DPH Official: Prescription Program Is a Tool, Not a 'Blunt Instrument'

State Update

Vital Signs: May 2012

Editor's Note: Madeleine Biondolillo, M.D., bureau director for health care quality and safety at the Department of Public Health (DPH), is approaching her first full year at the Massachusetts DPH. She is an MMS member with a background in geriatric service provision and primary care.

Vital Signs recently interviewed Dr. Biondolillo about the Drug Control Program and the Prescription Monitoring Program (PMP), which fall under her oversight at the DPH.

VS: Can you give us some background on the PMP?

Dr. Biondolillo: The program was created as a joint effort of the MMS and DPH 25 years ago to identify Schedule II prescriptions. In 2010, the Legislature created the opportunity for there to be an electronic version. Massachusetts is leading the way in making the technology available to prescribers so they can have it in their armamentarium of tools to provide care to patients. Online access started in December 2010. About 2,000 prescribers have enrolled since then and every pharmacy is enrolled. The database includes prescriber and patient data on all prescriptions filled in Massachusetts for federally scheduled medications.

We've taken a paper-based tool and automated it for better access. Physicians we speak to all the time who use this in their care are almost uniformly thrilled with it… particularly those who do pain management and emergency care. There are also a lot of primary care physicians who feel they would benefit greatly from this tool. In general, it gives the opportunity to work with patients when the physicians have a concern, either on the basis of their own judgment or when they use the system and find a reason for concern in a patient's history.

We do screens and define areas of questionable activity to be four or more prescriptions from different prescribers filled at three or more pharmacies. That benchmark was defined in collaboration with the medical review group, which balances issues of patient privacy and needs with diversion concerns.

VS: What role does the medical review group play?

Dr. Biondolillo: These are physicians, dentists, and a podiatrist brought together on a quarterly basis to look at data and case report studies of prescriber utilization of the PMP, reports of which information is accessed by law enforcement, and they set the threshold on questionable activity.

Right now, data show that two-thirds of one percent of patients fall into the questionable category and they account for four percent of prescriptions.

VS: What can the program do to identify the scope and areas of the problem in Massachusetts?

Dr. Biondolillo: Depending on how the data is viewed, we will be able to see where patients live, and for providers, to determine if they are in an at-risk location. The data will help us allocate treatment and law enforcement resources.

The technology is about to be upgraded to allow expanded capabilities in many areas. We have the opportunity to link data sources together with the trauma registry and ambulance trip records (to identify overdoses). We're planning to reduce our lag time for the data down to about 10 days as a priority and to improve batch lookups, which will allow a physician or their designee, such as a nurse, to screen all patients scheduled for a particular day.

The providers who are using the system now, such as emergency physicians, are looking up lots of people. When you get used to doing it, it takes seconds. When you do the risk-benefit analysis of not doing it, if it takes about 10 or 15 seconds, it's completely worth doing. I agree that it would be best to integrate and automate the search process, but if batch lookups are delegated, it has to be to a licensed health care provider, such as a nurse, over whom the department has regulatory authority and who has patient privacy and confidentiality responsibilities.

VS: What about efforts to make it automatic for prescribers to be eligible to access the system?

Dr. Biondolillo: You mean when they renew their licenses? We're very amenable to that and anything that will increase the ability of the system to be used. There is a tension between the rights of privacy of the patients and ease of use of the system, but because there are such protections in license renewals, it seems feasible to make that happen.

Integration into EHR systems when you're considering writing a prescription is absolutely ideal, and I believe the technology is available. We're very interested in this. We're doing a test pilot with a local hospital integrating its EHR into the database. We're also trying to embed screening tools in the system that will show appropriate referral to treatment if patients trigger screens.

This is a tool that is part of a compendium of things to deal with this issue. If we don't use it right, it will be a blunt instrument; if we use it correctly, it will be a good start, but you absolutely have to have a conversation with the patient and the physician as to what is going on.

We know we have a crisis, and we have to be more sophisticated than we've been.

- William Ryder

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