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Stakeholders need to prepare for the loss of long-term care's exemption to e-prescribing

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Cynthia Morton
Cynthia Morton

This one could be called, "How e-everything is making e-anything seem cutting edge — even faxing."

The Centers for Medicare & Medicaid Services is set to lift long-term care's exemption from its e-prescribing rule as of November 1. This is bigger news than most realize right now, and there has been no indication CMS is going to postpone things.

While CMS' e-Prescribing Rule has been on the books for nearly a decade, understanding it is a recent phenomenon that can be traced back to a single slide in a webinar held in June. Illustrating the adage “A picture is worth 1,000 words,” the slide presented by a CMS official revealed key nuances about how CMS interprets its e-Prescribing Rule – and why long term and post-acute care pharmacies, vendors and providers need to pay attention to it now.

What is e-prescribing?

It's probably not what you think.

CMS defines e-prescribing as “the transmission using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager or health plan, either directly or through an intermediary, including an e-prescribing network.” The definition further states that e-prescribing “includes, but is not limited to, two-way transmissions between the point of care and the dispenser.” [42 CFR §423.159]

CMS' definition is helpful, but it requires more digging to learn what “electronic media” means. Under Title 45, Subtitle A, Subchapter C, Part 160, Subpart A, Section 160.103 of the Code of Federal Regulations, you'll find “electronic media” can refer to storage devices or transmission media. The regulations describe electronic media this way: “Transmission media used to exchange information already in electronic storage media. Transmission media include, for example, the Internet, extranet or intranet, leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media if the information being exchanged did not exist in electronic form immediately before the transmission.” [45 CFR 160.103]

That's two paragraphs to simply define the term “e-prescribing,” leaving little doubt as to why there's been some confusion. And it takes more than a few lines of code to implement, too. For e-prescribing to work, everyone has to be ready for it – pharmacies, information technology vendors and providers. Many aren't.

What's old is new again

Did you catch the reference to “dial-up lines” in that definition? Remember, the e-Prescribing Rule was implemented in 2005. There was no “cloud,” no iPad, no Twitter.

Today, we immediately associate anything labeled with the prefix “e-” with innovations around “e-health.” So, it seems logical for “e-Prescribing” to invoke images of new, cutting-edge technology. The problem is – it isn't.

The “e-” in “e-Prescribing” simply refers to “electronic” – as in prescriptions that are transmitted “electronically.” That includes computer-generated faxes (aka “e-faxes”). This is a huge distinction.

C'mon, everyone's doing it — well, not everyone.

The fact is there has been an “LTC exemption” to the e-Prescribing Rule since it was ushered in along with Medicare Part D as part of the Medicare Modernization Act (MMA). Actually, CMS' e-prescribing program was the agency's first effort to incentivize physicians to “go electronic” and like the more recent Meaningful Use, no incentives were provided for e-prescribing in long-term care/post-acute (LTPAC) settings.

Why care about an almost decade-old policy?

Because “LTC” settings will no longer be exempt from this rule as of November 1, 2014. Therefore, prescriptions for Medicare Part D beneficiaries that are sent to a pharmacy electronically — regardless of care setting — must use the NCPDP SCRIPT 10.6.

CMS' recent clarification that the agency considers medication orders as “valid prescriptions” has tremendous implications in terms of what falls under the e-Prescribing Rule. Barring a few small caveats*, as of November 1, if a prescriber or facility uses virtually any technology (other than the telephone or manual fax) to transmit a Part D prescription or “prescription-related information,” that transmission must use the NCPDP SCRIPT 10.6 standard. That means computer-generated faxes (CGFs) or “e-faxes” and electronic messages that are coded for proprietary systems or using standards other than the NCPDP SCRIPT 10.6 will not be considered “valid prescriptions” as of November 1.

*[There are two small caveats in terms of e-Prescribing — sending electronic messages within the “same legal entity” (i.e., the facility and pharmacy are part of the same legal entity) and using a manual process (i.e., phone and manual fax) to transmit medication orders to a pharmacy. The e-Prescribing Rule also contains a provision that allows for contingency planning such as may occur due to a telecommunications system interruption during a natural disaster.]

One reason for the exemption: It's complicated.

Perhaps in recognition of how daunting the task, CMS included several exemptions in the original e-prescribing regulation, to include computer-generated/e-faxes, “LTC” settings, same legal entities and e-prescribing of controlled substances. One of the reasons for the LTC exemption is that the then-named e-prescribing standard (NCPDP SCRIPT 8.1) could not accommodate necessary workflow requirements of long-term care facilities.

We've learned a great deal since the e-Prescribing Rule was first implemented. We've learned even more in the weeks since CMS clarified what it considers a valid prescription as that affects which transactions are subject to the e-Prescribing Rule.

Implementing this CMS requirement is complicated and demands the participation of prescribers, pharmacies, software developers, IT vendors, providers and others.

The National Association for the Support of Long-Term Care (NASL) has been a part of the tremendous, full-on collaborative effort that's been underway all summer as we collectively work toward the November 1 deadline. We've been buoyed to learn the myriad ways NASL members have invested in the technology, testing and technical support that is required to implement this change.

Even so, just having eMAR, EMR or EHR software that can send messages via NCPDP SCRIPT 10.6 is not enough to implement e-prescribing. Much like the policy itself, implementing e-prescribing in LTPAC settings is a complex endeavor that involves multiple stakeholders — all of whom have to be in sync to make it work.

How do you know if you're ready for November 1?

Ironically, if you do not send medication orders electronically today — for example, you phone-in medication orders and manually fax over the physician's signed medication order — you are NOT performing e-prescribing and do not need to change your existing process due to CMS' lifting of the LTC exemption starting November 1.

If you have an eMAR, EMR or EHR system or e-fax medication orders to your pharmacy, however, you might need to upgrade your software or change your current process for sending medication orders to your pharmacy. Consider contacting your pharmacy to ask if the process you have in place now will be OK to use after November 1, or check with your IT vendor to see whether or not an upgrade is available.

If an updated version of your current software is not readily available, you might need to adjust your workflow to accommodate a manual process as you transition to using an NCPDP SCRIPT 10.6-compliant process. Once you know where you stand, you can develop a plan to be sure you have the IT support and training you and your staff need moving forward.

For more information on this issue, visit www.NASL.org.

Cynthia Morton is executive vice president of the National Association for the Support of Long Term Care.


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