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William M. Vollmer, PhD; Ashli A. Owen-Smith, PhD; Jeffrey O. Tom, MD, MS; Reesa Laws, BS; Diane G. Ditmer, PharmD; David H. Smith, PhD; Amy C. Waterbury, MPH; Jennifer L. Schneider, MPH; Cyndee H. Yo
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Adoption of Electronic Prescribing for Controlled Substances Among Providers and Pharmacies
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Adoption of Electronic Prescribing for Controlled Substances Among Providers and Pharmacies

Meghan Hufstader Gabriel, PhD; Yi Yang, MD, PhD; Varun Vaidya, PhD; and Tricia Lee Wilkins, PharmD, PhD
We present the first reported national trends in the adoption of electronic prescription of controlled substances, from July 2012 to December 2013. The results show that the uptake rates of this newly allowed process are steadily increasing.
Objectives
Electronic prescribing for Schedule II through V controlled substances was legalized in the United States by the Drug Enforcement Administration in June 2010. However, little information exists about adoption and use of the electronic prescribing of controlled substances (EPCS) at the national level. Therefore, the objective of this study is to present the first information about national trends surrounding the adoption and use of the newly allowed EPCS by providers and pharmacies in the United States.

Study Design
Trends of EPCS adoption and use were examined for the number of EPCS, number of pharmacies enabled to accept EPCS, and the number of providers prescribing controlled substances electronically.

Methods
Using nationally representative transactional Surescripts data from July 2012 to December 2013, we examined EPCS trends.

Results
During the study period, the total number of EPCS increased from 1535 to 52,423, and the number and percentage of all pharmacies enabled for EPCS increased from 8768 (13%) to 20,498 pharmacies (30%). The proportion of all providers prescribing controlled substances electronically is currently 1%, but increasing steadily each month.

Conclusions
There is a positive national growth for EPCS in pharmacy preparedness to accept EPCS, the number of EPCS prescriptions sent each month, and the number of providers with the ability to send EPCS.

Am J Manag Care. 2014;20(11 Spec No. 17):SP541-SP546
The electronic prescribing of medications is on the rise, but only recently did federal regulations in the United States allow for the electronic prescription of controlled substances (EPCS).
  • As of December 2013, one-third of pharmacies in the United States are enabled for EPCS, although only about 1% of all e-prescribers are enabled.
  • On the provider side, the initial adoption of EPCS has been slow, but the rate of growth in adoption is substantial.
  • Using the most recent nationally representative transactional data, we show a significant upward trend in the adoption of EPCS in the United States by pharmacies and providers.
Electronic prescribing (e-prescribing) refers to the process by which a prescriber generates and transmits an “accurate, error-free and understandable” prescription directly to a pharmacy through a special secure network.1,2 While evidence is still accumulating, research has shown that e-prescribing is perceived to be efficient by providers. E-prescribing may help reduce medication errors and adverse drug events, improve formulary adherence by prescribers, and improve patient adherence to prescription medications, therefore improving quality of care and reducing healthcare costs.3-5

Although early adoption of e-prescribing was slow due to concerns over the potential for unintended consequences, as well as some organizational barriers such as financial constraints of small medical practices, significant growth was seen in the adoption and use of e-prescribing in recent years.6-10 For example, a recent study using data from Surescripts shows that the proportion of providers e-prescribing via an electronic health record (EHR) increased from 7% in December 2008 to 54% in December 2012.7 It is reported that financial incentives authorized by the Medicare Improvements for Patients and Providers Act of 2008 has played a significant role in the increase in the adoption and use of health information technology such as e-prescribing.11

Controlled substances, such as opioid narcotics and stimulants, have potential for abuse and may cause dependence when abused. Approximately 27,000 unintentional drug overdose deaths occur in the United States each year, and opioid drugs are the most common causes of drug overdose mortality.12 Controlled substances account for approximately 10%-11% of all prescriptions in the United States.13 Historically, a prescription for a controlled substance was required to be “written in ink or indelible pencil or typewritten and must be manually signed by the practitioner on the date when issued” and could not be e-prescribed.14

However, in June 2010, the Drug Enforcement Administration (DEA) revised its regulations on controlled substance prescribing in a DEA Interim Final Rule (IFR) to allow e-prescribing for drugs in schedules II (for example, opiates and opioids such as morphine and fentanyl used for moderate to severe pain), III (for example, anabolic steroids and preparations of narcotic drugs), IV (primarily benzodiazepines), and V (for example, narcotic and non-narcotic preparations such as cough syrup with codeine).15 It is believed that e-prescribing for controlled substances (EPCS), because of its potential to reduce prescription forgery and to identify multiple prescribers at the point of prescribing and dispensing, may improve pain management. Thus, it may play an important role in alleviating the growing public health problem of the abuse and overdose of controlled substances.16,17

While the DEA IFR sets the minimum standards, state laws and regulations can lay out further restrictions and requirements for EPCS. As of now, 49 states allow EPCS for scheduled drugs, with only 2 states limiting it to schedules III through V.18 However, use of EPCS is not mandatory from the DEA’s perspective; pharmacies are still able to dispense controlled substances based on paper-and-ink prescriptions from providers.15 Providers and pharmacies interested in adopting EPCS need to undergo identity-proofing to ensure the security of EPCS; various technologies such as a hard token or certain biometric information (eg, fingerprints) have been employed for identity-proofing purposes. Providers and pharmacies also need to ensure that their software system is compliant with DEA requirements.19,20 Currently, 26 software solutions are certified and actively available for EPCS, with another 3 that are certified but may not yet be available to route EPCS.21

Research on EPCS has been scarce. Preceding the DEA IFR, Thomas et al17 surveyed a group of 102 prescribers in a community to assess prescribers’ early experience with a testing EPCS program. They found that even though pharmacy participation was limited, over half of the surveyed prescribers rated EPCS positively. Thomas et al16 also reported that prescribers were generally optimistic about the benefits of EPCS while expressing concerns about some of its security measures. However, more than 4 years have passed since the DEA IFR became effective; little is known about the actual adoption and use of EPCS nationwide.

The objective of this study is to present the first information about national trends surrounding the adoption and use of the newly allowed EPCS by providers and pharmacists in the United States, using 18 months of pharmacy and provider transactional data (July 2012 to December 2013) from Surescripts.

METHODS

Data Source and Analysis


Surescripts is a leading e-prescription network utilized by a majority of chain, franchise, and independently owned pharmacies in the United States. It routes prescriptions for more than 240 million patients through its network, excluding closed systems such as Kaiser Permanente. In 2013, about 73% of office-based physicians sent over 1 billion electronic prescriptions via Surescripts, representing 58% of eligible prescriptions written in the United States.22 In 2011, Surescripts began a limited deployment to upgrade its network to allow for EPCS in states in which it was legal. After the upgrade was completed in those states, pharmacies and providers were required to use certified software applications and successfully complete a DEA third-party audit before a controlled substance could be e-prescribed. The network expanded as states allowed for EPCS. The data used in this study represent electronic transactions of controlled substances from all states that have granted state regulatory approval for EPCS.18,22

Surescripts data contain 2 components: pharmacy data and provider data. Surescripts pharmacy data include all pharmacies registered with the National Council for Prescription Drug Programs (NCPDP) containing indicators of whether each pharmacy is connected to the Surescripts network and whether a pharmacy is enabled to receive prescriptions for controlled substances electronically. For this analysis, we included physicians, nurse practitioners, and physician assistants as providers.

Using transactional Surescripts data, we examined trends from July 2012 to December 2013 in the quantity of EPCS, the number of pharmacies enabled to accept EPCS, and the number of providers enabled to electronically prescribe controlled substances.

RESULTS

During the study period, the total volume of prescriptions for controlled substances sent electronically increased from 1535 to 52,423 (Figure 1). On average, the total number of EPCS increased by an average of nearly 3000 scripts every month during the study period.

As shown in Figure 2, during the study period the number and percentage of all pharmacies enabled for EPCS increased from 8768 (13%) to 20,498 pharmacies (30%). On average, 690 new pharmacies are becoming enabled for EPCS every month.

On the provider side, only 1% of all e-prescribers were enabled for EPCS as of December 2013. EPCS adoption is steadily increasing, however, with an average of 287 providers adding this capability every month (Figure 3). In July 2012, 424,629 total physicians, nurse practitioners, and physician assistants were e-prescribing on the Surescripts network. Of these, 225 were sending electronic prescriptions for controlled substances (0.05%). As of December 2013, of 552,497 total physicians, nurse practitioners, and physician assistants on the network, 5101 (1%) were prescribing controlled substances electronically.

DISCUSSION

In this analysis, our focus was to explore the adoption of EPCS by providers and the availability of pharmacies enabled to process EPCS in the United States. By using the most recent data available, we were able to plot initial trends of EPCS adoption and use by providers and pharmacies from July 2012 to December 2013.

We found that there is positive growth at both levels: pharmacy preparedness, and the number of controlled-substance prescriptions written by providers. In the relatively short period of 18 months, the number of EPCS-enabled pharmacies increased by 130%. Among providers, EPCS adoption is still very low compared with overall e-prescribing rates. Several reasons might explain the slower EPCS adoption among prescribers. First, there may be a lack of trust of technologies to handle prescriptions for controlled substances among prescribers, who may fear prescriptions getting “lost in the system.” Second, there is not enough perceived incentive for providers to adopt EPCS, while the authentication and registration process might be viewed as “additional work.”11,17 In contrast, the business case for adoption is stronger among pharmacies; if they do not keep up with the competition, they may lose business, and so they tend to adopt more quickly than providers. Compared with the beginning of the study period, when EPCS was almost nonexistent among providers, we observed a significant growth in number of providers participating in EPCS. Based on this 18-month trend, growth in the adoption of EPCS by providers and pharmacy systems is expected to rise significantly in the near future. Providers and pharmacies who will be engaged in EPCS should quickly familiarize themselves with federal and state requirements of EPCS. In addition, providers should undergo identity proofing and both providers and pharmacies should ensure that their software complies with DEA requirements.19,20

Due to increased efficiency5 and the reduced risk of associated errors, e-prescribing in general is a tool to help provide safe and effective care. In fact, Radley et al estimated that e-prescribing resulted in a decrease in the likelihood of prescription errors by 48%.23 Despite initial limitations and barriers, e-prescribing has been adopted rapidly in the United States in the last few years,7 due in large part to the active role of federal agencies in crafting policies and incentive programs with this aim. Through funding delivered via the Health Information Technology for Economic and Clinical Health Act and the American Recovery and Reinvestment Act, both CMS and the Office of the National Coordinator for Health Information Technology have worked closely to create a national framework for meaningful use of EHRs. One hallmark of the program is the adoption of health information technologies for electronic prescribing to support safe and efficient use of medications.

Although e-prescriptions overall have seen significant growth, concerns remain regarding EPCS. EPCS is a more secure and advanced way to handle controlled substances than traditional paper prescriptions, which according to the Institute of Medicine may account for as many as 1.5 million preventable injuries.24 The highly sensitive nature of the scheduled agents poses several concerns among providers regarding regulatory and other technical complexities. For some providers, confusion exists about the legality of EPCS. For example, while 49 states allow the e-prescribing of Schedule II through V substances, Kansas and Vermont allow only Schedule III through V substances to be electronically prescribed.18

 
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