November 25, 2013

Tom Sullivan, M.D.

Which one is more important…PDMP versus EPCS?

UPDATE: DrFirst Urges DEA to Change EPCS Rules

Since the Drug Enforcement Administration (DEA) developed standards for electronic prescribing of controlled substances (EPCS) and states developed their own individual protocols for prescription drug monitoring programs (PDMPs) a decade ago, technology has advanced significantly. Both programs are key tools to help ensure the safe and appropriate prescribing of opioids and other controlled substances, but some physicians are frustrated by cumbersome workflows. See our proposal to remove workflow barriers and adopt practical, industry-standard solutions that promote patient safety and help avoid drug fraud, abuse, and diversion.

Please read our original blog post below.

This is the fourth installment of a five blog series on Prescription Drug Monitoring Programs (PDMPs) and the Electronic Prescribing of Controlled Substances (EPCS).
As the title suggests, one might ask which program is more important. Of course, as the reader may suspect, the answer depends on the perspective of each individual user.
PDMP Importance
Professionals working in fields such as public health, epidemiology and law enforcement are acutely aware of the accelerating epidemic of prescription drug abuse that has been growing across the United States for some time now (see my first blog in this series). The effects of this social problem have become so widespread that it has been affecting medical professionals in a wide range of other fields as well. Providers who work in behavioral health, addiction disorders, pain management, emergency departments, urgent care centers and even surgical specialists are all becoming, sadly, more familiar with the prescription drug abuse crisis.
The rising cost of this drug abuse crisis, as well as its accelerating pace, has made the issue of strengthening state PDMPs an important area of concern for many professionals in these circles. As a result, these programs are finally beginning to garner more attention. The benefits of utilizing PDMPs are relatively easy to summarize. When providers have access to accurate records regarding a patient’s prescription medication history they are more easily able to spot patterns of abuse and diversion of controlled substances and medications.
PDMPs eliminate the guess work for physicians who otherwise have to make intuitive decisions about a patient’s credibility in seeking powerful, highly regulated drugs. Judging by current national trends, this more empirical approach to handling prescriptions is important because leaving controlled substance distribution to the ‘gut level decisions’ of physicians has been a proven failure. Drug seekers and individuals who are seeking to abuse the system are quite often smart people, skilled manipulators, and, in many cases, highly innovative entrepreneurs with a strong motivation to deceive. Physicians need real information about a patient’s prescription history and drug consumption patterns in order to effectively counter this dynamic.
As mentioned in a recent blog, the state of New York has been a pioneer with its I-STOP legislation which mandates that medical providers consult PDMPs prior to writing any new prescriptions. Any medical provider in the state of New York who fails to comply with this mandate as of August 27, 2013, is liable to incur penalties including “fines, jail time and loss of licensure” according to a memorandum from the Medical Society of the State of New York.
New York’s I-STOP law is a major breakthrough for proponents of PDMP expansion for a number of reasons; the law effectively solves the problem of widespread non-participation through mandating that all physicians and practices actively consult the New York PDMP. In addition to this all important first step, the state of New York has also made an effort to adequately fund their PDMP to the extent that it always functions and functions well. These two developments effectively counter the largest obstacle which most state PDMPs are currently facing—a lack of willingness on behalf of providers to consistently utilize their local PDMP, as well as a lack of funding to make sure that PDMPs work well and are maintained effectively.
EPCS Importance
If the prescriber’s practice generates a high volume of controlled substance prescriptions it generally makes good sense to consider EPCS. This is particularly true if the clinician is already using electronic prescribing for legend drugs since EPCS eliminates the need to switch between these workflows, or to revert to paper or fax prescriptions.
With EPCS it is much easier to track and audit drug usage within an individual practice as well as a large group. This function is growing in importance as one of the management tools to help deal with the current crisis. In addition, prescribing controlled substances electronically also has the advantage of built-in clinical decision support in terms of drug-drug interactions, and drug dosage reminders, as well as other factors needed for reducing errors, enhancing patient safety, and improving overall treatment quality. The availability of modular, DEA compliant and certified EPCS applications that can interface with existing EHRs makes this solution more feasible and certainly faster to implement.
Which is More Important?
From the point of view of choosing which program is more important, clearly it depends on a number of factors including a risk analysis of the specific types and number of prescriptions, as well as the individual statutes in your area. It is clear that other states have recently addressed this issue with stricter regulations including reporting and tracking requirements that apply to prescribers, pharmacies, and, for some cases at the federal level, drug manufacturers. Probably the most effective single new tool in the armamentarium to help mitigate and manage the epidemic is the requirement for pharmacies to upload controlled substance dispensing information to the state PDMPs within 24 hours (or a very short timeframe following pickup of the prescription). Not all states have this narrow timeframe and many do not currently have the funds to support more sophisticated approaches to effectively monitor the problem and take action. Despite this fact, the regulations are becoming much more detailed and they require more action and accountability from providers and pharmacists.
My personal opinion is that both PDMPs and EPCS should be coupled in usage whenever and wherever possible. They are actually complementary. In selected cases, where a person is identified as someone who is clearly abusing opioids the first approach is to confront the patient with the evidence and offer specialized treatment as the best option. If addiction is clearly not the central issue, the physician must consider discharging the patient if appropriate. Of course, the duty to report abuse to authorities will vary by state so that each individual patient and their behavior must be addressed on a case-by-case basis.
DrFirst has been working with a few states over the past 18 months to pilot applications that improve office workflow, making it much easier to access highly secure PDMP databases from inside an e-prescribing application. These new features, being tested now, help reduce or eliminate the inefficiency of separate, time consuming PDMP logins and reduce the need to decide which system is more important.
My next and final blog on this topic will address differing prescriber roles and clinical workflow considerations.

UPDATE: As we are publishing this blog, the ONC has announced that it is convening a new series of webinars to promote standardization of PDMPs, thus reflecting their importance to the national fight against prescription drug abuse. (

  1. The Controlled Substance Epidemic and Crisis
  2. PDMP – What is it?
  3. EPCS – What’s New?
  4. Which one is more important…PDMP versus EPCS?
  5. The Physician and prescriber role in Controlled Substance Fraud and Abuse

About Tom Sullivan, M.D.

Thomas E. Sullivan, M.D is a board-certified specialist in cardiology and internal medicine with over 40 years of clinical practice. He currently works for DrFirst and sees patients part-time in Massachusetts. His expertise in the application of information technology to health care has helped to create an international standard (ASTM) for the exchange of medical record information called the Continuity of Care Record (CCR). With AMA, he was founding chair of their e-Medicine Advisory Committee, worked with the Physician Consortium for Performance Improvement, represented the AMA and helped create the Physician EHR Coalition and is past chair of the AMA Council on Medical Service.