A looming debacle appears to have been averted involving a Medicaid mandate requiring the use of tamper-proof paper in printing prescriptions with electronic prescribing systems.
A physician informaticist who worked on resolving the problem told attendees at the 17th annual Physician-Computer Connection Symposium in Ojai, Calif., about the breakthrough Thursday.
The CMS has accepted the recommendations that soon should be released by the National Council for Prescription Drug Programs, or NCPDP, to create anti-fraud measures using computerized printing technology deployable in electronic health-record systems and stand-alone e-prescribing tools as a substitute for expensive tamper-proof paper, which the CMS originally stipulated.
The Scottsdale, Ariz.-based NCPDP is a standards-development organization for pharmaceutical claims-data interchange. An NCPDP task force has been working on the problem since January.
Peter Basch, medical director of ambulatory clinical systems at MedStar Health, Columbia, Md., worked to overturn the CMS regulation interpreting a federal 2007 law that required tighter security on Medicaid prescriptions, a law Congress passed with the aim of saving taxpayers an estimated $100 million a year on fraudulent prescriptions.
The mandate, which was slated to go into effect Oct. 1, would have required physicians using e-prescribing tools to print paper prescriptions on expensive, tamper-resistant paper, which costs many times what ordinary printer paper costs, Basch said. That mandate now has an alternative, he said. The NCPDP will issue a guideline to state Medicaid officials saying that the CMS will soon clarify its prior policy and unequivocally state that compliance for handwritten or printed prescriptions for fee-for-service Medicaid patients can be achieved without special paper.
Basch said that he got involved in the lobbying effort late last year because the original paper mandate left him with few options to try and stave off potential losses for MedStar. The system had purchased more than 1,000 new printers with only one paper tray for a physician IT extension program, Basch said. In addition to the higher costs from requiring tamper-proof paper, the mandate likely would have required many providers to either buy separate printers for printing prescriptions only for Medicaid patients, or buy new printers with multiple paper trays to accommodate both ordinary and tamper-resistant paper.
Other options physicians faced if the mandate had gone through unamended, Basch explained, would have been for providers to use tamper-proof paper for all printing. That would include printing out medical education texts for patients as well as prescriptions on the more expensive paper, and incurring the greater expense, or continuing writing and recording prescriptions electronically, but returning to using handwritten prescription pads for tamper-proof prescriptions for Medicaid patients. That option, according to Basch, likely would have stymied ongoing efforts to increase physician adoption of e-prescribing systemsas doctors may have said, to heck with e-prescribingor reintroduced the patient safety and workflow issues of illegible handwriting and transcription errors that e-prescribing attempts to solve. Given all of these bad options, Basch said he saw only one viable alternative, "Try to change the law."
But when he got started, last November, time was already short. The initial compliance deadline was April 1, which was subsequently extended to Oct. 1.
Among his first stops was to approach the NCPDP and the CMS. The CMS had asked the NCPDP to convene a focus group to rapidly achieve consensus on industry recognized features for fraud-fighting techniques such as copy resistance, erasure, and modification and counterfeit resistance, Basch said.
Initially, Basch said, he met with stiff resistance from the CMS official in charge, who told him the paper requirement could not be amended. With persistence and some coalition building, however, the CMS official changed perspective and became "my best buddy in CMS" and "a delight to work with."
Basch said there were a number of players in the lobbying effort in addition to the NCPDP, including the Electronic Health Record Vendors Association, an affiliate of the Healthcare Information and Management Systems Society and SureScripts.
Basch said at least two print technologies have been deemed acceptable by the CMS. One of them involves a patented process from Toronto-based firm, AdlerTech International, called Sentinel void pantograph, which incorporates a hidden security word or image into the background of a computer printed prescription. The image will show up when the document is copied or scanned. The other security technology is called micro printing, which uses a strip of tiny type that can be read with a 5x magnifying glass or loupe. The type appears to be smeared when photocopied by most copying machines.
Basch said that Hewlett-Packard Co. is working on a micro-type font for that purpose that it intends to distribute without charge to providers and IT vendors. Both technologies could be deployed within EHRs and other e-prescribing systems, Basch said. Prescriptions would include easily readable text alerting pharmacists which security systems are in place on a prescription.
Michele Vilaret, director of telecommunications standards for the National Association of Chain Drug Stores and an NCPDP board member, helped coordinate activities around the print-technology solution with various industry groups working under an NCPDP task force.
Vilaret said the CMS signed off Tuesday on the proposed print-technology solutions. An advisory letter to state Medicaid directors informing them of the acceptance by the CMS of the proposed guidelines is in the hands of NCPDP President Lee Ann Stember.
"We just finished the documents yesterday," Vilaret said. "They have been sent to the NCPDP. We are waiting for our president to sign it, then it will go off to the state Medicaid directors."
"CMS has put the guidance in the hands of the states," Vilaret said. "CMS is not issuing (its) own guidance. They feel it should come state by state. Each state has the prerogative of issuing its own rules. All CMS has done is say this guidance is fine."
Vilaret said Medicaid program officials from several states were involved in the NCPDP-convened work group. Vilaret said the group also is working on educational materials for pharmacists, physicians and patients it hopes to have distributed by the end of the month.
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