Is electronic prescribing a potential solution to the opioid crisis?

Despite the opioid crisis facing the country, few physicians prescribe narcotics electronically. But doctors who do electronic prescribing of controlled substances (EPCS) say it helps prevent diversion of these drugs and say it isn’t hard to do.

Internist Jeffrey Kagan, MD, and his partner in Newington, Connecticut, have been doing EPCS for about a year, even though the state doesn’t require it. Their practice embraced EPCS, Kagan says, because it was more efficient than paper prescriptions, and it reduced the chance of drug diversion.

Previously Kagan had to print a narcotic prescription from his electronic health record (EHR). If the patient wasn’t in the office at the time, he or she would have to come to the office to pick it up. This process wasted staff time. Sometimes the prescription would get lost or the patient would say it had been lost, and then it would have to be reissued. There was also the risk of someone copying a prescription and selling it. EPCS prevents all of this, says Kagan, who is also a member of the Medical Economics Editorial Advisory Board.

Christine Doucet, MD, a primary care physician in Patchogue, New York, has also adopted EPCS, partly because of a state law that requires it. But she also admits that the murder of four people by an opioid addict at a nearby pharmacy five years ago played a role in her decision.

“The killings were down the street from me,” she notes. “And that was tragic. [We] had to do something.”

While some doctors view EPCS as a moral imperative, many other physicians are dissatisfied with their dual workflow of paper and electronic prescriptions. Yet they may be deterred from adopting EPCS because of a perception that it is too complex. To bridge that gap involves understanding EPCS and what it entails. 

The lack of EPCS awareness

The U.S. Drug Enforcement Administration (DEA) approved EPCS in 2012. Two states, New York and Maine, mandate it. (Minnesota requires e-prescribing, but without an enforcement mechanism.) Moreover, all of the leading EHRs in the marketplace now include EPCS modules.

Yet nationally, only 6% of prescribers did EPCS last year, according to the 2015 annual report of Surescripts, a company that connects physician offices to pharmacies online. While that’s nearly a fourfold jump in adoption from 2014, it still represents only a tiny portion of physicians and other prescribers. 

There is considerably more awareness of prescription drug monitoring programs, which now exist in 42 states. These programs include online databases that list all of the narcotic prescriptions that individuals have filled in a particular state and sometimes in multiple states. For example, Kagan says Connecticut’s controlled substance registry enables him to see data from 20 states.

Charles Rothberg, MD, a Patchogue ophthalmologist who is president-elect of the Medical Society of the State of New York, supports the goal of New York’s EPCS mandate. Still, he wonders how much more effective it is in preventing narcotic diversion than the New York drug database, which doctors must consult when they prescribe a controlled substance.

Doucet agrees that the state registry is more effective than EPCS in preventing drug diversion. She points out that it’s very difficult to mimic the special paper she uses to print out a prescription or to rewrite anything in it. But she believes that the EPCS mandate makes sense because some doctors may be careless in writing prescriptions for controlled substances. 

John Franco, MD, a primary care physician and medical director of the Independent Practice Association (IPA) of Nassau/Suffolk Counties, says that the organization and its 800 members recognize the legitimacy of the EPCS mandate. “Our doctors’ complaints have declined,” he says. “They’ve adapted and have recognized that the law is here to stay and that EPCS has a societal benefit, although it might not be realized for some time.”

How New York physicians are reacting

New York’s EPCS mandate-part of its Internet System for Tracking Over-Prescribing (I-STOP) statute aimed at controlling narcotics abuse-went into effect in March. At that time, 47% of New York prescribers had been enabled for EPCS. Most of the remaining doctors who prescribe controlled substances were expected to start using it within a few months, the Medical Society of the State of New York said at the time.

Rothberg says that most New York physicians are complying with the law. But a number of physicians have stopped prescribing controlled substances and are therefore not subject to the statute. He stopped prescribing them a few years ago, when the state began requiring doctors to check the drug database. It was too much trouble, he says, to install a computer connection to the drug database and establish a process for checking with it.

Michael LaPenna, a healthcare consultant based in Grand Rapids, Michigan, has worked with about 60 New York practices in the past year, preparing them to transition to hospital employment. None of them are using EPCS, perhaps because they’re counting on their future employers to take it on, he suggests.

One measure of prescriber compliance is the number of one-year waivers that the New York State Department of Health has issued to those who claim economic hardship, technological barriers beyond their control or other exceptional circumstances. As of July 31, the department had approved 6,200 waivers for about 38,000 practitioners-more than twice as many as it had greenlighted in March. By comparison, about 75,000 physicians are licensed to practice in New York. While not all doctors prescribe and not all prescribers are doctors, many physicians are still clearly struggling with EPCS.

Technical challenges

Doucet and Kagan haven’t had much trouble with EPCS since implementing it. But Doucet says she has encountered some technical challenges.

To begin with, she notes, the software doesn’t let all prescriptions go through. For example, it wouldn’t allow her to write a Vicodin prescription for a patient with acute fractured ribs, so she had to substitute Tramadol, which had previously proved ineffective with this patient. In other cases, the software has rejected prescriptions that included dosages that it didn’t recognize. And sometimes pharmacies say they haven’t received a controlled substance prescription online, although the software indicates it has gone through, Doucet adds. 

Paul Uhrig, executive vice president and chief administrative, legal and privacy officer for Surescripts, says his company hasn’t noticed any problems with EPCS transmission to pharmacies. But Franco attests that some IPA members have encountered both of the problems that Doucet mentioned.

Despite the extra work entailed in EPCS, Doucet says, she’d do it even it wasn’t mandated. Besides her concern over narcotics diversion, she says that EPCS makes more sense than having one workflow for non-controlled substance prescriptions and another for narcotics scripts. 

Kenneth Hertz, a consultant with the Medical Group Management Association, notes that EPCS can help doctors streamline their workflows and better document and track what they’re doing with these prescriptions. “If we’re looking at foundational changes in healthcare, e-prescribing and EPCS are going to be a critical piece of that,” Hertz says.