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A Mandate in the Making?

April 1, 2008
by David Raths
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As e-prescribing talk swirls around the halls of congress, the industry braces for a fiat

A February 2008 study conducted by David Bates, M.D., of Brigham and Women's Hospital in Boston estimated that Massachusetts hospitals could prevent 55,000 dangerous medication errors every year and save $170 million annually if all implemented computerized physician order entry.

Douglas henley

Douglas Henley

As more research is published pointing to the clinical and financial benefits of e-prescribing (one component of CPOE), the drumbeat grows louder for legislative action to spur adoption. The Centers for Medicare and Medicaid Services (CMS) is pushing e-prescribing as a stepping stone to widespread use of EHRs.

The momentum picked up last fall when in November the American Health Information Community (AHIC) recommended that the Secretary of Health and Human Services seek authority from Congress to mandate e-prescribing, although AHIC also outlined conditions that should be met in the next few years before a mandate takes effect.

In December, Sen. John Kerry, D-Mass., introduced the Medicare Electronic Medication and Safety Protection (E-MEDS) Act of 2007, which would offer financial incentives to help cover the cost of e-prescription software but also calls for a Medicare mandate by 2011, with lower reimbursements for doctors not e-prescribing.

“It has a better chance of passing than any other piece of health IT legislation this year,” says David Merritt, project director at the Washington, D.C.-based Center for Health Transformation, which is headed by former Speaker of the House Newt Gingrich. “The time is right for CMS to use its power as a purchaser to push for this adoption.”

Others aren't so sure of the legislation's chances. Mary Griskewicz, director of ambulatory information systems for the Chicago-based Healthcare Information and Management Systems Society (HIMSS), says the idea of any piece of health IT legislation passing this year is a bit of a stretch. “We're still at war; there's a major election coming up,” she says. “And even though the administration has wanted health IT initiatives to move forward, they haven't wanted to legislate it.”

Allyson schwartz

Allyson Schwartz

Yet even groups representing clinicians, such as the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP), which have traditionally opposed health IT mandates, have expressed support for aspects of the E-MEDS legislation.

AAFP Executive Vice President Douglas Henley, M.D., an AHIC member, recommends putting the financial incentives in place but holding off on the mandate until certain requirements are met, including having clear guidelines about prescribing controlled substances, which account for about 11 percent of all prescriptions. (Under pressure from Congress, the United States Drug Enforcement Agency announced in February that it would work on rules to allow e-prescription of controlled substances.)

“If they are going to move toward mandates, there are things that need to be accomplished in order to make it as easy as possible for doctors to comply,” Henley stresses. For instance, despite the DEA's assurances, many state laws dictate paperwork for controlled substances, he says. In addition, approximately 30 percent of U.S. pharmacies still can't accept e-prescriptions, he adds. And CMS guidelines call for software not just to send prescriptions back and forth, but also to offer clinical decision support; otherwise physicians won't get the bonuses described.

Henley says that without a certification process, physicians must determine for themselves which software meets the guidelines and which doesn't. “That is going to be very confusing, and doctors are going to be buying the wrong stuff,” he says. “If you are going to mandate physicians, then mandate pharmacies, mandate the states, and mandate the software vendors as well.”

U.S. Rep. Allyson Schwartz, D-Pa., a former healthcare administrator and one of the bill's co-sponsors in the House, says legislators are trying to be as reasonable as possible by pushing out mandates three years and by saying CMS can offer exemptions if need be. “We have put financial incentives in the bill,” she says, “so it's mostly carrots with a little bit of stick at the end.”

She says CIOs working on their long-term planning should anticipate that the legislation is going to pass in 2008. “This is the beginning of a longer conversation about using technology to improve healthcare,” she says, “and we'll learn from our experiences along the way.”

HIMSS' Griskewicz says hospital CIOs should be looking at e-prescribing legislation as it relates to their current systems and their business plans. Some have internal retail pharmacies whose systems are much easier to integrate, she says. “But with the Stark relaxation, they have to consider making e-prescribing part of an overall package they offer physicians, whatever law or mandate passes,” Griskewicz says.

CIOs want to keep physicians who work with their hospitals happy, she says, but from a business perspective, it is a great opportunity for them, particularly in competitive situations, to work with their CFOs on aligning more closely with local doctors.