E-Prescribing Workflow

Complete electronic prescribing workflow from provider order through pharmacy fulfillment, including safety checks, PDMP queries, and controlled substance handling

Flow

E-Prescribing Workflow

Complete workflow for electronic prescribing from provider order through pharmacy fulfillment, demonstrating safety checks, regulatory compliance, and patient safety measures.

Workflow Overview

This flow illustrates the sophisticated process of e-prescribing in the US healthcare system, including:

  • PDMP Integration: Controlled substance monitoring
  • Clinical Decision Support: Multi-layered safety checking
  • Formulary Checking: Insurance coverage verification
  • NCPDP SCRIPT: Standard electronic prescription transmission
  • Pharmacist Review: Independent safety verification
  • Patient Counseling: Medication education

Key Safety Layers

1. Controlled Substance Screening (DEA/PDMP)

  • PDMP Query: Required before prescribing opioids (varies by state)
  • Red Flags: Multiple prescribers, overlapping prescriptions, “doctor shopping”
  • MME Calculation: Morphine Milligram Equivalent monitoring
  • Concurrent Medications: Opioid + benzodiazepine alerts

2. Clinical Decision Support

  • Drug-Drug Interactions: First Databank database
  • Drug-Allergy Checking: Against patient allergy list
  • Dose Range: Validate min/max dosing
  • Duplicate Therapy: Same medication or drug class
  • Renal/Hepatic Dosing: Adjust for organ function
  • Pregnancy/Lactation: Contraindication checking

3. Formulary & Benefits

  • Real-Time Benefit Check (RTPB): Live insurance verification
  • Formulary Status: Tier 1-3, non-formulary
  • Prior Authorization: Identify requirements upfront
  • Cost Transparency: Patient copay information
  • Alternatives: Suggest covered alternatives

4. Pharmacist Verification

  • Independent Review: Pharmacist clinical judgment
  • Prescriber Communication: Resolve concerns
  • Patient Counseling: Medication education

NCPDP SCRIPT Messages

NewRx (New Prescription)

Electronic transmission of new prescription to pharmacy

RefillRequest

Pharmacy-initiated refill request to prescriber

RxChangeRequest

Pharmacist requests modification (dose, quantity, etc.)

RxChangeResponse

Prescriber approves or denies change

FillStatus

Pharmacy notifies EHR of dispensing

CancelRx

Prescriber cancels prescription before fill

Controlled Substance Compliance

EPCS (Electronic Prescribing for Controlled Substances)

  • Two-Factor Authentication: Required for provider
  • Identity Proofing: Initial enrollment verification
  • Logical Access Controls: Role-based security
  • Audit Trails: All access logged (DEA requirement)

DEA Schedules

  • Schedule II: No refills (Oxycodone, Fentanyl, Adderall)
  • Schedule III-IV: Up to 5 refills (Hydrocodone/APAP, Xanax)
  • Schedule V: Up to 12 refills (Cough syrup with codeine)

State PDMP Requirements

  • Mandatory Query: Many states require PDMP check before opioid Rx
  • Query Timing: Often required every 90 days for chronic prescriptions
  • Documentation: Query results documented in chart

Common Prescription Scenarios

Scenario 1: Routine Antibiotic

  • No PDMP query needed
  • Safety checks (allergy only)
  • Typically formulary
  • Quick transmission
  • Filled within hours

Scenario 2: Controlled Substance (Opioid)

  • PDMP query required
  • Enhanced safety screening
  • MME calculation
  • Provider documentation
  • Potential for prior authorization
  • Pharmacist extra diligence

Scenario 3: Expensive Specialty Medication

  • Non-formulary likely
  • Prior authorization required
  • Specialty pharmacy routing
  • Patient assistance programs
  • Extended approval timeline (days)

Technology Standards

  • NCPDP SCRIPT 2017071: E-prescription messaging
  • RxNorm: Medication terminology
  • NDC: National Drug Codes
  • First Databank: Drug database and checking
  • ASAP (SCRIPT): Secure transmission network

Performance Metrics

  • Prescription Send Time: < 5 seconds
  • Safety Check Latency: < 2 seconds
  • PDMP Query Time: < 10 seconds
  • Pharmacy Receipt: Real-time (seconds)
  • Fill Time: Varies (1 hour - several days)

Patient Experience

  • Convenience: Prescription sent electronically, no paper
  • Safety: Multiple safety checks protect patient
  • Cost Transparency: Know copay before filling
  • Choice: Select preferred pharmacy
  • Reminders: Refill reminder notifications
  • Access: View prescription in patient portal

Provider Benefits

  • Efficiency: No phone/fax to pharmacy
  • Safety: Integrated CDS
  • Formulary Info: Know coverage upfront
  • Medication List: Automated updates with fills
  • Prior Auth: Electronic submission
  • Audit Protection: Documentation of decision-making

Pharmacy Benefits

  • Legibility: No handwriting errors
  • Completeness: All required fields
  • Early Notification: Prepare before patient arrival
  • Efficiency: No phone clarifications
  • Inventory: Anticipate demand

Quality & Safety Improvements

Traditional paper prescribing had significant issues:

  • Illegibility: Handwriting errors caused harm/death
  • Incomplete: Missing information common
  • Formulary Blind: Provider didn’t know coverage
  • No CDS: Manual checking only
  • Slow: Patient had to transport paper

E-prescribing addresses all these issues with:

  • ✅ Digital transmission (no illegibility)
  • ✅ Required fields enforced
  • ✅ Real-time formulary checking
  • ✅ Automated safety screening
  • ✅ Instant delivery

Regulatory Requirements

  • DEA: EPCS for controlled substances
  • Medicare Part D: E-prescribing mandated (with exceptions)
  • Meaningful Use: Incentive programs required e-Rx
  • State Laws: Vary by state (some mandate e-Rx)
  • Lab Order Workflow
  • Patient Admission
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