While there are many flow charts and diagrams that outline the details of each type of transaction, this section will look at the overarching processes involved in e-prescribing. Below we include a schematic that outlines the various steps involved in the e-prescribing process.

Prescriber
First, a system user-clinician or staff-signs into a system through a verification process authenticating their identity.  Standard authentication requires username and password, although other technologies such as random-number cards (SecureID), digital certificates, or fingerprint readers are available. Once authenticated, the system provides functionality specific to a user's role and authorization level. Different user types (e.g. clinicians and office staff) have different legal permissions to enter, review, or modify prescriptions.

The prescriber identifies the patient record within the e-prescribing system. Records can be identified by typing in identifying information (first name, last name, date of birth, zip code, etc.) to the e-prescribing system. If the e-prescribing system is connected to the practice management system, the e-prescribing system can recognize all patient records matching the day's schedule, providing a quick, simple way of accessing relevant patient records.

The next steps in the process correspond to reviewing the medical history, entering, and editing a prescription. E-prescribing systems should allow the prescriber to perform the following functions:

• Review patients' current medication list and medication history information within the practice.
• Work with an existing medication within the practice, this can involve viewing details of a medication, remove a medication from the active medication list, change dose, etc., for a medication or renew one or more medications
• Prescribe or add new medication and select the pharmacy where the prescription will be filled.
• The information is then sent to the Transaction Hub, where information on the patient eligibility, formulary, and medication history/fill status is sent back to the prescriber. 

Transaction Hub
The Transaction Hub is the common link between the prescriber, pharmacy, and pharmacy benefits manager (PBM). It maintains a master patient index and list of pharmacies and it routes inquires to the PBM and prescriptions to the pharmacy. 

Once the Transaction Hub receives the patient demographics and medication from the prescriber, it will verify the patient against the master patient index sending an electronic message to the PBM. In response the PBM will send information on the patient eligibility, formulary, and medication history back to the Transaction Hub. The Transaction Hub then sends this information back to the prescriber, who then can make a decision about the prescription based on this information. The prescriber then:

• Completes the prescription and authorizes (electronically sign)
  • One item
  • Multiple items
  • Items created by ancillary staff, residents, or others
• Transmit prescriptions
  • Choose print, fax, or transmit options in real-time or batch mode
  • Print formats and prescription information, conforming to state regulations
  • Handle restrictions on certain medications (e.g. medications requiring prior authorization from the PBM)
• Ensure prescription is sent to preferred patient pharmacy (identified by practice staff prior to interaction with prescriber). The prescriber may also select the pharmacy during the patient encounter.

Pharmacy
Once the pharmacy receives the prescription data from the Transaction Hub it provides confirmation back to the Transaction Hub.  All pharmacy systems are enabled to send messages back to the provider offices letting them know that a prescription has been filled. Systems are changing so that a message can be sent back indicating if a patient picks up their prescription(s) or if the patient is late picking up the prescriptions.  This can help prescribers and patients better manage their care.

Currently some pharmacies contact physician's office for renewal requests using an e-prescribing system. These requests will require action on the part of the provider.

The following resource provides additional information on the process of e-prescribing:

• E-prescribing process - Developed by the American College of Rheumatology.