In the first two installments of this series, we addressed the severity of the opioid-abuse epidemic and the need for providers being able to make sure that the right patient is taking potentially addictive medications. The second installment addresses the imperative of improved medical record keeping which includes the ability of the provider to audit their own prescribing of opioids and/or controlled substances, and the important of accurate medication lists in the medical record.

This installment continues to look at the importance of excellent medical records.  Without doubt, the most difficult problem facing healthcare providers has always been the imperative for the maintenance of accurate, complete, up-to-date medication lists in the medical record.  Who does not remember paper records where the medication list became so filled with cross-through, scratch-outs and overwrites that they were illegible.  First, electronic medical records and the with electronic prescribing of medications and finally with electronic prescribing of controlled substances, all of this changed.

Does anyone remember the prescription refill sequence before e-Prescribing of all medications?  The movie about this would not be entitled “Seven Days in May,” but “Seven Details to Madness.”

• Prescription is written
• Taken by patient to pharmacy
• Pharmacist can’t read it
• Pharmacy calls provider
• Provider doesn’t remember what was prescribed
• Provider asks for chart
• Chart can’t be found

Three days later the prescription was finally filled by which time everyone is mad and the proper care of the patient has been delayed.  At several points within this process there was potential for abuse and misuse by the changing of the number of pills to be dispensed or by the changing of the number of refills, etc.

In the Nursing Home, the process was even more complicated, particularly with controlled substances.  The Nursing Home staff:

• Called the doctor
• The doctor wrote the prescription
• The practice called the institution that the prescription was ready
• The Institution sent someone to get the prescription
• They took the prescription to the pharmacy
• They went back to get the medication

This process was repeated at least twelve times a year for each resident.  If these steps took only 60 minutes for each refill, and the institution had 50 patients on these medications, the time/cost to the facility “was twelve times a year x 60 minutes an event x 50 patients divided by 8 hours a day,” which is a great deal of time. 

As with routine prescriptions, prescriptions for controlled substances with e-prescribing (ePCS), the math changed:

• Secure Text or e-mail sent to provider by the facility - 30 seconds to one minute
• Provider ePCS - thirty seconds to one minute
• Pharmacy receives electronic order - zero time
• Pharmacy notifies the provider that the prescription has been received - zero time
• Pharmacy batches, fills and delivers the medication - 5 minutes due to shared cost    
• The equation changes to 12 times a year 5-7 minutes x 40 patients divided by 8 hours in a day - The current system takes 8.57 times the effort and time and cost to do the same tasks as can be done by ePCS.

In this process quality, safety and convenience are increased.  With ePCS, patients have increased confidence that their medication needs are and will continue to be met and the process is more convenient than ever before.  Electronic prescribing and electronic prescribing of controlled substances created a collaboration between Physicians, Nurse Practitioners, Physician Assistants and pharmacists which has never more real.  While the credentialed provider must complete the prescription process, the entire team was involved. 

Gone are the days when pharmacists had to interpret prescription orders.  Now pharmacies receive prescriptions electronically and providers receive notifications that a prescription has been received by the pharmacist. 

SETMA’s use of ePCS decreases the potential for abuse/harm by:

• Eliminating the duplication of prescriptions
• Eliminating alteration of numbers of refills and of quantity prescribed
• Creating a record of all e-prescribed controlled substances
• Requiring a provider-specific, unique six-digit number, which changes every thirty-seconds for ePCS
• Eliminating the ability for anyone but the prescribing physician to create the e-prescription
• Allowing the provider to audit own use of controlled substances
• Eventually, it is hoped that we can demonstrated significant cost reductions by the use of ePCS.  In the short run, we can make inferences from the fact that efficiency has an element of cost effectiveness.  If you look at the institutional (Long-Term Care Facility) cost of controlled-substance medication refills which include the following steps:

Individual provider auditing of their own prescribing of controlled substances and the power of electronic patient records, coupled with electronic prescribing of controlled substances dramatically decrease opioid abuse by healthcare providers who are using new technologies.

Medication prescribing is a multifaceted and multifunctional process which includes the following:

• e-Prescribing of Routine Medications - most healthcare providers have been doing this for several years.  The effectiveness and efficiency of this procedure is discussed below.
• e-Prescribing of Control Substances - only a small percentage of providers nationwide are using this tool but those who are find it extremely valuable.
• Auditing of Prescription Drug Usage with Urine Drug Screens -- When I started practicing medicine in 1973, urine drug screens were done to determine whether or not a person was abusing medications, whether illegal or prescription drugs.  Today, urine drugs screens are used to determine whether patients are taking their prescription pain medications or whether they or others are diverting them to illicit sales and/or use. 
• Decreasing the use of antipsychotics in the elderly - A uniform theme in prescribing of medication is the decreasing of the use of potentially harmful drugs.   In an effort to decrease the inappropriate use of antipsychotic medications in Texas Nursing Homes, The Texas Medical Foundation and the Texas Department of Aging and Disability produced a booklet which addresses alternative method of treating behavioral and cognitive functions in the elderly.    Because SETMA provides care to almost 80% of the long-term care residents in Southeast Texas and because SETMA documents the care of those patients in our electronic patient record (EMR), we have taken this tool kit and created a Clinical Decision Support tool to improve the care of the patients for whom we have responsibility.  This tool was discussed in the conference with suggestions for how to improve quality and safety in the use of these medications.