Medicare reform debate: Bill sets electronic prescribing deadline

Physicians support the concept but not the mandate.

By Markian Hawryluk, amednews staff. Sept. 15, 2003.

Washington -- After witnessing the pitfalls of developing electronic transaction standards under the Health Insurance Portability and Accountability Act, physician groups fear that a proposal to mandate electronic prescribing in Medicare could become a mini-HIPAA.

Lawmakers included the plan in the House version of the Medicare reform bill. It would require Medicare officials, with help from an advisory panel, to establish electronic prescribing standards by Jan. 1, 2006. Doctors would have to write electronic prescriptions for all Medicare patients starting in 2007, except in emergencies and other circumstances.

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The Senate Medicare reform bill would develop standards by the same date, but physicians could choose whether they wanted to prescribe electronically.

In a letter to House Ways and Means Committee Chair Bill Thomas (R, Calif.), a group of medical specialty societies and the AMA called for lawmakers to adopt the Senate framework. The House's 2007 deadline, they said, is unrealistic.

"Difficulties and delays in implementing [HIPAA transaction] standards are a case in point," the groups said. "Congress passed HIPAA in 1996, and these standards have yet to be fully implemented. Development of electronic prescribing will be equally complicated."

The groups said the rigid implementation deadline would be an unfunded mandate on physicians, forcing them to purchase untested and expensive systems to comply. Small practices, and in particular those in rural areas, would be hit hardest without the economies of scale to offset implementation costs, they said.

Medication errors cost the health care system more than $1 billion a year.

"It's important to note that electronic prescribing technology is in the early stages of development," said AMA Trustee Joseph M. Heyman, MD. "Once established and tested, uniform electronic prescribing standards may be helpful, but it should be up to physicians to decide whether adopting this expensive technology is in the best interest of their patients and practices."

Many physicians might avoid HIPAA requirements through exemptions for small practices. It is unclear what exemptions would be available for electronic prescribing.

Still, physicians remain supportive of the concept of electronic prescribing. With collaborative development of standards, widespread pilot testing and voluntary adoption, e-prescribing promises to improve patient safety by preventing errors and adverse drug interactions, physician groups say.

A 1999 Institute of Medicine report estimated that medication errors, many of which are caused by illegible handwritten prescriptions or by drug interactions, cost the health care system more than $1 billion a year.

"E-Rx offers the potential of reducing medical errors, improving patient safety and compliance, and reducing administrative costs," said Munsey Wheby, MD, president of the American College of Physicians. "However, a federal mandate to require that within three years all prescriptions be written and transmitted electronically, as [the House bill] proposes to do, forces unproven systems and technologies on patients and clinicians."

ACP has developed a set of principles to guide development of e-prescribing standards aimed at ensuring physician involvement and protecting doctors' clinical decision-making. Some physicians fear electronic prescribing could be used by managed care companies to switch patients to preferred or lower-cost drugs.

Pharmacists are also wary of federal mandates. The National Assn. of Chain Drug Stores said Congress could help facilitate the development of standards as long as it takes a free-market approach. "Electronic prescribing is one of those great ideas that has had difficulty getting off the ground," said NACDS President and CEO Craig Fuller. "What we need now from Congress is a commitment to ensure that the Medicare legislation will allow physicians, patients and pharmacists to work together to build broad-based adoption."

NACDS and the National Community Pharmacists Assn. have formed a joint venture called SureScripts that is rolling out an electronic prescribing option this year. More than 50% of U.S. pharmacies are expected to be connected to SureScripts by year's end.

Other private ventures also are marketing electronic prescribing systems. Neither SureScripts nor the other commercial ventures can be assured that their products will meet standards developed as a result of the Medicare bills.

"Development of e-prescribing technology is proceeding rapidly, so federal attempts to create new task forces, advisory committees or standards could well delay the adoption of the technology," Fuller said.

Pharmacy benefit managers also have expressed support for electronic prescribing. The three largest -- AdvancePCS of Irving, Texas; Express Scripts Inc. of St. Louis; and Medco Health Solutions of Franklin Lakes, N.J. -- founded RxHub, an electronic prescribing venture, in 2001.

RxHub officials said electronic prescribing could help reduce hassles for physicians who must deal with multiple formularies from various insurers. Prescribing drugs not on the formulary invariably means phone calls from insurers, pharmacists and even patients requesting authorization for an alternative. An electronic prescribing system, they said, would give physicians instant access to formularies and prevent follow-up calls. "Despite the increasing complexity and volume of prescriptions and dramatic advances in health care and technology, the tasks of prescription writing and fulfillment remain largely manual, much as they were 50 years ago," RxHub said in a white paper on electronic prescribing.

ADDITIONAL INFORMATION:

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Both the House and Senate Medicare reform bills seek to encourage electronic prescribing.

House

Standards would be developed by Jan. 1, 2006.
Physicians would be required to write and transmit electronically all prescriptions for Medicare patients starting in 2007.