Connecticut just passed Public Act No. 17-131¹ which mandates that prescribers must electronically prescribe controlled substances by January 1, 2018. The legislation was unanimously passed.

The law was originally proposed by Governor Dannel Malloy in an effort to combat opioid abuse and addiction. By requiring controlled substances prescriptions to be sent electronically, it allows the prescriptions to be tracked and prevents fraud from forged or stolen paper prescriptions.

The law also increases the ability of state agencies to share data on opioid abuse, as well as allows patients to insert a form in their medical records refusing to be prescribed opioids.

Most pharmacies appear ready, but it’s going to be a change for the majority of prescribers in the state. According to Surescripts’ EPCS State Readiness page², 96.7% of pharmacies are enabled for e-Prescribing of controlled substances in Connecticut, but only 5% of prescribers are currently enabled. Surescripts National Progress Report also showed that in 2016 only 6% of controlled substances were prescribed electronically in Connecticut.

Connecticut is the fourth state to enact a mandate requiring electronic prescriptions for controlled substances (EPCS). Minnesota, New York, and Maine were the first three states to pass similar laws. Several other states are considering similar legislation as well.

We are pleased that many states have seen the benefits of EPCS and are taking action to combat the ever growing opioid crisis in our nation with this important tool. Find out more about EPCS and start e-Prescribing controlled substances today.

   1.  Public Act No. 17-131: An Act Preventing Prescription Opioid Diversion and Abuse. https://www.cga.ct.gov/2017/ACT/pa/2017PA-00131-R00HB-07052-PA.htm

   2.  Surescripts State Readiness and Local Search Tool http://surescripts.com/products-and-services/e-prescribing-of-controlled-substances

   3. Surescripts National Progress Report 2016 http://surescripts.com/news-center/national-progress-report-2016/#/EPCS-readiness-by-state

Prescribers in Maine have less than 3 weeks until the mandate requiring all opioid prescriptions be sent electronically goes into effect. As of July 1^st, 2017, licensed practitioners in Maine may no longer write paper prescriptions for opioid medications according to Public Law Chapter 488¹.

As we wrote about earlier, the mandate was put in place in an effort to combat opiate abuse and heroin addiction. E-Prescribing prevents forged prescriptions, eliminates errors from illegible handwriting and misunderstood oral prescriptions, and helps prevent overprescribing of pain medications. It’s hoped that by limiting the pain pills, it will prevent people from even trying heroin to begin with.  

The Office of Substance Abuse and Mental Health Services in Maine produced a document “Electronic Prescribing in Maine: A Guide to Understanding E-Prescribing and its Benefits²,” which addresses some frequently asked questions about the mandate.  Among the FAQs, it’s stated that an electronic prescription will be required for any amount of opioid medication being prescribed, even those for fewer than 7 days. Sending a prescription via facsimile will also not meet the requirements. Opioid prescriptions must be sent electronically using software that meets all of the federal security requirements and has been approved by the DEA for EPCS.

The DEA requirements for EPCS include:

• Using certified software that has gone through a 3^rd Party Audit – software systems must show that they meet the DEA requirements for signing, transmitting, and processing controlled substances prescriptions

• Identity proofing – all prescribers must prove they are who they say they are and have the proper credentials to prescribe controlled substances

• 2-Factor Authentication – prescribers must use 2-factor authentication to sign controlled substance prescriptions electronically. This involves using 2 of the following: something you know (a password), something you have (most commonly a software or hardware token), or something you are (biometric information).

While the requirements can make it seem overwhelming, MDToolbox has simplified the process. Signing up for MDToolbox-Rx e-Prescribing with EPCS is a simple process with only a few steps that can be completed within minutes. Once signed up, utilizing the software is just as easy with an intuitive workflow.

Although it’s quick and easy to get started with MDToolbox, we do not recommend waiting any longer. If you prescribe opioids in Maine and still need e-Prescribing software to meet the mandate, contact us today at info@mdtoolbox.com or 206-331-4420! We are ready to answer any questions you have and help make your transition to EPCS as smooth as possible.

1.  https://legislature.maine.gov/legis/bills/bills_127th/chapters/PUBLIC488.asp

2. Electronic Prescribing in Maine, A Guide to Understanding E-Prescribing and its Benefits. http://www.maine.gov/dhhs/samhs/osa/data/pmp/Electronic-Prescribing.pdf

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/

As we ring in the new year, medical providers now can say goodbye to the CMS’s “Meaningful Use Incentive Program” (MU) and start preparing for the new Medicare incentive program.

Providers who used qualified systems in 2016 can still attest to Meaningful Use for the 2016 year (you must have been a “meaningful user” of certified electronic medical record system(s) for the minimum reporting period. Visit this website for more info on how the previous year’s MU programs worked and deadlines for attesting: 

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2016ProgramRequirements.html

Now in 2017, Meaningful Use will become one of four components of the new “Merit-Based Incentive Payment System” or MIPS. MIPS is part of the bigger Medicare Access and CHIP Reauthorization or MACRA.² 

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment penalties for 13 years.  

The MACRA program introduces two paths that Medicare providers can choose from for participation:

• Advanced Alternative Payment Models (APMs) (providers apply for a special payment model program) or
• The Merit-based Incentive Payment System (MIPS)  (a performance-based program)

Who Does this Affect?

Providers who are in an Advanced APM or who bill Medicare for more than $30,000 a year and care for more than 100 Medicare patients a year are affected. Providers with less than that are not affected and not part of the program.³  This includes:

• Physician
• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Certified registered nurse anesthetist

Advanced Alternative Payment Models (APMs)

The Advanced APMs program allows certain providers to apply for the APM track. This gives added incentive payments to provide high-quality and cost-efficient care. See the APM website for more information on the special programs and how providers can apply:

https://qpp.cms.gov/learn/apms

The Merit-based Incentive Payment System (MIPS)

Most Medicare Providers will be part of MIPS. They will earn a payment adjustment based on evidence-based and practice-specific quality data submitted. According to CMS, the Quality Payment Program policy will reform Medicare payments for more than 600,000 clinicians across the U.S.

Providers participating in the program in 2017 will submit their data by March 2018 and based on submission, their 2019 Medicare payments will be adjusted up, down, or not at all. 

MIPS is broken down into four categories and is setup so that the more Providers participate (and attest to), the higher score (and incentive) providers will get. A Medicare provider who does not participate at all (0%) may see up to 4% negative adjustment in 2019. A provider with a minimal amount of participation (e.g. submit one measure) may be able to avoid adjustment. For partial submission (submit the minimums for a partial year) they will see neutral or positive adjustments, and submit a full year and earn a positive payment adjustment.

If we take a quick look at how each category works:

•  Quality
•  Most Providers will report up to 6 quality measures (including an outcome type measure). Quality measures selected should be focused based on type of care and specialty as appropriate.
•  Reporting period must be a minimum of 90 days.
• There are over 250 quality measures available, be sure to check your health record software system to see which ones they support (can help gather data for you) when planning.
• Measures go across many specialties and problem sets:  For example, “Age Appropriate Screen Colonoscopy” – Report the percentage of patients greater than 85 years old seen by the Provider who received a colonoscopy screening Jan 1 to December 31.

•  Improvement Activities
• Most Providers will attest to completing a minimum of 4 improvement activities for at least 90 days.
• As of the writing of this blog, the CMS tools shows 92 activities to choose from.
• Activities range from care coordination, patient safety changes and beneficiary engagements.
• Examples: Join and participate (for a minimum of 6 months) in your States Prescription Monitoring Program (PMP). Or another example: Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the certified EHR technology.

• Advancing Care Information
• Use a qualified (certified) product (or products) for a minimum of 90 days.
• There are two different programs to pick from depending on your Electronic Health Record Software Certification. For 2017, you will be able to use either a 2014 Certified Product (previously called Stage 2 MU Certification) or a 2015 certified product (certified for the MU Final Ruling criteria). Attest to a minimum of:

• E-Prescribing
• Provide Patient Access
• Send Summary of Care Records
• Receive Summary of Care Records
• Report up to 9 additional measures for bonus credits
• Cost
• No actions required: Cost will be computing from your claims
• The cost category will be calculated in 2017, but will not be used to determine your payment adjustment. In 2018, CMS will start using the cost category to determine your payment adjustment.

Medicare Providers will want to research the programs and decide their level of participation early in 2017. Full year participation would require making sure their Electronic Health Record system is setup for minimal data tracking and other required features like E-Prescribing and Direct Messaging.

References

1. 2017 Program requirements:

   https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2017ProgramRequirements.html

2. MIPS and MACRA:

   http://www.impact-advisors.com/meaningful-use/mips-macra-mu-the-next-evolution-of-healthcare-payment-reform/#sthash.vMkVGSvN.dpuf

3. https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf

4. MIPS Quality Payment Program Website: 

   https://qpp.cms.gov/measures/performance

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/

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