Electronic Prescribing: CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the Use of Health Information Technology
Published: 2011-02-17T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Congress established two CMS-administered programs--the Electronic Prescribing Program and the Electronic Health Records (EHR) Program--that provide incentive payments to eligible Medicare providers who adopt and use health information technology, and penalties for those who do not. The Medicare Improvements for Patients and Providers Act of 2008 required GAO to report on the Electronic Prescribing Program. To do so, GAO examined how CMS determines which providers receive incentive payments and avoid penalties from that program and how many providers received incentive payments in 2009. Also, GAO was asked to examine how the requirements of the two programs compare. GAO reviewed relevant laws and regulations, interviewed CMS officials, and analyzed CMS data on incentive payments made for 2009, which were the most recent data available for a full year.
section_title: What GAO Found
paragraphs: CMS analyzes information reported by eligible providers on their Medicare Part B claims--which are used to submit charges for covered services--to determine which Medicare providers should receive Electronic Prescribing Program incentive payments or be subject to penalties. In 2009--the first year the program provided incentive payments--CMS paid approximately $148 million in incentive payments to about 8 percent of the approximately 600,000 Medicare providers who had an applicable patient visit--that is, supplied 1 of 33 CMS-designated services typically provided in the office or outpatient setting. For 2009, CMS examined Part B claims to determine whether, after each applicable patient visit, providers marked any one of three electronic prescribing reporting codes used to report information on the adoption and use of electronic prescribing systems. To receive an incentive payment that year, the provider had to report the codes for at least 50 percent of applicable patient visits, and at least 10 percent of the provider's total allowed Medicare Part B charges for the year had to be from the applicable patient visits. CMS made changes in the reporting requirements for 2010. For example, the agency reduced the number of reporting codes to one and required that individual providers report the code after at least 25 applicable visits, instead of for 50 percent of applicable visits. From 2012 through 2014, the Electronic Prescribing Program will assess penalties on providers that do not adopt and use electronic prescribing. Individual providers will have to submit the electronic prescribing reporting code at least 10 times in the first 6 months of 2011 to avoid penalties in 2012. Although GAO found similarities in the technology and reporting requirements for both programs, GAO also found that the requirements of the two programs are inconsistent in several areas. The EHR Program provides incentives from 2011 to 2016 and introduces penalties beginning in 2015, while the Electronic Prescribing Program provides incentives from 2009 to 2013 and provides for penalties from 2012 to 2014, when the program ends. Both the EHR and Electronic Prescribing Programs require providers to adopt and use technology that can perform similar electronic prescribing-related activities. However, the EHR Program requires providers to adopt and use certified EHR systems that meet criteria established by HHS, which include electronic prescribing-related capabilities, while the Electronic Prescribing Program does not have a certification requirement. As a result, providers have no assurance that the systems they invest in will meet the Electronic Prescribing Program's requirements. Additionally, the two programs have established separate reporting requirements related to electronic prescribing, potentially requiring physicians--the largest and only group of providers eligible to earn incentive payments in both programs--to report to both programs from 2011 through 2014. CMS recognizes that this duplication places additional burden on physicians; however, CMS is still in the process of developing a strategy to address this duplication.
section_title: What GAO Recommends
paragraphs: GAO is recommending that the CMS Administrator take four actions, including (1) encourage physicians and other providers in the Electronic Prescribing Program to adopt certified technology and (2) expedite efforts to remove the overlap in reporting requirements for physicians who may be eligible for incentive payments or subject to penalties under both programs. CMS generally agreed with three recommendations and disagreed with a fourth recommendation, which GAO clarified based on CMS's comments.

section_title: Letter
paragraphs: According to the Department of Health and Human Services (HHS),  widespread use of health information technology could improve the  quality of care received by patients and reduce health care costs. One such  technology, electronic prescribing, can be used, for example, to  electronically transmit a prescription or prescription-related information  between a health care provider and a pharmacy or to provide other  technological capabilities, such as alerting a provider to a potential  interaction between a drug and the patient’s existing medications. Health  care providers can access electronic prescribing technological capabilities  by adopting stand-alone electronic prescribing systems or electronic  health record systems that include an electronic prescribing component.  Others have reported that stand-alone electronic prescribing systems can  cost up to $2,500 annually per provider, and EHR systems can cost  approximately $25,000 to $45,000 per provider with additional annual costs  to operate and maintain the system.
Congress has established two programs, administered by the Centers for  Medicare & Medicaid Services (CMS), that aim to increase the use of  electronic prescribing in Medicare by providing incentive payments or  penalties for certain providers who participate in the Medicare Program.  The time frames for the two programs overlap, and each program has  established the following requirements that providers must meet in order  to receive incentive payments under Medicare and avoid program  penalties: (1) technological requirements that specify the types of health  care information technology providers must adopt; and (2) reporting  requirements that describe the information that providers report to CMS to  demonstrate that they have not only adopted, but also used, the requisite  health care information technology. For both of these programs,  physicians are the largest group of eligible providers that may earn  incentive payments or be subject to penalties.
The first program, established by the Medicare Improvements for Patients  and Providers Act of 2008 (MIPPA) and referred to here as the Electronic  Prescribing Program, provides incentive payments from 2009 through 2013  to certain Medicare providers—physicians and other health care  providers, such as physician assistants and nurse practitioners—who have  prescribing authority and who adopt and use systems that meet CMS’s  definition of a qualified electronic prescribing system. From 2012  through 2014, the program may apply a payment adjustment, or penalty,  on the program’s eligible providers that do not adopt and use such  systems.  With incentive payments scheduled to end in 2013 and penalties  scheduled to end in 2014, the Electronic Prescribing Program will cease to  provide positive and negative incentives to encourage eligible providers to  electronically prescribe after 2014.
The second incentive program was established by the Health Information  Technology for Economic and Clinical Health (HITECH) Act, as part of the  American Recovery and Reinvestment Act of 2009 (Recovery Act).  HITECH established a program, referred to here as the Electronic Health  Records (EHR) Program, that provides incentive payments from 2011  through 2016 to Medicare physicians that adopt and “meaningfully use”  certified EHR technology, which includes electronic prescribing  technological capabilities. Beginning in 2015, the EHR Program may apply  a payment adjustment, or penalty, on eligible providers that do not adopt  and meaningfully use certified EHR technology.
MIPPA requires us to report on the implementation of the incentives for  electronic prescribing established by MIPPA by September 1, 2012. In  addition, because of the overlapping time frames of the programs, we were  asked to obtain information on the relationship between the Electronic  Prescribing Program and the EHR Program. As agreed with committee  staff, our specific objectives for this report were to examine (1) how CMS  determines which providers should receive incentive payments and avoid  penalties from the Electronic Prescribing Program and how many  providers received such incentive payments in 2009, and (2) how the  requirements in the EHR Program and the Electronic Prescribing Program  compare to each other. MIPPA also directed us to report on information  related to reductions in avoidable medical errors and estimated savings to  Medicare resulting from the use of electronic prescribing. In response, we  provide information in appendix II on how others have measured whether  or to what extent electronic prescribing improves quality or reduces costs.
To address both objectives, we reviewed relevant provisions in MIPPA and  the Recovery Act, and regulations and other published material pertaining  to the Electronic Prescribing and EHR Programs. We also interviewed  officials from CMS and from the Office of the National Coordinator for  Health Information Technology (ONC) in HHS. ONC reports to the  Secretary of HHS and plays a role in the EHR Program by establishing the  standards and specifications that providers’ systems must meet for the  EHR Program, coordinating with CMS on the development of the  meaningful use criteria, and creating and administering the certification  program that authorizes organizations to certify EHR technology. To  report how many providers received payments in 2009, we analyzed CMS  data on (1) 2009 Electronic Prescribing Program participation as  determined by CMS and (2) providers’ state locations. For more  information on our data analysis, see appendix III. To ensure the reliability  of the various data we analyzed, we interviewed CMS officials, reviewed  CMS documentation, and conducted electronic testing to identify obvious  errors. On the basis of these activities, we determined that CMS data were  sufficiently reliable for our analysis. To compare the EHR Program and the  Electronic Prescribing Program, we examined similarities and differences  in the two programs’ technology and reporting requirements and identified  inconsistencies that may limit the effectiveness of the programs. Because  the EHR Program is broader than electronic prescribing, we focused our  comparison on the electronic prescribing–related aspects of that  program’s technology and reporting requirements. We also interviewed  knowledgeable stakeholders, including officials from HHS’s Agency for  Healthcare Research and Quality and the Department of Veterans Affairs  (VA). To obtain information about studies that measured whether or to  what extent electronic prescribing improves quality or reduces costs, we  interviewed organizations, such as CVS Caremark, and reviewed published  studies.
We conducted this performance audit from February 2010 through  February 2011 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: HHS and others have promoted electronic prescribing as one way to  improve the quality of health care that beneficiaries receive and as one  way to reduce costs. Health care costs are typically paid for by health care  payers, such as CMS in the Medicare Program. In traditional, or paper- based, prescribing, health care providers that are licensed to issue  prescriptions for drugs (e.g., physicians or physician assistants in some  states) write a prescription, and the beneficiary takes that prescription to a  dispenser (e.g., pharmacy) to be filled. In contrast, electronic prescribing  consists of a licensed health care provider using a computer or hand-held  device to write and transmit a prescription directly to the dispenser.  Before doing so, the health care provider can request the beneficiary’s  eligibility, formulary, benefits, and medication history. This information  can be used to improve quality and reduce costs. For example, a health  care provider can use this information to avoid potentially adverse drug  events such as drug-to-drug or drug-to-allergy interactions and to prescribe  less-expensive medications, such as lower-cost generic drugs. Figure 1  illustrates the flow of information during the electronic prescribing  process and identifies areas in this process that may result in  improvements in the quality of health care provided to beneficiaries and  reductions in costs to health care payers. Appendix II provides  information from studies measuring whether or to what extent electronic  prescribing improves quality or reduces costs.
subsections: section_title: Eligibility for the Electronic Prescribing and EHR Programs
paragraphs: The types of Medicare providers eligible to earn incentive payments or  who may be subject to penalties in the EHR and Electronic Prescribing  Programs were established in statute, and although they overlap they are  not identical. Specifically, only physicians, who are the largest population  among each program’s eligible providers, can earn incentive payments or  be subject to penalties from both programs, but they cannot receive  incentive payments or be subject to penalties from both programs during  the same year. Other health care providers, such as nurse practitioners  and physician assistants, are only eligible to receive incentive payments or  are subject to penalties from the Electronic Prescribing Program. (See  fig. 2.)
section_title: Incentive Payments and Penalties in the Electronic Prescribing and EHR Programs
paragraphs: There is some overlap in the time frames for incentive payments and  penalties for the Electronic Prescribing and EHR Programs. Incentive  payments for the Electronic Prescribing Program are available from 2009  through 2013. Incentive payments for the EHR Program begin in 2011 and  may be available until 2016, depending on which calendar year the  provider initially receives an incentive payment from the program.  Incentive payments for both programs are determined by multiplying the  provider’s total allowed charges for provider services covered by Medicare  Part B for the year by the incentive percent authorized by statute.  However, in the EHR Program the year in which the provider first adopts  and meaningfully uses the EHR technology determines the maximum  annual incentive payment a provider can earn and the total number of  years incentive payments are available. For both programs, incentive  payments are disbursed after providers demonstrate that they met the  applicable program requirements. Figure 3 displays the timeline and  maximum incentive payments and penalties for both programs. (App. IV  provides additional detail on the annual and total incentive payments an  eligible provider could receive from the EHR Program based on the initial  year the provider receives an incentive payment.) By law, providers  cannot receive an incentive payment for both programs during the same  year.
Penalties for the Electronic Prescribing Program and the EHR Program  may be automatically applied to providers that fail to meet the programs’  requirements. Penalties for the Electronic Prescribing Program begin in  2012 and end after 2014. Penalties for the EHR Program begin in 2015, and  there is no statutory end-point provided for when the penalties will end.  Since the Electronic Prescribing Program ends after 2014 and penalties for  the EHR Program do not begin until 2015, providers will not receive  penalties from both programs during the same year. However, providers  who are subject to penalties from the Electronic Prescribing Program in  2014 and who are subject to penalties from the EHR Program in 2015 will  face a higher penalty from the EHR Program—2 percent instead of   1 percent. Similar to the incentive payments, penalties for not adopting a  program’s technologies are also calculated by multiplying the provider’s  total allowed charges for provider services covered by Medicare Part B by  the penalty percent authorized by statute. Penalties will be assessed by  reducing the reimbursement that the provider would ordinarily receive for  furnishing Part B services by the applicable penalty percentage.
The amount of incentive payments or penalties eligible providers may  receive depends on the year in which the provider chooses to begin  participating in—that is, meeting the requirements of—either or, if eligible,  both programs. In general, the earlier a provider begins participating in the  program, the more incentive payments the provider will earn and the  fewer penalties the provider will be assessed. Figure 4 below presents  three scenarios of participation in the Electronic Prescribing and EHR  Programs between 2009 and 2018. In each scenario, we assume that the  provider is eligible for both programs and has $24,000 in total allowed  Medicare Part B charges each year.
section_title: Reporting Requirements for the EHR Program
paragraphs: CMS will develop the reporting requirements that providers will have to  meet for the EHR Program in three stages. To date, CMS has only  developed the reporting requirements that eligible providers will have to  meet to receive incentive payments for the first stage, which will apply to  providers first obtaining incentive payments from the EHR Program from  2011 through 2014. By the end of 2011, CMS expects to develop reporting  requirements for receiving incentives in the second stage and, by the end  of 2013, develop reporting requirements for receiving incentives in the  third stage. CMS has stated that it may include information on the  reporting requirements that eligible providers must meet to avoid penalties  at the same time it issues regulations describing the third-stage  requirements. CMS intends to make the reporting requirements more  stringent over time as EHR technology and providers’ use of that  technology becomes more sophisticated.
To receive an incentive payment for the EHR Program, eligible providers  must meet or exceed a total of 20 reporting requirements established by  CMS. Of the 20 reporting requirements, 15 are mandatory, and providers  must choose an additional 5 from a menu of 10 other reporting  requirements. The reporting requirements encompass a variety of  activities related to the delivery of health care to encourage providers to  capture the following types of information in their EHR systems: patient  demographics and clinical conditions, use of clinical decision support,  and the coordination of care across health care settings. See app. V for a  complete list of the stage-one reporting requirements for receiving  incentive payments.
The reporting requirements that CMS develops for the second and third  stages of the EHR Program may be influenced by the Patient Protection  and Affordable Care Act of 2010 (PPACA), which directed CMS to develop  a plan to integrate the reporting requirements used in the EHR Program  with the information that CMS collects from eligible providers in the  Physician Quality Reporting System (PQRS). Similar to the EHR and  Electronic Prescribing Programs, CMS, as directed by Congress,  implemented PQRS to provide incentive payments to eligible providers  who satisfactorily reported data on various quality measures and impose  penalties on those providers who did not. Specifically, PPACA directed  CMS to develop an integration plan by January 1, 2012, that would identify  reporting requirements that could be used to demonstrate meaningful use  for the EHR Program and also be used to demonstrate quality of care  provided to individuals for PQRS.
section_title: CMS Analyzed Medicare Part B Claims to Pay Electronic Prescribing Program Incentive Payments to about 8 Percent of Certain Medicare Providers for 2009
paragraphs: To determine which providers should receive the Electronic Prescribing  Program’s incentive payments, CMS analyzes information reported by  providers on their Medicare Part B claims, which are used to submit  charges for covered services. To determine which providers are subject to  penalties, which begin in 2012, CMS will also analyze information reported  by providers on their Part B claims, but the requirements for avoiding  penalties are different than those for obtaining incentive payments. In  2009, CMS paid incentive payments to about 8 percent of certain Medicare  providers—that is, of the over 597,000 Medicare providers who had at least  one applicable visit during 2009—and another 7 percent of those same  Medicare providers participated in the Electronic Prescribing Program but  did not receive incentive payments.
subsections: section_title: CMS Analyzes Information Reported by Providers on Part B Claims to Determine Which Providers Should Receive Incentive Payments and Avoid Penalties
paragraphs: Incentive payments for the Electronic Prescribing Program are available  from 2009 through 2013, and to determine which providers meet the  program’s requirements and should receive the payments, CMS analyzes  information reported by providers on their Part B claims. Specifically, for  2009, CMS first examined 2009 Part B claims to determine whether, after  each applicable patient visit, providers marked any one of three electronic  prescribing reporting codes used to report information on the adoption  and use of electronic prescribing systems. For 2009, the three electronic  prescribing reporting codes were:  the provider had a qualified electronic prescribing system and used it to  generate all prescriptions during the visit; the provider had a qualified electronic prescribing system but did not use  it to generate one or more prescriptions during the visit for one of the  following reasons: the patient requested a paper prescription, the  pharmacy could not receive an electronic transmission, or the prescription  was for a narcotic or other controlled substance and could therefore not  be electronically prescribed; and the provider had a qualified electronic prescribing system but did not  generate any prescriptions during the visit.
By submitting any one of the three electronic prescribing reporting codes  to CMS, providers attested that they met the program’s technology  requirement by adopting a qualified electronic prescribing system and are  eligible to earn incentive payments from the program.
Second, CMS analyzed the 2009 Part B claims to determine which of the  providers who submitted the electronic prescribing reporting codes also  met or exceeded both components of the following reporting  requirement:  the provider submitted one of the three electronic prescribing reporting  codes at least 50 percent of the time that the provider had an applicable  visit; and   at least 10 percent of the provider’s total allowed Medicare Part B charges  for the year were from the services designated as applicable patient visits.
If the provider met or exceeded the reporting requirement, CMS gave the  provider an incentive payment for 2009, which the agency calculated as   2 percent of the provider’s total allowed Medicare Part B charges for the  year and by applying a small adjustment factor.
For 2010, to increase the adoption of electronic prescribing technology,  CMS made some changes to the Electronic Prescribing Program’s  reporting requirement that providers had to meet in order to receive an  incentive payment. CMS eliminated the three electronic prescribing  reporting codes for 2009 and replaced them with a single code for  providers to submit to CMS. The new code indicates that after each  applicable visit the provider generated and transmitted at least one  prescription during the visit using a qualified electronic prescribing  system. The agency stated that it believed that this change would simplify  reporting. CMS also changed the first portion of the reporting requirement  related to how frequently providers must submit the new electronic  prescribing code in order to receive an incentive payment. Instead of  requiring that providers submit the electronic prescribing reporting code  at least 50 percent of the time that they had an applicable visit—the  requirement in 2009—CMS required that an individual provider submit the  new electronic prescribing reporting code for at least 25 visits. CMS noted  that the agency believes that meeting the 2010 reporting requirement is  achievable by a majority of eligible providers. If providers participated in  the Electronic Prescribing Program as a group practice containing 200 or  more providers—a new option in 2010—the practice had to submit the  electronic prescribing reporting code for at least 2,500 applicable visits  before all of the providers in the practice could receive incentive  payments. When it proposed the change to at least 25 and at least 2,500  visits for individual providers and group practices, respectively, CMS  noted that it assumed that once a provider has invested in an electronic  prescribing system, integrated the use of that system into the practice’s  work flows, and used that system to some extent, the provider is likely to  continue to use the electronic prescribing system for most of the  prescriptions generated. The other component of the reporting  requirement remained unchanged from 2009: at least 10 percent of the  provider’s or practice’s total allowed Medicare Part B charges for the year  were from the services designated as applicable visits. Finally, as an  individual or as part of a group practice, providers could report the  electronic prescribing code on their Part B claims, as they did in 2009, or  they could do so using one of two alternative reporting mechanisms CMS  created.
CMS has described how it will determine which providers should receive  incentive payments for 2011, but the agency has not yet indicated how it  will determine which providers should receive incentive payments for  2012 or 2013. CMS will determine which providers meet the program’s  requirements and should receive an incentive payment in 2011 generally  using the same methods the agency used in 2010. However, one important  change CMS made for 2011—one that is consistent with changes the  agency is making to PQRS—is that CMS expanded the definition of group  practice to include practices containing 2 through 199 individuals and will  require those group practices to report the electronic prescribing code for  a minimum of between 75 and 1,875 applicable visits, depending on the  size of the group practice. The requirement for group practices of 200 or  more providers is unchanged; those practices must report the code for at  least 2,500 applicable visits.
From 2012 through 2014, the Electronic Prescribing Program will assess  penalties on individual providers and group practices that do not adopt  and use electronic prescribing. To avoid these penalties in 2012, individual  providers and group practices will have to meet certain reporting  requirements. Individual providers will have to submit the electronic  prescribing reporting code on their Part B claims for at least 10 applicable  visits between January 1, 2011, and June 30, 2011. However, CMS will  not penalize certain individuals in 2012 if they do not prescribe or do so  infrequently. In addition, both individual providers and groups that  practice in rural areas or areas with a limited number of pharmacies that  accept electronic transmissions will be exempt from penalties. The  reporting requirement for individuals and the exemption criteria are  consistent with the agency’s statement that it does not want to penalize  providers with low prescribing volumes. Group practices will have to  submit the electronic prescribing reporting code on their Part B claims the  same number of times required to receive incentive payments in 2011, but  they must do so within the 6-month period from January 1, 2011, through  June 30, 2011. For example, group practices containing 200 or more  providers will have to submit the electronic prescribing reporting code at  least 2,500 times from January 1, 2011, through June 30, 2011. CMS has  noted that it did not think that group practices would be disadvantaged by  having to meet the reporting requirement in a 6-month period to avoid the  penalty in 2012 rather than in a 12-month period to earn an incentive in  2011 because the agency requires group practices to submit the electronic  prescribing reporting code fewer times on average to earn an incentive  payment than it requires for individual providers to submit to earn an  incentive payment.
CMS has not yet established all the requirements for providers to avoid  penalties in 2013 or 2014. However, for 2013, CMS has indicated that it  will not penalize individual providers or group practices that year if they  reported the electronic prescribing code the minimum number of times  required to qualify for incentive payments in 2011. Additionally, CMS  indicated that it may publish an alternative reporting requirement that  providers could meet to avoid penalties in 2013. A CMS official that we  interviewed told us that the agency could, for example, require individual  providers to submit the electronic prescribing reporting code at least 10  times between January 1, 2012, and June 30, 2012, in order to avoid  penalties in 2013.
CMS is exploring an alternative to using electronic prescribing code  submissions to determine which providers should receive incentive  payments or penalties. As a part of CMS’s Medicare Part D, which provides  outpatient prescription drug benefits for Medicare beneficiaries, CMS has  required that Part D plan sponsors submit additional data on the claims  they send to Medicare for reimbursement. CMS officials believe that  Medicare Part D data could be used at some point instead of the electronic  prescribing reporting code to determine which providers should receive  incentive payments. However, CMS officials have concerns about the  reliability of data from Part D claims, and note that these concerns should  be resolved before the data can be used. CMS does not have specific  plans or a time frame for implementing such a change.
section_title: CMS Paid about 8 Percent of Certain Medicare Providers Electronic Prescribing Program Incentive Payments for 2009
paragraphs: CMS paid Electronic Prescribing Program incentive payments for 2009 to  about 8 percent (about 47,500) of the over 597,000 Medicare providers who  had at least one applicable visit during 2009. Each of these  approximately 47,500 providers received incentive payments equal to   2 percent of their total allowable Medicare Part B charges in 2009, with  payments totaling approximately $148 million. The mean payment was  about $3,120, the median payment was about $1,700, and the five highest  payments were between about $54,500 and $67,500. CMS disbursed these  payments to providers for 2009 in September and October 2010. CMS  officials expect that the number of Medicare providers reporting the  electronic prescribing reporting code in 2010 will increase over 2009 and  noted that lowering the reporting requirement for 2010 to submitting the  applicable electronic prescribing reporting code for at least 25 visits may  increase the number of providers receiving incentive payments. CMS  officials also told us that the penalties, which do not begin until 2012,  might have a bigger effect on participation than the incentive payments.
For the 2009 Electronic Prescribing Program, the percentage of Medicare  providers who received incentive payments and the average incentive  payment varied by state. (See fig. 5 and fig. 6.) Although Minnesota and  Wisconsin had the largest share of providers receiving incentive payments  at about 17 and 15 percent, respectively, providers in those two states also  received the lowest mean incentive payment at about $740 and $1,500,  respectively. Alaska and North Dakota had the smallest share of providers  receiving incentive payments at about 2 percent each. Providers in Florida  and South Carolina had the highest mean incentive payments at about  $5,800 and $4,700, respectively. According to a report prepared for CMS  about the 2009 Electronic Prescribing Program, the physician specialties  with the largest number of providers that earned incentive payments were  family practice and internal medicine, and the nonphysician specialties  with the largest number of providers that earned incentive payments were  nurse practitioners and physician assistants.
About 87,500 Medicare providers—approximately 15 percent of Medicare  providers who had at least one applicable visit during 2009—participated  in the program in 2009 by reporting the electronic prescribing reporting  codes to CMS. However, about 40,000 of those participating providers— approximately 7 percent of Medicare providers who had at least one  applicable visit during 2009—did not receive incentive payments because  they did not meet or exceed both components of the reporting  requirement. (See fig. 7.) Specifically, these providers (a) submitted the  electronic prescribing reporting codes less than 50 percent of the time that  they had an applicable visit, (b) had less than 10 percent of their total  allowed Medicare Part B charges for the year from the services designated  as applicable visits, or (c) both (a) and (b) occurred. The vast majority of  the about 40,000 Medicare providers that participated in the program but  did not receive incentive payments submitted the electronic prescribing  escribing  codes less than 50 percent of the time they had an applicable visit.  codes less than 50 percent of the time they had an applicable visit.
section_title: While the Requirements in the EHR and Electronic Prescribing Programs Are Similar in Some Cases, Aspects of These Requirements Are Not Consistent
paragraphs: We compared the electronic prescribing–related technology and reporting  requirements in the EHR Program with the requirements in the Electronic  Prescribing Program. The EHR Program provides incentives from 2011 to  2016 and introduces penalties beginning in 2015, while the Electronic  Prescribing Program provides incentives from 2009 to 2013 and introduces  penalties beginning in 2012. In comparing the programs’ requirements, we  found some similarities but also areas where the requirements of the  programs are not consistent.
Technology requirement. Both the EHR and Electronic Prescribing  Programs require eligible providers to adopt and use technology that  meets certain requirements. The EHR Program requires providers to adopt  certified EHR technology and the Electronic Prescribing Program requires  providers to adopt qualified electronic prescribing systems. (For more  details, see fig. 8.)
Certified EHR systems and qualified electronic prescribing systems must  be able to perform similar electronic prescribing–related activities. For  example, both types of systems must be able to generate and transmit  prescriptions electronically, check for potential drug and allergy  interactions, and provide formulary information.
The technology that providers must adopt and use for the EHR Program  must pass a certification process, which is used to designate a technology  as having met the program’s technology requirements. For the EHR  Program, HHS’s ONC, through the work of several advisory committees,  established a set of standards and specifications for EHR technology and  then created a program that will certify EHR technology for use in the  EHR Program based upon those standards and specifications. According  to ONC’s Web site, the certification process will ensure that the EHR  technology that providers adopt and use has the technological capabilities  necessary for providers to obtain incentive payments or avoid penalties  from the EHR Program. Further, the agency notes that certifying EHR  technology to these standards enhances the interoperability of health  information technology—that is, the ability of different systems or  components to exchange information and to use the information that has  been exchanged. EHRs that conform to interoperability standards allow  health information to be created, managed, and consulted by authorized  health care providers across more than one health care organization, thus  providing patients and their caregivers the necessary information required  for optimal care.
The EHR Program’s certification process is designed to produce a list of  certified EHR systems and certified EHR modules, which ONC has made  available to the public on its Web site. Accordingly, this information  should allow providers to identify and adopt systems that meet the EHR  Program’s technological requirements. A module is a component of an  EHR system that meets at least one of the certification criteria established  by ONC. Individual EHR modules can be certified and integrated with  other certified EHR modules to form a complete, certified EHR system. At  the time of our review, technologies certified for use in the EHR  Program—that is, complete EHR systems or combinations of modules that  collectively can perform the capabilities that constitute a qualified  electronic prescribing system—appeared to also meet the Electronic  Prescribing Program’s technological requirements. Although according to  ONC officials, certified EHR technology is not required to provide  information on lower-cost alternatives—which is a component of the  Electronic Prescribing Program’s technology requirement—CMS has  indicated that an electronic prescribing system that does not conform to  that component of the Electronic Prescribing Program’s technology  requirement would still meet the definition of a qualified system in 2011  and until this function is more widely available in the marketplace.
Although providers seeking incentive payments or trying to avoid penalties  from the Electronic Prescribing Program must adopt and use qualified  electronic prescribing systems, according to a CMS official the Electronic  Prescribing Program does not have a process like the EHR Program’s to  identify and certify which electronic prescribing systems meet the   requirements of a qualified system. As a result, providers may not be  certain which systems meet the program’s technological requirement.
Reporting requirements. Both the EHR Program and Electronic  Prescribing Program require eligible providers to report certain  information about their electronic prescribing activities to CMS in order to  receive incentive payments, which began in 2009 for the Electronic  Prescribing Program and began in 2011 for the EHR Program. (See   fig. 9 for a summary of the two programs’ electronic prescribing–related  reporting requirements.) However, we also found that the electronic  prescribing–related reporting requirements in the EHR Program are more  rigorous. Providers seeking incentive payments from the EHR Program  have at least five reporting requirements related to electronic  prescribing, while providers in the Electronic Prescribing Program h  Moreover, the EHR Program requires  only one reporting requirement. providers to report more-detailed information—namely, information on  their use of various electronic prescribing–related technological  capabilities—a requirement that should increase their use of these capabilities. Additionally, while CMS has established reporting  ave  requirements providers must meet in order to avoid the penalties under  the Electronic Prescribing Program that begin in 2012, CMS has not yetidentified what providers must report in order to avoid penalties under the  EHR Program, but plans to do so in future rulemakings.
We also found that the two programs’ reporting requirements are not  consistent because they make certain Medicare providers subject to both  programs’ reporting requirements during the same year. Specifically,  physicians—the largest population among each program’s eligible  providers—may choose to participate in the EHR Program in 2011 because  the potential incentive payment will likely be higher under that program  than under the Electronic Prescribing Program in 2011. However, to  avoid the penalty assessed by the Electronic Prescribing Program in 2012,  CMS will require physicians to meet the Electronic Prescribing Program’s  reporting requirement in 2011, even if they elect to participate in the EHR  Program in 2011. Public comments on the agency’s proposed  requirements for the 2011 Electronic Prescribing Program included the  concern that providers are burdened by having to submit electronic  prescribing data more than once. In response, CMS stated that it will study  possible methods of aligning the two programs and will include this  information in the integration plan it is already required to develop by  January 1, 2012, to integrate the reporting requirements in the EHR  Program and PQRS, CMS’s quality measures program. However, if CMS  adheres to this schedule, the agency will not be able to remove the  reporting burden placed on physicians subject to penalties from the  Electronic Prescribing Program in 2013, given that the requirements for  avoiding penalties in 2013 would likely be proposed in July 2011 and  finalized in November 2011. If CMS includes possible methods of aligning  the two programs in the integration plan, any action to propose and  finalize requirements will take place sometime after January 1, 2012, well  beyond the date for making changes to the program in 2013. In technical  comments provided on a draft of this report, HHS noted that it plans to  include possible methods of aligning the two programs for the 2012  program year (and possibly for the 2013 program year) in rulemaking  during 2011.
Both the EHR Program and Electronic Prescribing Program require  providers seeking incentive payments to attest that they have met the  programs’ reporting requirements. In the EHR Program, providers will  submit the results of their performance on each of the reporting  requirements once per program year, while providers in the Electronic  Prescribing Program attest that they adopted and used a qualified  electronic prescribing system by reporting the electronic prescribing code  to CMS. At least with reference to the EHR Program, CMS has  acknowledged that attestation may create a potential for fraud and abuse  and noted that the agency is developing an audit strategy to address this  risk. CMS officials from the Office of E-Health Standards and Services  told us they plan to make guidance on this strategy available by May 2011.
In the case of the Electronic Prescribing Program, an official from CMS’s  Office of Clinical Standards and Quality, which administers that program,  told us that the agency did not audit electronic prescribing codes  submitted by providers for 2009 and does not have plans to develop an  audit strategy for the program. However, this official did tell us that CMS  reserves the right to audit any program participant.
section_title: Conclusions
paragraphs: Health information technology, such as electronic prescribing, has the  potential to improve the quality of care received by patients and also  reduce costs for the health care system. To help encourage the adoption of  such technologies among Medicare providers, Congress first established  the Electronic Prescribing Program and then the EHR Program, both of  which provide incentive payments to eligible providers that adopt and use  the appropriate health information technologies and impose penalties on  those eligible providers that fail to do so.
Despite both programs having a goal to expand the adoption and use of  health information technologies by health providers, and in particular,  physicians—the largest and only group of providers eligible to earn  incentive payments in both programs—we found inconsistencies in the  requirements. We believe these inconsistencies may limit the programs’  effectiveness in encouraging the use of health information technologies.  First, we found that because the Electronic Prescribing Program lacks a  certification process like that established for the EHR Program, physicians  and other health care providers who want to obtain incentive payments or  avoid penalties from the former program have no assurance that the  systems they invest in will meet that program’s technology requirements.  In contrast, physicians who invest in certified EHR systems can be assured  that in doing so they would meet the current requirements of both  programs. In addition, physicians that invest in certified EHR modules  integrated together to perform the electronic prescribing–related  capabilities could also be assured that they meet the current requirements  of the Electronic Prescribing Program and that the adopted technology  could later be integrated with other certified modules to form a complete,  certified EHR system. This inconsistency between the programs has the  potential to create uncertainty among physicians as to what technology  they should adopt, because although the Electronic Prescribing Program  ends after 2014, the EHR Program continues; encouraging physicians to  adopt certified electronic prescribing technology now may also help  facilitate their later transition between the programs. Nonphysician health  care providers who are not eligible to earn incentive payments from the  EHR Program could adopt certified technology and in so doing could have  assurance that the electronic prescribing technology they invest in meets  the Electronic Prescribing Program’s technology requirements. Second,  we also found that the two programs have established separate reporting  requirements related to electronic prescribing, requiring some physicians  who elect to report to the EHR Program to report to both programs in  2011 and potentially requiring physicians to report to both programs  through 2014, when penalties for the Electronic Prescribing Program end.  CMS recognizes that this duplication places additional burden on  physicians, and we believe this duplication could affect the decision of  physicians to adopt and use health information technology. However, CMS  is still in the process of studying possible ways to address this duplication,  and if the agency wants to eliminate the burden for providers in 2012, it  would need to do so during its 2011 rulemaking. In addition, CMS has not  been consistent in the steps it has taken to ensure the appropriate use of  these programs’ resources. Namely, CMS plans to establish an audit  program for the EHR Program—under which the maximum incentive  payment for a provider will generally not exceed $18,000 per year—to  address potential fraud and abuse that might arise from the use of self- attestations, but CMS does not have plans to develop a similar approach in  the Electronic Prescribing Program, under which CMS paid providers up  to approximately $67,500 for 2009.
The Electronic Prescribing Program began before the EHR Program, so  CMS has already had the opportunity to encounter and learn from  challenges in implementation. For example, in the first year of the  Electronic Prescribing Program, only about 8 percent of providers  received incentive payments, and CMS changed some of the program’s  requirements in the second year to encourage greater adoption and use of  electronic prescribing technology. For the EHR Program, it is too soon to  know how many providers will adopt EHR systems. However, given that  the electronic prescribing–related reporting requirements in the EHR  Program are more rigorous than the reporting requirement in the  Electronic Prescribing Program, CMS may find that it needs to modify the  EHR Program requirements to better encourage the adoption and use of  EHR systems. Because implementation of the Electronic Prescribing  Program preceded the EHR Program, CMS has an opportunity to use the  experiences gained in implementing the Electronic Prescribing Program to  inform its implementation of the EHR Program in order to determine how  to best encourage the adoption and use of health information technology  among Medicare providers. One approach could be to incorporate these  experiences into the integration plan the agency is already required to  develop by January 1, 2012, to integrate the reporting requirements in the  EHR Program and PQRS.
section_title: Recommendations for Executive Action
paragraphs: To help improve the effectiveness of the Electronic Prescribing and EHR  Programs to encourage the adoption of health information technologies  among Medicare providers, the Administrator of CMS should take the  following three actions:    Encourage physicians and other health care providers in the Electronic  Prescribing Program to adopt certified electronic prescribing technology.
Expedite efforts to remove the overlap in reporting requirements for  physicians who may be eligible for incentive payments or subject to  penalties under both the Electronic Prescribing and EHR Programs by, for  example, aligning the reporting requirements so that successfully  qualifying for incentive payments or for avoiding penalties under the EHR  Program would likewise result in meeting the requirements for the  Electronic Prescribing Program.
Identify factors that helped or hindered implementation of the Electronic  Prescribing Program to help support the ongoing implementation of the  EHR Program. CMS could include consideration of such factors in the  integration plan that the agency is required to develop by January 1, 2012.
To help ensure that Electronic Prescribing Program resources are used  appropriately, the Administrator of CMS should develop a risk-based  strategy to audit a sample of providers who received incentive payments  from the Electronic Prescribing Program to help ensure that providers  who receive incentive payments meet that program’s requirements. A risk- based strategy could, for example, focus on those providers who received  larger incentive payments.
section_title: Agency and External Party Comments and Our Evaluation
paragraphs: We obtained written comments on our draft report from HHS on behalf of  CMS, which are reprinted in appendix VI. CMS agreed in full with two  recommendations, agreed in principle with one recommendation, and  disagreed with a fourth recommendation.
CMS disagreed with our first recommendation that the agency direct  providers in the Electronic Prescribing Program to use technology  certified as an EHR system or module(s). While CMS said that it concurred  with the notion that eligible providers should be able to use certified EHR  systems for the Electronic Prescribing Program, it did not agree that it  should direct eligible providers to use prescribing technology that has  been certified as an EHR system. CMS said that doing so could result in  Electronic Prescribing Program participants having to replace their  qualified electronic prescribing systems with systems certified under the  EHR Program. We do not recommend that CMS direct those providers  who are already participating in the Electronic Prescribing Program to  replace their current systems with certified systems. On the contrary, the  intent of our recommendation is to have CMS encourage providers in the  Electronic Prescribing Program who have not yet adopted electronic  prescribing systems, or who plan on upgrading their existing systems, to  choose systems that have already been certified through the EHR  Program’s certification process. We continue to assert our  recommendation because, as we noted in our draft report, this  certification process identifies a list of available systems that meet the  certification requirements and provides assurance that the technology  physicians and other health care providers adopt would meet the  technology requirements of the Electronic Prescribing Program.  Additionally, the physicians who later participate in the EHR Program  could be assured that the technology also meets the requirements in the  EHR Program. In our draft report, we noted that there is no comparable  process in the Electronic Prescribing Program, and as a result, providers  have no assurance that the systems they invest in for the EHR Program  will meet that program’s technology requirements. Given that the  Electronic Prescribing Program ends after 2014 while the EHR Program  will continue, encouraging providers to adopt certified electronic  prescribing technology now may also help facilitate physicians’ transition  between the programs. We have clarified the recommendation to state that  CMS should encourage physicians and other health care providers in the  Electronic Prescribing Program to adopt certified electronic prescribing  technology.
CMS agreed with our second recommendation that it expedite efforts to  remove the overlap in reporting requirements for physicians eligible for  both programs, and noted that it plans to address this overlap in  rulemaking during 2011, where applicable. We support CMS’s efforts to  expeditiously remove the overlap in the reporting requirements as we  recommended.
CMS agreed with our third recommendation that it would be helpful for  the agency to identify factors that helped or hindered implementation of  the Electronic Prescribing Program to help support the ongoing  implementation of the EHR Program. While CMS identified factors that  may be affecting implementation of electronic prescribing, other factors  that may have broader applicability to the implementation of the EHR  Program could include the effect of penalties on technology adoption,  measuring compliance with program requirements, and validating self- reported attestations.
CMS agreed in principle with our fourth recommendation that CMS  develop a risk-based strategy to audit a sample of providers who received  incentive payments from the Electronic Prescribing Program. In response  CMS said that it agrees that an audit of a sample of providers may be  needed, however, it disagreed that such a strategy should necessarily  focus on eligible providers who received large incentive payments, noting  that such an audit process, if implemented, could select providers at  random. As we recommended, we believe that an audit strategy should be  implemented for this program. We recommended a risk-based audit  strategy because although many providers received modest incentive  payments in 2009, some providers received payments at least three times  as high as the maximum annual incentive payment in the EHR Program.  However, if implemented by CMS, a random audit would be consistent  with the intent of our recommendation. CMS also noted that because it is  considering using Part D data in the future to determine which providers  should receive incentive payments for this program, use of these data  could also alleviate the need for an audit. However, as we noted in our  draft report, CMS officials raised several concerns—concerns echoed in its  comments on our draft report—about the reliability of Part D data to  determine which providers receive incentive payments. As we reported,  CMS officials told us that these data reliability concerns should be  resolved before Part D data can be used to determine which providers  should receive incentive payments for this program.
HHS has also provided technical comments, which we incorporated as  appropriate. We also provided excerpts of our report to the VA, Blue Cross  Blue Shield of Massachusetts, CVS Caremark, the Florida Agency for  Health Care Administration, and organizations that participated in the  Southeastern Michigan ePrescribing Initiative, which provided technical  comments that we incorporated as appropriate.
We are sending copies of this report to the Secretary of HHS, the  Administrator of CMS, and the National Coordinator for Health  Information Technology in HHS and interested congressional committees.  In addition, the report will be available at no charge on the GAO Web site  at http://www.gao.gov.
If you or your staffs have questions about this report, please contact me at  (202) 512-7114 or at kohnl@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made key contributions to this report are  listed in appendix VII.
section_title: Appendix I: List of Committees
section_title: Appendix II: Effect of Electronic Prescribing on Quality or Cost
paragraphs: This appendix addresses congressional interest in how others have  measured whether or to what extent electronic prescribing improves  quality or reduces cost. For example, the Medicare Improvements for  Patients and Providers Act of 2008 (MIPPA) directed us to report on  information related to reductions in avoidable medical errors and  estimated savings to Medicare resulting from the use of electronic  prescribing. To address these issues, we obtained information from  organizations about research they conducted, funded, or participated in  that measured the effects of electronic prescribing on quality, cost, or  both. Specifically, we obtained information from the following  organizations: Blue Cross Blue Shield of Massachusetts, CVS Caremark,  the Florida Agency for Health Care Administration, and the Southeastern  Michigan ePrescribing Initiative. In addition, we reviewed 29 published  studies that measured the effects of electronic prescribing on quality, cost,  or both.
Our information collection, review of published studies, and summaries  contained in this appendix focused on specific aspects of quality and cost  that we believed were most similar to the policy goals underlying the  development of the Electronic Prescribing Program and the Electronic  Health Records (EHR) Program.
Quality. We included studies that reported findings related to beneficiary  quality, such as reductions in avoidable medical errors.
Cost. We included studies that reported findings related to savings to  health care payers, which are those parties generally responsible for  paying claims for health care services, because we believed they would be  the most applicable to determining the effects of electronic prescribing on  costs for Medicare. We did not review studies that estimated potential  savings for providers, such as savings associated with reductions in time  spent writing prescriptions or resolving questions about prescriptions.
The studies evaluated the effects of a variety of different types of  electronic prescribing technology, such as stand-alone electronic  prescribing systems and EHR systems that include electronic prescribing– related functions. According to the Healthcare Information and  Management Systems Society (HIMSS), EHR systems also typically  include information such as patient demographics, progress notes,  problems, medications, vital signs, past medical history, immunizations,  laboratory data, and radiology reports. Additionally, computerized  physician order entry (CPOE) systems (also referred to as computerized  provider order entry systems or computerized prescriber order entry  systems) allow for electronic ordering of medications and may include  other functions, such as ordering laboratory procedures and referrals.  Hospitals may employ CPOE systems as part of a strategy to reduce  medication errors. Some organizations and published studies evaluated  the effects of electronic prescribing systems that had clinical decision  support (CDS) capabilities, which can include checks for allergies, drug– drug interactions, overly high doses, clinical conditions, and other patient- specific dose checking, and can provide access to information on patient  medical histories, pharmacy eligibility, and formulary and benefits. It is  important to note that the electronic prescribing systems evaluated by the  organizations we obtained information from and published studies we  reviewed may have had technical capabilities that differ from the  technological requirements in the Electronic Prescribing Program or the  EHR Program.
subsections: section_title: Methodology
paragraphs: The studies utilized a variety of different methodologies, including the  following: (1) pre-post methodologies, which compare dimensions of  quality or cost before and after the implementation of electronic  prescribing systems or CPOE systems; (2) comparison methodologies,  which are used to compare dimensions of quality, cost, or both between a  control group (i.e., one that does not electronically prescribe) and an  intervention group (i.e., one that does electronically prescribe); and (3)  cost simulations and cost-benefit analyses that projected the costs and  savings of implementing electronic prescribing systems.
section_title: How Electronic Prescribing Was Determined
paragraphs: Some studies identified compared a population of providers that  electronically prescribed to a population that did not (e.g., handwrote  prescriptions). For example, some studies identified a population of  providers who had access to electronic prescribing systems and compared  them to a population of other providers who did not have access to  electronic prescribing systems, while other studies identified prescriptions  before CPOE implementation and compared those prescriptions to  prescriptions transmitted after CPOE implementation. Other studies only  looked at populations of providers known to be electronic prescribers.  Other studies were designed to evaluate the effect of advanced features of  the electronic prescribing system. For example, one study by Steel et al.  was designed to compare medication ordering behavior when no alert was  triggered by the CPOE system to ordering behavior after alerts were  triggered.
section_title: Outcomes Measured
paragraphs: The organizations we interviewed and published studies we reviewed  examined a variety of different outcomes in order to evaluate the effect on  quality, cost, or both. Examples of the outcomes measured to evaluate the  effect of electronic prescribing on health care quality include the  following:    medication order changes resulting from information provided by the  electronic prescribing system, such as alerts for potentially inappropriate  medications or formulary information, or changes resulting from problems  with the quality of the prescription such as errors identified by the  electronic prescribing system related to dosage, directions, or illegibility;    changes in potential or actual adverse drug events (ADE); and    provider satisfaction that the electronic prescribing system was improving  safety.
Examples of the outcomes measured to evaluate the effect of electronic  prescribing on cost include the following:    drug costs or other outcomes that have cost implications, such as  formulary compliance or generic utilization; and  follow-up health care costs resulting from reductions in adverse drug  events.
section_title: Reported Findings
paragraphs: In terms of health care quality, some studies found differences in  medication error rates when electronic prescribing was used. For  example, a study conducted by Weingart et al. and funded by Blue Cross  Blue Shield of Massachusetts estimated that medication safety alerts  prevented an estimated 402 ADEs (49 serious or life threatening, 125  significant, and 228 minor) and that alerts that resulted in physicians  canceling or changing the medication order may have prevented deaths in  3 cases, permanent disability in 14 cases, and temporary disability in   31 cases. Another study by Devine et al. reported that rates of errors in  prescriptions declined from 18.2 percent before to 8.2 percent after  implementation of a CPOE system. However, some studies found no  significant differences in medication error rates before and after the  implementation of electronic prescribing systems.
Some of the evaluations that focused on prescription drug costs showed  savings when electronic prescribing systems were used. For example, a  cost-benefit analysis conducted by Byrne et al. estimated that the use of  Veterans Health Information Systems and Technology Architecture  (VistA), which includes electronic prescribing and CDS capabilities of the  Department of Veterans Affairs (VA) health system electronic health  records, contributed to a cumulative $4.64 billion in value due to the  prevention of unnecessary hospitalizations and outpatient visits resulting  from prevented ADEs. In this study, the total net value of the VA’s  investments in the VistA components modeled was estimated to exceed  $3.09 billion. A study by McMullin et al. of an electronic prescribing system  that provided patient formulary information shifted prescriber behavior  from selecting drugs from eight high-cost therapeutic groups to less- expensive alternatives. However, a study by Ross et al. found no  significant difference in formulary compliance between electronic  prescribers (83.2 percent) and paper prescribers (82.8 percent).
Of the studies we reviewed in which the electronic prescribing systems  were reported to have CDS capabilities—such as drug–drug, drug–allergy  alerts, or drug–formulary checks—most reported health care quality or  cost effects. For example, a study by DesRoches et al. reported that  providers who adopted EHR with electronic prescribing decision support  capabilities averted potentially dangerous drug–drug interactions. One  study by Galanter et al. found that the likelihood of contraindicated drugs  being administered to patients of inadequate kidney function decreased by  42 percent after electronic prescribing CDS alerts were implemented.   Ko et al. surveyed providers and found that the majority viewed drug–drug  interaction alerts as increasing their potential to more safely prescribe  medications. Another study by Kaushal et al. attributes the implementation  of a CPOE with CDS as leading to an estimated $28.5 million in savings— $12.9 million from decreased adverse drug events and $6 million from  decreased drug costs—however, the study also estimated that the cost to  develop, implement, and operate the CPOE system was $11.8 million.
Summaries of Evaluations Obtained from Organizations  Blue Cross Blue Shield of Massachusetts   Beginning in 2003, Blue Cross Blue Shield of Massachusetts contracted with software vendors to provide electronic prescribing  software, which included CDS, free of charge to high-volume prescribers in their provider network. Blue Cross Blue Shield of  Massachusetts continues to sponsor a limited number of electronic prescribing software licenses free of charge. As of September  2010, Blue Cross Blue Shield of Massachusetts estimated that 60 percent of its network physicians were electronically prescribing.
A pre-post study comparing 1,932 Blue Cross Blue Shield of Massachusetts’s  providers that were using an electronic prescribing device to the providers in the  network that were not electronically prescribing (control group). The preintervention  period was calendar year 2003 and the postintervention period was 2006.
Whether the prescriber used an electronic prescribing device, as determined from  data obtained from Blue Cross Blue Shield of Massachusetts’s pharmacy benefits  manager.   (1) Prescribing patterns by drug tier. (2) Savings in drug costs as a result of  different prescribing patterns.   (1) Prescribers who used an electronic prescribing device prescribed more generic  and on-formulary prescriptions. (2) Prescribers saved Blue Cross Blue Shield of  Massachusetts 5 percent on drug costs relative to those prescribers that did not use  an electronic prescribing device.
Blue Cross Blue Shield of Massachusetts noted that some of the individuals in the  control group may have been electronically prescribing but they assumed in the  study that they were not because of the absence of data.
Study #2: Fischer, M.A., C. Vogeli, M. Stedman, T. Ferris, M.A. Brookhart, and J.S. Weissman. “Effect of Electronic Prescribing With  Formulary Decision Support on Medication Use and Cost.” Archives of Internal Medicine, vol. 168, no. 22. (2008): 2433-39.
Blue Cross Blue Shield of Massachusetts provided pharmacy claims data used by  the researchers in a pre-post study of the implementation of electronic prescribing  software with formulary decision support. The study consisted of an intervention  group of 1,198 prescribers who wrote at least one electronic prescription, and a  control group of 34,453 prescribers who did not electronically prescribe. Claims data  were collected for 18 months—6 months before the intervention (October 2003  through March 2004) and 12 months postintervention (April 2004 through March  2005)—and data on electronic prescriptions were collected in the 12 month  postintervention period.
Whether the prescriber wrote at least one electronic prescription, as captured by the  electronic prescribing system.   (1) The change in the proportion of prescriptions for three formulary tiers before and  after electronic prescribing was implemented; and (2) the potential savings  associated with this change.   (1) Electronic prescribing led to a 3.3 percent increase in Tier 1 prescribing—that is,  those medications with the lowest copayment. (2) On the basis of average costs, the  study estimated that implementation of electronic prescribing software with  formulary decision support could lead to a savings of $845,000 per 100,000  patients.
Study #3: Weingart, S.N., B. Simchowitz, H. Padolsky, T. Isaac, A.C. Seger, M. Massagli, R.B. Davis, and J.S. Weissman. “An  Empirical Model to Estimate the Potential Impact of Medication Safety Alerts on Patient Safety, Health Care Utilization, and Cost in  Ambulatory Care.” Archives of Internal Medicine, vol. 169, no. 16. (2009): 1465-73.
Blue Cross Blue Shield of Massachusetts funded and provided some data for a  study that estimated the quality improvement and savings associated with  medication safety alerts. The study examined 1,833,254 prescriptions written using  a commercial electronic prescribing system by 2,321 clinicians for 60,352 patients.  During the study period (January through June 2006), 279,476 drug–drug interaction  alerts were generated. For each drug–drug interaction, expert panelists examined  whether it might result in an adverse drug event and the severity of that event. The  study used published sources and payer data to estimate the costs to third-party  payers associated with different types of health care services due to adverse drug  events.
All prescriptions were generated from the electronic prescribing system. The  company that developed the electronic prescribing system provided researchers  information on all drug–drug interactions generated and data on the prescribers’  action on receiving the alert.   (1) The likelihood and severity of the potential ADE that the alert prevented, and (2)  cost savings estimated from reduced health care utilization.   (1) The study estimated that medication safety alerts prevented an estimated 402  adverse drug events (49 serious or life threatening, 125 significant, and 228 minor).  Alerts that physicians “accepted,” meaning the physician either cancelled the  prescription or changed to an alternative medication, may have prevented deaths in  3 cases, permanent disability in 14 cases, and temporary disability in 31 cases. (2)  Due to lower utilization of health care services the study estimated annual savings to  be $402,619.
Beginning in 2000, CVS Caremark made electronic prescribing available through its proprietary iScribe system to interested providers  by download from a Web site. In late 2004, CVS Caremark supported electronic prescribing by providing software, hardware,  installation, training, and service to providers on behalf of health care payers.
Study #1: Hutchins, D.S., M. Lewis, R. Velazquez, and J. Berger. “E-Prescribing Reduces Beers Prescribing Among the Elderly.” CVS  Caremark, May 22, 2007.
A control group study of 383,855 prescription claims written for 14,557 persons over  65 years of age between April 2002 and June 2005 by over 3,700 providers, 70 of  whom implemented an electronic prescribing tool that alerted them to the  prescribing of “Beers List” medications to patients over 65 years of age.
Whether the prescription was dispensed before or after a provider adopted the  electronic prescribing tool.
Whether use of the specific electronic prescribing tool had an effect on the  prescribing of potentially inappropriate drugs from the Beers List to the elderly.
Use of the specific electronic prescribing tool that provided alerts specific to Beers  List medications can reduce prescribing of those medications among the elderly.
Study #2: Hutchins, D.S., J.N. Liberman, J. Berger, S. Jan, M. M. Johnson. “The Impact of an Electronic Prescribing Solution on the  Selection and Prescribing of Cost-Effective Therapeutic Options.” CVS Caremark, 2009.
A pre-post control group study of over 9 million claims in seven drug classes  prescribed by one of over 29,000 providers (about 250 of which used the electronic  prescribing tool) that were filled between July 2002 and December 2005.
Whether the provider used an electronic prescribing tool.
Whether the use of an electronic prescribing system has an effect on prescribing  low-cost generic and mail-delivered drugs.
Across multiple drug classes, study reported a link between use of electronic  prescribing systems and a greater likelihood that generic drugs were prescribed and  that they were dispensed through mail order, both of which likely lower overall costs.
The Florida Agency for Health Care Administration  The Florida Agency for Health Care Administration provided Medicaid providers, at no charge, access to a CDS tool called  EMPOWERx, which allows for electronic prescribing and includes the following capabilities: provides comprehensive medication  histories, alerts providers to drug–drug and drug–allergy interactions, and provides formulary information.
A comparison of the costs and savings for 1,000 Medicaid providers in the state in  the EMPOWERx personal digital assistant program to the total population of  Medicaid providers in the state.
Whether or not the provider was in the EMPOWERx personal digital assistant  program.   (1) The average cost per patient for all prescriptions. (2) The estimated savings for  prescriptions written by providers in the EMPOWERx personal digital assistant  program, based on the difference between costs for providers in the two groups and  the number of patients associated with the EMPOWERx personal digital assistant  program providers. (3) The estimated savings for the 1,000 Medicaid providers in  the EMPOWERx personal digital assistant program based on information collected  about alerts those providers received about drug interactions in response to a  medication order, assumptions about avoidable hospitalizations, and assumptions  about hospitalization costs.
In the fourth quarter of 2009 (1) average costs per patient for all prescriptions were  about $28 to $30 lower for the providers in the EMPOWERx personal digital  assistant program; (2) the cost differences between the two groups represents  estimated savings of approximately $5.5 million; and (3) by assuming that 5 percent  of the 12,480 high- or very-high-severity drug interactions would have led to  hospitalizations and that hospitalizations resulting from preventable drug interactions  are associated with an average increased cost of $4,685 per incident, the study  estimated that the state Medicaid program saved approximately $2.9 million.
The Southeastern Michigan ePrescribing Initiative, a collaborative effort of employers, health plans, pharmacy benefit managers,  physician groups, and others, was launched in 2005 to speed the adoption of electronic prescribing. Some of the studies that resulted  from this collaboration are summarized below.
Study #1: An official with Medco described a study it conducted. Medco is a pharmacy benefit manager and member of the  collaborative.
A comparison study of a group of 1,165 physicians who electronically prescribed to  Medco’s mail-order drug program and 1,000 physicians that did not. Data were  collected in the second quarter of 2008.
Providers were included in the electronic prescribing group if they had sent at least  20 prescriptions electronically to Medco’s mail-order drug program during the study  time period. Providers were included in the nonelectronic prescribing group if they  had not met this criterion and provided services in the same zip codes as the  providers in the electronic prescribing group.
The average cost per prescription per group for retail and mail order prescriptions,  which was calculated by dividing total costs (identified through claims data) for each  category and group by the number of prescriptions for each category and group.
Providers in the electronic prescribing group saved an average of $2.11 per retail  prescription and $7.44 per mail-order prescription compared to the group that did  not electronically prescribe.
The Medco official noted that the findings were not tested for significance or  subjected to other more-rigorous validations. It is possible that providers in the  group that did not electronically prescribe were electronic prescribing, just not to  Medco’s mail order service drug program. In addition, while the providers in each  group were from the same geographic service areas, Medco did not examine the  types of patients served by the providers, so it is possible that the groups were  serving different patient populations.
Study #2: An official described a study conducted by HaldyMcIntosh, under the direction of the Southeastern Michigan ePrescribing  Initiative project manager, Point-of-Care Partners.
A telephone survey of 500 providers participating in the collaborative that responded  to the survey, conducted in the fourth quarter of 2007.
Only providers that were electronically prescribing were surveyed.
Providers’ perceptions of the effect of electronic prescribing on quality.
Nearly 70 percent of respondents highly agreed that electronic prescribing improves  quality of care; almost 75 percent highly agreed that electronic prescribing improves  patient safety; approximately 70 percent were very satisfied with the ease of  identifying drug-related interactions; and more than 60 percent reported that they  changed a prescription in response to a safety alert at least once.
Study #3: An official with the Health Alliance Plan described a study conducted by Henry Ford Medical Group and the Health Alliance  Plan that looked at generic utilization.
A comparison study conducted in 2005 of a group of 24 physicians who  electronically prescribed from eight practice sites and 26 physicians from eight  comparable practice sites that did not.
Whether the practice site had converted to electronic prescribing.
Rate of generic prescribing using pharmacy claims data and associated savings.
Facilities with access to an electronic prescribing system had a 1.25 percent larger  increase in their rate of generic prescribing compared with sites that did not have  access to an electronic prescribing system. The study estimated that the health plan  can save $800,000 per year for each 1 percentage point improvement in the rate of  generic prescribing.
Study #4: An official with the Health Alliance Plan described a study conducted by Henry Ford Medical Group and the Health Alliance  Plan that looked at the savings associated with adverse drug events.
A cost estimate conducted in 2006 of the savings associated with decreases in  ADEs.
Whether a prescription was changed based on an alert from the electronic  prescribing system, identified from internal data sources.
Estimated savings in (1) avoidable hospitalizations and (2) avoidable emergency  room admissions, due to the decrease in ADEs.   (1) By assuming that 2 percent of hospitalizations are attributable to ADEs, that   33 percent of those are avoidable due to use of the electronic prescribing system,  and that $7,000 is saved per avoidable hospitalization, the study estimated that  $441,000 was saved in 2007. (2) By assuming that 1 percent of emergency room  visits are attributable to ADEs, that 33 percent of those are avoidable due to use of  the electronic prescribing system, and that $500 is saved per avoidable emergency  room visit, the study estimated that $99,000 was saved in 2007.
Study #5: An official with the Health Alliance Plan described a study it conducted that identified patients taking contraindicated  prescription drug combinations.
A file review of pharmacy and medical claims for about 200,000 patients before  implementation of electronic prescribing (in 2004) and after implementation of  electronic prescribing (in 2007) to identify patients that were prescribed  contraindicated drug combinations.
The study identified claims before and after implementation of electronic prescribing.
The rate of patients taking contraindicated drug combinations.
The study reported a 24 percent decrease in the incidence of patients with generally  contraindicated medications and a 48 percent decrease in patients taking  medications contraindicated for pregnancy 1 year after the implementation of  electronic prescribing.
Study #6: An official with the Health Alliance Plan described a survey conducted by Henry Ford Medical Group and the Health Alliance  Plan.
A 2006 survey about electronic prescribing attitudes. About 100 physicians in the  Henry Ford Medical Group responded to the survey.
Only physicians who were electronically prescribing were included in the survey.
A variety of questions related to electronic prescribing attitudes, some of which  focused on physician attitudes regarding the effect of electronic prescribing on  safety.
Various findings reported including the following percentages of respondents who  “strongly agreed” or “somewhat agreed”: 84.6 percent of respondents reported that  electronic prescribing has improved the practice of medicine in their clinics; 77.2  percent and 74.8 percent reported that electronic prescribing improves the safety of  the care and the quality of the care, respectively, provided to their patients; 66.7  percent reported that the drug–drug warnings were helpful, 80.5 percent reported  that the drug–allergy warnings were helpful, and 68.3 percent reported that the  formulary warnings were helpful.
Summaries of Evaluations Obtained from Literature Review  Byrne, C.M., L.M. Mercincavage, E.C. Pan, A.G. Vincent, D.S. Johnston, and B. Middleton. “The Value from Investments in Health  Information Technology at the U.S. Department of Veterans Affairs.” Health Affairs, vol. 29, no. 4 (2010): 629-638.
A comparison study of the VA health system and the private-sector health systems on  information technology spending, adoption, and quality of care. The study also  conducts a cost-benefit analysis to estimate the financial value of key components of  the VA’s VistA.
Whether or not the health system surveyed had adopted health information  technology and whether the health information technology system had certain  capabilities as defined by six frameworks in relevant literature and internal VA and  publicly available documents.  (1) The information technology–related quality of care quantified using previously  collected quality measures from the VA that could be compared to measures  available for the private sector for 2004 to 2007. (2) Cost-benefit analysis that  estimates the costs and effects of the core components of the VA VistA system from  2001 to 2007.  (1) The VA was found to have higher performance on preventive care process  measures from 2004 to 2007 relative to the private sector. The VA averaged about   15 percentage points higher than the private sector on preventive care for patients  with diabetes and 17 percentage points higher for patients with diabetes who have  well-controlled cholesterol. (2) The gross value of the investment in VistA applications  was projected to be $7.16 billion. Of the gross value, the researchers estimated that  cumulative reductions in unnecessary care attributable to VistA in preventing ADE- related hospitalizations and outpatient visits was valued at $4.64 billion, or 65 percent  of the total estimated value.
The VA system electronically captures and reports allergies and adverse reactions,  inpatient and outpatient medications, medication orders, and includes CDS such as  clinical reminders and order checking.
Cunningham, T.R., E.S. Geller, and S.W. Clarke. “Impact of Electronic Prescribing in a Hospital Setting: A Process-Focused  Evaluation.” International Journal of Medical Informatics, vol. 77, no. 8 (2008): 546-554.
A pre-post study reviewing the medication orders of two different hospitals, a control  hospital that did not implement a CPOE system and an intervention hospital that did  at each of three different phases of the study—a 4-week baseline phase, a 3-week  pilot phase, and 5-week post-CPOE implementation phase. At the control hospital,  247 handwritten orders were reviewed from the baseline phase, 279 handwritten  orders from the pilot phase, and 453 handwritten orders from the post-CPOE  implementation phase. At the intervention hospital, 201 handwritten orders were  reviewed from the baseline period, 283 electronically submitted orders were reviewed  from the pilot phase, and 587 orders (276 handwritten and 311 submitted  electronically) were reviewed from the post-CPOE implementation phase.
Whether or not the physicians’ medication orders were handwritten or submitted  electronically in the three different phases of the study, as identified from the files of  previously processed medication orders stored in the pharmacy departments of each  hospital.   (1) Rates of compliance with hospital medication protocols (such as recording date,  time, drug name, or dosage) by examining behavioral checklists used to collect  information on each prescription written; and (2) time it took for a patient to receive  antibiotics, as recorded in the hospital medication ordering database.   (1) Medication orders submitted electronically at the intervention hospital were  compliant with hospital medication protocols 79.9 percent of the time, compared to a  62.9 percent compliance rate for paper orders written at the same hospital, and a  64.2 percent compliance rate for paper orders written at the control hospital. (2) At  the intervention hospital, the average amount of time from the medication order until  the first dose of antibiotics was administered was shorter for orders submitted through  the CPOE system (185.0 minutes) than paper orders (326.2 minutes).
The CPOE had CDS but the specific features of the CDS system are not discussed.
DesRoches, C.M., E.G. Campbell, S.R. Rao, K. Donelan, T.G. Ferris, A. Jha, R. Kaushal, D.E. Levy, S. Rosenbaum, A.E. Shields,  and D. Blumenthal. “Electronic Health Records in Ambulatory Care—A National Survey of Physicians.” New England Journal of  Medicine, vol. 359, no. 1 (2008): 50-60.
A survey of 2,758 physicians conducted between September 2007 and March 2008.
Whether or not physicians reported on the survey that they adopted an EHR system,  including whether the EHR system was a “fully functional” or “basic” EHR. The study  defined a “fully functional” EHR as one that allows physicians to record patients’  clinical and demographic data, view and manage results of laboratory tests and  imaging, manage order entry (including electronic prescriptions), and support clinical  decisions (including warnings about drug interactions or contraindications). In the  study, the principal differences between “fully functional” and “basic” EHRs were the  absence of certain order-entry capabilities and CDS in a basic system.
The survey asked respondent a variety of questions related to EHR adoption,  including questions related to quality of care.
Findings reported by the study included the following: of the respondents with fully  functional EHR systems, 80 percent reported averting a potentially dangerous drug  allergic reaction and 71 percent of respondents reported averting a potentially  dangerous drug interaction compared to 66 percent and 54 percent of respondents  with basic EHR systems.
DesRoches, C.M., E.G. Campbell, C. Vogeli, J. Xheng, S.R. Rao, A.E. Shields, K. Donelan, S. Rosenbaum, S.J. Bristol, and A.K. Jha.  “Electronic Health Records’ Limited Successes Suggest More Targeted Uses.” Health Affairs, vol. 29, no. 4 (2010): 639-646.
The researchers created a survey and surveyed 4,840 acute-care general medical  and surgical hospitals from March to September 2008 that were members of the  American Hospital Association. The researchers linked the information gathered in  their survey to information from three other data sources.
Whether the hospital had a comprehensive EHR, defined as an EHR with 24 clinical  functions used across all major clinical units in the hospital, a basic EHR system,  defined as a system with 10 key functions in at least one major clinical unit in the  hospital, or no EHR system.   (1) Performance on quality metrics based on data released from the Hospital Quality  Alliance for three clinical conditions—acute myocardial infarction, congestive heart  failure, and pneumonia—and prevention of surgical complications, and (2) efficiency,  as measured by the hospitals’ risk-adjusted length of stay, risk-adjusted 30-day  readmission rates, and risk-adjusted inpatient costs, which were determined using  two sources of data, the Medicare Inpatient Impact File and the Area Resource File.   (1) No relationships were found between EHR adoption and quality process  measures for acute myocardial infarction, congestive heart failure, pneumonia, or 30- day risk-standardized mortality of these conditions. Hospitals with EHR had  somewhat better performance on the prevention of surgical complications measures  than hospitals without EHR (93.7 percent for hospitals with a comprehensive EHR,  93.3 percent for hospitals with a basic EHR, and 92.0 percent for those without EHR).  (2) No relationships between the level of EHR adoption and overall risk-adjusted  length of stay were found. Hospitals with comprehensive EHRs had similar rates of  readmissions within 30 days of hospital discharge compared to hospitals with basic or  no EHRs. The researchers found that hospitals with such systems had comparable  inpatient costs to hospitals without them. Pneumonia patients in hospitals with a  comprehensive EHR had a length of stay that was, on average, 0.5 days shorter than  those of patients in hospitals without EHR.
In this article, CDS consisted of clinical reminders and clinical practice guidelines and  was associated with marginally better performance on each of the Hospital Quality  Alliance quality metrics.
Devine, E.B., R.N. Hansen, J.L. Wilson-Norton, N.M. Lawless, A.W. Fisk, D.K. Blough, D.P. Martin, and S.D. Sullivan. “The Impact of  Computerized Provider Order Entry on Medication Errors in a Multispecialty Group Practice.” Journal of the American Medical  Informatics Association, vol. 17, no. 1 (2010): 78-84.
A pre-post study compared prescriptions written at a multilocation clinic before and  after the implementation of a CPOE system. For the pre-CPOE implementation  period between March 1, 2002, and July 15, 2002, for one clinic and between  January 2, 2004, and March 4, 2004, for other clinics, 5,016 prescriptions were  evaluated. For the post-CPOE implementation period between January 14, 2004, and  July 13, 2004, for one clinic and between July 1, 2005, and April 26, 2006, for other  clinics, 5,153 prescriptions were evaluated.
Whether the prescription was written before or after the implementation of the CPOE  system.   (1) Rates, (2) types, and (3) severity of errors in prescriptions written before CPOE  system implementation compared to prescriptions submitted electronically after the  implementation of the CPOE system.   (1) Rates of errors in prescriptions declined from 18.2 percent before to 8.2 percent  after implementation of the CPOE system, and the adjusted odds of an error  occurring postimplementation of CPOE system were 70 percent lower than  preimplementation. (2) There were reductions in the adjusted odds of the following  error types: illegibility (97 percent), inappropriate abbreviations (94 percent),  information missing (85 percent), wrong strength (81 percent), drug–disease  interaction (79 percent), and drug–drug errors (76 percent). (3) Electronic prescribing  led to a 57 percent decrease in the odds of an error occurring that did not cause  harm. There was a 49 percent reduction in the odds of errors occurring that caused  harm. The authors note that this reduction was not significant and that the small  number of errors in this category could have caused this result to not be significant.
The CPOE had limited CDS alerts that included basic dosing guidance and duplicate  therapy checks.
Feldstein, A.C., D.H. Smith, N. Perrin, X. Yang, S.R. Simon, M. Krall, D.F. Sittig, D. Ditmer, R. Platt, and S.B. Soumerai. “Reducing  Warfarin Medication Interactions: An Interrupted Time Series Evaluation.” Archives of Internal Medicine, vol. 166, no. 9 (2006): 1009- 1015.
A pre-post study of 239 primary care providers with 9,910 patients taking Warfarin at  15 primary care clinics that implemented medication interaction alerts for the drug  Warfarin into their electronic medical records with computerized order entry and  decision support. The baseline period was from January 2000 through November  2002 and the postintervention period was from April 2003 through August 2004.
The presence of electronic medical record alerts for selected coprescriptions of  medications that interact with Warfarin. When Warfarin and a targeted interacting  medication were coprescribed, an alert would appear, whereupon the clinician had to  click “OK” to continue prescribing the interacting medication or prescribe a different  drug.
The interacting prescription rate, defined as the number of coprescriptions of  Warfarin-interacting medications per 10,000 Warfarin users per month.
At baseline, about a third of patients had an interacting prescription. Coinciding with  the implementation of the alerts, the estimated Warfarin-interacting medication  prescription rate decreased from 3,294 interacting prescriptions per 10,000 Warfarin  users to 2,804 interacting prescriptions per 10,000 Warfarin users, resulting in a 14.9  percent relative reduction.
The electronic medical record had CDS in the form of medication alerts.
Galanter, W.L., R.J. Didomenico, and A. Polikaitis. “A Trial of Automated Decision Support Alerts for Contraindicated Medications  Using Computerized Physician Order Entry.” Journal of the American Medical Informatics Association, vol. 12, no. 3 (2005): 269-274.
A comparison, pre-post study of a CPOE alert designed to appear when a clinician  attempted to order potentially contraindicated drugs for patients with decreased  kidney function through the CPOE. The study was conducted with 233 patients over  an 18 month period (4-month pre-CPOE alert period and 14-month post-CPOE alert  period).
Whether or not CPOE alerts were generated when contraindicated drugs were  ordered electronically.   (1) The likelihood of a contraindicated drug being administered before and after  implementation of the CPOE alerts, as collected from electronic medical records. (2)  Alert compliance.   (1) Likelihood of a patient receiving at least one dose of the contraindicated  medication decreased from 89 percent in the prealert period to 47 percent in the  postalert period. (2) Patient gender was associated with alert compliance rate, with  compliance in female patients lower than that in male patients. Alert compliance also  decreased as kidney function increased. Housestaff with more than 1 year of  residency training had a higher compliance rate than those with less than 1 year of  training.
Gandhi, T.K., S.N. Weingart, A.C. Seger, J. Borus, E. Burdick, E.G. Poon, L.L. Leape, and D.W. Bates. “Outpatient Prescribing Errors  and the Impact of Computerized Prescribing.” Journal of General Internal Medicine, vol. 20, no. 9 (2005): 837-841.
A comparison study of 1,879 prescriptions reviewed by a pharmacist and submitted at  four adult primary care practices, two of which utilized electronic prescribing and two  that did not, over a period of 7 months (September 1999 to March 2000).
Whether prescriptions were written at computerized or noncomputerized sites.
Rates of (1) prescribing errors and (2) potential adverse drug events as determined  by the expert reviewers from conducting prescription reviews, chart reviews, and  conducting patient surveys.   (1) Sites with electronic prescribing contained errors in 4.3 percent of prescriptions,  compared to 11.0 percent of prescriptions written at sites without electronic  prescribing. (2) Sites with electronic prescribing contained potential ADEs in   2.6 percent of prescriptions, compared to 4.0 percent of prescriptions at sites without  electronic prescribing. The authors note that the differences between the two groups  in errors and prevented ADEs were not significant, but that the rates of prescribing  errors and prevented ADEs could have been substantially reduced with more  advanced CDS.
The system provided no automatic checks for correct doses, frequencies, allergies, or  drug interactions, and authors found that decision support (such as drug-dose  checking and drug-frequency checking) could have prevented 97 percent of  prescribing errors and 95 percent of potential ADEs.
Kaushal, R., A.K. Jha, C. Franz, J. Glaser, K.D. Shetty, T. Jaggi, B. Middleton, G.J. Kuperman, R. Khorasani, M. Tanasijevic, and  D.W. Bates. “Return on Investment for a Computerized Physician Order Entry System.” Journal of the American Medical Informatics  Association, vol. 13, no. 3 (2006): 261-266.
A cost-benefit assessment of the implementation of CPOE with CDS at Brigham and  Women’s Hospital, a 720-adult bed tertiary care medical center in Boston from 1993  through 2002. Determined the capital and operational costs of implementing a CPOE  with CDS and of each CDS intervention through internal documents and interviews  with the CPOE developers and reviewing published literature.
Whether or not the CDS intervention was active.
Identified cost savings associated with specific CDS interventions. GAO grouped the  savings into those resulting from: (1) decreased ADEs and (2) decreased drug costs.
Of the estimated $28.5 million in estimated savings from the CPOE, (1) $12.9 million  in estimated savings were due to CDS interventions that reduced ADEs, and (2)   $6 million in estimated savings were due to CDS interventions that reduced drug  costs. The cost to develop, implement, and operate the CPOE was $11.8 million,  resulting in cumulative savings of $16.7 million.
The CPOE was equipped with CDS.
Kaushal, R., L.M. Kern, Y. Barrón, J. Quaresimo, and E.L. Abramson. “Electronic Prescribing Improves Medication Safety in  Community-Based Office Practices.” Journal of General Internal Medicine, vol. 25, no. 6 (2010): 530-536.
A pre-post study of 30 ambulatory care providers (15 electronic prescribers and 15  paper prescribers) in 12 practices in Hudson Valley region of New York (conducted  from September 2005 to June 2007). The researchers collected 2 weeks of carbon  copies and downloads of prescriptions to identify medication errors at baseline and   1 year follow-up and compared error rates among and between the electronic and  paper prescriber groups.
Whether or not the physicians’ medication orders were handwritten or submitted  electronically through a stand-alone electronic prescribing system as identified  through the carbon copies of prescriptions or prescription downloads.   (1) Medication prescribing errors (including omitting the quantity or incorrect  medication dose and duration), (2) illegibility errors, (3) near misses (i.e., potentially  harmful errors that were intercepted or reached the patient but caused no harm),   (4) ADEs, (5) rule violations (e.g., failing to write “po” for a medication taken orally),  and (6) effects of CDS on medication errors.   (1) The medication prescribing error rate among electronic prescribers decreased  from 42.5/100 prescriptions at baseline to 6.6/100 prescriptions at 1 year follow-up.  Electronic prescribers had a lower medication prescribing error rate than paper  prescribers (6.6/100 v. 38.4/100). (2) Electronic prescribing eliminated all illegibility  errors. (3) Electronic prescribers had fewer near misses (1.3/100 v. 2.7/100) than  paper prescribers. (4) Rates of preventable adverse drug events trended lower  among electronic prescribers (0.04 vs. 0.26 per 100 prescriptions). The authors noted  that this was not a significant difference between electronic and paper prescribers.   (5) Electronic prescribing eliminated nearly all types of rule violation errors.   (6) Electronic prescribers had fewer errors judged preventable by advanced/basic  CDS than paper prescribers at 1 year than paper prescribers.
The stand-alone electronic prescribing system was equipped with CDS.
Kim, G.R., A.R. Chen, R.J. Arceci, S.H. Mitchell, K.M. Kokoszka, D. Daniel, and C.U. Lehmann. “Error Reduction in Pediatric  Chemotherapy: Computerized Order Entry and Failure Modes and Effects Analysis.” Archives of Pediatrics and Adolescent Medicine,  vol. 160 (2009): 495-498.
A pre-post study of chemotherapy orders written in a pediatric oncology unit. The  study compared 1,259 paper orders written before implementation of the CPOE  system (from July 31 to August 1, 2001, and from August 14, 2001, to August 22,  2002) to 1,116 electronic orders written after implementation of the CPOE system  (from February 3, 2003, to February 12, 2004).
Whether the orders were submitted before or after the implementation of the CPOE.  A paper based survey was used to capture the pre-CPOE data, and the post-CPOE  data were captured through the system.
Data on chemotherapy steps of high morbidity/mortality potential if missed, as  determined by attending oncologists.
Findings reported by the study included: after CPOE implementation, daily  chemotherapy orders (1) were less likely to have improper dosing, incorrect dosing  calculations, missing cumulative dose calculations, and incomplete nursing  checklists, and (2) had a higher likelihood of not matching medication orders to  treatment plans.
Ko, Y., J. Abarca, D.C. Malone, D.C. Dare, D. Geraets, A. Houranieh, W.N. Jones, W.P. Nichol, G.P. Schepers, M. Wilhardt.  “Practitioners’ Views on Computerized Drug-Drug Interaction Alerts in the VA System.” Journal of the American Medical Informatics  Association, vol. 14, no. 1 (2007): 56-64.
A survey of 258 prescribers and 84 pharmacists from seven VA Medical Centers  across the United States. The time period of the survey was between 2004 and 2005.
Survey participants had prescribing authority in a VA Medical Center and an active  outpatient practice. In the VA’s computerized patient record system, prescribers enter  prescription orders electronically for review and verification by a pharmacist before  dispensing.
The survey asked respondent a variety of questions including those related to   (1) respondent satisfaction with the combined inpatient and outpatient CPOE system  (the computerized patient record system), (2) attitude towards drug–drug interaction  alerts, and (3) suggestions for improving drug–drug interaction alerts.
Findings reported in the study included the following: (1) in general, both prescribers  and pharmacists indicated that the computerized patient record system had a positive  effect on their jobs. Pharmacists revealed more favorable attitudes toward  computerized patient record system than prescribers. (2) Sixty-one percent of  prescribers felt that drug–drug interaction alerts had increased their potential to  prescribe safely. Thirty percent of prescribers felt that drug–drug interaction alerts  provided them with exactly what they needed most of the time. (3) Both prescribers  and pharmacists agreed that drug–drug interaction alerts should be accompanied by  management alternatives (73 percent and 82 percent, respectively) and more  detailed information (65 percent and 89 percent, respectively).
Kocakulah, M.C., and J. Upson. “Cost Analysis of Computerized Physician Order Entry Using Value Stream Analysis: A Case Study.”  Research in Healthcare Financial Management, vol. 10, no. 1 (2005): 13-25.
A case study of a 400-bed urban hospital, using value-stream mapping to conduct a  cost analysis of a CPOE system. The study determined the potential costs and  adverse drug reaction reductions related to CPOE implementation in this hospital,  which did not have CPOE installed.
This hospital did not have an electronic prescribing or CPOE system.
Using published studies or reports and data from the hospital, this study determined  (1) the projected decrease in medication errors, (2) the potential net savings, (3) net  present value, and (4) project internal rate of return for a CPOE system based on the  severity, average cost, and projected reduction of adverse drug reactions.   (1) The percentage of illegible orders is projected to decrease by 78 percent,  incomplete orders by 71 percent, incorrect orders by 46 percent, and drug therapy  problems by 9 percent. (2) The projected net savings were $155,686 per year. (3)  The projected project 5-year net present value was a negative $1,270,112. (4) The  projected 5-year internal rate of return was negative 24 percent. Because of these  projections, the authors did not recommend the hospital invest in a CPOE system at  the current time.
McCullough, J.S., M. Casey, I. Moscovice, and S. Prasad. “The Effect of Health Information Technology on Quality in U.S. Hospitals.”  Health Affairs, vol. 29, no. 4 (2010): 647-654.
A comparison study of 3,401 nonfederal acute-care U.S. hospitals from 2004 to 2007.
Whether the hospital had an EHR and a CPOE system, as identified from information  from the American Hospital Association’s annual survey and the HIMSS analytics  database that describes hospitals’ health information technology adoption decisions.
Performance on six process quality measures in the CMS Hospital Compare  database.
For nearly all measures, average quality was higher for hospitals with EHR and  CPOE (with larger effects for academic hospitals than when compared to all  hospitals). However, the difference was only significant for pneumococcal vaccine  administration (2.1 percent increase) and use of the most appropriate antibiotic for  pneumonia (1.3 percent increase).
The study defined an EHR as a set of applications including a computerized patient  record with a clinical data repository and some CDS capabilities, such as providing  treatment recommendations.
McMullin, S.T., T.P. Lonergan, and C.S. Rynearson. “Twelve-Month Drug Cost Savings Related to Use of an Electronic Prescribing  System with Integrated Decision Support in Primary Care.” Journal of Managed Care Pharmacy, vol. 11, no. 4 (2005): 322-332.
A comparison study of 38 primary care clinicians (19 electronic prescribing system  users; 19 electronic prescribing system nonusers) conducted from June 2002 through  May 2003.
Whether or not the physician was using an electronic prescribing system with CDS  capabilities as identified through the study design.
Using pharmacy claims, determined (1) if the 6-month savings on new prescriptions  were sustained during the 12-months of follow-up, (2) the 12-month cost savings  associated with CDS on pharmacy claims, and (3) prescribing behavior of clinicians  on eight high-cost therapeutic groups targeted by electronic messages to prescribers.  (1) Savings seen in the last 6 months of the 12 month follow-up period were greater  than the first 6 months ($748 per-member-per-month at 6 months to $794 at   12 months per-member-per-month). (2) Use of the electronic prescribing system was  associated with a sustained decrease in prescription costs. Over the 12 month follow- up period, the average cost per new prescription for the intervention group decreased  by $1.00 and increased by $3.75 in the control group. The number of other refilled  prescriptions decreased more in the intervention group than in the control group. The  number of new prescriptions increased slightly more in the intervention group than  the controls. (3) Prescriptions for high-cost target medications overall decreased by  9.1 percent in the intervention group because of CDS and increased in the control  group by 8.2 percent. Compared with the control group, the prescription ratio for high- cost drug classes was a relative 17.5 percent lower in the group using the CDS   (35.8 percent versus 43.4 percent).
The electronic prescribing system had integrated CDS, formulary, payor, and clinical  guideline alert messaging capabilities.
Peterson, J.F., G.J. Kuperman, C. Shek, M. Patel, J. Avorn, and D.W. Bates. “Guided Prescription of Psychotropic Medications for  Geriatric Inpatients.” Archives of Internal Medicine, vol. 165, no. 7 (2005): 802-807.
A comparison study at a tertiary care hospital, including 3,718 patients 65 years or  older that were prescribed a psychotropic medication targeted in the intervention and  admitted for medical, surgical, neurology, or gynecology services from October 8,  2001, to May 16, 2002.
Whether the geriatric decision support system, which included medication dosing and  selection guidelines for elderly patients, was activated.
The study measured several outcomes including: (1) The rate at which prescriptions  were written in agreement with expert recommendations regarding recommended  daily dose for the initial drug order, (2) incidence of dosing at least 10-fold greater  than the recommended daily dose, and (3) prescription of nonrecommended drugs.
Findings presented included: (1) The prescriptions for psychotropic medications  agreed with the system recommendations for dosing more frequently during the  intervention periods when the geriatric decision support application was available.  The agreement rate for both control periods was lower than the agreement rate for  the intervention periods. (2) During the intervention periods, the incidence of 10-fold  dosing decreased from 5.0 percent to 2.8 percent, (3) the prescription of  nonrecommended drugs decreased from 10.8 percent to 7.6 percent.
Ross, S.M., D. Papshev, E.L. Murphy, D.J. Sternberg, J. Taylor, and R. Barg. “Effects of Electronic Prescribing on Formulary  Compliance and Generic Drug Utilization in the Ambulatory Care Setting: A Retrospective Analysis of Administrative Claims Data.”  Journal of Managed Care Pharmacy, vol. 11, no. 5 (2005): 410-415.
A comparison study of 110,975 paid pharmacy claims submitted by two groups—95  providers using predominantly electronic prescribing and a matched sample of 95  providers who did not electronically prescribe—between August 1, 2001, and July 31,  2002.
Whether or not a provider used electronic prescribing during the study period.  (1) Formulary compliance, which was assessed using the formulary code field in  pharmacy data claims, and (2) generic utilization rates, which was assessed using  First DataBank National Drug Data File Plus software to determine the brand or  generic status of each drug.  (1) Formulary compliance for both groups was similar. The electronic prescribing  group was 83.2 percent compliant, compared to 82.8 percent compliance in the group  that did not electronically prescribe. (2) Generic utilization rates were also similar,  37.3 percent for those who electronically prescribed and 36.9 percent for those that  did not.
The electronic prescribing system provided drug and formulary information during the  prescribing process.
Spencer, D.C., A. Leininger, R. Daniels, R. Granko, and R.R. Coeytaux. “Effect of a Computerized Prescriber-Order-Entry System on  Reported Medication Errors.” American Journal of Health-System Pharmacy, vol. 62, no. 4 (2005): 416-419.
A pre-post study and comparison of two medicine units at an academic hospital  before and after implementation of a CPOE with CDS, compared to units in the  hospital that did not implement a CPOE system. Data were collected over a period of  16 months.
Whether the medication error was reported before or after the implementation of the  CPOE system in two medicine units of the hospital and whether or not the medication  error was reported from the two medicine units of the hospital that implemented  CPOE.
Reported medication errors and potential medication errors, as obtained from the  hospital’s center for medication safety.
Implementation of the CPOE system in the two units was associated with an increase  in reported errors, from 0.068 per discharge preimplementation to 0.088 per  discharge after implementation. The units in the hospital that did not implement  CPOE systems had a decrease in the number of reported errors from 0.133 per  discharge to 0.079 per discharge.
The authors note that while the error rates increased in the units with CPOE, the error  rates in the units in the hospital without CPOE decreased. Therefore, the increase in  reported medication errors on units with CPOE systems may have been attributable  to the direct or indirect consequences of introduction of the CPOE system.
Steele, A.W., S. Eisert, J. Witter, P. Lyons, M.A. Jones, P. Gabow, and E. Ortiz. “The Effect of Automated Alerts on Provider Ordering  Behavior in an Outpatient Setting.” PLoS Medicine, vol. 2, no. 9 (2005): 864-870.
A pre-post study of the implementation and effect of alerts generated during  medication ordering in primary care clinics. The baseline data were collected from  August 1, 2002, to November 29, 2002, and the postintervention data were collected  from December 1, 2002, to April 30, 2003.
All provider staff entered medication orders using CPOE. The study design compared  baseline ordering behavior (when no alert was triggered) to ordering behavior after  alerts were triggered.   (1) The number of medication orders not completed in response to an alert, (2) the  number of rule-associated laboratory test orders initiated after an alert was displayed,  as captured in the electronic prescribing system, and (3) the rates of adverse drug  events assessed by completing file reviews on a random sample of medication  orders.   (1) Before the alerts were implemented, prescribers did not complete medication  orders 5.4 percent of the time, compared to 8.3 percent of the time after the alerts  were implemented. The authors noted that this was not a significant difference  between the groups. When the alert was for an abnormal laboratory value, the  percentage of times where the medication order was not completed increased from  5.6 percent at baseline to 10.9 percent during the intervention. (2) Comparing the pre-  and postintervention periods for medication orders when no alert was displayed,  prescribers ordered associated laboratory tests 17 percent of the time during the  preintervention period, compared to 16.2 percent of the time in the postintervention  period. The authors state that this finding was not significant and indicates that there  was no trend, in general, to increased laboratory test ordering during the study  period. (3) The preintervention group had a potential ADE in 10.3 percent of charts  compared to in 4.3 percent of the charts in the postintervention group. The authors  state that the difference between the groups was not significant and that the study  was too small to show for sure whether there was any true effect on adverse drug  reactions.
Stone, W.M., B.E. Smith, J.D. Shaft, R.D. Nelson, and S.R. Money. “Impact of a Computerized Physician Order-Entry System.”  Journal of the American College of Surgeons, vol. 208, no. 5 (2009): 960-969.
A pre-post study of patient-safety measures before and after CPOE implementation  at the Mayo Clinic Hospital in Phoenix, Arizona. The CPOE system was implemented  from May 8, 2007, to April 30, 2008.
Whether or not the physicians’ orders were submitted electronically using the CPOE  system.   (1) Medication errors and (2) order-implementation time.  (1) There were no significant differences in the rate of medication errors in any of the  study time periods, which were captured through self-reporting. (2) The time from a  doctor placing an order, which was recorded or captured electronically, to a nurse  receiving that order decreased from 41.2 minutes pre-CPOE to 27 seconds post- CPOE.
Taylor, J.A., L.A. Loan, J. Kamara, S. Blackburn, and D. Whitney. “Medication Administration Variances Before and After  Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit.” Pediatrics, vol. 121, no. 1 (2008): 123-128.
A comparison, pre-post study of how the actual medication administration differed  from the medication order before and after CPOE implementation. The study was  conducted in the 30-bed Neonatal Intensive Care Unit at Madigan Army Medical  Center from August 2004 to April 2006 (pre-CPOE: August 2004 to June 2005; post- CPOE: August 2005 to April 2006).
Whether or not the physicians’ medication orders were handwritten or submitted  electronically using a CPOE system.  (1) Differences between the medication order and how the medication was actually  administered. (2) Reasons for variances between the medication order and  administration, as noted by the research nurses.   (1) The variation between the medication order and how the medication was actually  administered was lower post-CPOE than pre-CPOE (11.6 percent and 19.8 percent,  respectively). (2) Findings related to rates of variance in medication order and  administration in the pre- and post-CPOE included the following: similar variances in  both periods were found for administration mistakes, pharmacy problems, and  prescribing problems; and variances related to administration of drugs by the wrong  route and the wrong time were significantly lower after CPOE implementation.
The CPOE utilized CDS and display formats and defaults configured specifically for  use in the Neonatal Intensive Care Unit for ordering prescriptions.
Upperman, J.S., P. Staley, K. Friend, W. Neches, D. Kazimer, J. Benes, and E.S. Wiener. “The Impact of Hospitalwide Computerized  Physician Order Entry on Medical Errors in a Pediatric Hospital.” Journal of Pediatric Surgery, vol. 40, no.1 (2005): 57-59.
A pre-post study comparing orders written before the implementation of a CPOE  system in a children’s hospital from January 2002 to October 2002 to those written  after the implementation of CPOE system in November 2003 (the end point of the  study period was not specified).
Whether a prescription was written before or after the implementation of CPOE.
The rate and types of ADEs determined by analyzing data collected at the hospital.
ADE rates pre-CPOE were 0.3 per 1,000 doses, compared to 0.37 per 1,000 doses  post-CPOE. The authors note that the study demonstrates a substantial decrease in  harmful ADEs, but no significant difference in all ADEs between the pre- and post- CPOE periods. The rate of harmful ADEs pre-CPOE were 0.05 per 1,000 doses,  compared to 0.03 per 1,000 doses post-CPOE.
The CPOE had CDS.
Vaidya, V., A.K. Sowan, M.E. Mills, K. Soeken, M. Gaffoor, and E. Hilmas. “Evaluating the Safety and Efficiency of a CPOE System  for Continuous Medication Infusions in a Pediatric ICU.” AMIA Symposium Proceedings, 2006.
A comparison study evaluating the safety of a CPOE system compared to a  handwritten, hand-calculated method for prescribing continuous drug infusions for  pediatric ICU patients. The time period of the study was not specified.
Whether the orders for the drug infusions were generated in the CPOE system or  through a handwritten, hand-calculated method.
The (1) occurrence and (2) risk level of errors, as identified through a review of order  sheets for errors.   (1) The drug infusion orders generated using the CPOE system had fewer errors   (4.3 percent) than those that were handwritten (73 percent). (2) Twenty-five percent  of the errors in the handwritten group were judged to be “high-risk” compared to 0  percent in the CPOE group. All of the errors in the CPOE group were missing  signatures.
The CPOE included decision support.
Varkey, P., P. Aponte, C. Swanton, D. Fischer, S.F. Johnson, and M.D. Brennan. “The Effect of Computerized Physician-Order Entry  on Outpatient Prescription Errors.” Managed Care Interface, vol. 20, no. 3 (2007): 53-57.
A retrospective survey of 4,527 prescriptions ordered from March 1996 through  March 2002 at Mayo Clinic ambulatory clinics comparing prescriptions ordered  through the clinic’s CPOE to handwritten orders.
Whether or not the type of prescription generated was handwritten, computerized, or  preprinted.
The (1) prevalence and (2) type of pharmacist-intercepted prescription errors in  computerized and handwritten prescriptions.   (1) The frequency of intercepted prescription errors were highest in handwritten  prescriptions (7.4 percent), followed by computerized prescriptions (4.9 percent), and  preprinted prescriptions (1.7 percent). (2) The most commonly intercepted  prescriptions involved the dosage form, dispense quantity, medication dosage, and  drug allergies. CPOE resulted in lower rates in every type of intercepted prescription  error, including form, dosage, quantity, allergy, frequency, drug name, patient name,  illegibility, route, and drug–drug interaction, compared to handwritten prescriptions.
The CDS included required fields and duplicate order checking.
Wang, C.J., M.H. Patel, A. Schueth, M. Bradley, S. Wu, J.C. Crosson, P.A. Glassman, and D.S. Bell. “Perceptions of Standards- based Electronic Prescribing Systems as Implemented in Outpatient Primary Care: A Physician Survey.” Journal of the American  Medical Informatics Association, vol. 16, no. 4 (2009): 493-502.
Cross-sectional survey of physicians was fielded from October 2006 to December  2006 among physicians enrolled in a Blue Cross Blue Shield electronic prescribing  sponsorship program.
Whether or not the physician had installed an electronic prescribing system.   (1) Adequacy of available drug formulary and medication history information and   (2) perceptions of the electronic prescribing system’s enhancement of job  performance.   (1) Electronic prescribing users were more likely than nonusers to “agree” or “strongly  agree” that the information available about the patient’s medication history helps them  to identify clinically important drug–drug interactions and prevent callbacks from  pharmacies for safety problems. Electronic prescribing users were slightly more  favorable toward statements that electronic prescribing system drug coverage helps  patients maintain lower drug costs. (2) Sixty-two percent of electronic prescribers  “agreed” or “strongly agreed” that electronic prescribing improves the quality of care  they can deliver.
Weingart, S.N., B. Simchowitz, L. Shiman, D. Brouillard, A. Cyrulik, R.B. Davis, T. Isaac, M. Massagli, L. Morway, D.Z. Sands, J.  Spencer, and J.S. Weissman. “Clinicians’ Assessments of Electronic Medication Safety Alerts in Ambulatory Care.” Archives of  Internal Medicine, vol. 169, no. 17 (2009): 1627-1632.
A survey mailed to 300 clinicians in December 2007 about the value of electronic  prescribing.
Whether clinicians adopted a commercial electronic prescribing system with a drug- allergy and interaction alerts drug reference database and used the electronic  prescribing system to write at least 100 prescriptions per month between January 1  and June 30, 2006.  (1) Clinicians’ satisfaction with electronic prescribing and (2) perceptions of the  effects of electronic prescribing and alerts on the safety, efficiency, and cost of care.   (1) Forty-seven percent were satisfied or very satisfied with medication safety alerts.  Clinicians said electronic prescribing would improve the quality of care delivered   (78 percent); prevent medical errors (83 percent); enhance patient satisfaction   (71 percent); and improve clinician efficiency (75 percent). (2) Seventy-eight percent  said at least one alert had caused them to change their behavior in the past 6  months. Fifty-seven percent said an alert might have prevented at least one error or  injury in the average month. Twenty-two percent said an alert had prevented a  serious error or injury in their practice. Sixty-three percent of respondents said an  alert caused them to take action other than change an alerted prescription (counsel  patient, look up information in a drug reference, or change how they monitor a  patient). The study also reported participant ratings on potential problems associated  with the drug allergy or interaction alerts. For example, 58 percent of respondents  reported that alerts were triggered by discontinued medications.
Yu, F.B., N. Menachemi, E.S. Berner, J.J. Allison, N.W. Weissman, and T.K. Houston. “Full Implementation of Computerized  Physician Order Entry and Medication Related Quality Outcomes: A Study of 3364 Hospitals.” American Journal of Medical Quality,  vol. 24, no. 4 (2009): 278-286.
A comparison study of hospitals—264 that used a CPOE system to enter all orders  and 3,100 that did not—over a 1–year period (July 2003 to June 2004).
Whether the hospital reported on the HIMSS analytics survey that it entered all orders  through CPOE.
Performance on hospital quality-of-care measures from CMS.
Of the 11 medication-related measures, the mean performance on 6 cardiovascular- related measures was higher among CPOE hospitals than non-CPOE hospitals, and  the mean performance on one measure, antibiotics within 4 hours of arrival, was  lower among CPOE hospitals than non-CPOE hospitals.
Yu, F., M. Salas, Y. Kim, and N. Menachemi. “The Relationship Between Computerized Physician Order Entry and Pediatric Adverse  Drug Events: A Nested Matched Case-Control Study.” Pharmacoepidemiology and Drug Safety, vol. 18, no. 8 (2009): 751-755.
A comparison study between 54 pediatric hospitals that had CPOE systems and 68  pediatric hospitals that did not. Patient data were retrieved between October 1, 2005,  and September 30, 2006.
Whether a CPOE system was fully implemented for all orders and clinical domains,  as identified through the HIMSS analytics database.
The odds of ADEs, using data from the national association of children’s hospitals  and related institutions case-mix comparative data program and HIMSS.
The odds of experiencing an ADE were 42 percent higher for hospitals without CPOE  compared to those with CPOE.
Zhan C., R.W. Hicks, C.M. Blanchette, M.A. Keyes, and D.D. Cousins. “Potential Benefits and Problems with Computerized Prescriber  Order Entry: Analysis of a Voluntary Medication Error-Reporting Database.” American Journal of Health-System Pharmacy, vol. 63,  no. 4. (2006): 353-358.
Comparison study of 120 facilities that reported having a CPOE in all clinical areas to  339 facilities that did not have a CPOE. Facilities included general community  hospitals, specialty hospitals, and outpatient clinics. Data analyzed were from 2003.
Whether the facility had CPOE, as determined by Medmarx, a national voluntary  medication-error reporting database.  (1) The number of errors reported by CPOE versus non-CPOE facilities and (2) the  characteristics of errors caused by CPOE, as captured in the Medmarx database.
The authors stated that the different facilities that self-reported data to the Medmarx  database appeared to have different levels of underreporting of medication errors,  and therefore, these data cannot be used to assess the potential benefits of CPOE or  compare rates of medication errors between providers though facilities with CPOE  had fewer inpatient errors, more outpatient errors, and smaller numbers of outpatient  and inpatient errors that reached or harmed patients compared to facilities without  CPOE. The article did not evaluate the sophistication of the CDS employed by the  studied CPOE systems.
section_title: Appendix III: Scope and Methodology
paragraphs: This appendix provides additional details regarding our scope and  methodology for reporting information on the providers who participated  in and received incentive payments from the 2009 Electronic Prescribing  Program.
To conduct our analyses, we analyzed four Centers for Medicare &  Medicaid Services (CMS) files.    2009 Electronic Prescribing Program Participation. We obtained a  file from CMS in October 2010 that provided summary information for  each provider that participated in the Electronic Prescribing Program in  2009, which CMS also used to make payments to providers for 2009. For  each combination of national provider identifier and tax identification  number, this file contained the following information: the total number of  times each of the three electronic prescribing codes were submitted; the  total number of applicable visits; whether CMS determined that the  provider would receive an incentive payment; and the amount of the  incentive payment.   2009 Electronic Prescribing Program Eligible Providers. We  obtained a file from CMS in October 2010 that listed each provider that  had at least one applicable visit for the Electronic Prescribing Program in  2009—which we refer to in this appendix as “applicable providers.” Over  597,000 providers had at least one applicable visit for the Electronic  Prescribing Program in 2009. This number represents a count of all  Medicare providers who had at least one applicable visit in 2009. However,  not all of these providers have prescribing authority. Consequently, there  may be some individuals included in the count of 597,000 providers that  were not eligible for an electronic prescribing incentive payment.
National Plan and Provider Enumeration System (NPPES)
Downloadable File. We downloaded this file from CMS’s Web site  (http://nppes.viva-it.com/NPI_Files.html) in October 2010. We used the  variable “Provider Business Practice Location Address State Name” to  obtain the state for providers.
Provider Enrollment, Chain, and Ownership System (PECOS)
Global Extract File. We obtained this file from CMS in October 2010. In  the few cases when we were unable to obtain the state for providers using  the NPPES Downloadable File, we attempted to determine the state for  providers using either the “Practice Location State” variable or the  “Correspondence Address State” variable from the PECOS Global Extract  File.
CMS determined which providers met or exceeded the reporting  requirement for 2009 using each unique combination of providers’ national  provider identifiers and tax identification numbers. However, we analyzed  and report information at the national provider identifier level only so that  we could present results for unduplicated providers. We were unable to  match 1,052 applicable providers (less than 0.2 percent of applicable  providers) to either the NPPES Downloadable File or the PECOS Global  Extract file.
To determine the percent of Medicare providers who received incentive  payments by state and the average incentive payment by state using the  state for each provider, we obtained state information for over 99 percent  of applicable providers using data from the NPPES Downloadable File and  for the remaining applicable providers using data from the PECOS Global  Extract File. We excluded the about 0.2 percent of applicable providers  mentioned above that we could not match to either the NPPES  Downloadable File or the PECOS Global Extract File. In addition, we  excluded about another 0.2 percent of applicable providers for whom we  were unable to obtain state information, the 0.9 percent of applicable  providers who were from U.S. insular areas, and six providers whose state  information we deemed unreliable.
section_title: Appendix IV: Maximum Electronic Health Record (EHR) Program Incentive Payments, Based on First Year of Payment
paragraphs: Appendix IV: Maximum Electronic Health  Record (EHR) Program Incentive Payments,  Based on First Year of Payment Maximum EHR incentive payments by year   ual to 75 percent of the provider’s total allowed charges for  services covered by Medicare Part B for the year, but are subject to the annual limits displayed in this  table.
section_title: Appendix V: Stage-One Reporting Requirements for the Electronic Health Records (EHR) Program
subsections: section_title: 1. Generate and transmit more than 40 percent of permissible
paragraphs: 1.  Perform medication reconciliation for more than 50 percent  of all transitions of care.
2.  Enter medication order into computerized physician order  entry (CPOE) system for more than 30 percent of patients  with at least one medication in their medication lists.3.  Enter medication lists or indicate no current prescriptions for  2.  Enable the EHR system’s ability to check a prescription  against a formulary and maintain access to at least one  internal or external drug formulary for the entire EHR  reporting period.  3.
Incorporate as structured data more than 40 percent of all  clinical lab tests results ordered. allergies for more than 80 percent of patients.5.  Enable the EHR system’s ability to check a prescription for  4.  Generate at least one list of patients by a specific condition.  5.  Send reminders during the EHR reporting period for  potential drug–drug and drug–allergy interactions.  6.  Record as structured data demographics for more than   preventative or follow-up care to more than 20 percent of  patients aged 65 and over or aged 5 and younger.  6.  Provide electronic access to health information within 4  7.  Record as structured data list of current and active diagnoses  business days of being updated in the EHR system to more  than 10 percent of patients. or indicate no known problems for more than 80 percent of  patients.
7.  Provide patient-specific education resources to more than   8.  Record as structured data height, weight, and blood pressure  10 percent of all patients. for more than 50 percent of patients aged 2 and over.
8.  Provide summary of care record to more than 50 percent of  9.  Record as structured data smoking status for more than   transitions of care and referrals.
50 percent of patients aged 13 and over.
9.  Perform at least one test of certified EHR technology’s  10.  Implement one clinical decision support rule relevant to  capacity to submit electronic data to immunization registries  and follow-up submission if the test is successful.
Medicare & Medicaid Services (CMS) or the states.  12.  Provide electronic copy of health information within 3 business  capacity to provide electronic syndromic surveillance data to  public health agencies and follow-up submission if the test is  successful. days to more than 50 percent of all patients who requested  that information.  13.  Provide clinical summaries to patients within 3 business days  for more than 50 percent of all office visits.  14.  Perform at least one test of certified EHR technology’s  capacity to electronically exchange key clinical information   (i.e., problem list, medication list, medication allergies, or  diagnostic test results).  15.  Protect electronic health information created or maintained by  the certified EHR technology by conducting or reviewing a  security risk analysis, implementing security updates as  necessary, and correcting identified security deficiencies. uirement is electronic prescribing-related.  uality measures help uantify health care processes, outcomes, patient  perceptions, and organizational structure. To meet this reporting reuirement, providers must report  on 6 out of 44 clinical uality measures identified by CMS.
The reuirement is public health–related.
section_title: Appendix VI: Comments from the Department of Health and Human Services
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact name above, Robert Copeland, Assistant  Director; Nick Bartine; George Bogart; Julianne Flowers; Krister Friday;  Toni Harrison; Daniel Lee; Shannon Legeer; and Sarah Marshall made key  contributions to this report.