Attachment M - Public Comment APhA

October 1, 2009
Agency for Healthcare Research
540 Gaither Road
Rockville, MD 20850
Attention: OMB Desk Officer
[Submitted electronically to: [email protected]]
RE: AHRQ Proposed Collection Project: “Health IT Community Tracking Study 2009.”
Dear Sir/Madam:
Thank you for the opportunity to provide comments to the Agency for Healthcare Research and
Quality (AHRQ) on its request to the Office of Management and Budget to approve the proposed
collection project “Health IT Community Tracking Study 2009,” published in the Federal
Register on September 1, 2009 (74 FR 45211). APhA, founded in 1852 as the American
Pharmaceutical Association, represents more than 62,000 pharmacists, pharmaceutical scientists,
student pharmacists, pharmacy technicians, and others interested in improving medication use
and advancing patient care. APhA members provide care in all practice settings, including
community pharmacies, hospitals, long-term care facilities, community health centers, managed
care organizations, hospice settings and the uniformed services.
As outlined in the notice, AHRQ is proposing to collect data on electronic prescribing (eprescribing) as it is a central component to promote health information technology and has the
potential to improve patient safety by reducing medication errors. APhA support the use of eprescribing and agrees that there are benefits to utilizing e-prescribing because of the potential to
increase efficiency, enhance patient safety, and provide users with access to critical patient
information. However, successful implementation requires the resolution of implementation
challenges related to the effective design and utility of the user interfaces for e-prescribing
software systems used by prescribers and pharmacies. E-prescribing is not a fool-proof solution
for preventing prescription order errors. Unfortunately, an increasing number of new errors are
associated with and unique to e-prescribing.
We believe that AHRQ’s focus on e-prescribing is timely given the increasing efforts to expand
the use of e-prescribing through incentive programs authorized in the Medicare Improvements
for Patients and Providers Act of 2008 (MIPPA, P.L. 110-275) and the American Recovery and
Reinvestment Act of 2009 (ARRA, P.L. 111-5). We agree with AHRQ’s description of current,
but limited, research showing that not all e-prescribing systems have the full range of eprescribing features required under MIPPA; that even when the features are available,

APhA Comments to AHRQ on E-Prescribing Study
October 1, 2009

prescribers face barriers to implementing them effectively; and even when they are implemented
at the practice level, prescribers may not use them.
Therefore, we support AHRQ’s efforts to conduct qualitative research designed to collect data on
issues that facilitate or create barriers to the effective implementation and use of e-prescribing.
In addition, we support the focus on how features required under MIPPA are being implemented
and used by prescribers and pharmacists. However, we strongly recommend expanding the
research questions to capture data on the quality of the prescriber and pharmacist user interfaces
built into e-prescribing systems and the quality of the e-prescriptions that these systems generate.
APhA continue to receive feedback from our members on transmission and translation errors
related to e-prescribing. APhA recommends that AHRQ researchers consider the following
issues that continue to limit the effectiveness, safety, and efficiencies of e-prescribing:
• Confusion over what a “certified” e-prescribing software system/vendor means for the
quality of an e-prescribing system.
• Unrealistic views of the quality of e-prescriptions in the current market.
• Significant number of telephone calls from pharmacists to prescribers to address eprescription errors and to seek clarifications.
• Administrative, workflow, and financial burdens on pharmacists/pharmacies to address errors
and to seek clarifications.
• Unfair financial burdens on pharmacies for all transaction fees related to the transmission of
e-prescriptions (original, two-way follow-up, and re-sent/corrected).
• Potential to reduce e-prescribing errors and improve patient safety if the indication of
use/diagnosis is included on e-prescriptions.
• Lack of authority from the Drug Enforcement Administration (DEA) to allow e-prescribing
of controlled substances.
• Ongoing need for feedback data on the quality of e-prescriptions not just the quantity being
transmitted.
• Design issues with computerized physician order entry (CPOE) systems:
o E-prescribing systems may lack initial and/or ongoing user training/support.
o User interfaces contribute to errors.
o Drop down menu functionality errors – wrong drug/dose/directions/pharmacy
selection.
o Transmitted with dual directions – drop down and free text.
o Transmitted with missing patient, prescriber and/or prescription information.
o Final screen review of a complete e-prescription may not be available before
transmission.
o Patient confusion with selection of a pharmacy at point-of-prescribing.
o Transmission fails to arrive at the pharmacy.
o Unintentional transmission to a pharmacy (did not mean to send).
o Transmitted for a controlled substance (not allowed by DEA).
o Limited utilization or functionality of two-way communication between prescribers
and pharmacists (follow-up communications).
• Design issues with pharmacy operating systems:
o Re-keying by pharmacist of all or some of the e-prescription information into the
pharmacy operating system (lack of auto-population).
o Viewing of a complete e-prescription may require multiple screens.

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APhA Comments to AHRQ on E-Prescribing Study
October 1, 2009

o Receiving e-prescriptions for controlled substances (not allowed by DEA).
o Limited utilization of two-way communication between pharmacists and prescribers
due to interoperability and/or transaction fees (pharmacists opt to utilize phone).
Finally, as implementation of e-prescribing moves forward, e-prescribing should not create
additional administrative or financial burdens on pharmacies or pharmacists. In addition, eprescribing should be treated as more than just an electronic transaction (e.g. it is not simply a
one-way transaction like an online bill payment). All efforts to increase the utilization of eprescribing must ensure that systems are in place to protect patient safety and the ongoing health
care interactions among the patient, prescriber, and pharmacist.
Again, we are encouraged by AHRQ’s focus on better understanding the facilitators of and
challenges to the use of e-prescribing systems by prescribers and pharmacists. APhA is willing
to meet with AHRQ to discuss these issues and to help identify ways to capture both the
utilization of e-prescribing and the quality of the e-prescriptions being transmitted from
prescribers to pharmacies.
Thank you for the opportunity to comment on the proposed e-prescribing research project. We
look forward to working with AHRQ on this important issue. If you have any questions or
require additional information, please contact Marcie Bough, Director of Federal Regulatory
Affairs, at (202) 429-7538 or at [email protected].
Sincerely,

Thomas E. Menighan, BSPharm, MBA, FAPhA
Executive Vice President & CEO
cc:

Kristina E. Lunner, Vice President, Government Affairs
Marcie A. Bough, PharmD, Director, Federal Regulatory Affairs

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