Pilot Testing of Electronic Prescribing Standards

This project, one of five grants awarded by the Agency for Healthcare Research and Quality to conduct electronic prescribing (e-prescribing) pilots, evaluated six standards that were being considered as potential initial standards for e-prescribing under Medicare Part D. The standards included Drug Formulary and Benefit (F&B); Medication History Transaction (Med Hx); Fill Status Notification (RxFill); Electronic Prior Authorization (ePA); RxNorm drug nomenclature (RxNorm); and Structured and Codified Sig (Sig). The study was conducted among participants in the E-Prescribe program of Horizon Blue Cross Blue Shield of New Jersey.

The project's aims were to:

• Develop quantitative work process models that link information from the standards to their effects on clinical and drug utilization outcomes.
• Elucidate the standards' technical adequacy and implementation through an expert panel process.
• Assess the effects on physician office operations of implementing e-prescribing systems that use the formulary and the medication history standards.
• Compare changes in drug use patterns, possible medication errors, and hospitalizations based on medication claims from before and after the implementation of e-prescribing with these two standards.
• Explore methods for presenting patient adherence information to prescribers.
• Evaluate a working prototype for electronic prior authorization using the proposed standards.
• Assess the completeness and semantic content of RxNorm.
• Assess the potential completeness and semantic content of the structured and codified Sig standard.

Each of the standards was evaluated with a mixed-methods approach, including workflow modeling; an expert panel process; physician and pharmacy site visits; a survey of e-prescribing participants and non-participants; analyses of prescription claims before and after e-prescribing activation; the creation and deployment of a working prototype system for ePA; prescriber focus groups; and tests of the standard’s capacity to represent a sample of actual prescriptions.

Use of e-prescribing was varied. Thirty-seven percent of those surveyed reported use of e-prescribing for nearly all prescription, whereas 17 percent reported having ceased to use e-prescribing. The evaluation found that the F&B and Med Hx standards were hindered by usability challenges, which included inadequate drug identifiers. RxNorm identifiers were available for 99 percent of 19,956 non-device prescriptions and renewal requests. ePA, while well received, was felt to need modification. Prescribers had significant concern regarding RxFill. Reviewers in the pilot test did not map Sigs accurately or consistently, indicating little agreement in the use of the Sig standard. As such, the team made a recommendation against adopting it as an initial standard. The study conclusions included a recommended that each of the standards be further developed and evaluated before being mandated, with RxNorm warranting the highest priority for further testing.