Prescription Fixes: Is delegating prescription tracking to doctors’ staff the answer?

Requiring prescribers to check a database to see if there may be drug abuse problems seems to work. But does adding extra work onto providers’ already busy schedules mean that such a mandate will only result in doctors going through the motions to avoid getting a fine? Will doctors check the box but not really check to see if their patients are in trouble with painkillers?

One way to make such programs more effective is to broaden the types of people who are able to check prescription drug monitoring program (PDMP) databases. The Pew Charitable Trusts, in an excellent report first plugged in my last Antidote post, recommends that prescribers should be allowed to delegate the task of checking the database to someone on their staff.

Kentucky, Maine, and Oregon allow delegates to check prescription databases.

Here’s how it worked in Maine.

Maine started its prescription drug monitoring program in 2004. After the program was up and running, the state surveyed the staff who ran the program, health care providers, law enforcement officials, and others to get a sense of how it was running.

One of the themes that emerged was that providers wanted the ability to delegate. So in 2011, the state began allowing health care providers to delegate the database queries to people on their staff. There was a hitch, though. The providers had to register each delegated staff member with the state. Nonetheless, one would think that health care providers would have had every reason and opportunity, at that point, to participate in the tracking program.

Not so.

Jackie Farwell at the Bangor Daily News reported in 2014 that the program was only being checked by four out of every 10 prescribers.

Yet until registration in the prescription monitoring program became mandatory earlier this year, only about 40 percent of Maine’s roughly 7,000 prescribers of controlled drugs — doctors, nurses and dentists, among others — participated in the program through May 2012, according to program assessments.

Making such prescription checking mandatory for prescribers was the first step. The second step was making registration of delegates less of a hassle. The paper-based system was a pain for the providers and a pain for the state’s staff, too. The program is not big. It has an annual budget of about $300,000 a year. In October 2015, the state created an online registration system, and it also put the burden of verifying staff registrations on the health care providers themselves.

It’s still a bit early to know if the changes are working. But reporters would do well to follow this and similar efforts in other states. For example, one would hope that both the number of provider and staff registrations went up, and also that the number of times they actually checked the database went up.

Another thing to watch for would be whether having staff members do the checks has any relationship with prescribing practices. For example, after a doctor checks the database and finds a pattern of addictive medications being prescribed in previous months or years, is that doctor more likely to avoid writing a prescription for another addictive drug than if a staff member does the check? Or does it make an even more powerful impression on the prescriber if a third party brings the findings to the physician, with the message that a patient has a pattern of heavy prescription use and so therefore might not be the best candidate for a new addictive drug prescription? The staff members may have less emotion tied up in the process because they are not the ones necessarily dealing directly with the patients, seeing the kind of pain they are in, hearing their stories, etc.

The Pew Charitable Trusts have put their vote of confidence behind delegating these database checks as a way to improve prescribing practices, and we will keep our eyes open to see if their faith is backed up by the evidence.

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Prescription Fixes: Drug databases work, but only if they are queried