A question about e-prescribing: Should it extend to controlled substances?

September 1, 2006

There's a running debate over the wisdom of electronic prescribing of drugs, and on one side is the opinion of the US Department of Health and Human Services (HHS): For the sake of both patient safety and medical efficiency, it is important that physicians begin using e-prescribing to help prevent medication errors. Aligning with that side is The Institute of Medicine, whose report on medication error this summer offered a stunning prediction: All physicians and pharmacists will be using e-prescribing in just over three years.

There's a running debate over the wisdom of electronic prescribing of drugs, and on one side is the opinion of the US Department of Health and Human Services (HHS): For the sake of both patient safety and medical efficiency, it is important that physicians begin using e-prescribing to help prevent medication errors. Aligning with that side is The Institute of Medicine, whose report on medication error this summer offered a stunning prediction: All physicians and pharmacists will be using e-prescribing in just over three years.

Move to the other side of the debate and you'll find the US Drug Enforcement Administration (DEA), which is worried-very much so-about a significant catch to e-prescribing: Eleven percent of prescriptions written in the US are for controlled substances, and e-prescribing of drugs that come under that classification is likely to inspire criminal creativity that the nation's law enforcement and medical communities have not yet dreamed of.

On the other side, again, HHS fears that, if physicians are forced to use a system (read: paper) for prescribing controlled substances that is distinct from what they use to prescribe other medications, they will be discouraged from adopting e-prescribing technology.

The two agencies, unable to resolve this issue for months, arranged to listen to testimony from a range of professionals at a joint hearing on July 11 and 12 just outside of Washington, DC.

Pharmacists, physicians, and vendors of information technology testified that e-prescribing systems are probably secure enough now to prevent and detect most attempts at fraud involving controlled substances. And electronic systems are, they pointed out, certainly more secure than current paper systems.

On the other side of the aisle, law-enforcement professionals said they are frightened by proposals that e-prescribing of controlled substances begin now and that enforcement agencies watch to see what happens at the current level of security. They pointed to the reported rapid increase in the diversion of prescription drugs, the high level of interest by fraudulent parties in Internet pharmacies, and the myriad ways in which security systems can be circumvented.

No action had been taken on the matter by either agency at press time.

The Academy weighs in

In a statement submitted to the July hearing by the AAP, however, the Academy asserted: "The greatest risk for electronic prescribing is that people will not use it. The value of electronic prescribing has been well established and well demonstrated to advance the quality of care and promote patient safety as well as save time for patients and physicians and decrease phone calls to the office."

The AAP statement noted that the principal use of controlled substances in pediatrics is, of course, to treat attention deficit hyperactivity disorder with stimulant medication. This essential therapy is interrupted for some children, however, because the medicine can only be dispensed with a 30-day, nonrenewable prescription that cannot be phoned in-and that requires a "wet" signature on a scrip that cannot be faxed. Parents, the AAP noted, are often inconvenienced by having to pick up the prescription every month, or are sometimes unable to pick it up-a situation that e-prescribing for controlled substances would greatly ameliorate.

E-prescribing of controlled substances should be permitted "as soon as possible, on an interim basis, while additional security requirements are evaluated," testified Alan Zuckerman, MD, program director of primary care informatics at Georgetown University, on behalf of AAP and in support of the Academy's prepared statement.

Pilot studies to test large-scale use of the so-called public key infrastructure (PKI) digital signature should be performed as soon as possible, Zuckerman urged; so should deployment of the PKI digital signature in small practices. PKI uses third-party systems of vouching for the identity of users when business is conducted over the Internet.