When Dr. Jeanmarie Perrone and Dr. Lewis S. Nelson traveled to Washington in early June to meet with administrators of state-based prescription drug monitoring programs, they were stunned by the group’s unfamiliarity with the clinician user experience.
For the Harold Rogers Prescription Drug Monitoring Program National Meeting, "we made PowerPoint slides of the steps required to access a state-based prescription drug monitoring program in real time in an emergency department," recalled Dr. Perrone of the department of emergency medicine at the University of Pennsylvania, Philadelphia. "It was 15 slides – 15 steps. It was illustrative to the attendees, who are nonclinicians and who are implementing requirements that are administrative and privacy based. They were very grateful for our input. They may have had representation from pharmacists about what a pharmacy needs to do to upload information into the system, but I’m not sure that they understood the needs and time constraints of a clinical end user."
Dr. Jeanmarie Perrone
Shortly before this meeting, Dr. Perrone and Dr. Nelson published a paper that spelled out the characteristics of an ideal prescription drug monitoring program (PDMP) in the wake of the current epidemic of prescription drug abuse and drug diversion (N. Engl. J. Med. 2012;366:2341-3). Federal legislation has supported the formation and expansion of state-based PDMPs since the early 1990s, but most of the early systems were paper-based and cumbersome. "They might have worked for very motivated pain medicine physicians who were trying to keep some log of how many opioid analgesics their patients were getting in the few states where the pharmacies were voluntarily contributing to the data," Dr. Perrone said. "Now, with the advent of things like real-time reporting and everything being online, it’s not unreasonable to think that an emergency physician could log onto a website in real time and get a sense of how many other prescriptions the patient in front of them may have had from other prescribers."
One study found that using PDMP data in an emergency department changed clinical management in 41% of cases (Ann. Emerg. Med. 2010;56:19-23). Of these, 61% of patients received fewer or no opioid pain medications than had been originally intended by the physician prior to reviewing the PDMP data, while 39% received more opioids than initially intended because the physician could confirm that the patient did not have a recent history of opioid use.
Dr. Perrone described current PDMPs in the United States as being a state of "rejuvenated infancy," with a wide variability in scope and quality. Of the 42 states that have operational PDMPs, Colorado, Florida, Minnesota, and North Carolina have some of the more user-friendly programs, she said, while 7 other states have enacted legislation to develop programs. The largest network of PDMPs is the National Association of Boards of Pharmacy’s PMP InterConnect, which currently allows 9 states to share data and is expected to include 20 states by the end of 2012. A 2011 report published by the White House Office of National Drug Control Policy called for a "major effort" to improve state PDMPs, "especially regarding real-time data access by clinicians, and to increase interstate operability and communication. Furthermore, we must identify stable financial support to maximize the utility of PDMPs, which will help reduce prescription drug diversion and provide better health care delivery."
In their New England Journal of Medicine paper, Dr. Perrone and Dr. Nelson, who is the fellowship director in medical toxicology and a professor in the department of emergency medicine at New York University, compiled a list of characteristics of an ideal PDMP:
• Ease of access.
• Standardized content.
• Real-time updates.
• Mandatory pharmacy reporting.
• Monitoring of prescribing of schedule II-V drugs and other drugs of concern.
• Interstate accessibility.
• Confidentiality and security.
• Support for public health initiatives and research.
• Strict monitoring of access by nonprescribers.
In Pennsylvania, where Dr. Perrone practices, only law enforcement officials can access data generated by that state’s PDMP. "It’s not available to physicians," she said. "We’ve lobbied, but that’s still where it stands. There needs to be a national push as well as a clinician push saying that this [information] is valuable."
New York State has approved a plan that would require clinicians to write prescriptions in an online program, "meaning that it’s mandatory to sign into the program prior to prescribing," Dr. Perrone said. "I think that it may be too cumbersome, and I think that may actually decrease prescribing for patients who need their medications. Clinician education about these programs and removal of some of the barriers to access will help expand the use of PDMPs. In North Carolina, for example, in order to access the PDMP as a physician, you have to apply to the program and get your application notarized. That’s burdensome. We are all tied down by paperwork."