives requests from patients for renewals, the system should make it easy to check information against the clinical record and to route this information electronically to the optometrist for review and approval. There should be an efficient method for processing and documenting pharmacy callbacks. Standard messaging conventions should be included in the e-prescribing system to facilitate communication between the pharmacy and the practice.

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Communications 

Communication is critical to the successful implementation of e-prescribing. The entire practice should be involved, with practitioners and staff regularly sharing insights on best practices and lessons learned.

The practice should contact local pharmacies to alert them that the practice will be e-prescribing. The practice should then inquire about any pertinent pharmacy policies and procedures. (How long does it generally take to fill a prescription? Are prescriptions filled in the order received?) Cooperation with local pharmacies often is essential in working out issues that arise and for improving the prescribing process. A good understanding of pharmacy polices will be important in informing patients regarding the service they can expect. “Mishandled prescriptions” often are the result of inadequate training in the pharmacy, according to the eHealth Initiative. However, practices sometimes exacerbate such problems by sending out prescriptions in batches rather than one at a time as they are written. Problems should be reported to the pharmacy, the software vendor, and the Pharmacy Health Information Exchange (SureScripts), so they can be addressed promptly, the eHealth Initiative advises.

Communicating with patients about e-prescribing is also important. Some patients may express initial reluctance to electronic prescribing. Prescribers can make patients more comfortable by explaining e-prescribing and its benefits—including faster prescription pick-up. (Pharmacies typically fill prescriptions on a first-come first-served basis. Not only does e-prescribing get the prescription to the pharmacy faster, the patient does not have to make one trip to the pharmacy to drop off the order and another to pick up the prescription.) The most critical information to relate to patients is when prescriptions will be ready, according to the eHealth Initiative. One of the most common problems associated with e-prescribing is patient dissatisfaction over having to wait for prescriptions at the pharmacy.

Practices may find it helpful to conduct an education campaign to let patients know that it handles prescriptions electronically. The eHealth Initiative report offers a guide for consumers that can serve as the basis for such an effort. Although the elimination of the need to print paper prescriptions is one of the advantages of e-prescribing, practices may initially find it helpful to provide patients with a prescription document of some kind that takes the place of the physical prescription, such as a “prescription receipt,” as a means of making patients more comfortable with e-prescriptions. This step generally can be phased out over time. Patients should be advised to call the pharmacy to request prescription renewals, because this streamlines the communication between pharmacy and practice and will reduce the time it takes for the patient to receive the renewed prescription.

Communicating between the e-prescribing software provider and the practice is important, particularly during the implementation phase. The practice should know how to get in touch with support personnel if problems arise. (A list of the most common communications-related e-prescribing problems encountered by practices appears in Box 4.)

Box 4.
Common e-prescribing problems

According to the eHealth Initiative, common communication-related problems that practices encounter when they begin to e-prescribe include:

•Patients arriving in the pharmacy and being told the prescription is not there

•Mixes of electronic and faxed prescriptions being sent by practices to pharmacies resulting in confusion for the pharmacy staff

•Mixes of electronic and faxed prescriptions renewal requests being sent to practices by pharmacies resulting in confusion for the practice staff

•Lack of adequate training and support by their technology vendors

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Training and support 

Everyone in the practice should receive appropriate training on the e-prescribing systems, according to the eHealth Initiative. The practice must work with the software vendor to ensure that prescribers and staff who will use e-prescribing understand how to prepare and send a new prescription to a pharmacy electronically and how to look for, review, and respond to prescription refill requests that are sent electronically by the pharmacy.

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Summary 

E-prescribing offers optometrists and other health care providers important opportunities to prevent medical errors and adverse reactions, facilitate smooth claims filing, and encourage proper patient compliance with care regimens. However, as with any new technology, practitioners first need to implement it, learn how to use it, and become accustomed to it. The AOA-HITTC is continuing to develop materials on e-prescribing in optometric practices. AOA members should watch the electronic and print versions of the AOA News as well as the AOA Web site for details. The eHealth Initiative's list of the top tips for successful e-prescribing (see Box 5) can provide some valuable hints. Health care providers should also be aware that the federal Drug Enforcement Administration presently prohibits the e-prescribing of controlled substances (see Box 6). For those who wish an even more detailed discussion, the eHealth Initiative offers The Guide to E-Prescribing for Physician Practices. However, it will ultimately be up to each practice to make sure practitioners, staff, and patients realized the full range of benefits e-prescribing can offer.

Box 5.
Top e-prescribing tips

The eHealth Initiative offers the following hints for effective e-prescribing implementation and use:

•A designated project leader for e-prescribing should be appointed. The project leader will be the central point of contact and reference, serving as a resource to the practice team and helping everyone become comfortable with e-prescribing. The project leader will generally become increasingly adept at using the e-prescribing system and will therefore be able to make the process run more smoothly. A practitioner (or staff person) who deals with the e-prescribing software vendor or who manages prescription renewals would generally be a good choice for the project leader. It can often be important for the project leader to regularly monitor prescription renewal requests that are received electronically in the practice. The project leader can then streamline the e-prescribing process by pulling charts as needed and recommending that prescription renewal requests be approved or denied. The optometrist, then, has only to provide the final response. (Note that these approaches may be different for small practices.)

•Integration of patient demographic information from the practice management system in advance of e-prescribing implementation is important. If the prescriber has to add each patient to the e-prescribing system one by one, the implementation of e-prescribing will be dramatically slowed, the eHealth Initiative contends.

•Each e-prescribing practice should establish a process to regularly update or correct patient information as needed when submitting prescriptions to the pharmacy.

•When a patient checks in for an appointment (or visits the practice for any reason), staff should inquire about the pharmacy the patient prefers and make sure information for that pharmacy is already programmed into the e-prescribing system.

•It is important to respond to electronic pharmaceutical prescription refill requests as quickly as possible—and always within 24 hours. Pharmacies that do not receive a response within that time frame or who have a patient waiting in the pharmacy to pick up a renewed prescription that has not yet been authorized often will send a duplicate renewal request. The eHealth Initiative emphasizes that designating a staff member to monitor refill requests can be important in avoiding such situations.

•Practices should avoid queuing or “batching” prescriptions before sending them to pharmacies electronically. Sending prescriptions to pharmacies as soon as possible after they are prepared ensures that the pharmacy has adequate time to receive the prescription before the patient arrives to pick it up. Otherwise, the practice may receive unnecessary calls from pharmacies asking where the prescription is, further delaying the patient's receipt of the medication.

•Advise patients to call their pharmacies directly to request prescription refills. This will reduce the volume of calls coming into the practice from patients and pharmacies. If prescriptions have been transmitted properly to the pharmacy electronically, renewal requests and reauthorizations can then be electronically transmitted between the practice and the pharmacy using the bidirectional electronic connectivity in the e-prescribing network, streamlining the prescription refill process.

•Use the e-prescribing system consistently to send new prescriptions electronically. Consistent and frequent use of e-prescribing is necessary to get used to e-prescribing and to realize its benefits. It can improve the efficiency of the practice by reducing the number of telephone calls and faxes required to deal with legibility, pharmacy eligibility, formulary and benefits, and refill authorization issues.

•Keep the practice's e-prescribing software vendor informed of any problems so that they can be fixed quickly and, hopefully, future issues can be addressed before they occur. Be sure that everyone in the practice who uses the e-prescribing system understands how to use the technical support services offered by the vendor.

Box 6.
DEA prohibits e-prescribing controlled substances

Optometrists and other health care providers should follow Federal Drug Enforcement Administration (DEA) regulations by refraining from electronic transmission of prescriptions for controlled substances until federal regulations are changed to allow electronic transmission, both the eHealth Initiative and the AOA Washington office emphasize. Prescriptions for Schedule II drugs can never be sent electronically. Hand-signed hard copies of prescriptions for Schedule III through V drugs can be sent using manual fax. Neither computer-generated faxes containing electronic signatures nor totally electronic prescriptions for controlled substances can be sent to pharmacies at this time. The DEA in June proposed new regulations that would allow electronic prescribing of controlled substances; however, those regulations probably will not be finalized until sometime in 2009, the AOA-HITTC notes.

“For the practice to have the optimum experience with e-prescribing, it is important that leadership is committed to realizing its benefits and working through issues rather than giving up when they hit a bump in the road; the entire practice is involved in planning and selection and chooses software and hardware solutions that have robust functionality and support the practice workflow; the practice communicates with pharmacies, patients, and the vendor about e-prescribing; an individual is assigned to manage prescription renewal and provide assistance to all users of the system to help them get comfortable; and training and support is adequate,” the eHealth Initiative reports emphasizes.

 Col. Francis L. McVeigh, II, O.D., is the chair of the AOA Health Information Technology and Telemedicine Committee. Opinions expressed are those of the author and are not necessarily those of the American Optometric Association.

PII: S1529-1839(08)00516-2

doi:10.1016/j.optm.2008.09.005

Optometry - Journal of the American Optometric Association
Volume 79, Issue 11 , Pages 692-701, November 2008

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