New York State Attorney General Eric Schneiderman’s office sent a letter¹ September 20th asking Governor Andrew Cuomo to veto two bills seen as loopholes to the newly implemented Internet System for Tracking Over-Prescribing (I-STOP) laws. I-STOP mandates electronic prescribing in New York and requires prescribers to check the state Prescription Monitoring Progarm (PMP) before prescribing controlled substances.  The goal is to prevent drug abuse and drug seeking and increase patient safety. Read more about I-STOP here.

The first bill (S.6778/A.9334)² relates to nursing homes. It would provide an exception to the requirement to e-Prescribe for prescribers in nursing homes. The reasoning behind the bill is that prescribers are not in nursing homes 24 hours a day and patients need to get their medications in a timely manner. The letter requesting the veto points out that oral prescription orders are already allowed in emergency situations which should suffice any true needs and the bill would only serve to weaken I-STOP. The Deputy Attorney General, Brian Mahanna, stated in the letter that healthcare errors and drug diversion are particularly problematic in nursing homes and electronic prescribing has proven to reduce them. Not only does electronic prescribing reduce errors such as illegible handwriting and increase patient safety, it offers the ability for an on-call Long Term Care prescriber to approve and send medications even when they are away from the facility. Many software systems (including MDToolbox) have easy to use mobile apps and web versions that can be securely accessed from wherever the prescriber is.

The second bill (S.6779-B/A.9335-B)³ would provide an exception to prescribers who write paper prescriptions from having to report them to the state Department of Health. I-STOP requires all prescriptions to be sent electronically, but there are three statutory exemptions. These include a temporary electrical or technical failure, if e-Prescribing would result in a delay that would adversely impact a patient’s health, or if the prescription is to be filled out-of-state.  Currently, if a prescriber writes a paper prescription because of one of these exemptions they are required to file a report with the Department of Health. The bill removes this requirement and only calls for a notation in the patient’s record. Mahanna states in his letter this bill would “create a gaping loophole in ISTOP’s universal e-Prescribing reporting requirements.” He points out that prescribers could avoid compliance with I-STOP and “doctor shopping” patients could lie about a prescription being filled out of state.

The two bills passed the NYS legislature earlier this year and were just delivered to the Governor.

1.https://www.scribd.com/document/324826179/2016-9-20-Ltr-to-a-David-Re-ISTOP#from_embed

2.  An act to amend the public health law and the education law, in relation to exceptions to requirements for electronic prescriptions 

3. An act to amend the public health law and the education law, in relation to electronic prescriptions 

Last week the governor of Maine signed into law “An Act To Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program.” In addition to mandated use of the state Prescription Monitoring Program (PMP), the law will require prescribers to electronically prescribe controlled substances.

The aim of the law is to reduce opioid abuse and heroin addiction. “Heroin addiction is devastating our communities,” said Governor LePage. “For many, it all started with the overprescribing of opioid pain medications. We can prevent many people from even trying heroin in the first place by putting these limits on the flow of pain pills into our homes. I am thankful to prescribers and pharmacists who helped to craft this legislation and ultimately support it before the Legislature. They recognize that the status quo hasn’t worked and it’s time for some serious reform.”¹

The law requires prescribers to do the following: 

1. Check the state Prescription Monitoring Program prior to writing scripts for opioids or benzodiazepines
2. Abide by prescription caps - seven days for acute pain and 30 days for chronic pain by January 2017
3. E-Prescribe Controlled Substances by July 2017
4. Attend addiction training every two years

This will be a big change for many prescribers. Currently, as little as seven percent of prescribers use the state PMP and according to Surescripts, less than one percent of controlled substance prescriptions were sent electronically in Maine in 2015.

Maine follows New York and Minnesota in mandating e-Prescribing of controlled substances, although Minnesota does not enforce the requirement. New York’s law, which requires e-Prescribing of both non-controlled and controlled substances, went into effect last month. Several more states have similar laws up for legislative discussion as well.

It’s clear that now is the time for anyone not e-Prescribing yet to get started. MDToolbox is offering free trials for anyone who wants to test out e-Prescribing as either a standalone solution for prescribers or an integration solution for Health IT vendors, click here for more information or contact us at 206-331-420 or info@mdtoolbox.com.

1. Governor Signs Major Opioid Prescribing Reform Bill, State of Maine Office of Governor Paul R. LePage, http://www.maine.gov/tools/whatsnew/index.php?topic=Gov+News&id=675718&v=article2011

E-prescribing makes it quick and easy for a doctor to prescribe a medication to a patient.  However, doctors need to take extra precautions to ensure that they are not prescribing unnecessary medications too quickly. 

Prescription drug abuse is a fast growing problem in America.  According to a study by the National Institute on Drug Abuse, approximately 7 million Americans abuse prescription drugs¹.  Furthermore, the CDC reported that in 2010, over 22,000 drug overdose deaths involved pharmaceutical drugs².  While the prescription medications can be obtained several unlawful ways (stealing someone else’s prescription or getting them through a drug dealer), a majority of them are obtained through prescriptions written directly for the drug abuser.  Drug seekers will “doctor shop” to find a doctor (or multiple doctors) who is willing to write them a prescription for their chosen drug. 

What Is Being Done?

49 states (all except Missouri) have put a Prescription Drug Monitoring Program (PDMP) in place.  These are electronic databases that prescribers can access to check a patient’s controlled substance prescription history within the state.  These are valuable tools that can help reduce prescription drug abuse.

Surescripts®, the nation’s largest e-Prescribing hub, also offers access to some Nationwide Pharmacy Fill History and Pharmacy Benefit Managers (PBM) claim history.  For e-Prescribing software systems that certify on this feature and prescribers that take advantage of it, this is an invaluable tool.

Is It Enough?

These tools can only help if they are actually used.  Checking these databases is voluntary in most states.  The Tampa Bay Times did an investigation in Florida on the actual use of their drug monitoring program.  They found that out of 48 million controlled substance prescriptions written, prescribers had only checked the database before writing 2 percent³.   There are only two states that have taken lead in making the use of these databases mandatory.  In August, New York put into effect the I-STOP law which requires prescribers to check their state database before prescribing controlled substances.  Tennessee also has a similar law in effect. 

In addition to actually using the databases, another key component to their effectiveness is that they provide current information.   One more significant part of New York’s I-STOP law is that it requires real-time reporting by pharmacists dispensing prescriptions.  The reporting requirements vary from state to state with only a couple requiring real-time reporting, some requiring reporting done within 24 hours and others only requiring monthly reporting. 

The PDMPs also vary from state to state as to which agency houses the database, which controlled substances are reported, who is required to submit data, and how noncompliance is enforced.  Some states are able to share data with other states while others are not.

And while e-Prescribing systems that offer access to the Surescripts® claims and fill history do allow for a nationwide accessible database, not all pharmacies and PMBs are in the network.  More importantly, not all prescribers take the time to pull the history even when they have the tool.

While Surescripts® and many states have taken a step in the right direction, in order to be as effective as possible in reducing prescription drug abuse, a database needs to:

• Be National – Each state having their own database is not the most effective model.  Drug abusers can easily cross state lines or even move to a new state to get more prescriptions.  The drug database information needs to be available nationwide.   An e-Prescribing Vendor wanting to give their prescribers access to all data would currently need to integrate with 49 PDMP systems and Surescripts®.

• Be Mandatory – Every prescriber should be required to check the drug database.  The information is of no use if it isn’t seen.

• Require pharmacy real-time reporting – Having the most current data available will prevent drug abusers from being able to get prescriptions from multiple pharmacies. 

• Include all prescriptions – Schedules of drugs can be changed and drugs that were once non-controlled substances become controlled substances.  A complete history of all prescriptions would be most beneficial to prescribers.  This information is not only helpful in fighting drug abuse, it can aid in the overall quality of patient care. 

• Be Standardized and Interoperable – Prescribers are much more likely to make use of the data if it is part of their normal workflow.  Having to login to a separate database in a new window is a hassle.  However, if the data is available in a standardized format that can be integrated with a prescriber’s current e-Prescribing solution it becomes much more effective.  While a Nationwide centralized database would allow for prescribers (and technology vendors) to be able to have one complete picture, interoperability between the PDMPs and Health Systems becomes important until that can happen.  Moving in that direction, the Office of the National Coordinator for Health Information Technology (ONC) just launched the PDMP & Health IT Initiative last week.  It aims to create standard methods for exchanging the data between PDMPs and health systems.  As described in the challenge statement, “There are a lack of common technical standards and vocabularies to enable PDMPs to share computable information with the EHR that providers can use to support clinical decision-making.”⁴

What Can Prescribers Do In The Mean Time?

Until there is one central database or interoperability between all e-Prescribing systems and PDMPs, prescribers should ensure they use their state systems and in addition, that they are using e-Rx programs that make national drug usage information available.  Programs like MDToolbox have access to the Surescripts® Nationwide Medication History through participating PBMs and pharmacies.   While this is still limited to the PBMs and pharmacies in the network and not mandated, it does give prescribers one more tool to stop abuse and prescription shoppers.  

1. "Topics in Brief: Prescription Drug Abuse" NIDA, December 2011.
2. “Opioids drive continued increase in drug overdose deaths,” CDC, February 2013.
3. Cox, John W. “Florida drug database intended to save lives is barely used by doctors.” Tampa Bay Times 6 Oct. 2012. http://www.tampabay.com/news/health/florida-drug-database-intended-to-save-lives-is-barely-used-by-doctors/1255062
4. Prescription Drug Monitoring Program (PDMP) & Health IT Integration Initiative, Office of the National Coordinator for Health IT http://wiki.siframework.org/PDMP+%26+Health+IT+Integration+Charter+and+Members