Iowa Considering Mandated E-Prescribing

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Iowa is the latest state to consider legislation that would require electronic prescribing. The Iowa Board of Pharmacy suggested Senate Study Bill 30741 which would require all prescriptions to be sent electronically. Like several other states with similar enacted and proposed legislation, lawmakers in Iowa hope to curb the opioid epidemic with this bill.

Executive director of the Iowa Board of Pharmacy, Andrew Funk, informed senators that currently 65% of Iowa prescriptions for non-addictive drugs are sent electronically, but only 9% of prescriptions for addictive drugs are electronic. This leaves a lot of room for fraudulent prescriptions.

Iowa Senator Tom Greene, a former pharmacist, is all too familiar with forged paper prescriptions. "A patient presented me with a prescription for sleeping medication-a controlled substance," said Greene. "And the doctor had ordered ten tablets. Well, the patient changed the one-zero to a four-zero. There are cases like that out there, and again electronic prescribing and the electronic transmission of that information is very accurate." Lawmakers hope that in addition to preventing phony prescriptions, it would also help with mistakes caused by handwritten prescriptions. Prescriptions sent electronically eliminate the possibilities for patients to alter them, as well as remove the potential for pharmacists to misinterpret illegible prescriptions.

The bill allows for providers to ask for temporary exemptions if they aren’t able to meet the requirements in time, but any prescriber without an exemption would be subject to $250 fines per violation of the law, up to $5,000 per year. There are also exemptions for prescriptions for patients in nursing homes, long-term care facilities, or jail, as well as veterinary prescriptions. In addition, the bill states the requirements do not apply to compound prescriptions containing two or more components and prescriptions requiring “information that makes electronic submission impractical, such as complicated or lengthy directions for use or attachments.”

As the bill is written now, it would begin July 1, 2019. Some lobbyists, however, feel that this is too soon especially for rural hospitals and physicians. They are pushing for the date to moved to July 1, 2020. Senator Greene and two other senators on the subcommittee were said to informally agree to a compromise of January 1, 2020.

One of the great things about our stand-alone web-based e-Prescribing products is that there is not a lot of setup needed. As long as a prescriber has a device that can access the internet (computer, tablet, or phone), they can send their prescriptions electronically. While sending controlled substances electronically does require a 2nd device to electronically sign the prescription, it is as simple as using a phone or key fob.  Most prescribers can get setup and start e-Prescribing with MDToolbox in just a matter of minutes. There is no need to stress about putting complex systems in place or wait until the deadline. To see how quick and easy it is, sign up for a free trial or request a demo here.

 

1.  https://www.legis.iowa.gov/legislation/BillBook?ba=SSB3074

Arizona to Require E-Prescribing to Fight Opioid Abuse

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Last week, Arizona Governor Doug Ducey called a special legislative session to pass the Arizona Opioid Epidemic Act1. In record speed, the Arizona Legislature voted unanimously to approve it and Ducey signed it into law on Friday.

The act is aimed at combating the opioid epidemic in Arizona, where in just the last 6 months there have been more than 800 opioid-related deaths. The focus of the act is to reduce opioid misuse, promote safe prescribing and dispensing, and improve access to treatment.

As stated in the Governor’s news release outlining the act, the policy includes:

  • Identifying gaps in and improving access to treatment, including for uninsured or underinsured Arizonans, with a new $10 million investment;
  • Expanding access to the overdose reversal drug Naloxone for law enforcement or corrections officers currently not authorized to administer it;
  • Holding bad actors accountable by ending pill mills, increasing oversight mechanisms, and enacting criminal penalties for manufacturers who defraud the public about their products;
  • Enhancing continuing medical education for all professions that prescribe or dispense opioids;
  • Enacting a Good Samaritan law to allow people to call 911 for a potential opioid overdose;
  • Cracking down on forged prescriptions by requiring e-prescribing;
  • Requiring all pharmacists to check the Controlled Substances Prescription Monitoring Program prior to dispensing an opioid or benzodiazepine;
  • And limiting the first-fill of an opioid prescription to five days for all opioid naïve patients and limiting dosage levels to align with federal prescribing guidelines. These proposals contain important exemptions to protect chronic pain suffers, cancer, trauma or burn patients, hospice or end-of-life patients, and those receiving medication assisted treatment for substance use disorder.

The e-Prescribing requirement will begin January 1, 2019 and mandates schedule II controlled substances must be sent electronically. There is some concern that those in rural areas do not have the necessary technology for e-Prescribing. Therefore, the act gives those providers additional time and outlines that e-Prescribing will not be mandated until July 1, 2019 for counties with less than 150,000. It also allows for the Board of Pharmacy to grant waivers to prescribers with a lack of broadband Internet access or other hardships.

At MDToolbox, we urge providers not to wait until the mandate and to e-Prescribe all prescriptions. In addition to preventing forged prescriptions and helping combat opioid abuse, e-Prescribing provides many other benefits for providers and patients. Contact us to get started with a free trial today.

 

1.       Arizona Opioid Epidemic Act Policy Primer https://azgovernor.gov/sites/default/files/related-docs/arizona_opioid_epidemic_act_policy_primer.pdf

MIPS Deadlines Approaching Fast

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As 2017 comes to a close, the deadline for providers to avoid a Medicare penalty in 2019 is approaching and the 2018 reporting periods are about to begin. The Centers for Medicare & Medicaid Services (CMS) has designed the Quality Payment Program (QPP) with two tracks clinicians can take under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) - Advanced Alternative Payment Models (APMs) or Merit-based Incentive Payment System (MIPS). As we mentioned at the beginning of this year, the well-known Meaningful Use program has been added as a part of MIPS. There are four components to MIPS: Quality, Improvement Activities, Advancing Care Information (ACI), and Cost. Meaningful Use is part of the ACI component. Providers have until March 31, 2018 to send in their data for 2017 which will increase, decrease, or keep their 2019 Medicare payments the same. The reporting period for 2018 starts January 1, 2018. CMS is taking a gradual approach to implementing the program so the requirements for each year differ.

2017 Requirements:

CMS offers “pick your pace” options in 2017. These include:

  • Zero participation – receive a 4% penalty in 2019
  • Test – submit a minimum of one quality measure, one improvement activity, or the four required ACI measures and avoid a negative payment adjustment.
  • Partial participation – Submit at least 90 days of 2017 data for more than one quality measure, OR more than one improvement activity, OR more than the four required ACI measures and avoid a negative payment adjustment and possibly receive a positive payment adjustment.
  • Full participation - Submit at least 90 days of data for all required quality measures, AND all required improvement activities, AND all four required ACI measures and earn a positive payment adjustment.
  • Advanced Alternative Payment Model - receive 25% of Medicare payments or see 20% of Medicare patients through an Advanced APM in 2017, and earn a 5% incentive payment in 2019.

Certified Electronic Health Record Technology (CEHRT) Requirements:

  • Use either 2014 or 2015 Edition CEHRT or a combination

 

2018 Requirements:

  • Zero participation – penalty increases to 5% in 2020
  • MIPS Participation Minimum Performance Periods

o   Quality – 12 months

o   Cost – 12 months

o   Improvement Activities – 90 days

o   Advancing Care Information – 90 days

  • To meet the point threshold to avoid a negative payment adjustment, clinicians must:

o   Report all required Improvement Activities.

o  Meet the Advancing Care Information base score and submit 1 Quality measure that meets data completeness.

o  Meet the Advancing Care Information base score, by reporting the 5 base measures, and submit one medium-weighted Improvement Activity.

o   Submit 6 Quality measures that meet data completeness criteria.

CEHRT Requirements:

  • Use either 2014 or 2015 Edition CEHRT or a combination
  • Receive a 10% bonus if only use 2015 Edition CEHRT

 

There are only a couple days left in 2017 to make sure you have at least met the requirements for the “Test” option to avoid the penalty in 2019. It’s also important to note that 2018 requires 12 months of reporting for Quality and Cost measures meaning that reporting period is also starting in just a couple days. It’s vital to make sure you are using a product or combination of products that are certified. MDToolbox was one of the only stand-alone e-Prescribing vendors to certify on the 2015 edition CEHRT requirements earlier this year. We are certified for e-Prescribing and Patient Education and are able to integrate with many other products to meet all of the requirements. Contact us for more info on how we can help you meet the MIPS requirements.

Opioid Commission Recommends Increased Electronic Prescribing

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President Donald Trump declared the opioid epidemic a national public health emergency on October 26, 2017. In his address, Trump called opioids the “worst drug crisis in American history.”

After the President’s declaration, the President’s Commission on Combating Drug Addiction and the Opioid Crisis issued its final report1. In the Chairman’s letter written by Governor Chris Christie, he points out that 175 Americans are dying a day from this epidemic. The 131-page report goes on to include more than 50 recommendations.

One of the most prudent recommendations is that the Office of National Drug Control Policy (ONDCP) and the DEA increase electronic prescribing to prevent diversion and forgery. They also recommend that the DEA revise the Interim Final Rule which lays out the requirements for electronically prescribing controlled substances in order to make registration and using EPCS easier.

Other recommendations include mandatory PDMP checks, the creation of a Department of Justice-led data-sharing hub, and integrated PDMP data in EHRs. The report suggests passing the Prescription Drug Monitoring (PDMP) Act of 2017 which mandates using PDMPs in states that receive federal funding. This Act also directs the Department of Justice (DOJ) to fund the establishment and maintenance of a data-sharing hub so information could be shared across states. The Commission points out that many providers resist using PDMPs because they don’t integrate well into EHRs, so they believe improving these integrations is necessary to increase effectiveness.

While these are great strides in the right direction, there is still a huge issue at hand. Trump did not mention any specific actions the administration will take or how they will be funded. With only declaring it a national public health emergency as opposed to a national emergency, there is not much more funding available. The commission’s report urges Congress and the Administration to block grant federal funding for opioid-related and SUD-related activities to the states. However, the report does not address the amount of funding needed for their recommendations.

1. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf

National E-Prescribing of Controlled Substances Bill Gaining Traction

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Congressman Markwayne Mullin (R-OK) and Congresswoman Katherine Clark (D-MA) are confident the Every Prescription Conveyed Securely (EPCS) Act they proposed will be passed. The bill mandates electronic prescribing of controlled substances for Medicare patients nationwide.

When speaking at a forum in Washington, DC, the representatives said the bill has five cosponsors and the strong bipartisan support needed to become law.1 They want to pass it in whatever way necessary - either as a stand-alone bill or attached to another piece of legislation. Clark emphasized the importance of the bill stating, “we will put it on any vehicle that we see, and I hope we can do it in the next few months.”

The EPCS Act is meant to combat the opioid epidemic by helping providers detect fraud and abuse by patients who may be seeking the same prescriptions from multiple sources. Mullin pointed out that currently only about 14% of opioids are e-Prescribed. This leaves a huge amount of handwritten prescriptions that can be easily forged.

The bill sponsors said that opioid manufacturers and distributors as well as pharmacy benefit managers are in full support of the bill. Steve Miller, MD, the chief medical officer of one of the nation’s largest pharmacy benefit managers, Express Scripts, expressed his support of mandator e-Prescribing at the forum stating, “We're really excited the federal government is getting into the act.” He pointed out a few of the many benefits of e-Prescribing for Medicare patients – increasing convenience, improving access to needed pain medications, and eliminating fraud and abuse.

There has been some resistance from healthcare providers and hospitals due to the expenses that would go along with implementing e-Prescribing. While there is a cost associated with e-Prescribing controlled substances, we have seen the benefits of e-Prescribing for providers more than make up for this cost. Clark stated that e-Prescribing is a “critical tool going forward” in the fight against the opioid epidemic that’s worth the cost.

The law would also not go into effect until 2020, leaving plenty of time for prescribers to prepare. In addition, there would be a number of exemptions including economic hardship and technologic limitations for up to a year, during public health emergencies or in clinical trials.

Find out more about Electronic Prescribing of Controlled Substances.

   1.  e-Prescribing Bill for Controlled Substances May Soon Be Law - Medscape - Oct 24, 2017 

National PDMP Data Sharing Proposed by White House Commission

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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 1st 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

Forwarding Unfilled Electronic Prescriptions for Controlled Substances

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The pharmacy protocol for forwarding unfilled e-Prescribed controlled substance prescriptions was recently clarified by the Drug Enforcement Agency (DEA). The DEA has specified that if for any reason one pharmacy cannot fill the original controlled substance e-Prescription, it may be forwarded to another DEA-registered pharmacy. This was clarified by the DEA’s associate section chief of the liaison and policy section of the DEA’s Diversion Control division Loren Miller in an email to National Association of Boards of Pharmacy CEO Carmen Catizone1.

The email states, “As posted in the preambles of the [notice of proposed rulemaking] and the [interim final rule], an unfilled original EPCS prescription can be forwarded from one DEA registered retail pharmacy to another DEA registered retail pharmacy, and this includes Schedule II controlled substances.”

The National Association of Chain Drug Stores (NACDS) had contacted the DEA for clarification on the issue in May and applauded the response that was received.2 “Simply put, this guidance encourages the use of electronic prescribing for controlled substances, and removes a substantial barrier to doing so,” NACDS president and CEO Steve Anderson, IOM, CAE said. “Electronic prescribing has significant advantages over other forms of transmitting a prescription because it reduces opportunities for fraud and abuse. NACDS is unwavering in its commitment to working with all parties to help find and implement solutions to opioid issues, while providing appropriate patient care. This has been, and remains, a top priority of NACDS, and we appreciate the DEA's action on this guidance, which we consider to be entirely consistent with patient care and with the proper handling of controlled substances.”

This is an important clarification that benefits both patients and prescribers by streamlining the process. It eliminates the need for a pharmacist to call the prescriber for a new prescription if it needs to be sent to a different pharmacy. This makes it quicker for patients to receive the medications they need and makes less work for the prescribers. This helps encourage prescribers to e-Prescribe which in turn improves prescription safety and prevents fraud and abuse.

 

1. http://www.ncbop.org/PDF/LMillerDEAGuidanceTransferofOnFileCSPrescriptions.pdf

2. NACDS Applauds DEA Guidance on Forwarding of Electronic Prescriptions for Controlled Substances  

https://www.nacds.org/news/nacds-applauds-dea-guidance-on-forwarding-of-electronic-prescriptions-for-controlled-substances/

National E-Prescribing of Controlled Substances Bill Proposed to Fight Opioid Abuse

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Congressman Markwayne Mullin (R-OK) and Congresswoman Katherine Clark (D-MA) recently introduced legislation that would mandate Electronic Prescribing of Controlled Substances (EPCS) under Medicare Part D. The “Every Prescription Conveyed Securely Act”, H.R. 35281, was introduced into the House of Representatives.

It states that a prescription for a covered part D drug under a prescription drug plan for schedule II – V controlled substances must be transmitted electronically. If the bill passes, it would apply to coverage of drugs prescribed on or after January 1, 2020.

The aim of the legislation is to combat the national opioid epidemic. E-Prescribing does this by providing safer and more secure prescriptions. Electronic prescriptions can’t be forged or stolen like paper prescriptions. It also allows prescribers to easily track prescriptions and prevents patients from doctor shopping.

“Opioids claim nearly a hundred lives a day, and parents across the country worry they will be next to get the call their child has overdosed,” said Clark.  “Modernizing public health practices to include electronic prescriptions will curb the over-prescribing of opioids, eliminate the costs and inefficiencies of paperwork, and strengthen communication between doctors and patients.  Congress should come together to pass this commonsense solution to prevent overdoses and save lives.”

Mullen stated, “We need to ensure that patients are receiving opioids only when absolutely necessary and take precautionary measures to prohibit them from falling into the wrong hands.  Our bill, the EPCS Act, aims to close a dangerous loophole that has been fueling the problem of excessively prescribed opioids. By requiring all doctors and pharmacists to use an online database when prescribing these highly addictive drugs, we allow e-prescriptions to control, track, and monitor these highly addictive painkillers on a new level. This bill prevents patients from doctor shopping and prevents fraudulent, handwritten paper prescriptions.”

We have seen several states including New York, Maine, Connecticut, Virginia, and North Carolina take a similar approach to combat opioid abuse by mandating e-Prescribing of controlled substances at the state level, but this would be the first bill passed at the national level. This is definitely a step in the right direction of fighting the national opioid epidemic and we are hopeful that Congress will recognize the benefits e-Prescribing can bring. We also urge prescribers and health IT vendors alike not to wait for such bills to be enacted and to start taking advantage of the benefits of EPCS now. Contact us for more information about EPCS for prescribers and integrating EPCS for vendors at info@mdtoolbox.com.

 

https://www.congress.gov/bill/115th-congress/house-bill/3528/text/ih?overview=closed&format=xml

Missouri Final State to Implement a Prescription Drug Monitoring Program

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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

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