New York State’s drive to prod clinicians to use electronic prescriptions exclusively is making progress, but providers’ ability to use e-prescriptions is not yet universal.

The state is the first in the nation to require that all prescriptions—both for controlled and non-controlled substances—be created electronically. Its legislation mandates that physicians who fail to comply face possible fines and imprisonment. While New York is the first, all 50 states have legalized the electronic prescribing of controlled substances.

The deadline for complying with the mandate passed on March 27, and the vast majority of New York State providers have migrated to e-prescribing all medications. However, many small and large providers have yet to do so, illustrating the state’s challenges in achieving a total switchover, and the extent to which technology can thwart the process.

Providers typically use their electronic health records systems to create and send e-prescriptions. However, not all EHRs used by the physicians in the state are able to handle e-prescriptions for controlled and non-controlled drugs. In addition, some physicians have not completed the lengthy process that enables them to use their EHRs to e-prescribe controlled substances.

The state established a waiver system that enables physicians or organizations to request exclusion from the mandate. As of April 1, the state’s Department of Health (DOH) had received 4,165 waiver requests; of those, 1,610 were granted because of technology issues. To qualify for a waiver, a prescriber must demonstrate that he or she is unduly burdened by economic hardship, technological limitations that are “not reasonably within the control of the prescriber” or other exceptional circumstances.

But the number of providers who are not using e-prescription capabilities could be even higher.

The DOH is “treating the hospital systems as one entity, rather than counting all of the physicians within each system,” says Joseph Maldanado, MD, president of the Medical Society of the State of New York. The number of waivers thus understates the number of physicians unable to electronically prescribe controlled substances, he contends.

Mount Sinai Health System, a large integrated delivery system based in New York City, received a waiver because some of its physicians work at sites that do not have technology in place to file electronic prescriptions for controlled substances.

“As a health system, we have already incorporated e-prescribing at several of our campuses, where it is actively up and running, ahead of the state’s deadline,” says Kathy Robinson, a spokeswoman for Mount Sinai. “We are committed to working closely with the state on this important initiative and have been doing so since well before the last year’s original deadline. We have requested and received a waiver on behalf of our physicians who work at sites where there is no viable technological solution at this time."

Similarly, Montefiore Health System, another large integrated delivery system based in the city, has received a waiver from the DOH for the e-prescribing mandate, due to a planned switchover to an EHR from Epic at some of its sites that needed time to make the migration.

“All of Montefiore’s ambulatory sites and most of the broader Montefiore Health System are up and running with e-prescribing, but our Epic go-live implementation for two of our inpatient areas is scheduled for June/July,” says Tracy Gurrisi, director of public relations for Montefiore. “The timing for this latest onboarding to Epic would technically disrupt compliance with the e-prescribing rule, which is why we reached out for a waiver.”

In addition, vendor readiness for expansion of e-prescriptions to controlled substances has been a concern. It was part of the reason that the state’s medical society sought a delay from New York Gov. Andrew Cuomo, who signed legislation in March 2015 granting a one-year delay of the state’s e-prescribing mandate, because some vendors were not in compliance with the Drug Enforcement Administration (DEA) rules for e-prescribing of controlled substances (EPCS), Maldanado says.

Software companies achieved much progress in the past year. EHR vendors serving 96 percent of prescribers in New York are already certified to process controlled substance prescriptions electronically, according to Surescripts, a health information network company that supports the electronic transmission of prescriptions between healthcare organizations and pharmacies, and which tracks data on prescribers and vendors.

The EPCS certification process can take several months, but the vast majority of New York’s prescribers use products from large EHR vendors, which have had the resources to achieve DEA certification. However, some small EHR vendors have missed the March 27 deadline for certification, and that’s impacted providers that use those systems, says Ken Whittemore, senior vice president for professional and regulatory affairs at Surescripts.

Achieving certification is “a bit of a heavy lift on the EHR side,” he notes, and providers also face requirements in receiving DEA approval to prescribe controlled substances. Whittemore describes four key steps in the process for providers, which include:

  • Completing EHR software updates
  • Identity proofing of prescribers
  • Obtaining credentials for secure two-factor authentication prescription signing
  • Setting secure access controls

After completing those four steps, physicians are able to legally transmit EPCS. Still, Sarah Corley, MD, chief medical officer for EHR vendor NextGen Healthcare, says the process of getting physicians enrolled in EPCS is complex and time-consuming. “They must go through identity proofing, which is more problematic for smaller practices than it is for larger health systems that can do this internally,” says Corley. “The physicians must use two-factor authentication when signing these electronic prescriptions, and while it’s not a significant barrier, it’s one more thing that practices have to deploy.”

To be certain that their EHR has been certified to digitally sign a prescription for a controlled substance and send it to a pharmacy, Surescripts recommends that doctors always consult with their respective vendors to verify that the software version they are using has been certified and approved for EPCS. In addition, they must register their DEA-certified EPCS software with New York State’s Bureau of Narcotic Enforcement.

Peter Kaufman, MD, chief medical officer for e-prescribing vendor DrFirst, says he sympathizes with EHR vendors that missed New York’s deadline to be ready for electronic prescribing. “I think there’s a lot of EHR [vendors] out there who thought that this would be really easy,” he says. “They did not realize how complicated it is, not just with the identity proofing and the two-factor authentication, but the audit that’s required by the DEA.”

Large vendors serving prescribers in New York State say it’s mandate approach is being closely watched in other states, which want to streamline and monitor prescription processes, especially in better regulating prescriptions for controlled substances and addictive drugs, such as opioids.

“With New York now mandating it—and only allowing a year’s grace period for technology issues—we should see widespread adoption in the coming months,” says Corley of NextGen, one of the vendors that met the deadline. “We expect other states will follow suit in an attempt to stem the tide of prescription opioid abuse. We look forward to our clients adopting this important technology that will eliminate duplicate processes of paper and eRx.”

Yet, MSSNY‘s Maldanado is not as optimistic. “I think everyone recognizes that this has not been a smooth rollout in New York,” he concludes.

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