e-Prescribing

anonymous wrote on Monday, August 31, 2009:

Have we come to a decision in regards to e-prescribing and which method we are going with? Is Fred Trotter on board with helping out with a low-cost e-prescribing method that will integrate directly into OpenEMR?  or can we still look into National eRX?

Sena and his team are anxiously awaiting big projects to help us and I suggest we give them something to tackle.

ideaman911 wrote on Wednesday, September 02, 2009:

My prime concern is the definition of "low cost".  Right now my client uses Allscripts, which is FREE.  That is MY idea of "low cost".  But it has no direct linkage, nor plans to, for any EMR system.  So I am attacking it from a keyboard emulation plan which will transfer data entered in OpenEMR to another (typically tabbed in Firefox) window as a batch process for e-Rx, and to include a batched printing ability for state-specific script pages, which would track their state code sequentially.

Joe Holzer    Idea Man
http://www.holzerent.com

anonymous wrote on Monday, September 07, 2009:

I am curious to know how your client is interacting directly with AllScripts… because AllScripts doesn’t provide connections to individual practices… only to service providers.

drpwayne wrote on Tuesday, September 08, 2009:

Allscripts has a free service open to all providers. They also sell an EHR of their own and have connections with several other vendors’ EHR systems.  I am using Allscripts through my present EHR system – I open a browser window, point it to Allscripts, send it the username and password, then send it the patient’s name and zip code. At that point the provider has to enter the script via the Allscripts interface, but after the script is entered, the contents of the browser window are read and the prescription saved to the patient’s record. The technique is not all that different from the PERL script that Rod created to download ICD9 codes from a web site, except that in the Allscripts case, I have to open a browser window so the provider can finish the prescription. I don’t know whether the opening of a new browser window and reading from it and making entries into it is something like this is possible with OpenEMR and PHP

ideaman911 wrote on Tuesday, September 08, 2009:

Dr Wayne;

I have noted a number of postings from you, but many suggest you are not yet a "committed" user of OpenEMR.  I have a few questions about your current e-Rx process and EMR vis a vis Allscripts.  OpenEMR has the ability to enter Rx data by patient, and to retrieve same.  But it has no specific interface with Allscripts, which has no plans to allow direct linkages per them.  So my wife (client) manually double-enters the data, which is tedious.

My plan as indicated earlier is to allow entry into OpenEMR, then have it selectably batch for e-Rx entry or print state-specific script papers, depending on DEA/State requirements for Controlled Substance (CS) and Patient Preference.

The paper print would track the state codes on the script papers, but could print as a batch for dissemination, or singularly.  A specific need there is for use in House Calls, where connectivity to neither internet nor printer is commonly available.  So batch printing when they can be is critical.  Obviously, a batch of one would work for most clinicians, if the printer is available full-time.  Similarly, e-Rx would batch those which could process that way to emulate keyboard entry into the Allscripts window with tab step screen positioning once the cursor was placed at the start position by the user.  By allowing that to record a "macro", most users could use whatever portal is desired by them.

In both cases, OpenEMR would keep track of all parameters, and ideally be populated by checkoffs from the free FDA databases for Rx, where all generic equivalents are available as well (my wife says Allscripts has limits for that, obviously driven by their funds sources).  It would also track and auto prep/remind for script renewals, so the user need only "accept" if a renewal.  Again. OpenEMR would track all that as well, including any requiring "prior auth", and ideally produce faxes for those, though I have not mapped that process just yet.  I know psyche users are especially interested given the number of CS scripts they write, which must be printed each and every month.

So if it would be so great (do I sound like Bill Gates? :wink: why does it not exist?  Because I am feverishly studying so I can get programming skills to allow it to be done.  They ain’t there just yet :wink:

But your description does not seem as though your EMR (EHR) system knows what e-Rx you have done through Allscripts (or any other), unless you double-enter as well.  In that respect it looks like OpenEMR is in the same boat.  Or do I misunderstand?

I know Rod Roark is working on the Rx section, but I do not know what his plans are.  Rod?

Joe Holzer    Idea Man
http://www.holzerent.com

drpwayne wrote on Wednesday, September 09, 2009:

Hello Joe.
Thank you for your thoughtful comments. Let me reply:
1) You’re right, I’m not a committed user of OpenEMR. In fact, I’m not using it at all, I’m trying to test-drive it.  There are many wonderful features of OpenEMR, and I’m blown away by the clear and beautiful code that Rod has produced in such prodigious quantities.  (When I grow up I want to program like Rod does.)
2) Your plan for eprescribing sounds good but it doesn’t pass muster, I’m afraid. Two of the federal requirements for a qualifying eprescribing solution is that it (a) knows the patient’s insurance companies formulary of preferred drugs, and (b) is able to alert the prescriber to drug-drug interactions. You really can’t do this on a standalone basis – you have to have a connection to Surescripts, which is a pharmacy consortium.  I’m doing my present connection through Allscripts. And no, we don’t do dual entry – the drug entry is made in Allscripts and then I capture the output by reading the DOM in the HTML on the Allscripts site. The captured prescription is then entered into our electronic record.
3) I haven’t seen any limit on generic equivalents for Allscripts. I don’t think they are funded from pharmaceutical companies; their big money is from selling full EHR solutions.
4) Also, paper prescriptions don’t cut it for federal stimulus funds. I know that controlled substances have to be written on paper prescriptions, but as much as possible, all others should be done electronically. And like it or not, they all have to go through Surescripts – it’s a monopoly and the government has endorsed it.  You don’t have to use Allscripts to access Surescripts, but the Surescripts people will only talk to a developer who has at least 100 sites (I know – they didn’t even return my email asking for information).

- Peter

drbowen wrote on Wednesday, September 09, 2009:

Fred Trotter has confirmed that he is very willing to donate his prescribing to the code.  We will need to set up and test a connection to SureScripts.  As Fred has been very generous with his code and his time I would like to thank him personally for this.

The OSMS board met on 8-28-2009 and voted to except Fred Trotter’s donated solution.  We also discussed charging a modest per physician connection to cover the the administrative costs.  I propose that we split proceeds (if any) between the OpenEMR-CCHIT certification project and with Fred Trotter’s Liberty HSF.

We do need help getting the c ode incorporated into the OpenEMR code base so that we can all use this e-Prescribing module.

Sam Bowen,MD

ideaman911 wrote on Wednesday, September 09, 2009:

Sam & Peter;

Since I am not a prescriber, I am dependent on the feedback from those who are.  What I wrote and suggested is based on that feedback.  A "modest fee" for one person can be exhorbitant for another, since it seems it would be based on the number of prescribers, rather than the number of prescriptions written.

Home Care is a reality of the healthcare community which has been sadly overlooked by the people in Washington as they redistribute wealth from providers to those Washington determines are the best.  They never asked.  Whatever my beliefs about a “single payer” system, you need only look at the fact that CMS is the regulator for both Medicare and Medicaid, both of which are “single payer”.  Neither uses the others’ form, and there is no forwarding by Medicare when Medicaid is the secondary.  Medicaid, unlike Medicare, accepts no NP as having a specialty, yet at the same time promulgates rules which insist that ONLY an NP in Psyche can care for a patient with a psyche ICD.  So I have no illusions about whether government will make the system workable, especially for those least able to afford it.  I was under the impression that OpenEMR was especially valuable for small and non-profit organizations.  So ANY designed-in costs are a contrary consideration.

I have configured many, and advised on their usage on the forums, for the G844x codes for the medicare Incentive for e-Rx.  There are three codes which can be described as  a)  All scripts for an encounter were submitted as e-Rx,  b)  e-Rx was available but NO scripts were needed, or  c)  e-Rx was available but was unused for SOME of the scripts because of State, DEA or other regulatory rules, or because the patient wished to have a paper script.  Those G codes must be submitted with a zero, or minimal if zero is not possible, dollar charge (OpenEMR must use $.01) on the same claim as the service code(s) for the encounter.  ANY of the three will result in the N365 acknowledgement code from Medicare.  And by the way, Medicare even recognizes the lower cost and at least as good outcomes from Home Care vs institutional, and pays a higher amount to offset the lower frequency of visits and higher costs for those providers.

As to the question of the drug interactions, the FDA database provides that.  Its data is free, and frequently updated without any effort on our part, which would be the useful way for OpenEMR users to utilize it as well.  But it could still stand-alone.  I have not seen the “private formularies” requirement you mention, but I have a LOT of concerns about the individual providers’ actually keeping those records up to date.  The Fed may have an unlimited budget for data inputs, as evidenced by the regular mailings from Medicaid (paid for by the only 20% of “allowed” 50% unpaid by Medicare for psyche they cover as “full” when they actually do pay).  But if it is hard to get providers to even use EMR/EHR systems right now, which at least give THEM some benefit, imagine trying to maintain any listing purporting to include ALL private payers’ formularies.  How?  Even Surescripts will eventually decide it is too expensive for little benefit.

And as to the generics issue; Allscripts will accept the ENTRY of generics, it simply does not provide them in the listing of the brand name meds as an alternative, again as I understand it from the person who actually uses Allscripts.  She says it does not give the generic equivalent for brand-name prescriptions.  And if you are entering to the Allscripts, then "screen grabbing" to post to your own EMR/EHR, did you develop that widget or someone else?  It will almost certainly be different for another e-Rx portal.   But it implicitly requires full-time connectivity to Allscripts, which still blows you off after THEY determine you are finished, thereby requiring a login (again).  What do those logins cost you?  My approach would allow the reverse - put the info into OpenEMR, where YOU need it to properly care for your patient, then post to the e-Rx portal or print the state required paper at YOUR convenience, and as automatically (read - you can do other things while it processes in the background) as possible, with a single login.  And STILL be fully usable for House Calls.

I have no problem using code developed by others - it saves me having to learn to do it myself at the very least.  But my reason for looking at OpenEMR in the first place WAS its ability to stand alone, precisely because that was what my wife & client needed.  And I AM COMMITTED to its use and making it the most functional it can be for my client base.  That is why I have and am making revisions to suit the specific needs of my clients, the prime advantage of Open Source based OpenEMR.

Unlike Washington, though, the concepts of compromise & truthiness DO exist in my vocabulary :wink:

Joe Holzer    Idea Man
http://www.holzerent.com

drpwayne wrote on Thursday, September 10, 2009:

Joe,
The FDA database is not enough. I took this from the CMS web site and their description of an eprescribing solution:

A qualified e-prescribing system is one that is capable of ALL of the following:

Generate a complete active medication list incorporating electronic data received from applicable pharmacies and pharmacy benefit managers (PBMs) if available

Select medications, print prescriptions, electronically transmit prescriptions, and conduct all alerts (defined below)

Provide information related to lower cost, therapeutically appropriate alternatives (if any). (The availability of an e-prescribing system to receive tiered formulary information, if available, would meet this requirement for 2009)

Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan (if available)

I do not see any way to do this outside of subscribing to Surescripts or using something like Allscripts, which itself connects to Surescripts. The only way you can expect feedback from the patient’s pharmacy benefits management system (to tell you what other drugs have been prescribed by other providers) is if your system connects to Surescripts. 

Logins to Allscripts are free, which is one good reason why I’m using them. Although I would have paid Surescripts a nominal fee to connect to them directly if they would let me, because, as you point out, if Allscripts changes the layout of their screen, then I have to recode the screen grabbing.
I coded the screen grabbing using a basic-like language, opening an Internet Explorer window as an ActiveX window. Then I have access to the HTML and DOM of the Internet Explorer window; I can point it to Allscripts, do an automatic login, enter the patient demographics, all from my system. After the provider enters the prescription into Allscripts I can then capture the prescription and the pharmacy and enter it into my patient’s medical record.  I don’t know whether anything similar would be possible with Javascript – I know with Javascript one can open a new window, but I don’t know whether you can respond to events in the window, enter text into it, read the reply by reading the DOM, and then send the results back to the OpenEMR system.

drbowen wrote on Friday, September 11, 2009:

As pointed out by Peter Wayne, Allscripts is free but it lacks quite a bit.  The Federal drug database while free is clearly short of what is necessary for what CMS requires.

To use SureScripts and to get the features CMS requires, you have to pay.

What I am proposing is a real SureScripts connection with the full CMS requirements.  If this is handled through the Non-profit it wound be vendor neutral and could allow free connections on a case by case basis.  Those who have the ability to pay can help support the cost of setting up the connection ($6,000) and the administration of the program.

There is nothing to prevent you from continuing to use Allscripts for free.  But as you have already said, Allscripts even for you, is not an ideal solution.

Sam Bowen, MD

ideaman911 wrote on Friday, September 11, 2009:

Guys;

I also read the CMS rules.  “If Available” means ALL of;
a)  Are all the prescribers connected through whatever portal to ALL pharmacies, and with direct connectivity to ALL payers’ who maintain their own formularies listings because nobody else will be willing to dedicate the resources.
b)  Can ALL care provided to ALL patients receive equal accessibility to the data, and will they all submit their data so it IS a complete picture?  Including everybody who does NOT have access to internet or promised connectivity by the local wireless provider, “if available”?  Including all those rural populations who cannot afford Hughesnet, since dialup is incapable of handling the data loads?
c)  Does EITHER of the CMS regulated healthcare funders actually comply with their own rules for everybody else?  Since when?

The chasm between intent and actuality is monumental.  And Washington continues to make their exclusive-or sanctifications of for-profit approaches, then wonders at the rising cost of healthcare.  And when "If Available" is NOT satisfied, then the "requirement" is null - ask any programmer about the logic.

WHEN all of the circumstances described above are demonstrably true will be the FIRST time any real compliance with that CMS promulgation is even POSSIBLE.  While 80% of the health care delivery in this country is provided by small providers, most of whom have NO connectivity, to say nothing of interconnected systems, I won’t hold my breath.  Instead, I will continue to champion the efforts of the forgotten in the rush to prove that Washington’s housing is not its only claim to density.  I only ask that OpenEMR not EXCLUDE those who don’t work from the fixed clinical settings with real-time connectivity which are actually the statistical anomoly.

Joe Holzer    Idea Man
http://www.holzerent.com

drpwayne wrote on Sunday, September 13, 2009:

Sam,
I can say without question that if I can get OpenEMR to work for my practice (unfortunately, a big "if" still), we’d have no problem helping to support the connection to Surescripts.  Doctors/NPs will receive incentive money from the federal government to use a certified EHR system. I can’t imagine too many will balk at paying a small subscription fee. Any commercial EHR system is in the neighborhood of $20,000/provider, so OpenEMR, even with a small license fee to connect to Surescripts, is a bargain.

ideaman911 wrote on Monday, September 14, 2009:

Dr Wayne;

Will YOU pay 25% of your gross to connect to a system to save some keystrokes?  YOUR profitability is not that of EVERY provider.  For ANY non-profit, a $20,000 per provider cost is simply unwarranted.  That is why those who DO use EMR systems are STILL the minority.  ONLY a VERY low cost EMR like OpenEMR is justifiable to the VAST majority of POTENTIAL users.

Speaking of which - who has ASKED those NOT using the expensive systems why NOT?  PLEASE do not project that YOUR expectations are those of ANY subset of the universe, least of all the majority.  There is NO empirical evidence to support your faith-based assumptions.  In fact, it could readily be argued that those who have chosen to use the expensive commercial EMR systems are the CAUSE of the rise of healthcare costs, not the solution.  Washington’s selection of a singular portal as sacrosanct is how they get themselves into situations for which no economical solutions exist.  But the costs paid by those "early adopters" are largely passed along in the form of lobbying to those very regulators.  Do you see a pattern here?

MY perspective is to find a solution which does not EXCLUDE anybody, for any reason.  Design from the perspective of the LEAST wealthy and sophisticated and you will actually meet the needs of the MOST users.

Joe Holzer    Idea Man
http://www.holzerent.com

drpwayne wrote on Tuesday, September 15, 2009:

Joe,
I think you misunderstood me. Of course $20,000 is unreasonable, although that’s the typical cost for a commercial EMR system. If the cost for a connection to Surescripts is $6000 then I can’t see how many providers would balk at paying $10/month to connect - which would pay it off if in a year if only 50 providers signed up. 
Even nonprofits have to pay phone bills, electricity, stamps, etc.  $10/month is a nominal sum, wouldn’t you agree? 
My own EMR and billing system is home-grown.  I would love to switch to OpenEMR because I think (1) OpenEMR has some great features, not the least of which is that it’s browser-based, and (2) the OpenEMR community has a fair crack at getting CCHIT certification. Unfortunately unless I can learn enough PHP and Javascript to modify OpenEMR, I can’t use it without going broke. It just won’t do the billing we need to do to keep our practice running, and even the patient notes are a little primitive.
A "free" system isn’t necessarily a good solution if we can’t remain solvent while using it. But I have been studying PHP and working on some simple scripts and hope in a few months to be able to make serviceable contributions to OpenEMR.