The State of Missouri has passed legislation establishing their State PMP (prescription drug monitoring program) to track controlled substances that have been prescribed to patients throughout the State in an effort to curb Opioid overdoses.  Missouri is the final state in the US to establish a PMP.  St. Louis County, along with 75 additional Jurisdictions had previously established its own PMP which now covers 85% of the State population but is not sanctioned by the State.  This County-run PMP also recently signed an agreement to share data with 18 other States.[1]  The St. Louis County PMP will now likely be absorbed into the State program once it becomes active.

Legislation to establish a State-wide PMP had been presented annually since 2005, but stalled or was dismissed at various stages of the legislative processes.  Senator Holly Rehder has filed Missouri’s PMP legislation for nine consecutive years.[2]

Missouri Senate Bill 63 is the 2021 legislation that has become law establishing the PMP.  The Act was signed into law by Missouri Governor Mike Parson on June 8^th, 2021.  Governor Parson said. “SB 63 will help provide necessary information to health care professionals and empower them to make decisions that better serve their patients and assist in fighting the opioid epidemic in Missouri.” The Act establishes the Joint Oversight Task Force for Prescription Drug Monitoring which will supervise and regulate the collection and use of patient dispensation information.  The task force is to contractually enter an agreement with a vendor to operate the program.  The St. Louis County PMP currently utilizes Appriss Health as their vendor.  The Task Force will also enforce fines that the legislation establishes for dispensers that fail to report controlled substance dispensings.

The legislation goes on to set specifications for data that must be included in the PMP entries by dispensers within 24 hours of dispensing the medication.  Beginning January 1^st, 2023, the State is expected to begin phasing in real-time reporting to the PMP, with a mandate for real-time reporting required by January 1^st, 2024.

MDToolbox makes checking most State PMP databases convenient with our PMP Integration. This allows prescribers to pull a patient specific PMP report directly from the prescription writer, drastically reducing the steps required to check the database.  Prescribers save time by not having to navigate to another website, login, search for a patient and pull up the report. See our recent blog post on the benefits of integrating your State’s PMP.

While some studies have not found a clinically significant reduction in Opioid prescribing rates due directly to PMP usage, certain specific PMP features have been shown to reduce Opioid related Emergency Department visits.  According to a study produced by the Healthcare Cost and Utilization Project[3], States that have implemented mandatory PMP usage have shown a 6% reduction in the growth of ED visits for Opioid overdoses over States that did not require PMP usage.  Studies such as this demonstrate that with proper utilization, PMPs can be a powerful tool for reducing Opioid Overdoses.

MDToolbox applauds the State of Missouri for passing legislation to create their PMP and join the rest of the country in further attempting to remedy the Opioid Crisis.  We continually encouraging providers to take full advantage of the time and stress saving technologies we provide including Electronic Prescribing of Controlled Substances (EPCS), Electronic Prior Authorization (e-PA) and Real-time Price Transparency as they are important tools to use in fighting the devastating opioid epidemic and making electronic prescribing as convenient as possible for prescribers. Contact us for more information on about electronic prescribing and setting up a PMP Integration.

[1] https://pdmp-stlcogis.hub.arcgis.com/

[2] https://themissouritimes.com/missouri-legislature-gives-final-approval-to-statewide-pdmp-bill/

[3] https://hcup-us.ahrq.gov/reports/PDMPsAndOpioidHospitalizations.pdf

This week President Trump signed into law the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act¹. The legislation is aimed at combating the opioid epidemic by focusing on several information technology tools that help prevent prescription fraud and abuse.

One of those tools is e-Prescribing. One of the more than 60 policies included is the Every Prescription Conveyed Securely Act. Beginning in January 2021, prescribers will be required to electronically prescribe controlled substances for Schedule II-V drugs covered under a Medicare Part D or Medicare Advantage prescription drug plan. While many states have enacted their own laws requiring e-Prescribing, this is the first federal mandate.

Another tool included in the law is electronic prior authorization. Also by January 2021, electronic prior authorization will be required for Medicare Part D covered drugs. Electronic prescription programs will be required to securely transmit the requests. A facsimile, proprietary payer portal, or an electronic form that does not meet the standards will not be counted as an electronic submission.

The legislation also contains provisions to enhance states’ Prescription Drug Monitoring Programs (PDMPs). The goal is to ensure each state has a PDMP, improve their functionality, make sure all prescribers are utilizing the systems, and foster data sharing between states. Beginning October 1, 2021 States must require health care providers to check their PDMP for a Medicaid enrollee's prescription drug history before prescribing controlled substances to the enrollee.

MDToolbox applauds this bipartisan legislation. We are continually encouraging providers to take advantage of the technologies we provide including Electronic Prescribing of Controlled Substances (EPCS) and Electronic Prior Authorization (e-PA) as they are important tools to use in fighting the devastating opioid epidemic. Putting these federal mandates in place is an important step towards fully utilizing the available technology to save lives. 

1. H.R.6 - SUPPORT for Patients and Communities Act https://www.congress.gov/bill/115th-congress/house-bill/6

Starting October 2, 2018, prescribers in California will be required to check the state’s prescription monitoring database, Controlled Substance Utilization Review and Evaluation System (CURES), before prescribing Schedule II, III, or IV drugs. California is one of 39 states that mandate prescribers to check prescription monitoring databases in an effort to combat the opioid epidemic. By checking a database before prescribing, prescribers can identify “doctor shoppers” who go from doctor to doctor to obtain multiple prescriptions.

Prescribers will now be required to check CURES if it is the first time prescribing the scheduled drug for the patient or if it has been four months since the last time they checked the database for the patient. The check must be completed no earlier than 24 hours or the previous business day prior to the prescribing, ordering, administering or furnishing of a controlled substance to the patient.

All prescribers who were authorized to prescribe or dispense Schedule II-IV controlled substances were originally required to just register to use CURES by July 1, 2016. The requirement to check the database was to start six months after the state certified the database was ready. The California Department of Justice (DOJ) certified CURES was ready for statewide use on April 2, 2018.

If prescribers do not comply, it could result in disciplinary proceedings against a practitioner’s license. The Medical Board of California states in their CURES Mandatory Use FAQs¹, “Failing to consult CURES is a violation of the law and it could result in the issuance of a citation and fine, or could be a cause of action In an accusation that leads to disciplinary action. Disciplinary action could be a public reprimand, suspension, probation, or revocation. Each violation of the law is reviewed on a case-by-case basis.”

The Medical Board of California also recommends that prescribers either note in the patient’s chart that they checked the CURES database or print the report and put it in the patient’s file to document that the check was completed.

MDToolbox makes it convenient for prescribers to check CURES by providing a link directly to the database from within the prescription writer. The system also automatically makes note that the database was checked for the prescriber. For more information and to request a free trial, see California E-Prescribing or contact us at info@mdtoolbox.com.

1. Medical Board of California CURES Mandatory Use FAQs http://www.mbc.ca.gov/Licensees/Prescribing/CURES/CURES_FAQ.pdf?utm_source=link&utm_medium=email&utm_campaign=CURES&utm_content=faq

In a draft report, the Commission on Combating Drug Addiction and the Opioid Crisis proposed that state and federal prescription drug monitoring programs (PDMPs) should be completely interoperable by July 1, 2018¹. The White House-appointed commission is led by New Jersey Governor Chris Christie and is tasked with addressing the national opioid crisis.

The commission proposed several recommendations to President Trump in the report including declaring the opioid epidemic a national emergency. Specifically relating to the PDMPs it states, “Provide federal funding and technical support to states to enhance interstate data sharing among state-based prescription drug monitoring programs (PDMPs) to better track patient-specific prescription data and support regional law enforcement in cases of controlled substance diversion. Ensure federal health care systems, including Veteran’s Hospitals, participate in state-based data sharing.”

The report states that currently 49 states have PDMPs but many do not share data. As we wrote about earlier, 37 states are connected to NABP PMP InterConnect which is run by the National Association of Boards of Pharmacy. The commission urged that the VA and HHS should lead the effort to have all state and federal PDMP systems share information.

The report went on to state that PDMPs need to be easy to use and include other data to assist prescribing doctors. Interestingly, the commission said that “ideally, clinician should check their state PDMP before making the decision to prescribe either an opioid or benzodiazepine” but there was no recommendation to make it mandatory for prescribers to check.

The commission’s final report is due in just a couple weeks on October 1^st and it’s expected to include several other recommendations related to health IT.

1.  https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf

Missouri Governor Eric Greitens recently signed Executive Order (EO) 17-18¹ directing the Missouri Department of Health and Senior Services (DHSS) to create a statewide Prescription Drug Monitoring Program (PDMP). Despite legislative efforts for more than a decade, Missouri is currently the only state lacking such a program.

The governor’s announcement of the statewide PDMP said that it will utilize de-identified data from private sector partners to target “pill mills” that pump out prescription drugs at dangerous and unlawful levels. It will monitor both prescribers and dispensers of Schedule II through Schedule IV controlled substances in an effort to go directly to the source of drug shoppers. Opioids are the main focus as the national plague is hitting hard in Missouri with over 900 deaths in 2016 being due to opioid overdoses.

The executive order received national praise. Richard Baum, Acting Director of National Drug Control Policy stated, “In the context of both the ongoing opioid epidemic and the health of Missourians, it’s vital to have safeguards in place to make sure that doctors aren’t overprescribing opioids that can be misused and patients aren’t doctor-shopping for multiple prescriptions that could be misused or diverted.” Secretary Tom Price of the U.S. Department of Health and Human Services also praised the Governor stating, “I commend Missouri Governor Eric Greitens for taking a strong step in fighting the opioid epidemic by joining other states in establishing a Prescription Drug Monitoring Program (PDMP). I commend Governor Greitens for his leadership in Missouri as we all work to detect and deter the abuse of prescription drugs.”

State statute prevents Missouri from identifying patients, so they will be focusing on the prescribers and the dispensers with data from pharmacy benefit management organizations. They plan to be live with data from Express Scripts Holding Co. later this summer and hope to contract with two additional pharmacy benefit management organizations as well.

Due to the lack of a statewide program, local counties, led by St. Louis County, took it upon themselves earlier this year to create a prescription monitoring program. The St. Louis County PDMP focuses at the patient level instead of on prescribers and dispensers. The county program has three goals listed on its website²:

   1) Improve controlled substance prescribing by providing critical information regarding a patient’s controlled substance prescription history
   2) Inform clinical practice by identifying patients at high-risk who would benefit from early interventions
   3) Reduce the number of people who misuse, abuse, or overdose while making sure patients have access to safe, effective treatment

The new statewide PDMP is hoped to be a companion to the county program which covers the majority of the state, not a replacement, as the two systems take different approaches to combating the opioid epidemic.

1.https://governor.mo.gov/news/archive/governor-eric-greitens-announces-statewide-prescription-drug-monitoring-program

2. http://www.stlouisco.com/HealthandWellness/PDMP

North Carolina is the most recent state to pass a law requiring the use of e-Prescribing in an effort to combat opioid abuse. Governor Roy Cooper recently signed the Strengthen Opioid misuse Prevention (STOP) Act into law. The act requires that certain schedule II and schedule III controlled substances be electronically prescribed by January 1, 2020.

The act also sets a 5-day limit for initial prescriptions for acute pain and a 7-day limit for post-operative pain. It sets requirements for utilizing the North Carolina Controlled Substance Reporting System as well. The statewide reporting system tracks patients’ Schedule II-V controlled substance prescriptions so that prescribers can identify patients who may be misusing those controlled substances.

The opioid epidemic is hitting nationwide and North Carolina is no exception. There was a 73 percent increase in the number of opioid-related deaths from 2005 to 2015 in North Carolina with more than 13.000 opioid-related deaths during the period. 

North Carolina is the 5^th state to pass such legislation. New York, Virginia, Maine and Connecticut have similar laws requiring e-Prescribing. Several other states have pending legislation as well. All of these states hope to fight the opioid epidemic by reducing the number of opioids available and preventing the addictions from even starting.

E-Prescribing is an important tool in the opioid battle and we are happy to see so many states recognizing that. We are sure more and more states will join in the fight with this tool, but we also hope that prescribers will recognize the benefits and not wait for state mandates to start utilizing it. If you are a prescriber ready to start employing e-Prescribing of controlled substances in your practice, contact us to get started right away. 

Massachusetts, New Hampshire, New York and Texas are the four most recent states to join the prescription monitoring program (PMP) run by the National Association of Boards of Pharmacy (NABP) – NABP PMP InterConnect¹. This brings the total number of states connected to 37, making it the largest prescription data sharing network. Over 3.9 million requests and 8.2 million responses are processed through the system each month.

The complete list of connected states includes: Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Nevada, New Jersey, New Hampshire, New Mexico, New York, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia and Wisconsin.

It is expected that other states will be joining soon too. “We’re excited about the growth and response to PMP InterConnect,” said NABP President Hal Wand, MBA, RPh. “Our goal is to reach every state with a PMP to guarantee a true connection across our country in an effort for greater medical knowledge and our patients’ safety.”

There is no charge to the states to use the system and it’s setup to enforce each state’s data-access rules. Authorized healthcare professionals including physicians and pharmacists in each of the connected states are able to access multi-state histories of their patients’ controlled substance prescriptions. This is an important tool in combating prescription drug abuse and identifying potential problems by allowing providers to see a comprehensive history, especially for those patients who cross state lines.

1. "Four States Join NABP PMP InterConnect, the Nation’s Largest Prescription Data Sharing Network," National Association of Boards of Pharmacy (NABP) https://nabp.pharmacy/four-states-join-nabp-pmp-interconnect-nations-largest-prescription-data-sharing-network/

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/