Contact: Cara Campbell Senior Policy Analyst, Health Division 202-624-5372; ccampbell@nga.org July 27, 2009 Accelerating the Adoption of Electronic Prescribing Executive Summary Electronic prescribing, or e-prescribing, is computer-based electronic generation and transmission of a prescription. It improves patient safety and quality of care, increases prescribing accuracy and efficiency and reduces healthcare costs by making critical information available to healthcare providers. Implementing strategies to promote e-prescribing will move states toward a higher quality, more efficient health care system. E-prescribing also can serve as an important step in the movement toward fully integrated electronic health records (EHRs) and the electronic exchange of health information. The use of e-prescribing will grow as states and others provide support for e-prescribing. In recent years, states annually have doubled the number of prescriptions sent electronically. If states stay the course, this rate of adoption will reach at least 50% by 2012. 1 With the American Recovery and Reinvestment Act, Congress provides additional momentum towards widespread e-prescribing adoption. The Act establishes incentive programs within Medicare and Medicaid for physicians and hospitals that adopt and use EHRs in a meaningful manner, which includes the use of e-prescribing. However, several challenges have hindered more widespread e-prescribing, such as misalignment of financial incentives and concerns over an adverse impact on office workflow. The prohibition on e- prescribing controlled substances under current Drug Enforcement Agency (DEA) regulations also requires that providers maintain a separate process to manage those prescriptions. Despite these challenges, there is much progress that can be made, and a strong place for e-prescribing in health IT efforts overall. Developing and implementing plans to promote e-prescribing can help governors achieve critical health reform goals: achieving higher quality care and enhancing the delivery of health care services. There are several strategies available to states in promoting an e- prescribing agenda, including: Developing e-prescribing policies; Incorporating e-prescribing into state publicly funded health programs; and Implementing financial incentive programs for e-prescribing.
Page 2 Accelerating the Adoption of Electronic Prescribing What is e-prescribing? E-prescribing enables health care providers to electronically generate and submit prescriptions directly to a pharmacist. An e-prescribing system also allows providers to evaluate a patient s medication history, allergies, possible drug interactions, and drug coverage information (see Figure 1). This can ensure that informed choices are made for patients. Pharmacies can also communicate with physicians through e-prescribing systems to clarify prescription orders and process renewal requests. E-prescribing is conducted by physicians through technology that is available for use within their practice. These include stand-alone e-prescribing systems, which work on a desktop computer, laptop, or PDA, and e-prescribing applications that are part of EHR systems. Implementing a stand-alone system automates the prescribing process and allows physicians to store and manage prescription information, and some physicians have used this as a first step toward broader IT use in their practice. Implementing an EHR that contains e-prescribing has even greater impact by integrating prescription information with other patient data such as medical conditions, allergies and laboratory results to enhance efficiency and care coordination. Cost and required time for implementation can be less for stand-alone systems, however. Stand-alone systems cost approximately $3,000 per physician, which is significantly less than an EHR system at an average of $25,000 $50,000 per physician. 2 Figure 1: E-Prescribing reduces the steps associated with the prescribing process and allows prescriptions to be sent directly to pharmacies E-prescribing relies on a network infrastructure to connect health care providers through their choice of technology to pharmacies, health plans and pharmacy benefit managers (PBMs). A provider s
Page 3 Accelerating the Adoption of Electronic Prescribing connection is built into his or her e-prescribing system, while pharmacies, health plans and PBMs work with network suppliers, such as SureScripts, to process prescription orders and provide drug coverage information. The certification of health IT systems, such as EHRs and stand-alone e-prescribing systems, ensures that well-vetted, secure systems are implemented and that technologies continue to meet increasingly higher benchmarks as certification requirements advance each year. The Certification Commission for Healthcare Information Technology (CCHIT), an officially recognized certification body for health IT systems in the United States, tests EHR products to ensure that they meet its criteria. Among the criteria, products must have the ability to execute e-prescribing. In 2009, CCHIT also is developing certification criteria for stand-alone e-prescribing systems. Advantages of e-prescribing E-prescribing can provide significant benefits: lower costs through better drug utilization, fewer medication errors, fewer coordination issues, and a faster way to transmit prescription information directly to the pharmacy. At a time when rising health care costs and the impact of poor quality are major concerns for states, e-prescribing is a promising approach to reducing or alleviating these concerns. Evidence today suggests that the use of e-prescribing can result in: Reduction in costs. The American College of Physicians estimates over 3 billion prescriptions are written each year and universal adoption of e-prescribing in the United States could save the health care system $27 billion annually. 3 Some of these savings would come from prevention of adverse drug events (e.g., drug errors and drug-drug interactions), while the majority of savings would result from better utilization of drugs, particularly an increase in the use of generics. A 2008 AHRQ study of physicians using e-prescribing found that the physicians increased their use generic prescriptions by 3 percent. 4 Furthermore, it is estimated that e-prescribing systems could reduce drug costs by up to $2.9 million per 100,000 patients per year. 5 Florida, which implemented an e-prescribing program in Medicaid in 2003, has now reported $1.8 $2 million in monthly savings from physicians now using e-prescribing. 6 Florida improved its overall generic use rate and decreased the number of prescriptions by one per patient per month, thereby generating savings in claims. Other participants have demonstrated similar returns on investment. The Henry Ford Medical Group has improved its overall generic use rate by 7.3 percent, which saved $3.1 million in pharmacy costs over a one-year period. 7 Any short term start-up costs associated with widespread adoption of e-prescribing should be quickly offset by significant cost avoidance, as noted above. E-prescribing promises many other potential benefits to physicians, pharmacists, and patients; for example:
Page 4 Accelerating the Adoption of Electronic Prescribing Improved patient safety. Medication errors are the most common type of medical errors. According to a 2006 report by the Institute of Medicine (IOM), at least 1.5 million preventable adverse drug events occur each year in the United States. 8 The clinical decision support capability of e-prescribing, available at the point-of-care, doubles the number of times a possible prescribing error is inspected the first is at the physician level at the point of prescribing, and the second is at the pharmacist level at the point of dispensing. This double-check lessens the dependence on the later review by the pharmacist. According to the Center for Information Technology Leadership, use of e-prescribing and advanced decision-support capabilities could help prevent 130,000 medication errors annually. 9 Improved coordination of care. Four of five patients who visit a physician leave with at least one prescription. 10 Patients with five or more chronic conditions fill more than 50 prescriptions per year. Many patients with chronic conditions also see three or more physicians and report receiving conflicting information from each of those physicians. 11 E-prescribing provides physicians greater information at the point-of-care about the patient s medication history, and enables the physician to determine how a medication may interact with existing illnesses and medications. E-prescribing also can improve patient compliance by enabling pharmacies and physicians to track whether a patient has picked up a medication or whether it has been refilled. Administrative efficiencies. Physicians and pharmacists spend up to 25% of their time clarifying prescription orders and processing renewal requests. This estimate does not take into account lost 12 wages and productivity or additional health care costs. By electronically transmitting prescriptions, e-prescribing reduces the likelihood of pharmacists need to clarify handwritten prescriptions. 13 When prescriptions are electronically transmitted directly to a pharmacy s computer system, staff processing time is reduced and potential for communication failures is avoided. Estimates by the Medical Group Management Association (MGMA) suggest that administrative problems related to prescriptions costs $15,700 a year for each full-time physician. Nationwide, e- prescribing could reduce up to $8.8 billion worth of physician and staff time spent clarifying prescription orders. The pharmacy industry would experience similar savings. The National Community Pharmacists Association estimates that the savings in pharmacy labor costs created by e-prescribing is $0.97 for every new prescription and $0.37 for every renewed prescription. 14 Deciding which strategy will best spur progress in health IT is complex. Many state policymakers wish to see more consistent use of health IT and electronic HIE, and have initiated projects in their states. State projects in e-prescribing may emphasize the technology as a pathway to other health IT systems or electronic HIE. States also may focus on e-prescribing because it is a more manageable undertaking, and e-prescribing can be more quickly disseminated and adopted than other health IT systems.
Page 5 Accelerating the Adoption of Electronic Prescribing In planning, states must recognize that e-prescribing use is not guaranteed among physicians who adopt EHRs. Evidence has shown that physicians often do not use all of the functions of an EHR, particularly e-prescribing. Recent estimates still put e-prescribing use at less than one in 10 physicians. 15 Therefore, specific projects promoting e-prescribing can be an important and valuable tool in any effort to move toward full realization of the benefits of health IT and electronic HIE. Support for e-prescribing In recent years, e-prescribing has gained momentum at all levels. Many were introduced to the issue in July 2006, when the Institute of Medicine, directed by Congress, crafted a national agenda for reducing medication errors with a recommendation that all providers use e-prescribing systems and all pharmacists receive prescriptions electronically by 2010. 16 Consequently, many stakeholder groups, including policymakers, physicians, pharmacies, health plans and consumers worked to promote the adoption of e-prescribing through both financial and technical commitments. State initiatives to encourage e-prescribing are maturing. Currently, e-prescribing is doubling annually in every state, and all states have had some level of transmission over the past four years (see Figure 2). Governors and state legislators have used various approaches to promote e-prescribing. They are addressing policy barriers, implementing incentives, and using regulatory and contract authorities to support efforts. Much like the national discussion on health IT and e-prescribing, states are working to find a middle ground that promotes e-prescribing while still encouraging physicians to keep updating their systems and workflows until they adopt and use an EHR system that also does e-prescribing. 17
Page 6 Accelerating the Adoption of Electronic Prescribing In 2008, both the National Governors Association (NGA) and National Conference of State Legislatures (NCSL) adopted e-prescribing resolutions. Through these resolutions, they encourage states to adopt a goal for e-prescribing adoption. Further, NGA calls for states to aim at annually doubling the rate of eligible prescriptions sent electronically, as well as increasing the number of pharmacies and providers that are e-prescribing capable. The federal government also is working to promote e-prescribing. Under Medicare s prescription drug benefit for Medicare beneficiaries (Part D), health plans are required to support physicians and pharmacies that voluntarily choose to use e-prescribing. In 2009, Medicare also began offering incentive payments to physicians who e-prescribe. The incentives start at 2 percent increased reimbursement for two years, and phase out over time until reimbursements are decreased by 2 percent for physicians who still are not using e-prescribing. Furthermore, the American Recovery and Reinvestment Act, passed by Congress in February 2009, includes the Health Information Technology for Economic and Clinical Health (HITECH) Act. The goal of HITECH is to promote the use of health information technology (IT); in the Act, Congress established new Medicare and Medicaid programs that will provide incentives to physicians and hospitals to use EHR technology. For health care providers to qualify for the programs, the law requires that they make meaningful use of IT. Solidifying the importance of e-prescribing in the context of health IT adoption and use, meaningful use requires that eligible physicians and hospitals use e-prescribing. Often physicians are interested in e-prescribing for its ability to improve office efficiency and patient safety. Many physician associations are working together at the national level to promote e- prescribing. Thirteen groups support a Web site that guides physicians through evaluating and acquiring technology that supports e-prescribing, and also helps physicians and other health care professionals assess the financial impact of e-prescribing. 18 Pharmacies across the country also are investing in e-prescribing by upgrading hardware and software, training pharmacy staff and raising consumer awareness. More than 95 percent of pharmacies in the United States are equipped for e-prescribing and connected to SureScripts, and approximately 75 percent actively process e-prescriptions (see Figure 3). 19 Pharmacies are working to raise awareness about e-prescribing through a consumer-oriented Web site and national marketing campaign. In April 2008, a Web site was created by 10 major pharmacy chains, including CVS, Duane Reade, Walgreens, and Wal-Mart to explain e-prescribing to consumers. Among other features, the Web site allows consumers to enter a ZIP code and find physicians and pharmacies that support e-prescribing.
Page 7 Accelerating the Adoption of Electronic Prescribing Figure 3: E-prescribing pharmacies Source: SureScripts, 2008 Health plans and employers are using payment and policy levers to promote e-prescribing. A number have sought to link e-prescribing to eligibility for pay-for-performance programs and provided direct financing for e-prescribing. The programs recognize and reward physicians for meeting certain quality and safety goals. Some offer incentives to physicians who meet an e-prescribing threshold, and others subsidize the upfront costs of e-prescribing and provide ongoing support to physicians using it. Barriers Remain With much of the infrastructure and standards in place to facilitate e-prescribing, it is becoming more mainstream. However, barriers remain that must be addressed before the full potential of e-prescribing can be realized. The most significant of these barriers are: The business case for e-prescribing is not clear for providers. Only 10 percent of U.S. physicians use e-prescribing. In 2008, an estimated 68 million prescriptions were routed electronically between physicians and pharmacists across the U.S, a small fraction of the estimated 1.45 billion prescriptions and renewals that were eligible. 20 Even physicians using EHRs are often not using the available e-prescribing component. Misaligned financial incentives, limited reliable
Page 8 Accelerating the Adoption of Electronic Prescribing purchasing guidance, adverse impact on office workflow and expense contribute to the slow adoption of e-prescribing by physicians. Some communities have limited access to e-prescribing. States with large numbers of independent pharmacies have seen slow adoption of e-prescribing. Exacerbating the challenges of buy-in and expense is the lack of broadband service in some areas. Rural pharmacies and physicians may lack the ability to conduct e-prescribing. In fact, connecting to e-prescribing through reliable broadband is not an option for up to a third of rural practices. 21 Federal laws and regulations prohibit controlled substances from being prescribed electronically. E-prescribing is not allowed for controlled substances under regulations promulgated by the Drug Enforcement Administration (DEA). In 2008, 359 million prescriptions issued for controlled substances were not eligible for e-prescribing because of the DEA rules. This has stopped many providers from e-prescribing, as they are reluctant to switch between e- prescribing for some drugs and paper prescribing for controlled substances. In 2008, DEA issued a proposed rule to allow controlled substances to be e-prescribed, and public comments on the proposed rule were due in September 2008. Many stakeholders expressed the view that the proposed rule was too restrictive and, in some cases, too expensive for providers to absorb. DEA is currently developing a final rule that will be available in the near future. State Strategies to Spur Adoption Developing and implementing plans to promote e-prescribing can help governors achieve critical health reform goals: achieving higher quality care and enhancing the delivery of health care services. There are several strategies available to states in promoting an e-prescribing agenda, including: Developing e-prescribing policies; Incorporating e-prescribing into state publicly funded health programs; and Implementing financial incentive programs for e-prescribing. Developing e-prescribing policies States are able to bring together a wide range of health care stakeholders to inform e-prescribing activities and to promote greater collaboration. Several governors have built support for e-prescribing by establishing entities to implement e-prescribing policy recommendations. Some have launched communications campaigns to build awareness. Others have implemented regulatory changes, such as a requirement for e-prescribing adoption. Tennessee Governor Phil Bredesen launched e-prescribe Tennessee to advise and support the state as it implements a strategy for e-prescribing adoption. The organization includes a steering committee, advisory committee and specific working groups made up of stakeholder volunteers. A major part of
Page 9 Accelerating the Adoption of Electronic Prescribing Tennessee s e-prescribing strategy is a grant program that has assisted 2,000 providers in purchasing IT systems. Florida also established a publicprivate partnership to promote and otherwise support the adoption of e- prescribing. In addition, Florida aimed to improve public awareness through a new Web site with information on the technology and its benefits. The Florida e-prescribing clearinghouse is a collection of e- prescribing resources, including information on developments and trends in e-prescribing. The overall goal of the initiative is promoting the adoption of e-prescribing in the state. New Mexico s Medicaid program is participating in an e-prescribing pilot program designed through the collaborative efforts of public and private health plans and community health organizations. This program is designed to implement e-prescribing with 100 physicians sponsoring the cost of implementation and subscription fees through 2009. Additionally, New Mexico Medicaid is interested in sponsoring rural, nonprofit physicians to adopt e- prescribing. New Hampshire s governor issued an executive order in 2006 to have all healthcare providers implement e- prescribing by October 2008. The project coordination to support the order was carried out by the NH Citizens Health Initiative. New Leading the Way: A Look at Comprehensive Approaches Rhode Island and Minnesota have developed extensive e-prescribing initiatives with multiple activities, including establishing entities to manage this issue, educating physicians and consumers, implementing financial incentives for physicians and requiring everyone to use e-prescribing. Their approach has helped get physician adoption beyond its average point in most states. Rhode Island for many years has had more physicians using e-prescribing than any other state aside from Massachusetts. At the foundation of Rhode Island s e-prescribing success is a publicprivate partnership comprised of many organizations. This committee has worked on many initiatives, such as vendor communication, which involved requesting information from EHR vendors on how they make their e-prescribing available to providers; also, professional education, including an e-prescribing conference featuring a panel of physicians who use e-prescribing; and purchasing, where health plans provided incentives conditioned upon health IT adoption. The state government provides statewide leadership and plays a role in purchasing and consumer education, including publicly reporting physicians who are actively e-prescribing on the Department of Health s Web site. Political support provided by Rhode Island s policymakers and health professional boards has been important to priority-setting in the e- health arena. Governor Donald Carcieri announced e-prescribing as part of his Anywhere, Anytime Health Information platform and set a goal of 75 percent of all prescriptions be completed electronically. In addition, both the Rhode Island Board of Medical Licensure and Discipline and the Rhode Island Board of Pharmacy have developed policy statements that support the adoption of e- prescribing. It is their position that e-prescribing can promote the overall quality, safety, and efficiency of healthcare.
Page 10 Accelerating the Adoption of Electronic Prescribing Hampshire has seen a 437% increase in adoption between the time when the executive order was issued and May 2009. All major payers save one have been connected, including Medicaid. Similarly, Massachusetts enacted a law in 2008 that requires hospitals and community health centers to implement federally certified computerized physician order entry systems by October 2012, and requires them to implement certified, interoperable EHR systems by October 2015, in order to receive or retain their license to operate. Incorporating E-Prescribing into State Publicly Funded Health Programs States can make a significant investment in e- prescribing by leveraging state-administered healthcare programs, including Medicaid, the state employee health plan and public health. In fact, the approach seen most frequently in states is to establish programs within their state healthcare programs. In a 2007 NGA survey, 18 states indicated that e- prescribing activities had been implemented within at least one public program, predominantly in Medicaid. 22 There are many areas where Medicaid represents a natural leverage point for investments in e- prescribing. Medicaid s sizeable influence in certain provider settings, the significant IT investments made through the Medicaid Management Information Systems (MMIS) and Medicaid Transformation Grants, and most importantly, its role in supporting the health of U.S. citizens in need, positions Medicaid as an essential place to accelerate the adoption and use of e-prescribing. Leading the Way: A Look at Comprehensive Approaches, continued Minnesota Governor Tim Pawlenty also has stated his support for e-prescribing. In 2007, he announced that the state would implement e-prescribing for 115,000 state employees and their dependents. The Department of Finance, which oversees the state employee health plan, has implemented an e-prescribing program and consolidated to a single PBM, expecting to save $5 million per year from this initiative. Minnesota also is requiring that all hospitals and health care providers implement e-prescribing by January 1, 2011, and interoperable EHRs by January 1, 2015. The strategy to achieve success and meet these deadlines is delegated to a statewide advisory committee comprised of public and private stakeholders. This committee has produced a statewide implementation plan, which outlines a model for adopting technology and offers recommendations to all participants, including policymakers, health plans, providers, and trade associations. Minnesota also has made investments in the implementation of e-prescribing. In 2007, the governor signed a bill to provide $14 million to assist rural health care providers and community clinics in meeting the state s e- prescribing and EHR mandates. Increasingly states are expanding Medicaid s IT systems into areas such as e-prescribing. For years, Medicaid agencies have invested in electronic claims processing and information retrieval and reporting systems, called MMIS. Now by linking with an e-prescribing network, MMIS can enable Medicaid physicians to more easily transition to e-prescribing. Many state Medicaid programs are connected to the SureScripts network, or are in planning stages (see Figure 4). The state Medicaid
Page 11 Accelerating the Adoption of Electronic Prescribing programs currently connected for e-prescribing are Arkansas, California (Medi-Cal), Delaware, Michigan, New Hampshire, New Mexico and Nevada. Connecticut, Pennsylvania and South Carolina are in the process of connecting. In addition to connecting to an e-prescribing network, states are providing resources to assist Medicaid physicians to adopt e-prescribing. Florida and Delaware have developed programs to supply personal digital assistants (PDAs) free to high-volume Medicaid physicians. The PDAs come with software that performs e-prescribing. The systems also provide access to medication history, Medicaid drug lists, drug utilization reports and drug pharmacology information. Florida also later made the software available to additional Medicaid providers in Florida, upon request, for use on desktop or tablet computers. Similarly, Missouri provided e-prescribing and an EHR to all its Medicaid physicians. The CyberAccess system, launched in 2006, has e-prescribing in the same portal used for Medicaid s claims-based EHR. Figure 4: Medicaid e-prescribing connectivity Medicaid MMIS Processor Relationship Alaska Washington Hawaii Production - MedMetrics - SXC Implementation - First Health - ACS Contracted - EDS Oregon Nevada California Idaho Utah Arizona Montana Wyoming Colorado New Mexico North Dakota Minnesota New Hampshire South Dakota Wisconsin New York Massachusetts Michigan Rhode Island Connecticut Nebraska Iowa Pennsylvania New Jersey Ohio DC Illinois Indiana West Virginia Delaware Kansas Virginia Missouri Kentucky Maryland North Carolina Oklahoma Tennessee Arkansas South Carolina Mississippi Alabama Georgia Louisiana Texas Florida Vermont Maine Discussions - CSC - GHS - Unisys State Administered * Near-term RxHub Connectivity: New Mexico, Delaware, Arkansas, California and others Source: RxHub, 2008
Page 12 Accelerating the Adoption of Electronic Prescribing Implementing Financial Incentive Programs A direct way of encouraging physicians to adopt and use e-prescribing systems is through funding initiatives enabled by appropriations, grants, tax incentives and loans. States are directly funding community initiatives to help alleviate costs associated with hardware purchased by healthcare providers. Kentucky and New York have created grant programs to assist with purchases in the community. Most practices and clinics that received grants in Kentucky used the funds to implement EHR systems with an e-prescribing component. States, such as Pennsylvania, plan to implement incentive programs similar to Medicare, which starts at 2 percent additional reimbursement for two years and then phases out over time. Pennsylvania s program will gradually phase out and be replaced by fee reductions to providers who do not use e- prescribing. Pennsylvania specifically defined what qualifies as successful e-prescribing, the requirement that physicians must meet in order to qualify for Pennsylvania s incentives. A "successful e-prescriber" is an eligible professional who reports using a qualifying electronic prescribing system for at least 50 percent of the prescriptions written. Tennessee implemented a pilot project that gave IT systems to primary care physicians in small rural counties to allow them to utilize e-prescribing. The program also provided physicians with training and technical assistance to assure a smooth transition to e-prescription. Conclusion The Health Information Technology for Economic and Clinical Health (HITECH) Act sets a new direction that greatly expands the roles of states in utilizing HIE and the adoption of health IT. HITECH also clearly emphasizes e-prescribing. As such, there remains a critical need to provide support directly for e-prescribing. Recent growth shows that steps taken by states to promote e- prescribing are having an impact. States can leverage their leadership now to ensure the modernization of this aspect of health care. By providing support through developing e-prescribing policies, incorporating e-prescribing into publicly funded health programs, and implementing financial incentives for e-prescribing, states will have a major impact on accelerating e-prescribing adoption.
Page 13 Accelerating the Adoption of Electronic Prescribing 1 State Alliance for e-health Call to Action for NGA, State Alliance for e-health, May 2008. Available at: h ttp://www.nga.org/files/pdf/0805ehealthstatement.pdf 2 Electronic Prescribing Becoming Mainstream Practice, ehealth Initiative and The Center for Improving Medication Management, June 2008. Available at: http://www.ehealthinitiative.org/assets/documents/ehi_cimm_eprescribing_report_6-10-08_final.pdf 3 Written testimony of the American College of Physicians. Presented to the National Committee on Vital and Health Statistics Subcommittee on Standards and Security, May 2004. Available at: http://www.acponline.org/advocacy/where_we_stand/health_information_technology/erxfin.pdf 4 Fischer, Michael, MD, MS, Christine Vogeli, PhD, et al, Effect of Electronic Prescribing with Formulary Decision Support on Medication Use and Cost. Archives of Internal Medicine 168(22), pp.2433-2439. December 2008. 5 Ibid. 6 Testimony of Christopher Sullivan, PhD, Florida Agency for Health Care Administration, at the CMS E-prescribing Conference, October 2008. Available at: http://207.114.10.22/e-prescribe/presentations/e-prescribingandmedicaid/e- PrescribingAndMedicaid-Sullivan14.HTM 7 Ibid. 8 Preventing Medication Errors, Institute of Medicine (Washington, DC: National Academies Press, 2006). 9 The Value of CPOE in Ambulatory Settings, Center for Information Technology Leadership, 2003. Available at: http://www.citl.org/research/acpoe_executive_preview.pdf 10 Electronic Prescribing, ehealth Initiative, 2004. 11 Key Capabilities of an Electronic Health Record System, Committee on Data Standards for Patient Safety, Board on Health Care Services of the Institute of Medicine (Washington, DC: National Academies Press, 2003). 12 Preventing Medication Errors, Institute of Medicine (Washington, DC: National Academies Press, 2006). 13 E-Prescribing, The California Health Care Foundation, November 2001. Available at: http://www.chcf.org/documents/hospitals/eprescribing.pdf 14 Rupp, Michael, E-Prescribing: The Value Proposition. America s Pharmacist. National Community Pharmacists Association, April 2005. 15 Electronic Prescribing Becoming Mainstream Practice, ehealth Initiative and The Center for Improving Medication Management, June 2008. Available at: http://www.ehealthinitiative.org/assets/documents/ehi_cimm_eprescribing_report_6-10-08_final.pdf 16 Preventing Medication Errors, Institute of Medicine (Washington, DC: National Academies Press, 2006). 17 E-Health Initiative. Available at: http://www.ehealthinitiative.org/erx/policystate.mspx 18 Get Connected Program, The Center for Improving Medication Management, March 2008. Available at: www.getrxconnected.com 19 2008 National Progress Report on e-prescribing, SureScripts. 20 Ibid. 21 Rural Broadband Internet Use, Pew Internet and American Life Project, June 2009. Available at: http://www.pewinternet.org/media-mentions/2009/us-broadband-report-more-popular-more-expensive.aspx 22 Smith, Vernon, et al. State e-health Activities in 2007: Findings from a State Survey. The Commonwealth Fund, National Governors Association, and Health Management Associates, February 2008. Available at: http://www.commonwealthfund.org/usr_doc/1104_smith_state_e-hlt_activities_2007_findings_st.pdf?section=4039