What the CMS Tamper-Proof Guidelines Could Cost E-Prescribers

Kathryn Mackenzie, for HealthLeaders Media, September 30, 2008

Think the new tamper-proof prescription rules don't affect e-prescribers? Think again.

Tomorrow is the deadline by which all written Medicaid prescriptions must be on tamper resistant pads. Although proponents of e-prescribing have added the new guidelines to the laundry list of benefits of switching from paper to computer (since the rules don't apply to electronic, faxed, or telephone prescriptions), in most cases e-prescribers and electronic health record-users will still have to make some adjustments to their prescribing practices.

While it's true that the Centers for Medicare and Medicaid guidelines do not apply to electronic prescriptions sent via fax or computer directly to the pharmacy, there are still a good number of instances in which an e-prescribing physician will need to print the prescription out and hand it to the patient, says Peter Basch, MD, medical director of ambulatory clinical systems at MedStar Health.

"Physicians still must print prescriptions for controlled substances, and there are those patients who would prefer a paper printout rather than the prescription being sent electronically to their pharmacy, or those who do not know the exact pharmacy where their prescription will be sent. And you can't post-date an e-prescription, so those patients that need their prescriptions filled at a later date will need a printout," he says.

Unlike their prescription pad-using counterparts, who can replace the old pads with new tamper-resistant pads from vendors, medical providers who e-prescribe would likely be forced to invest in expensive tamper-proof paper (standard printing paper costs—on average—less than a dollar per sheet, while tamper-proof paper can cost several dollars per sheet), and laser printers capable of printing to multiple trays at a high resolution. For an eight-hospital system like MedStar, Basch estimates that process would have cost $1.5 million upfront to become compliant, with ongoing costs of about $200,000 annually.

Basch, an early adopter of e-prescribing and a proponent of electronic health records, says he foresaw those costs becoming a barrier to adoption of e-prescribing and EHRs and decided to form a coalition to push for revised anti-tampering requirements that focus on using new print technologies, rather than using expensive tamper-proof paper, as originally mandated by Medicaid. "We are all for this change, but we want to do it in a way that works and a way that is consistent with the federal mandate by the president to encourage adoption of EMRs and e-prescribing. Our concern was, if you create a new barrier by adding tens of thousands of dollars to a physician's budget, you are sending the opposite message," says Basch.

And so, the National Council for Prescription Drug Programs, a coalition of national organizations comprised of the American College of Physicians, Physicians' Electronic Health Record Coalition, and the Electronic Health Record Vendors Association, looked to the financial world for inspiration and ultimately adopted two print technologies that have been deemed by CMS to be compliant with the new guidelines.

The first, called a digital void pantograph, incorporates a hidden security word or image into the background of a computer printed prescription. The image will show up if the prescription is copied or scanned. The second, called microprinting uses a strip of minute type that can be read with a 5X magnifying glass or loupe. The type will appear smeared when photocopied on most machines. Neither of these technologies requires special paper or printers, says Bausch, eliminating the need for that potentially large upfront investment.

While Bausch says he's pleased that CMS and the NCPDP were able to come up with a less expensive, effective alternative to the government's original plan, the group's work is not done. He says within a short time-frame (read months, not years) the prescription information itself will become tamper-proof. "What we will do is make the information tamper resistant. The physician will send that information electronically to a network and print a receipt for the patient. The pharmacist can then check the patient's receipt against the stored information, if the two match, the prescription is filled."

Hopefully by now providers have already figured how to become compliant with the new guidelines, but if you're considering the move to e-prescribing or implementing an electronic health record, now might be a good time to talk to your suppliers about the latest print technology options.

Kathryn Mackenzie is technology editor of HealthLeaders magazine. She can be reached at kmackenzie@healthleadersmedia.com.
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