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.
