Written Testimony on E-prescribing
Submitted to NCVHS by SureScripts, LLC
May 17, 2004
To assure that the adoption of new standards recommended to the Secretary by NCVHS maintains the current momentum of e-prescribing deployment that is supported and facilitated by existing standards, SureScripts makes the following recommendations.
We recommend that the 2006 pilots required by the Medicare Prescription Drug, Improvement & Modernization Act (MMA) be fully utilized to demonstrate efficiencies, including cost savings, and that the new standards mentioned in the MMA do not impose an undue administrative burden on health care professionals involved in e-prescribing. Examples of these new standards/code sets include: the Prescriber Identifier Code Sets; Drug Ingredient Code Sets; RxNorm; NDFRT; and drug labeling and drug listing information maintained by the FDA/NLM. It is imperative that these standards/codes sets be proven to work in the private sector before their use is required nationwide.
In addition, to further accelerate the adoption and use of e-prescribing standards and code sets, SureScripts recommends that the financial grant provisions of the MMA be expanded to include pharmacies, which currently are supporting a disproportionate share of overall e-prescribing infrastructure and transaction costs.
SureScripts was created by the National Community Pharmacists Association and the National Association of Chain Drug Stores in 2001 to improve the overall prescribing process by facilitating true electronic connectivity between prescribers and pharmacies and by promoting the widespread adoption of e-prescribing. Working with the nation’s premier health care technology vendors, SureScripts is creating an open and secure system that is compatible with all major pharmacy software systems and physician prescribing technologies. More than 75 percent of the nation’s chain pharmacies and organizations representing independent community pharmacies have endorsed SureScripts and are in various stages of connecting to SureScripts Messenger Services as their gateway for e-prescription communications.
Responses to NCVHS’s Questions on Standards for E-prescribing
NCVHS has requested that SureScripts identify the ways in which the standards and code sets it uses address the list of Requirements for E-prescribing Standards set forth in the MMA. SureScripts is pleased to respond to NCVHS’s questions below and in the accompanying Excel spreadsheets that NCVHS provided.
• What are the best standards or code sets to meet the requirements of the Law? (Your oral testimony only needs to focus on the major standards/code sets that you think the NCVHS should consider.)
SureScripts Response: In implementing basic e-prescribing, SureScripts selected the nationally recognized NCPDP SCRIPT Standard to serve as the foundation for its transaction engine software. The NCPDP SCRIPT Standard was developed to facilitate the electronic, bidirectional transmission of prescription information between prescribers and pharmacies. It adheres to EDIFACT syntax requirements, utilizes standard EDIFACT and ASC X12 data tables, and is an American National Standard (ANS). SureScripts believes NCPDP SCRIPT is the best standard to meet the e-prescribing needs of Medicare patients and the prescribers and pharmacists who serve them.
The NCPDP SCRIPT Standard was developed through a consensus process among community pharmacy organizations, pharmacy software vendors, database providers, and other stakeholders. Currently, the standard addresses the electronic transmission of new prescriptions, prescription refill requests, prescription fill status notifications, and cancellation notifications. Future enhancements could address other data communication possibilities that may include patient eligibility, compliance, lab values, diagnosis, disease management protocols, patient drug therapy profiles, prescription transfers, etc.
In terms of the best code sets to be used, we have found that the NCPDP Provider Identification Number for community pharmacies that was adopted several decades ago and is used universally for the processing and payment of prescription drug claims works extremely well as a Pharmacy Identifier Code Set for e-prescribing. The NCPDP Provider Identification Number provides over 70,000 pharmacies with a unique identifying number for interactions with federal agencies and third-party processors.
With respect to Packaged Drug Code Sets, we believe that NCVHS should consider the NDC number as the best standard. The NDC number has also been used for several decades both for prescription drug claims processing and to facilitate internal data processing needs in community pharmacy computers.
• Which of these standards/code sets do you use?
SureScripts Response: SureScripts uses the NCPDP SCRIPT Standard, the NCPDP Provider Identifier for community pharmacies, and transmits the NDC number when submitted by prescriber or pharmacy software.
• What are the strengths and weaknesses of the standards/code sets that you use?
SureScripts Response: The strengths of NCPDP SCRIPT are that it is a national standard that addresses the vast majority of the core functionality required in the MMA. It currently facilitates the bidirectional transmission of prescription information between prescribers, dispensing pharmacies and pharmacists and holds the potential to allow for the transmittal of information on eligibility and benefits and medication history. A weakness of the NCPDP SCRIPT Standard is that it is not widely used in the inpatient and long-term care settings. However, to address this weakness, NCPDP and HL7 have initiated a collaborative effort to harmonize the two standards with respect to e-prescribing.
The strength of the NCPDP Provider Identifier is that it is used nationally to identify a participating community pharmacy. This unique identifier is used by boards of pharmacy, payers, and telecommunication switches to precisely identify pharmacies for a variety of purposes. This identifier has been used effectively by these stakeholders for several decades, and it has been refined substantially over that time. We do not see that it has any weaknesses.
The strength of the NDC number is its universal acceptance as a Packaged Drug Code Set and use by payers (including CMS), pharmacies, manufacturers, and database companies. The primary weakness of the NDC number is that it does not specify component ingredients in a drug product and thus is not useful as a Drug Ingredient Code Set. Even when the NDC number is used in combination with proprietary drug databases to meet this need, there are problems because there are no standardized cross references between the databases.
• Is nationwide adoption of these standards/code sets necessary?
SureScripts Response: All three of the standards/code sets—the NCPDP SCRIPT Standard, the NCPDP Provider Identifier for pharmacies, and the NDC number as a Packaged Drug Code Set—are already recognized and adopted nationwide.
• What are the e-prescribing standard/code set gaps? (These may be standards/code sets that are needed to address requirements in the law or other functions, but are not yet available.)
SureScripts Response: The first e-prescribing code set gap that SureScripts encountered was that of a Prescriber Identifier Code Set. Code sets that have been suggested as useful for this purpose include the prescriber’s DEA number, NCPDP’s HCIdea, and the NPI. The DEA frowns on the use of the DEA number as a prescriber identifier for any purpose not related to the prescribing of controlled substances. HCIdea has the potential to be a universal identifier but does not have the full acceptance of the industry at this time due to the industry’s need to evaluate the utility of the NPI. The NPI is fatally flawed because it is not required for all prescribers, nor does it have the capability of specifying more than two address locations, which is necessary in the e-prescribing environment. CMS currently plans that the National Provider System (NPS) will only collect “the mailing address and one physical location address for a health care provider. It would not assign location codes.”
Because there is not a Prescriber Identifier Code Set that uniquely and adequately identifies prescribers on a national basis, SureScripts was compelled to create its own SureScripts Prescriber ID (SPI) for internal use. The SPI consists of an SPI root and a location ID. The SPI Root is generated by SureScripts and is a ten-digit numeric value. Each prescriber has a unique SPI Root. However, since a prescriber can prescribe from more than one location, the Location ID is used in order to distinguish between multiple locations for the same prescriber. It is in this way that SureScripts has been able to overcome the location deficiency of the NPI.
Another e-prescribing code set gap is the lack of a nationally accepted, nonproprietary prescription direction (sig) database. Because of this, SureScripts must now transmit prescription directions in free-text format, which compromises a small portion of the efficiencies that pharmacy providers had hoped to achieve when implementing e-prescribing.
• What are the barriers to the development/adoption of these standards/code sets?
SureScripts Response: The NCPDP SCRIPT Standard has been widely embraced by pharmacies, prescribers, and the software vendors that serve them. The NCPDP development process continues to be flexible and responsive to industry needs. Thus, there really are no barriers to the development/adoption of this standard.
In terms of the Prescriber Identifier Code Set, the NPI, as defined in the Final Rule, has three major barriers for its adoption in the e-prescribing realm: (1) it is not required for all prescribers, (2) it does have the capability of specifying more than two address locations, and (3) it does not validate the provider. These barriers must be removed as quickly as possible in order for the NPI to be useful to those engaged in e-prescribing.
As to Drug Ingredient Code Sets, there needs to be a cross reference between proprietary drug databases, as the NDC number was not created to meet this need.
• What incentives or other suggestions should the government consider to accelerate the development/adoption of e-prescribing standards/code sets?
SureScripts Response: The MMA recognizes the financial challenges that e-prescribing will likely represent for prescribers by providing a grant program that will provide a 50 percent financial match toward the (1) purchase, lease or installation of computer software and hardware, (2) upgrades or other improvements to existing computer software, and (3) providing education and training to prescriber staff on use of e-prescribing technologies. The widespread implementation and use of the developed/adopted e-prescribing standards and code sets could be further accelerated by expanding the grant program to pharmacies, which are supporting a disproportionate share of the overall e-prescribing infrastructure and transaction costs.
· Discussion of NCVHS Additional Requirements Questions
SureScripts Response: It is SureScripts’ experience that the use of the NCPDP SCRIPT Standard does improve patient safety, quality of care, and efficiency, without presenting an undue administrative burden on prescribers and pharmacists.
It could also serve as a foundation upon which quality assurance measures and systems are built. It permits the patient designation of dispensing pharmacy and supports this choice with no change in patient benefits, no constraints of electronic access to or from pharmacies, and no differences in benefits or payments based on the dispensing of part D drugs. It can be and is used in a manner that is compliant with HIPPA Privacy Regulations, and it can support interactive and real-time transactions when end user software systems are programmed and capable of handling said transactions.
Addressing the issue of compatibility with other standards such as RxNorm or NDFRT, it must be said that the proponents of these standards have not approached NCPDP to make sure that these standards are compatible with the SCRIPT Standard. Therefore, it is not possible to state whether or not these other standards are compatible with NCPDP SCRIPT. NCPDP is a collaborative organization that is responsive to meeting the legitimate business needs of the users of its standards, so it is quite likely that these issues of compatibility could be addressed expeditiously.
The question as to whether the NCPDP SCRIPT Standard permits the electronic exchange of drug labeling and drug listing information maintained by the FDA/NLM is not one that has been posed before. The professional and business needs for the exchange of this information between prescribers and pharmacies have never been raised at NCPDP in relation to e-prescribing. Thus, the NCPDP SCRIPT Standard does not currently include this functionality.
In closing, we at SureScripts thank NCVHS for the opportunity to share our experiences and findings with respect to standards currently used in the United States to facilitate the adoption of bidirectional electronic prescribing communications between prescribers and pharmacies. We encourage NCVHS to support current e-prescribing efforts that have evolved using these standards.
Further, we recommend that the 2006 pilots be used to assure that the new standards mentioned in the MMA do not impose an undue administrative burden on health care professionals involved in e-prescribing. To reiterate, it is imperative that these standards/codes sets be proven to work in the private sector prior to requiring their use nationwide.
Finally, to further accelerate the adoption and use of e-prescribing standards and code sets, SureScripts recommends that the financial grant provisions of the MMA be expanded to include pharmacies. If you have any questions about this written testimony, please contact Ken Whittemore at 703-921-2114. Thank you.