Last June, Connecticut lawmakers passed legislation that would begin to require electronic prescribing of opioid medication starting in 2018. The bill, “An Act Preventing Prescription Opioid Diversion and Abuse 2016,” was passed so that the further steps could be taken to fix a growing statewide epidemic: in 2016, Connecticut had 917 fatal overdoses involving painkillers—a 26-percent year-over-year increase. And since 2013, Connecticut has overwhelmingly surpassed the national death rate for drug and opioid overdoses.
Now, Connecticut joins New York, Maine, and Virginia as the fourth state to pass similar electronic prescribing mandates, while eight other states have had similar legislation introduced. Health IT leaders point out that e-prescribing of opioids and other controlled substances helps address drug diversion, fraud, and doctor shopping by taking the paper prescription—and the prescriber’s DEA number—out of the hands of the patient. Prescriptions are more securely sent directly to the pharmacy, which should improve patient safety and prescription security.
Although one might fairly assume that giving Connecticut providers just six months to implement e-prescribing of opioid medication across their organizations could be difficult, at Hartford Health, a mid-sized clinically integrated network with five hospitals, some 225 locations and 4,000 providers in total, clinical and IT leaders were ready for the challenge—even if they were a little taken aback by the government’s mandated timeframe.
“Legislators passed the bill and [Connecticut] Governor [Dannel Malloy] signed it on June 30 of last year, so what shocked us was that they gave us just six months to implement everything,” says Spencer Erman, M.D., vice president and CMIO of Hartford Health. “We had to get it up and running by January 1, 2018. We didn’t think that was enough time, even though we were considering doing this anyway—just not in that timeframe,” he says.
Nonetheless, Erman and his team quickly got to work. Prior to leveraging EPCS (electronic prescriptions for controlled substances) the Hartford Health system was exclusively prescribing these medications on paper, even though four of its hospitals were live on the system’s electronic health record (EHR). Erman explains that because of a discrepancy between federal and state regulations, electronically prescribing Schedule II drugs was not a seamless or efficient process for providers.
“So, for Schedule II [drugs], we had to print [the prescription] out, sign it, and fax it to the pharmacy, or write a paper prescription and note in the EHR that we prescribed it. That was not an efficient system. It created dual workflows and it was frustrating for patients,” Erman recalls. For example, if patients needed refills they had to pick up another prescription rather than having the provider simply send it over electronically. In turn, this increased risk of fraud, forgery, and drug diversion because “you have these paper prescriptions floating around on a pad, on a counter or even in a doctor’s lab coat,” Erman contends. “You just never know,” he says.
Complicating matters was that at the time the legislation passed, Hartford Health also had a double EHR upgrade as well as a hospital go-live that October. “We didn’t have a lot of bandwidth to take on this project. But we had to do it, so we did,” admits Erman. After looking at a few different vendors, Hartford Health chose the Lexington, Mass.-based Imprivata, a technology company that the health system already had a relationship with.
Hartford Health leaders then established a panel, inclusive of about 30 subject matter experts at first, such as providers, advanced practitioners, and physicians from all over the state to figure out how EPCS would be best implemented. The panel got trimmed down to 18 active folks, who decided that the health system, with the aid of Imprivata technology, would deploy fingerprint biometrics and push notifications for cell phones, with the goal of securely establishing the prescribing provider’s identity, says Erman.
“With smartphones, you prescribe [the medication] in Epic, put in your password, and you get a pop-up on your phone. You don’t have to open other apps; you just get asked if you want to authorize this prescription. Then you swipe and it’s done,” explains Erman. “And if you are not within Wi-Fi or cellular range, you can use the phone as a token by opening the Imprivata app and getting a code to enter in. We also use fingerprints in certain high-flow areas such as ambulatory surgery operating rooms or emergency departments,” he adds.
Hartford Health decided to instill what Erman calls “institutional identity proofing,” where the health system registers each person individually in person to issue the credentials and then get him or her signed up to use EPCS. “We used a combination of internal resources to enroll providers, but we did hire some external help since we were in a time crunch. In all, this took about six weeks,” he attests.
Getting this all done in six weeks was no simple task, and Erman notes that one key was to identify the system’s “heavy prescribers,” or any provider who wrote more than two controlled prescriptions per week. That narrowed the number down to about 2,000 providers. “We went after those [2,000] with e-mails, posters, and meeting announcements. We set up kiosks in physician lounges and cafeterias, and went to offices and meetings to sign them all up,” Erman says.
On the first day the mandate went into effect, the health system had a 74-percent rate of people using EPCS, rather than printing out and signing the prescriptions. By day four, the rate improved to 91 percent and as of just a few weeks ago, the health system was e-prescribing controlled substances at a 98-percent rate, says Erman. “We don’t expect to reach 100 percent because there are some prescriptions that need to be faxed or printed if it is complex or a compounded medication, or if the patient is taking it out of country. So, it happens, but it’s minimal,” he says, noting that less than 100 out of 3,700 prescriptions during the month of April fell in these exception buckets. At the time of this interview, more than 3,200 providers were enrolled in EPCS and the signup process is part of the onboarding for new hires, says Erman.
Now the question becomes, can this be enacted across all states? Indeed, this past February, U.S. Senators Elizabeth Warren (D-MA), Michael Bennet (D-CO), Dean Heller (R-NV), and Pat Toomey (R-PA) introduced the “Every Prescription Conveyed Securely (EPCS) Act” to combat opioid overdoses by requiring all states to implement e-prescribing for controlled substances under Medicare by 2020. To this point, Sean Kelly, a practicing ER doctor and chief medical officer at Imprivata—as well as being a member of CHIME’s Opioid Task Force—notes that the benefits of this legislation will be clear for both providers and patients.
“EPCS can be an incredibly effective deterrent to fraud, drug diversion, and abuse. EPCS prescriptions cannot be altered, cannot be copied, and are electronically tracked, complete with a full audit trail,” he says. Furthermore, Kelly attests, “The federal DEA rules for EPCS establish strict security and identification measures, such as two-factor authentication, that reduce the likelihood of fraudulent prescribing. At the same time, EPCS actually makes it faster and more efficient for patients who legitimately need medications to get them prescribed and filled. Provider and patient satisfaction increases with EPCS, while fraud, diversion, and abuse decrease.”