E-Prescribing: Adapting to Fraud Reduction in the Opiate Crisis

A federal law taking effect on January 1, 2021, will require electronic prescribing (e-prescribing, or eRx) of all controlled substances for Medicare Part D beneficiaries. Similarly, many states have enacted laws that mandate e-prescribing for controlled substances. Optum Rx elected to get in front of the trend and require e-prescribing for home delivery of controlled substances by January 1, with a brief grace period that ended on February 29.

The e-prescribing impetus is an attempt to reduce fraudulent opiate prescriptions. Although most psychiatrists don’t prescribe opiate pain medications, we do prescribe other controlled substances, including buprenorphine, stimulants, and benzodiazepines. Those of us who are employed by large health care systems with electronic health records (EHR) are probably already e-prescribing through the EHR. For the third of us in private practice, we must quickly adapt by adopting an e-prescribing software. They vary in pricing and range from free (for an initial period) to several hundred dollars annually, billed monthly or annually.

DrFirst, a company that offers an a-la-carte suite of electronic resources, launched iPrescribe approximately one year ago. It is a phone app that uses a keychain fob for two-factor authentication for each controlled substance prescription. Two devices are necessary to set up an account, so I used my laptop to register and my phone for the initial two-factor authentication. Registration took less than an hour to complete, and I was able to e-prescribe noncontrolled medications right away; however, there are additional hurdles for controlled substance prescriptions, and these took close to a month to navigate successfully. Although there are aspects of the software that are less than intuitive, necessitating several calls to the company’s helpline for assistance, the people who staff the helpline are uniformly friendly and eager to resolve any problems. Had I known in advance it was an option, I would have used the helpline to set up my account rather than attempting it on my own, as that would have mitigated at least one missing data field that delayed my ability to e-prescribe controlled drugs.

DAW Systems offers a web-based program for those of you who prefer to prescribe from a tablet or computer. It requires an internet connection and the use of Google Chrome. The company has a similarly rigorous system of authentication, so it takes a few weeks before you can prescribe controlled substances. A colleague who opted for this product reported, “Once I got in the system, it works beautifully.” The company also offers staff assistance with setup if you don’t want to do it on your own. In November 2019, I contacted a third company, EazyScripts, because of the promise suggested by its name. At the time, the company representative told me that the company was in the process of building its self-service portal designed for solo or small practices, and the portal is now live.

Before you start e-prescribing, you must comply with HIPAA regulations by providing the HIPAA Notification of Privacy Practices to patients for whom you plan to e-prescribe and having them sign an acknowledgment form, repeated annually. Both are available on APA’s practice management webpage.

Is refusal to adapt to e-prescribing an option? If you are in solo private practice, you set the rules for your practice. Once the grace periods for Medicare and individual states expire, you may inform your patients that you will no longer prescribe any controlled substances and refer them to their primary care provider if they need benzodiazepines or stimulants. This is not likely to endear you to these patients’ PCPs and may not be the most ethical course of action because it places your interests above those of the patient; however, if you are late in your career, plan to retire soon, and have few patients on controlled substances, it may be a reasonable alternative.

Like other recent technological directives, e-prescribing requirements are well intentioned and designed to improve patient care and safety. Solo practitioners will have to decide which product to choose based on its features and costs, and all prescribers will have to learn to adapt to the technology and its inevitable glitches. Although it is easy to feel resentful about yet another unfunded mandate, this may be offset, at least in part, by recognizing some helpful features offered by the technology. For me, the ease of checking a patient’s prescription drug monitoring program (PDMP) profile from within the iPrescribe app replaces a less efficient PDMP process so I experience less stress and greater adherence to best practices for controlled substance prescribing.

I invite readers to send reviews of your experiences with e-prescribing products to Nathan Tatro, APA’s associate director of digital health quality improvement, at [email protected]. He will provide the reviews to APA members who request information on e-prescribing products. Additional information on e-prescribing is posted on APA’s website. Those who wish to read clinicians’ user experiences with various mental health software products may visit this site.  ■