E-prescribing's Next Steps: Controlled Substances

To realize the most benefit for e-prescribing, providers, regulators, and vendors alike must address piecemeal state laws and integrating data from e-prescribing for controlled substances with EHR/EMRs.

Electronic prescribing is now widely used by providers, but it has not yet fulfilled its potential.

Controlled substances can be legally e-prescribed in all 50 states, but use of e-prescribing for controlled substances (EPCS) is not mandatory in 47 states, limiting its benefits at a time when abuse of prescription drugs such as opioids is still grabbing news headlines.

Meanwhile, for e-prescribing in general, physicians who are just beginning to use the electronic system to bypass time-consuming calls to pharmacists when trying to obtain information on the lowest-cost, most-effective drugs for patients are challenged by the lack of transparency of pharmacy pricing and formularies at the point of prescribing any medication.

This could impact patient medication adherence rates if prescription costs are too high.

Despite the challenge that price comparison is not always available when e-prescribing, healthcare leaders are encouraged by the more secure system of e-prescribing.

"E-prescribing provides not only a more secure way of doing things, but a more efficient way of doing things as well, and it's more patient-centric," says Brian Herrick, MD. He is chief medical information officer at Cambridge Health Alliance, a two-hospital safety-net organization that operates three emergency departments and covers about 100,000 lives in the northeast suburbs of Boston.

The number of e-prescriptions written in the U.S. doubled from 2012 to 2015, according to Surescripts, a nationwide health information network connecting providers and pharmacies.

Because practitioners are electronically prescribing, it eliminates the need for patients to carry paper prescriptions to pharmacies, circumventing problems created by illegible handwriting on paper prescriptions.

"An EPCS prescription goes directly to the pharmacy, so there's a lower chance of forgery, as well as clinical alerts to ensure the safety of the prescription," says Peter Kaufman, MD, chief medical officer of DrFirst based in Rockville, Maryland. DrFirst offers providers an EHR-agnostic, web-based secure EPCS connection to Surescripts' network, which, in turn, connects securely to pharmacies.

EPCS finished 2014 with a small portion of the total controlled substance prescription mix, but experienced a surge in 2015, growing from 341,000 prescriptions in 2013 to 1.67 million in 2014 and 12.81 million in 2015, according to Surescripts.

Nationwide, 88% of pharmacies are enabled to accept EPCS, although only 13% of prescribers are enabled, says Paul Uhrig, chief administrative, legal, and privacy officer at Surescripts in Arlington, Virginia.

E-prescribing for Controlled Substances Zooms 600%

In 2015, a state law in New York was enacted that required all medications, including all controlled substances, to be prescribed electronically. However, the effective date of the law was pushed back a year, from March 2015 to March 2016. In 2011, Minnesota, and in 2016, Maine, required EPCS as well.

EHR vendors' lack of readiness to integrate EPCS into the prescribing workflow was a major reason for the delay in New York's law. The process also required provider leadership to implement two-factor authentication to verify the identity of prescribing clinicians, according to George Hickman, executive vice president and system chief information officer of the 734-licensed-bed Albany (New York) Medical Center.

The second authentication factor varies, according to technology and healthcare providers. Even within provider groups, prescribers sometimes have a choice of a second factor. For instance, a healthcare provider's IT management/operations department may offer a biometric second factor, or as an alternative, may send a one-time password to the prescriber's mobile phone as the second factor.

"Physicians obviously have a lot going on in terms of providing care, so when you're changing the workflow, that takes a little bit of time and effort," says Uhrig.

The reason EPCS became imperative in New York state had everything to do with the prescription opioid drug abuse epidemic, which had ravaged rural and urban areas of the state. "The New York Bureau of Narcotic Enforcement (BNE) was seeking to utilize technology to forensically discover the providers who are abusing narcotics dispensing," Hickman says.

By implementing e-prescribing and multifactor authentication, the BNE and other state and federal enforcement agencies, such as the U.S. Drug Enforcement Administration, aim to reduce theft of prescriber passwords and prescribing pads intended for controlled substance prescriptions. But first, information systems of prescribers had to be made ready by the vendors and provider organizations.

In Cambridge Health Alliance’s case, EPCS technology provider Imprivata integrated EPCS into Epic, Cambridge Health Alliance’s EHR. "The biggest challenge is really getting the [physicians] in and doing the registration in person so that you can verify their identification," Herrick says.

Healthcare's battle to curtail prescription drug abuse is being fought on multiple fronts. In many states, physicians already have to log into a prescription drug monitoring programs (PDMP) database to review the history of any controlled substances prescribed to a patient.

"The PDMPs have been around for 30 or 40 years depending on the state," says Thomas Sullivan, MD, chief strategic officer at DrFirst. The problem is, "they just weren't adequately funded. They weren't online, and they're completely under the control of each state," Sullivan says.

Piecemeal Mandates
States have implemented piecemeal mandates for use of PDMP and EPCS. Prior to its 2016 EPCS mandate deadline, New York in 2012 had mandated prescribers use its PDMP website by 2013, known as I-STOP (Internet System for Tracking Over-Prescribing Act). Neighboring state Massachusetts enacted severe penalties beginning in January for prescribers who do not consult its PDMP, says Sullivan.

With the I-STOP PDMP, "the real impact on curbing drug-seeking behaviors really kicked in long before electronic prescribing," says Michael Oppenheim, MD, chief medical information officer at Northwell Health, which operates 21 hospitals and approximately 550 ambulatory sites in metropolitan New York and Florida.

EPCS can build on PDMP use by sending data from EHRs to the PDMP databases, which state agencies such as New York's BNE can query to look for patterns of abuse by prescribers as well as patients.

But at this point, not all EPCS data collected by EHRs makes its way into the PDMP databases, due to the inability of many PDMPs to accept such data from some EHRs.

DrFirst and other companies that seek to integrate EPCS data with EHRs, such as those in use at Northwell, are waiting for the state to publish an application program interface (API) that would permit EPCS data to flow from EHRs to I-STOP, says Kaufman.

Multiple Systems
As if the variation from state to state wasn't complicated enough, many healthcare organizations use multiple vendors' EHRs or specialty-specific clinical systems across their own enterprises.

Northwell Health is one such organization. It turned to DrFirst's web-based or smartphone-based service to provide an EPCS service for these systems that did not have EPCS functionality as provided by their specialty-specific systems, or for practices that had no EHR, including Allscripts, Oppenheim says.

"I-STOP took us a couple of steps forward," he says. "EPCS is taking us a couple of steps forward. Each bit builds on the previous and helps us tackle this issue a little bit better."

Because DrFirst's service operates independently from a healthcare provider's own EHR, DrFirst also envisions EPCS use within Northwell at community-based programs and school-based clinics where EHRs are not present, Oppenheim says.

Albany Medical Center is also waiting for the I-STOP API to be added to its Cerner-, Allscripts-, and Medent-based EHRs to eliminate the need to log into the I-STOP website before moving back to the EHR to electronically order the prescription, says Azmat Z. Ahmad, vice president at Albany Medical Center.

Any organization where physicians must use multiple EHRs also requires downloading or possession of multiple second factors of authentication, Hickman notes. "Think of even simple inconveniences of workflow to a clinician, a provider that’s doing ordering. One EHR uses a different authentication provider than another, so that means clinicians have to either download more than one token-giving application onto their phone, or carry more than one fob."

Patient convenience is also a benefit of EPCS because patients no longer have to go to their physician for every prescription, Herrick says.

"As long as they're on their treatment plan and have the appropriate tests done and have the appropriate agreement with the providers, they can … go straight to the pharmacy," he says.