A long lead time before computer-generated faxes are eliminated for electronic prescribing under a proposed new federal rule will probably make safer a bet by the CMS last week that the agency will promote and not harm government efforts to promulgate e-Rx, according to industry experts.
On Monday, the CMS released the proposed rule change it had authorized as part of 924 pages of rule-making that includes the physician fee schedule and payment policies for ambulance services for 2008. But the change in e-prescribing rules for faxed prescriptions probably won't be operational until sometime thereafter.
"We anticipate having this change effective one year after the effective date of the CY (calendar year) 2008 (physician fee schedule) final rule," according to a CMS spokesman.
That should be time enough for everyone to adjust, according to Kane St. John, who is chief operations officer and general counsel for Atlanta-based electronic medical-record vendor JMJ Technologies.
"Because the rule will not take effect until sometime in 2009, there will be no near-term problems created for end-userseither prescribers or dispensers," St. John said in an e-mail. "When the rule does take effect, the EHR software vendors that are lagging behind in upgrading their clients may complain. However, we think that CMS got it rightthe physicians (and their EHR vendors) who want the efficiency of computer-generated scripts need to take the small steps necessary to ensure that the benefits of structured data redound to the pharmacists. Besides, the physicians' refill and change-order procedures (and their patients' safety) will benefit from avoiding the need for re-keyboarded data. It's a case of creating significant economies with a small effortthe classic big bang for the buck."
Still, the move has inherent risks, spelled out in the proposed rule itself.
On Nov. 7, 2005, HHS published its final rule for e-prescribing required under the Medicare Modernization Act for the Medicare Part D program. HHS accepted as "foundation standards" to be used by Part D participants engaged in electronic transactions the ASC X 12N 270/271 standards for eligibility checking and responses between prescribers and Part D plans; the National Council for Prescription Drug Programs', or NCPDP, Telecommunication and Batch standards for exchanges between drug dispensers and plans; and the NCPDP Script standard for communication of e-prescription information between prescribers and dispensers.
But the 2005 final rule exempted computer-generated faxes from comporting with the NCPDP Script standards, seeing the intermediate technology of faxes as sort of electronic pump priming for more complete e-prescribing technology to come.
According to a background statement in the proposed new rule, "Comments received from the healthcare industry indicated that this would cause computer-generated faxers to revert to paper prescribing. As the secretary believed that prescribers/dispensers using computer fax capabilities would eventually migrate to fully functional e-prescribing, possibly at the same time as they implemented electronic health record systems, the Nov. 7, 2005 final rule exempted entities transmitting computer-generated faxes from having to comply with the NCPDP Script standard."
"Since January 2006, we have seen little reduction in the use of computer-generated fax technology," the proposed rule said. Hence the change in strategy.
But in its rationale for the policy switch, the CMS cited market information supplied by SureScripts indicating that not just prescribers are lagging in adoption of e-prescribing technology. SureScripts is a for-profit company formed in 2001 by the two main trade groups for pharmacies, the National Association of Chain Drug Stores and the National Community Pharmacists Association. SureScripts markets a data exchange network to facilitate e-prescribing that uses the NCPDP Script standard. While SureScripts reports that all 400 chain drugstores are capable of sending and receiving NCPDP Script transactions, just 20% of independent pharmacies share that capability.
"Independent pharmacies are less likely to perceive a return on investment for e-prescribing due to low numbers of practices seeking to move to e-prescribing using the Script transaction," the CMS proposed rule said.
A spokesman for the National Community Pharmacists Association, whose members are among that 20%, said it is assessing the policy move and declined to comment.
The CMS proposed rule cites SureScripts estimates "that of the 150,000 prescribers now using software that is capable of generating NCPDP Script transactions, only 15% are doing so."
Charles Webster, chief medical informatics officer for JMJ, said he supports the basic premise, that eliminating faxes will be a good thing, "However, the 150,000 prescribers capable of submitting NCPDP Scripts seems very high. I'd like to know how they estimated it. There's a lot of legacy software out there that may happen to have the same name as some more modern version, but will not be painless to upgrade."
"With today's announcement, Secretary (Mike) Leavitt is delivering on his promise to use the federal government's leverage as the nation's largest healthcare insurer to promote health IT adoption," said Kevin Hutchinson, president and chief executive officer of SureScripts in a news release. "It is now up to private industry to seize upon this important proposed change in Medicare policy. The sooner we take action, the sooner we will establish a safer, more cost-effective, more automated process for providing prescriptions to millions of patients across the nation."
Richard Spurr is chairman and CEO of Zix Corp., a developer of a stand-alone e-prescribing tool for office-based physicians that claims 3,200 physicians actively use its services. Spurr said physicians using Zix software don't know the difference between whether a prescription is sent via fax or through the NCPDP Script standard because all of that software is behind the interface. "The doctor hits a button and he doesn't care how it gets there and neither does the patient, as long as it gets there."
In 2005, Spurr said, when the final rule was written, virtually all e-prescriptions that went through Zix were faxed or printed out on paper because that was all that was available on the pharmacy side of the transaction. Today, somewhere between 50% to 80% of Zix e-prescriptions are sent using electronic data exchange, not faxes, Spurr said.
"I hesitate a little bit, because SureScripts is a friend and partner of ours and this is the flag that they're carrying," Spurr said. But, "This (rule change) benefits retail pharmacy industry, period. And one would say there is at least some impact on safety, and there is nothing wrong with that. The retail pharmacies of course prefer the electronic script because of the reduced administrative costs.
"An analyst that covers the retail pharmacy industry and put a report out on this last year and said there was a savings of a dollar or two dollars a script. This benefits retail pharmacy, period. And one would say there is at least some impact on safety, and there is nothing wrong with that."
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