Electronic Prescribing of Controlled Substances (EPCS) is an innovative technology that allows healthcare providers to write electronic prescriptions for controlled substances. The Drug Enforcement Administration (DEA) legalized EPCS in 2010. State laws subsequently were independently changed as well to permit EPCS. By 2014, 30% of pharmacies in the United States were accepting EPCS as a method of prescribing, but only 1% of providers in the country were prescribing controlled substances via EPCS. Today, EPCS is being implemented into health-system workflows across the nation and mandatory EPCS is on the horizon with a minority of states already requiring it.
When implementing EPCS, there are items to keep in mind for a more successful implementation.
- Prescription Workflows: Many clinics rely on non-prescribers to help with the prescription writing and refill process. With EPCS, those workflows need to be evaluated and updated to reflect how, and by whom, the controlled substance prescriptions are to be entered. This results in a shift in workflow from ordering “on behalf of” to a “proposal” workflow where the DEA registrant is required to digitally sign the controlled substance prescription.
- Registering Providers: Critically evaluate how, and who, will be registering the providers. In an institutional setting, a non-DEA registrant can register providers. However, in individual and private practice settings, a DEA registrant must be the one who grants the logical access. What double checks will be put into place? What type of identification will be required to register for EPCS? What documentation is needed? What are the retention times needed for the registration documentation to comply with DEA regulations?
- Location Build: For those healthcare institutions with multiple hospitals, clinics, and/or priority care locations, keeping on top of the location builds at the organization is key. For example, if there is a clinic move, the prescribers may need to be updated in the system to allow for prescribing at that new location. Evaluate what the prescribers can do at each location as well. Should refill requests come to a prescriber practicing in an Emergency Department where the intervention is short-term? If a prescriber is part of a patient’s longitudinal care, does that change the response?
- Formularies: Many institutions view and update the ordering catalog based on the formulary approved by their P&T committee. For e-prescribing in general, and for EPCS in particular, the prescription catalog should not be limited. Evaluate what is viewed, not viewed, and order sentences available for convenience and safety. Ensure the order catalog allows an easy and transparent medication reconciliation between inpatient and ambulatory visits. New regulations regarding medications with high abuse potential are beginning to reference MME limits in the Medicare Part D space. The formulary build within the electronic health record needs to be able to calculate and provide the MME data for these medications.
- Clinical Decision Support: When medication ordering was fairly limited to non-prescriptions, clinical decision support was built to support that process. With prescriptions being entered through the electronic health record as well, evaluate what alerts may, or may not, be applicable to the prescription process and adjust accordingly.
As adoption increases, EPCS may help to standardize prescribing practices and improve care by optimizing workflow, increasing the accuracy of prescriptions, and creating transparency in diversion activity. However, there are still present challenges and considerations that come with adoption. Each institution may require a different implementation strategy involving multiple stakeholders before going live. With proper implementation, EPCS can bring about an efficient experience for prescribers and a safer experience for patients.
Authors
Published on behalf of the Clinical Application Workgroup for the Clinical Application SAG:
Alec Huang, Pharm.D. Epic Business Intelligence Developer. Thomas Jefferson University Hospital. Philadelphia, PA.
Ben Iredell, Pharm.D. MBA, BCPS, Pharmacy Informatics Manager, Cedars-Sinai Medical Center. Los Angeles, CA.
Chad S. Stashek, Pharm.D., M.S., Clinical Informatics Pharmacist, Affiliated Faculty. Oregon Health & Science University. Portland, OR.
Hesham Mourad, Pharm.D., BCPS, BCCCP, CPHIMS, Medication Management Informaticist, Assistant Professor of Pharmacy. Mayo Clinic. Jacksonville, FL
John Siejak, Pharm.D., CPHIMS, Pharmacy Informaticist, Kaleida Health. Buffalo, NY
Lisa Starost, PharmD. Manager – Pharmacy Informatics and Program Director, PGY2 Informatics Residency. Indiana University Health. Indianapolis, IN
Tanya O. Ezekiel, Pharm.D., BCPS. Clinical Informatics Pharmacist. Prisma Health–Midlands. Columbia, SC
References
Hufstader Gabriel M, Yang Y, Vaidya V, Wilkins TL. Adoption of electronic prescribing for controlled substances among providers and pharmacies. Am J Manag Care. 2014;20(11 Spec No. 17):SP541-6.
Practice Fusion. What is EPCS? https://www.practicefusion.com/epcs/what-is-epcs. Accessed March 20, 2019.
Terry, K.J. B warned: e-Prescribing’s 6 big challenges for doctors. Medscape. https://www.medscape.com/viewarticle/773404. Updated November 1, 2012. Accessed March 13, 2019.
Thomas CP, Kim M, Mcdonald A, et al. Prescribers' expectations and barriers to electronic prescribing of controlled substances. J Am Med Inform Assoc. 2012;19(3):375-81.