Electronic prescription monitoring struggles to gain traction

Florida’s State Board of Pharmacy is looking into ways it can increase use of its prescription drug monitoring database, including making it a required standard of care, after a report found that most physicians aren’t consulting it.

Some in the state say requiring physicians to utilize the database would increase use. But others, including physicians, say improved access and usability would spur popularity of the tool. Two bills introduced in Florida’s 2013 legislative session would have mandated use of the database, but both died when the state House and Senate adjourned for the summer before the bills came up for a vote.

In a presentation to the State Board of Pharmacy in June, officials with the prescription drug monitoring program said about 10% of physicians and 35% of pharmacists have signed on to take advantage of the database. The report led some on the pharmacy board to call for an investigation into how they can make the database a required standard of care.

Drug monitoring databases have emerged nationwide as a tool to alert physicians when a patient might be doctor-shopping or to fight prescription drug abuse with other means. As of October 2012, 49 states passed legislation that created a prescription drug monitoring program, and 41 states have programs up and running. As of 2013, five states have required physicians to consult the database every time they prescribe a controlled substance or when abuse is suspected. The American Medical Association supports prescription drug monitoring programs but does not have a position on mandates for their use.

Officials have credited Florida’s program, which began in 2011, along with greater enforcement against so-called pill mill operations and other measures, with reducing the number of unnecessary prescriptions. The Drug Enforcement Administration reported that 90 of the top 100 oxycodone-purchasing doctors were in Florida in 2010. No doctors from the state were on the list in 2013.

Despite that progress, Florida’s pharmacy board is concerned about what it sees as low physician use of prescription drug-monitoring programs. But Jeff Scott, general counsel for the Florida Medical Assn., isn’t convinced that use of the database is as woefully low as the state is making it out to be.

“No one has demonstrated to us that those who should consult the database aren’t,” Scott said. For example, he said some physicians don’t prescribe controlled substances and therefore should not be included in an analysis of database use.

Scott said the association has not conducted its own analysis of database use, but he thinks it would increase if the system were easier for physicians to use. One issue, he said, is that doctors cannot assign someone else in their practices, such as a registered nurse, to consult the database on their behalf. Other barriers include a time-consuming process of logging in and out of multiple systems.

In her presentation to the pharmacy board in June, Rebecca Poston, the prescription drug monitoring program manager at the state Dept. of Health, said her department based its percentage of physicians using the database on the number of physicians in the state who have written a prescription for a controlled substance in the time period examined.

Attempts to improve convenience

The U.S. Dept. of Health and Human Services’ Office of the National Coordinator for Health Information Technology has acknowledged that getting physicians to use prescription drug monitoring databases in states where it is voluntary has been a challenge. They also said part of the challenge was making the databases more convenient for physicians to access.

The ONC launched pilot programs in 2012 aimed at improving access by embedding the prescription drug database tool into electronic health record systems in select facilities in Indiana and Ohio, where use of the database is voluntary. Florida is working on ways to embed the information into physicians’ EHR systems, making it more accessible.

Lawmakers in Indiana attempted to pass legislation making it a requirement for physicians to consult the database, which physicians, including John Finnell, MD, opposed. Dr. Finnell, an associate professor of emergency medicine at Indiana University School of Medicine, said improving access has been the biggest victory for physicians and had a much bigger impact than a mandate would have had.

Since the pilot program was introduced in Indiana, the database has expanded to be accessible through EHRs for all participants of the statewide health information exchange, said Dr. Finnell, an investigator with the Regenstrief Institute, a health research and education organization in Indianapolis involved with the ONC pilot program. It now also gives physicians access to data from neighboring states that are connected to Indiana’s HIE.

Dr. Finnell said one issue with a mandate is a lack of options when the system is unavailable. He said the requirement would have applied to prescriptions for 30 or more pills, which physicians could get around by prescribing 29 pills. It came down to requiring something that would have been nearly impossible to enforce, he said. With the ONC program’s focus on accessibility instead of mandates, physicians have come to rely on it. When the system is unavailable, Dr. Finnell said he gets several phone calls from physicians throughout the state who are trying to access the system but can’t.