Thursday, June 05, 2008

Online Access to Prescription Medication History

I saw a headline this morning that the California attorney general is moving to provide instant access to a patient's prescription history for doctors and pharmacists (regulatory boards and law enforcement organizations currently have ready access to this info).  

State Atty. Gen. Jerry Brown unveiled a plan Wednesday to provide doctors and pharmacists with almost instant Internet
 access to patient prescription drug histories to help prevent so-called doctor shopping and other abuses of pharmaceuticals.

Brown told a Los Angeles news conference that the state's prescription monitoring is a "horse-and-buggy" system that needs significant improvements because it now can take healthcare professionals weeks to obtain information on drug use by patients. That delay can allow some patients to get large quantities of drugs from multiple doctors for personal use or sale.

"If California puts this on real-time access, it will give doctors and pharmacies the technology they need to fight prescription drug abuse, which is burdening our healthcare system," Brown said.

The database, known as the Controlled Substance Utilization Review and Evaluation System, contains 86 million entries for prescription drugs dispensed in California.
I have mixed feelings about this issue.  Maryland passed a similar bill this past session to study such a program.  There is a very serious problem with abuse and diversion of controlled medications, such as Percocet, OxyContin, Lortab, and Xanax.  It is indeed very easy to get scripts from duped physicians and nurse practitioners and PAs, get it filled, and then sell it on the street for a 1000-5000% profit.  We need methods to control this.

The flip side is the risk of privacy violation.  Patients could have their privacy breached.  So, how much are we as a society willing to give up to combat this problem?

My suggestion:  Build in banking-level protections, provide patients access to their own histories, provide patients the ability to permit or deny access on an individual basis (so that they have control over access), and permit patients to see who has accessed their records.  Also, provide protections to prescribers and pharmacists which allow them to not prescribe or fill a medication if the patient refuses access to their history.

This provides a greater amount of control over access to personal info, while still providing the ability of prescribers and pharmacists to exercise careful judgment about the medications they write or fill.

I'm not totally sold on this solution, but it does seem to be a better compromise than the big brother approach.  I'd like to hear your thoughts on this difficult problem.  Please add your comment below.

28 comments:

Therapy Patient said...

I like your ideas very much, but that would be more cumbersome than just restricting access to this information to physicians only. Physicians are writing the prescriptions, they already have confidentiality agreements with their patients so there'd be no need for layers of additional restrictions if you just dropped pharmacists out of the loop.

At my grocery-based pharmacy all the grocery clerks rotate through the pharmacy department and already some do not undestand the right of a patient to privacy. I don't mind a clerk commenting on my cat food but I do mind that same clerk rotated to the pharmacy commenting on my meds. I would hate these non-pharmacists to have access to my entire pharmaceutical record.

Tigermom said...

My normal first reaction would be to tread very carefully and keep privacy concernc paramount. That was until trecently when I found out a patient had been doctor shopping and using multiple pharmacies and canceling appointments and so on and so on.

Now I feel used and if there is no modicum of trust, can I rebuild the relationship or get the person the real help the person has been refusing?

A way to consolidate the care and verify what's going on would enable me to safely care for the person at a minimum.

RJS said...

Pharmacists will always need to have access to such a system because:

1) Contrary to popular belief, doctors/NPs/PAs aren't the gatekeepers to Rx-only medications. Pharmacists are.

2) Forged prescriptions are a prevalent and real problem*

3) It's the pharmacist's license just as much as it is the doctor's when an Rx goes out to a patient.

* I can't tell you how easy it would be for me or any other similarly tech-savvy person to manufacture customized prescriptions like the ones in the linked post there, and sell them quickly and easily for a huge profit. Even the so-called "tamper proof" (hah!) prescriptions.

--

I think patients having an ability to permit or deny access to providers and pharmacists on an individual level should have a corollary: doing so gives the prescriber or pharmacist the choice to refuse to prescribe or dispense a medication by default. So by restricting access, you are waiving your right to litigate based on refusal to dispense/fill.

Patient rights must take a backseat if we are to retain our (apparently) God-given right to sue in this country, because the two ideas are inherently in conflict with one another in some circumstances.

--

therapy patient,

I think that's a phenomenally bad idea for that chain to have the non-pharmacy personnel rotate through. In my chain (not a grocery store or big box retailer), you aren't even allowed to step foot in the pharmacy unless you have gone through a whole bunch of privacy testing and certification. This includes front-store management.

Still Dreaming said...

I honestly don't see anything wrong with that. I don't know, maybe I'm too accepting of implied confidentiality, or maybe I am just an open person, but I have no problem with the doctor and pharmacist having access to my medication history. I actually think it would be useful. Like when the Doctor at the walk in asks me the name of the antibiotic I took a year ago that worked really well. I couldn't remember, if he could have just looked it up, it would have been awesome.

My pharmacy already keeps my medication history in the computer because of my pharmacare (when the government gives me free drugs; go Canada). Even if I pharmacy shopped I'm pretty sure that information is tied to my health card number. Universal health care changes things.

In anycase, when I worked in assertive community treatment, we were able to limit pharmacy use and prescribing doctor use of our clients who were under the public trustee. Somehow, and I'm not sure how, it got flagged under their health card number that they weren't allowed to have prescriptions filled except through our pharmacy and approved by our staff. This was good because we also found out each time they were drug seeking. Mandated clients are of course different though.

So, my final thoughts are. I think it's a great idea. I think it should have happened long ago. I think it helps keep people safe. And helps medications be used for their correct intentions. People will find a way to circumvent it eventually, but for now. It's a great plan.

Aqua said...

I agree that people abuse the system, but I am not willing to give up my privacy rights because a small percentage of people abuse the system.

To me providing a patient the right to protect their records and not allow access to their prescription history, and then, in the same breathe allowing pharmascists to decline to fill prescriptions unless the patient allows access to said history, is what I term "coerced consent".

It is analogous to how Canadian insurance companies are "bullying people with depression" (the CMA's words).

The Insurance companies are saying (and my insurance company did this) "we want all your psyhiatrist's,doctor's/therapists notes about you, sign here...and if you don't you receive no insurance".

Where are my privacy rights in therapy in a situation like that if I need the insurance to survive AND I need to feel I can talk about anything openly in therapy in order to get well.

I see this kind of thing all the time and it drives me crazy...we change rules for all the people, because a few people are cheating the system. What about all the honest people?

Also, I really feel that little by little we are allowing governments and corporations too much access to our private information (think grocery store and other store's points programs tracking everything you buy).

It may seem innocuous now, but what happens if our democracy crumbles and bad people (think WWII)...get access to all that consumer information?

Do we want an evil government to all of a sudden have access to who is buying books on mental health, or shopping in gay bookstores, or giving money to the Jewish temple. All that information would be accesible to the government if they seized your banks files, or your points program files. I really believe we need to remember what happened to the mentally ill, to homosexuals and to Jewish people when Hitler's army took over.

I am not paranoid, or delusional, I just think (and I know this saying is cliche, but cliches often remark on reality)...if we forget the past we are more likely to relive it.

I think we are forgetting the past when we allow governments and commercial organizations so much power over us, our choices and our personal information.

Still Dreaming said...

wow, I never even thought of that stuff aqua. I tend to be young, idealistic and naive. It gives me something to think about it any case...

Alison Cummins said...

My thoughts are not so much about people who abuse the system as people who cannot give an accurate medication history, whether because of lack of education or lack of interest. As a youngish, healthy person my concerns are strictly about privacy: who will know what my psych drug history is. If, for whatever reason, I fear that I am not being taken seriously, I wouldn’t want to give access to my medical and pharmaceutical files to someone who may be looking for a reason to discredit me. This could conceivably even apply to a medical person, even though it shouldn’t. (And whether or not medical personnel ever really look for reasons to discredit people, I would feel violated if I thought they were and I knew that they had access to that kind of personal information.)

But as I age, and take more drugs, and find it more difficult to think about what they are all for, I would probably be quite happy to think that my family doctor could just look up my history in the computer and know who had prescribed me what, and why.

At this point I am also less worried about “evil governments” (though they certainly do exist and most certainly have used personal information against their citizens) than about “evil corporations.” In this global economy, economic bodies have more force than political ones.

Anonymous said...

sure there is a reason to log every drug i am prescribed and the doc can also check and see if i fill the precription and there would be a good reason to have a camera installed in the back of my throat to see i i swallowed the pills and did not sell them instead and it would save a lot of trouble and cut down on waiting lists to have a cattle prod in the doc's office to get me to share all the things i have a tough time time bringing up and i can think of other uses for the prod but i bet the gov't has already thought of those too. oh yes, this solution will win the war on drugs because all that prescrition cocaine and crystal meth and heroin and plain old weed will disappear just like that.

Midwife with a Knife said...

I agree with AC. Although abuse of the system is a problem, and it is irritating, and a system like this may help combat that, if I had a dime for every patient who comes in and doesn't know what meds they're taking or their dosage or whatever, I'd be a rich woman.

Some sort of accurate record of what patients are taking and when would help us take better care of our patients, as would being able to look and see if they're refilling their rx's (a surrogate guide to medication compliance)

Dr. Pink Freud said...

Abuse of private information is, and should remain a primary concern. However, an issue that, surprisingly nobody raised is that patients are abusing prescription drugs in the first place. That someone would dedicate the time and effort necessary to gain access to multiple docs and prescriptions is disturbing, and perhaps, suggest larger, more systemic issues in both healthcare and American society.

A thought. We can't mandate Tx., but certainly, a psychiatrist, or physician could refuse to prescribe unless a form of Tx. that addresses the underlying condition (e.g., anxiety, pain) is agreed upon. From an ethical standpoint, aren't we setting people up to fail, if say, the script is written for a benzo (ostensibly achieving symptom relief only), without requiring concomitant psychotherapy (a more preventitive approach). If we don't provide patients with the tools that provide an inoculating effect against future episodes, or equip them to deal with future episodes, via non-pharmacologically based Txs, we set up the conditions for abuse to occur. Ultimately, we may be creating a system that perpetuates reliance on medication.

Granted, meds certainly can and will continue to play a part in preventing mental illness, e.g, preventing depression in post-stroke patients. But, if we can avoid the onset of illness through psychotherapy based approaches, we minimize potential side-effects and decrease reliance on meds. Check out the article on exposure therapy and PTSD at medscape:

http://www.medscape.com/viewarticle/575599

Anonymous said...

I hate being duped.

I hate privacy violations.

I strongly dislike it when patients don't know what meds they are on.

I like your post.

There are already some limits on the system: insurance companies won't pay for meds renewed early, pharmacies are very helpful about helping with medication histories. None of this is very helpful if the patient uses multiple docs and pharmacies and pays for the meds in cash.

Okay, so online pharmacy access. What's to prevent a patient from going to a doctor and using a fake name? Will we require dental records or thumb prints or Disney World Scanners to verify identity?

Therapy Patient said...

Good post, Dr. Pink Freud!

Psychiatry101 said...

I beleive its a great idea.As long as patient has some control, like knowing who has accessed his/her records.
It can definitely reduce abuse and also pharmacists could catch silly mistakes doctors do, like prescribing sildanfil to a patient taking nitrates?
I am just saying....I have no real experience in this matter....just theoretically.
Also Happy Fathers Day tomorrow to all dads!

Mrs Cake said...

In the USA all it would take would be one pliant pharmacist and one curious insurance company to blow this system into privacy limbo.

There's a saying that the real tragedies don't come when choosing good over evil -- they come when you have to choose one of two equally urgent, mutually exclusive goods.

It's infuriating that I have to jump through hoops to get ordinary necessary stimulants, because some [epithet] sneaks the pills and misuses them.

Could it be possible to provide patients with pharmacy memberships and a photo ID card, which membership could be transferred, or suspended for bad behaviour? Suspended people could still get their meds, but with much more scrutiny and control. But so long as they had the membership, prescriptions could be taken at face value... Possible?

But then the US system is so fragmented and people move so much, it might not work.

RJS said...

"In the USA all it would take would be one pliant pharmacist and one curious insurance company to blow this system into privacy limbo."

What does that even mean? Your insurance company already knows what drugs you take, and in many cases, what your diagnosis is.

In the UK, the government knows what drugs you take, and probably what your diagnosis is.

Privacy is a gigantic myth: Who are you keeping your records private from? Insurance companies? No. The government? They don't care anyway.

Who, then?

John and Jane Smith have next to nothing to worry about because no one in the world cares what their medical problems are. Except for John and Jane themselves.

I have no delusions that I am a beautiful, unique, or important snowflake. No one cares what my medical problem are, and you know what? It wouldn't matter anyway even if they did know.

--

Note that I am not advocating wholesale privacy violations. I am pro-privacy. I just think that the whole privacy-as-holy-grail is way overblown if one actually stops to think about it.

Therapy Patient said...

rjs

Prospective employers and current employers would be one category many people would not want informed of their mental illness, or their AIDS or their other chronic illness. Realistically, most people don't go blabbing to all their friends and acquaintances about their major illnesses either. A VERY close friend's WIFE just told me he has had leukemia for 3 YEARS and during that time neither of them had told me. Now the symptoms have gotten severe enough that I got an explanation of why he needed to lay down while I was visiting. Many if not most people don't share this information ESPECIALLY illnesses that have a social stigma attached. When a huge data base is established there is certainly the possibility that all this info might at some point be accidentally or intentionally leaked.

Aqua said...

If you want to go to China's Bejing Olympics you might care that others have access to your health records. In the paper today they said no one with "a mental ilness, or insanity" would be allowed in the country.

Seems like, who cares about this, it's just one country, but I have heard of people being denied entry into the USA for this very reason.

Also, who are people going to hire someone with a history of mental illness, or someone who is healthy.

It IS important that my medical files and therapy files be kept confidential. unfortunately, people, countries and organizations DO care if you have a history of illness; any illness, but the stigma around mental illness is still huge.

Anonymous said...

as a general thing for all prescriptions- hell no.

Yes, I understand the concern when it comes to drugs of common abuse, but really, does every person who has access to the pharmacy computer (and I'm generally not talking about the pharmacist) need to know what I am or have ever taken? really? the need to know for the vast majority of my prescriptions is absolutely not there. Nor is it anyone's business if I have the prescription written by several different docs because it's simply more convenient when my insurance changes plans to get a new prescription than to have the old one transferred, and if my OB doesn't mind writing the same script as my family practice or other specialist, why add a layer of intrusion and bureaucracy?

HIPAA be damned, I have had my records accidentally shared with others by accident and without my permission. I have had pages of other people's charts mixed in with copies I request. So, I have no confidence in organizations maintaining privacy.

Now, if they wanted to make all records of certain drugs- say the narcotics and substances of common abuse- accessible, well, maybe.

Of course, you realize they already do track OTC drugs like claritin and other items that are commonly used in illicit drug labs. If you try to buy a box you have to provide your driver's license, and most stores do limit the amount you can buy to two boxes.

Roy said...

Of course, the problem that occurs when folks become afraid that their medical records are not confidential, is that they stop seeking treatment. Know many pilots or police officers who willingly seek help for addiction or depression?

The other point to make is that there is a difference, like anon above is saying, between tracking drugs of abuse and tracking all drugs. If the purpose is to reduce abuse and diversion, then just track those drugs. It is a totally different thing to track all drugs so that it is easy to find out what meds a pt takes when they cannot recall. Let's start with the more limited one first and see if this can be managed without a big Britany fiasco (you know, over a dozen people looked at her medical record who shouldn't have).

But regardless, pts should be able to look at their own controlled drug file and to see who has been looking at it. Yes, I guess a pt could use a fake name, but there should be some way of minimizing this ploy.

Tigermom... tread lightly, indeed.

rjs... absolutely, pharmacists need to be in on this. They are professionals and pick up more of the phony prescriptions than doctors do.

and, aqua... pharmacists have always had the right, even obligation, to refuse to fill a prescription which they thing is unsafe or inappropriate.

a psychiatrist who learned from veterans said...

I use electronic prescribing. I don't think I should be able to write a prescription for clinkshrink and see all his prescriptions. OTOH, I had he disconcerting experience of giving someone samples of Geodon which he resposnded well to... When I entered the Rx I was told there was a medication interation with a cancer drug I hadn't know he was on and wouldn't have known w/o having prescribed a potential interacting drug. Doctors are held responsible for sensible prescribing; so when I write a prescription for somebody AND THEY PICK IT up that indicates we have a doctor patient relationship, and I should be able to know what else is being prescribed. Heath Ledger would have been so lucky.

Aqua said...

Hi Roy,
I was not talking about pharmascist's not having the right to refuse to fill my prescription, I was talking about their right to have access to my medical/or prescription history.

My main concern is that we are slowly allowing more and more people (whether it be individuals, corporations etc.) access to our private information.

Privacy laws only work if the privacy cannot be taken away from you by an outside source (i.e. a pharmascist) who demands you wave your privacy rights in order to receive service).

I have nothing to hide, but to me my Dr./patient privacy is sacred. My knowing that what I say to my pdoc is between myself and him, period, is the only way I can truly trust and be open and completely honest within our therapeutic relationship.

Also...and this happened to me

...computer data is very easy to misplace, be stolen etc. (someone stole my bank's data tapes one day along with all my account numbers(and all account holder's) balances, social insurance # etc. The last thing I want is my medical files electronic data being stolen.

Kiwi Pill Pusher said...

As a pharmacist I'd like to add another comment to this immensely interesting discussion. I have to admit right now that I'm not in the USA or Canada though! - I'm on the opposite side of the world in NZ. My comment relates to a specific situation that I'm fully aware a lot of folks may not ever encounter. One of the major issues we find in the hospital where I work is when folks get admitted to the inpatient setting - working out what the heck people are taking (and whether that does or doesn't match what their various prescribers think they're taking) is a huge issue for us and can have major detrimenla outcomes if it isn't got right. This has nothing necessarily to do with folks abusing/misusing/doing their own thing with their meds/whatever you want to call it (although obviously sometimes it does) - simply making sure that what they were taking when they hit our doors is that same immediately afterwards - or at least not made different accidentally. A lot of people don't know what they're taking, especially older folks and folks on multiple meds. We often get admission letters from the person's General Practitioner but they will often not match when the person is actually taking, so we discuss the meds with the person as our first port of call, with checking of collaterel information in place as well to pick up any discrepancies. Given the potentially disastrous charting errors on admission we routinely pick up and head off before they reach the person, I do think such access to prescription records would be helpful. And if me being able to see a prescription record improves medication safety for the person involved then I'm all for it. Privacy is important but as far as I'm concerned (and I realise this might be a bit blunt) so is decreasing the risk of someone ending up dead (worst case scenario admittedly but it does happen) as a result of vital information about medication not being available in a timely manner. If access is dealt with properly it should be possible to strike a good balance. As a professional I don't take such access lightly - and neither does the organisation I work for. Anyone caught accessing their own health record or the health record of anyone they are not involved in the care of is immediately disciplined, and usually sacked.

Right, I'll get off my soapbox now.

stevebMD said...

Sorry for the slightly off-topic question, but this issue makes me wonder:

Is there a way to find out the "street value" of various psych meds in different cities? We know that benzos and opioids are highly valued, but I'm curious about other things like antipsychotics and sleep meds.

Anyone?

Mrs Cake said...

In listening to this discussion, I realize that in almost every situation medical access to a patient's prescriptions is valuable.

The arguments against it aren't medical, but social and financial, particularly the perverse entanglement in the USA between employment, insurance and medical care.

On the balance I must concede that such a system should be put in place, followed by ongoing efforts to minimize the side effects of the data getting loose. "Privacy" in the abstract is a trailing consideration.

Roy said...

stevebmd asked about the street value of psych meds. I did some googling and could not find much. So, I put together a little survey. Please add any knowledge you might have on the matter so that we can all learn.

Go to the SURVEY here.

NeoNurseChic said...

Well, since my surgery, I've spent a great deal of time out at my parents' house, which is quite far away from work and the pharmacy I usually fill all my meds at. I wasn't making any special trips to the city just to fill my prescriptions, so I had to do the unusual for me and fill my scripts out in Podunk, PA at a major pharma retail.

I almost felt criminal - like I was doing some secretly bad thing. A few issues popped up - one, I found that I could only fill my concerta and receive 90 days supply by filling it at work pharma, so I went a week without it and experienced EXTREME fatigue (think narcolepsy - driving was my worst nightmare), tardive dyskinesia, and overall very bad jitteriness - like restless leg syndrome gone wild all day long. I could've gotten 34 days of it at major retail pharma, but I didn't think stopping it would cause such havoc, or perhaps I would've considered that and simply gotten a new script from my doctor.

Then, I started having some post-op problems over the weekend, and after multiple calls to neurosurgery, they called in something to major retail pharma for me. When speaking with the on-call fellow (?) for nsrgy, he wouln't tell me what exactly he was planning to call in, so I had to wait until it finally got called into the pharmacy to find out. As it turns out, it is a med I take for my migraines sporadically, but the restrictions on it for migraine are quite different than what he was prescribing it for around the clock pain. (Ultracet) So I went to the pharmacy and tried to fill the script, still not knowing it was the same thing I already take, and they said my insurance wouldn't pay for it until the end of July, so would I like to pay for it out of pocket?

This threw me for a loop. For one, the new script is for dosing quite different than the script I already have. If I take the script I already have and take it in the new dosing way, then I will run out far too soon and will be stuck up $***'s creek with no paddle. However, if I were trying to fill this at the usual pharma I go to, they wouldn't have offered to let me buy it out of pocket because they watch very closely about what meds you get, when, etc. For the record, I haven't paid for it out of pocket yet, although it does create a dilemma. This is part of the reason why I felt that going to a new pharmacy was like doing something really bad or dishonest!

So if something were online, maybe that would alleviate some of my personal guilt about rightfully having to go to a new pharmacy, being an hour away from the one I usually go to. The whole thing, no matter what I was trying to fill these past few weeks, made me feel like I was lying to someone.

Once before, I filled a med at a local pharmacy because I needed it before I went back to work and could use the hospital pharmacy. Then, my doctor increased the dose, and I took the script to my usual pharmacy and they said insurance wouldn't pay for it because I ran out too soon. They flat out asked me if I had gone to another pharmacy, and why. I explained the situation, and the med ended up being covered due to a dose increase, but once again it was like being on trial.

You can go to different pharmacies for legitimate reasons, and still feel like you're doing something wrong.

And for the record, I take 99% of my prescriptions to the same pharmacy. If I were in the city every single time I needed a prescription filled, then I would take 100% of my scripts to the same pharmacy. It is the very rare occasion that I go to a different one, and always under extenuating circumstances. I will even wait a few days to fill something until I can get to the usual pharma if I can go without the med for that long. I feel it is in my best interest that the same pharmacy have all of my information on record. If I go to different ones, then how will they catch a drug interaction or other problem? It's downright dangerous!

So in the interest of patient safety, I do believe there should be some pharmacy network. I have to think on it whether or not doctors should be able to have access, but I don't think it's a terrible idea. I've always felt that the right hand doesn't know what the left hand is doing when I go to various specialists, and it would help if they had something unified to look at. Granted, I'm very good about making sure they all have all the pieces together, but still - it would be an extra mechanism of unification.

I do worry about the privacy implications, but ultimately if it is going to make my life a little safer, then I say, go for it. I didn't even address the issue of drug abuse. Clearly it would help to be able to identify those who are trying to cheat the system, but aside from all that, it would also aid patient medication safety, which I think is extremely important.

My 2+ cents worth!

Take care,
Carrie :)

Medication said...

This is a very tricky area with a lot of gray area.

Trust is something people give out to freely, and with a little caution a whole world of deceit is revealed.

I say take a step back, ask yourself how trusting you are of others and judge your decision from that answer

Unknown said...

If you feel you are entitled to my private health information, then I want to know who you are. I am appalled at the thought of just going by the "honor system" when it comes to my prescription history and who can access it. If I contact my state's pharmaceutical tracking system and ask for the names of those who have accessed my information, it better be only those persons who according to HIPAA, are in the "need to know" catagory and not just interested parties....I am a MLP (Family Nurse Practitioner) with prescriptive authority in my state for Sch 2-5 medications. I am appalled at the lack of checks and balances in this relatively new system. Patients must be allowed to review their own prescription history and be allowed to see the names and dates that their personal prescription information has been accessed. Otherwise, this is a breach of privacy with huge abuse potential and will be the basis of many a multi-million dollar lawsuit in the near future....mark my words....