Without question, the ability to prescribe controlled substances electronically is a major step forward in healthcare quality and safety.  Yet, only 5% of physicians in the United States currently can perform this function; all can do it legally but only 5% are taking advantage of the ability.  The following links are a series of articles, thoughts and tutorials for SETMA’s deployment of electronic prescription of control substances (ePCS) with an explanation of how it fits into SETMA’s vision of the future:

1. August 20, 2015 -- Your Life Your Health - Prescribing Pain Medications: A Conundrum for Patient and Provider
2. August 31, 2015 -- Letters - SETMA Tools for e-prescribing controlled substances, pain management policy and Urine Drug Screens
3. September 10, 2015 -- Letters - SETMA's letter with Inclusions sent to 105 Pharmacies About e-Prescribing
4. September 17, 2015 -- Your Life Your Health - ePCS and High Intensity Drug Trafficking Areas (HIDTA) Program
5. October 22, 2015 -- Letters - Texas e-Prescribing of Controlled Substance Outreach Planning Group
6. October 25, 2015 --- EPM Tools - ePrescribing of Controlled Substances Tutorial
7. January 7, 2016 -- Your Life Your Health - Looking Back as a Foundation for Envisioning the Future Part I
8. January 14, 2016 -- Your Life Your Health - Looking Back as a Foundation for Envisioning the Future Part II -- the following is an excerpt from this link:

ePCS has been a major advance in quality and safety for patients.  All of SETMA’s providers, including nurse practitioners are participating in this program and SETMA is working with the Texas section of Medicaid-CHIP Health Information Technology Health and Human Services Commission to expand the usage of this tool across Texas.  (see:  ePCS and High Intensity Drug Trafficking Areas (HIDTA) Program)”

9. January 21, 2016 -- Your Life Your Health - SETMA's Past Defined by Three Seven-Year Segments which Help Guide the Future
10. December 24, 2015 --  Transforming Your Practice - Introduction to SETMA’s TCPI Library

To complete the process of ePCS, SETMA designed and deployed an auditing tool which allows each provider, at the point of service, to review all e-prescribed controlled substances they have created in the last 30, 60, 90 or 180 days.  The following is a screen shot of how the new auditing tool is accessed in SETMA’s EMR.  (See the button outlined in green below.)  This screen is where every visit with every patient at SETMA begins. 

The following is a real example - de-identified - of an audit of my personal ePCS for the past 30 days. This was created on 1.25.16.  Several things are worth noting:

• The time frame is selected by the provider (30,60,90, 180, days)
• The audit gives you the essential information about the prescriptions
• The audit also tells you how many medications you have ePCS and how many discreet patients that represents. 
• The provider can only audit his/her use.   The systems manager can audit all use.
• None of this audit is recorded so as not to violate HIPAA when a medical record is copied for external use.

This audit, which takes about two seconds to perform, tells me that in the past thirty days, I have prescribed 23 controlled substances for 17 different patients.  The audit also tells me:

1. Type of prescription, i.e., new or refill?
2. When the prescription was sent?
3. Who prescribed the drug?
4. What patient the prescription was for?
5. What was prescribed?
6. How many pills were prescribed?
7. How many refills were given?
8. The directions given to the patient for how to take the medication?

Several HIPAA issues are worth noting:

• This information is not saved to the chart.  The reason is that if it were, Personal Health Information (PHI) for multiple patients would be put on a chart note which could be and would be sent to others, thus violating HIPAA.
• There is no link or computer footprint created.  When the chart is closed all evidence of this audit disappears completely and permanently.

Convenience and Quality

The reality is that all changes in health care are measured by quality and safety and by whether or not the change produces a decrease in cost.  In a recent discussion of this, i.e., “does ePCS produce a decrease in cost,” the idea of “efficiency” was examined as efficiency has an element of cost effectiveness. 

In one area of clinical practice, the nursing home, this is clearly seen.  If you look at the institutional cost of medication refills, you have to do what we call a “process analysis.”  In this analysis, the organization examines each step in the process which is required to complete the task under review.   In regard to ePCS in the nursing home (NH), we find the following steps are needed:

1. NH calls the doctor
2. Dr. writes the prescription
3. Dr. Calls and tells the institution it is ready
4. NH sends someone to get the prescription or sends someone to the NH with the prescription.
5. NH takes the prescription to the pharmacy
6. NH goes back to get the medication or the mediation is delivered

This process is repeated 12 times a year, or more, for each resident.  If all of this takes only 60 minutes, and the institution has 50 patients.  That’s 12 times a year x 60 minutes per event x 50 patients divided by 8 yours a day - you can see it is an enormous cost the institution. 

With ePCS, the math changes:

1. Secure Text or e-mail sent to provider - 1 minute
2. Provider ePCS - 1 minute
3. Pharmacy receives electronic order - zero minutes
4. Pharmacy batches, fills and delivers the medication - 5 minutes due to shared cost   

For a fair comparisons these times are slightly exaggerate as each step actually takes less time than indicated.  The equation changes to 12 times a year 7 minutes x 40 patients divided by 8 hours in a day.  The current system takes 8.57 times the effort time and cost to do the same tasks as can be done by ePCS.

 For non-institutional use of ePCS, patient satisfaction is increased which contributes to patient adherence and quality of care.  This concept was described in a 2012 presentation entitled,  “Convenience, the new word for quality.” (see http://jameslhollymd.com/Presentations/HIMSS-2012-Leaders-and-Innovators-Breakfast-Meeting)

The following logic shows the link between “convenience” and quality:

1. Convenience for the patient which
2. Results in increased patient satisfaction which contributes to
3. The patient having confidence that the healthcare provider cares personally which
4. Increases the trust the patient has in the provider, all of which,
5. Increases compliance in obtaining healthcare services recommended which,
6. Promotes cost savings in travel, time and expense of care  which
7. Results in increased patient safety and quality of care.

e-Prescribing of all medication and especially e-prescribing of control substances contributes to this sequence which connects convenience and quality.  Over the next few year all physicians will be using e-Prescribing.