Primary nonadherence occurs when prescriptions written by a physician are never filled by the patient and is a common problem. A study published by JAMA Dermatology¹ shows that the use of electronic prescribing increases the likelihood of patients picking up their prescriptions.

The study looked at 4,318 prescriptions written for 2,496 patients. Of these, 803 patients received electronic prescriptions and 1,693 received written paper prescriptions. Overall, the primary nonadherence rate was 31.6%. However, when comparing the electronic prescriptions to the paper prescriptions, the primary nonadherence rate was lowered by 16%. Only 15.2% of patients who received an electronic prescription did not fill it. 

“Electronic prescribing has become one of the major criteria to evaluate meaningful use of electronic health records by health care professionals,” stated the researchers. “In this study, we demonstrated that e-prescribing is associated with reduced rates of primary nonadherence. As the healthcare system transitions from paper prescriptions to directly routed e-prescriptions, it will be important to understand how that experience affects patients, particularly their likelihood of filling the prescriptions.”

Why does e-prescribing increase adherence?   A huge part of it might be because e-prescribing eliminates the need to drop off the prescription at the pharmacy and can significantly reduce wait times.   Electronic prescribing allows the Pharmacy to begin filling a prescription before the patient has even left the Doctors office.   It is a huge difference to a patient who can just “swing by” the pharmacy and pick up their prescription, versus handing a prescription to the pharmacist and waiting for them to fill it.   Another factor, may be that many Pharmacies call to remind patients to pick up prescriptions.   If the patient doesn’t show up, the Pharmacy will follow up and remind them their prescription is ready and waiting.    A paper prescription many times never gets to a pharmacist, hence no one reminds them it is waiting.

Medication non-adherence can have many negative health consequences for patients. The JAMA study is a prime example of just how important e-Prescribing is to not only help prescribers and pharmacists, but to also improve adherence in patients. 

¹ Adamson AS, Suarez EA & Gorman AR. Association Between Method of Prescribing and Primary Nonadherence to Dermatologic Medication in an Urban Hospital Population. JAMA Dermatol.  2016. doi: 10.1001/jamadermatol.2016.3491

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 

All eyes have been on New York State as their I-STOP law requiring prescriptions to be sent electronically went into effect in March. Electronic Prescribing of Controlled Substances (EPCS) and non-controlled substances is mandatory across the state. Due to this mandate, New York leads the nation with the highest percentage of e-Prescribing pharmacies and prescribers. Other states are looking to New York to see how successful their mandate is and some have started to follow suit.

Maine is following New York by requiring controlled substance prescriptions to be sent electronically by July 2017. However, Maine is not requiring non-controlled substances to be prescribed electronically. It would follow that if prescribers are sending controlled substances electronically, they will most likely prescribe non-controlled substances through the same route though. Their law is in combination with required use of their state Prescription Monitoring Program (PMP) in an effort to combat opiate abuse. Read more about it in our post Maine to Require e-Prescribing of Controlled Substances.

Minnesota was actually the first state to require electronic prescribing. However, there are no penalties for writing paper prescriptions so many prescribers still pick up their paper pad when they need to prescribe. According to Surescripts’ National Progress Report¹, in 2015 Minnesota ranked 24^th compared with other states with less than 3% of their prescribers enabled for EPCS.

Massachusetts just launched an updated version of their state PMP to the tune of $6.2 million. They updated it with the aim of making it easier and faster for prescribers to use, as the old system was said to be very difficult to navigate and severely underutilized. The system now also offers interstate operability by giving Massachusetts prescribers access to data from other states. Currently, the number of other states’ data available is limited but the system has the potential to connect with up to 45 other states. Other updates include the ability to sync with EMRs, the ability to easily assign delegates to check the system on the prescriber’s behalf, and allowing for easy reporting to compare prescribing practices with other physicians. Starting October 15^th, prescribers will be required to check the state PMP any time they prescribe a schedule II or schedule III drug, as opposed to the current requirement of only checking the first time they prescribe one of these drugs.

Now that Massachusetts has their new PMP in place, it is rumored they may be the next state to require EPCS. They ranked number 9 in Surescripts’ National Progress Report with over 90% of their pharmacies enabled for EPCS, but the percent of prescribers with EPCS capabilities was only 4%. As of last week, 63% of their prescribers who had prescribed opioids were registered with the PMP but the number is growing daily.

At MDToolbox, we are watching closely in anticipation to see which state will be the next to take this important step in combating drug fraud and abuse.

1. 2015 National Progress Report http://surescripts.com/news-center/national-progress-report-2015/

As of June 2016, the oral antidepressant drug named Brintellix (vortioxetine) has changed to Trintellix.  The drug is used to treat major depressive disorder in adults and nothing about the drug has changed except the name. The formulation, indication and dosages have not changed.

The name change is due to confusion with a similarly named drug. The anti-blood clotting therapy Brilinta (ticagrelor) has been reported as being confused with Brintellix and causing prescribing and dispensing errors.

During the transition period, providers, pharmacists, and patients may still see bottles labeled with the brand name Brintellix. New shipments will have the new name, but pharmacists may still dispense their current stock that has the old name on it.   

Prescribers are encouraged to include the generic name of the medication to reduce the risk of name confusion during the transition. In MDToolbox, you will see the generic name is already included for you in parenthesis next to the Trintillex name for this reason.

Patients also need to make sure they received the right medication. The Trintellix tablets look exactly the same as the Brintellix tablets.

See this link for a complete information flyer on the name change: https://www.trintellixhcp.com/trintellix-announcement/

In response to a significant number of electronic prescriptions being sent by individuals who were not allowed to transmit them, the Nevada State Board of Pharmacy recently sent out a communique addressing exactly who is allowed to send new electronic prescriptions.  The only ones allowed to send electronic prescriptions in Nevada are the prescribers themselves. Agents such as medical assistants (M.A.s), registered nurses (R.N.s), and other office staff are not allowed to transmit electronic prescriptions for the prescribers.

Two regulations pertaining to the use of computer systems for transmission of electronic prescriptions include:

• NAC 639.7102:

1. A practitioner may:

(a) Issue a prescription using a computer system approved by the Board; and

(b) Transmit the prescription using that computer system to a pharmacy specified by the patient for whom the practitioner issues the prescription.

• NAC  639.7105:

2. A practitioner shall not transmit a prescription electronically to a pharmacy unless:

(a) The practitioner is the only person who will have access to the prescription until it is received by the pharmacy.¹

The Nevada State Board of Pharmacy has instructed all pharmacists to diligently check each electronic prescription they receive was submitted by a prescriber only. Any electronic prescription that states the agent is anyone other than a practitioner is considered invalid and won’t be accepted or filled.

The only thing M.A.s and R.N.s are allowed to do is authorize refills on behalf of the practitioner. It cannot be a new electronic prescription acting as a refill though, it must clearly be a refill.

Nevada is not the only state with such laws on the books. There are many states with similar laws and it is important for prescribers to understand and follow the laws pertaining to e-Prescribing in their individual state.

1. Nevada Administrative Code, http://leg.state.nv.us/NAC/NAC-639.html#NAC639Sec7102 

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

With the March 27^th mandatory e-Prescribing deadline in New York State looming, the New York Commissioner of Health has waived the following exceptional circumstances from the requirements of electronic prescribing¹:

1. any practitioner prescribing a controlled or non-controlled substance, containing two (2) or more products, which is compounded by a pharmacist;
2. any practitioner prescribing a controlled or non-controlled substance to be compounded for the direct administration to a patient by parenteral, intravenous, intramuscular, subcutaneous or intraspinal infusion;
3. any practitioner prescribing a controlled or non-controlled substance that contains long or complicated directions;
4. any practitioner prescribing a controlled or non-controlled substance that requires a prescription to contain certain elements required by the federal Food and Drug Administration (FDA) that are not able to be accomplished with electronic prescribing;
5. any practitioner prescribing a controlled or non-controlled substance under approved protocols under expedited partner therapy, collaborative drug management or in response to a public health emergency that would allow a non-patient specific prescription;
6. any practitioner prescribing an opioid antagonist that would allow a non-patient specific prescription;
7. any practitioner prescribing a controlled or non-controlled substance under a research protocol;
8. a practitioner prescribing a controlled or non-controlled substance either through an Official New York State Prescription form or an oral prescription communicated to a pharmacist serving as a vendor of pharmaceutical services, by an agent who is a health care practitioner, for patients in nursing homes and residential health care facilities as defined in section twenty-eight hundred one of the public health law.
9. a pharmacist dispensing controlled and non-controlled substance compounded prescriptions, prescriptions containing long or complicated directions, and prescriptions containing certain elements required by the FDA or any other governmental agency that are not able to be accomplished with electronic prescribing;
10. a pharmacist dispensing prescriptions issued under a research protocol, or under approved protocols for expedited partner therapy, or for collaborative drug management;
11. a pharmacist dispensing non-patient specific prescriptions, including opioid antagonists, or prescriptions issued in response to a public health emergency issued; and
12. a pharmacist serving as a vendor of pharmaceutical services dispensing a controlled or non-controlled substance through an Official New York State Prescription form or an oral prescription communicated by an agent who is a health care practitioner, for patients in nursing homes and residential health care facilities as defined in section twenty-eight hundred one of the public health law.

Prescribers who issue prescriptions in any of these circumstances may use the Official New York State Prescription Form or issue the prescription orally. The waiver is effective until March 26, 2017. Before that time, the Commissioner of Health will reevaluate whether the e-Prescribing software available has adequate functionality for these exceptional circumstances. 

1. New York State Department of Health, Letter from the NYS Commissioner of Health to practictioners and pharmacists regarding a blanket waiver for additional exceptional circumstances related to electronic prescribing - March 16, 2016

http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/docs/2016-03-16_blanket_waiver_letter.pdf

The New York State Internet System for Tracking Over-Prescribing (I-STOP) Act mandates that all prescriptions, both controlled and non-controlled, be sent electronically. Last year the deadline for prescribers to meet the regulation was postponed until March 27, 2016. This new deadline is fast approaching.

In order to comply with I-STOP, prescribers must select and use a certified electronic prescribing computer application that meets all federal requirements for electronic prescriptions for controlled substances (EPCS).  This includes going through Identity Proofing and setting up 2-Factor authentication. The practitioner must also register each unique certified computer application used to electronically prescribe controlled substances with the New York State Department of Health (DOH), Bureau of Narcotic Enforcement (BNE).

The BNE recently sent out a letter to all prescribers advising the following:

“Please be aware that implementation timelines for EPCS software vary and may be lengthy. If you have not already begun this process, BNE strongly recommends that you begin immediately. Prescribers who have certified EPCS software and have completed the registration process are highly encouraged to begin electronically prescribing instead of using paper, to allow for time to resolve technical or workflow issues prior to the mandate’s effective date.”

MDToolbox has a simple signup process for both standard e-Prescribing and to setup EPCS. Most prescribers can complete the required ID proofing and 2-Factor Authentication setup within one day, but we also urge prescribers in NY to get started as soon as possible. This will ensure time to complete the application process and get all staff setup and trained.

To sign up for a free 30 day e-Prescribing trial with EPCS: New York e-Prescribing Account

Once you have signed up, you can register the application at:          

http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/ropes.htm

Prior authorizations are one of the biggest frustrations for doctors and their staff. In order to get certain medications approved by patients’ insurance companies, the standard method of paper prior authorizations involves filling out long forms, spending time on the phone, and faxing back and forth potentially multiple times over several days. However, there is now a new alternative. Introducing: Electronic Prior Authorization or e-PA.

What is e-PA?

Electronic Prior Authorization also known as, e-PA, is a streamlined method of completing prior authorizations electronically. A message with the patient’s information and prescription information is securely sent online to the Pharmacy Benefit Managers (PBMs) for review. A lot of the time e-PAs are completed directly in the Electronic Health Record system making it that much easier for the provider and staff to complete in their workflow.

How does e-PA work?

There are several different kinds of electronic prior authorization on the market today.  Many early versions turn the paper forms into PDF documents and give providers a way to fill out those forms online or electronically. Many times they are the same forms as the paper versions but allow online entry and submitting to the insurance company which saves time over manually filling and faxing. Newer e-PA implementations (like MDToolbox offers) take it to the next level by pre-filling all of the patient and medication pertinent information. They also have simple question sets that are filled out and submitted to get the prior approval instead of needing to complete the long forms.

What are the benefits?

• Saves Time for Physicians

In a 2010 AMA survey it was found that physicians alone, not including other staff, spend on average 20 hours a week dealing with prior authorizations¹.  The time saved by using e-PA means that physicians can devote more time to caring for their patients.

•  Saves Time for Patients

The same survey showed 69% of physicians typically wait several days to receive prior authorization from an insurer for drugs, while 10% wait more than one week. By using e-PA, physicians can sometimes get a response immediately, therefore patients would not be stuck waiting several days or making failed attempts to pick up their prescription at the pharmacy.

• Improves Patient Care and Outcomes

20-30% of patients waiting on PAs ultimately give up without getting their prescription² while up to 70% of patients don’t receive the original prescription prescribed by their provider if a prior authorization is required³. Not only will physicians have more time to devote to patient care by reducing the time spent on prior authorizations with e-PA, patients will also be more likely to follow through with their originally prescribed treatment.

• Saves Money

A study presented in Health Affairs put the monetary cost of physicians interacting with insurance plans at $83,000 annually⁴. By utilizing e-PA and reducing administrative efforts put into manual prior authorizations, these costs can be drastically reduced as well.

It is clear to see that there are many obvious reasons providers should be happy to switch to completing prior authorizations electronically and it’s expected that this technology will be a welcome change in offices across the nation.

1. American Medical Association, “New AMA Survey Finds Insurer Preauthorization Policies Impact Patient Care,” November 22, 2010
2. Journal of Managed Care Pharmacy, K.A. Hanson, et.al An analysis of Antihypertensive Use Following Initially Rejected Pharmacy Claims for Aliskiren, Sept. 2009, Vol. 15, No. 7, pg 573-57
3. FrostSullivan Study, The Impact of the Prior Authorization Process on Branded Medications
4. Health Affairs: “What Does It Cost Physician Practices To Interact With Health Insurance Plans?”; May 2009

Electronic Prescribing of Controlled Substances (EPCS) is now legal in all 50 States.  Missouri and Vermont were the last two states to authorize electronic prescribing of controlled substances.  Missouri’s regulations became effective July 30^th, 2015.  Today, August 28^th, Vermont became the final state to allow prescribers to legally prescribe controlled substances electronically for schedule II-V drugs.  Prescribers can now electronically prescribe controlled substances at any participating pharmacy in the United States. 

National EPCS availability is a key step in combating prescription drug fraud and abuse.  With the adoption of EPCS, patients will no longer be able to forge paper prescriptions.  Drug seeking behaviors and patterns will also be easier to identify and respond to.  With the increased electronic connectivity of pharmacies, medication histories will be more readily available.  All of these factors will also create a much safer environment for patients. 

The state of New York has passed legislation requiring prescribers to do all of their prescribing electronically starting in March next year.  As that deadline draws near and potentially other states follow, it will be necessary to stay current and have a viable EPCS solution.  Currently, the national average of pharmacies enabled for EPCS is 80.3%. Now that EPCS is legal in all states and as more states make EPCS a requirement, we expect to see more and more pharmacies coming online and allowing receipt of EPCS. 

MDToolbox offers both a certified stand-alone e-Prescribing solution, as well as an integratable solution for EHR or PM systems to add full e-Prescribing capabilities or add on just EPCS capabilities. MDToolbox is ready to help prescribers and software companies through the DEA requirements to get fully prescribing controlled and non-controlled substances electronically. Check out our EPCS page or contact us at info@mdtoolbox.com for more info.