Enabling Electronic Prescribing and Enhanced Management of Controlled Medications

While the use of electronic prescribing (e-prescribing) has led to significant improvements in medication safety, there remain a number of barriers to its widespread adoption. One significant barrier has been the lack of standards for the electronic prescribing of federally controlled substances (EPCS) (e.g., narcotics, stimulants, and sedatives). This deficit has meant that prescriptions for controlled substances must be manually written or signed, and historically have not been transmitted electronically along with other prescriptions. The security standards needed for EPCS are a unique challenge because they need to allow for the prevention, detection, and elimination of the diversion of these substances from the legitimate medical market to the illicit market. While the Drug Enforcement Agency (DEA) has moved forward with regulations allowing for EPCS, not all States have authorized e-prescribing for controlled substances, particularly those with significant potential for abuse.  

This project was conducted to demonstrate how this particular barrier to e-prescribing can be removed. Specifically, the project team developed the capability to electronically create and securely transmit prescriptions for controlled substances, thus improving medication management at the point of care.  

The main objectives of this project were to:

• Develop, implement, and verify a system of safe and secure electronic transmission of prescriptions for federally-controlled substances in an ambulatory care setting.
• Develop and test the interfacing of this e-prescribing system with the Massachusetts Prescriptions Monitoring Program (PMP) to monitor prescription fraud and nonmedical use of controlled medications.
• Conduct systems process and outcomes evaluations of the improvements to patient care, risk reduction, patient and clinician benefits, patient safety, and information privacy and confidentiality that are expected as a result of this system. 
• Develop and implement a plan for dissemination of findings.

The study team worked with the Massachusetts PMP to develop a model to reconcile e-prescribed and dispensed controlled substance prescriptions. For the study, providers were given hard tokens, an electronic key to access the system that served as a digital signature of the provider, allowing for two-factor authentication when they created and transmitted EPCS in ambulatory settings. Non-users of the system did not receive tokens until later in the study. Users were surveyed before implementation and again at 6 months. Non-users were surveyed before and after the implementation of the system, and again after they received tokens. 

The surveys indicated that security concerns initially held by the providers were not realized.  Over time the use of EPCS increased dramatically. It was noted that the availability of pharmacies able to dispense EPCS is critical to adoption. The project team concluded that EPCS is a promising tool able to improve public health and public safety by identifying diversion or misuse of controlled substances. It will likely become a major tool to help curb substance abuse and contribute to patient safety, practice efficiency, and positive health outcomes.