Medicolegal Issues

e-Prescription for Success?


CMS has taken up the e-prescribing torch. In July, the agency announced a preliminary program to promote widespread adoption of electronic prescribing.

E-prescribing is a natural goal for CMS; it has been proven to improve quality of care, reduce medication errors, increase efficiency, and lower administrative costs. Kerry Weems, the acting CMS administrator, says an all-electronic prescribing system could save Medicare as much as $156 million over five years—largely through improved quality care.

Though details on the e-prescribing plan are not yet decided, CMS has revealed that beginning in 2009 (and for the next four years) it will provide incentive payments to physicians who are “successful electronic prescribers.”

Policy Points

Arizona Proactive in e-Prescribing

Arizona has already started plans to increase the use of e-prescribing. Gov. Janet Napolitano issued an order directing state agencies to work with the Arizona Health-e Connection initiative, health plans, and providers to increase the use of electronic prescribing and other medication safety tools.

Providers: Curb Bad Behavior

The Joint Commission is warning healthcare professionals that rude language and hostile behavior pose threats to patient safety and quality of care. This issue is targeted in a new standard effective Jan. 1, 2009, which requires hospitals to establish a code of conduct that defines acceptable and inappropriate behavior, as well as a process for dealing with disruptive behavior. The standard applies to all hospital personnel.

In the Joint Commission’s field review of the standard, 57% of respondents at hospitals said they’d seen disruptive behavior, but only by certain individuals. An additional 25% said such behavior occurred in more than one or two individuals.

Find Out Your PQRI Feedback

CMS has made the 2007 PQRI Final Feedback Reports available on a secure Web site. Practices must register for access to their reports through a new CMS security system called the Individuals Authorized Access to CMS Computer Services–Provider Community (IACS-PC). Note: If you are an individual physician and have no staff who will use the system on your behalf, CMS advises you to wait until further notice to register in IACS.

Reports will include information on reporting rates, clinical performance, and incentives earned by individual professionals, with summary information on reporting success and incentives earned at the practice (Tax Identification Number) level.

Information on how to register for IACS-PC is available online at and General information can be found at—JJ

Details to Be Determined

The e-prescribing plan will be included in the Physician Quality Reporting Initiative (PQRI), with guidelines included in the 2009 PQRI. (How the new plan will work with the current PQRI e-prescribing measure is one of the unknown details.)

Weems says CMS will use its standard rule-making process to shape the e-prescribing plan. Therefore, details of the incentives program will not be available until this fall, when Medicare releases its final rule on the 2009 physician fee schedule. According to Weems, the 2009 fee schedule and PQRI will clarify some murkiness. “They will be specific about what constitutes e-prescribing, including the extent and reporting of what needs to be done through PQRI,” he says.

Rewards, Then Possible Punishments

Physicians can start reporting on e-prescribing Jan. 1, and those who do will reap the benefits. Patrick Conway, MD, MSc, a hospitalist, an assistant professor at Cincinnati Children’s Hospital Medical Center, and a 2007-2008 White House Fellow working in the Department of Health and Human Services (HHS), says initial discussions about promoting e-prescribing included talk of an incentive-based plan.

“It’s my opinion that, for physicians, it’s beneficial to start with a reward or carrot rather than a punishment,” he says. “And generally, CMS has approached physician programs with this method—like the PQRI.”

The current plan’s outlines indicates that in 2009 and 2010, physicians who successfully report on e-prescribing will receive an incentive payment of up to 2% of their total Medicare allowed charges, matching the maximum bonus they can earn under the regular PQRI. Payment will be additive, so a physician can earn up to 4% (2% for PQRI and 2% for e-prescribing.)

The e-prescribing incentive will drop to 1% in 2011 and 2012, and to 0.5% incentive payment in 2013. After 2013, the carrot is replaced with a stick, and those who do not use e-prescribing will suffer a reduction in payment.

Cost Concerns

CMS estimates the cost of adopting e-prescribing will be approximately $3,000 per individual prescriber. This includes equipment, training, and program maintenance. That can add up to a sizeable expense—particularly for small groups. For that reason, the agency promises a built-in hardship exemption for small practices and others who prove they cannot afford to adopt e-prescribing.

Also, some funding is available: Dr. Conway says CMS has a financial-incentive program for electronic health records, many of which include e-prescribing. “The CMS Electronic Health Records Demonstration is a $150 million program that will provide funds to 1,200 physician practices to adopt this technology,” he says. “They’re currently recruiting practices.” Details on the demonstration are available at

It’s possible that hospitalists will be able to participate in the current plan—we don’t know yet.

—Patrick Conway, MD, MSc

Will Hospitalists Participate?

Until details of the e-prescribing program are published, no one can say whether the plan will encompass hospitalists. However, Dr. Conway says, “I think this plan is conceptually relevant to hospitalists: It’s possible that hospitalists will be able to participate in the current plan. We don’t know yet. But CMS will continue to push forward on initiatives that increase quality and decrease costs, including e-prescribing. They’ll support electronic health records, whether this particular initiative applies to hospitals or not.”

Even if it turns out hospital medicine groups can’t reap incentive payments from the new plan, Dr. Conway hopes they still will adopt the technology. “Computerized physician order entry (CPOE) and e-prescribing have the potential to decrease errors and increase the quality of care,” he says. “Therefore, I would encourage hospitals and hospitalists to implement electronic health records with computerized order entry and e-prescribing when possible.”

He says the real benefit to hospitals seeking to improve quality and reduce error is not the electronic transmission of prescriptions to the pharmacy, but CPOE. “Most evidence of increased quality is around computerized physician order entry, which includes decision support at the time of the order,” he points out. “One could argue that you could have an incentive for hospitals that utilize CPOE, but I have no idea if CMS will pursue that.”

Next Steps

On Oct. 6-7 CMS will host a conference on the complete e-prescribing plan for pharmacists and physicians in Boston. For details, check the CMS site at or

Dr. Conway thinks the meeting is a good next step for CMS. “I believe it’s very important to engage frontline providers and stakeholders, so the concept of holding a conference to ensure the design of the program is understood, and to get buy-in from the people participating, is a wise choice,” he says.

In the next few months, physicians likely will be inundated with information on e-prescribing processes under the CMS plan. Stay abreast of the latest information through the CMS Web site and, if it turns out, hospitalists can actively participate in the plan, through the SHM Web site at TH

Jane Jerrard is a medical writer based in Chicago.

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