Study Shows e-Prescriptions Aid in Best Practices for Opioid Prescribing

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 E-Prescriptions Safer than Hand Written

Implementing ways to fight the national opioid epidemic is at the forefront of many states’ legislative sessions.  As we’ve mentioned in several previous posts, a growing number of states are fighting the epidemic by requiring prescribers to electronically prescribe these controlled substances. A new study published by the Journal of Opioid Management shows that these lawmakers are on the right track. And it’s more than just increasing legibility and preventing prescription fraud.

Researchers from John Hopkins University analyzed 510 prescriptions for opioids looking for errors, discrepancies, and variations from ideal practice1. The study included both handwritten and electronically generated prescriptions filled at an outpatient pharmacy. An alarming 89% of handwritten prescriptions contained errors. What’s more is that 41% of those prescriptions were noncompliant with DEA rules. Overall, 92% of handwritten prescriptions failed to meet ideal practice standards, contained errors, or were noncompliant with DEA rules.

In contrast, none of the EHR computer-generated prescriptions contained errors and all of them were fully compliant with DEA rules. Electronic prescriptions are written using standard templates where most of the time the software will not even allow a prescriber to save the prescription without including necessary information such as the date, amount, and at least two patient identifiers. The software also aids in making sure any additional DEA rules and best practices are being followed.

The opioid epidemic needs to be tackled from several angles, including making sure the prescriptions that are being provided are accurate and safe for patients. Patient safety needs to be a top priority and prescribers need to make use of the tools available to aid them in following best practices and ensuring all DEA rules are abided by. Electronically prescribing has been shown time and time again to be a powerful resource. For more information on how to get started with e-Prescribing, contact us at info@mdtoolbox.com or 206-331-4420. 

 

  1.  An analysis of errors, discrepancies, and variation in opioid prescriptions for adult outpatients at a teaching hospital http://www.wmpllc.org/ojs-2.4.2/index.php/jom/article/view/556

North Carolina Joins Fight Against Opioid Abuse with Mandated e-Prescribing

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North Carolina e-Prescribing

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 5th 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. 

E-Prescribing Growth Continues to Soar

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E-Prescribing makes the prescribing process easier and safer for patients, prescribers, and pharmacists alike, so it comes as no surprise that e-Prescribing rates continue to surge each year. Surescripts recently released its 2016 National Progress Report1 detailing the e-Prescribing growth they’ve seen on their network.

A total of 1.6 billion e-prescriptions were sent in 2016, up 12% from 1.4 billion in 2015. This accounts for 73% of all prescriptions being sent electronically.

The rates for e-Prescribing of Controlled Substances (EPCS) saw one of the biggest increases with a 256% jump from 2015. There were 45.3 million e-prescriptions for controlled substances sent in 2016 as compared to only 12.8 million in 2015. Part of this increase can be attributed to states such as New York, Minnesota and soon to be Maine mandating that all controlled substances be sent electronically.

The mandate helped New York be ranked number 1 in the Surescripts report with 72.1% of prescribers enabled for EPCS, 98.1% of pharmacies enabled, and 91.9% of controlled substances prescribed electronically. Minnesota, who doesn’t enforce their mandate, was ranked number 7 with 14.3% of prescribers enabled for EPCS, 93.8% of pharmacies enabled, and 19.8% of controlled substances prescribed electronically.

States are putting these mandates in place in an effort to combat substance abuse and increase patient safety. With software, like MDToolbox-Rx, incorporating EPCS into the existing e-Prescribing workflows, it really leaves little reason for those prescribers who are already e-Prescribing not to electronically prescribe controlled substances as well.

The ability to access patient medication histories electronically at the point of prescribing also plays an important role in patient safety. It allows prescribers the ability to see a more complete history and avoid adverse drug events. The amount of providers accessing medical histories on the Surescripts network also increased in 2016. More than 1.08 billion medication histories were accessed.

2016 also saw a 22% increase in the number of healthcare professional connected to the Surescripts network with 1.3 million healthcare professionals connecting. However, although the number of prescribers connected increased by 7%, it’s somewhat surprising that 36% of prescribers are still not connected. We are confident that the number of prescribers who connect will continue to increase though, as prescribers continue to realize the value of e-Prescribing and the ease of use provided by software like MDToolbox-Rx.

 

1. Surescripts 2016 National Progress Report http://surescripts.com/news-center/national-progress-report-2016/

Connecticut Mandates e-Prescribing of Controlled Substances

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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

Maine e-Prescribing Deadline Fast Approaching

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Prescribers in Maine have less than 3 weeks until the mandate requiring all opioid prescriptions be sent electronically goes into effect. As of July 1st, 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 3rd 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

37 States Now Sharing Prescription Data

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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/

2017 Brings Changes to Medicare Incentive Programs and Meaningful Use

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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.

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.

CMS has setup a new website for the Quality Program4 which breaks down the four components of the MIPS:

  • Quality (replaces PQRS)   (60%)
  • Improvement Activities (new)  (25%)
  • Advancing Care Information (replaces Meaningful Use)   (15%)
  • Cost (replaces Value Based Modifier)   (0% in 2017)

Image Credit:  MIPS Quality Payment Program Website:  https://qpp.cms.gov/measures/performance

 

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

Study Finds E-Prescribing Improves Medication Adherence

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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 Asks Governor to Veto I-STOP Loopholes

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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 

Will Massachusetts be the Next State to Require EPCS?

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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 24th 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 15th, 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/