HIT Perspectives: Controlled Substances

By Michael Burger, Senior Consultant Electronic prescribing (ePrescribing) now is the norm for most prescriptions, except those for controlled substances. In fact, electronic prescribing for controlled substances (EPCS) has gotten off to a slow and somewhat rocky start. Some consider EPCS to be the “last mile” in getting the nation wired to send and receive prescriptions electronically. But things are changing — and fast. Recent metrics show significant progress in physician and pharmacy adoption of EPCS. Although the actual number of physicians using EPCS is relatively low (less than 4,000), the rate of uptake is rapidly accelerating. A DrFirst industry briefing notes a 428% increase in physician adoption of EPCS just in the latter half of 2012. Pharmacy enablement to accept EPCS appears to have grown to a point where some 14,000 pharmacies are now able to accept electronic prescriptions for controlled substances. (Surescripts lists 14 pharmacy systems that have completed certification for EPCS, including Walgreens, CVS and Rite-Aid). In Arizona, where Point-of-Care Partners (POCP) helped Arizona Health e-Connection (AzHeC) flood the state with “EPCS is legal” messaging, EPCS transactions increased more than 7-fold from less than 200 to more than 15,000 in only seven months (May to December 2013). We saw these kinds of numbers in the early days of ePrescribing, right when adoption really began to skyrocket. In short: the momentum for EPCS adoption is growing. Why is EPCS adoption picking up steam? How can that trend be accelerated? Adoption of EPCS should continue on its rapid trajectory due to several drivers. Some reveal market readiness while others reflect broader stakeholder needs.

• • Vendors are ready. EPCS has finally bubbled to the top of vendors’ to-do list, which was dominated for the past couple of years by development for meaningful use (MU) compliance and certification and the changeover to the International Classification of Diseases, 10th edition (ICD-10). Vendors also suffered from uncertainty. If they built EPCS-compliant products, would anybody buy them? Those issues are resolving and vendors are now bringing EPCS-compliant products to market. Currently, Surescripts reports 14 vendors with EPCS-certified products. Wider availability of certified products will help drive volume as well as enable physicians meet the higher ePrescribing threshold for MU stage 2.
• • Pharmacies are ready. Pharmacy willingness to become wired and ready to receive ePrescriptions for controlled substances was a real barrier to EPCS adoption. That changed as big pharmacy chains began to go live with EPCS. In Arizona, for example, Walgreens turned on all of its 250 stores for EPCS in August 2012. CVS turned on all of its pharmacies and trained its pharmacists in August 2013. Frys and Safeway were expected to be onboard at the end of 2013. So, the top 4 chains in Arizona — 704 stores or 80% of the chain drugstores in the state — were expected to be live for EPCS at the end of last year.
• • EPCS is a tool to fight drug abuse and diversion. Drug abuse and diversion are at epidemic proportions, especially for Schedule II medications. To aid in the fight, stakeholders are increasingly calling for the end of paper prescriptions for controlled substances and demanding a move to EPCS. New York is leading the way, mandating ePrescribing for all prescriptions, including controlled substances, effective March 27, 2015. Stakeholders, including CVS Caremark, are also calling for mandatory EPCS. There is also congressional interest in making ePrescribing a requirement for coverage of controlled substances under Medicare Part D, which is a provision of H.R. 3392 — Medicare Part D Patient Safety and Drug Abuse Prevention Act of 2013.
• • The rise of value-based care. America’s health care system is gradually transforming to value-based systems of care and reimbursement. In a value- based model, participants will want EPCS to ensure a complete picture of patients’ medications in order to better understand and control costs, manage risk, conduct medication reconciliation and improve care coordination. Although controlled substances account for less than 20% of all prescriptions, they largely represent treatments for the chronically ill —high-cost patients who are growing in number for all payers but will be a core group for accountable care organizations and other value-based systems. A more accurate accounting of the costs and use of controlled substances for the chronically ill will be a critical success factor.

With so many opportunities in place, it is clear why EPCS is gaining attention. However, there are still opportunities for improvement that can help move the dial even further in 2014.

• • More education is needed. Despite the educational efforts of vendors and others, providers still have many misconceptions about EPCS. We realized this recently in Arizona, where POCP was engaged by the AzHeC to promote EPCS adoption. One eye-opening finding was that many physicians and pharmacists weren’t aware that it was legal, even though that had been the case for more than a year. Through this engagement and others, we learned that providers are still mystified and overwhelmed about how to begin the EPCS process. Resolution of such problems and perceptions will ultimately drive adoption.
• In the face of these challenges, there are many opportunities for stakeholders to step up educational efforts. For example, we’ve produced some webinars with leading ePrescribing vendors for prescribers (EPCS for webinar for prescribers) and pharmacists (EPCS webinar for pharmacists) that were well received by these audiences, who don’t have the time or resources to attend conferences and off-worksite training. ePrescribing vendors should view EPCS as an opportunity to assist their users with the identity-proofing process. Prescribers and their practice staff will also need training to become efficient with EPCS. More of these concerted efforts are needed to move the dial.
• • Complete pharmacy connectivity. Although many chain pharmacies have EPCS-certified systems, there are many others that are not yet certified. It’s one thing to have a certified system; it’s another to actually accept electronic prescriptions for controlled substances and integrate them into the pharmacy work flow. EPCS will be more of a struggle for independent pharmacies. Specialty pharmacies still need to get wired and are unable to accommodate regular ePrescribing, much less EPCS.
• • Reconcile discrepancies in state prescribing laws. Variations in state EPCS laws are problematic. Some states allow EPCS and some don’t; some allow only certain schedules while others allow all schedules; some change the schedule of individual drugs from that defined by the Drug Enforcement Administration. Resolving differences in state laws would remove a great barrier to EPCS adoption and improve prescribers’ work flow. Consistency of rules across all states will reassure prescribers that EPCS is allowed wherever they practice.
• • Keep current with the laws and regulations. One barrier to EPCS adoption is the ever-shifting legal and regulatory landscapes at the federal and state levels. Electronic health record and ePrescribing system vendors need to stay ahead of new legal, regulatory and board of pharmacy developments. This is necessary now more than ever to ensure the accuracy of their products and prevent going into panic mode to address some new wrinkle of which they were unaware. Associations and other groups representing providers, medical specialties and pharmacies need to keep current so they can get the word out to their constituent groups and help prevent them from getting caught up in an enforcement action. (For additional information regarding state prescribing laws, see the article in the December 2013 issue of HIT Perspectives about POCP’s ePrescribing law compendium, which is a major resource concerning ePrescribing and EPCS).

POCP has been involved with EPCS since ePrescribing was barely a notion in the minds of federal regulators. Let us put our long-term experience and up-to-date expertise to work for you.