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ePrescribing has a compelling value proposition, and your Northern Sierra Rural Health Network e-Prescribing project team (NSRHN) is uniquely positioned to provide solutions that deliver on the promise of reducing medication errors substantially and to improve the efficiency of health care. The e-prescribing initiative will eliminate common errors associated with handwritten prescriptions, including wrong drugs sold because a pharmacist can't read a doctor's writing, and a lack of drug interaction checks.

The goals of the National ePrescribing Patient Safety Initiative (NEPSI), http://www.nationalerx.com/ are to get every U.S. doctor and pharmacy to use e-prescribing software and to eliminate thousands of injuries and deaths in the U.S. each year caused by prescription errors, supporters said at a press conference in Washington, D.C.

Northern Sierra Rural Health Network e-Prescribing project team is positioned to provide solutions that deliver on the promise of the ePrescribing goals. Like any implementation, a key objective is to deploy a production ready system. The goal of implementing your ePrescribing system should be to add value at the point of physician decision-making without adding additional burdens to the physician. This eliminates most of the costly tasks and processes that occur after a script leaves the office, such as clarifying illegible or incorrect scripts. NSRHN ensures that you, the physician and your staff, have a robust, reliable, and appropriately configured production ready system to meet your objectives as well as that of NEPSI.

The objectives of this project are to use electronic prescribing to demonstrate the ability to:

· Reduce prescription errors and Adverse Drug Events (ADEs)

2. What is the e-Prescribing solution of choice for this project? If I have an e-Prescribing platform may I participate in the project?

eRx NOW™ product, developed by Allscripts and available via the NEPSI coalition, is the solution being used for the pilot project. As the project gains momentum and experience, providers with other solutions may participate in Year 2 of the program. However, in order to maximize the benefits of e-Prescribing based on current standards and data availability and transportation methods, it will be advised that ONLY SureScripts certified products will be considered for project activity.

3. Why is eRx NOW™ used for the purposes of the project?

eRx NOW™ is being used for the pilot project as a means of offering a low cost and easily accessible e-Prescribing solution to a large geographic area without incurring substantive costs associated with technical infrastructure and without requiring considerable hardware and software costs to a rural healthcare provider population.

Task	Timeline
Project Organization/Program Management	Month 0 – Month 3
Practice Management Integration	Month 0 – Month 6
Training and Support	Month 3 – Month 9
Provider and Pharmacy Adoption Strategy	Month 6 – Month 12
Pilot Launch Implement e-prescribing solution at six pilot sites	Month 6 – Month 12
Program Roll-Out Roll-out e-prescribing to additional regional sites	Month 12 – Month 24

5. Will there be an evaluation process for this project? If yes, what criteria will be measured?

Yes there will be an evaluation process. Some of the questions which will be addressed in this evaluation are:

· How successful is the pilot program in impacting clinical and other outcomes, such as adverse drug events (ADEs), medication errors, medication adherence/management, and patient satisfaction with using ePrescribing?

· What impact, if any, does ePrescribing have on operational costs, quality, and efficiencies to both providers and pharmacies? More specifically, what impact, if any, does ePrescribing have on operational processes, efficiencies, and costs to provider offices and pharmacies related to:

▪ communications among practices, pharmacies, health plans/payers, patients and others; and,

· What are the shorter-term vs. longer-term benefits and costs associated with implementing ePrescribing to providers and pharmacies? What percentage of providers are actually adopting ePrescribing tools for use in their practices and does this percentage changed over the course of the project? For those providers who have adopted ePrescribing, what percentage of their prescriptions is still written on paper, and what barriers remain preventing 100% electronic prescribing?

· What recommendations do the project’s key stakeholders (e.g., safety net providers, pharmacists, hospital, health plan administrators and payers including Medi-Cal) have in sustaining and spreading this model to other health care delivery settings? What do these stakeholders view as the major challenges and barriers to more widespread adoption of ePrescribing? What specific challenges at the operational level (e.g., conflicting stakeholder incentives, regulatory issues, startup costs, connectivity, standards for information exchange, and integration/interoperability issues with existing practice management systems) would need to be addressed based on the perspectives of providers vs. pharmacists vs. hospital administrators?

· What are the benefits and costs associated with ePrescribing to the Medi-Cal program in terms of costs savings and investments in infrastructure, patient safety, formulary compliance, communications with pharmacies/clinicians, efficiency, and patient satisfaction?

The evaluation will provide recommendations regarding initial standards’ functionality, interoperability with foundation standards, and their impact on workflow, clinical, and other outcomes. Specifically, the primary objectives of the evaluation will be:

· Systematically collect and interpret the evidence (e.g., testing methods and findings) reported by the site

· Determine the initial standards that will be reported to be functional (and those which are not), and

· Document the benefits, challenges, and technical considerations for mass implementation of the initial standards in different settings.

6. What could be the key questions for each components of the evaluation: both functionality of the standards as well as their outcomes and likely impacts?

While evaluating the functionality of the standards, one of the important things is to determine whether the standards allow participants to effectively communicate the necessary information between all participants in the transaction, such as the pharmacy, PBM, router, plan and prescriber. This includes questions like:

· Do the initial standards work well together and with the foundation standards?

· What workarounds will be used, and how can the standards be improved to address them?

· How long does it take to conduct each transaction using the initial standards?

In addition to testing the basic functionality of the standards, a study of a wide variety of outcomes is also important that includes:

· Does eRx affect the number of medication errors and adverse drug events? Does it reduce the rate of hospitalizations and emergency department visits associated with adverse drug events?

· Does eRx improve workflow in prescriber offices (fewer interactions with pharmacies, freeing up support staff time for other functions, more time available for patient interaction)?

The National ePrescribing Patient Safety Initiative (NEPSI) is a new coalition of the nation’s most prominent technology companies and healthcare organizations dedicated to improving patient safety and reducing harmful medication errors.

To accelerate the adoption of electronic prescribing, NEPSI will make safe, simple and secure web-based electronic prescribing software from Allscripts available for free to every physician in America. The NEPSI offering, eRx NOW™, is web-based software from Allscripts powered by the same engine used today by more than 20,000 physicians to write millions of electronic prescriptions each year. Designed to appeal to physicians in solo practice or small groups, eRx NOW™ is available free to any healthcare provider with legal authority to prescribe medications, and requires no download, no new hardware, and minimal training.

NEPSI was developed by a coalition of technology companies, health benefit companies and healthcare providers to help address common barriers to the adoption of electronic prescribing by physicians. The coalition is led by Allscripts (Nasdaq: MDRX), the leading provider of clinical software, information and connectivity solutions that physicians use to improve healthcare, and by national sponsor Dell (Nasdaq: DELL), the world’s leading computer company.

3. How is NEPSI different from other electronic prescribing initiatives announced recently?

The National ePrescribing Patient Safety Initiative is the largest and most significant coalition of key healthcare stakeholders ever to address the issue of medication errors, and the only group to offer a proven solution at no cost to every physician across America. Physicians can trust that NEPSI includes more than a dozen large medical centers, IDN’s and health plans, and other healthcare provider groups from across the country.

Additional important points of differentiation between NEPSI and other electronic prescribing initiatives:

· We are not talking about a complex system – it’s smart, simple, and safe.

· We are not trying to lock providers into a one-vendor solution – we have a solution that works with any Electronic Health Record, Personal Health Record or practice management system from any vendor certified by the Certification Commission on Healthcare Information Technology (CCHIT).

· We are not looking for partners to launch - we already have more than a dozen major healthcare provider organizations across the country that have joined NEPSI as regional supporters to accelerate the adoption and ensure the utilization of electronic prescribing by physicians in their states and regions.

· We are not conducting a trial or experiment – a more complex version of the product is being used today by 20,000 physicians to generate millions of electronic prescriptions across the country.

NEPSI seeks to improve patient safety by transforming the way prescriptions are created and delivered. We believe the time for positive change is now and that removing the key barriers to adoption (cost and set-up) will increase adoption and utilization by physicians, especially those who practice individually or in smaller groups. Additionally, NEPSI’s offering will make it easier for physicians to move down the pathway to full electronic documentation of patient visits with an Electronic Health Record.

The coalition includes the leading organization in every key sector of the healthcare and technology markets. NEPSI is led by Allscripts (Nasdaq: MDRX), the leading provider of clinical software, information and connectivity solutions that physicians use to improve healthcare, and by national sponsor Dell (Nasdaq: DELL), the world’s leading computer company. Other technology companies sponsoring NEPSI are:

A key element of the NEPSI initiative is the participation of a number of the nation’s largest health benefits companies, including Aetna and WellPoint, the nation’s largest payer, and notable regional payers such as Horizon Blue Cross Blue Shield of New Jersey. The coalition’s health benefits sponsors will provide a range of incentives to physicians in their networks to encourage adoption and use of electronic prescribing technology. These health benefits companies believe that electronic prescribing adds quality and efficiency to the patient care process.

To add local presence and expertise, NEPSI also includes more than a dozen of the most prestigious and leading academic medical centers, integrated delivery networks and physician groups representing thousands of physicians across the country. These organizations will serve as regional supporters of NEPSI, leading the delivery and support of electronic prescribing to physicians in their states and regions by providing education, training, incentives and local physician support.

Leading healthcare provider organizations serving as regional supporters of the NEPSI rollout of free electronic prescribing include:

· Delta Health Alliance/University of Mississippi Medical Center, Stoneville, MS

NEPSI’s offering of free electronic prescribing software to every physician in America will finally make safe, accurate and easy electronic prescribing attainable for all physicians, especially those practicing in underserved areas, where the cost of implementing this technology has been a significant barrier to adoption. In addition to the offering itself, NEPSI members are making individual efforts to encourage adoption of eRx NOW™.

Cisco, Fujitsu Computers of America; Microsoft Inc.; Sprint, Inc.; Wolters Kluwer Health,

Horizon Blue Cross Blue Shield of New Jersey, NJ (they are also a provider group);

9. Is NEPSI closed to other sponsors or can organizations/individuals join as a sponsor of NEPSI?

Given how quickly we are moving, we could not include all of the organizations that we are in discussions with today. We expect many organizations to join in this effort to transform healthcare, either on a national or regional level, over the next few months.

eRx NOW™ is a free, comprehensive, easy-to-use web-based electronic prescribing software program that provides a complete medication database and prescription history for physicians, real-time notification of insurance formulary status and real-time connectivity with 99 percent of the nation’s pharmacies. The product’s medication database performs instant checks on drug interactions, dosage levels, prior adverse reactions and other safety metrics. eRx NOW™ meets the National Council for

Prescription Drug Program’s SCRIPT standards, ensuring that communication with a pharmacist is secure and convenient.

11. How is eRx NOW™ different from existing Allscripts electronic prescribing software?

eRx NOW™ is a stand-alone, web-based version of Allscripts existing electronic prescribing solution. The product requires no installation and can run on any computer that has a browser, including cell phones.

eRx NOW™ performs a detailed check of a patient’s prescription against all major types of error: drug-to-allergy, drug-to-drug, minimum and maximum dosage, minimum and maximum duration of therapy, drug-to-gender, drug-to-age, drug-to-food and drug-to-alcohol.

In addition to real-time protections at the point of prescribing, eRx NOW™ prevents errors on the pharmacy side that may occur due to illegible handwriting or filing mistakes.

A major challenge for physicians’ today is that many of their patients are being treated by multiple physicians at the same time. Often, a physician may not know what medications other physicians have prescribed to a patient. eRx NOW™ provides the prescribing physician with the fill history of all prescriptions.

The FDA issues drug recalls, black-box warnings and “dear doctor” letters advising them about new issues regarding prescription medications. When a medication is recalled by the FDA, the software immediately inactivates the medication to prevent new prescriptions from being written. The eRx NOW™ database is updated on a real-time basis to reflect FDA actions such as black-box warnings and “dear doctor” letters. Physicians also can instantly generate electronic reports to determine which patients may have received recall medications. This process is vastly more efficient and faster than searching by hand through thousands of paper charts, which can take up to several weeks.

eRx NOW™ offers physicians and patients the highest levels of security available, with multiple and redundant layers of protection. We are using the same tools and techniques that protect credit card transactions, including firewall, deep packet inspection, SSL encryption, database encryption, intrusion prevention and detection systems, virus, spyware and malware protection for the program’s remote servers. Because all patient information is stored on remote servers in a secure location, patient privacy will not be compromised even if a physician’s computer or phone is stolen. Additionally, to further protect privacy, all patients are given a private identifier that ties their medication record to their physician, and only their physician can access the record. Allscripts is legally required never to divulge to third parties information identified by the federal HIPAA regulations as “personal health information.” And Allscripts has developed an elaborate process for verifying and credentialing physician prescribers.

A breach is highly unlikely, in the same way that access to your bank account information is highly unlikely. However, in the remote chance that a security breach does occur, we have a detailed procedure to notify both physician and patient. The intrusion detection system is able to identify any and all affected patients and physicians.

This system enables us to immediately notify patients and physicians, as well as identify and stop the mechanism of attack from reoccurring.

Yes. Between 14 percent and 21 percent of patients never fill their original prescriptions, and up to 75 percent fail to take their medications as prescribed, according to a study by Merck. eRx NOW™ helps to ensure that prescriptions are filled by sending them directly to the pharmacy rather than leaving that task to the patient. Moreover, most pharmacies will phone patients who do not pick up their filled prescriptions, adding a layer of redundancy to the process. The application also provides patients with medication specific education materials, which have been show to improve therapy compliance

18. Will physicians using eRx NOW™ be able to send prescriptions electronically to any pharmacy in the country?

eRx NOW™ is connected to the Pharmacy Health Information Exchange™. Founded by the pharmacy industry and operated by SureScripts, the Pharmacy Health Information Exchange facilitates the transmission of prescription orders and refills between physicians and pharmacists. Today, more than 95 percent of retail pharmacies are certified for a connection to the Pharmacy Health Information Exchange and approximately two-thirds are live. eRx NOW™ enables physicians to generate faxes electronically to nearly any pharmacy not connected to the Pharmacy Health Information Exchange.

19. Will physicians using eRx NOW™ be able to send prescriptions electronically to pharmacies outside the U.S.?

Using eRx NOW™, physicians can send prescriptions to all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and Guam. The program also enables physicians to generate faxes electronically. While faxes are not as beneficial as computer-to-computer transactions, the capability does allow for a broader universe of recipients. A prescription could be printed by the medical staff and faxed to a pharmacy outside the U.S. And if patients chose, they could receive a printed prescription in the event that they had not yet made up their mind where they wanted to go

The same thing that keeps them for picking up a prescription pad lying around the office – it’s illegal. Given that each physician has a password and some will be using fingerprint identification, it is far more difficult to forge a prescription electronically than with the old paper method.

In certain states, current law authorizes approved medical personnel to send prescriptions electronically to the physician for approval. As allowed by law, Physician

Assistants, Licensed Practicing Nurses or other trusted members of a physician’s staff can create prescriptions under physician supervision, exactly as they do today in the paper system. Unlike the paper system, eRx NOW™ produces a tamper-proof audit trail of every prescription created using the system, enabling practices to track the prescribing habits of each user. This level of security is more comprehensive and safer than the existing paper based system.

· Work with pharmacies and pharmacy vendors to get them on the network and optimize utilization.

· Work with certified physician vendors to get their users on the network and optimize utilization.

· Work with health systems, health plans, state agencies, multi-stakeholder groups and others to coordinate e-prescribing initiatives with pharmacy interoperability.

· SureScripts does not develop, sell, or endorse software: It certifies software to connect to pharmacies.

RxHub® manages the RxHub National Patient Health Information Network™ which electronically routes up-to-date patient-specific medication history and pharmacy benefit information to caregivers at every point of care. This end-to-end solution enables physicians to prescribe the most clinically appropriate and cost effective prescription and send it electronically to the patient’s pharmacy of choice. Operating as a cost recovery business model, RxHub partners with stakeholders in the prescribing industry to improve patient safety, increase workflow efficiency and reduce the overall cost of health care delivery.

Step 1: Patient visits a physician using an RxHub certified technology application.

Step 2: Physician obtains patient consent, First Name, Last Name, DOB, Gender and Zip and submits a request for patient pharmacy eligibility, benefit, and formulary and medication history to RxHub.

Step 3: RxHub uniquely identifies the patient in the master patient index and forwards the request for patient pharmacy eligibility, benefit, and formulary and medication history onto the PBM/Payer who process the patient pharmacy claims.

Step 4: PBM/Payer(s) find patient eligibility, benefit, and formulary and medication history information and send it back to RxHub who forwards onto requesting physician.

Step 5: Physician and patient validate eligibility, benefit, and formulary and medication history information. Physician then prescribes and informed medication and electronically generates the prescription. The patient selects the pharmacy to fill the prescription.

Step 6: The physician routes the electronic prescription to the pharmacy of choice (mail

24. What are the benefits of using RxHub to Patients, Clinicians, Pharmacists and Payers?

· Patients can optimize their prescription drug benefits, choose any pharmacy of their choice, whether it be a retail or home delivery service, and enjoy greater convenience and reduced hassles of prescription delivery.

· Clinicians can use any RxHub certified electronic prescribing tool to improve patient safety – informed by the patients’ prescription drug benefits, and save time in the prescribing and renewal process.

· Pharmacists can increase productivity in the prescription delivery process, delivery the safest possible medical care, and improve quality of patient care.

· Health Benefit Plans can improve formulary compliance, achieve more efficient generic/therapeutic interchange, and reduce administrative time and cost.

Payers will make drug history available only for members of health plans who choose to participate under their existing agreements with payers. Patient information is transmitted with the patient's consent, consistent with the requirements of HIPAA and applicable federal and state laws. At RxHub, security practices are an integral part of our service. We encrypt all transactions in transit over public networks. We employ firewalls and other network security controls. We take steps to secure our internal systems and have designed security into our transaction infrastructure.

Currently, between five and 18 percent of the nation’s 550,000 practicing physicians regularly write prescriptions electronically.

2. Electronic prescribing has been around in one form or another since 1998, and yet fewer than five percent of physicians have adopted it. Why?

One of the original precepts of medicine is “First, do no harm.” Written prescriptions have been around for thousands of years, and physicians are very comfortable with the system. So it is difficult to encourage the investment of time and financial resources in change. The barriers to adoption of electronic prescribing that are most commonly reported by physicians are cost, time required to install and change prescribing behavior, and uncertainty about which local pharmacies accept electronic prescriptions. Again, NEPSI provides the answer to each of those questions with eRx NOW™.

3. What have been the major drawbacks for physicians to adopt electronic prescribing and how does this solution address those issues?

According to a 2002 study published by the American Psychiatric Association, the barriers most commonly reported by physicians are system costs, time required to install electronic prescribing and change prescribing behavior, and uncertainty about which local pharmacies accept electronic prescriptions. NEPSI addresses each of these challenges by providing free web-based electronic prescribing software that is easy to install and use. The eRx NOW™ solution is accessible to any physician with an Internet browser or Internet-enabled phone, requires no downloading or new hardware, and produces prescriptions in a matter of seconds that can be electronically sent and are accepted at thousands of U.S. pharmacies.

4. If physicians are reluctant to take the time to enter prescriptions electronically, can they designate an office manager or nurse to do it for them?

Prescriptions must be written in the manner required by law. Where allowed by law, Licensed Practicing Nurses Registered Nurses, and Physician Assistants can write prescriptions under their own credentials. Generally however, they cannot write prescriptions for controlled substances.

Market research indicates that the majority of physicians who currently do not use an electronic prescribing platform are in office practices of 10 or fewer physicians or are independent primary care physicians or pediatricians. Larger groups are moving directly to invest in a fully functioned Electronic Health Record that includes electronic prescribing.

7. Will Nurse Practitioners and Physician Assistants who have prescribing privileges in their states be eligible for NEPSI?

The average user of eRx NOW™ will be able to master the product in less than 15 minutes. The only technology requirement is an Internet browser. Prescriptions may be completed in a matter of a few seconds. Physicians will have access to free internet training and support.

Physicians can use eRx NOW™ for free with any Internet browser. The estimated 90 percent of physicians who currently have an Internet connection in their offices can use it to connect with eRx NOW.

Although, the benefits of e-prescribing will not be fully realized with fax transmission of prescriptions, computer-generated faxes are another common technology in today's e-prescribing environment in which the prescriber's computer generates an electronic prescription. The prescription is then transmitted to a dispenser's fax machine which prints a hard copy of the original computer-generated fax.

No. A patient will be able to take their prescription form to any pharmacy. If a patient nominates a preferred pharmacy, they can choose to change that nomination if they wish to use a different pharmacy.

While there is no direct interface currently available, NEPSI does supply a Continuity of Care Record (CCR) out of NEPSI that provides medication information that can be imported by any EMR system that is capable of accepting a CCR.

13. What type of market research did you do to determine if physicians would embrace NEPSI?

Allscripts has been in the software business for more than ten years. During that time, the company has listened to thousands of physicians – their concerns, their desires, and what they really want. Today, Allscripts – through NEPSI – has the opportunity to act on that information by delivering a comprehensive solution that solves the problems of the past.

e-Prescribing can help prevent medication errors because each prescription can be electronically checked at the time of prescribing for dosage, interactions with other medications, and therapeutic duplication. E prescribing can improve the quality of care, efficiency, and reduce costs by—

· Actively promoting appropriate drug usage, such as following a medication regimen for a specific condition.

· Providing information about formulary-based drug coverage, including formulary alternatives and co-pay information.

· Speeding up the process of renewing medications by reducing the number of phone calls.

· Providing instant connectivity between the health care provider, the pharmacy, health plans/PBMs, and other entities, improving the speed and accuracy of prescription dispensing, pharmacy callbacks, renewal requests, eligibility checks, and medication history.

The Institute of Medicine of the National Academies of Science estimated in its July 2006 report, “Preventing Medication Errors,” that preventable medication mistakes cost the lives of more than 7,000 Americans each year. The IOM reports that the extra medical costs of treating drug-related injuries conservatively amount to at least $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs, according to the IOM report.

Studies show that so-called “prescription hand-offs” contribute to medication errors. “Hand-offs” are the most common type of prescription fulfillment in which a physician writes a prescription on a prescription pad, gives it to a patient who then takes it to a pharmacist to fill. The Institute of Medicine study showed that much of the error is due to illegible hand-writing and unclear abbreviations and doses. Verbal communication among physicians, patients and pharmacists also contributes to lost or confusing information that can contribute to life-threatening problems.

According to the Institute of Medicine, physicians write more than 3.2 billion prescriptions each year for the 17,000 pharmaceutical brands and their generic alternatives available in the United States.

NEPSI charges sponsors to underwrite the transaction costs of their initiative. In this project the costs are 0.25c per script and will be covered by CHCF for all pilot provider participants for year 1 of the project. It is anticipated that Medi-cal will take on this fee after year 1, if they do not the impact is such that Medi-Cal data will no longer be available. For private payers, Allscripts is moving adoption so that the private payers will pick up the fees moving forward.

SureScripts charges $0.20 or less for the electronic delivery of messages to the pharmacy. This is for ONLY true electronic transactions, not faxes. So if the pharmacy wishes to take advantage of the efficiencies of electronic communication, they can choose to pay that fee. If they do not want to, the script is still created and captured in NEPSI’s system and then either faxed or printed by the provider. This is a fee that is between the pharmacies and SureScripts. We are not getting involved in this. However, we will create awareness with the pharmacies and anticipate that only those who see the business case, turning on the capability….otherwise they will still be able to accept the printed and faxed scripts.

There is an assumption/vision that under the current business model for this initiative that the transactions for the eRX created by the providers becomes not a provider based payment but a payer based payment given the benefits to the payer. Allscripts, as we understand will not charge NSRHN or their pilot providers this fee during the course of the project.

Allscripts views NEPSI as an investment in our future. Given that Allscripts is the leader in electronic healthcare systems for ambulatory physicians, it has assumed a leadership role. Allscripts expects that it will benefit from brand recognition, and physicians who sign up for eRx NOW™ may eventually upgrade to other Allscripts products, including its Electronic Health Records. The company believes the coalition will benefit the entire healthcare IT sector by accelerating the adoption of electronic prescribing, which has traditionally been viewed as the onramp to the health information highway.