E-prescribing of controlled substances: The next generation of medication ordering

In healthcare technology circles, e-prescribing is among today’s hottest topics. A vital component of patient-centered care, it creates a connectivity platform that encourages collaboration between the physician and pharmacist who are in joint pursuit of an enhanced patient experience.

Less widely discussed but equally valuable is e-prescribing of controlled substances, or EPCS. With a regulatory go-ahead — courtesy of a 2010 decision to lift the ban on EPCS — technology developers are racing to merge the practical functionality offered by traditional e-prescribing with a sophisticated set of security measures that allow physicians to electronically order these tightly regulated substances.

EPCS promises to virtually eliminate paperwork from the ordering process, create administrative efficiencies for medical professionals and prevent medication errors that are commonly affiliated with illegible or misinterpreted handwritten notes. EPCS also is likely to impact meaningful use initiatives. An meaningful-use core measure, e-prescribing technology assists physicians in their quest to maximize electronic medical record solutions with enabling features, such as real-time transactions, automated requests and responses, intelligent routing, complete active medication lists and formulary information.

EPCS can overcome industry barriers

Most providers will be able to take advantage of EPCS: Approximately 90% of prescribers write prescriptions for controlled substances, which in turn accounts for about 11% of all medication orders. But until recently, EPCS’s reception by the industry was lukewarm at best. Some medical professionals had doubts that these prescriptions couldn’t be adequately protected in an electronic environment. Others expressed concern over the activity’s certification time and cost commitments, as well as potential disruptions in their traditional workflow.

As the technology matured with more sophisticated security controls — including passwords, biometrics and secure tokens that fit smoothly within physician workflow — the Drug Enforcement Agency was convinced that EPCS platforms, combined with certifications and credentialing requirements for both doctors and pharmacies, created an intrinsically secure portal for prescribing and dispensing controlled medications. As a result of the vote of confidence, more than 30 states have made it legal for physicians to electronically prescribe these medications, though requirements and restrictions vary from state to state, either permitting EPCS for all controlled substances, or for either CII or CIII-V.

E-prescribing vendors and technology partners are working to try to limit the interruption to physician workflow that can result from the EPCS regulatory requirements. As a result, a physician’s experience with EPCS is similar to electronically prescribing noncontrolled substances — with a few added authentication and security requirements. In fact, providers can utilize a single platform to send orders for controlled and noncontrolled substances alike — helping save time and expenses.

With a certified e-prescribing application, providers first complete an identity proofing process that matches their practice license information with a valid DEA identification number. This activity is conducted remotely or face to face via a credentialing service provider or certification authority approved by the federal government. Providers then log on to the e-prescribing system with two-factor authentication, utilizing at least 2-of-3 devices that include a security token, unique password or biometric scan. Finally, the prescriber creates the e-prescription using the EPCS system and securely sends it to the pharmacy via a third-party transaction processing vendor.

Enhancing patient safety, engagement
EPCS delivers many of the same patient safety measures that traditional e-prescribing offers. As a fully electronic platform, it helps reduce the errors inherent in the paper-based process, such as illegible handwriting, misinterpreted abbreviations and unclear dosages. Similarly, EPCS technology can be configured with a medication reconciliation module, allowing providers to capture and view more complete prescription histories at the point of care, which can further reduce the chance of an adverse drug event. And when real-time patient clinical decision support information is combined with transparent drug pricing models, clinicians can select both the most therapeutically appropriate medications for the patient and the most cost-effective.

Prescription monitoring program features also are being incorporated into EPCS modules. This capability is designed to reduce instances of drug diversions and ensure patient compliance by preventing physicians from ordering controlled substances they are not legally permitted to prescribe or an individual is not eligible to receive. E-prescribing of controlled substances is far more secure than previous paper-based processes in which ordering pads may be stolen and counterfeit drugs can be easily produced and drug quantities altered prior to the prescription being delivered to the pharmacy.

EPCS
also can help identify patients who hop from doctor to doctor to gather multiple prescriptions for controlled substances. Through the medication history gathered from a transaction database, a provider may see which other physicians have requested controlled substances for the patient and where orders have been filled — whether at a pharmacy nearby or one several states away.

By providing important data-driven insights about noncompliant individuals, controlled substance e-prescribing is becoming a significant component of patient engagement programs as well. Medication histories from pharmacies, health plans and pharmacy benefit managers — for controlled and noncontrolled substances — can be sent to  providers through the EPCS process. This can allow the physician to initiate a dialog with an individual to determine why they are not adhering to their medication regimen and discuss the importance of sticking with their drug therapies.

Finally, EPCS provides a conduit for the pharmacy to communicate with the patient by notifying them when a prescription is ready, for example, which adds a new level of convenience for patients. When a prescriber submits an order, the system can automatically send an email, text or voice message to the individual confirming the order and pharmacy destination of choice.

Next steps on the path to EPCS
A study by MGMA’s Group Practice Research Network estimated that the time spent managing unnecessary administrative complications related to prescriptions is approximately $15,700 annually for each full-time physician. Specialty practices that tend to prescribe higher numbers of controlled substances stand to reap the most benefits by an e-prescribing platform’s advanced capabilities, including verifications of formularies, generic substitutions, dosages, drug-to-drug interactions and drug-to-allergy reactions.  

But EPCS is not just for specialties; any practice can benefit from a highly secure e-prescribing platform. There are a number of actions physicians can take to determine if they are ready to take the first step toward adoption. For one, they should conduct a thorough needs assessment within the context of their technology acquisition plans and budgetary priorities. This will help them determine what type of application makes the most sense for the organization — a basic add-on to their electronic medical record or a more robust turnkey solution.

It’s also imperative for providers to determine their e-prescribing vendor’s readiness for EPCS. Similarly, physicians should ask local pharmacists about their plans for supporting their customers by offering EPCS as a patient-centered care benefit. And when assessing new electronic technologies, it’s important to ask vendors if their solution meets state and DEA identity proofing requirements, and if they offer on-site training to help ease the transition of EPCS into the office workflow.

In order to provide EPCS capabilities, vendors will likely bear a significant financial burden. To start, technology companies will have to complete the audit/certification process for each version released of their software. For example, if a vendor were to release a version of its EMR in January that includes EPCS support and then release a new version the following June, it would need to go through the auditing process again. Unfortunately for solutions providers, according to the DEA, it is estimated that the auditing/certification process carries a cost of approximately $15,000 and re-audit of the certification also carries a $15,000 fee. This means vendors can face a $30,000 fee simply to provide EPCS capability to prescribers.

While many providers are keeping the technology at arm’s length — largely due to concerns that such prescriptions cannot be adequately secured or that costs required to receive the appropriate certifications are prohibitive — the reality is that e-prescribing of controlled substances is a highly efficient and cost-effective process, and can easily be managed with the right protocols in place at the doctor’s office and pharmacy.

Fortunately, the next generation of tools is emerging to enable caregivers to have the same e-prescribing capabilities for controlled substances, which promises to create a safer medical environment by reducing errors and promoting medication compliance, a win-win for the patient and provider.


Lathe Bigler
Senior director of clinical services, pharmacy services division
Lathe Bigler serves as Emdeon’s senior director of clinical services for the pharmacy services division. His focus on developing layers of competitive advantage and increasing market growth are instrumental in Emdeon’s advancement in the exchange of electronic prescriptions and other clinical information. Bigler has more than 15 years of experience in the healthcare and information technology fields, and has held roles in marketing, product management, business development and industry relations with such corporations as NDC Health, Midmark Diagnostics, DrFirst and AltaPoint Data Systems. Bigler has a bachelor’s degree in marketing and business administration.

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Comments

- 3:39 PM
Scotland57 says

As a mother of a child with disabilites requiring behavior modification drugs (which are controlled substances), I welcome the availability of e-prescribing. Each month I am required to take her to the Dr.'s office, without an appointment, for her weight and blood pressure to be checked. Ordinarily, we sit from 15 minutes to an hour waiting for this procedure. More than likely, the "wait" happens because the Dr.'s nurse has to pin him down between patient exams to write out the two prescriptions. Then I have to drive and hand deliver the prescriptions to the pharmacy. Later that day or the next I make a return trip to pick up the prescriptions. On average, this process involves a good hour to an hour and a half of time each month to accomplish. What a blessing it would be to a caregiver like myself if physicians would take the plunge and avail themselves the convenience and security of EPCS.

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