Qualityblue, a Physician Pay-For-Performance Program

Electronic Prescribing (eRx) Initiative Data Submission / Review Form

Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______Practice NPI: ______(Required: Please accurately complete your 10-digit #)

Office Contact Name: ______Title: ______Phone Number: (_____) ______-______Ext.______

NOTE: Submissions with incomplete or erroneous information will delay review of your submission by the QualityBLUE Submission Committee and could affect your QualityBLUE score.

Implementation activities are reviewed quarterly. The submissions must be POSTMARK ED on or before the indicated quarterly deadline: November 1 for 1st Quarter February 1 for 2nd Quarter May 1 for 3rd Quarter August 1 for 4th Quarter

Section 2 Required: eRx Vendor Name, Software Solution, and Software Version

Please Vendor Name: ______indicate Software Solution: ______selected eRx System: Software Version: ______

Highmark is a registered mark of Highmark Inc. Blue Shield, and the Shield symbols are registered service marks, and QualityBLUE is a service mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

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Highmark Blue Shield V1.0 05/08 Page 1 of 3 Electronic Prescribing (eRx) Initiative Submission Form Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______

Section 3 Required: Proof of Purchase or Commitment to Purchase eRx System

Proof of existing eRx system:  Choose One: Proof of commitment to purchase:  Proof of purchase:  Acceptable Documentation: Signature page from Signed Vendor Contract which includes, Please check all both Signatures of eRx Vendor and Practice:  that apply and OR attach copy. Signed Purchase order form: 

Section 4 Required: eRx Software

Electronically order medications from the patient’s pharmacy of 1.  Verification of choice, record and maintain medication history Functionality: 2. Identify drug-to-drug interactions at point of care  3. Protect confidential patient information  Please check all Direct electronic connections with majority of pharmacies in the functional 4. 49-county area to place prescription orders (faxing capabilities elements that  acceptable) apply to your Communication with the Pharmacy Benefits Manager to show practice’s existing 5. benefits and formulary information at point of care  or purchased eRx Communication with the Pharmacy Benefits Manager to display system. 6. dispensed medications prescribed by other physicians  Bi-directional electronic communications with pharmacies to 7. respond to Pharmacy initiated refill requests  To help with future planning, please tell us if your eRx system is interoperable with an Electronic Health Record (EHR) system? YES  NO 

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Highmark Blue Shield V1.0 05/08 Page 2 of 3 Electronic Prescribing (eRx) Initiative Submission Form Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______

Faxes will not be accepted. Please mail this entire form with attachments to:

Highmark Blue Shield QualityBLUE Submission Review Committee P.O. BOX 535098 Pittsburgh, PA 15253-5098

QualityBLUE Submission Review Results – Highmark use only

Date Received by Highmark: ____/____/_____

Points Not Review Committee eRx Activity Approved Assigned Approved Date Signature Proof of existing eRx system with minimum functionality (functional 3 elements 1-4), not upgraded with full functionality/bidirectional elements 1-7. Proof of commitment to purchase or proof of purchased eRx system with 3 minimum functionality (functional elements 1-4). Proof of purchased eRx system with full functionality including bidirectional 5 (functional elements 1-7).

Additional Committee Notes: ______

Highmark Blue Shield V1.0 05/08 Page 3 of 3 Electronic Prescribing (eRx) Initiative Submission Form