Massachusetts Medical Society: Testimony in Opposition to “An Act Relative to Electronic Prescribing of Opiates And Other Controlled Substances”

Testimony in Opposition to “An Act Relative to Electronic Prescribing of Opiates And Other Controlled Substances”

The Massachusetts Medical Society (MMS) appreciates the opportunity to provide comment on H.2453, “An Act relative to electronic prescribing of opiates and other controlled substances.” The Medical Society supports the increased adoption of electronic prescribing in general, and that of controlled substances in particular, in Massachusetts. When appropriate, electronic prescribing can provide security and convenience to patients and physicians alike. 

The Medical Society urges balance in determining the best means by which to enact policy regarding the electronic prescribing of controlled substances, so as to maximize those benefits and avoid unintended pitfalls. These programs have a substantial impact on physicians across the state. Electronic prescribing of controlled substances is expensive, often exceeding $1,000 per year, per prescriber. There are hidden initial costs as well: for physicians with existing electronic medical records who need to purchase add-on modules to their records, switching to electronic prescribing can be even more expensive. And for physicians whose current practices rely on paper records, the upfront capital investment can be significant to allow for the acquisition of technology to support the prescribing and uploading of patient information into these software programs. 

In light of these realities, electronic prescribing of controlled substances is a worthy upgrade for many physician practices in Massachusetts. For others, however, the costs of compliance with a mandate to purchase this functionality would be so high as to compromise their ability to care for patients. This sizable investment may not be in the best interest, for example, of a small pediatric practice that occasionally prescribes a controlled substance for attention deficit disorder. This mandate might compel such practices to refer patients to whom they currently provide high-quality and continuous care to other providers, causing unnecessary handoffs and creating barriers to patient care that would adversely effect both patients and physicians. The Medical Society continues to share concern that a mandate such as this could disproportionately affect patients’ access to solo and small group physician practices and physicians nearing the end of their career.

House Bill 2453 would significantly alter prescribing laws in Massachusetts by prohibiting, with some narrow exceptions, the longstanding practice of prescribing controlled substances by paper prescription. Instead, the bill would require physicians to electronically process such prescriptions. Unfortunately, due to complex Drug Enforcement Agency (DEA) regulations of this practice, this would prohibit over 85% of prescribers in Massachusetts from being able to lawfully prescribe opioid medications unless they obtain this software.

The electronic prescribing of controlled substances is an entirely different practice than electronic prescribing of routine medications. For years, physicians have increasingly been able to transmit a non-controlled substance prescription for an antibiotic, for example, directly to the pharmacy from the electronic health record in the exam room. The same is not true for controlled substances. Electronic prescribing of controlled substances was illegal in the United States until 2010. The DEA regulations that now permit electronic prescribing of controlled substances contain complex requirements that necessitate advanced, expensive security features for such prescribing programs.

DEA regulations for electronic prescribing of controlled substances require secure, audited and certified software systems as well as two-factor identification for each prescriber. This means that along with enhanced, highly secure software and networking requirements, prescribers must also have a unique, secure password, and the prescription software must also be able to process either a biometric verification (i.e., fingerprint or eye scan) or a unique object such as a cryptographic token or key. Electronic prescribing of controlled substances thus requires prescribers to purchase additional hardware and software, which is hopefully compatible with electronic health records. While enhanced security provisions are important to ensure that misuse does not occur, the complexity and expense of programs that comply with the DEA regulations have led to very slow uptake by providers. 

Given the Medical Society’s 1) support conceptually for electronic prescribing, and 2) concern about the relevant regulations, we have been engaged with the American Medical Association and others to work with the Drug Enforcement Agency to improve the regulations for electronic prescribing of controlled substances to strike the right balance between security and ease of implementation and use. We believe that policies mandating electronic prescribing would be best implemented when more nuanced regulations have been promulgated. 

Meanwhile, security protocols for paper prescribing continue to be modified to prevent abuse. Massachusetts law currently requires that all paper prescriptions for drugs in Schedules II-VI be executed on a tamper-resistant form consistent with the Medicaid requirements even if not written for a Medicaid patient. These requirements include security provisions to prevent 1) unauthorized copying of prescription pads, 2) unauthorized modifying of prescription pads or 3) the creation of counterfeit prescription pads. While the Medical Society sees value in promoting electronic prescribing of controlled substances in the proper situations, there is no reason to abolish paper prescriptions entirely.  

Physicians of Massachusetts have long embraced the integration of information technology into the practice of medicine. As of June 2012, Massachusetts led the country as the highest rate of adoption of electronic prescribing of non-controlled substances in the country at 77%. The Medical Society has long promoted the thoughtful use of electronic health records and electronic prescribing. We hope to see more physicians embrace electronic prescribing of controlled substances as costs go down and complications are reduced.

The Medical Society looks forward to engaging with the legislature to identify the best legislative solutions that best promote electronic prescribing of controlled substances.

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