E-Prescribing and Standards for E-Prior Authorization

Recently, colleagues have raised questions about pending state legislation related to electronic prescribing (e-prescribing) and in particular the concept of electronic prior authorization (ePA) for medications. We thought it would be helpful to discuss what we know about the current state of e-prescribing and ePA. E-prescribing provides significant advantages in contrast to its paper analog. Coupled with other complementary technologies, such as drug-drug interaction checking, e-prescribing can improve patient safety, increase prescribing accuracy and efficiency, and lower costs by notifying providers of generic or preferred drug list alternatives. 

Over the past three years, Congress has signaled its support for e-prescribing by promoting its use in two major laws: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act covers certain eligible professionals seeking to become meaningful users of certified electronic health record (EHR) technology in the Medicare and Medicaid EHR Incentive Programs. The HITECH Act specifically identified e-prescribing as a requirement for eligible professionals participating in the EHR incentive programs, and therefore it is part of the “core set” of meaningful use objectives and measures (which also includes objectives and associated measures for using computerized provider order entry [CPOE], maintaining active medication and medication allergy lists, and implementing clinical decision support). MIPPA focuses on Medicare eligible professionals to encourage e-prescribing with a separate incentive program requiring use of a qualified e-prescribing system. Below are a few points that address some of the questions raised by our state colleagues as they consider e-prescribing related legislation.

  • It is useful to keep apprised of the technical requirements (capabilities and technical standards) that are currently part of Federal health IT programs to ensure consistency and avoid potential conflicts.
  • While ONC requires as a condition of certification (for the purposes of meaningful use) that EHR technology be capable of generating and transmitting electronic prescriptions, certification does not require that EHR technology also be capable of performing electronic prior authorization.
  • We are not aware of a widely adopted, common, industry transaction standard that has been demonstrated to support real-time ePA, nor are we aware of a common or universal electronic format that has been demonstrated to facilitate distribution of prior authorization forms. We are aware of work that has been done by the National Council for Prescription Drug Programs (NCPDP) to create an XML-based ePA messaging standard and a real-time eligibility check messaging standard. We understand that these are draft standards that have not yet been tested in pilots and have not been fully “balloted” (voted on) through NCPDP’s process or been finalized as American National Standards Institute (ANSI)-accredited standards.
  • There is a lack of established and fully vetted standards to support ePA and the current lack of capability to support ePA in implemented EHR systems. Therefore, requiring real-time electronic prior authorization as a prerequisite technical capability before health care providers could e-prescribe and/or access drug formulary information may be difficult to implement, and could otherwise prevent providers from being able to e-prescribe. If such requirements prevent providers from being able to e-prescribe, it could also keep them from being able to participate in the incentive programs noted above.

We look forward to continued work and collaboration with our state colleagues through all of the ONC-administered HITECH programs and hope that this blog provides useful context.


  1. Rod Baird says:

    This is not the only problem with the eRx incentive program, or its intergation into the Meaningful Use criteria.

    Our PCP staff works exclusively in Nursing Facility settings. They are required to demonstrate the use of eRx or face a penalty. At the same time, Nursing Facilities are required to procure all drugs ordered in their facility, once that order is authorized by the physician. However, no Nursing Facilities, and few LTC pharmacies connect with any ePrescribing hub (e.g.Surescripts).

    Similar hurdles are associated with all other meaningful use criteria related to CPOE – the patient’s ‘official’ medical record is maintained by the Nursing Facility; the Physician’s EHR and meaningful use standards exist in a separate universe.

    CMS and hte ONC should recognize this significant problem. The Medicare/Medicaid population residing in the LTC setting is the most managable (from a cost avoidance view) patient population in the health care system. They consume more public $s over a long period of time than any other prospectively identifiable group.

    The ONC should address this care delivery system in its standards.

    Rod Baird
    Extended Care Physicians, PA
    Asheville, NC

  2. Dr. Joseph kousa, MD says:

    According to meaningful use criteria, we are expected to submit certain percentage of prescriptions electronically. In practice however, we find patients declining electronic prescriptions in favor of paper prescriptions for many reasons:

    1) They do not want to be bound to one pharmacy.
    2) They shop different pharmacies for different medications for better price.
    3) They are not able to afford all prescriptions at the same time.
    4) They buy only the medications they run out of one at a time.
    5) They prefer to have prescriptions In hand

    I find giving the patients the freedom and choice is important and is compatible with free market standards and having to squeeze certain percentage of eRX in order to qualify for meaningful use a bit impractical.

  3. Jim Morrow, MD says:

    Having done e-prescribing since it was legalized in Georgia, I have found patients to be very accepting of it. With some time spent to educate them as to the need and benefits, they quickly accept this new technology.

    While some do share the concerns of Dr. Jousa’s patients, most of these concerns are easily assuaged. Prescriptions can be sent electronically but do not have to be picked up immediately and when they express a desire to have them in hand, I simply print them a clinical summary (another meaningful use measure) which lists their medication list, including any new medications from that visit.

    When the patient needs a refill, they can contact the pharmacy and if a new prescription is required, it can be requested electronically, saving time and money for everyone involved.

    E-prescribing, for me and my patients, has been a tremendous success. Now, bring on the electronic prior authorizations!!

  4. Electronic Prescribing says:

    E-prescriptions are saving time, money, and lives.

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