Electronic Prescribing
CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the Use of Health Information Technology
Gao ID: GAO-11-159 February 17, 2011
In Process
CMS analyzes information reported by eligible providers on their Medicare Part B claims--which are used to submit charges for covered services--to determine which Medicare providers should receive Electronic Prescribing Program incentive payments or be subject to penalties. In 2009--the first year the program provided incentive payments--CMS paid approximately $148 million in incentive payments to about 8 percent of the approximately 600,000 Medicare providers who had an applicable patient visit--that is, supplied 1 of 33 CMS-designated services typically provided in the office or outpatient setting. For 2009, CMS examined Part B claims to determine whether, after each applicable patient visit, providers marked any one of three electronic prescribing reporting codes used to report information on the adoption and use of electronic prescribing systems. To receive an incentive payment that year, the provider had to report the codes for at least 50 percent of applicable patient visits, and at least 10 percent of the provider's total allowed Medicare Part B charges for the year had to be from the applicable patient visits. CMS made changes in the reporting requirements for 2010. For example, the agency reduced the number of reporting codes to one and required that individual providers report the code after at least 25 applicable visits, instead of for 50 percent of applicable visits. From 2012 through 2014, the Electronic Prescribing Program will assess penalties on providers that do not adopt and use electronic prescribing. Individual providers will have to submit the electronic prescribing reporting code at least 10 times in the first 6 months of 2011 to avoid penalties in 2012. Although GAO found similarities in the technology and reporting requirements for both programs, GAO also found that the requirements of the two programs are inconsistent in several areas. The EHR Program provides incentives from 2011 to 2016 and introduces penalties beginning in 2015, while the Electronic Prescribing Program provides incentives from 2009 to 2013 and provides for penalties from 2012 to 2014, when the program ends. Both the EHR and Electronic Prescribing Programs require providers to adopt and use technology that can perform similar electronic prescribing-related activities. However, the EHR Program requires providers to adopt and use certified EHR systems that meet criteria established by HHS, which include electronic prescribing-related capabilities, while the Electronic Prescribing Program does not have a certification requirement. As a result, providers have no assurance that the systems they invest in will meet the Electronic Prescribing Program's requirements. Additionally, the two programs have established separate reporting requirements related to electronic prescribing, potentially requiring physicians--the largest and only group of providers eligible to earn incentive payments in both programs--to report to both programs from 2011 through 2014. CMS recognizes that this duplication places additional burden on physicians; however, CMS is still in the process of developing a strategy to address this duplication. GAO is recommending that the CMS Administrator take four actions, including (1) encourage physicians and other providers in the Electronic Prescribing Program to adopt certified technology and (2) expedite efforts to remove the overlap in reporting requirements for physicians who may be eligible for incentive payments or subject to penalties under both programs. CMS generally agreed with three recommendations and disagreed with a fourth recommendation, which GAO clarified based on CMS's comments.
GAO-11-159, Electronic Prescribing: CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the Use of Health Information Technology
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
February 2011:
Electronic Prescribing:
CMS Should Address Inconsistencies in Its Two Incentive Programs That
Encourage the Use of Health Information Technology:
GAO-11-159:
GAO Highlights:
Highlights of GAO-11-159, a report to congressional committees.
Why GAO Did This Study:
Congress established two CMS-administered programs-”the Electronic
Prescribing Program and the Electronic Health Records (EHR) Program”-
that provide incentive payments to eligible Medicare providers who
adopt and use health information technology, and penalties for those
who do not. The Medicare Improvements for Patients and Providers Act
of 2008 required GAO to report on the Electronic Prescribing Program.
To do so, GAO examined how CMS determines which providers receive
incentive payments and avoid penalties from that program and how many
providers received incentive payments in 2009. Also, GAO was asked to
examine how the requirements of the two programs compare. GAO reviewed
relevant laws and regulations, interviewed CMS officials, and analyzed
CMS data on incentive payments made for 2009, which were the most
recent data available for a full year.
What GAO Found:
CMS analyzes information reported by eligible providers on their
Medicare Part B claims”which are used to submit charges for covered
services”to determine which Medicare providers should receive
Electronic Prescribing Program incentive payments or be subject to
penalties. In 2009-”the first year the program provided incentive
payments-”CMS paid approximately $148 million in incentive payments to
about 8 percent of the approximately 600,000 Medicare providers who
had an applicable patient visit”that is, supplied 1 of 33 CMS-
designated services typically provided in the office or outpatient
setting. For 2009, CMS examined Part B claims to determine whether,
after each applicable patient visit, providers marked any one of three
electronic prescribing reporting codes used to report information on
the adoption and use of electronic prescribing systems. To receive an
incentive payment that year, the provider had to report the codes for
at least 50 percent of applicable patient visits, and at least 10
percent of the provider‘s total allowed Medicare Part B charges for
the year had to be from the applicable patient visits. CMS made
changes in the reporting requirements for 2010. For example, the
agency reduced the number of reporting codes to one and required that
individual providers report the code after at least 25 applicable
visits, instead of for 50 percent of applicable visits. From 2012
through 2014, the Electronic Prescribing Program will assess penalties
on providers that do not adopt and use electronic prescribing.
Individual providers will have to submit the electronic prescribing
reporting code at least 10 times in the first 6 months of 2011 to
avoid penalties in 2012.
Although GAO found similarities in the technology and reporting
requirements for both programs, GAO also found that the requirements
of the two programs are inconsistent in several areas. The EHR Program
provides incentives from 2011 to 2016 and introduces penalties
beginning in 2015, while the Electronic Prescribing Program provides
incentives from 2009 to 2013 and provides for penalties from 2012 to
2014, when the program ends. Both the EHR and Electronic Prescribing
Programs require providers to adopt and use technology that can
perform similar electronic prescribing–related activities. However,
the EHR Program requires providers to adopt and use certified EHR
systems that meet criteria established by HHS, which include
electronic prescribing–related capabilities, while the Electronic
Prescribing Program does not have a certification requirement. As a
result, providers have no assurance that the systems they invest in
will meet the Electronic Prescribing Program‘s requirements.
Additionally, the two programs have established separate reporting
requirements related to electronic prescribing, potentially requiring
physicians-”the largest and only group of providers eligible to earn
incentive payments in both programs”-to report to both programs from
2011 through 2014. CMS recognizes that this duplication places
additional burden on physicians; however, CMS is still in the process
of developing a strategy to address this duplication.
What GAO Recommends:
GAO is recommending that the CMS Administrator take four actions,
including (1) encourage physicians and other providers in the
Electronic Prescribing Program to adopt certified technology and (2)
expedite efforts to remove the overlap in reporting requirements for
physicians who may be eligible for incentive payments or subject to
penalties under both programs. CMS generally agreed with three
recommendations and disagreed with a fourth recommendation, which GAO
clarified based on CMS‘s comments.
View [hyperlink, http://www.gao.gov/products/GAO-11-159] or key
components. For more information, contact Linda T. Kohn at (202) 512-
7114 or kohnl@gao.gov.
[End of section]
Contents:
Letter:
Background:
CMS Analyzed Medicare Part B Claims to Pay Electronic Prescribing
Program Incentive Payments to about 8 Percent of Certain Medicare
Providers for 2009:
While the Requirements in the EHR and Electronic Prescribing Programs
Are Similar in Some Cases, Aspects of These Requirements Are Not
Consistent:
Conclusions:
Recommendations for Executive Action:
Agency and External Party Comments and Our Evaluation:
Appendix I: List of Committees:
Appendix II: Effect of Electronic Prescribing on Quality or Cost:
Appendix III: Scope and Methodology:
Appendix IV: Maximum Electronic Health Record (EHR) Program Incentive
Payments, Based on First Year of Payment:
Appendix V: Stage-One Reporting Requirements for the Electronic Health
Records (EHR) Program:
Appendix VI: Comments from the Department of Health and Human Services:
Appendix VII: GAO Contact and Staff Acknowledgments:
Figures:
Figure 1: Electronic Prescribing Information Flow and How Electronic
Prescribing May Improve the Quality of Health Care Provided to
Beneficiaries and Reduce Costs to Health Care Payers:
Figure 2: Types of Providers Eligible to Receive Incentives and Who
May Be Subject to Penalties under the Electronic Prescribing and EHR
Programs:
Figure 3: Incentives and Penalties for Eligible Providers in the
Electronic Prescribing and EHR Programs:
Figure 4: Electronic Prescribing and EHR Program Participation
Scenarios and Resulting Incentive Payments and Penalties:
Figure 5: Percentage of Medicare Providers Who Received 2009
Electronic Prescribing Program Incentive Payments, by State:
Figure 6: Mean Incentive Payments from the 2009 Electronic Prescribing
Program, by State:
Figure 7: Electronic Prescribing Program, 2009:
Figure 8: Technology Requirement for the EHR and Electronic
Prescribing Programs, 2011:
Figure 9: Electronic Prescribing-Related Reporting Requirements for
the EHR and Electronic Prescribing Programs, 2011:
Abbreviations:
ADE: adverse drug event:
CDS: clinical decision support:
CMS: Centers for Medicare & Medicaid Services:
CPOE: computerized physician order entry:
EHR: electronic health record:
HHS: Department of Health and Human Services:
HIMSS: Healthcare Information and Management Systems Society:
HITECH: Health Information Technology for Economic and Clinical Health:
MIPPA: Medicare Improvements for Patients and Providers Act of 2008:
NPPES: National Plan and Provider Enumeration System:
ONC: Office of the National Coordinator for Health Information
Technology:
PECOS: Provider Enrollment, Chain, and Ownership System:
PPACA: Patient Protection and Affordable Care Act of 2010:
PQRS: Physician Quality Reporting System:
Recovery Act: American Recovery and Reinvestment Act of 2009:
VA: Department of Veterans Affairs:
VistA: Veterans Health Information Systems and Technology Architecture:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
February 17, 2011:
Congressional Committees:
According to the Department of Health and Human Services (HHS),
widespread use of health information technology could improve the
quality of care received by patients and reduce health care costs. One
such technology, electronic prescribing, can be used, for example, to
electronically transmit a prescription or prescription-related
information between a health care provider and a pharmacy or to
provide other technological capabilities, such as alerting a provider
to a potential interaction between a drug and the patient‘s existing
medications. Health care providers can access electronic prescribing
technological capabilities by adopting stand-alone electronic
prescribing systems or electronic health record[Footnote 1] systems
that include an electronic prescribing component. Others have reported
that stand-alone electronic prescribing systems can cost up to $2,500
annually per provider, and EHR systems can cost approximately $25,000
to $45,000 per provider with additional annual costs to operate and
maintain the system.[Footnote 2]
Congress has established two programs, administered by the Centers for
Medicare & Medicaid Services (CMS), that aim to increase the use of
electronic prescribing in Medicare by providing incentive payments or
penalties for certain providers who participate in the Medicare
Program.[Footnote 3] The time frames for the two programs overlap, and
each program has established the following requirements that providers
must meet in order to receive incentive payments under Medicare and
avoid program penalties: (1) technological requirements that specify
the types of health care information technology providers must adopt;
and (2) reporting requirements that describe the information that
providers report to CMS to demonstrate that they have not only
adopted, but also used, the requisite health care information
technology. For both of these programs, physicians are the largest
group of eligible providers that may earn incentive payments or be
subject to penalties.
The first program, established by the Medicare Improvements for
Patients and Providers Act of 2008 (MIPPA) and referred to here as the
Electronic Prescribing Program, provides incentive payments from 2009
through 2013 to certain Medicare providers-”physicians and other
health care providers, such as physician assistants and nurse
practitioners”-who have prescribing authority and who adopt and use
systems that meet CMS‘s definition of a qualified electronic
prescribing system.[Footnotes 4,5] From 2012 through 2014, the program
may apply a payment adjustment, or penalty, on the program‘s eligible
providers that do not adopt and use such systems.[Footnote 6] With
incentive payments scheduled to end in 2013 and penalties scheduled to
end in 2014, the Electronic Prescribing Program will cease to provide
positive and negative incentives to encourage eligible providers to
electronically prescribe after 2014.
The second incentive program was established by the Health Information
Technology for Economic and Clinical Health (HITECH) Act, as part of
the American Recovery and Reinvestment Act of 2009 (Recovery Act).
[Footnote 7] HITECH established a program, referred to here as the
Electronic Health Records (EHR) Program, that provides incentive
payments from 2011 through 2016 to Medicare physicians that adopt and
’meaningfully use“[Footnote 8] certified EHR technology, which
includes electronic prescribing technological capabilities.[Footnote
9] Beginning in 2015, the EHR Program may apply a payment adjustment,
or penalty, on eligible providers that do not adopt and meaningfully
use certified EHR technology.[Footnote 10]
MIPPA requires us to report on the implementation of the incentives
for electronic prescribing established by MIPPA by September 1, 2012.
[Footnote 11] In addition, because of the overlapping time frames of
the programs, we were asked to obtain information on the relationship
between the Electronic Prescribing Program and the EHR Program. As
agreed with committee staff, our specific objectives for this report
were to examine (1) how CMS determines which providers should receive
incentive payments and avoid penalties from the Electronic Prescribing
Program and how many providers received such incentive payments in
2009, and (2) how the requirements in the EHR Program and the
Electronic Prescribing Program compare to each other. MIPPA also
directed us to report on information related to reductions in
avoidable medical errors and estimated savings to Medicare resulting
from the use of electronic prescribing. In response, we provide
information in appendix II on how others have measured whether or to
what extent electronic prescribing improves quality or reduces costs.
To address both objectives, we reviewed relevant provisions in MIPPA
and the Recovery Act, and regulations and other published material
pertaining to the Electronic Prescribing[Footnote 12] and EHR
Programs.[Footnote 13] We also interviewed officials from CMS and from
the Office of the National Coordinator for Health Information
Technology (ONC) in HHS. ONC reports to the Secretary of HHS and plays
a role in the EHR Program by establishing the standards and
specifications that providers‘ systems must meet for the EHR Program,
coordinating with CMS on the development of the meaningful use
criteria, and creating and administering the certification program
that authorizes organizations to certify EHR technology. To report how
many providers received payments in 2009, we analyzed CMS data on (1)
2009 Electronic Prescribing Program participation as determined by CMS
and (2) providers‘ state locations.[Footnote 14] For more information
on our data analysis, see appendix III. To ensure the reliability of
the various data we analyzed, we interviewed CMS officials, reviewed
CMS documentation, and conducted electronic testing to identify
obvious errors. On the basis of these activities, we determined that
CMS data were sufficiently reliable for our analysis. To compare the
EHR Program and the Electronic Prescribing Program, we examined
similarities and differences in the two programs‘ technology and
reporting requirements and identified inconsistencies that may limit
the effectiveness of the programs. Because the EHR Program is broader
than electronic prescribing, we focused our comparison on the
electronic prescribing–related aspects of that program‘s technology
and reporting requirements. We also interviewed knowledgeable
stakeholders, including officials from HHS‘s Agency for Healthcare
Research and Quality and the Department of Veterans Affairs (VA). To
obtain information about studies that measured whether or to what
extent electronic prescribing improves quality or reduces costs, we
interviewed organizations, such as CVS Caremark, and reviewed
published studies.[Footnote 15]
We conducted this performance audit from February 2010 through
February 2011 in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
Background:
HHS and others have promoted electronic prescribing as one way to
improve the quality of health care that beneficiaries receive and as
one way to reduce costs. Health care costs are typically paid for by
health care payers, such as CMS in the Medicare Program. In
traditional, or paper-based, prescribing, health care providers that
are licensed to issue prescriptions for drugs (e.g., physicians or
physician assistants in some states) write a prescription, and the
beneficiary takes that prescription to a dispenser (e.g., pharmacy) to
be filled. In contrast, electronic prescribing consists of a licensed
health care provider using a computer or hand-held device to write and
transmit a prescription directly to the dispenser. Before doing so,
the health care provider can request the beneficiary's eligibility,
formulary,[Footnote 16] benefits, and medication history. This
information can be used to improve quality and reduce costs. For
example, a health care provider can use this information to avoid
potentially adverse drug events such as drug-to-drug or drug-to-
allergy interactions and to prescribe less-expensive medications, such
as lower-cost generic drugs. Figure 1 illustrates the flow of
information during the electronic prescribing process and identifies
areas in this process that may result in improvements in the quality
of health care provided to beneficiaries and reductions in costs to
health care payers. Appendix II provides information from studies
measuring whether or to what extent electronic prescribing improves
quality or reduces costs.
Figure 1: Electronic Prescribing Information Flow and How Electronic
Prescribing May Improve the Quality of Health Care Provided to
Beneficiaries and Reduce Costs to Health Care Payers:
[Refer to PDF for image: illustration]
The provider can identify a patient‘s record and enter patient
information in the electronic prescribing system.
The electronic prescribing system can be used to confirm or obtain the
following information related to the beneficiary:
* the beneficiary‘s enrollment in a health plan;
* the beneficiary‘s formulary and benefits; and;
* a list of medications previously dispensed to the beneficiary.
The provider can update the electronic prescribing system with the
beneficiary‘s current medications and allergies.
* Potential Quality Effects: By maintaining an updated medication
history, the provider may be able to better monitor medication
adherence and potential side effects. Maintaining an updated
medication history can help prevent the prescription of duplicate
medications and help beneficiaries transition through health care
settings.
To order the medication using the electronic prescribing system, the
provider specifies certain information such as dosage, quantity, and
directions.
* Potential Cost Savings: By having access to formulary information,
the provider may be able to select a less-expensive medication, such
as a lower-cost generic drug.
The electronic prescribing system may allow a comparison between the
medication ordered and the patient‘s information (e.g., body weight,
age, diagnoses, and medication history) and also check the order for
completeness.
* Potential Quality Effects and Cost Savings: Alerting the provider to
(a) potential contraindications, adverse reactions, or duplicate
therapy, and (b) possible problems with the medication order such as
missing or incorrect dosage and frequency, may prevent patient harm or
costly medical treatments, or both.
After reviewing any alerts provided by the electronic prescribing
system, the provider changes the prescription or authorizes the
prescription, or both.
The provider can transmit the medication order electronically to the
pharmacy.
* Potential Quality Effects: A prescription transmitted electronically
is not handwritten, which helps prevent errors caused by illegibility.
Sources: GAO (data); Art Explosion (clip art).
[End of figure]
Eligibility for the Electronic Prescribing and EHR Programs:
The types of Medicare providers eligible to earn incentive payments or
who may be subject to penalties in the EHR and Electronic Prescribing
Programs were established in statute, and although they overlap they
are not identical. Specifically, only physicians, who are the largest
population among each program's eligible providers, can earn incentive
payments or be subject to penalties from both programs, but they
cannot receive incentive payments or be subject to penalties from both
programs during the same year. Other health care providers, such as
nurse practitioners and physician assistants, are only eligible to
receive incentive payments or are subject to penalties from the
Electronic Prescribing Program[Footnote 17]. (See figure 2.)
Figure 2: Types of Providers Eligible to Receive Incentives and Who
May Be Subject to Penalties under the Electronic Prescribing and EHR
Programs:
[Refer to PDF for image: table]
Electronic Prescribing Program:
Eligible providers must be physicians or other providers, including
nurse practitioners or physician assistants.[A]
EHR Program:
Eligible providers are physicians under the Medicare Program, the
definition of which includes chiropractors.[B]
Source: GAO analysis of MIPPA and the Recovery Act.
[A] To receive incentive payments or be subject to penalties under the
Electronic Prescribing Program, providers must have prescribing
authority, which varies by state. Although chiropractors are
identified as eligible providers in the Electronic Prescribing
Program, chiropractors do not have prescribing authority and,
therefore, are not able to earn incentive payments from the program.
[B] See Pub. L. No. 111-5 § 4101, 123 stat. 467, 472 (adding SSA §
1848(o)(5)(C)). Medicare physicians who perform substantially all of
their services in hospital inpatient or emergency room settings are
excluded from the provisions of the EHR Program. Pub. L. No. 111-5 §
4101 as amended by the Continuing Extension Act of 2010, Pub. L. No.
111-157, § 5, 124 Stat. 1116, 1117 (clarifying HITECH Act provision
providing for nonapplication of EHR incentives). CMS has determined
"substantially all" to mean 90 percent or more of the eligible
provider's services are performed in a hospital inpatient or emergency
room setting. See 42 C.F.R. § 495.4 (as added by 75 Fed. Reg. 44314,
44565).
[End of figure]
Incentive Payments and Penalties in the Electronic Prescribing and EHR
Programs:
There is some overlap in the time frames for incentive payments and
penalties for the Electronic Prescribing and EHR Programs. Incentive
payments for the Electronic Prescribing Program are available from
2009 through 2013. Incentive payments for the EHR Program begin in
2011 and may be available until 2016, depending on which calendar year
the provider initially receives an incentive payment from the program.
Incentive payments for both programs are determined by multiplying the
provider's total allowed charges for provider services covered by
Medicare Part B[Footnote 18] for the year by the incentive percent
authorized by statute. However, in the EHR Program the year in which
the provider first adopts and meaningfully uses the EHR technology
determines the maximum annual incentive payment a provider can earn
and the total number of years incentive payments are available. For
both programs, incentive payments are disbursed after providers
demonstrate that they met the applicable program requirements. Figure
3 displays the timeline and maximum incentive payments and penalties
for both programs. (Appendix IV provides additional detail on the
annual and total incentive payments an eligible provider could receive
from the EHR Program based on the initial year the provider receives
an incentive payment.) By law, providers cannot receive an incentive
payment for both programs during the same year.[Footnote 19],[Footnote
20]
Figure 3: Incentives and Penalties for Eligible Providers in the
Electronic Prescribing and EHR Programs:
[Refer to PDF for image: illustration]
Electronic Prescribing Program:
Incentive:
* Percentage of Part B charges:
2009: 2%;
2010: 2%;
2011: 1%;
2012: 1%;
2013: 0.5%.
Penalty:
* Percentage of Part B charges:
2012: -1%;
2013: -1.5%;
2014: -2.0%.
EHR Program:
Incentive:
* 75 percent of Part B charges, up to a maximum amount:
2011: Up to $18,000;
2012: Up to $18,000;
2013: Up to $15,000;
2014: Up to $12,000;
2015: Up to $8,000;
2016: Up to $4,000;
Penalty:
* Percentage of Part B charges:
2015: -1%[A];
2016: -2%;
2017: -3%;
2018+: -3%.
Source: GAO analysis of MIPPA and the Recovery Act.
Notes: (1) The percentages in this figure are applied to total allowed
Part B charges for providers that meet the programs' requirements. (2)
In the EHR Program, the total and annual incentive payment amounts
depend on the year the provider initially receives an incentive
payment. See appendix IV. Providers that adopt and meaningfully use in
2015 or later receive no incentive payments, but would also not be
subject to the penalty, which begins in 2015. (3) In the EHR Program,
CMS will increase the incentive payments that would otherwise apply by
10 percent each year for providers that predominantly furnish services
in geographic areas designated as health professional shortage areas,
such as areas that have a shortage of primary medical care. (4) In the
EHR Program, for 2018 and subsequent years, the law provides for CMS
to increase the penalty by 1 percentage point from the previous year,
up to a maximum of 5 percent, if less than 75 percent of eligible
providers meet the EHR Program's requirements.
[A] Providers who are subject to penalties from the Electronic
Prescribing Program in 2014 and who are subject to penalties from the
EHR Program will face a higher penalty from the EHR Program in 2015--2
percent instead of 1 percent.
[End of figure]
Penalties for the Electronic Prescribing Program and the EHR Program
may be automatically applied to providers that fail to meet the
programs' requirements.[Footnote 21] Penalties for the Electronic
Prescribing Program begin in 2012 and end after 2014. Penalties for
the EHR Program begin in 2015, and there is no statutory end-point
provided for when the penalties will end.[Footnote 22] Since the
Electronic Prescribing Program ends after 2014 and penalties for the
EHR Program do not begin until 2015, providers will not receive
penalties from both programs during the same year. However, providers
who are subject to penalties from the Electronic Prescribing Program
in 2014 and who are subject to penalties from the EHR Program in 2015
will face a higher penalty from the EHR Program--2 percent instead of
1 percent.[Footnote 23] Similar to the incentive payments, penalties
for not adopting a program's technologies are also calculated by
multiplying the provider's total allowed charges for provider services
covered by Medicare Part B by the penalty percent authorized by
statute. Penalties will be assessed by reducing the reimbursement that
the provider would ordinarily receive for furnishing Part B services
by the applicable penalty percentage.[Footnote 24]
The amount of incentive payments or penalties eligible providers may
receive depends on the year in which the provider chooses to begin
participating in--that is, meeting the requirements of--either or, if
eligible, both programs. In general, the earlier a provider begins
participating in the program, the more incentive payments the provider
will earn and the fewer penalties the provider will be assessed.
Figure 4 below presents three scenarios of participation in the
Electronic Prescribing and EHR Programs between 2009 and 2018. In each
scenario, we assume that the provider is eligible for both programs
and has $24,000 in total allowed Medicare Part B charges each year.
[Footnote 25]
Figure 4: Electronic Prescribing and EHR Program Participation
Scenarios and Resulting Incentive Payments and Penalties:
[Refer to PDF for image: illustration]
In each scenario, the Medicare provider has $24,000 of total allowable
Medicare Part B charges each year:
Scenario 1: Early participation:
The provider participates in and meets the requirements of the
Electronic Prescribing Program beginning in 2009, earning incentive
payments from 2009 through 2011, and avoiding penalties assessed by
that program beginning in 2012. In 2012, the provider switches
participation to the EHR Program and meets that program's
requirements, earning incentive payments from 2012 through 2016 and
avoiding penalties, which begin in 2015.
Calendar year: 2009: Electronic Prescribing Program: $480;
Calendar year: 2010: Electronic Prescribing Program: $480;
Calendar year: 2011: Electronic Prescribing Program: $240;
Calendar year: 2012: EHR Program: $18,000;
Calendar year: 2013: EHR Program: $12,000;
Calendar year: 2014: EHR Program: $8,000;
Calendar year: 2015: EHR Program: $4,000;
Calendar year: 2016: EHR Program: $2,000;
Incentive payments/penalties:
Electronic Prescribing Program: $1,200;
EHR Program: $44,000;
Total incentive payments/penalties: $45,200.
Scenario 2: Late participation:
The provider participates in and meets the requirements of the
Electronic Prescribing Program beginning in 2011, earns incentive
payments from 2011 through 2013, and avoids penalties assessed by that
program beginning in 2012. In 2014, the provider switches
participation to the EHR Program and meets the program's requirements,
earning incentive payments from 2014 through 2016 and avoiding
penalties, which begin in 2015.
Calendar year: 2011: Electronic Prescribing Program: $240;
Calendar year: 2012: Electronic Prescribing Program: $240;
Calendar year: 2013: Electronic Prescribing Program: $120;
Calendar year: 2014: EHR Program: $12,000;
Calendar year: 2015: EHR Program: $8,000;
Calendar year: 2016: EHR Program: $4,000;
Incentive payments/penalties:
Electronic Prescribing Program: $600;
EHR Program: $24,000;
Total incentive payments/penalties: $24,600.
Scenario 3: No participation:
The provider chooses not to participate in or meet the requirements of
either the Electronic Prescribing Program or the EHR Program. As a
result, the Electronic Prescribing Program assesses penalties on the
provider from 2012 through 2014 and the EHR Program assesses penalties
on the provider, which begin in 2015.
Calendar year: 2012: Electronic Prescribing Program: -$240;
Calendar year: 2013: Electronic Prescribing Program: -$360;
Calendar year: 2014: Electronic Prescribing Program: -$480;
Calendar year: 2015: EHR Program: -$480[B]
Calendar year: 2016: EHR Program: -$480;
Calendar year: 2017: EHR Program: -$720;
Calendar year: 2018[A]: EHR Program: -$720;
Incentive payments/penalties:
Electronic Prescribing Program: -$1,080;
EHR Program: -$2,400;
Total incentive payments/penalties: -$3,480.
Source: GAO analysis of MIPPA and the Recovery Act.
Notes: (1) See figure 3 for information on the incentive payments and
penalties that eligible providers are subject to for both programs.
(2) In the EHR Program, the total and annual incentive payment amounts
depend on the initial year the provider receives an incentive payment
from the EHR Program, and these specific amounts are provided in
appendix IV. In the EHR Program, CMS will increase the incentive
payments by 10 percent each year for providers that predominantly
furnish services in geographic areas designated as health professional
shortage areas, such as areas that have a shortage of primary medical
care.
[A] After 2018, providers that do not participate in or meet the EHR
Program's requirements will continue to be assessed penalties. In the
EHR Program, for 2018 and subsequent years, the law provides for CMS
to increase the penalty by 1 percentage point from the previous year,
up to a maximum of 5 percent, if less than 75 percent of eligible
providers meet the EHR Program's requirements.
[B] Providers who are subject to penalties from the Electronic
Prescribing Program in 2014 and who are subject to penalties from the
EHR Program will face a higher penalty from the EHR Program in 2015--2
percent instead of 1 percent.
[End of figure]
Reporting Requirements for the EHR Program:
CMS will develop the reporting requirements that providers will have
to meet for the EHR Program in three stages. To date, CMS has only
developed the reporting requirements that eligible providers will have
to meet to receive incentive payments for the first stage, which will
apply to providers first obtaining incentive payments from the EHR
Program from 2011 through 2014.[Footnote 26] By the end of 2011, CMS
expects to develop reporting requirements for receiving incentives in
the second stage and, by the end of 2013, develop reporting
requirements for receiving incentives in the third stage.[Footnote 27]
CMS has stated that it may include information on the reporting
requirements that eligible providers must meet to avoid penalties at
the same time it issues regulations describing the third-stage
requirements. CMS intends to make the reporting requirements more
stringent over time as EHR technology and providers' use of that
technology becomes more sophisticated.
To receive an incentive payment for the EHR Program, eligible
providers must meet or exceed a total of 20 reporting requirements
established by CMS.[Footnote 28] Of the 20 reporting requirements, 15
are mandatory, and providers must choose an additional 5 from a menu
of 10 other reporting requirements.[Footnote 29] The reporting
requirements encompass a variety of activities related to the delivery
of health care to encourage providers to capture the following types
of information in their EHR systems: patient demographics and clinical
conditions, use of clinical decision support,[Footnote 30] and the
coordination of care across health care settings. See appendix V for a
complete list of the stage-one reporting requirements for receiving
incentive payments.
The reporting requirements that CMS develops for the second and third
stages of the EHR Program may be influenced by the Patient Protection
and Affordable Care Act of 2010 (PPACA), which directed CMS to develop
a plan to integrate the reporting requirements used in the EHR Program
with the information that CMS collects from eligible providers in the
Physician Quality Reporting System (PQRS).[Footnote 31] Similar to the
EHR and Electronic Prescribing Programs, CMS, as directed by Congress,
implemented PQRS to provide incentive payments to eligible providers
who satisfactorily reported data on various quality measures and
impose penalties on those providers who did not.[Footnote 32]
Specifically, PPACA directed CMS to develop an integration plan by
January 1, 2012, that would identify reporting requirements that could
be used to demonstrate meaningful use for the EHR Program and also be
used to demonstrate quality of care provided to individuals for PQRS.
CMS Analyzed Medicare Part B Claims to Pay Electronic Prescribing
Program Incentive Payments to about 8 Percent of Certain Medicare
Providers for 2009:
To determine which providers should receive the Electronic Prescribing
Program's incentive payments, CMS analyzes information reported by
providers on their Medicare Part B claims, which are used to submit
charges for covered services. To determine which providers are subject
to penalties, which begin in 2012, CMS will also analyze information
reported by providers on their Part B claims, but the requirements for
avoiding penalties are different than those for obtaining incentive
payments. In 2009, CMS paid incentive payments to about 8 percent of
certain Medicare providers--that is, of the over 597,000 Medicare
providers who had at least one applicable visit during 2009--and
another 7 percent of those same Medicare providers participated in the
Electronic Prescribing Program but did not receive incentive payments.
CMS Analyzes Information Reported by Providers on Part B Claims to
Determine Which Providers Should Receive Incentive Payments and Avoid
Penalties:
Incentive payments for the Electronic Prescribing Program are
available from 2009 through 2013, and to determine which providers
meet the program's requirements and should receive the payments, CMS
analyzes information reported by providers on their Part B claims.
[Footnote 33] Specifically, for 2009, CMS first examined 2009 Part B
claims to determine whether, after each applicable patient visit,
providers marked any one of three electronic prescribing reporting
codes used to report information on the adoption and use of electronic
prescribing systems.[Footnote 34] For 2009, the three electronic
prescribing reporting codes were:
* the provider had a qualified electronic prescribing system and used
it to generate all prescriptions during the visit;
* the provider had a qualified electronic prescribing system but did
not use it to generate one or more prescriptions during the visit for
one of the following reasons: the patient requested a paper
prescription, the pharmacy could not receive an electronic
transmission, or the prescription was for a narcotic or other
controlled substance and could therefore not be electronically
prescribed;[Footnote 35] and:
* the provider had a qualified electronic prescribing system but did
not generate any prescriptions during the visit.
By submitting any one of the three electronic prescribing reporting
codes to CMS, providers attested that they met the program's
technology requirement by adopting a qualified electronic prescribing
system and are eligible to earn incentive payments from the program.
Second, CMS analyzed the 2009 Part B claims to determine which of the
providers who submitted the electronic prescribing reporting codes
also met or exceeded both components of the following reporting
requirement:[Footnote 36]
* the provider submitted one of the three electronic prescribing
reporting codes at least 50 percent of the time that the provider had
an applicable visit; and:
* at least 10 percent of the provider's total allowed Medicare Part B
charges for the year were from the services designated as applicable
patient visits.
If the provider met or exceeded the reporting requirement, CMS gave
the provider an incentive payment for 2009, which the agency
calculated as 2 percent of the provider's total allowed Medicare Part
B charges for the year and by applying a small adjustment factor.
[Footnote 37],[Footnote 38]
For 2010, to increase the adoption of electronic prescribing
technology, CMS made some changes to the Electronic Prescribing
Program's reporting requirement that providers had to meet in order to
receive an incentive payment. CMS eliminated the three electronic
prescribing reporting codes for 2009 and replaced them with a single
code for providers to submit to CMS. The new code indicates that after
each applicable visit[Footnote 39] the provider generated and
transmitted at least one prescription during the visit using a
qualified electronic prescribing system.[Footnote 40] The agency
stated that it believed that this change would simplify reporting. CMS
also changed the first portion of the reporting requirement related to
how frequently providers must submit the new electronic prescribing
code in order to receive an incentive payment. Instead of requiring
that providers submit the electronic prescribing reporting code at
least 50 percent of the time that they had an applicable visit--the
requirement in 2009--CMS required that an individual provider submit
the new electronic prescribing reporting code for at least 25 visits.
CMS noted that the agency believes that meeting the 2010 reporting
requirement is achievable by a majority of eligible providers. If
providers participated in the Electronic Prescribing Program as a
group practice containing 200 or more providers--a new option in 2010--
the practice had to submit the electronic prescribing reporting code
for at least 2,500 applicable visits before all of the providers in
the practice could receive incentive payments.[Footnote 41] When it
proposed the change to at least 25 and at least 2,500 visits for
individual providers and group practices, respectively, CMS noted that
it assumed that once a provider has invested in an electronic
prescribing system, integrated the use of that system into the
practice's work flows, and used that system to some extent, the
provider is likely to continue to use the electronic prescribing
system for most of the prescriptions generated. The other component of
the reporting requirement remained unchanged from 2009: at least 10
percent of the provider's or practice's total allowed Medicare Part B
charges for the year were from the services designated as applicable
visits. Finally, as an individual or as part of a group practice,
providers could report the electronic prescribing code on their Part B
claims, as they did in 2009, or they could do so using one of two
alternative reporting mechanisms CMS created.[Footnote 42]
CMS has described how it will determine which providers should receive
incentive payments for 2011, but the agency has not yet indicated how
it will determine which providers should receive incentive payments
for 2012 or 2013.[Footnote 43] CMS will determine which providers meet
the program's requirements and should receive an incentive payment in
2011 generally using the same methods the agency used in 2010.
However, one important change CMS made for 2011--one that is
consistent with changes the agency is making to PQRS--is that CMS
expanded the definition of group practice to include practices
containing 2 through 199 individuals and will require those group
practices to report the electronic prescribing code for a minimum of
between 75 and 1,875 applicable visits, depending on the size of the
group practice.[Footnote 44] The requirement for group practices of
200 or more providers is unchanged; those practices must report the
code for at least 2,500 applicable visits.
From 2012 through 2014, the Electronic Prescribing Program will assess
penalties on individual providers and group practices that do not
adopt and use electronic prescribing. To avoid these penalties in
2012, individual providers and group practices will have to meet
certain reporting requirements. Individual providers will have to
submit the electronic prescribing reporting code on their Part B
claims for at least 10 applicable visits between January 1, 2011, and
June 30, 2011.[Footnote 45],[Footnote 46] However, CMS will not
penalize certain individuals in 2012 if they do not prescribe or do so
infrequently.[Footnote 47] In addition, both individual providers and
groups that practice in rural areas or areas with a limited number of
pharmacies that accept electronic transmissions will be exempt from
penalties. The reporting requirement for individuals and the exemption
criteria are consistent with the agency's statement that it does not
want to penalize providers with low prescribing volumes.[Footnote 48]
Group practices will have to submit the electronic prescribing
reporting code on their Part B claims the same number of times
required to receive incentive payments in 2011, but they must do so
within the 6-month period from January 1, 2011, through June 30, 2011.
[Footnote 49] For example, group practices containing 200 or more
providers will have to submit the electronic prescribing reporting
code at least 2,500 times from January 1, 2011, through June 30, 2011.
CMS has noted that it did not think that group practices would be
disadvantaged by having to meet the reporting requirement in a 6-month
period to avoid the penalty in 2012 rather than in a 12-month period
to earn an incentive in 2011 because the agency requires group
practices to submit the electronic prescribing reporting code fewer
times on average to earn an incentive payment than it requires for
individual providers to submit to earn an incentive payment.[Footnote
50]
CMS has not yet established all the requirements for providers to
avoid penalties in 2013 or 2014.[Footnote 51] However, for 2013, CMS
has indicated that it will not penalize individual providers or group
practices that year if they reported the electronic prescribing code
the minimum number of times required to qualify for incentive payments
in 2011.[Footnote 52] Additionally, CMS indicated that it may publish
an alternative reporting requirement that providers could meet to
avoid penalties in 2013. A CMS official that we interviewed told us
that the agency could, for example, require individual providers to
submit the electronic prescribing reporting code at least 10 times
between January 1, 2012, and June 30, 2012, in order to avoid
penalties in 2013.
CMS is exploring an alternative to using electronic prescribing code
submissions to determine which providers should receive incentive
payments or penalties. As a part of CMS's Medicare Part D, which
provides outpatient prescription drug benefits for Medicare
beneficiaries, CMS has required that Part D plan sponsors[Footnote 53]
submit additional data on the claims they send to Medicare for
reimbursement. CMS officials believe that Medicare Part D data could
be used at some point instead of the electronic prescribing reporting
code to determine which providers should receive incentive payments.
[Footnote 54] However, CMS officials have concerns about the
reliability of data from Part D claims, and note that these concerns
should be resolved before the data can be used.[Footnote 55] CMS does
not have specific plans or a time frame for implementing such a change.
CMS Paid about 8 Percent of Certain Medicare Providers Electronic
Prescribing Program Incentive Payments for 2009:
CMS paid Electronic Prescribing Program incentive payments for 2009 to
about 8 percent (about 47,500) of the over 597,000 Medicare providers
who had at least one applicable visit during 2009.[Footnote 56],
[Footnote 57] Each of these approximately 47,500 providers received
incentive payments equal to 2 percent of their total allowable
Medicare Part B charges in 2009, with payments totaling approximately
$148 million. The mean payment was about $3,120, the median payment
was about $1,700, and the five highest payments were between about
$54,500 and $67,500. CMS disbursed these payments to providers for
2009 in September and October 2010. CMS officials expect that the
number of Medicare providers reporting the electronic prescribing
reporting code in 2010 will increase over 2009 and noted that lowering
the reporting requirement for 2010 to submitting the applicable
electronic prescribing reporting code for at least 25 visits may
increase the number of providers receiving incentive payments. CMS
officials also told us that the penalties, which do not begin until
2012, might have a bigger effect on participation than the incentive
payments.
For the 2009 Electronic Prescribing Program, the percentage of
Medicare providers who received incentive payments and the average
incentive payment varied by state. (See figure 5 and figure 6.)
Although Minnesota and Wisconsin had the largest share of providers
receiving incentive payments at about 17 and 15 percent, respectively,
providers in those two states also received the lowest mean incentive
payment at about $740 and $1,500, respectively. Alaska and North
Dakota had the smallest share of providers receiving incentive
payments at about 2 percent each. Providers in Florida and South
Carolina had the highest mean incentive payments at about $5,800 and
$4,700, respectively. According to a report prepared for CMS about the
2009 Electronic Prescribing Program, the physician specialties with
the largest number of providers that earned incentive payments were
family practice and internal medicine, and the nonphysician
specialties with the largest number of providers that earned incentive
payments were nurse practitioners and physician assistants.[Footnote
58]
Figure 5: Percentage of Medicare Providers Who Received 2009
Electronic Prescribing Program Incentive Payments, by State:
[Refer to PDF for image: illustrated map of the U.S.]
Nationally, about 47,500 providers (about 8 percent) received
incentive payments.
Less than 5%:
Alaska:
Arizona:
Colorado:
District of Columbia:
Hawaii:
Kentucky:
Nevada:
New Hampshire:
New Mexico:
North Dakota:
Oklahoma:
Utah:
Vermont:
Wyoming:
Greater than or equal to 5% and less than or equal to 6.5%:
Alabama:
Arkansas:
Idaho:
Louisiana:
Maryland:
Missouri:
Montana:
Nebraska:
New York:
Ohio:
South Carolina:
Texas:
Washington:
Greater than or equal to 6.5% and less than 9.0%:
California:
Connecticut:
Delaware:
Florida:
Georgia:
Illinois:
Kansas:
Maine:
Mississippi:
New Jersey:
Tennessee:
West Virginia:
Greater than 9.0%:
Indiana:
Iowa:
Massachusetts:
Michigan:
Minnesota:
North Carolina:
Oregon:
Pennsylvania:
Rhode Island:
South Dakota:
Virginia:
Wisconsin:
Sources: GAO analysis of CMS data; Map Resources (map).
[End of figure]
Figure 6: Mean Incentive Payments from the 2009 Electronic Prescribing
Program, by State:
[Refer to PDF for image]
Less than $2,500:
Alaska:
Colorado:
Connecticut:
Idaho:
Massachusetts:
Minnesota:
Montana:
New Hampshire:
North Dakota:
Pennsylvania:
Rhode Island:
South Dakota:
Vermont:
Wisconsin:
Greater than or equal to $2,500 to less than $3,200:
California:
Maine:
Michigan:
North Carolina:
Oklahoma:
Tennessee:
Utah:
Virginia:
Washington:
West Virginia:
Wyoming:
Greater than or equal to $3,200 to less than $4,000:
Arizona:
Hawaii:
Illinois:
Indiana:
Iowa:
Kansas:
Maryland:
Missouri:
Nebraska:
Nevada:
New Mexico:
New York:
Ohio:
Texas:
Greater than $4,000:
Alabama:
Arkansas:
Delaware:
Florida:
Georgia:
Kentucky:
Louisiana:
Mississippi:
New Jersey:
South Carolina:
Sources: GAO analysis of CMS data; Map Resources (map).
[End of figure]
About 87,500 Medicare providers--approximately 15 percent of Medicare
providers who had at least one applicable visit during 2009--
participated in the program in 2009 by reporting the electronic
prescribing reporting codes to CMS. However, about 40,000 of those
participating providers--approximately 7 percent of Medicare providers
who had at least one applicable visit during 2009--did not receive
incentive payments because they did not meet or exceed both components
of the reporting requirement.[Footnote 59] (See figure 7.)
Specifically, these providers (a) submitted the electronic prescribing
reporting codes less than 50 percent of the time that they had an
applicable visit, (b) had less than 10 percent of their total allowed
Medicare Part B charges for the year from the services designated as
applicable visits, or (c) both (a) and (b) occurred. The vast majority
of the about 40,000 Medicare providers that participated in the
program but did not receive incentive payments submitted the
electronic prescribing codes less than 50 percent of the time they had
an applicable visit.
Figure 7: Electronic Prescribing Program, 2009:
[Refer to PDF for image: pie-chart]
Did not participate (about 510,000 providers): 85%;
Participated-”received incentive (about 47,500 providers): 8%;
Participated”-did not receive incentive (about 40,000 providers): 7%.
Source: GAO analysis of CMS data.
[End of figure]
While the Requirements in the EHR and Electronic Prescribing Programs
Are Similar in Some Cases, Aspects of These Requirements Are Not
Consistent:
We compared the electronic prescribing-related technology and
reporting requirements in the EHR Program with the requirements in the
Electronic Prescribing Program. The EHR Program provides incentives
from 2011 to 2016 and introduces penalties beginning in 2015, while
the Electronic Prescribing Program provides incentives from 2009 to
2013 and introduces penalties beginning in 2012. In comparing the
programs' requirements, we found some similarities but also areas
where the requirements of the programs are not consistent.
Technology requirement. Both the EHR and Electronic Prescribing
Programs require eligible providers to adopt and use technology that
meets certain requirements. The EHR Program requires providers to
adopt certified EHR technology and the Electronic Prescribing Program
requires providers to adopt qualified electronic prescribing systems.
(For more details, see figure 8.)
Figure 8: Technology Requirement for the EHR and Electronic
Prescribing Programs, 2011:
[Refer to PDF for image: table]
EHR Program[A]:
Providers must adopt and use systems that meet CMS‘s definition of a
qualified electronic prescribing system. A qualified electronic
prescribing system must be able to perform the following technical
capabilities: (1) generate a complete medication list; (2) generate
and transmit prescriptions electronically, and conduct alerts; (3)
provide information on formulary or tiered formulary medications,
patient eligibility, and authorization requirements; and (4) provide
information on lower-cost, therapeutically appropriate alternatives
(if any).[B]
Electronic Prescribing Program:
Providers must adopt and use certified EHR technology, which is
technology that meets certain certification criteria established by HHS‘
s ONC. The certification criteria describe the minimum related
standards and implementation specifications. Each reporting
requirement, including those related to electronic prescribing, is
linked to certification criteria.
Notes: Where applicable, systems used for the EHR and Electronic
Prescribing Programs will be consistent with CMS's Part D electronic
prescribing standards. For example, systems for both programs use the
National Council for Prescription Drug Programs' standard on
prescription transmission.
[A] In addition to 2011, this requirement also applies for the
duration of the first stage of the EHR Program, which remains in
effect from 2012 to 2014.
[B] According to CMS, the ability of an electronic prescribing system
to receive tiered formulary information would suffice for the
requirement to provide information on lower-cost alternatives in 2011
or until this function is more widely available in the marketplace.
See 75 Fed. Reg. 73556.
[End of figure]
Certified EHR systems and qualified electronic prescribing systems
must be able to perform similar electronic prescribing-related
activities. For example, both types of systems must be able to
generate and transmit prescriptions electronically, check for
potential drug and allergy interactions, and provide formulary
information.
The technology that providers must adopt and use for the EHR Program
must pass a certification process, which is used to designate a
technology as having met the program's technology requirements. For
the EHR Program, HHS's ONC, through the work of several advisory
committees, established a set of standards and specifications for EHR
technology and then created a program that will certify EHR technology
for use in the EHR Program based upon those standards and
specifications.[Footnote 60] According to ONC's Web site, the
certification process will ensure that the EHR technology that
providers adopt and use has the technological capabilities necessary
for providers to obtain incentive payments or avoid penalties from the
EHR Program.[Footnote 61],[Footnote 62] Further, the agency notes that
certifying EHR technology to these standards enhances the
interoperability of health information technology--that is, the
ability of different systems or components to exchange information and
to use the information that has been exchanged.[Footnote 63] EHRs that
conform to interoperability standards allow health information to be
created, managed, and consulted by authorized health care providers
across more than one health care organization, thus providing patients
and their caregivers the necessary information required for optimal
care.
The EHR Program's certification process is designed to produce a list
of certified EHR systems and certified EHR modules, which ONC has made
available to the public on its Web site. Accordingly, this information
should allow providers to identify and adopt systems that meet the EHR
Program's technological requirements.[Footnote 64] A module is a
component of an EHR system that meets at least one of the
certification criteria established by ONC.[Footnote 65] Individual EHR
modules can be certified and integrated with other certified EHR
modules to form a complete, certified EHR system. At the time of our
review, technologies certified for use in the EHR Program--that is,
complete EHR systems or combinations of modules that collectively can
perform the capabilities that constitute a qualified electronic
prescribing system--appeared to also meet the Electronic Prescribing
Program's technological requirements.[Footnote 66] Although according
to ONC officials, certified EHR technology is not required to provide
information on lower-cost alternatives--which is a component of the
Electronic Prescribing Program's technology requirement--CMS has
indicated that an electronic prescribing system that does not conform
to that component of the Electronic Prescribing Program's technology
requirement would still meet the definition of a qualified system in
2011 and until this function is more widely available in the
marketplace.[Footnote 67]
Although providers seeking incentive payments or trying to avoid
penalties from the Electronic Prescribing Program must adopt and use
qualified electronic prescribing systems, according to a CMS official
the Electronic Prescribing Program does not have a process like the
EHR Program's to identify and certify which electronic prescribing
systems meet the requirements of a qualified system.[Footnote 68] As a
result, providers may not be certain which systems meet the program's
technological requirement.[Footnote 69]
Reporting requirements. Both the EHR Program and Electronic
Prescribing Program require eligible providers to report certain
information about their electronic prescribing activities to CMS in
order to receive incentive payments, which began in 2009 for the
Electronic Prescribing Program and began in 2011 for the EHR Program.
(See figure 9 for a summary of the two programs' electronic
prescribing-related reporting requirements.) However, we also found
that the electronic prescribing-related reporting requirements in the
EHR Program are more rigorous. Providers seeking incentive payments
from the EHR Program have at least five reporting requirements related
to electronic prescribing,[Footnote 70] while providers in the
Electronic Prescribing Program have only one reporting requirement.
[Footnote 71] Moreover, the EHR Program requires providers to report
more-detailed information--namely, information on their use of various
electronic prescribing-related technological capabilities--a
requirement that should increase their use of these capabilities.
[Footnote 72] Additionally, while CMS has established reporting
requirements providers must meet in order to avoid the penalties under
the Electronic Prescribing Program that begin in 2012, CMS has not yet
identified what providers must report in order to avoid penalties
under the EHR Program, but plans to do so in future rulemakings.
Figure 9: Electronic Prescribing-Related Reporting Requirements for
the EHR and Electronic Prescribing Programs, 2011:
[Refer to PDF for image: table]
Electronic Prescribing-–Related Reporting Requirements to Receive an
Incentive Payment:
EHR Program[A]: Generate and transmit more than 40 percent of
permissible prescriptions electronically;[B,C] [Bolded]
Electronic Prescribing Program: Individual providers must report the
electronic prescribing code for at least 25 applicable visits.
Submitting the code indicates the provider electronically transmitted
at least one prescription during a visit using a qualified electronic
prescribing system. Providers that choose to report to CMS as part of
a group practice must report the electronic prescribing code for at
least 75 to 2,500 applicable visits, depending upon the size of the
group practice.[D] For individuals or groups, 10 percent of their
total Part B charges must be designated as applicable patient visits.
EHR Program[A]: Enter medication order into Computerized Physician
Order Entry system for more than 30 percent of patients with at least
one medication in their medication lists;[B,E] [Bolded]
Electronic Prescribing Program: Not a reporting requirement.
EHR Program[A]: Enter medication lists or indicate no current
prescriptions for more than 80 percent of patients; [Bolded]
Electronic Prescribing Program: Not a reporting requirement.[F]
EHR Program[A]: Enter medication allergy lists or indicate no known
medication allergies for more than 80 percent of patients; [Bolded]
Electronic Prescribing Program: Not a reporting requirement.
EHR Program[A]: Enable the EHR system‘s ability to check a
prescription for potential drug–drug and drug–allergy interactions;
[Bolded]
Electronic Prescribing Program: Not a reporting requirement.[F]
EHR Program[A]: Perform medication reconciliation for more than 50
percent of all transitions of care;[G,H]
Electronic Prescribing Program: Not a reporting requirement.
EHR Program[A]: Enable the EHR system‘s ability to check a
prescription against a formulary and maintain access to at least one
internal or external drug formulary for the entire EHR reporting
period;[B]
Electronic Prescribing Program: Not a reporting requirement.[F]
Electronic Prescribing–Related Reporting Requirements to Avoid a
Penalty:
EHR Program[A]: CMS has yet not determined what providers will be
required to report in order to avoid penalties, which begin in 2015;
Electronic Prescribing Program: To avoid the penalty in 2012:
Individual providers must report the electronic prescribing code for
at least 10 applicable visits between January 1, 2011, and June 30,
2011, using a qualified electronic prescribing system.[I] Providers
that choose to report to CMS as part of a group practice must report
the electronic prescribing code for at least 75 to 2,500 applicable
visits between January 1, 2011, and June 30, 2011, depending upon the
size of the group practice.[D]
Source: GAO analysis of CMS data.
Notes: For the EHR Program, the five bolded requirements above are
mandatory and the two nonbolded requirements are additional
requirements that providers may choose to report. Providers wanting to
obtain incentive payments for the EHR Program will have to meet a
total of 20 reporting requirements (15 mandatory and an additional 5
that they choose from a menu of 10 additional requirements). See
appendix V for a complete list of the reporting requirements. Certain
reporting requirements may not apply to all eligible providers; in
such cases, eligible providers would report to CMS which reporting
requirements did not apply to their practices. For example,
chiropractors--who do not have prescribing authority--would report to
CMS that the reporting requirements listed above did not apply to
their practices.
[A] In addition to 2011, these requirements also apply for the
duration of the first stage of the EHR Program, which remains in
effect from 2012 to 2014.
[B] Providers who write fewer than 100 prescriptions during the
reporting period would be exempt from this reporting requirement.
[C] A prescription is considered permissible if it is not subject to
Department of Justice restrictions on the electronic prescription of
narcotics or other controlled substances.
[D] Group practices of 2-10 providers must report the electronic
prescribing code for at least 75 applicable visits; 11-25 providers
must report the code for at least 225 applicable visits; 26-50
providers must report the code for at least 475 applicable visits; 51-
100 providers must report the code for at least 925 applicable visits;
101-199 providers must report the code for at least 1,875 applicable
visits; and 200 or more providers must report the code for at least
2,500 applicable visits.
[E] Computerized physician order entry refers to systems used for
medication-ordering designed to help ensure that medication orders are
standardized, legible, and complete.
[F] When providers report the electronic prescribing code, they are
attesting that they used a qualified electronic prescribing system,
which has the technological capability that corresponds to this EHR
Program reporting requirement.
[G] Medication reconciliation is the electronic comparison of two or
more medication lists in instances such as when a patient's provider
or setting of care changes.
[H] Providers who do not receive a transition of care during the
reporting period would be exempt from this reporting requirement.
[I] Certain individual providers may be exempt from receiving a
penalty under the Electronic Prescribing Program. For example, a
provider with fewer than 100 applicable patient visits between January
1, 2011, and June 30, 2011, would be exempt from receiving a penalty.
[End of figure]
We also found that the two programs' reporting requirements are not
consistent because they make certain Medicare providers subject to
both programs' reporting requirements during the same year.
Specifically, physicians--the largest population among each program's
eligible providers--may choose to participate in the EHR Program in
2011 because the potential incentive payment will likely be higher
under that program than under the Electronic Prescribing Program in
2011.[Footnote 73] However, to avoid the penalty assessed by the
Electronic Prescribing Program in 2012, CMS will require physicians to
meet the Electronic Prescribing Program's reporting requirement in
2011,[Footnote 74] even if they elect to participate in the EHR
Program in 2011.[Footnote 75] Public comments on the agency's proposed
requirements for the 2011 Electronic Prescribing Program included the
concern that providers are burdened by having to submit electronic
prescribing data more than once. In response, CMS stated that it will
study possible methods of aligning the two programs and will include
this information in the integration plan it is already required to
develop by January 1, 2012, to integrate the reporting requirements in
the EHR Program and PQRS, CMS's quality measures program.[Footnote 76]
However, if CMS adheres to this schedule, the agency will not be able
to remove the reporting burden placed on physicians subject to
penalties from the Electronic Prescribing Program in 2013, given that
the requirements for avoiding penalties in 2013 would likely be
proposed in July 2011 and finalized in November 2011. If CMS includes
possible methods of aligning the two programs in the integration plan,
any action to propose and finalize requirements will take place
sometime after January 1, 2012, well beyond the date for making
changes to the program in 2013. In technical comments provided on a
draft of this report, HHS noted that it plans to include possible
methods of aligning the two programs for the 2012 program year (and
possibly for the 2013 program year) in rulemaking during 2011.
[Footnote 77]
Both the EHR Program and Electronic Prescribing Program require
providers seeking incentive payments to attest that they have met the
programs' reporting requirements. In the EHR Program, providers will
submit the results of their performance on each of the reporting
requirements once per program year, while providers in the Electronic
Prescribing Program attest that they adopted and used a qualified
electronic prescribing system by reporting the electronic prescribing
code to CMS. At least with reference to the EHR Program, CMS has
acknowledged that attestation may create a potential for fraud and
abuse and noted that the agency is developing an audit strategy to
address this risk.[Footnote 78] CMS officials from the Office of E-
Health Standards and Services told us they plan to make guidance on
this strategy available by May 2011. In the case of the Electronic
Prescribing Program, an official from CMS's Office of Clinical
Standards and Quality, which administers that program, told us that
the agency did not audit electronic prescribing codes submitted by
providers for 2009 and does not have plans to develop an audit
strategy for the program. However, this official did tell us that CMS
reserves the right to audit any program participant.[Footnote 79]
Conclusions:
Health information technology, such as electronic prescribing, has the
potential to improve the quality of care received by patients and also
reduce costs for the health care system. To help encourage the
adoption of such technologies among Medicare providers, Congress first
established the Electronic Prescribing Program and then the EHR
Program, both of which provide incentive payments to eligible
providers that adopt and use the appropriate health information
technologies and impose penalties on those eligible providers that
fail to do so.
Despite both programs having a goal to expand the adoption and use of
health information technologies by health providers, and in
particular, physicians--the largest and only group of providers
eligible to earn incentive payments in both programs--we found
inconsistencies in the requirements. We believe these inconsistencies
may limit the programs' effectiveness in encouraging the use of health
information technologies. First, we found that because the Electronic
Prescribing Program lacks a certification process like that
established for the EHR Program, physicians and other health care
providers who want to obtain incentive payments or avoid penalties
from the former program have no assurance that the systems they invest
in will meet that program's technology requirements. In contrast,
physicians who invest in certified EHR systems can be assured that in
doing so they would meet the current requirements of both programs. In
addition, physicians that invest in certified EHR modules integrated
together to perform the electronic prescribing-related capabilities
could also be assured that they meet the current requirements of the
Electronic Prescribing Program and that the adopted technology could
later be integrated with other certified modules to form a complete,
certified EHR system. This inconsistency between the programs has the
potential to create uncertainty among physicians as to what technology
they should adopt, because although the Electronic Prescribing Program
ends after 2014, the EHR Program continues; encouraging physicians to
adopt certified electronic prescribing technology now may also help
facilitate their later transition between the programs. Nonphysician
health care providers who are not eligible to earn incentive payments
from the EHR Program could adopt certified technology and in so doing
could have assurance that the electronic prescribing technology they
invest in meets the Electronic Prescribing Program's technology
requirements. Second, we also found that the two programs have
established separate reporting requirements related to electronic
prescribing, requiring some physicians who elect to report to the EHR
Program to report to both programs in 2011 and potentially requiring
physicians to report to both programs through 2014, when penalties for
the Electronic Prescribing Program end. CMS recognizes that this
duplication places additional burden on physicians, and we believe
this duplication could affect the decision of physicians to adopt and
use health information technology. However, CMS is still in the
process of studying possible ways to address this duplication, and if
the agency wants to eliminate the burden for providers in 2012, it
would need to do so during its 2011 rulemaking. In addition, CMS has
not been consistent in the steps it has taken to ensure the
appropriate use of these programs' resources. Namely, CMS plans to
establish an audit program for the EHR Program--under which the
maximum incentive payment for a provider will generally not exceed
$18,000 per year--to address potential fraud and abuse that might
arise from the use of self-attestations, but CMS does not have plans
to develop a similar approach in the Electronic Prescribing Program,
under which CMS paid providers up to approximately $67,500 for 2009.
The Electronic Prescribing Program began before the EHR Program, so
CMS has already had the opportunity to encounter and learn from
challenges in implementation. For example, in the first year of the
Electronic Prescribing Program, only about 8 percent of providers
received incentive payments, and CMS changed some of the program's
requirements in the second year to encourage greater adoption and use
of electronic prescribing technology. For the EHR Program, it is too
soon to know how many providers will adopt EHR systems. However, given
that the electronic prescribing-related reporting requirements in the
EHR Program are more rigorous than the reporting requirement in the
Electronic Prescribing Program, CMS may find that it needs to modify
the EHR Program requirements to better encourage the adoption and use
of EHR systems. Because implementation of the Electronic Prescribing
Program preceded the EHR Program, CMS has an opportunity to use the
experiences gained in implementing the Electronic Prescribing Program
to inform its implementation of the EHR Program in order to determine
how to best encourage the adoption and use of health information
technology among Medicare providers. One approach could be to
incorporate these experiences into the integration plan the agency is
already required to develop by January 1, 2012, to integrate the
reporting requirements in the EHR Program and PQRS.
Recommendations for Executive Action:
To help improve the effectiveness of the Electronic Prescribing and
EHR Programs to encourage the adoption of health information
technologies among Medicare providers, the Administrator of CMS should
take the following three actions:
* Encourage physicians and other health care providers in the
Electronic Prescribing Program to adopt certified electronic
prescribing technology.
* Expedite efforts to remove the overlap in reporting requirements for
physicians who may be eligible for incentive payments or subject to
penalties under both the Electronic Prescribing and EHR Programs by,
for example, aligning the reporting requirements so that successfully
qualifying for incentive payments or for avoiding penalties under the
EHR Program would likewise result in meeting the requirements for the
Electronic Prescribing Program.
* Identify factors that helped or hindered implementation of the
Electronic Prescribing Program to help support the ongoing
implementation of the EHR Program. CMS could include consideration of
such factors in the integration plan that the agency is required to
develop by January 1, 2012.
To help ensure that Electronic Prescribing Program resources are used
appropriately, the Administrator of CMS should develop a risk-based
strategy to audit a sample of providers who received incentive
payments from the Electronic Prescribing Program to help ensure that
providers who receive incentive payments meet that program's
requirements. A risk-based strategy could, for example, focus on those
providers who received larger incentive payments.
Agency and External Party Comments and Our Evaluation:
We obtained written comments on our draft report from HHS on behalf of
CMS, which are reprinted in appendix VI. CMS agreed in full with two
recommendations, agreed in principle with one recommendation, and
disagreed with a fourth recommendation.
CMS disagreed with our first recommendation that the agency direct
providers in the Electronic Prescribing Program to use technology
certified as an EHR system or module(s). While CMS said that it
concurred with the notion that eligible providers should be able to
use certified EHR systems for the Electronic Prescribing Program, it
did not agree that it should direct eligible providers to use
prescribing technology that has been certified as an EHR system. CMS
said that doing so could result in Electronic Prescribing Program
participants having to replace their qualified electronic prescribing
systems with systems certified under the EHR Program. We do not
recommend that CMS direct those providers who are already
participating in the Electronic Prescribing Program to replace their
current systems with certified systems. On the contrary, the intent of
our recommendation is to have CMS encourage providers in the
Electronic Prescribing Program who have not yet adopted electronic
prescribing systems, or who plan on upgrading their existing systems,
to choose systems that have already been certified through the EHR
Program's certification process. We continue to assert our
recommendation because, as we noted in our draft report, this
certification process identifies a list of available systems that meet
the certification requirements and provides assurance that the
technology physicians and other health care providers adopt would meet
the technology requirements of the Electronic Prescribing Program.
Additionally, the physicians who later participate in the EHR Program
could be assured that the technology also meets the requirements in
the EHR Program. In our draft report, we noted that there is no
comparable process in the Electronic Prescribing Program, and as a
result, providers have no assurance that the systems they invest in
for the EHR Program will meet that program's technology requirements.
Given that the Electronic Prescribing Program ends after 2014 while
the EHR Program will continue, encouraging providers to adopt
certified electronic prescribing technology now may also help
facilitate physicians' transition between the programs. We have
clarified the recommendation to state that CMS should encourage
physicians and other health care providers in the Electronic
Prescribing Program to adopt certified electronic prescribing
technology.
CMS agreed with our second recommendation that it expedite efforts to
remove the overlap in reporting requirements for physicians eligible
for both programs, and noted that it plans to address this overlap in
rulemaking during 2011, where applicable. We support CMS's efforts to
expeditiously remove the overlap in the reporting requirements as we
recommended.
CMS agreed with our third recommendation that it would be helpful for
the agency to identify factors that helped or hindered implementation
of the Electronic Prescribing Program to help support the ongoing
implementation of the EHR Program. While CMS identified factors that
may be affecting implementation of electronic prescribing, other
factors that may have broader applicability to the implementation of
the EHR Program could include the effect of penalties on technology
adoption, measuring compliance with program requirements, and
validating self-reported attestations.
CMS agreed in principle with our fourth recommendation that CMS
develop a risk-based strategy to audit a sample of providers who
received incentive payments from the Electronic Prescribing Program.
In response CMS said that it agrees that an audit of a sample of
providers may be needed, however, it disagreed that such a strategy
should necessarily focus on eligible providers who received large
incentive payments, noting that such an audit process, if implemented,
could select providers at random. As we recommended, we believe that
an audit strategy should be implemented for this program. We
recommended a risk-based audit strategy because although many
providers received modest incentive payments in 2009, some providers
received payments at least three times as high as the maximum annual
incentive payment in the EHR Program. However, if implemented by CMS,
a random audit would be consistent with the intent of our
recommendation. CMS also noted that because it is considering using
Part D data in the future to determine which providers should receive
incentive payments for this program, use of these data could also
alleviate the need for an audit. However, as we noted in our draft
report, CMS officials raised several concerns--concerns echoed in its
comments on our draft report--about the reliability of Part D data to
determine which providers receive incentive payments. As we reported,
CMS officials told us that these data reliability concerns should be
resolved before Part D data can be used to determine which providers
should receive incentive payments for this program.
HHS has also provided technical comments, which we incorporated as
appropriate. We also provided excerpts of our report to the VA, Blue
Cross Blue Shield of Massachusetts, CVS Caremark, the Florida Agency
for Health Care Administration, and organizations that participated in
the Southeastern Michigan ePrescribing Initiative, which provided
technical comments that we incorporated as appropriate.
We are sending copies of this report to the Secretary of HHS, the
Administrator of CMS, and the National Coordinator for Health
Information Technology in HHS and interested congressional committees.
In addition, the report will be available at no charge on the GAO Web
site at [hyperlink, http://www.gao.gov].
If you or your staffs have questions about this report, please contact
me at (202) 512-7114 or at kohnl@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to
this report are listed in appendix VII.
Signed by:
Linda T. Kohn:
Director, Health Care:
[End of section]
Appendix I: List of Committees:
The Honorable Max Baucus:
Chairman:
The Honorable Orrin G. Hatch:
Ranking Member:
Committee on Finance:
United States Senate:
The Honorable Tom Harkin:
Chairman:
The Honorable Michael B. Enzi:
Ranking Member:
Committee on Health, Education, Labor, & Pensions:
United States Senate:
The Honorable Fred Upton:
Chairman:
The Honorable Henry A. Waxman:
Ranking Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Dave Camp:
Chairman:
The Honorable Sander M. Levin:
Ranking Member:
Committee on Ways and Means:
House of Representatives:
[End of section]
Appendix II: Effect of Electronic Prescribing on Quality or Cost:
This appendix addresses congressional interest in how others have
measured whether or to what extent electronic prescribing improves
quality or reduces cost.[Footnote 80] For example, the Medicare
Improvements for Patients and Providers Act of 2008 (MIPPA) directed
us to report on information related to reductions in avoidable medical
errors and estimated savings to Medicare resulting from the use of
electronic prescribing.[Footnote 81] To address these issues, we
obtained information from organizations about research they conducted,
funded, or participated in that measured the effects of electronic
prescribing on quality, cost, or both. Specifically, we obtained
information from the following organizations: Blue Cross Blue Shield
of Massachusetts, CVS Caremark, the Florida Agency for Health Care
Administration, and the Southeastern Michigan ePrescribing Initiative.
[Footnote 82] In addition, we reviewed 29 published studies that
measured the effects of electronic prescribing on quality, cost, or
both.[Footnote 83]
Our information collection, review of published studies, and summaries
contained in this appendix focused on specific aspects of quality and
cost that we believed were most similar to the policy goals underlying
the development of the Electronic Prescribing Program and the
Electronic Health Records (EHR) Program.[Footnote 84]
* Quality. We included studies that reported findings related to
beneficiary quality, such as reductions in avoidable medical errors.
* Cost. We included studies that reported findings related to savings
to health care payers, which are those parties generally responsible
for paying claims for health care services, because we believed they
would be the most applicable to determining the effects of electronic
prescribing on costs for Medicare. We did not review studies that
estimated potential savings for providers, such as savings associated
with reductions in time spent writing prescriptions or resolving
questions about prescriptions.
The studies evaluated the effects of a variety of different types of
electronic prescribing technology, such as stand-alone electronic
prescribing systems and EHR systems that include electronic
prescribing-related functions. According to the Healthcare Information
and Management Systems Society (HIMSS), EHR systems also typically
include information such as patient demographics, progress notes,
problems, medications, vital signs, past medical history,
immunizations, laboratory data, and radiology reports. Additionally,
computerized physician order entry (CPOE) systems (also referred to as
computerized provider order entry systems or computerized prescriber
order entry systems) allow for electronic ordering of medications and
may include other functions, such as ordering laboratory procedures
and referrals. Hospitals may employ CPOE systems as part of a strategy
to reduce medication errors. Some organizations and published studies
evaluated the effects of electronic prescribing systems that had
clinical decision support (CDS) capabilities, which can include checks
for allergies, drug-drug interactions, overly high doses, clinical
conditions, and other patient-specific dose checking, and can provide
access to information on patient medical histories, pharmacy
eligibility, and formulary and benefits. It is important to note that
the electronic prescribing systems evaluated by the organizations we
obtained information from and published studies we reviewed may have
had technical capabilities that differ from the technological
requirements in the Electronic Prescribing Program or the EHR Program.
Methodology:
The studies utilized a variety of different methodologies, including
the following: (1) pre-post methodologies, which compare dimensions of
quality or cost before and after the implementation of electronic
prescribing systems or CPOE systems; (2) comparison methodologies,
which are used to compare dimensions of quality, cost, or both between
a control group (i.e., one that does not electronically prescribe) and
an intervention group (i.e., one that does electronically prescribe);
and (3) cost simulations and cost-benefit analyses that projected the
costs and savings of implementing electronic prescribing systems.
How Electronic Prescribing Was Determined:
Some studies identified compared a population of providers that
electronically prescribed to a population that did not (e.g.,
handwrote prescriptions). For example, some studies identified a
population of providers who had access to electronic prescribing
systems and compared them to a population of other providers who did
not have access to electronic prescribing systems, while other studies
identified prescriptions before CPOE implementation and compared those
prescriptions to prescriptions transmitted after CPOE implementation.
Other studies only looked at populations of providers known to be
electronic prescribers. Other studies were designed to evaluate the
effect of advanced features of the electronic prescribing system. For
example, one study by Steel et al. was designed to compare medication
ordering behavior when no alert was triggered by the CPOE system to
ordering behavior after alerts were triggered.
Outcomes Measured:
The organizations we interviewed and published studies we reviewed
examined a variety of different outcomes in order to evaluate the
effect on quality, cost, or both. Examples of the outcomes measured to
evaluate the effect of electronic prescribing on health care quality
include the following:
* medication order changes resulting from information provided by the
electronic prescribing system, such as alerts for potentially
inappropriate medications or formulary information, or changes
resulting from problems with the quality of the prescription such as
errors identified by the electronic prescribing system related to
dosage, directions, or illegibility;
* changes in potential or actual adverse drug events (ADE); and:
* provider satisfaction that the electronic prescribing system was
improving safety.
Examples of the outcomes measured to evaluate the effect of electronic
prescribing on cost include the following:
* drug costs or other outcomes that have cost implications, such as
formulary compliance or generic utilization; and:
* follow-up health care costs resulting from reductions in adverse
drug events.
Reported Findings:
In terms of health care quality, some studies found differences in
medication error rates when electronic prescribing was used. For
example, a study conducted by Weingart et al. and funded by Blue Cross
Blue Shield of Massachusetts estimated that medication safety alerts
prevented an estimated 402 ADEs (49 serious or life threatening, 125
significant, and 228 minor) and that alerts that resulted in
physicians canceling or changing the medication order may have
prevented deaths in 3 cases, permanent disability in 14 cases, and
temporary disability in 31 cases. Another study by Devine et al.
reported that rates of errors in prescriptions declined from 18.2
percent before to 8.2 percent after implementation of a CPOE system.
However, some studies found no significant differences in medication
error rates before and after the implementation of electronic
prescribing systems.
Some of the evaluations that focused on prescription drug costs showed
savings when electronic prescribing systems were used. For example, a
cost-benefit analysis conducted by Byrne et al. estimated that the use
of Veterans Health Information Systems and Technology Architecture
(VistA), which includes electronic prescribing and CDS capabilities of
the Department of Veterans Affairs (VA) health system electronic
health records, contributed to a cumulative $4.64 billion in value due
to the prevention of unnecessary hospitalizations and outpatient
visits resulting from prevented ADEs. In this study, the total net
value of the VA's investments in the VistA components modeled was
estimated to exceed $3.09 billion. A study by McMullin et al. of an
electronic prescribing system that provided patient formulary
information shifted prescriber behavior from selecting drugs from
eight high-cost therapeutic groups to less-expensive alternatives.
However, a study by Ross et al. found no significant difference in
formulary compliance between electronic prescribers (83.2 percent) and
paper prescribers (82.8 percent).
Of the studies we reviewed in which the electronic prescribing systems
were reported to have CDS capabilities--such as drug-drug, drug-
allergy alerts, or drug-formulary checks--most reported health care
quality or cost effects. For example, a study by DesRoches et al.
reported that providers who adopted EHR with electronic prescribing
decision support capabilities averted potentially dangerous drug-drug
interactions. One study by Galanter et al. found that the likelihood
of contraindicated drugs being administered to patients of inadequate
kidney function decreased by 42 percent after electronic prescribing
CDS alerts were implemented. Ko et al. surveyed providers and found
that the majority viewed drug-drug interaction alerts as increasing
their potential to more safely prescribe medications. Another study by
Kaushal et al. attributes the implementation of a CPOE with CDS as
leading to an estimated $28.5 million in savings--$12.9 million from
decreased adverse drug events and $6 million from decreased drug
costs--however, the study also estimated that the cost to develop,
implement, and operate the CPOE system was $11.8 million.
Table 1: Summaries of Evaluations Obtained from Organizations:
Blue Cross Blue Shield of Massachusetts:
Beginning in 2003, Blue Cross Blue Shield of Massachusetts contracted
with software vendors to provide electronic prescribing software,
which included CDS, free of charge to high-volume prescribers in their
provider network. Blue Cross Blue Shield of Massachusetts continues to
sponsor a limited number of electronic prescribing software licenses
free of charge. As of September 2010, Blue Cross Blue Shield of
Massachusetts estimated that 60 percent of its network physicians were
electronically prescribing.
Study #1: Prescribing Patterns:
Methodology; A pre-post study comparing 1,932 Blue Cross Blue Shield
of Massachusetts's providers that were using an electronic prescribing
device to the providers in the network that were not electronically
prescribing (control group). The preintervention period was calendar
year 2003 and the postintervention period was 2006.
How electronic prescribing was determined: Whether the prescriber used
an electronic prescribing device, as determined from data obtained
from Blue Cross Blue Shield of Massachusetts's pharmacy benefits
manager.
Outcome(s) measured: (1) Prescribing patterns by drug tier. (2)
Savings in drug costs as a result of different prescribing patterns.
Reported findings: (1) Prescribers who used an electronic prescribing
device prescribed more generic and on-formulary prescriptions. (2)
Prescribers saved Blue Cross Blue Shield of Massachusetts 5 percent on
drug costs relative to those prescribers that did not use an
electronic prescribing device.
Other issues: Blue Cross Blue Shield of Massachusetts noted that some
of the individuals in the control group may have been electronically
prescribing but they assumed in the study that they were not because
of the absence of data.
Study #2: Fischer, M.A., C. Vogeli, M. Stedman, T. Ferris, M.A.
Brookhart, and J.S. Weissman. "Effect of Electronic Prescribing With
Formulary Decision Support on Medication Use and Cost." Archives of
Internal Medicine, vol. 168, no. 22. (2008): 2433-39.
Methodology: Blue Cross Blue Shield of Massachusetts provided pharmacy
claims data used by the researchers in a pre-post study of the
implementation of electronic prescribing software with formulary
decision support. The study consisted of an intervention group of
1,198 prescribers who wrote at least one electronic prescription, and
a control group of 34,453 prescribers who did not electronically
prescribe. Claims data were collected for 18 months--6 months before
the intervention (October 2003 through March 2004) and 12 months
postintervention (April 2004 through March 2005)--and data on
electronic prescriptions were collected in the 12 month
postintervention period.
How electronic prescribing was determined: Whether the prescriber
wrote at least one electronic prescription, as captured by the
electronic prescribing system.
Outcome(s) measured: (1) The change in the proportion of prescriptions
for three formulary tiers before and after electronic prescribing was
implemented; and (2) the potential savings associated with this change.
Reported findings: (1) Electronic prescribing led to a 3.3 percent
increase in Tier 1 prescribing--that is, those medications with the
lowest copayment. (2) On the basis of average costs, the study
estimated that implementation of electronic prescribing software with
formulary decision support could lead to a savings of $845,000 per
100,000 patients.
Study #3: Weingart, S.N., B. Simchowitz, H. Padolsky, T. Isaac, A.C.
Seger, M. Massagli, R.B. Davis, and J.S. Weissman. "An Empirical Model
to Estimate the Potential Impact of Medication Safety Alerts on
Patient Safety, Health Care Utilization, and Cost in Ambulatory Care."
Archives of Internal Medicine, vol. 169, no. 16. (2009): 1465-73.
Methodology: Blue Cross Blue Shield of Massachusetts funded and
provided some data for a study that estimated the quality improvement
and savings associated with medication safety alerts. The study
examined 1,833,254 prescriptions written using a commercial electronic
prescribing system by 2,321 clinicians for 60,352 patients. During the
study period (January through June 2006), 279,476 drug-drug
interaction alerts were generated. For each drug-drug interaction,
expert panelists examined whether it might result in an adverse drug
event and the severity of that event. The study used published sources
and payer data to estimate the costs to third-party payers associated
with different types of health care services due to adverse drug
events.
How electronic prescribing was determined: All prescriptions were
generated from the electronic prescribing system. The company that
developed the electronic prescribing system provided researchers
information on all drug-drug interactions generated and data on the
prescribers' action on receiving the alert.
Outcome(s) measured: (1) The likelihood and severity of the potential
ADE that the alert prevented, and (2) cost savings estimated from
reduced health care utilization.
Reported findings: (1) The study estimated that medication safety
alerts prevented an estimated 402 adverse drug events (49 serious or
life threatening, 125 significant, and 228 minor). Alerts that
physicians "accepted," meaning the physician either canceled the
prescription or changed to an alternative medication, may have
prevented deaths in 3 cases, permanent disability in 14 cases, and
temporary disability in 31 cases. (2) Due to lower utilization of
health care services the study estimated annual savings to be $402,619.
[End of Blue Cross Blue Shield of Massachusetts]
CVS Caremark:
Beginning in 2000, CVS Caremark made electronic prescribing available
through its proprietary iScribe system to interested providers by
download from a Web site. In late 2004, CVS Caremark supported
electronic prescribing by providing software, hardware, installation,
training, and service to providers on behalf of health care payers.
Study #1: Hutchins, D.S., M. Lewis, R. Velazquez, and J. Berger. "E-
Prescribing Reduces Beers Prescribing Among the Elderly." CVS
Caremark, May 22, 2007.
Methodology: A control group study of 383,855 prescription claims
written for 14,557 persons over 65 years of age between April 2002 and
June 2005 by over 3,700 providers, 70 of whom implemented an
electronic prescribing tool that alerted them to the prescribing of
"Beers List" medications to patients over 65 years of age.
How electronic prescribing was determined: Whether the prescription
was dispensed before or after a provider adopted the electronic
prescribing tool.
Outcome(s) measured: Whether use of the specific electronic
prescribing tool had an effect on the prescribing of potentially
inappropriate drugs from the Beers List to the elderly.
Reported findings: Use of the specific electronic prescribing tool
that provided alerts specific to Beers List medications can reduce
prescribing of those medications among the elderly.
Study #2: Hutchins, D.S., J.N. Liberman, J. Berger, S. Jan, M. M.
Johnson. "The Impact of an Electronic Prescribing Solution on the
Selection and Prescribing of Cost-Effective Therapeutic Options." CVS
Caremark, 2009.
Methodology: A pre-post control group study of over 9 million claims
in seven drug classes prescribed by one of over 29,000 providers
(about 250 of which used the electronic prescribing tool) that were
filled between July 2002 and December 2005.
How electronic prescribing was determined: Whether the provider used
an electronic prescribing tool.
Outcome(s) measured: Whether the use of an electronic prescribing
system has an effect on prescribing low-cost generic and mail-
delivered drugs.
Reported findings: Across multiple drug classes, study reported a link
between use of electronic prescribing systems and a greater likelihood
that generic drugs were prescribed and that they were dispensed
through mail order, both of which likely lower overall costs.
[End of CVS Caremark]
The Florida Agency for Health Care Administration:
The Florida Agency for Health Care Administration provided Medicaid
providers, at no charge, access to a CDS tool called EMPOWERx, which
allows for electronic prescribing and includes the following
capabilities: provides comprehensive medication histories, alerts
providers to drug-drug and drug-allergy interactions, and provides
formulary information.
Methodology: A comparison of the costs and savings for 1,000 Medicaid
providers in the state in the EMPOWERx personal digital assistant
program to the total population of Medicaid providers in the state.
How electronic prescribing was determined: Whether or not the provider
was in the EMPOWERx personal digital assistant program.
Outcome(s) measured: (1) The average cost per patient for all
prescriptions. (2) The estimated savings for prescriptions written by
providers in the EMPOWERx personal digital assistant program, based on
the difference between costs for providers in the two groups and the
number of patients associated with the EMPOWERx personal digital
assistant program providers. (3) The estimated savings for the 1,000
Medicaid providers in the EMPOWERx personal digital assistant program
based on information collected about alerts those providers received
about drug interactions in response to a medication order, assumptions
about avoidable hospitalizations, and assumptions about
hospitalization costs.
Reported findings: In the fourth quarter of 2009 (1) average costs per
patient for all prescriptions were about $28 to $30 lower for the
providers in the EMPOWERx personal digital assistant program; (2) the
cost differences between the two groups represents estimated savings
of approximately $5.5 million; and (3) by assuming that 5 percent of
the 12,480 high-or very-high-severity drug interactions would have led
to hospitalizations and that hospitalizations resulting from
preventable drug interactions are associated with an average increased
cost of $4,685 per incident, the study estimated that the state
Medicaid program saved approximately $2.9 million.
[End of The Florida Agency for Health Care Administration]
Southeastern Michigan ePrescribing Initiative:
The Southeastern Michigan ePrescribing Initiative, a collaborative
effort of employers, health plans, pharmacy benefit managers,
physician groups, and others, was launched in 2005 to speed the
adoption of electronic prescribing. Some of the studies that resulted
from this collaboration are summarized below.
Study #1: An official with Medco described a study it conducted. Medco
is a pharmacy benefit manager and member of the collaborative.
Methodology: A comparison study of a group of 1,165 physicians who
electronically prescribed to Medco's mail-order drug program and 1,000
physicians that did not. Data were collected in the second quarter of
2008.
How electronic prescribing was determined: Providers were included in
the electronic prescribing group if they had sent at least 20
prescriptions electronically to Medco's mail-order drug program during
the study time period. Providers were included in the nonelectronic
prescribing group if they had not met this criterion and provided
services in the same zip codes as the providers in the electronic
prescribing group.
Outcome(s) measured: The average cost per prescription per group for
retail and mail order prescriptions, which was calculated by dividing
total costs (identified through claims data) for each category and
group by the number of prescriptions for each category and group.
Reported findings: Providers in the electronic prescribing group saved
an average of $2.11 per retail prescription and $7.44 per mail-order
prescription compared to the group that did not electronically
prescribe.
Other issues: The Medco official noted that the findings were not
tested for significance or subjected to other more-rigorous
validations. It is possible that providers in the group that did not
electronically prescribe were electronic prescribing, just not to
Medco's mail order service drug program. In addition, while the
providers in each group were from the same geographic service areas,
Medco did not examine the types of patients served by the providers,
so it is possible that the groups were serving different patient
populations.
Study #2: An official described a study conducted by HaldyMcIntosh,
under the direction of the Southeastern Michigan ePrescribing
Initiative project manager, Point-of-Care Partners.
Methodology: A telephone survey of 500 providers participating in the
collaborative that responded to the survey, conducted in the fourth
quarter of 2007.
How electronic prescribing was determined: Only providers that were
electronically prescribing were surveyed.
Outcome(s) measured: Providers' perceptions of the effect of
electronic prescribing on quality.
Reported findings: Nearly 70 percent of respondents highly agreed that
electronic prescribing improves quality of care; almost 75 percent
highly agreed that electronic prescribing improves patient safety;
approximately 70 percent were very satisfied with the ease of
identifying drug-related interactions; and more than 60 percent
reported that they changed a prescription in response to a safety
alert at least once.
Study #3: An official with the Health Alliance Plan described a study
conducted by Henry Ford Medical Group and the Health Alliance Plan
that looked at generic utilization.
Methodology: A comparison study conducted in 2005 of a group of 24
physicians who electronically prescribed from eight practice sites and
26 physicians from eight comparable practice sites that did not.
How electronic prescribing was determined: Whether the practice site
had converted to electronic prescribing.
Outcome(s) measured: Rate of generic prescribing using pharmacy claims
data and associated savings.
Reported findings: Facilities with access to an electronic prescribing
system had a 1.25 percent larger increase in their rate of generic
prescribing compared with sites that did not have access to an
electronic prescribing system. The study estimated that the health
plan can save $800,000 per year for each 1 percentage point
improvement in the rate of generic prescribing.
Study #4: An official with the Health Alliance Plan described a study
conducted by Henry Ford Medical Group and the Health Alliance Plan
that looked at the savings associated with adverse drug events.
Methodology: A cost estimate conducted in 2006 of the savings
associated with decreases in ADEs.
How electronic prescribing was determined: Whether a prescription was
changed based on an alert from the electronic prescribing system,
identified from internal data sources.
Outcome(s) measured: Estimated savings in (1) avoidable
hospitalizations and (2) avoidable emergency room admissions, due to
the decrease in ADEs.
Reported findings: (1) By assuming that 2 percent of hospitalizations
are attributable to ADEs, that 33 percent of those are avoidable due
to use of the electronic prescribing system, and that $7,000 is saved
per avoidable hospitalization, the study estimated that $441,000 was
saved in 2007. (2) By assuming that 1 percent of emergency room visits
are attributable to ADEs, that 33 percent of those are avoidable due
to use of the electronic prescribing system, and that $500 is saved
per avoidable emergency room visit, the study estimated that $99,000
was saved in 2007.
Study #5: An official with the Health Alliance Plan described a study
it conducted that identified patients taking contraindicated
prescription drug combinations.
Methodology: A file review of pharmacy and medical claims for about
200,000 patients before implementation of electronic prescribing (in
2004) and after implementation of electronic prescribing (in 2007) to
identify patients that were prescribed contraindicated drug
combinations.
How electronic prescribing was determined: The study identified claims
before and after implementation of electronic prescribing.
Outcome(s) measured: The rate of patients taking contraindicated drug
combinations.
Reported findings: The study reported a 24 percent decrease in the
incidence of patients with generally contraindicated medications and a
48 percent decrease in patients taking medications contraindicated for
pregnancy 1 year after the implementation of electronic prescribing.
Study #6: An official with the Health Alliance Plan described a survey
conducted by Henry Ford Medical Group and the Health Alliance Plan.
Methodology: A 2006 survey about electronic prescribing attitudes.
About 100 physicians in the Henry Ford Medical Group responded to the
survey.
How electronic prescribing was determined: Only physicians who were
electronically prescribing were included in the survey.
Outcome(s) measured: A variety of questions related to electronic
prescribing attitudes, some of which focused on physician attitudes
regarding the effect of electronic prescribing on safety.
Reported findings: Various findings reported including the following
percentages of respondents who "strongly agreed" or "somewhat agreed":
84.6 percent of respondents reported that electronic prescribing has
improved the practice of medicine in their clinics; 77.2 percent and
74.8 percent reported that electronic prescribing improves the safety
of the care and the quality of the care, respectively, provided to
their patients; 66.7 percent reported that the drug-drug warnings were
helpful, 80.5 percent reported that the drug-allergy warnings were
helpful, and 68.3 percent reported that the formulary warnings were
helpful.
[End of Southeastern Michigan ePrescribing Initiative]
Summaries of Evaluations Obtained from Literature Review:
Byrne, C.M., L.M. Mercincavage, E.C. Pan, A.G. Vincent, D.S. Johnston,
and B. Middleton. "The Value from Investments in Health Information
Technology at the U.S. Department of Veterans Affairs." Health
Affairs, vol. 29, no. 4 (2010): 629-638.
Methodology: A comparison study of the VA health system and the
private-sector health systems on information technology spending,
adoption, and quality of care. The study also conducts a cost-benefit
analysis to estimate the financial value of key components of the VA's
VistA.
How electronic prescribing was determined: Whether or not the health
system surveyed had adopted health information technology and whether
the health information technology system had certain capabilities as
defined by six frameworks in relevant literature and internal VA and
publicly available documents.
Outcome(s) measured: (1) The information technology-related quality of
care quantified using previously collected quality measures from the
VA that could be compared to measures available for the private sector
for 2004 to 2007. (2) Cost-benefit analysis that estimates the costs
and effects of the core components of the VA VistA system from 2001 to
2007.
Reported findings: (1) The VA was found to have higher performance on
preventive care process measures from 2004 to 2007 relative to the
private sector. The VA averaged about 15 percentage points higher than
the private sector on preventive care for patients with diabetes and
17 percentage points higher for patients with diabetes who have well-
controlled cholesterol. (2) The gross value of the investment in VistA
applications was projected to be $7.16 billion. Of the gross value,
the researchers estimated that cumulative reductions in unnecessary
care attributable to VistA in preventing ADE-related hospitalizations
and outpatient visits was valued at $4.64 billion, or 65 percent of
the total estimated value.
Other issues: The VA system electronically captures and reports
allergies and adverse reactions, inpatient and outpatient medications,
medication orders, and includes CDS such as clinical reminders and
order checking.
Cunningham, T.R., E.S. Geller, and S.W. Clarke. "Impact of Electronic
Prescribing in a Hospital Setting: A Process-Focused Evaluation."
International Journal of Medical Informatics, vol. 77, no. 8 (2008):
546-554.
Methodology: A pre-post study reviewing the medication orders of two
different hospitals, a control hospital that did not implement a CPOE
system and an intervention hospital that did at each of three
different phases of the study--a 4-week baseline phase, a 3-week pilot
phase, and 5-week post-CPOE implementation phase. At the control
hospital, 247 handwritten orders were reviewed from the baseline
phase, 279 handwritten orders from the pilot phase, and 453
handwritten orders from the post-CPOE implementation phase. At the
intervention hospital, 201 handwritten orders were reviewed from the
baseline period, 283 electronically submitted orders were reviewed
from the pilot phase, and 587 orders (276 handwritten and 311
submitted electronically) were reviewed from the post-CPOE
implementation phase.
How electronic prescribing was determined: Whether or not the
physicians' medication orders were handwritten or submitted
electronically in the three different phases of the study, as
identified from the files of previously processed medication orders
stored in the pharmacy departments of each hospital.
Outcome(s) measured: (1) Rates of compliance with hospital medication
protocols (such as recording date, time, drug name, or dosage) by
examining behavioral checklists used to collect information on each
prescription written; and (2) time it took for a patient to receive
antibiotics, as recorded in the hospital medication ordering database.
Reported findings: (1) Medication orders submitted electronically at
the intervention hospital were compliant with hospital medication
protocols 79.9 percent of the time, compared to a 62.9 percent
compliance rate for paper orders written at the same hospital, and a
64.2 percent compliance rate for paper orders written at the control
hospital. (2) At the intervention hospital, the average amount of time
from the medication order until the first dose of antibiotics was
administered was shorter for orders submitted through the CPOE system
(185.0 minutes) than paper orders (326.2 minutes).
Other issues: The CPOE had CDS but the specific features of the CDS
system are not discussed.
DesRoches, C.M., E.G. Campbell, S.R. Rao, K. Donelan, T.G. Ferris, A.
Jha, R. Kaushal, D.E. Levy, S. Rosenbaum, A.E. Shields, and D.
Blumenthal. "Electronic Health Records in Ambulatory Care--A National
Survey of Physicians." New England Journal of Medicine, vol. 359, no.
1 (2008): 50-60.
Methodology: A survey of 2,758 physicians conducted between September
2007 and March 2008.
How electronic prescribing was determined: Whether or not physicians
reported on the survey that they adopted an EHR system, including
whether the EHR system was a "fully functional" or "basic" EHR. The
study defined a "fully functional" EHR as one that allows physicians
to record patients' clinical and demographic data, view and manage
results of laboratory tests and imaging, manage order entry (including
electronic prescriptions), and support clinical decisions (including
warnings about drug interactions or contraindications). In the study,
the principal differences between "fully functional" and "basic" EHRs
were the absence of certain order-entry capabilities and CDS in a
basic system.
Outcome(s) measured: The survey asked respondent a variety of
questions related to EHR adoption, including questions related to
quality of care.
Reported findings: Findings reported by the study included the
following: of the respondents with fully functional EHR systems, 80
percent reported averting a potentially dangerous drug allergic
reaction and 71 percent of respondents reported averting a potentially
dangerous drug interaction compared to 66 percent and 54 percent of
respondents with basic EHR systems.
DesRoches, C.M., E.G. Campbell, C. Vogeli, J. Xheng, S.R. Rao, A.E.
Shields, K. Donelan, S. Rosenbaum, S.J. Bristol, and A.K. Jha.
"Electronic Health Records' Limited Successes Suggest More Targeted
Uses." Health Affairs, vol. 29, no. 4 (2010): 639-646.
Methodology: The researchers created a survey and surveyed 4,840 acute-
care general medical and surgical hospitals from March to September
2008 that were members of the American Hospital Association. The
researchers linked the information gathered in their survey to
information from three other data sources.
How electronic prescribing was determined: Whether the hospital had a
comprehensive EHR, defined as an EHR with 24 clinical functions used
across all major clinical units in the hospital, a basic EHR system,
defined as a system with 10 key functions in at least one major
clinical unit in the hospital, or no EHR system.
Outcome(s) measured: (1) Performance on quality metrics based on data
released from the Hospital Quality Alliance for three clinical
conditions--acute myocardial infarction, congestive heart failure, and
pneumonia--and prevention of surgical complications, and (2)
efficiency, as measured by the hospitals' risk-adjusted length of
stay, risk-adjusted 30-day readmission rates, and risk-adjusted
inpatient costs, which were determined using two sources of data, the
Medicare Inpatient Impact File and the Area Resource File.
Reported findings: (1) No relationships were found between EHR
adoption and quality process measures for acute myocardial infarction,
congestive heart failure, pneumonia, or 30-day risk-standardized
mortality of these conditions. Hospitals with EHR had somewhat better
performance on the prevention of surgical complications measures than
hospitals without EHR (93.7 percent for hospitals with a comprehensive
EHR, 93.3 percent for hospitals with a basic EHR, and 92.0 percent for
those without EHR). (2) No relationships between the level of EHR
adoption and overall risk-adjusted length of stay were found.
Hospitals with comprehensive EHRs had similar rates of readmissions
within 30 days of hospital discharge compared to hospitals with basic
or no EHRs. The researchers found that hospitals with such systems had
comparable inpatient costs to hospitals without them. Pneumonia
patients in hospitals with a comprehensive EHR had a length of stay
that was, on average, 0.5 days shorter than those of patients in
hospitals without EHR.
Other issues: In this article, CDS consisted of clinical reminders and
clinical practice guidelines and was associated with marginally better
performance on each of the Hospital Quality Alliance quality metrics.
Devine, E.B., R.N. Hansen, J.L. Wilson-Norton, N.M. Lawless, A.W.
Fisk, D.K. Blough, D.P. Martin, and S.D. Sullivan. "The Impact of
Computerized Provider Order Entry on Medication Errors in a
Multispecialty Group Practice." Journal of the American Medical
Informatics Association, vol. 17, no. 1 (2010): 78-84.
Methodology: A pre-post study compared prescriptions written at a
multilocation clinic before and after the implementation of a CPOE
system. For the pre-CPOE implementation period between March 1, 2002,
and July 15, 2002, for one clinic and between January 2, 2004, and
March 4, 2004, for other clinics, 5,016 prescriptions were evaluated.
For the post-CPOE implementation period between January 14, 2004, and
July 13, 2004, for one clinic and between July 1, 2005, and April 26,
2006, for other clinics, 5,153 prescriptions were evaluated.
How electronic prescribing was determined: Whether the prescription
was written before or after the implementation of the CPOE system.
Outcome(s) measured: (1) Rates, (2) types, and (3) severity of errors
in prescriptions written before CPOE system implementation compared to
prescriptions submitted electronically after the implementation of the
CPOE system.
Reported findings: (1) Rates of errors in prescriptions declined from
18.2 percent before to 8.2 percent after implementation of the CPOE
system, and the adjusted odds of an error occurring postimplementation
of CPOE system were 70 percent lower than preimplementation. (2) There
were reductions in the adjusted odds of the following error types:
illegibility (97 percent), inappropriate abbreviations (94 percent),
information missing (85 percent), wrong strength (81 percent), drug-
disease interaction (79 percent), and drug-drug errors (76 percent).
(3) Electronic prescribing led to a 57 percent decrease in the odds of
an error occurring that did not cause harm. There was a 49 percent
reduction in the odds of errors occurring that caused harm. The
authors note that this reduction was not significant and that the
small number of errors in this category could have caused this result
to not be significant.
Other issues: The CPOE had limited CDS alerts that included basic
dosing guidance and duplicate therapy checks.
Feldstein, A.C., D.H. Smith, N. Perrin, X. Yang, S.R. Simon, M. Krall,
D.F. Sittig, D. Ditmer, R. Platt, and S.B. Soumerai. "Reducing
Warfarin Medication Interactions: An Interrupted Time Series
Evaluation." Archives of Internal Medicine, vol. 166, no. 9 (2006):
1009-1015.
Methodology: A pre-post study of 239 primary care providers with 9,910
patients taking Warfarin at 15 primary care clinics that implemented
medication interaction alerts for the drug Warfarin into their
electronic medical records with computerized order entry and decision
support. The baseline period was from January 2000 through November
2002 and the postintervention period was from April 2003 through
August 2004.
How electronic prescribing was determined: The presence of electronic
medical record alerts for selected coprescriptions of medications that
interact with Warfarin. When Warfarin and a targeted interacting
medication were coprescribed, an alert would appear, whereupon the
clinician had to click "OK" to continue prescribing the interacting
medication or prescribe a different drug.
Outcome(s) measured: The interacting prescription rate, defined as the
number of coprescriptions of Warfarin-interacting medications per
10,000 Warfarin users per month.
Reported findings: At baseline, about a third of patients had an
interacting prescription. Coinciding with the implementation of the
alerts, the estimated Warfarin-interacting medication prescription
rate decreased from 3,294 interacting prescriptions per 10,000
Warfarin users to 2,804 interacting prescriptions per 10,000 Warfarin
users, resulting in a 14.9 percent relative reduction.
Other issues: The electronic medical record had CDS in the form of
medication alerts.
Galanter, W.L., R.J. Didomenico, and A. Polikaitis. "A Trial of
Automated Decision Support Alerts for Contraindicated Medications
Using Computerized Physician Order Entry." Journal of the American
Medical Informatics Association, vol. 12, no. 3 (2005): 269-274.
Methodology: A comparison, pre-post study of a CPOE alert designed to
appear when a clinician attempted to order potentially contraindicated
drugs for patients with decreased kidney function through the CPOE.
The study was conducted with 233 patients over an 18 month period (4-
month pre-CPOE alert period and 14-month post-CPOE alert period).
How electronic prescribing was determined: Whether or not CPOE alerts
were generated when contraindicated drugs were ordered electronically.
Outcome(s) measured: (1) The likelihood of a contraindicated drug
being administered before and after implementation of the CPOE alerts,
as collected from electronic medical records. (2) Alert compliance.
Reported findings: (1) Likelihood of a patient receiving at least one
dose of the contraindicated medication decreased from 89 percent in
the prealert period to 47 percent in the postalert period. (2) Patient
gender was associated with alert compliance rate, with compliance in
female patients lower than that in male patients. Alert compliance
also decreased as kidney function increased. House staff with more
than 1 year of residency training had a higher compliance rate than
those with less than 1 year of training.
Gandhi, T.K., S.N. Weingart, A.C. Seger, J. Borus, E. Burdick, E.G.
Poon, L.L. Leape, and D.W. Bates. "Outpatient Prescribing Errors and
the Impact of Computerized Prescribing." Journal of General Internal
Medicine, vol. 20, no. 9 (2005): 837-841.
Methodology: A comparison study of 1,879 prescriptions reviewed by a
pharmacist and submitted at four adult primary care practices, two of
which utilized electronic prescribing and two that did not, over a
period of 7 months (September 1999 to March 2000).
How electronic prescribing was determined: Whether prescriptions were
written at computerized or noncomputerized sites.
Outcome(s) measured: Rates of (1) prescribing errors and (2) potential
adverse drug events as determined by the expert reviewers from
conducting prescription reviews, chart reviews, and conducting patient
surveys.
Reported findings: (1) Sites with electronic prescribing contained
errors in 4.3 percent of prescriptions, compared to 11.0 percent of
prescriptions written at sites without electronic prescribing. (2)
Sites with electronic prescribing contained potential ADEs in 2.6
percent of prescriptions, compared to 4.0 percent of prescriptions at
sites without electronic prescribing. The authors note that the
differences between the two groups in errors and prevented ADEs were
not significant, but that the rates of prescribing errors and
prevented ADEs could have been substantially reduced with more
advanced CDS.
Other issues: The system provided no automatic checks for correct
doses, frequencies, allergies, or drug interactions, and authors found
that decision support (such as drug-dose checking and drug-frequency
checking) could have prevented 97 percent of prescribing errors and 95
percent of potential ADEs.
Kaushal, R., A.K. Jha, C. Franz, J. Glaser, K.D. Shetty, T. Jaggi, B.
Middleton, G.J. Kuperman, R. Khorasani, M. Tanasijevic, and D.W.
Bates. "Return on Investment for a Computerized Physician Order Entry
System." Journal of the American Medical Informatics Association, vol.
13, no. 3 (2006): 261-266.
Methodology: A cost-benefit assessment of the implementation of CPOE
with CDS at Brigham and Women's Hospital, a 720-adult bed tertiary
care medical center in Boston from 1993 through 2002. Determined the
capital and operational costs of implementing a CPOE with CDS and of
each CDS intervention through internal documents and interviews with
the CPOE developers and reviewing published literature.
How electronic prescribing was determined: Whether or not the CDS
intervention was active.
Outcome(s) measured: Identified cost savings associated with specific
CDS interventions. GAO grouped the savings into those resulting from:
(1) decreased ADEs and (2) decreased drug costs.
Reported findings: Of the estimated $28.5 million in estimated savings
from the CPOE, (1) $12.9 million in estimated savings were due to CDS
interventions that reduced ADEs, and (2) $6 million in estimated
savings were due to CDS interventions that reduced drug costs. The
cost to develop, implement, and operate the CPOE was $11.8 million,
resulting in cumulative savings of $16.7 million.
Other issues: The CPOE was equipped with CDS.
Kaushal, R., L.M. Kern, Y. Barrón, J. Quaresimo, and E.L. Abramson.
"Electronic Prescribing Improves Medication Safety in Community-Based
Office Practices." Journal of General Internal Medicine, vol. 25, no.
6 (2010): 530-536.
Methodology: A pre-post study of 30 ambulatory care providers (15
electronic prescribers and 15 paper prescribers) in 12 practices in
Hudson Valley region of New York (conducted from September 2005 to
June 2007). The researchers collected 2 weeks of carbon copies and
downloads of prescriptions to identify medication errors at baseline
and 1 year follow-up and compared error rates among and between the
electronic and paper prescriber groups.
How electronic prescribing was determined: Whether or not the
physicians' medication orders were handwritten or submitted
electronically through a stand-alone electronic prescribing system as
identified through the carbon copies of prescriptions or prescription
downloads.
Outcome(s) measured: (1) Medication prescribing errors (including
omitting the quantity or incorrect medication dose and duration), (2)
illegibility errors, (3) near misses (i.e., potentially harmful errors
that were intercepted or reached the patient but caused no harm), (4)
ADEs, (5) rule violations (e.g., failing to write "po" for a
medication taken orally), and (6) effects of CDS on medication errors.
Reported findings: (1) The medication prescribing error rate among
electronic prescribers decreased from 42.5/100 prescriptions at
baseline to 6.6/100 prescriptions at 1 year follow-up. Electronic
prescribers had a lower medication prescribing error rate than paper
prescribers (6.6/100 v. 38.4/100). (2) Electronic prescribing
eliminated all illegibility errors. (3) Electronic prescribers had
fewer near misses (1.3/100 v. 2.7/100) than paper prescribers. (4)
Rates of preventable adverse drug events trended lower among
electronic prescribers (0.04 vs. 0.26 per 100 prescriptions). The
authors noted that this was not a significant difference between
electronic and paper prescribers. (5) Electronic prescribing
eliminated nearly all types of rule violation errors. (6) Electronic
prescribers had fewer errors judged preventable by advanced/basic CDS
than paper prescribers at 1 year than paper prescribers.
Other issues: The stand-alone electronic prescribing system was
equipped with CDS.
Kim, G.R., A.R. Chen, R.J. Arceci, S.H. Mitchell, K.M. Kokoszka, D.
Daniel, and C.U. Lehmann. "Error Reduction in Pediatric Chemotherapy:
Computerized Order Entry and Failure Modes and Effects Analysis."
Archives of Pediatrics and Adolescent Medicine, vol. 160 (2009): 495-
498.
Methodology: A pre-post study of chemotherapy orders written in a
pediatric oncology unit. The study compared 1,259 paper orders written
before implementation of the CPOE system (from July 31 to August 1,
2001, and from August 14, 2001, to August 22, 2002) to 1,116
electronic orders written after implementation of the CPOE system
(from February 3, 2003, to February 12, 2004).
How electronic prescribing was determined: Whether the orders were
submitted before or after the implementation of the CPOE. A paper
based survey was used to capture the pre-CPOE data, and the post-CPOE
data were captured through the system.
Outcome(s) measured: Data on chemotherapy steps of high morbidity/
mortality potential if missed, as determined by attending oncologists.
Reported findings: Findings reported by the study included: after CPOE
implementation, daily chemotherapy orders (1) were less likely to have
improper dosing, incorrect dosing calculations, missing cumulative
dose calculations, and incomplete nursing checklists, and (2) had a
higher likelihood of not matching medication orders to treatment plans.
Ko, Y., J. Abarca, D.C. Malone, D.C. Dare, D. Geraets, A. Houranieh,
W.N. Jones, W.P. Nichol, G.P. Schepers, M. Wilhardt. "Practitioners'
Views on Computerized Drug-Drug Interaction Alerts in the VA System."
Journal of the American Medical Informatics Association, vol. 14, no.
1 (2007): 56-64.
Methodology: A survey of 258 prescribers and 84 pharmacists from seven
VA Medical Centers across the United States. The time period of the
survey was between 2004 and 2005.
How electronic prescribing was determined: Survey participants had
prescribing authority in a VA Medical Center and an active outpatient
practice. In the VA's computerized patient record system, prescribers
enter prescription orders electronically for review and verification
by a pharmacist before dispensing.
Outcome(s) measured: The survey asked respondent a variety of
questions including those related to (1) respondent satisfaction with
the combined inpatient and outpatient CPOE system (the computerized
patient record system), (2) attitude towards drug-drug interaction
alerts, and (3) suggestions for improving drug-drug interaction alerts.
Reported findings: Findings reported in the study included the
following: (1) in general, both prescribers and pharmacists indicated
that the computerized patient record system had a positive effect on
their jobs. Pharmacists revealed more favorable attitudes toward
computerized patient record system than prescribers. (2) Sixty-one
percent of prescribers felt that drug-drug interaction alerts had
increased their potential to prescribe safely. Thirty percent of
prescribers felt that drug-drug interaction alerts provided them with
exactly what they needed most of the time. (3) Both prescribers and
pharmacists agreed that drug-drug interaction alerts should be
accompanied by management alternatives (73 percent and 82 percent,
respectively) and more detailed information (65 percent and 89
percent, respectively).
Kocakulah, M.C., and J. Upson. "Cost Analysis of Computerized
Physician Order Entry Using Value Stream Analysis: A Case Study."
Research in Healthcare Financial Management, vol. 10, no. 1 (2005): 13-
25.
Methodology;: A case study of a 400-bed urban hospital, using value-
stream mapping to conduct a cost analysis of a CPOE system. The study
determined the potential costs and adverse drug reaction reductions
related to CPOE implementation in this hospital, which did not have
CPOE installed.
How electronic prescribing was determined: This hospital did not have
an electronic prescribing or CPOE system.
Outcome(s) measured: Using published studies or reports and data from
the hospital, this study determined (1) the projected decrease in
medication errors, (2) the potential net savings, (3) net present
value, and (4) project internal rate of return for a CPOE system based
on the severity, average cost, and projected reduction of adverse drug
reactions.
Reported findings: (1) The percentage of illegible orders is projected
to decrease by 78 percent, incomplete orders by 71 percent, incorrect
orders by 46 percent, and drug therapy problems by 9 percent. (2) The
projected net savings were $155,686 per year. (3) The projected
project 5-year net present value was a negative $1,270,112. (4) The
projected 5-year internal rate of return was negative 24 percent.
Because of these projections, the authors did not recommend the
hospital invest in a CPOE system at the current time.
McCullough, J.S., M. Casey, I. Moscovice, and S. Prasad. "The Effect
of Health Information Technology on Quality in U.S. Hospitals." Health
Affairs, vol. 29, no. 4 (2010): 647-654.
Methodology: A comparison study of 3,401 nonfederal acute-care U.S.
hospitals from 2004 to 2007.
How electronic prescribing was determined: Whether the hospital had an
EHR and a CPOE system, as identified from information from the
American Hospital Association's annual survey and the HIMSS analytics
database that describes hospitals' health information technology
adoption decisions.
Outcome(s) measured: 629-638.: Performance on six process quality
measures in the CMS Hospital Compare database.
Reported findings: For nearly all measures, average quality was higher
for hospitals with EHR and CPOE (with larger effects for academic
hospitals than when compared to all hospitals). However, the
difference was only significant for pneumococcal vaccine
administration (2.1 percent increase) and use of the most appropriate
antibiotic for pneumonia (1.3 percent increase).
Other issues: The study defined an EHR as a set of applications
including a computerized patient record with a clinical data
repository and some CDS capabilities, such as providing treatment
recommendations.
McMullin, S.T., T.P. Lonergan, and C.S. Rynearson. "Twelve-Month Drug
Cost Savings Related to Use of an Electronic Prescribing System with
Integrated Decision Support in Primary Care." Journal of Managed Care
Pharmacy, vol. 11, no. 4 (2005): 322-332.
Methodology: A comparison study of 38 primary care clinicians (19
electronic prescribing system users; 19 electronic prescribing system
nonusers) conducted from June 2002 through May 2003.
How electronic prescribing was determined: Whether or not the
physician was using an electronic prescribing system with CDS
capabilities as identified through the study design.
Outcome(s) measured: Using pharmacy claims, determined (1) if the 6-
month savings on new prescriptions were sustained during the 12-months
of follow-up, (2) the 12-month cost savings associated with CDS on
pharmacy claims, and (3) prescribing behavior of clinicians on eight
high-cost therapeutic groups targeted by electronic messages to
prescribers.
Reported findings: (1) Savings seen in the last 6 months of the 12
month follow-up period were greater than the first 6 months ($748 per-
member-per-month at 6 months to $794 at 12 months per-member-per-
month). (2) Use of the electronic prescribing system was associated
with a sustained decrease in prescription costs. Over the 12 month
follow-up period, the average cost per new prescription for the
intervention group decreased by $1.00 and increased by $3.75 in the
control group. The number of other refilled prescriptions decreased
more in the intervention group than in the control group. The number
of new prescriptions increased slightly more in the intervention group
than the controls. (3) Prescriptions for high-cost target medications
overall decreased by 9.1 percent in the intervention group because of
CDS and increased in the control group by 8.2 percent. Compared with
the control group, the prescription ratio for high-cost drug classes
was a relative 17.5 percent lower in the group using the CDS (35.8
percent versus 43.4 percent).
Other issues: The electronic prescribing system had integrated CDS,
formulary, payor, and clinical guideline alert messaging capabilities.
Peterson, J.F., G.J. Kuperman, C. Shek, M. Patel, J. Avorn, and D.W.
Bates. "Guided Prescription of Psychotropic Medications for Geriatric
Inpatients." Archives of Internal Medicine, vol. 165, no. 7 (2005):
802-807.
Methodology: A comparison study at a tertiary care hospital, including
3,718 patients 65 years or older that were prescribed a psychotropic
medication targeted in the intervention and admitted for medical,
surgical, neurology, or gynecology services from October 8, 2001, to
May 16, 2002.
How electronic prescribing was determined: Whether the geriatric
decision support system, which included medication dosing and
selection guidelines for elderly patients, was activated.
Outcome(s) measured: The study measured several outcomes including:
(1) The rate at which prescriptions were written in agreement with
expert recommendations regarding recommended daily dose for the
initial drug order, (2) incidence of dosing at least 10-fold greater
than the recommended daily dose, and (3) prescription of
nonrecommended drugs.
Reported findings: Findings presented included: (1) The prescriptions
for psychotropic medications agreed with the system recommendations
for dosing more frequently during the intervention periods when the
geriatric decision support application was available. The agreement
rate for both control periods was lower than the agreement rate for
the intervention periods. (2) During the intervention periods, the
incidence of 10-fold dosing decreased from 5.0 percent to 2.8 percent,
(3) the prescription of nonrecommended drugs decreased from 10.8
percent to 7.6 percent.
Ross, S.M., D. Papshev, E.L. Murphy, D.J. Sternberg, J. Taylor, and R.
Barg. "Effects of Electronic Prescribing on Formulary Compliance and
Generic Drug Utilization in the Ambulatory Care Setting: A
Retrospective Analysis of Administrative Claims Data." Journal of
Managed Care Pharmacy, vol. 11, no. 5 (2005): 410-415.
Methodology: A comparison study of 110,975 paid pharmacy claims
submitted by two groups--95 providers using predominantly electronic
prescribing and a matched sample of 95 providers who did not
electronically prescribe--between August 1, 2001, and July 31, 2002.
How electronic prescribing was determined: Whether or not a provider
used electronic prescribing during the study period.
Outcome(s) measured: (1) Formulary compliance, which was assessed
using the formulary code field in pharmacy data claims, and (2)
generic utilization rates, which was assessed using First DataBank
National Drug Data File Plus software to determine the brand or
generic status of each drug.
Reported findings: (1) Formulary compliance for both groups was
similar. The electronic prescribing group was 83.2 percent compliant,
compared to 82.8 percent compliance in the group that did not
electronically prescribe. (2) Generic utilization rates were also
similar, 37.3 percent for those who electronically prescribed and 36.9
percent for those that did not.
Other issues: The electronic prescribing system provided drug and
formulary information during the prescribing process.
Spencer, D.C., A. Leininger, R. Daniels, R. Granko, and R.R. Coeytaux.
"Effect of a Computerized Prescriber-Order-Entry System on Reported
Medication Errors." American Journal of Health-System Pharmacy, vol.
62, no. 4 (2005): 416-419.
Methodology: A pre-post study and comparison of two medicine units at
an academic hospital before and after implementation of a CPOE with
CDS, compared to units in the hospital that did not implement a CPOE
system. Data were collected over a period of 16 months.
How electronic prescribing was determined: Whether the medication
error was reported before or after the implementation of the CPOE
system in two medicine units of the hospital and whether or not the
medication error was reported from the two medicine units of the
hospital that implemented CPOE.
Outcome(s) measured: Reported medication errors and potential
medication errors, as obtained from the hospital's center for
medication safety.
Reported findings: Implementation of the CPOE system in the two units
was associated with an increase in reported errors, from 0.068 per
discharge preimplementation to 0.088 per discharge after
implementation. The units in the hospital that did not implement CPOE
systems had a decrease in the number of reported errors from 0.133 per
discharge to 0.079 per discharge.
Other issues: The authors note that while the error rates increased in
the units with CPOE, the error rates in the units in the hospital
without CPOE decreased. Therefore, the increase in reported medication
errors on units with CPOE systems may have been attributable to the
direct or indirect consequences of introduction of the CPOE system.
Steele, A.W., S. Eisert, J. Witter, P. Lyons, M.A. Jones, P. Gabow,
and E. Ortiz. "The Effect of Automated Alerts on Provider Ordering
Behavior in an Outpatient Setting." PLoS Medicine, vol. 2, no. 9
(2005): 864-870.
Methodology: A pre-post study of the implementation and effect of
alerts generated during medication ordering in primary care clinics.
The baseline data were collected from August 1, 2002, to November 29,
2002, and the postintervention data were collected from December 1,
2002, to April 30, 2003.
How electronic prescribing was determined: All provider staff entered
medication orders using CPOE. The study design compared baseline
ordering behavior (when no alert was triggered) to ordering behavior
after alerts were triggered.
Outcome(s) measured: (1) The number of medication orders not completed
in response to an alert, (2) the number of rule-associated laboratory
test orders initiated after an alert was displayed, as captured in the
electronic prescribing system, and (3) the rates of adverse drug
events assessed by completing file reviews on a random sample of
medication orders.
Reported findings: (1) Before the alerts were implemented, prescribers
did not complete medication orders 5.4 percent of the time, compared
to 8.3 percent of the time after the alerts were implemented. The
authors noted that this was not a significant difference between the
groups. When the alert was for an abnormal laboratory value, the
percentage of times where the medication order was not completed
increased from 5.6 percent at baseline to 10.9 percent during the
intervention. (2) Comparing the pre-and postintervention periods for
medication orders when no alert was displayed, prescribers ordered
associated laboratory tests 17 percent of the time during the
preintervention period, compared to 16.2 percent of the time in the
postintervention period. The authors state that this finding was not
significant and indicates that there was no trend, in general, to
increased laboratory test ordering during the study period. (3) The
preintervention group had a potential ADE in 10.3 percent of charts
compared to in 4.3 percent of the charts in the postintervention
group. The authors state that the difference between the groups was
not significant and that the study was too small to show for sure
whether there was any true effect on adverse drug reactions.
Stone, W.M., B.E. Smith, J.D. Shaft, R.D. Nelson, and S.R. Money.
"Impact of a Computerized Physician Order-Entry System." Journal of
the American College of Surgeons, vol. 208, no. 5 (2009): 960-969.
Methodology: A pre-post study of patient-safety measures before and
after CPOE implementation at the Mayo Clinic Hospital in Phoenix,
Arizona. The CPOE system was implemented from May 8, 2007, to April
30, 2008.
How electronic prescribing was determined: Whether or not the
physicians' orders were submitted electronically using the CPOE system.
Outcome(s) measured: (1) Medication errors and (2) order-
implementation time.
Reported findings: (1) There were no significant differences in the
rate of medication errors in any of the study time periods, which were
captured through self-reporting. (2) The time from a doctor placing an
order, which was recorded or captured electronically, to a nurse
receiving that order decreased from 41.2 minutes pre-CPOE to 27
seconds post-CPOE.
Taylor, J.A., L.A. Loan, J. Kamara, S. Blackburn, and D. Whitney.
"Medication Administration Variances Before and After Implementation
of Computerized Physician Order Entry in a Neonatal Intensive Care
Unit." Pediatrics, vol. 121, no. 1 (2008): 123-128.
Methodology: A comparison, pre-post study of how the actual medication
administration differed from the medication order before and after
CPOE implementation. The study was conducted in the 30-bed Neonatal
Intensive Care Unit at Madigan Army Medical Center from August 2004 to
April 2006 (pre-CPOE: August 2004 to June 2005; post-CPOE: August 2005
to April 2006).
How electronic prescribing was determined: Whether or not the
physicians' medication orders were handwritten or submitted
electronically using a CPOE system.
Outcome(s) measured: (1) Differences between the medication order and
how the medication was actually administered. (2) Reasons for
variances between the medication order and administration, as noted by
the research nurses.
Reported findings: (1) The variation between the medication order and
how the medication was actually administered was lower post-CPOE than
pre-CPOE (11.6 percent and 19.8 percent, respectively). (2) Findings
related to rates of variance in medication order and administration in
the pre-and post-CPOE included the following: similar variances in
both periods were found for administration mistakes, pharmacy
problems, and prescribing problems; and variances related to
administration of drugs by the wrong route and the wrong time were
significantly lower after CPOE implementation.
Other issues: The CPOE utilized CDS and display formats and defaults
configured specifically for use in the Neonatal Intensive Care Unit
for ordering prescriptions.
Upperman, J.S., P. Staley, K. Friend, W. Neches, D. Kazimer, J. Benes,
and E.S. Wiener. "The Impact of Hospitalwide Computerized Physician
Order Entry on Medical Errors in a Pediatric Hospital." Journal of
Pediatric Surgery, vol. 40, no.1 (2005): 57-59.
Methodology: A pre-post study comparing orders written before the
implementation of a CPOE system in a children's hospital from January
2002 to October 2002 to those written after the implementation of CPOE
system in November 2003 (the end point of the study period was not
specified).
How electronic prescribing was determined: Whether a prescription was
written before or after the implementation of CPOE.
Outcome(s) measured: The rate and types of ADEs determined by
analyzing data collected at the hospital.
Reported findings: ADE rates pre-CPOE were 0.3 per 1,000 doses,
compared to 0.37 per 1,000 doses post-CPOE. The authors note that the
study demonstrates a substantial decrease in harmful ADEs, but no
significant difference in all ADEs between the pre-and post-CPOE
periods. The rate of harmful ADEs pre-CPOE were 0.05 per 1,000 doses,
compared to 0.03 per 1,000 doses post-CPOE.
Other issues: The CPOE had CDS.
Vaidya, V., A.K. Sowan, M.E. Mills, K. Soeken, M. Gaffoor, and E.
Hilmas. "Evaluating the Safety and Efficiency of a CPOE System for
Continuous Medication Infusions in a Pediatric ICU." AMIA Symposium
Proceedings, 2006.
Methodology: A comparison study evaluating the safety of a CPOE system
compared to a handwritten, hand-calculated method for prescribing
continuous drug infusions for pediatric ICU patients. The time period
of the study was not specified.
How electronic prescribing was determined: Whether the orders for the
drug infusions were generated in the CPOE system or through a
handwritten, hand-calculated method.
Outcome(s) measured: The (1) occurrence and (2) risk level of errors,
as identified through a review of order sheets for errors.
Reported findings: (1) The drug infusion orders generated using the
CPOE system had fewer errors (4.3 percent) than those that were
handwritten (73 percent). (2) Twenty-five percent of the errors in the
handwritten group were judged to be "high-risk" compared to 0 percent
in the CPOE group. All of the errors in the CPOE group were missing
signatures.
Other issues: The CPOE included decision support.
Varkey, P., P. Aponte, C. Swanton, D. Fischer, S.F. Johnson, and M.D.
Brennan. "The Effect of Computerized Physician-Order Entry on
Outpatient Prescription Errors." Managed Care Interface, vol. 20, no.
3 (2007): 53-57.
Methodology: A retrospective survey of 4,527 prescriptions ordered
from March 1996 through March 2002 at Mayo Clinic ambulatory clinics
comparing prescriptions ordered through the clinic's CPOE to
handwritten orders.
How electronic prescribing was determined: Whether or not the type of
prescription generated was handwritten, computerized, or preprinted.
Outcome(s) measured: The (1) prevalence and (2) type of pharmacist-
intercepted prescription errors in computerized and handwritten
prescriptions.
Reported findings: (1) The frequency of intercepted prescription
errors were highest in handwritten prescriptions (7.4 percent),
followed by computerized prescriptions (4.9 percent), and preprinted
prescriptions (1.7 percent). (2) The most commonly intercepted
prescriptions involved the dosage form, dispense quantity, medication
dosage, and drug allergies. CPOE resulted in lower rates in every type
of intercepted prescription error, including form, dosage, quantity,
allergy, frequency, drug name, patient name, illegibility, route, and
drug-drug interaction, compared to handwritten prescriptions.
Other issues: The CDS included required fields and duplicate order
checking.
Wang, C.J., M.H. Patel, A. Schueth, M. Bradley, S. Wu, J.C. Crosson,
P.A. Glassman, and D.S. Bell. "Perceptions of Standards-based
Electronic Prescribing Systems as Implemented in Outpatient Primary
Care: A Physician Survey." Journal of the American Medical Informatics
Association, vol. 16, no. 4 (2009): 493-502.
Methodology: Cross-sectional survey of physicians was fielded from
October 2006 to December 2006 among physicians enrolled in a Blue
Cross Blue Shield electronic prescribing sponsorship program.
How electronic prescribing was determined: Whether or not the
physician had installed an electronic prescribing system.
Outcome(s) measured: (1) Adequacy of available drug formulary and
medication history information and (2) perceptions of the electronic
prescribing system's enhancement of job performance.
Reported findings: (1) Electronic prescribing users were more likely
than nonusers to "agree" or "strongly agree" that the information
available about the patient's medication history helps them to
identify clinically important drug-drug interactions and prevent
callbacks from pharmacies for safety problems. Electronic prescribing
users were slightly more favorable toward statements that electronic
prescribing system drug coverage helps patients maintain lower drug
costs. (2) Sixty-two percent of electronic prescribers "agreed" or
"strongly agreed" that electronic prescribing improves the quality of
care they can deliver.
Weingart, S.N., B. Simchowitz, L. Shiman, D. Brouillard, A. Cyrulik,
R.B. Davis, T. Isaac, M. Massagli, L. Morway, D.Z. Sands, J. Spencer,
and J.S. Weissman. "Clinicians' Assessments of Electronic Medication
Safety Alerts in Ambulatory Care." Archives of Internal Medicine, vol.
169, no. 17 (2009): 1627-1632.
Methodology: A survey mailed to 300 clinicians in December 2007 about
the value of electronic prescribing.
How electronic prescribing was determined: Whether clinicians adopted
a commercial electronic prescribing system with a drug-allergy and
interaction alerts drug reference database and used the electronic
prescribing system to write at least 100 prescriptions per month
between January 1 and June 30, 2006.
Outcome(s) measured: (1) Clinicians' satisfaction with electronic
prescribing and (2) perceptions of the effects of electronic
prescribing and alerts on the safety, efficiency, and cost of care.
Reported findings: (1) Forty-seven percent were satisfied or very
satisfied with medication safety alerts. Clinicians said electronic
prescribing would improve the quality of care delivered (78 percent);
prevent medical errors (83 percent); enhance patient satisfaction (71
percent); and improve clinician efficiency (75 percent). (2) Seventy-
eight percent said at least one alert had caused them to change their
behavior in the past 6 months. Fifty-seven percent said an alert might
have prevented at least one error or injury in the average month.
Twenty-two percent said an alert had prevented a serious error or
injury in their practice. Sixty-three percent of respondents said an
alert caused them to take action other than change an alerted
prescription (counsel patient, look up information in a drug
reference, or change how they monitor a patient). The study also
reported participant ratings on potential problems associated with the
drug allergy or interaction alerts. For example, 58 percent of
respondents reported that alerts were triggered by discontinued
medications.
Yu, F.B., N. Menachemi, E.S. Berner, J.J. Allison, N.W. Weissman, and
T.K. Houston. "Full Implementation of Computerized Physician Order
Entry and Medication Related Quality Outcomes: A Study of 3364
Hospitals." American Journal of Medical Quality, vol. 24, no. 4
(2009): 278-286.
Methodology: A comparison study of hospitals--264 that used a CPOE
system to enter all orders and 3,100 that did not--over a 1-year
period (July 2003 to June 2004).
How electronic prescribing was determined: Whether the hospital
reported on the HIMSS analytics survey that it entered all orders
through CPOE.
Outcome(s) measured: Performance on hospital quality-of-care measures
from CMS.
Reported findings: Of the 11 medication-related measures, the mean
performance on 6 cardiovascular-related measures was higher among CPOE
hospitals than non-CPOE hospitals, and the mean performance on one
measure, antibiotics within 4 hours of arrival, was lower among CPOE
hospitals than non-CPOE hospitals.
Yu, F., M. Salas, Y. Kim, and N. Menachemi. "The Relationship Between
Computerized Physician Order Entry and Pediatric Adverse Drug Events:
A Nested Matched Case-Control Study." Pharmacoepidemiology and Drug
Safety, vol. 18, no. 8 (2009): 751-755.
Methodology: A comparison study between 54 pediatric hospitals that
had CPOE systems and 68 pediatric hospitals that did not. Patient data
were retrieved between October 1, 2005, and September 30, 2006.
How electronic prescribing was determined: Whether a CPOE system was
fully implemented for all orders and clinical domains, as identified
through the HIMSS analytics database.
Outcome(s) measured: The odds of ADEs, using data from the national
association of children's hospitals and related institutions case-mix
comparative data program and HIMSS.
Reported findings: The odds of experiencing an ADE were 42 percent
higher for hospitals without CPOE compared to those with CPOE.
Zhan C., R.W. Hicks, C.M. Blanchette, M.A. Keyes, and D.D. Cousins.
"Potential Benefits and Problems with Computerized Prescriber Order
Entry: Analysis of a Voluntary Medication Error-Reporting Database."
American Journal of Health-System Pharmacy, vol. 63, no. 4. (2006):
353-358.
Methodology: Comparison study of 120 facilities that reported having a
CPOE in all clinical areas to 339 facilities that did not have a CPOE.
Facilities included general community hospitals, specialty hospitals,
and outpatient clinics. Data analyzed were from 2003.
How electronic prescribing was determined;: Whether the facility had
CPOE, as determined by Medmarx, a national voluntary medication-error
reporting database.
Outcome(s) measured: (1) The number of errors reported by CPOE versus
non-CPOE facilities and (2) the characteristics of errors caused by
CPOE, as captured in the Medmarx database.
Reported findings: The authors stated that the different facilities
that self-reported data to the Medmarx database appeared to have
different levels of underreporting of medication errors, and
therefore, these data cannot be used to assess the potential benefits
of CPOE or compare rates of medication errors between providers though
facilities with CPOE had fewer inpatient errors, more outpatient
errors, and smaller numbers of outpatient and inpatient errors that
reached or harmed patients compared to facilities without CPOE. The
article did not evaluate the sophistication of the CDS employed by the
studied CPOE systems.
[End of table]
[End of section]
Appendix III: Scope and Methodology:
This appendix provides additional details regarding our scope and
methodology for reporting information on the providers who
participated in and received incentive payments from the 2009
Electronic Prescribing Program.
To conduct our analyses, we analyzed four Centers for Medicare &
Medicaid Services (CMS) files.
* 2009 Electronic Prescribing Program Participation. We obtained a
file from CMS in October 2010 that provided summary information for
each provider that participated in the Electronic Prescribing Program
in 2009, which CMS also used to make payments to providers for
2009.[Footnote 85] For each combination of national provider
identifier and tax identification number,[Footnote 86] this file
contained the following information: the total number of times each of
the three electronic prescribing codes were submitted;[Footnote 87]
the total number of applicable visits; whether CMS determined that the
provider would receive an incentive payment; and the amount of the
incentive payment.
* 2009 Electronic Prescribing Program Eligible Providers. We obtained
a file from CMS in October 2010 that listed each provider that had at
least one applicable visit for the Electronic Prescribing Program in
2009--which we refer to in this appendix as "applicable providers."
Over 597,000 providers had at least one applicable visit for the
Electronic Prescribing Program in 2009. This number represents a count
of all Medicare providers who had at least one applicable visit in
2009. However, not all of these providers have prescribing authority.
Consequently, there may be some individuals included in the count of
597,000 providers that were not eligible for an electronic prescribing
incentive payment.
* National Plan and Provider Enumeration System (NPPES) Downloadable
File. We downloaded this file from CMS's Web site [hyperlink,
http://nppes.viva-it.com/NPI_Files.html] in October 2010. We used the
variable "Provider Business Practice Location Address State Name" to
obtain the state for providers.
* Provider Enrollment, Chain, and Ownership System (PECOS) Global
Extract File. We obtained this file from CMS in October 2010. In the
few cases when we were unable to obtain the state for providers using
the NPPES Downloadable File, we attempted to determine the state for
providers using either the "Practice Location State" variable or the
"Correspondence Address State" variable from the PECOS Global Extract
File.
CMS determined which providers met or exceeded the reporting
requirement for 2009 using each unique combination of providers'
national provider identifiers and tax identification numbers. However,
we analyzed and report information at the national provider identifier
level only so that we could present results for unduplicated
providers. We were unable to match 1,052 applicable providers (less
than 0.2 percent of applicable providers) to either the NPPES
Downloadable File or the PECOS Global Extract file.[Footnote 88]
To determine the percent of Medicare providers who received incentive
payments by state and the average incentive payment by state using the
state for each provider, we obtained state information for over 99
percent of applicable providers using data from the NPPES Downloadable
File and for the remaining applicable providers using data from the
PECOS Global Extract File. We excluded the about 0.2 percent of
applicable providers mentioned above that we could not match to either
the NPPES Downloadable File or the PECOS Global Extract File. In
addition, we excluded about another 0.2 percent of applicable
providers for whom we were unable to obtain state information, the 0.9
percent of applicable providers who were from U.S. insular areas, and
six providers whose state information we deemed unreliable.[Footnote
89]
[End of section]
Appendix IV: Maximum Electronic Health Record (EHR) Program Incentive
Payments, Based on First Year of Payment:
First year provider participates in the EHR Program: 2011;
Maximum EHR incentive payments by year[A]: 2011: $18,000;
Maximum EHR incentive payments by year[A]: 2012: $12,000;
Maximum EHR incentive payments by year[A]: 2013: $8,000;
Maximum EHR incentive payments by year[A]: 2014: $4,000;
Maximum EHR incentive payments by year[A]: 2015: $2,000;
Maximum total incentive payment: $44,000.
First year provider participates in the EHR Program: 2012;
Maximum EHR incentive payments by year[A]: 2012: $18,000;
Maximum EHR incentive payments by year[A]: 2013: $12,000;
Maximum EHR incentive payments by year[A]: 2014: $8,000;
Maximum EHR incentive payments by year[A]: 2015: $4,000;
Maximum EHR incentive payments by year[A]: 2016: $2,000;
Maximum total incentive payment: $44,000.
First year provider participates in the EHR Program: 2013;
Maximum EHR incentive payments by year[A]: 2013: $15,000;
Maximum EHR incentive payments by year[A]: 2014: $12,000;
Maximum EHR incentive payments by year[A]: 2015: $8,000;
Maximum EHR incentive payments by year[A]: 2016: $4,000;
Maximum total incentive payment: $39,000.
First year provider participates in the EHR Program: 2014;
Maximum EHR incentive payments by year[A]: 2014: $12,000;
Maximum EHR incentive payments by year[A]: 2015: $8,000;
Maximum EHR incentive payments by year[A]: 2016: $4,000;
Maximum total incentive payment: $24,000.
Source: GAO analysis of the Recovery Act.
Notes: The Centers for Medicare & Medicaid Services (CMS) will
increase the incentive payments by 10 percent each year for providers
that predominantly furnish services in geographic areas designated as
health professional shortage areas, such as areas that have a shortage
of primary medical care.
[A] Incentive payment amounts are equal to 75 percent of the
provider's total allowed charges for services covered by Medicare Part
B for the year, but are subject to the annual limits displayed in this
table.
[End of table]
[End of section]
Appendix V: Stage-One Reporting Requirements for the Electronic Health
Records (EHR) Program:
Mandatory requirements:
1. Generate and transmit more than 40 percent of permissible
prescriptions electronically.[A]
2. Enter medication order into computerized physician order entry
(CPOE) system for more than 30 percent of patients with at least one
medication in their medication lists.[A]
3. Enter medication lists or indicate no current prescriptions for
more than 80 percent of patients.[A]
4. Enter medication allergy lists or indicate no known medication
allergies for more than 80 percent of patients.[A]
5. Enable the EHR system's ability to check a prescription for
potential drug-drug and drug-allergy interactions.[A]
6. Record as structured data demographics for more than 50 percent of
patients.
7. Record as structured data list of current and active diagnoses or
indicate no known problems for more than 80 percent of patients.
8. Record as structured data height, weight, and blood pressure for
more than 50 percent of patients aged 2 and over.
9. Record as structured data smoking status for more than 50 percent
of patients aged 13 and over.
10. Implement one clinical decision support rule relevant to specialty
or high clinical priority.
11. Report ambulatory clinical quality measures to the Centers for
Medicare & Medicaid Services (CMS) or the states.[B]
12. Provide electronic copy of health information within 3 business
days to more than 50 percent of all patients who requested that
information.
13. Provide clinical summaries to patients within 3 business days for
more than 50 percent of all office visits.
14. Perform at least one test of certified EHR technology's capacity
to electronically exchange key clinical information (i.e., problem
list, medication list, medication allergies, or diagnostic test
results).
15. Protect electronic health information created or maintained by the
certified EHR technology by conducting or reviewing a security risk
analysis, implementing security updates as necessary, and correcting
identified security deficiencies.
Additional requirements:
1. Perform medication reconciliation for more than 50 percent of all
transitions of care.[A]
2. Enable the EHR system's ability to check a prescription against a
formulary and maintain access to at least one internal or external
drug formulary for the entire EHR reporting period.[A]
3. Incorporate as structured data more than 40 percent of all clinical
lab tests results ordered.
4. Generate at least one list of patients by a specific condition.
5. Send reminders during the EHR reporting period for preventative or
follow-up care to more than 20 percent of patients aged 65 and over or
aged 5 and younger.
6. Provide electronic access to health information within 4 business
days of being updated in the EHR system to more than 10 percent of
patients.
7. Provide patient-specific education resources to more than 10
percent of all patients.
8. Provide summary of care record to more than 50 percent of
transitions of care and referrals.
9. Perform at least one test of certified EHR technology's capacity to
submit electronic data to immunization registries and follow-up
submission if the test is successful.[C]
10. Perform at least one test of certified EHR technology's capacity
to provide electronic syndromic surveillance data to public health
agencies and follow-up submission if the test is successful.[C].
Source: GAO analysis of CMS regulation.
Note: Unless a provider has an exception for all of the public health-
related reporting requirements, the provider must report at least one
of the public health-related reporting requirements among the five
additional requirements that the provider reports.
[A] The requirement is electronic prescribing-related.
[B] According to CMS, clinical quality measures help quantify health
care processes, outcomes, patient perceptions, and organizational
structure. To meet this reporting requirement, providers must report
on 6 out of 44 clinical quality measures identified by CMS.
[C] The requirement is public health-related.
[End of table]
[End of section]
Appendix VI: Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
January 24, 2011:
Linda T. Kohn:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Kohn:
Attached are comments on the U.S. Government Accountability Office's
(GAO) draft report entitled: "Electronic Prescribing: CMS Should
Address Inconsistencies in Its Two Incentive Programs That Encourage
the Use of Health Information Technology" (GA0-11-159).
The Department appreciates the opportunity to review this report
before its publication.
Sincerely,
Signed by:
Jim R. Esquea:
Assistant Secretary for Legislation:
Attachment:
[End of letter]
General Comments Of The Department Of Health And Human Services (HHS)
On The Government Accountability Office'S (GAO) Draft Report Entitled,
"Electronic Prescribing: CMS Should Address Inconsistencies In Its Two
Incentive Programs That Encourage The Use Of Health Information
Technology" (GAO-11-159):
The Department appreciates the opportunity to review and comment on
this draft report. GAO was asked to examine the Electronic Prescribing
(eRx) Incentive Program that was authorized by the Medicare
Improvements for Patients and Providers Act of 2008. GAO examined how
the Centers for Medicare & Medicaid Services (CMS) determines which
providers receive incentive payments and avoid payment adjustments
from the eRx Incentive Program and how many providers received
incentive payments in 2009. GAO also examined how the requirements of
the eRx Incentive Program compares with the requirements of the
Medicare and Medicaid Electronic Health Records (EHR) Incentive
Program authorized by the Health Information Technology for Economic
and Clinical Health Act of 2009.
Below are the recommendations for executive action made by GAO and
CMS' responses to them.
GAO Recommendations:
To help improve the effectiveness of the Electronic Prescribing and
EHR Programs to encourage the adoption of health information
technologies among Medicare providers, the Administrator of CMS should
take the following three actions:
* Direct physicians and other health care providers in the Electronic
Incentive Program to use electronic prescribing technology that has
been certified as an EHR system or an EHR module(s) for use in the EHR
Incentive Program.
* Expedite efforts to remove the overlap in reporting requirements for
physicians who may be eligible for incentive payments or subject to
penalties under both the Electronic Prescribing and EHR Programs by,
for example, aligning the reporting requirements so that successfully
qualifying for incentive payments or for avoiding penalties under the
EHR program would likewise result in meeting the requirements for the
Electronic Prescribing Program.
* Identify factors that helped or hindered implementation of the
Electronic Prescribing Program to help support the ongoing
implementation of the EHR Program. CMS could include consideration of
such factors in the integration plan that the agency is required to
develop by January 1, 2012.
To help ensure that the Electronic Prescribing Program resources are
used appropriately, the Administrator of CMS should develop a risk-
based strategy to audit a sample of providers who received incentive
payments from the Electronic Prescribing Program to help ensure that
providers who receive incentive payments meet that program's
requirements. A risk-based strategy could, for example, focus on those
providers who received large incentive payments.
CMS Response to Recommendation 1:
* Direct physicians and other health care providers in the Electronic
Incentive Program to use electronic prescribing technology that has
been certified as an EHR system or an EHR module(s) for use in the EHR
Incentive Program.
We concur with the recommendation in that we agree with the notion
that eligible professionals should be able to use certified EHR
systems for the eRx Incentive Program. We do not, however, agree that
CMS should direct eligible professionals to use only prescribing
technology that has been certified as an EHR system.
As pointed out in the report, the eRx Incentive Program began prior to
the enactment of the EHR Incentive Program and, thus, before the
availability of a Department of Health and Human Services (HHS)
administered certification process for EHR technology. As a result,
the eRx Incentive Program was based on the use of a "qualified" eRx
system with specific defined functionalities, as defined in the
electronic prescribing quality measure currently used for the eRx
Incentive Program. In addition, more health care providers are
eligible for the eRx Incentive Program than for the EHR Incentive
Program. Therefore, eligible professionals that implemented
"qualified" eRx systems in accordance with the current eRx Incentive
Program requirements may not have gone through the more recent EHR
certification process. We believe that additional rulemaking would be
needed to direct eligible professionals that only certified EHR
technology would meet requirements for the eRx Incentive Program. Such
direction may also add to the cost and burden for existing eRx
Incentive Program participants by potentially requiring professionals
to replace existing qualified electronic prescribing systems (for
example, stand-alone electronic prescribing systems that do not meet
current Office of the National Coordinator (ONC) certification
requirements for the EHR Incentive Program) merely to continue to
participate in the eRx Incentive Program.
CMS Response to Recommendation 2:
* Expedite efforts to remove the overlap in reporting requirements for
physicians who may be eligible for incentive payments or subject to
penalties under both the Electronic Prescribing and EHR Programs by,
for example, aligning the reporting requirements so that successfully
qualifying for incentive payments or for avoiding penalties under the
EHR program would likewise result in meeting the requirements for the
Electronic Prescribing Program.
We agree and are working actively to better align the reporting
requirements for the two programs, where applicable. As required by
the Affordable Care Act, CMS is required to develop a plan to
integrate reporting on the EHR Incentive Program with reporting on the
Physician Quality Reporting System by January 1, 2012. We plan to
discuss this plan for better alignment in our rulemaking for the 2012
program year during 2011. Section 1848(m)(3)(B) of the Social Security
Act (the Act) sets forth the requirements for a successful electronic
prescriber, and the standard currently adopted under the eRx Incentive
Program requires the submission of data on an electronic prescribing
measure established under the Physician Quality Reporting System.
Currently, the electronic prescribing measure that eligible
professionals are required to report under the eRx Incentive Program
is different from the electronic prescribing requirements of the EHR
Incentive Program and from the quality measures required under the EHR
Incentive Program. Given how both programs are currently structured
and the statutory construct of each program, CMS would need to undergo
further rulemaking in order to implement changes to better align the
reporting requirements under the 2 programs, where applicable. In the
meantime, we plan to conduct extensive education and outreach
activities regarding the eRx Incentive Program and the need to
participate in this program independent of the EHR Incentive Program
despite the prohibition under section 1848(m)(2)(D) of the Act on
duplicate payments under both programs.
CMS Response to Recommendation 3:
* Identify factors that helped or hindered implementation of the
Electronic Prescribing Program to help support the ongoing
implementation of the EHR Program. CMS could include consideration of
such factors in the integration plan that the agency is required to
develop by January I, 2012.
CMS believes this is a helpful recommendation. We have begun to look
into this through comments received on the calendar year 2011 Medicare
Physician Fee Schedule proposed rule. Some factors that we believe
have helped implementation are:
* Revising the reporting requirement for being a successful electronic
prescriber from reporting on 50 percent of applicable cases to
reporting on 25 unique electronic prescribing events beginning in 2010;
* Adding registry and FUR reporting mechanisms and the group practice
reporting option in 2010; and;
* Adding codes to the electronic prescribing measure's denominator in
2010 that expanded opportunities to report the electronic prescribing
measure.
Some commenters expressed challenges that they have encountered in
implementing electronic prescribing technology and/or participating in
the eRx Incentive Program. CMS has identified some potential issues
that eligible professionals have expressed (both via comments to our
proposed rule and during educational presentations which have
occurred). Some of these issues include:
a) The cost of purchasing and implementing electronic prescribing
systems (provider training, potential disruption to workflow, etc.);
b) The pending EHR Incentive Program. Some eligible professionals have
stated that they want to purchase a comprehensive EHR program and,
accordingly, have delayed purchasing and implementing their EHR (and,
therefore, their eRx component). They may be waiting for 2011 and the
first year of the EHR Incentive Program;
c) The difficulty of electronically prescribing narcotics and other
controlled substances. Some eligible professionals only prescribe
narcotics or other controlled substances. While the Drug Enforcement
Agency recently has allowed controlled substances to be electronically
prescribed, not all States have adopted this policy. Additionally,
electronically prescribing controlled substances requires an
electronic prescribing system that has capabilities beyond what is
currently required by the eRx Incentive Program measure, and these
systems are not readily available commercially.
d) The need for an electronic prescribing event to be associated with
an eligible encounter in the office or nursing home. Some eligible
professionals have suggested that refills or electronic prescriptions
generated in response to a phone call from the patient should be
counted. This information may be difficult to collect.
Section 1848(m)(3)(B)(iii) of the Act also permits CMS to determine
whether an eligible professional is a successful electronic prescriber
based on the electronic submission of a sufficient number of
prescriptions under Part D during the reporting period. We are
continuing to explore the feasibility of using Part D prescription
drug event (PDE) data to capture electronic prescribing events instead
of requiring eligible professionals to report an electronic
prescribing measure. There has been some concern about the accuracy
and completeness of the PDE data with respect to whether a
prescription was submitted electronically and with respect to the
National Provider Identifier data that is submitted with the PDE.
CMS Response to Recommendation 4:
To help ensure that the Electronic Prescribing Program resources are
used appropriately, the Administrator of CMS should develop a risk-
based strategy to audit a sample of providers who received incentive
payments from the Electronic Prescribing Program to help ensure that
providers who receive incentive payments meet that program's
requirements. A risk-based strategy could, for example, focus on those
providers who received large incentive payments.
We agree that an audit of a sample of eligible professionals who
received incentive payments may be needed, but disagree that it should
necessarily focus on eligible professionals who received large
incentive payments. As the eRx Incentive Program requires 25
electronic prescribing instances to be reported for purposes of
qualifying for an incentive (regardless of the amount of the incentive
received), we believe that the audit process, if implemented, could be
completely random. In fact, practices who receive smaller incentive
payments may have fewer Medicare encounters (as is evidenced by their
smaller incentive) which may make it more difficult to reach the 25
electronic prescribing events as required by the program.
Additionally, the option of using Part D prescription drug event data
in lieu of reporting on the electronic prescribing measure to
determine successful electronic prescribing may alleviate the need for
an audit.
We appreciate the efforts that went into this report and look forward
to working with the GAO on this and other issues.
[End of section]
Appendix VII: GAO Contact and Staff Acknowledgments:
GAO Contact:
Linda T. Kohn, (202) 512-7114 or kohnl@gao.gov:
Staff Acknowledgments:
In addition to the contact name above, Robert Copeland, Assistant
Director; Nick Bartine; George Bogart; Julianne Flowers; Krister
Friday; Toni Harrison; Daniel Lee; Shannon Legeer; and Sarah Marshall
made key contributions to this report.
[End of section]
Footnotes:
[1] An electronic health record is a collection of information about
the health of an individual or the care provided, including patient
demographics, progress notes, problems, medications, vital signs, past
medical history, immunizations, laboratory data, and radiology reports.
[2] See, for example, American Medical Association, Comparison of
Stand-Alone Versus EMR Systems, available at [hyperlink,
http://www.ama-
assn.org/assets/eprescribing/downloadable_resources/standalone-versus-
emr.pdf] (accessed Dec. 9, 2010).
[3] Not all providers that bill Medicare are eligible for incentive
payments or penalties under both programs. According to CMS, almost 1
million physicians and other nonphysician providers billed Medicare in
2009. See CMS, Data Compendium, 2009 Edition, available at [hyper;inl,
https://www.cms.gov/DATACOMPENDIUM/15_2009_DATA_COMPENDIUM.ASP],
accessed on October 26, 2010. The types of providers eligible for
incentive payments or penalties under the two programs are not
identical.
[4] Pub. L. No. 110-275, § 132(a), 122 Stat. 2494, 2527.
[5] A qualified electronic prescribing system must have several
technological capabilities, including the ability to perform the
following: generate a complete medication list; generate and transmit
prescriptions electronically, and conduct alerts; provide information
on formulary or tiered formulary medications, patient eligibility, and
authorization requirements; and provide information on lower-cost,
therapeutically appropriate alternatives (if any). Additionally, a
qualified electronic prescribing system must be consistent with CMS's
Part D electronic prescribing standards.
[6] Pub. L. No. 110-275, § 132(b), 122 Stat. 2529 (as amended by the
American Recovery and Reinvestment Act of 2009 [Recovery Act], Pub. L.
No. 111-5, § 4101(f), 123 Stat. 115, 476 [providing that payment
adjustments end after 2014]). In this report we use the term "penalty"
to denote a reduction in reimbursement to a non-compliant provider and
not the assessment of a fine or civil money penalty.
[7] Pub. L. No. 111-5, div. B, tit. IV, §4101(a), 123 Stat. 115, 467
(div. A, tit. XIII and div. B, tit. IV of Pub. L. No. 111-5 may be
cited as the Health Information Technology for Economic and Clinical
Health Act (HITECH Act)).
[8] In a general sense, Congress defined "meaningful use" in this
context to mean that the user of health information technology
demonstrates to the satisfaction of the Secretary of HHS that the
technology is certified and being used in a meaningful manner, that
the technology is connected in a manner that provides for the
electronic exchange of health information to improve the quality of
health care, and that such information is submitted in a form and
manner specified by the Secretary. See Pub. L. No. 111-5, § 4101(a)
123 Stat. 467, 469-470.
[9] The HITECH Act also established incentive programs for eligible
providers participating in Medicaid, Medicare Advantage organizations--
private companies that provide Medicare health insurance coverage to
beneficiaries for hospital, physician, and other services--and
hospitals that participate in Medicare or Medicaid and that adopt and
meaningfully use EHR technology. These programs are outside the scope
of this report. See Pub. L. No. 111-5, §§ 4101, 4102, 4201, 123 Stat.
467, 477, 489.
[10] Pub. L. No. 111-5, § 4101(b), 123 Stat. 472.
[11] Pub. L. No. 110-275, § 132(c), 1223 Stat. 2530.
[12] See Medicare Program; Payment Policies Under the Physician Fee
Schedule and Other Revisions to Part B for CY 2009, preamble II.O2.,
73 Fed. Reg. 69726, 69847 (Nov. 19, 2008) (program year 2009);
Medicare Program; Payment Policies Under the Physician Fee Schedule
and Other Revisions to Part B for CY 2010, preamble II.G.5., 74 Fed.
Reg. 61738, 61849 (Nov. 25, 2009) (program year 2010); and Medicare
Program; Payment Policies Under the Physician Fee Schedule and Other
Revisions to Part B for CY 2011, preamble VII.F.2, 75 Fed. Reg. 73170,
73551 (Nov. 29, 2010) (program year 2011).
[13] See Establishment of the Temporary Certification Program for
Health Information Technology, 75 Fed. Reg. 36158 (June 24, 2010)
(temporary certification provisions to be codified at 45 C.F.R. part
170); Medicare and Medicaid Programs; Electronic Health Record
Incentive Program, 75 Fed. Reg. 44314 (July 28, 2010) (standards and
certifications provisions to be codified at 42 C.F.R. part 495), and
Health Information Technology: Initial Set of Standards,
Implementation Specifications, and Certification Criteria for
Electronic Health Record Technology, 75 Fed. Reg. 44590 (July 28,
2010) (certification provisions to be codified at 45 C.F.R. part 170).
[14] As of the date of this report, the most recent complete-year data
available for the Electronic Prescribing Program were for 2009.
[15] We did not independently review these studies or the electronic
prescribing technologies referenced in them; their inclusion is not
intended to endorse the methods, practices, or technologies used.
[16] A formulary is a list of generic and brand name prescription
drugs, grouped by therapeutic class.
[17] Chiropractors are eligible providers in the EHR Program, but
because they do not have prescribing authority, they are not able to
obtain incentive payments and are not subject to penalties from the
Electronic Prescribing Program.
[18] Medicare Part B pays for physician, outpatient hospital, home
health care, and certain other services.
[19] Pub. L. No. 111-5, §4101(f)(2), 123 Stat. 477.
[20] Providers cannot receive incentive payments from the Electronic
Prescribing Program the same year they receive incentive payments from
the Medicare EHR Program. Providers that are eligible for both the
Medicare and Medicaid EHR Programs must choose the program from which
they will receive incentive payments. Until 2015, providers eligible
for both the Medicare and Medicaid EHR Program may switch programs
only once after the first incentive payment is initiated. If those
providers are eligible for and receive incentive payments from the
Medicaid EHR Program they are also permitted to receive incentive
payments from the Electronic Prescribing Program.
[21] On a case-by-case basis, CMS may exempt certain providers from
penalties assessed by either the Electronic Prescribing or EHR
Programs if it determines that complying with each program's reporting
requirements would result in a significant hardship to the provider.
See 42 U.S.C. §§ 1395w-4(a)(5)(B) (Electronic Prescribing Program),
(7)(B) (EHR Program).
[22] If CMS finds that less than 75 percent of providers meet the EHR
Program's requirements, CMS may increase the penalty percentage in the
EHR Program beginning in 2018 by up to 1 percent per year, with a
maximum penalty of 5 percent. See 42 U.S.C. §§ 1395w-4(a)(7)(A)(iii).
[23] In technical comments provided on a draft of this report, HHS
stated that this provision of the EHR Program promotes participation
in the Electronic Prescribing Program.
[24] The Electronic Prescribing Program will assess penalties
prospectively--that is, concurrently with claims submissions. A CMS
official told us that the agency has not yet determined how it will
assess penalties in the EHR Program. Similar to the Electronic
Prescribing Program, CMS could assess penalties for the EHR Program
concurrently with claims submission.
[25] A provider who earns at least $24,000 in total allowed Medicare
Part B charges in 2011 or 2012 and earns incentive payments from the
EHR program in 2011 or 2012 will earn the maximum payments from that
program, because the annual incentive payment amount is equal to 75
percent of the allowed charges, up to the annual limits displayed in
appendix IV.
[26] For providers who first obtain incentive payments from the EHR
Program in 2011, 2012, or 2013, the stage-one reporting requirements
will apply to their first 2 years of participation. For providers who
first obtain incentive payments from the EHR Program in 2014, the
stage-one reporting requirements will apply only to the first year of
participation. The years in which stage-two requirements will apply
for providers will depend on the first year they obtain incentive
payments. CMS has not yet determined what stages will apply to
providers for years 2015 and beyond.
[27] See 75 Fed. Reg. 44321.
[28] To obtain incentive payments from the EHR Program in 2011,
providers must meet or exceed the reporting requirements in a
continuous 90-day period. After 2011, eligible providers must meet or
exceed the reporting requirements over a full year.
[29] Certain providers may be exempted from reporting requirements
that fall outside the scopes of their practices.
[30] Clinical decision support can include checks for allergies, drug-
drug interactions, overly high doses, and clinical conditions, as well
as other patient-specific dose checking.
[31] Pub. L. No. 111-148, § 3002, 124 Stat. 363.
[32] PQRS, formerly known as the Physician Quality Reporting
Initiative or PQRI, was established by the Tax Relief and Health Care
Act of 2006 (Pub. L. No. 109-432, div. B, § 101(b), 120 Stat. 2922,
2975) as modified by MIPPA (Pub. L. No. 110-275, § 131(b), 122 Stat.
2521) and the Patient Protection and Affordable Care Act of 2010 (Pub.
L. No. 110-148, § 3002, 124 Stat. 363). Through PQRS, incentive
payments are available to physicians and other eligible providers
through 2014, and penalties will be assessed on providers that do not
report any quality measures after 2014. In a given year, providers may
obtain incentive payments from PQRS in addition to either the
Electronic Prescribing Program or the EHR Program.
[33] Congress directed CMS to use electronic prescribing quality
measures established for PQRS in 2008 to determine which eligible
providers would receive incentive payments for the Electronic
Prescribing Program in 2009. Pub. L. No. 110-275 §132, 122 Stat. 2527
(adding SSA § 1848(m) (3)(B)(ii)). After Congress established the
Electronic Prescribing Program, the electronic prescribing measure was
removed from PQRS. The Electronic Prescribing Program and PQRS have
other similarities. For example, the types of providers eligible for
both programs are identical. However, eligibility for the Electronic
Prescribing Program is further restricted to providers that have
prescribing authority.
[34] Providers reported the electronic prescribing codes on the claims
they submitted for reimbursement for the services performed during the
applicable patient visit. An applicable patient visit is any patient
visit identified by certain services included on a provider's Part B
claims. For 2009, CMS designated 33 services as applicable visits for
the Electronic Prescribing Program, which were typically services
provided in the office or outpatient settings.
[35] Beginning on June 1, 2010, the Drug Enforcement Administration
first authorized the electronic prescription of certain controlled
substances. See Electronic Prescriptions for Controlled Substances, 75
Fed. Reg. 16236 (Mar. 31, 2010) (to be codified in various sections at
21 C.F.R. parts 1300, 1304, 1306 and 1311). Prior to this date, such
authority did not exist.
[36] CMS made this determination in 2010.
[37] Because providers can belong to multiple unrelated health care
practices, CMS determined which providers met or exceeded the
reporting requirement using each unique combination of providers'
national provider identifier numbers--a unique number that identifies
each provider--and tax identification numbers--a unique number that
identifies each entity that bills CMS for Medicare reimbursements on
behalf of the provider. If the unique combination of national provider
identifier and tax identification number met the reporting
requirement, to calculate the incentive payment, CMS multiplied the
total allowed Medicare Part B charges for the year for that national
provider identifier and tax identification number combination by 2
percent. CMS made the payment to the practice represented by the tax
identification number associated with the provider.
[38] CMS included the adjustment factor--1.036 percent--to account for
claims submitted by providers for 2009 that were not final at the time
the agency determined the incentive payment amounts.
[39] CMS made some modifications to the list of services designated as
applicable visits for 2010, for a total of 56 services. For example,
compared to the services designated as applicable visits, beginning in
2010, CMS added services that occur in a nursing home or home care
setting. As a result, more providers may meet the 10 percent
participation threshold in 2010 than would have in 2009, which may
increase the number of providers that receive the incentive payment in
those years.
[40] In 2010, providers were not permitted to report the electronic
prescribing code if the electronic prescribing system transmitted the
prescription by fax. However, providers were permitted to report the
electronic prescribing code if the provider's electronic prescribing
system transmits the prescription to the pharmacy electronically, but
the pharmacy network converts the electronic prescription into a fax
because the pharmacy cannot receive electronic prescription
transmittals.
[41] To participate in the Electronic Prescribing Program as a group
practice, the practice must also participate in CMS's PQRS as a group
practice. For 2010, 27 group practices notified CMS that they would
participate in the Electronic Prescribing Program under the group
practice reporting option. If CMS determines that a group practice
will receive an incentive payment, the agency determines the incentive
payment amount based upon the total allowed Medicare Part B charges
for the year for all providers in the group practice even if some
providers in the group did not submit the electronic prescribing
reporting code during the year.
[42] The two alternative reporting mechanisms available in 2010 were
certain registries or EHR systems. A registry is an organization
identified by CMS that collects the electronic prescribing reporting
codes from providers and submits aggregated information to CMS. CMS
approved certain EHR systems for the Electronic Prescribing Program
and those systems are not necessarily systems certified for use in
CMS's EHR Program. For 2010, CMS approved 40 registries as
organizations able to submit the electronic prescribing code and seven
EHR vendors with products that providers could use to submit the
electronic prescribing code. In technical comments provided on a draft
of this report, HHS noted that these two reporting mechanisms were
significant additions to the program. However, at the time of our
work, it was unclear how many providers would use these alternative
reporting mechanisms for the 2010 period because providers were not
required to notify CMS in advance of their intention to use either
mechanism.
[43] See 75 Fed. Reg. 73551.
[44] Group practices of 2-10 providers must report the electronic
prescribing code for at least 75 applicable visits; 11-25 providers
must report the code for at least 225 applicable visits; 26-50
providers must report the code for at least 475 applicable visits; 51-
100 providers must report the code for at least 925 applicable visits;
and 101-199 providers must report the code for at least 1,875
applicable visits.
[45] CMS has noted that the data collection period would help the
agency make the determination of whether the penalty applies in
advance of 2012 in order to apply the penalty in 2012 concurrently
with claims submission. See 75 Fed. Reg. 40208.
[46] Although CMS allowed individual providers and group practices to
report the electronic prescribing code through one of two alternatives
to Part B claims--that is, a registry or certain EHR systems--to
obtain incentive payments in 2010 and 2011, CMS will not analyze
electronic prescribing code submissions reported through these
alternative mechanisms to determine which providers will be subject to
penalties in 2012.
[47] CMS will not apply the penalty to individual providers if they
meet one of the following criteria during the reporting period: (a)
are not physicians, nurse practitioners, or physician assistants and
therefore generally do not have prescribing authority; (b) have less
than 100 applicable visits; or (c) have less than 10 percent of their
total allowed Medicare Part B charges from the services designated as
applicable visits.
[48] See 75 Fed. Reg. 73551.
[49] CMS will not apply the penalty to group practices that have less
than 10 percent of their total allowed Medicare Part B charges from
the services designated as applicable visits.
[50] See 75 Fed. Reg. 73563.
[51] If CMS takes the same approach to establish the requirements
providers must meet to avoid penalties in 2013 and 2014 as the agency
took to avoid penalties in 2012, CMS will propose requirements
providers must meet to avoid penalties in 2013 in July 2011 and
finalize the requirements in November 2011, and will propose
requirements providers must meet to avoid penalties in 2014 in July
2012 and finalize the requirements in November 2012.
[52] See 75 Fed. Reg. 73565.
[53] CMS contracts with private companies--such as health insurance
companies and companies that manage pharmacy benefits--to provide
prescription drug benefits to Medicare beneficiaries. These companies
are referred to as Part D plan sponsors.
[54] Since April 1, 2009, prescription drug plan sponsors were
required to submit Part D claims with the individual provider's
national provider identifier included, if available. Since January 1,
2010, pharmacies have submitted a data field--called the prescription
origin code--on Part D claims for new prescriptions that indicates
whether the prescription was received by the pharmacy electronically,
by facsimile, by telephone, or in hardcopy. CMS required prescription
drug plan sponsors to submit the origin code on the Part D claim and
the drug plan sponsors are requiring that the pharmacies in their
network complete that data field.
[55] In technical comments provided on a draft of this report, HHS
noted that if CMS used Part D data instead of the electronic
prescribing reporting codes, CMS would not be able to determine
whether the electronic prescribing system used by the provider met the
capabilities of a qualified electronic prescribing system.
[56] While CMS determined which providers met or exceeded the
reporting requirement using each unique combination of providers'
national provider identifier numbers and tax identification numbers,
we analyzed 2009 Electronic Prescribing Program participation at the
national provider identifier level only so that we could present
results for unduplicated providers. The number 597,000 represents a
count of all Medicare providers who had at least one applicable visit
in 2009. However, not all of these providers have prescribing
authority. Consequently, there may be some individuals included in the
count of 597,000 providers that were not eligible for an electronic
prescribing incentive payment.
[57] The number of providers that received incentive payments from CMS
for the 2009 Electronic Prescribing Program differs from an estimate
made by Surescripts, a company that operates a network connecting
providers, pharmacists, and patients by electronically routing
prescriptions, providing electronic access to patient benefit and
formulary information, and providing electronic access to patients'
medication histories. Surescripts reported in September 2010 that more
than 200,000 office-based providers (physicians, nurse practitioners,
and physician assistants) had transmitted prescriptions
electronically. One possible reason for the difference is that the
Surescripts estimate counts any provider who transmitted at least one
prescription electronically in a 30-day period whereas CMS's estimate
is based on both elements of the 2009 reporting requirement. See
Surescripts, "1 In 3 Prescriptions Are Now E-Prescriptions in
Massachusetts as Number of E-Prescribing Physicians Grows to 200,000
Nationwide," press release (Sept. 21, 2010). Downloaded on September
21, 2010, from [hyperlink,
http://www.surescripts.com/media/683832/092110_safe_rx_final_release_quo
te.pdf].
[58] Buccaneer, PQRI 2009 Electronic Prescribing (eRx) Final Program
Monitoring and Evaluation Report (Oct. 22, 2010). In contrast to the
way we determined provider, this report determined provider at the
national provider identifier and the taxpayer identification number
basis.
[59] In 2009, about 66 percent of the time that the three electronic
prescribing reporting codes were submitted, the provider included the
one code indicating that no prescriptions were generated during the
visit.
[60] ONC reports to the Secretary of HHS and plays a role in the EHR
Program by establishing the standards and specifications that
providers' systems must meet for the EHR Program, coordinating with
CMS on the development of the meaningful use criteria, and creating
and administering the certification program that authorizes third-
party organizations to certify EHR technology. As of November 2010,
these third-party organizations had certified 73 EHR products. The
following committees contributed to the establishment of the standards
and specifications for the EHR Program: the American Health
Information Community, the Certification Commission for Health
Information Technology, the Health Information Technology Standards
Panel, and the HIT Policy and Standards Committees.
[61] Office of the National Coordinator for Health Information
Technology, "Temporary Certification Program," Available at
[hyperlink,
http://healthit.hhs.gov/portal/server.pt?open=512&objID=2885&parentname=
CommunityPage&parentid=72&mode=2&in_hi_userid=12059&cached=true]
(accessed Dec. 13, 2010).
[62] In April 2010, the Health IT Policy Committee, a federal advisory
committee that advises ONC on health IT policy issues, made several
recommendations to HHS on the topic of patient safety, including
recommendations related to the EHR certification criteria. The
committee recommended that the EHR certification criteria require
software vendors to maintain records on all patient safety concerns
reported by their customers and that vendors establish processes to
promptly provide all affected customers with safety alerts.
[63] Office of the National Coordinator for Health Information
Technology, "Standards & Certification Criteria Final Rule," Available
at [hyperlink,
http://healthit.hhs.gov/portal/server.pt?open=512&objID=1195&parentname=
CommunityPage&parentid=97&mode=2&in_hi_userid=11673&cached=true]
(accessed Dec. 13, 2010).
[64] Providers seeking incentive payments from the EHR Program must
also report the name of the EHR system they are using to CMS.
[65] All modules certified for use in the EHR Program must meet all
privacy and security standards established by ONC.
[66] Under the EHR Program, certified EHR technology must also be able
to support medication reconciliation, however, this is not a
technological requirement for the Electronic Prescribing Program.
[67] See 75 Fed. Reg. 73556.
[68] A CMS official in the Office of Clinical Standards and Quality,
which administers the Electronic Prescribing Program, told us that CMS
did not have the resources to develop a certification process for the
Electronic Prescribing Program. CMS does not collect information on
which electronic prescribing systems providers are using.
[69] In technical comments provided on a draft of this report, HHS
noted that, with the assistance of their electronic prescribing
system's vendor, providers should be able to determine whether their
electronic prescribing system contains the technical capabilities of a
qualified system. While this is an option for providers, it may be
unnecessary, given the existence of the list of certified EHR systems
and certified EHR modules on ONC's Web site.
[70] Providers wanting to obtain incentive payments for the EHR
Program will have to meet a total of 20 reporting requirements, which
include five mandatory and up to two additional reporting requirements
related to electronic prescribing.
[71] For the Electronic Prescribing Program, when providers report the
electronic prescribing code, they are attesting that they used a
qualified electronic prescribing system, which has the technological
capabilities listed in figure 8.
[72] Recent studies have shown that not all providers who adopt
electronic prescribing systems routinely use all of the technological
capabilities those systems provide, which may result in missed
opportunities to improve quality and control costs. For example, a
2010 study reported that fewer than 60 percent of physicians surveyed
had access to three advanced electronic prescribing features, and less
than a quarter routinely used all three features. See J.M. Grossman,
"Even When Physicians Adopt E-Prescribing, Use of Advanced Features
Lags," Center for Studying Health System Change, Issue Brief, no. 133
(2010): 1-5.
[73] For example, a physician with $24,000 in Medicare Part B
allowable charges in 2011 would receive an $18,000 incentive payment
under the EHR Program compared to a $240 incentive payment under the
Electronic Prescribing Program. (See figure 3.) About 1 percent of the
providers who earned incentive payments from the Electronic
Prescribing Program in 2009 earned more than $18,000.
[74] CMS will determine if providers should receive a penalty in 2012
from the Electronic Prescribing Program based on whether or not the
provider met certain reporting requirements in 2011.
[75] Certain physicians that do not prescribe or do so infrequently
will not be subjected to penalties, regardless of whether or not they
meet the Electronic Prescribing Program's reporting requirement.
[76] See 75 Fed. Reg. 73561.
[77] HHS added that one option that may be considered is using Part D
data, which would alleviate the need for providers to report to the
Electronic Prescribing Program to avoid penalties from that program.
However, as we have reported, CMS officials have raised several
concerns--concerns echoed by the agency in comments made on our draft
report--about the reliability of Part D data to determine which
providers should receive incentive payments. CMS officials told us
that these data reliability concerns should be resolved before Part D
data can be used to determine which providers should receive incentive
payments under the Electronic Prescribing Program.
[78] See 75 Fed. Reg. 44324.
[79] In addition, the HHS Office of Inspector General has the
authority to conduct audits and investigations of HHS-regulated
entities. See 5 U.S.C. app. 3. However, Inspectors General may not
carry out program operating responsibilities. See 5 U.S.C. app. 3, §
9(a).
[80] We did not independently review these studies or the electronic
prescribing technologies referenced in them; their inclusion is not
intended to endorse the methods, practices, or technologies used.
[81] Pub. L. No. 110-275, § 132(c), 1223 Stat. 2530.
[82] To select a nongeneralizable sample of four organizations, we
first conducted internet research to identify organizations that
appeared to have measured the effect of electronic prescribing
implementation on quality, cost, or both. Through this process, we
identified five types of organizations that appeared to have measured
the effects: state Medicaid programs, health insurance companies,
pharmacy benefit managers, collaborative groups, and state employee
benefit plans. In selecting our nongeneralizable sample, we identified
organizations that represented four of the five types of organizations
that appeared to have measured the effects. Through this process, we
confirmed that the organizations that we sampled had indeed measured
the effects of electronic prescribing on quality, cost, or both.
[83] To identify these articles, we conducted a literature search of
articles published from January 1, 2005, to May 14, 2010, and
supplemented that search with articles that we identified during the
course of our work. We limited our review to studies conducted in the
United States.
[84] The studies we reviewed may have reported outcomes and findings
not summarized in this appendix.
[85] In tiered systems, insurers identify preferred medications, often
generic medications, and designate them as Tier 1, with the lowest
copayment. Tier 2 medications generally require a higher copayment,
may include moderately priced brand-name medications. Tier 3
medications are generally expensive brand-name medications for which
generic alternatives are available in lower copayment tiers.
[86] The national provider identifier number is a unique number that
identifies each provider, and the tax identification number is a
unique number that identifies each entity that bills CMS for Medicare
reimbursements on behalf of the provider. Because providers can belong
to multiple unrelated health care practices, CMS determined which
providers met or exceeded the reporting requirement using each unique
combination of providers' national provider identifier numbers and tax
identification numbers.
[87] We only obtained a count of the valid electronic prescribing code
submissions.
[88] Of the applicable providers that we were unable to match at the
time of our analysis, CMS determined that 974 had national provider
identifier numbers that had been deactivated and were therefore not
available in the NPPES Downloadable File or the PECOS Global Extract
file that we analyzed and another 77 had national provider identifier
numbers that were not valid.
[89] CMS determined that five providers from Puerto Rico and one
provider from the Virgin Island obtained incentive payments. Providers
from American Samoa, Guam, the Northern Mariana Islands, Puerto Rico,
and the Virgin Islands had at least one applicable visit.
[End of section]
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