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The DEA, E-Prescribing and Prescription Monitoring Programs

April 6, 2010
by David Raths
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Taking a closer look at the push to allow physicians to electronically prescribe controlled substances.

For an upcoming issue of Healthcare Informatics, I have been working on a feature story that identifies a handful of healthcare IT-related issues that have proven difficult for policymakers to solve.

One issue I was considering for my list was the push to allow physicians to e-prescribe controlled substances. Many in the industry and in Congress have criticized the Drug Enforcement Administration’s reluctance to allow e-prescribing of controlled substances as a hindrance to wider e-prescribing adoption.

The ban has forced some prescribers to use a computer for half of their practice, then turn to paper for the rest.

But an important milestone was reached in late March when DEA published a 334-page Interim Final Rule, with a 60-day comment period, describing procedures providers must follow in order to electronically prescribe controlled substances, including the use of two-factor authentication. It will be interesting to see how difficult it is for providers and CIOs to match the new regulations to their e-prescribing workflow.

Another long-term challenge related to controlled substances is the goal of creating a national prescription drug-monitoring program (PDMP) in order to flag potential “doctor-shopping” by patients. A national database showing which controlled substances are already prescribed would help doctors avoid duplication of prescriptions and the possibility of prescribing one medication that could be harmful in combination with another, according to the American Society of Interventional Pain Physicians (ASIPP).

One legislative solution, the National All Schedules Prescription Electronic Reporting (NASPER), grew out of the efforts of states to develop PDMPs — registries that have been established in 34 states.

These state PDMPs, though valuable, have some limitations and inconsistencies. As Liesa Jenkins, executive director of CareSpark, a health information exchange covering parts of rural Virginia and Tennessee, explained to me recently, state PDMPs are maintained by entities that vary from state to state. For example, in Tennessee the state board of pharmacy is the responsible entity, while in Virginia the state healthcare licensing board is the owner of the registry. Each state has its own rules for who can access it, what information they can access, how users get permission to access it, how long it takes to receive information, and how often information is reported. And so far they don’t share much information, which would be valuable in bordering states.

A 2009 U.S. Government Accountability Office report, based on a study of five states, noted some other limitations:

“Officials from the five selected states said that physician participation in PDMP is not widespread and not required. In fact, one state did not have a Web-based PDMP; the health care provider has to put in a manual request to the agency to have a controlled substance report generated.” The GAO also noted that no nationwide PDMP exists, and only 33 states had operational prescription drug-monitoring programs as of June 2009. According to one state official, “people would sometimes cross state borders to obtain prescription drugs in a state without a program.”

The intent of NASPER is to develop consistent national criteria for PDMPs and create the capacity for the interstate exchange of information. President George W. Bush signed it into law in 2005, authorizing a total of $52 to be appropriated over a five-year period. So far, however, only a few million dollars have been appropriated.

ASIPP is urging Congress to fully fund the program.

Dr. David Kloth, M.D., founder, medical director, and president of Connecticut Pain Care, wrote last October in an opinion piece for Huffington Post, that fully funding NASPER would help significantly curtail doctor shopping and prescription drug abuse and allow physicians to “detect prescription drug abuse and identify if patients are doctor shopping — even if they cross state lines to avoid detection.”

Kloth, who is also a board member and past president of ASIPP, added that it would “save countless lives and significantly reduce the exorbitant cost of prescription drug abuse on our health care system. According to ASIPP's estimates, it also will pay for itself in less than a year.”

Is this a healthcare IT application whose time has come? Would harmonizing and sharing data between these state programs raise other issues?