AHRQ: Community-Based Physicians Test Safety and Workflow Benefits of E-Prescribing


January / February 2008


Community-Based Physicians Test Safety and Workflow Benefits of E-Prescribing

When the Federal Government proposes new standards to permit electronic prescribing in ambulatory care settings next April, the experiences of nearly 50 small, community-based physician practices in northeastern Ohio are likely to help shape their recommendations.

One of the much-anticipated benefits of health information technology, e-prescribing has the potential to greatly transform the current process, resulting in greater cost savings and fewer adverse drug events (ADEs). Experts predict that adoption of e-prescribing could avoid more than 2 million ADEs, of which 130,000 are life-threatening (Johnston, et al., 2004).

Instead of requiring the patient to fill the prescription and figure out their insurer’s drug coverage policy, e-prescribing allows a clinician to transmit an order directly from his or her office to the pharmacy. There, the prescription can be reviewed and processed by the pharmacist for accuracy of patient information, medication history, insurance coverage, potential adverse effects, and other important clinical and coverage data.

Despite these advantages, only as many as 18% of doctors use any form of e-prescribing, according to current estimates (Medicare Program, 2005). And fewer than 3% of all prescriptions are written with integrated systems that can provide the most significant benefits (NCPCP, 2004).

Medicare Law Calls for E-Prescribing Standards
As part of the Medicare Modernization Act (MMA) of 2003, which created the new Part D drug benefit, Congress identified the need for uniform standards to spur adoption of e-prescribing. To that end, it called on the U.S. Department of Health and Human Services’ (HHS) National Committee on Vital and Health Statistics to develop e-prescribing standards for use in ambulatory care settings; three “foundation” standards have already been adopted.

The Medicare law also called on HHS to propose areas in which further e-prescribing standard development was needed and to sponsor pilot sites to evaluate them.1 HHS selected six “initial” standards and five pilot sites, including the physician practices in Ohio, where the standards were tested during 2006. The pilot projects were funded by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality (AHRQ).

The initial standards tested by the pilot sites for Medicare Part D implementation are described in Table 1.

Table 1. Initial Standards for Medicare Part D
NCPDP* Formulary and Benefits Standard, Version 1.0 Displays formulary status, alternative drugs, co-pays, and other status information.
NCPDP Script** Medication History Includes status, provider, patient, coordination of benefit, repeatable drug requests.
NCPDP Script Fill Status Notification Informs when prescription is filled, not filled, or partially filled. Not yet generally used.
Prior authorization messages Requires relevant information for prior authorization requests.
Structured and Codified SIG (patient instructions) Displays indication, dose, dose calculation and restriction, route, frequency, interval, site, administration time and duration, stop time.
RxNorm 151; Clinical drug terminology (Versions 8/06 and 12/06) Provides standard name for clinical drugs and for dose forms as administered.
*National Council for Prescription Drug Programs, an accredited standards development organization.
**NCPDP’s Script Version 5.0 is a foundation standard for e-prescribing and provides for exchange of new prescriptions, changes, renewals, and cancellation notices.

Small Physician Practices Test Standards
Although the pilot sites included large physician practices, academic medical centers, and long-term care facilities, the experiences of the doctors in the community-based practices in northeastern Ohio are particularly relevant. (The evaluation report is available on AHRQ’s web site at http://healthit.ahrq.gov/erxpilots).

This project was led by Ohio KePRO, the State’s quality improvement organization and involved a network of multi-specialty physician practices called University Hospitals Medical Practices (UHMP), a subsidiary of University Hospitals of Cleveland. With a lightweight e-prescribing tool (OnCallData™) and a $500 incentive for physician adoption, the project created a study group of 25 practices (130 physicians) and a control group of 22 practices (77 physicians).

Testing five of the six initial standards (excluding the formulary and benefits standard), Ohio physicians concluded the following:

  • Medication History. The standard is working as intended, transmitting and generating a large volume of medication history information to the e-prescribing tool from the payer or pharmacy benefits manager. Even though the medication history is available, it was not viewed often, suggesting that many users were not aware it was available. Another concern raised was how to reconcile and present medication history data that comes from multiple sources, such as claims paid by one entity and medication dispensed by another.
  • Prescription Fill Status Notification. Fill transactions were successfully tested in a production setting, although messages were not generated directly by pharmacy systems, doctors noted. Instead, messages were generated indirectly by SureScripts, which operates a national pharmacy health information exchange, after prescription data was transferred to SureScripts by participating pharmacies. Using a prescription repository as an intermediate entity in the fill transaction process could create additional potential failure points and underscores the need for thorough transaction testing between partners.
  • Prior Authorization. Successful prior authorization transactions took place, and the process was well received by office staff. However, implementation was complicated by the need to comply with several different implementation guides, not all of which were complete. Physicians also noted the substantial work involved by payers to expand the electronic prior authorization process to include additional drugs and health plans.
  • Structured Signature. Not ready for adoption in current state.
  • RxNorm. Not ready for adoption in current state.

Based on results of the year-long pilot study, the overall impact of e-prescribing on patient safety in small physician practices appears to be positive. At the same time, some technology adoption characteristics of this pilot project likely contributed to its successful implementation.

For example, many UHMP practices were already using OnCallData’s e-prescribing application by the time the pilot study began, which was integrated into UHMP’s practice management system. A $500 discount on malpractice premiums to physicians who met e-prescribing levels (250 per month for full-time primary care practitioner) spurred further usage.

Nonetheless, AHRQ is very encouraged by the participation and feedback from small physician practices. Their input will help shape the standards to be developed by HHS and will inform additional analyses that, we hope, will allow more physicians and patients to realize the benefits of e-prescribing.

1 Pilot sites were carried out under four cooperative agreements and one contract entered into in accordance with a Request for Applications (RFA-HS-06-001) released by the Agency for Healthcare Research and Quality on behalf of the Centers for Medicare & Medicaid Services. Available at http://grants.nih.gov/grants/guide/rfa-files

P. Jon White is the director of health information technology for the Agency for Healthcare Research and Quality in Rockville, Maryland, and a board-certified family physician.

Carolyn M. Clancy is director of the Agency for Healthcare Research and Quality. She is a general internist and holds an academic appointment at George Washington University School of Medicine in Washington, DC. She may be contacted at carolyn.clancy@ahrq.hhs.gov.


Johnston, D., Pan, E., Middleton, B., Walker, J., Bates, D.W. (2004). The value of computerized order entry in ambulatory settings. Boston: Center for Information Technology Leadership.

Medicare Program; E-Prescribing and the Prescription Drug Program. Proposed Rule. Federal Register: 2005; 42 CFR Part 423: 6260-1.

National Council for Prescription Drug Programs, Testimony to National Center on Vital Health Statistics, Subcommittee on Standards and Security, March 31, 2004.