Here in Illinois we just became mandated to print all prescriptions on security paper for medicaid and medicare. I know some of you have been doing this longer. I have mediscripts security Rx pads, that I can get for free.
I had been working on trying out a solution to this using my mediscripts pads, but I have not found any of the prescription templates to work well. When I go to adjust them I can never quite get them right (things always move down and right and not up and left.)
I then came up with the idea of printing 4 on a page (I use mosly HP5Ps)with the standard Rx template which puts things in a good place except it prints the office name over where it is on the prescription pad.
The font, needless to say, is VERY SMALL. I hate to say it, but that is the pharmacies problem, not mine.
I have been getting the fax numbers to the various pharmacies and can fax through the server but for those I do not have, this is a short term substitute.
Anyone come up with a better solution?

Wendell,
First try and contact the right people at your state who are in charge of this program and get in touch with the guy or gal who is actually in charge of the EMR version of your new Rx and formats. I found this person in NYS years ago and it made life much easier for Jon and company to then create things for us here in our state.

Then I put the two sides together and Jon took it from there so now all NYS folks have the properly formatted Rx's. Obviously this will take them a while to get together but it is something they need to do anyway for you and many other users. So take the lead, Jon will apperciate it and hopefully in a few months you too can have your state Rx's formatted as you need them.....

FYI, here in NYS we are wasting 3/4's of a page using one Rx to a sheet to have it properly print NYS format on their supplied paper just like you. So make sure your state keeps suppling the paper for you or it could cost you big time later on down the road. We are just waiting here in NYS to have them pull this trick on us sometime soon. Good luck to you and AC....
Paul

We also are required to do with with Medicaid here in WA. We are faxing for now except for controlled substances.

Otherwise we print as usual using security paper.

Paul,
I wouldn't have a problem if the state was supplying paper. This is an unfunded mandate. I am using regular prescription pads from Mediscripts you get for free.

So, Wendell, do you get these free prescription blanks in the form of loose sheets, or are they glued into a pad, and you have to peel them off one at a time?

What kind of a printer are you using?

They are in pads, but you can pull 10-20 off at a time and just fan them.
I use HP 5P's in the office. I got them refurbed at a good price. The Rxes work fine in the manual feed tray in the front.

Just noticed this statement.

You can go up and left. You have to put a minus sign before the numeral.

For example:
1440 = 1" right
-1440 = 1" left

If this doesn't work, Wendell, the next step is we need to contact Jon and see if we can him to put a few new templates in version 3.7 before release. These would not have any practice information on them, just the drug info maybe, and they would be in a few standard sizes of pre-printed prescriptions. What do you think?

I can tell you from a ton of experience that the minus sign doesn't work. If it worked for you, that is great; but it has never worked for me.

I use the Star TPS800, and it is the best thing we ever put in. You can print right to tamper-proof paper. The best part is we don't make any more errors writing out controlled scripts, and it is MUCH faster.

A side effect of this is that you always have the same 4 by 6 inch scripts. It's impossible to go back and forth -- I have asked. So, when you do print out scripts, you use one sheet of paper per script. You also lose your electronic signature on the bottom, and some crazy pharamcies won't take them even though it doesn't mean anything. There is an easy workaround which is to change your name in the Users section to FName Digitally signed by and LName to your full name. It even shows up on letters like this so you don't have to sign them.

We fax all of our scripts like this from the room. We certainly don't print to expensive 2.4 cents per script for amoxicillin and MiraLax.

You must use the TPS 800 script size (the #1). Any questions, please PM me.

Also, in the AmazingMeds sheet, we name the medicationn:

Concerta tablets 36 mg Dx: ADHD so we never forget to put the diagnosis on. We just have to remember the 30 thirty, but that's the advantage because once you get them all in AC, you don't tend to leave it out.

Aargh. You are kidding me. I have never needed to try it. I just though Wendell might have overlooked it.

Well, dang! That's what needs to be fixed then!

Here's the priority list:
1. Fix the position adjuster on the Prescription Writer.
2. Create a prescription form that allows you to write on the free prescription pads we get. That's the cheapest and best solution.

The NYS set-up has the "30-Thirty" quantity thing in it already because that was a big hang-up for us. So if that set-up works for you perhaps you can use NYS. Or at least Jon has already sort of tackled this one, so one would hope it would be easy enough to put it in another format if you still need one created for your situation.

I would seriously suggest that you at least look at and play with all the various state formats that are in the admin section to see which one might fit you best. And if not, call AC and pester them to create one for your state. You are certainly not the only AC user in your area that is going to need this.

What I am saying is that many of us may be able to get security pads FREE from various sources. This could save us a lot of money! Aren't all of us struggling to keep costs down?!?

BUT - in order to use them, we need a special prescription template that allows us to use pre-printed pads!

This is not hard to do!

The simplest approach would be to have one template, which prints all of our information in a fairly compact space, say 2.5 x 3 inches. This would give a lot of wiggle room for the printed material to clear all the stuff that is already printed on the pad.

• You would want to leave the practice header and the signature lines off, since they're already printed on the pad.
• The type might need to be small. As Wendell said, "So what?" It's still clearer than your average hand-written Rx.
• You would want to have a good amount of space after the line with patient's name and DOB, to give you room for adjustment to make their name fall on the pre-printed line.
• You would have to have a portrait and landscape version, to give people more flexibility.

But for this to work, the little twip-adjustor thingy has to work!

I wish we could design our own prescription templates. I used to work in graphic design. People could just fax me their prescription pad and I could design them a template. Sigh...

The New Jersey format is close, and would probably work if the adjuster worked properly. It is a larger font than running it in 1/4 mode (4 on a page.) I too have done some graphic design, but
again the adjuster needs to go up and left for it to be useful.

Oh, I stated before I was using a 5P but actually they are HP 6Ps, which are much better than 5Ps (I had several 5Ps that were junk, never had a problem with refurb 6Ps)

I have found thta since only 0.0000001% use that feature and Vinny didn't even know it existed at least to its use (and maybe I am quoting him incorrectly), that it will never be looked at.

I have also found at least in Maine, they don't seem to care what format is used as long as all the info is on the script and it is tamper proof.

May I suggest something? Now granted it will cost more money than free prescription pads. I don't quite see how you will get something to print on them

Why reinvent the wheel. The Star TPS800 printer is designed to thermally print these prescriptions to perfectly designed 4" by 6" paper that is usually the standard. They are tamper proof and, generally, accepted in all 50 states. Once set up correctly, you can print PERFECT scripts all day long. While I guess you could do this a different way with graphics and twips, it is awesome to see two kids with four different Focalin XRs and print them off in less than two minutes. When we wrote them out, I would have made at least two errors, it would have taken me over five minutes, and the pharmacy would not have been able to read at least one.

And, the support guy for TPS800 is awesome. You can even get a locked version for the rooms if you have any patients which would be tempted to steal some, but I doubt anyone would have any patients like that. Right!

Bert's correct, his little tiny printers are awesome. They were a cinch to set up too.

Did anybody notice this?

http://www.amazingcharts.com/beta/

V3.7.7 Beta 4/12/2008

• Added ability to search for patients who have not had a specific lab performed
• Enhanced large text box to allow moving from field to field through note
• Fixed missing time stamp in some chart fields
• Fixed email buttons to resize better within the Desktop window
• Fixed interim message label in message frame which was sometimes partially obscured
• Fixed limitation in limit to nudging scripts down and left

Thanks, Jon!

Beta may removed limitation on values but it still does not go up and right (negative values don't work as promised.)

Well, this is evidence that Jon is digging into that portion of the program at the moment. We need to use the bug reporting feature on the beta and send a message that we need the repositioning function enabled!

I thought it was cool, but I don't need it now. I do know that printing in portrait mode using the Star TPS setting and using the Star TPS print works perfectly.

I live in Missouri and April 1st was the big day.
Have you considered eprescribing? There is a free service through the NEPSI-National Electronic Prescribing and Patient Safety Initiative. http://www.nationalerx.com/
You can send all the scripts directly to the pharmacy except for controlled substances. For those I still am using mediscripts. The website has a resource for laser or inkjet paper that does not require the purchase of another printer

PS I have been told that eprescribing is going to be "free" in AC with the next upgrade.

Vicki Roberts, MD
Family Medicine of Southeast Missouri

vicki,

Thanks for the post and welcome to AC. ePrescribing has been kicked around for some time now. I think possibly in 4.0 ePrescribing will take a big job in usefulness.

The whole KEY to it would be that ePrescribing would have to interface with AC or it would be a double entry each time.

Welcome again.

Did we ever get anywhere with this problem, Wendell?

I have a lot of free security paper prescription pads now, and I would like to try printing on them if I could.

I think you are going to have trouble printing on them. And, you will have to accept printing all prescriptions on that size paper as you can't go back and forth. The TPS800 is awesome, but you would have to pay for the paper.

I am using the New Jersey prescription format and it prints the name and address on the top of the main section.

None of the pharmacies has had an issue with it, especially the pharmacies that received my 1/4 size font prescriptions. (Everything lines up perfectly if you go 4 pages to 1 on the printer preferences for the HP6p, but the font is about size 4.)

I still have not been able to use twips. Jon and I discussed this at Primed recently. Twips apparently worked on his computer but not on any of mine. That was with an earlier beta and it is not corrected as of the latest (15) He is working on it he has said. If I could move it up, the name and address boxes would fit, and the last decimal of the year gets chopped off if the date is double digit.

Hmm.. what kind of PRINTER are you using? It may be more a printer problem than a computer problem. AC has been known to be picky about what kinds of printers it will talk to.

V.

In the office I use mostly HP 6p. But I have tried it with the canon copier, an HP 4100 inkjet I use at home and an HP 1100. no luck so far.

Currently I am using standard 8.5x11" security paper from www.rxpaper.com in laser printers. I practice in Florida. The cost of the paper has gone up 20% in past year (just like our payments, yeah right, ha ha).

Currently the paper is 8 cents a page. With toner and energy we are probably looking at 12 cents/page. This is getting too expensive. I'm an internist with some patients on 15 different meds.

I am experimenting with some e-prescribing through www.nationalerx.com, but of course that requires double entry and doesn't allow controlled prescriptions.

I am considering shelling out $600 for the Star TSP847U-24GRYRX – USB, dark gray with locking lid thermal printer as paper for that only 2.4 cents per page.

Any thoughts from fellow amazing charts users that have gone through similar issues? Thanks.

Why reinvent the wheel. The Star TPS800 printer is designed to thermally print these prescriptions to perfectly designed 4" by 6" paper that is usually the standard. They are tamper proof and, generally, accepted in all 50 states. Once set up correctly, you can print PERFECT scripts all day long. it is awesome to see two kids with four different Focalin XRs and print them off in less than two minutes. When we wrote them out, I would have made at least two errors, it would have taken me over five minutes, and the pharmacy would not have been able to read at least one.

And, the support guy for TPS800 is awesome. You can even get a locked version for the rooms so that patients can't take the rolls of scripts from your rooms. But, that isn't a problem for us as we keep the printer behind the front desk. I only print so many controlled substances. I usually walk the patient down the hall anyway, and the receptionist always has the scripts right on the counter ready for me to sign. The printer is right by her desk.

You calculated correctly. The paper is 2.4 cents per page, which is less than what we were paying for the script pads we had to pay for. We never got them here for free.

For regular scripts, I still print them out on an 8 1/2 x 11 sheet of paper for about a penny. But, I fax most scripts. So, usually it is:

1. Fax all scripts that aren't controlled.
2. Print scripts to patients that are self pay or insured if they prefer a hard copy rather than a fax.
3. Print scripts for drugs such as Paregoric, Vicodin, Tylenol with codeine, Lomotil, etc., sign them, then fax them. You can't fax those without a signature here except for one drug store.
4. Print all scripts to the TPS800 thermal printer for CIIs.
5. When a Medicaid patient wants a hard copy, I will print to a tamper proof script on the TPS800.

We RARELY call in prescriptions.

The TPS800 is one of the best purchases I have ever made. Configuration on the printer itself can be a bit daunting, but once it is done, you never have to do it again.

The only frustrating thing is that you can't switch back and forth between formats in AC or to two different print drivers. I tried, but I wasn't able to make it work perfectly. So, you are unable to print four scripts to a page as before.

Bert,
Thanks for your reply.
Do you have the USB or the ethernet version? (any problems printing through the Windows XP network to either? )

I had thought about just buying one Star TSP for the front desk. I have 3 exam rooms all right together.

I always go Ethernet if I can with anything especially printers. No problems with XP or Vista. I haven't used Vista with it, but they have drivers for Vista. But, since I am running Vista in a virtual machine, maybe I will give it a shot if for no other reason but to post here.

Yeah, I don't think it is worth getting more than one. If you did decide to go with more than one, I would highly suggest starting with one. It does take a bit of finesse setting it up so maybe best to learn with one. Plus 3 x ~ $650 = ~ $1,950. Where behind the front desk, you are talking ~ $550. I remember the locked version was about $100 more.

The scary thing is I can't recall if I had to verify I was a physician to buy the printer or the paper. One would think you would with the paper. Of course, with one machine, all of your scripts will look identical, and it would be hard for someone with the same paper and machine to make them look alike.

I got the Star TSP800 printer and it is working fine.
I bought it from International Point of sale.
(It is the Star Micronics TSP800, USB with locking lid, includes USB cable and power supply - $593)
I have it by the front desk. Instead of printing the presciptions in the exam room I end the patient visit with "Let's go up front and get your prescriptions."

A few installation notes:

1) I got the USB version. It is not plug and play. You have to download the driver from Star's website. Once you install it on one machine, and share it, it can easily be added to other computers on the network without further downloads.

2) The default options worked fine, except I had to change the "raster print options / Cut Action End Page End Doc" section on the properties section of the windows printer interface.
The default is Form Feed / Partial Cut.
This works fine if you are just printing one prescription, but when you print more than one the second won't form feed before printing. I changed the default to "Partial Cut / Partial Cut" and this fixed the problem.

I am using the roll presciption paper with the timing marks.

So far so good.

It sounds like yours is working just like mine, except you were able to set it up much more quickly. Are you using portrait or landscape. We finally got it to work portrait, which formatted better.

I set mine to Full Cut / Full Cut. So, if I print five or so, they are all cut and right there. I also print to the front and tell the patients to go up front. This has a couuple of good advantages. Patients can't say when they get out the door or close to it, "I never got that prescription, and my front desk person not only has it ready to be signed, but they can check to be sure it is correct. PLUS, if the patient looks at it (which I always TRY to make them do to check for errors), if it is wrong, my receptionist can print it right out, and I can sign the new one.

You will love it. And, the pharmacists will LOVE it.

Nice job, Ken.

One small frustrating thing, which is very small, but as you get close to the end of the roll, the scripts get more and more curly. Not a big deal.

My printer (TSP 800) is coming this week so I am not up and running with it yet. I am in a tourist area and have found the tourists are not going to the pharmacy the same day etc so the faxed Rx's were not there when they went. My plan was to print all non locals and continue to fax the local ones. Can you put an electronic signature on it? Thanks much in advance!

Alexis,

Hi. Once you set up your formatting (4 by 6) and the "twips" in the admin section, you can print anything that you would normally print on 8 1/2 by 11 paper. So, if you can do a digital signature on your regular script, then you can on this as well.

I am not sure what paper you will be using. We only use the TSP800 for printing controlled scripts and use tamper proof paper, so obviously, I have to actually sign the script anyway. If you were printing to plain paper, then you may not need to, but I tend to sign all my hard copy scripts anyway where I don't sign my faxed scripts.

I hope this helps. Let me know if I misunderstood your question.

Thank you, You did answer my question. I really appreciate all the help you have given me.

Hello,
Just another option to the paper issue since faxing scripts will no longer be hipaa compliant after the end of this calendar year. To get around this and the paper issue I am using the free electronic script writer through erxnow. It is clumsy and part of the "medical industrial complex", but I do have a sense of my scripts getting recorded accurately and legally. I have been worried about the alterability of rx data in ac. I am looking forward to v 4 and the updates that may bring.

I somehow missed that announcement that faxing scripts will disappear at the end of the year. Where is this published? This will be a major nightmare. On the plus side I'll get paid for doing refills since there is no way I will have my staff be tied up on the phone doing refills.

I've been eprescribing for 3 years now yet mainly use it only for refills. On eRxNow (Allscripts) you can not eprescribe to the mail order pharmacies (medco, caremark, etc) so you either fax or give them to the patient. Likewise you must fax or have a patient pick up controlled meds. Finally, not every pharmacy is hooked up into the network, and even if they are, once they send out a refill request they have no way of verifying that the request went through to the physician. I've had a lot of patients calling my office this past week asking why I didn't refill their medicine. I've had my staff inform them that no request came through on Allscripts. I do Allscripts almost every day including weekends so I have no backlog on my end, yet I find that on Saturday and Sunday there may only be 4-5 refills and then on Monday morning all of a sudden I have 18-25. Go figure. I've noticed there is a delay from when the patient calls the pharmacy to when I receive it of about 2-3 days at least. We tell patients we take 72 hours to turn around a refill request and that they are responsible to call the pharmacy a week before they will run out of medicine. Naturally some don't understand and blame us for them running out of medicine. Boy isn't medicine fun! (And I still enjoy what I do!)

I will look and see if I can find the blurb sent out by AAFP when they received it from CMS. I think it was in April. Enforcement will be a nightmare and problematic.

I agree, there are a lot of problems with Allscripts. I am in rural Missouri so there are a lot of pharmacies not on the network. Allscripts answer for now is to convert these to faxes for those pharmacies. Those are often problematic.

Some of the docs around here are charging $10/script for refills when they are not done in context of a visit. Don't blame them, but it sure hurts folks on a fixed income.

Medicine is such a mess, but for me too is a happy mess. I enjoy helping pts navigate the system. I have also appreciated the support these boards have provided in starting my practice using AC.

That is unbelievable. I wouldn't be able to collect five cents. Can't charge Medicaid anything over and above and even my private pay wouldn't pay that.

I plan to fax no matter what. Of course, the pharmacies won't take them. I also will use TSP800 which, IMHO, is the way to go.

Medicine is a mess, because we doctors want it to be. Business people, lawyers, etc. would never stand for this. Once again, just imagine every single docotr in Maine simply telling their patients they can't write scripts anymore because the government and HIPAA won't let them. What would it take? About three days?

I agree, Bert. I think come the first of the year all doctors all over the country should simply refuse to refill scripts unless they can fax them or charge the patient to come pick them up. I too plan to buck this with all my efforts.

Leslie

Well two of us can create a helluva boycott!

I also think it would benefit both the EDs and the PCPs and medicine as a whole if ED doctors could only give one dose of a sample or one dose on a script. To get the other nine doses, the patient would be forced to go to their PCP. I think that would stop the ear infections, etc. from going to the ED pretty quickly. Higher copays may work for the private pay patients but not for the others.

As a combination FP and ER doctor I tend to give the pt. only 12 pills - such as 12 ibuprofen, 12 vicoden, etc, but I do tend to give the whole course of antibiotics since I don't want to see all the earaches over again in my office. This cuts down the drug seekers looking for pain meds.

The problem with primary care is that we expect pt. to have personal responsibility - this weekend I saw multiple pt. who have had symptoms,complaints for 2 weeks to 3 months and just came to the ER because it is convenient and in our town has little or no waiting. Unfortunately due to liability we get backed into ordering workups on these things even if we think they can wait because they are already here...... sorry almost climbed back on that soapbox....

Take care. P.S. I tell my pt. that my policy is to fax all my scrips and I only write about 6 scrips per week on a pad because they are schedule II with medicaid.... I am planning on buying a TPS printer though, just because I am tired of typing the scrip in AC for bookkeeping and then handwriting it out.

Steven,

Thanks for your post and the view that only an FP and ED doctor could give. I have to say with all due respect that I couldn't disagree more. Granted, it would be a little uncomfortable and to the patient it would appear as though you are "double-dipping" so to speak to send them back to you. But, for the average PCP seeing the patient back who inappropriately went to the ED ear pain, especially when one dose at 10PM will make little or no difference in the outcome or pain.

One of the main way people learn is through consequences. They can get a letter from Medicaid over and over, but if they realize that they will have to be seen twice, they will think again before going to the ED inappropriately.

And, if a patient goes to the ED for something chronic from three weeks to three months, I find working that up due to medicolegal reasons is simply not good medicine. Most chronic conditions require a long history and physical with an algorithm approach that saves money and avoids needless tests. The responsibility for the patient going to their primary care doctor is on them, and I don't think there is any medicolegal pressure on the ED. In fact, our ED sometimes does the appropriate thing by calling me and making sure the patient follows up the next day. There are very few things that cannot wait 18 more hours before being seen by the PCP.

You make valid points, but in a system where pt's are told to followup and either don't because they fail to do it or some offices in many towns will tell an established pt. that they can't see pt. for 2 weeks for acute problems like sinusitis - this creates a problem. I would love to send pt. to PCP's office, but even in small towns I run into the above - even when we try to leave open slots for acute issues these are rapidly filled.

We spend a lot of time trying to screen people back to the office and many of them just learn to say the things that they think will get the right attention - chest pain, SOB, etc.

The other main issue for me is pediatrics - I really don't want any child to delay treatment once I see them - unfortunately children can't choose their parents and many of them don't have a real good chance anyway......

Good points. I guess pediatric patients just have it made in the Bangor area. 100% of pediatric offices will see a patient same day. I used to have my MA call each family that had a kid go in after three days of fever or vomiting to ask why they didn't come here (after asking how they were of course). It's the adult patients who have to wait. I wish the ED would simply ask the patient if they had called their PCP, then call me and send them over. The problem is there is no copay for a Medicaid patient either at the ED or at the PCP's office.

I solicited and got this email response from the eRx folks. They are considering adding in CCR exchange support:

---------------------------------------
Will your EMR accept an industry standard CCR for import? My developers are looking into possible interface solutions.

Thank you,

Ruth Hummel
eRx NOW Support
---------------------------------------

I'll look into this further. Anyone heard anything else about this?

Al