Florida and Delaware Governors Ron DeSantis and John Carney have both recently signed electronic prescribing mandates into law.  Florida HB831 mandates healthcare providers to electronically prescribe all medications with an effective date of either July 1^st, 2021, or upon license renewal (beginning January 1^st, 2020).  This bill was a bipartisan initiative that was amended several times in both the house and senate before being enacted.  Delaware HB115 mandates healthcare providers to electronically prescribe all medications with an effective date of January 1^st, 2021.

Other subsections of the Florida Act include:

• The Act makes changes to the required information included on written prescriptions.

• There are provisions in the Act for a waiver system with similar circumstances for approval as other states have enacted.  Some of these include economic hardship, technological limitations, and other circumstances determined by the board.

• The Act establishes that penalties may be issued if a prescriber fails to keep control over their prescription pads and authorized access to their electronic prescribing software.

• A large portion of the Act amends prior legislation that gives power to the “agency” that governs Florida health practitioners and practices.  There are several tasks detailed for the agency to complete pertaining to medications, pharmacies, and Medicaid.

Other subsections of the Delaware Act include:

• There are provisions in the Act for a waiver system with similar circumstances for approval as other states have enacted.  Some of these include economic hardship, technological limitations, and other circumstances determined by the board.

• Pharmacies and dispensers are not required to verify that a prescription presented to the pharmacy via other means than an electronic prescription is legally able to be filled.

Florida is currently above the national average for opioid-related overdose deaths, with 16.3 deaths per 100,000 people while the national average is 14.6 deaths.  Prescription opioid overdose deaths continued to gradually rise until 2011, then decreased until 2015.  Heroin, prescription Opioids, and synthetic opioid deaths have all risen drastically since then.[1]  Florida implemented their PMP in 2011 and also began restricting some controlled substances.  In 2017, Florida declared a state of emergency due to the Opioid epidemic and began writing additional legislation.  HB21 was a major change enacted in 2018 that required usage of the State Prescription Monitoring Program (PMP), required additional opioid training for prescribers, and placed limitations on the number of pills that can be prescribed.

Delaware is also currently above the national average for opioid-related overdose deaths, with 21.7 deaths per 100,000 people while the national average is 14.6 deaths.  Overdose deaths remained consistently above the national average from 2008 to 2016 and have risen drastically in 2016 and 2017 with 37.0 deaths per 100,000 people in 2017.[2]  Delaware enacted legislation that restricted opioid prescriptions to 7 days beginning in 2017.  Long-term opioid treatment is available, but only after certain criteria is met including regular queries of the State Prescription Drug Monitoring Program.

Florida currently has a 15.3% prescriber enablement for electronic prescribing of controlled substances; Delaware has a 20.3% prescriber enablement.  Both states are significantly below the national average of 35.4%.  Pharmacy enablement in Florida for EPCS is 92.9% which is the second lowest of any State in the US.  Delaware currently has a 99.5% pharmacy enablement, the national average is 95.4%.[3]  MDToolbox encourages providers not to wait until the last minute to setup electronic prescribing!

Please see our website for other states that have either passed or have pending legislation that mandates electronic prescribing.  MDToolbox looks forward to providing tools and resources to assist providers throughout Florida and Delaware to ease the transition and help our customers combat the opioid epidemic.  With MDToolbox, providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go e-prescribing with our mobile app!  We offer a free 30 day free trial, so Contact us for more information!

[1]https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/florida-opioid-summary

[2]https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/delaware-opioid-summary

[3]https://surescripts.com/enhance-prescribing/e-prescribing/e-prescribing-for-controlled-substances/

 Missouri Governor Mike Parson recently signed SB275 into law. This Act mandates Missouri healthcare providers to electronically prescribe all controlled substance medications contained in Schedules II-IV with an effective date of January 1^st, 2021.  Missouri was very determined to pass an EPCS mandate, as they had at least 6 pieces of legislation pending that contained a mandate.  SB275 contains many elements of the additional pieces of legislation that were being debated.

Other subsections of the Act include:

• The Act states that electronic prescriptions of controlled substances can be substituted for a written prescription at the direct request from the patient.

• There are provisions in the Act for a waiver system with similar circumstances for approval as other states have enacted.  Some of these include economic hardship, technological limitations, and other circumstances determined by the board.

• The Act establishes penalties for practitioners who do now follow regulations established in this Act.

• The Act establishes the “Joint Committee on Substance Abuse Prevention and Treatment”, a new commission consisting of Senate, House, and governor-elected members to explore solutions and modify legislation for the state of Missouri pertaining to substance abuse.

• Regulations for the cost of Medication-Assisted Treatment (MAT) are established within the Act.

• Dentists are no longer allowed to prescribe extended-release opioids and any doses greater than 50 Morphine Milligram Equivalents per day.

• Several other state regulations are changed including: Drug trafficking offenses, practitioner credentialing procedures, nicotine replacement therapy, and collaborative practice arrangements between physicians and physician assistants.

Missouri is currently above the national average for opioid-related overdose deaths, with 16.5 deaths per 100,000 people while the national average is 14.6 deaths.  Prescription opioid overdose deaths continued to gradually rise until 2010, then have remained stable.  Heroin deaths have gradually risen since 2007 and synthetic opioid deaths have all risen drastically since 2014, up from ~100 to 618 in 2017.[1]  Missouri is the only state in the US to have not established a Prescription Drug Monitoring Program (PDMP).  However, St. Louis County, MO created their own PDMP for use within their county.  Jackson County, MO has partnered with St. Louis County to use their PDMP.  Prescribers across the state have joined the PDMP on a voluntary basis, tired of waiting for Missouri State Legislators to establish an official state-wide PMP.  There is currently no state legislation for establishing a PDMP.

Missouri currently has a 25% prescriber enablement for electronic prescribing of controlled substances, which is below the national average of 35.4%.  Pharmacy enablement for EPCS is 97.9% which is above the national average for pharmacy enablement is 95.4%.[2]  There will likely be a big push leading up to 2021 to secure electronic prescribing, MDToolbox encourages providers not to wait!

Please see our website for other states that have either passed or have pending legislation that mandates electronic prescribing.  MDToolbox looks forward to providing tools and resources to assist providers throughout Missouri to ease the transition and help our customers combat the opioid epidemic.  With MDToolbox, providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go e-prescribing with our mobile app!  We offer a free 30 day free trial, so Contact us for more information!

[1]https://www.drugabuse.gov/opioid-summaries-by-state/missouri-opioid-summary

[2]https://surescripts.com/enhance-prescribing/e-prescribing/e-prescribing-for-controlled-substances/

Texas Governor Greg Abbott recently signed HB2174 into law, Nevada Governor Steve Sisolak has also signed AB310 into law.  Both Acts mandate Texas and Nevada healthcare providers to electronically prescribe all controlled substance medications with an effective date of January 1^st, 2021.

Both Acts contain provisions for a waiver system with similar circumstances for approval as other states have enacted.  Some of these include economic hardship, technological limitations, and other circumstances determined by the board.  Reapplying for a waiver for subsequent years is also covered.

The Texas Act also establishes:

• The Act allows for partial filling of Schedule II prescriptions, but only for patients in long-term care facilities or for hospice patients with a medical diagnosis documenting a terminal illness.

• Pharmacies and dispensers are not required to verify that a prescription presented to the pharmacy via other means than an electronic prescription is legally able to be filled.

• The Act clarifies what specific information needs to be contained in both written and electronic prescriptions.

• Prescribers and pharmacists are required to complete two hours of continuing education on procedures of prescribing and monitoring controlled substances.  This education must be completed within one year of receiving a license to prescribe or dispense controlled substances.

• Prescribers are unable to write prescriptions that exceed a 10 day supply when being written for acute care.

The Nevada Act also establishes:

• The Act establishes penalties for practitioners who do now follow regulations established in this Act.

• More than half of the Act amends various pieces of Nevada code discussing potential penalties for medical staff.

Texas is currently well below the national average for opioid-related overdose deaths, with 5.1 deaths per 100,000 people while the national average is 14.6 deaths.  Prescription opioid overdose deaths peaked in 2006 and have remained mostly stable since.  Heroin deaths have gradually risen since 2000 and synthetic opioid deaths have remained stable until 2014, when they began to rise.  Texas also has a lower than average opioid prescription rate, this number has been decreasing since 2012[1]  Effective 9/1/19, pharmacists and prescribers will be required to consult the state PMP prior to dispensing or prescribing controlled substances.

Nevada is currently also below the national average for opioid-related overdose deaths, with 13.3 deaths per 100,000 people while the national average is 14.6 deaths.  Prescription opioid overdose deaths continued to gradually rise until 2010, then have been reduced or remained stable.  Heroin deaths have gradually risen since 2011 and synthetic opioid deaths have slightly risen since 2015.[2]  Nevada passed SB459 in 2015 which mandated that Nevada prescribers check the state Prescription Drug Monitoring Program for controlled substance prescriptions.  AB474 was passed in 2017 which was considered “a comprehensive measure that addresses misuse, abuse, and diversion through enacting prescribing protocols at appropriate levels.”[3]

Texas currently has a 31.1% prescriber enablement for electronic prescribing of controlled substances while Nevada has nearly half the enablement of Texas.  Pharmacy enablement for both states is near the national average of 95.4%.[4]  There will likely be a big push leading up to 2021 to secure electronic prescribing, MDToolbox encourages providers not to wait!

Please see our website for other states that have either passed or have pending legislation that mandates electronic prescribing.  MDToolbox looks forward to providing tools and resources to assist providers throughout Texas and Nevada to ease the transition and help our customers combat the opioid epidemic.  With MDToolbox, providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go e-prescribing with our mobile app!  We offer a free 30 day free trial, so Contact us for more information!

[1]https://www.drugabuse.gov/opioid-summaries-by-state/texas-opioid-summary

[2]https://www.drugabuse.gov/opioid-summaries-by-state/nevada-opioid-summary

[3]https://oig.hhs.gov/oas/reports/region9/91801004_Factsheet.pdf

[4]https://surescripts.com/enhance-prescribing/e-prescribing/e-prescribing-for-controlled-substances/

The Centers for Medicare & Medicaid Services (CMS) issued their final ruling for improving and modernizing the Medicare Part C (Medicare Advantage) and Part D programs on May 16^th, 2019.  This 201-page document primarily focuses on implementing changes that will save money for patients as healthcare and prescription costs continue to rise. 

 The costs of oral brand-name drugs increased annually by 9.2% from 2008 to 2016, while oral specialty drugs increased 20.6%[1].  These numbers are only expected to continue rising, putting additional strain on patient budgets.  The national average inflation rate is roughly 2%, therefor prescription drugs are increasing 5-10 times as rapidly as the cost of living.

The price-tiered chart above shows how often prescriptions are being abandoned at the pharmacy due to drug prices.  An average of 10.7% of prescriptions under $30 are abandoned, while 69% of prescriptions over $250 are abandoned.[2]  A large percentage of those patients who abandoned their prescriptions do not follow-up with their medical provider for another potentially cheaper alternative.  Some patients may also take their medications off-label by skipping days, potentially resulting in even higher future healthcare costs.  Prescription non-adherence has been estimated to produce up to $300 billion in avoidable healthcare costs per year in the US.[3]

https://www.healthcarefinancenews.com

The CMS ruling contains many updates to Medicare policy including:

• Forcing sponsors to include formulary for all 6 categories/classes of drugs.  There was a proposed exception to exclude a class of drug from their formulary if the price rose too high, this exception was not included in the ruling. 

• Part D EOBs must contain information on drug price increases and include alternative therapy options and their pricing to better inform patients of possible ways to have a lower out of pocket cost

• The ruling prohibits sponsors from issuing “gag clauses” to pharmacies, which previously prohibited the pharmacy from advertising a cheaper cash price for a prescription.

• There are additional regulation changes for Step Therapy requirements with Medicare Advantage on Part B drugs.

• The final part of this ruling focuses on giving patients and prescribers better access to prescription drug pricing via their EHR or electronic prescribing system.

The CMS ruling will require that Medicare Part D sponsors adopt a tool that displays real-time price benefit information that is capable of integrating into e-prescribing software by January 1^st, 2021.  This means the tool must be functional by the deadline but not necessarily available in EHRs or e-prescribing software yet.  As of the date this blog was published, many of the EHRs and e-prescribing software on the market do not have the ability to show real-time pricing/benefit information at the point of prescribing.  Some vendors do have the ability so long as the feature has been added and the patient’s particular insurance plan has made that information available to EHRs.  For example, MDToolbox is proud to have the ability to display patient formulary information, drug prices, and preferred drug levels for patients on plans that support it.  The number of patients with accessible Medicare Part D pricing will continue to grow as the plan sponsors are required to make their pricing available.

Surescripts, a health information network hub that digitally connects healthcare providers to pharmacies and PBMs/insurance companies recently released their 2018 research showing that being able to view the real-time benefits caused prescribers to change their medication selections 28% of the time, actively saving the patient money.  The average cost saving per prescription written by a family practice in 2018 was $57, the average saving for a psychiatry office was $228 per prescription![4]

The increase in usage of Electronic Prescribing throughout the US means better protections and convenience for both prescribers and patients.  Real-Time Benefit Pricing will save patients money and help keep their satisfaction in their medical providers.  We look forward to working with providers throughout the US to better empower themselves, better inform their patients, and help provide tools and resources for making their practice more efficient.  With MDToolbox providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go mobile e-prescribing.  Contact us for more information or to start a free 30 day free trial.

[1]https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05147

[2]https://catalyst.phrma.org/69-percent-of-patients-abandon-medicines-when-cost-sharing-is-more-than-250

[3]https://www.pharmacytimes.com/contributor/timothy-aungst-pharmd/2018/06/does-nonadherence-really-cost-the-health-care-system-300-billion-annually

[4]https://surescripts.com/news-center/national-progress-report-2018/

South Carolina Governor Henry McMaster recently signed HB3728 into law.  This was a bipartisan bill that was amended a few times during the legislative process.  This Act mandates South Carolina healthcare providers to electronically prescribe all controlled substance medications with an effective date of January 1^st, 2021.

Other subsections of the Act include:

• The Act requires healthcare facilities and first responders who have diagnosed an opioid overdose to submit data to the state PMP (Prescription Monitoring Program) for each instance that an opioid antidote was administered to a patient.  This data will then be analyzed by the Bureau of Drug Control.

• The State PMP must be consulted when prescribing a Schedule II controlled substance and must be documented in the patient’s chart that the PMP was consulted.

• The Act makes dispensers immune from civil and criminal liability from the State Board of Pharmacy over dispensing prescriptions that potentially violate the laws established in the Act.  If a prescription is sent to the pharmacy in a non-electronic format, this section puts the responsibility on the prescriber to ensure that a valid exceptional circumstance (detailed in the bill) was utilized.

South Carolina is currently above the national average for opioid-related overdose deaths, with 15.5 deaths per 100,000 people in 2017 while the national average was 14.6 deaths.  Prescription opioid overdose rates rose steadily from 1999 to 2013, then more than doubled between 2013 and 2014.  Opioid overdose rates have remained stable since 2014.  Heroin and synthetic opioid deaths have risen since 2013, with synthetic opioids skyrocketing higher than the national average.  Synthetic opioid deaths are almost ten times what they were in 2013.  In 2015, South Carolina had one of the highest rates of opioid prescribing in the US, 109 prescriptions for every 100 people.  This number was reduced drastically in 2017 to 79.3 prescriptions but is still well above the national average of 58.7.[1] 

In 2015, South Carolina passed the South Carolina Overdose Prevention Act which raised public awareness for the severity of the opioid epidemic in South Carolina and outlined legislation for the administration of opioid antidotes during an overdose.  The law provided immunity from legal prosecution for any medical providers, caregivers, or pharmacists involved in dispensing or administering an opioid antidote.  South Carolina then established the Law Enforcement Officer Naloxone (LEON) program which focused on training and education for law enforcement first responders to identify and treat opioid drug overdoses.  In 2018, South Carolina passed S918 which established a report card for prescribers.  The report card pulls data about controlled substances that the practitioner has prescribed and compares their statistics to other prescribers.

South Carolina currently has a 21.4% prescriber enablement for electronic prescribing of controlled substances, which is well below the national average of 35.4%.  Pharmacy enablement for EPCS is 95.8% which is just above the national average for pharmacy enablement is 95.4%.[2]  There will likely be a big push leading up to 2021 to secure electronic prescribing, MDToolbox encourages providers not to wait!

South Carolina now aligns with several other states mandating electronic prescribing.  MDToolbox looks forward to working with providers throughout South Carolina to ease the transition and help provide tools and resources in combating the opioid epidemic.  With MDToolbox providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go mobile e-prescribing.  Contact us for more information or to start your free 30 day free trial.

[1]https://www.drugabuse.gov/opioid-summaries-by-state/south-carolina-opioid-summary

[2]https://surescripts.com/enhance-prescribing/e-prescribing/e-prescribing-for-controlled-substances/

Kansas Governor Laura Kelly recently signed HB2119 into law. This Act mandates Kansas healthcare providers to electronically prescribe all controlled substance medications that contain an opiate with an effective date of July 1^st, 2021.  The Kansas mandate details several circumstances where electronic prescribing is not required.  However, there are a couple of circumstances that are not typical or seen in mandates that other states have enacted:

• If the prescription is for a compounded controlled substance containing two or more components (one of which being an opiate) that make “electronic submission impractical”, electronic prescribing is not required. This provision is likely to help accommodate prescribers who are using software that does not support prescription orders for custom compounds.  At the time of writing this blog, many software systems only allow selecting orders from a list of drugs (MDToolbox e-Rx software however DOES accommodate custom compounds and would allow for this type of order to be electronically sent).

• If a prescriber issues 50 or fewer controlled substance prescriptions that contain an opiate per year, electronic prescribing is not required.

Other subsections of the Act include:

• There are provisions in the Act for a waiver system with similar circumstances for approval as other states have enacted.  Some of these include economic hardship, technological limitations, and other circumstances determined by the board.  The Act details penalties for practices that violate or misrepresent themselves when applying for waivers.

• The Act establishes penalties for any prescriber who violates “any lawful rules or regulations” set in place by the state which would include the EPCS mandate established by this Act.

• More than half of the Act amends previous legislation with new medical definitions for existing and future laws.

Kansas is currently well below the national average for opioid-related overdose deaths, with 5.1 deaths per 100,000 people in 2017 while the national average was 14.6 deaths.  Prescription opioid overdoses rose steadily from 2000 to 2007, then have consistently decreased from 2014 to 2017.  Heroin and synthetic opioid deaths have remained consistent despite the national average rising sharply in the last few years.[1]  Despite being one of the lowest states for opioid overdose deaths, Kansas prescribes more opioids than the national average.  Opioid prescriptions are 69.8 per 100 people while the national average is 58.7 per 100 people.[2]  Kansas was one of the first states to enact legislation for a prescription drug monitoring program (K-TRACS).  It went operational in 2010 but the state does not mandate it’s use for non-dispensing prescribers.  Funding issues threatened the K-TRACS program but support was reapproved by the Governor for 2018 and 2019.[3]

Kansas currently has an 18.6% prescriber enablement for electronic prescribing of controlled substances, which is significantly below the national average of 35.4%.  Pharmacy enablement for EPCS is 98.8% which is above the national average for pharmacy enablement of 95.4%.[4]  There will likely be a big push leading up to 2021 to secure electronic prescribing, MDToolbox encourages providers not to wait!

Kansas now aligns with several other states mandating electronic prescribing.  MDToolbox looks forward to working with providers throughout Kansas to ease the transition and help provide tools and resources in combating the opioid epidemic.  With MDToolbox providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go mobile e-prescribing.  Contact us for more information or to start your free 30 day free trial.

[1]https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/florida-opioid-summary

[2]https://opioid.amfar.org/KS

[3]http://www.kslegresearch.org/KLRD-web/Publications/BudgetBookFY19/2019BudgetAnalysisRpts/Biennial-Pharmacy.pdf

[4]https://surescripts.com/enhance-prescribing/e-prescribing/e-prescribing-for-controlled-substances/

Photo Credit: Tyler Bird

Washington Governor Jay Inslee recently signed SB5380 into law. This Act mandates Washington healthcare providers to electronically prescribe all controlled substances with an effective date of January 1^st, 2021.  This bill was created by request of the Governor and was one of several bills pushed through the House and Senate the day before Washington’s legislative session ended.

Other subsections of the Act include:

• Several sections of the bill state that prescribers of varying practice must inform patients of their right to refuse an opioid prescription.

• There are provisions in the Act for a waiver system with similar circumstances for approval as other states have enacted.  Some of these include economic hardship, technological limitations, and other circumstances determined by the board.

• Pharmacies are not required to verify if a controlled substance prescription received via written, oral, or fax falls within the state and federal laws.

• Effective January 1^st, 2021 medical entities with ten or more prescribers must use an EHR that is integrated with the state Prescription Monitoring Program (PMP) database.  The EHR must demonstrate both sending and receiving of PMP data.  A waiver process will be made available for this requirement as well.

• A large portion of the Act establishes regulations and oversight that governs opioid addiction treatment.  The Act establishes that substance use disorders are medical conditions and discusses various aspects of how law enforcement, the Department of Corrections, and school districts should act when dealing with substance abuse.

Washington has remained well above the national average for opioid-related overdose deaths since tracking began in 1999 but in 2015 was overtaken by the national average as US rates began to rise.  Prescription opioid overdose deaths have continued to gradually decrease since 2011, however heroin deaths have begun to rise.[1]  Washington State established and has been utilizing their PMP since 2012.  In 2017, Washington passed HB1427 which created 5 commissions and boards tasked with creating requirements and recommendations for WA prescribers to follow for curbing opioid misuse.  One requirement established is that prescribers must complete additional training for the prescribing of opioids.  The Agency Medical Director’s Group suggests using opioid misuse risk assessment tools with every new patient that is being considered for an opioid prescription.  These guides determine whether the patient should be prescribed opioids by assigning a score based on several history, illness, and risk questions.

Washington currently has an 18.2% provider enablement for electronic prescribing of controlled substances, which is significantly below the national average of 34.4%.  Pharmacy enablement for EPCS is 96.0% which is above the current national average for pharmacies of 95.3%.[2]  There will likely be a big push leading up to 2021 to secure electronic prescribing, MDToolbox encourages providers not to wait!

Washington now aligns with several other states mandating electronic prescribing.  MDToolbox looks forward to working with providers throughout Washington to ease the transition and help provide tools and resources in combating the opioid epidemic.  With MDToolbox providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go mobile e-prescribing.  Contact us for more information or to start your free 30 day free trial.

[1]https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/washington-opioid-summary

[2]https://surescripts.com/enhance-prescribing/e-prescribing/e-prescribing-for-controlled-substances/

While the United States government has been writing legislation to control addictive drugs since the early 1900’s, The Controlled Substances Act (CSA) of 1970 laid the groundwork for how controlled substances are regulated.  The CSA established the schedule system that is still used today for drug classification.  The act also established policy for regulations on the manufacture, importation, possession, use, and distribution of scheduled substances.  The CSA has been amended 9 times since its enactment, the eighth amendment in 2008 was titled The Ryan Haight Online Pharmacy Consumer Protection Act which brought portions of the CSA into the digital age.

The Ryan Haight Act amends the CSA to prohibit the delivery, distribution, and dispensing of controlled substances over the internet without a valid prescription.  The Ryan Haight Act forces online pharmacies to report their controlled substance prescriptions to the Attorney General and requires that online pharmacies to display compliance information on their website.  There are several definitions established in the Act, one of the most important being that a “valid prescription” must come from a practitioner that has conducted at least one in-person medical visit with the patient.  As technology has advanced and telehealth has risen in popularity, this section of the Act has created issues for digital practitioners that may never see their patient in face to face.

The Ryan Haight Act also contains a “Special Registration for Telemedicine” section that tasked the Attorney General to issue certain regulations to allow the prescribing of controlled substances without an in-person consult.  The Attorney General has not issued an update on this provision since the Ryan Haight Act was written and enacted in 2008.  Some States have taken that responsibility upon themselves to rule on controlled substances being issued by telemedicine such as Indiana, Michigan, Ohio, Florida, Delaware, New Hampshire, West Virginia, and Connecticut[1].  These states passed legislation allowing for controlled substances to be prescribed via telehealth without seeing the patient in-person so long as certain requirements are met.  The state laws contradict the federal law that the Ryan Haight Act established and there is uncertainty what the legal ramifications might be in court.

In 2018, President Trump signed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT Act.  The Support Act contains legislative changes for many aspects of healthcare including Medicaid and Medicare, funding the CURES Act, an EPCS mandate, State PMP requirements, and many more.  The Support Act also finally sets a date for the telehealth controlled-substance exemptions to be written that were established in the Ryan Haight Act of 2008.  The Support Act requires the Attorney General write the final regulations that specify “the limited circumstances in which a special registration under this subsection may be issued” and “the procedure for obtaining a special registration”[2].  The deadline for the Attorney General to establish these regulations is October 24^th, 2019.

We don’t exactly know what the regulations and restrictions will look like or how stringent the requirements for a telehealth provider to prescribe a controlled substance without an in-person visit will be until fall of this year.  The federal regulations could follow some of the State-level legislation or could be in contrast and create a necessary change for telehealth prescribers in those states who have attempted to setup their practice following their State’s laws.

We at MDToolbox are watching for any regulation changes on a federal level that would allow electronic prescription of controlled substances via a telehealth practitioner.  You will find any policy updates here in our blog.  MDToolbox looks forward to working with telehealth providers and help provide tools and resources in combating the opioid epidemic. Contact us for more information or to start your free 30 day free trial.

[1]https://www.healthcarelawtoday.com/2018/06/27/new-connecticut-law-allows-telemedicine-prescribing-of-controlled-substances/

[2]https://www.congress.gov/bill/115th-congress/house-bill/6/text#toc-HA8EADE1EA6CF4E62B8D435826C060821

Indiana Governor Eric Holcomb recently signed SB176 into law. This Act mandates Indiana healthcare providers to electronically prescribe all controlled substances with an effective date of January 1^st, 2021.  This bill began as an 8-line document allowing patients to transfer their prescription to another pharmacy.  Several amendments were made in the two weeks it took the Indiana House and Senate to pass the bill bringing it to 15 pages in length.

Other subsections include:

• The Act amends several sections of state code by adding the phrase “or electronically transmit” to add electronic prescribing as a valid means of prescribing.

• There are provisions in the Act for a waiver system with similar circumstances for approval as other states have enacted.  Some of these include: economic hardship, technological limitations, and other circumstances determined by the board.

• Pharmacies are not required to verify if a controlled substance prescription received via written, oral, or fax falls within the state and federal laws.

• The Act allows for advanced practice registered nurses to send prescriptions under their own credentials once they have met the requirements established by the board, previously nurse practitioners were required to send prescriptions under a supervising physicians’ credentials.

• Telemedicine is also addressed in this Act.  Indiana has allowed for the prescribing of controlled and non-controlled (excluding opioids) prescriptions for telemedicine providers so long as certain criteria is met.  One regulation is that an Indiana licensed practitioner has seen the patient in person and developed a medical plan that the telemedicine prescriber is following. (Note: Stay tuned for our next blog concerning U.S. Wide Telemedicine Prescribing that goes into more details about the uncertainty of telemedicine and the current laws governing it.)

Indiana has remained below the national average for opioid-related overdose deaths since 1999, following the national trend and increasing in number of deaths.  However, the rate has increased sharply in recent years catching up with the national average.  If the rate continues as forecasted, it will pass the national average for the first time since the National Institute on Drug Abuse has been collecting data.  Prescription opioid overdose deaths decreased in 2011 but have begun to rise again in recent years along with heroin and synthetic opioid deaths.  Indiana enacted SB226 on April 26^th, 2017, the Act limits the first fill prescription of opioids to seven days for adults.  The law also limits opioid prescriptions for minors to seven days.  Prescriptions can exceed seven days under certain circumstances, such as the doctor determines that the patient requires it and if the patient is in palliative care.[1]

Indiana currently has a 30.5% provider enablement for electronic prescribing of controlled substances, which is just below the national average of 33.4%.  Pharmacy enablement for EPCS is 97.8% which is above the current nation average for pharmacies, which is 95.2%.[2]  There will likely be a big push leading up to 2021 to secure electronic prescribing, MDToolbox encourages providers not to wait!

Indiana now aligns with several other states mandating electronic prescribing.  MDToolbox looks forward to working with providers throughout Indiana to ease the transition and help provide tools and resources in combating the opioid epidemic.  With MDToolbox providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go mobile e-prescribing.  Contact us for more information or to start your free 30 day free trial.

[1]http://www.hallrender.com/2017/06/21/new-indiana-law-imposes-a-seven-day-limit-on-opioid-prescriptions/

[2]https://surescripts.com/enhance-prescribing/e-prescribing/e-prescribing-for-controlled-substances

Tennessee Governor Bill Haslam recently signed SB0810 into law.  This Act mandates Tennessee healthcare providers to electronically prescribe all controlled substances with an effective date of January 1^st, 2021.  Tennessee had previously passed HB1993 which mandated EPCS for Schedule II drugs by January 1^st, 2020.  This latest Act makes several changes to the prior legislation:

• The new Act replaces Schedule II drugs with Schedule II-V.  Now, all controlled substances are required to be electronically prescribed. 

• The required date for prescribers to follow the mandate has been postponed to January 1^st, 2021 from January 1^st, 2020. 

• Tennessee pharmacies are now required to be able to issue partial prescriptions in their electronic system of Schedule II drugs by January 1^st, 2020 or face action by The Board of Pharmacy.  Tennessee previously passed 63-1-163 which regulated pharmacies when filling partial prescription orders.  The new amendment requires the pharmacy’s electronic system to be able to split the medication orders should a patient only want a partial order, or if the pharmacy is low on stock of the Schedule II drug.

Tennessee has remained above the national average for opioid-related overdose deaths since 2003, rising even faster than the national trend in number of deaths.  While some states have had a flattening or reduction in prescription opioid overdose deaths in recent years, Tennessee has continued to trend upward.  The number of deaths from synthetic opioids and heroin had remained stable until 2014, when the numbers began to rise.

Last year, Tennessee passed HB1831: “TN Together Opioid Reform” which made several major strides toward the fight against opioid addiction.  The Act budgeted $30 million for prevention, treatment, and law enforcement tasks in relation to the opioid epidemic.  The Act also mandated that pharmacies check the State PMP registry.  The biggest change has to do with how much of a drug you can get and when. Under the new law, pharmacists can only partially fill a prescription for no more than half of the number of days it’s written for. And there are limits on prescriptions, too: General prescriptions are limited to a 10-day supply (and no more than 500 cumulative morphine milligram equivalents).[1]

Tennessee currently has a 23.5% provider enablement for electronic prescribing of controlled substances, which is well below the national average of 33.4%.  Pharmacy enablement for EPCS is 96.7% which is above the current nation average for pharmacies is 95.2%.[2]  HB1993, which was passed a year ago would have required EPCS of Schedule II drugs only 8 month from the writing of this blog.  There will likely be a big push leading up to 2021 to secure electronic prescribing, MDToolbox encourages providers not to wait!

Tennessee now aligns with several other states mandating electronic prescribing.  MDToolbox looks forward to working with providers throughout Tennessee to ease the transition and help provide tools and resources in combating the opioid epidemic.  With MDToolbox providers have access to tools such as Electronic Prescribing of Controlled Substances (EPCS) and convenient on the go mobile e-prescribing.  Contact us for more information or to start your free 30 day free trial.

[1]https://www.knoxnews.com/story/news/health/2018/06/29/tennessee-opioid-prescription-law-pharmacy/746208002/

[2]https://surescripts.com/enhance-prescribing/e-prescribing/e-prescribing-for-controlled-substances/