ALABAMA
USING THE PDMP CONTROLLED SUBSTANCES DATABASE WEBSITE
The Prescription Drug Monitoring Program (PDMP) of the Alabama Department of Public Health (ADPH) includes a database of controlled substances prescriptions that physicians, other licensed practitioners, regulatory agencies and law enforcement may access through the Internet. Information may be obtained about the controlled substance usage of a patient, including drugs prescribed; prescriptions from other physicians; multiple pharmacies being used, etc. Law enforcement and regulatory agencies may obtain profiles of individual practitioners' controlled substance prescribing profiles. The database is being used by many practitioners, regulatory and law enforcement agencies in the state of Alabama.
Why was this program established and what does it do?
The non-medical use of prescription drugs is rampant in the United States. This problem is particularly acute for pain relievers and tranquilizers. Many of these drugs were obtained from friends and relatives.
Most of these prescriptions, however, were legally obtained from persons with prescribing authority. Alabama ranks in the top 20 of all prescription diversion categories, including being ranked second in the use of Demerol and fifth in the use of hydrocodone. Alabama Legislative Act 2004-443 authorized the ADPH to establish a database for the collection of controlled substances prescribing and dispensing data. All of the information in this database is privileged and confidential and is only to be used for investigatory or evidentiary proceedings. The database receives reports from licensed physicians, dentists, podiatrists, optometrists and veterinarians who dispense controlled substances*, as well as ambulatory and outpatient hospital departments and pharmacy entities, including mail order and pharmacy benefit programs filling prescriptions to patients in Alabama. The goal of this Act was to establish a statewide database of all Schedule II, IIN, III, IIIN, IV and V medications prescribed and dispensed that could assist in preventing diversion, abuse and misuse of controlled substances and could be used by Alabama regulatory and law enforcement agencies in the enforcement of laws concerning controlled substances.
Who has access and how is it obtained?
Regulatory boards, state licensed practitioners, state licensed pharmacists and state, local and federal law enforcement authorities can obtain access to the PDMP. Eligible practitioners may sign up for a password at the ADPH website and obtain the practitioner access request and privacy statement forms. These need to be filled out and a password will be created. The password is then sent in for approval. The PDMP technical support staff notifies users via two separate e-mails that will include links to the website, a login ID and confirmation of the approved password. Once you are able to log into the system, you can query the database using information that you provide, including patient's name, date of birth, sex and address if needed. The system will then generate a report that lists controlled substances prescribed and dispensed to the patient, dates of prescriptions, names of prescribers and names of pharmacies.
Limitations on accuracy of data
There are some issues with information obtained through the PDMP, including:
Incorrect biographical information on the patient
Multiple addresses or names for an individual patient
Family members' names used by the deceptive patient
Incorrect prescribers' names input by pharmacies
Out-of-state pharmacies may not always report
The available data may not be timely
Staff of the ADPH and other regulatory agencies is working to resolve these issues. Attempts are being made to develop regional and national compacts with the 25 other states that have a program similar to Alabama's. There is hope that a cooperative agreement may be reached that stretches across state lines to help minimize drug diversion. The PDMP website staff is working diligently to improve the speed and usability of the site.
What this means to you
As of April 30, 2008, more than 24.5 million prescriptions have been logged into the database. Forty one percent of those are hydrocodone combinations and 12 percent are alprazolam. More than 78,000 requests for information have been received, and the vast majorities are requests by medical personnel. The board would to like see an increase in the number of practitioners signed up to use the website. As of May 6, 2008, this number was 1,538. The board encourages all qualified physicians to be a part of this program. Many practitioners find it useful on a daily basis. Any physician who prescribes controlled substances to Alabama residents should utilize this program.
*A physician dispenses controlled substances when the controlled substances are purchased by the physician for distribution or sale to the patient for offsite use. Distributing samples is not considered dispensing.
Reprinted from the volume 23, number 2, issue of Newsletter and Report, published by the Alabama State Board of Medical Examiners.
CALIFORNIA
DOES NATIONAL LICENSURE MAKE SENSE?
California continues to be interested in and supportive of facilitating the benefits of national licensure. However, the progression to national licensure cannot be made at the expense of California consumers, who look to the board for assurance that those authorized to practice medicine in California meet our established laws and regulations. We look forward to continuing to participate in this important discussion and advocating for stricter licensure regulations by all states to promote the mandate of public protection.
For years the Medical Board of California has participated in many discussions regarding national licensure and how it compares to California licensure standards. Recently, representatives of the board attended the FSMB Annual Meeting and the subject of national licensure was a hot topic.
License portability across borders and abroad is being realized by the ever-advancing technologies of telemedicine. The board is supportive of joining the ranks of other states that are proactively discussing this alternative avenue to licensure, but, before that commitment can be made, California must ensure that its criteria are met. The requirements for licensure in California are specific and are set at a very high standard.
To become licensed as a physician in California, an applicant must obtain a medical education from a medical school approved or recognized in California. California laws and regulations specifically define the stringent criteria a school must meet to be recognized or approved by the board. Since many other states issue licenses to those who obtain their medical education from schools not meeting California's requirements, the board is unable and unwilling to allow those individuals to practice medicine in California simply based upon obtaining licensure in another state. Therefore, to establish one nationwide license that would allow the practice of medicine from state to state would, in some instances, require that other states establish a higher licensing standard, identical to what California law requires.
Other important obstacles include California's requirement for criminal history backgrounds on all its applicants, a process that requires the submission of fingerprints to the board, and the requirement that medical education and training be verified by primary source documents. Primary source verification is not currently required by all states or credential verification services.
Reprinted from the online version of the Medical Board of California Newsletter, published by the Medical Board of California.
IDAHO
RULE CHANGES
The Idaho Board of Medicine has proposed rule changes to the IDAPA22.01.01 — Rules of the Board of Medicine for Licensure to Practice Medicine and Surgery and Osteopathic Surgery in Idaho. The rule changes provide for expedited, minimal paperwork licensure by endorsement for qualified applicants. The rule change also provides a requirement for service on pre-litigation panels once every two years, similar to a jury duty requirement.
The board has done multiple presentations around the state regarding chronic pain management issues and the relatively small number of discipline actions that relate to pain care. The FSMB recently released information on a study that appears to affirm that information on a more . national basis. The article is reprinted below with permission from the FSMB's BoardNet News Aug. 15, 2008.
NEW STUDY FINDS LITTLE EVIDENCE OF PHYSICIAN SANCTIONS FOR PRESCRIBING PAIN MEDICATIONS
A new study that includes disciplinary data from state medical boards suggests physician concerns over publicized prosecutions for prescribing pain medications are disproportionate to actual numbers of legal and regulatory actions. The study, conducted by the FSMB, the National Association of Attorneys General (NAAG) and the Center for Practical Bioethics, was published in the Sept. 9, 2008, edition of Pain Medicine. The study incorporated data from 1998–2006. Its findings include:
As many as 725 physicians were identified as having been prosecuted or sanctioned for such violations during the eight-year timeframe, or only about 0.1 percent of nearly 700,000 practicing patient care physicians in the United States.
Most of the patient care doctors identified in such cases were primary care physicians rather than specialists in other fields, including pain medicine. Among the 725 physicians involved in these cases, only 25 were pain medicine specialists or self-identified as such. In contrast, general practice/family medicine physicians accounted for 285. In 2005 and 2006, the Drug Enforcement Administration reported having investigated an average of only four to five doctors per state each year for possible criminal offenses connected with improper prescribing or handling of pain medications.
The study continues the FSMB's support of the Balanced Pain Policy Initiative with the Center for Practical Bioethics and the NAAG. An abstract of the study can be accessed at www3.interscience.wiley.com/journal/120848348/abstract. The FSMB will make full copies of the study available to member medical boards at the time of publication.
Reprinted from the online version of issue 2, summer 2008, issue of The Report, published by the Idaho State Board of Medicine.
KENTUCKY
ILLEGIBLE PRESCRIPTIONS
Recently, our office has received several complaints involving the legibility of physicians' handwriting on prescriptions. Most of the complaints were made by pharmacists who are concerned about patient safety and the ongoing hassle of continually having to contact physicians to verify prescriptions.
The board realizes that the practice of medicine is often times fast paced and hectic, but notes that illegible and incorrectly completed prescriptions are increasingly becoming a problem throughout the Commonwealth. These oversights can lead to a possible medical error or cause an unknowing physician to incorrectly have a controlled substance prescription attributed to them, which may result in a review of his/her prescribing practices. In addition, physicians who write illegible prescriptions also run the risk of having the pharmacy reject filling the prescription, thus causing undue hardship on the patient and stress for the pharmacists.
The board would like to remind all physicians to take the extra time that is needed and complete their prescriptions with the legible and correct information as required by state law. Just a few moments of a physicians time can help avoid medical errors from occurring and improve the physician/pharmacist relationship.
BOARD ENDORSES FSMB MODEL POLICY GUIDELINES FOR OPIOID ADDICTION TREATMENT IN THE MEDICAL OFFICE
In recent months, the Kentucky Board of Medical Licensure has been studying the need to adopt best practice guidelines for Buprenorphine/Suboxone (B/S) treatment, which included a review of the FSMB's Model Policy Guidelines for Opioid Addiction Treatment in the Medical Office. After a thorough review of this issue, the board, at its March 2008 meeting, endorsed the guidelines developed by the FSMB.
It is the intention of the board that these guidelines will assist in minimizing the inappropriate, excessive prescribing of Buprenorphine/Suboxone simply to maximize the financial opportunity for the physician. The board would like to emphasize the benefits of involving the patient's significant other: collateral individual or group therapeutic efforts and self-help groups such as Narcotics Anonymous have historically yielded the best rewards.
The guidelines are available on the board's website, www.kbml.ky.gov/board/policies.htm for viewing or to be downloaded. The board would like to express its appreciation to board member C. William Briscoe, M.D., for his efforts regarding this matter.
TYPES OF GRIEVANCES
The chart below depicts the types of grievances received in the board's office for the past fiscal year. A total of 244 grievances were filed against physicians practicing in the Commonwealth.
Type of Grievance July 1, 2007–June 30, 2008
Sexual Misconduct two percent
Standard of Care 42 percent
Substance Abuse six percent
Prescribing 12 percent
Practicing without a License one percent
Other five percent
Malpractice three percent
Fraud two percent
Unethical Conduct 27 percent
Reprinted from the Summer 2008 online version of the Kentucky Board of Medical Licensure newsletter.
MASSACHUSETTS
A FREE-TO-REPORT CULTURE ELIMINATES FEAR OF REPORTING UNEXPECTED OUTCOMES
Blending a transparent performance improvement program with world-class physician leadership is key to safe medical practices and maximizing quality outcomes, while minimizing risks. Shriners Burns Hospital — Boston has worked to create a unique and compassionate process for identifying and reviewing unexpected outcomes. Eliminating the fear encourages unexpected outcome reporting. Reporting, in turn, helps identify actual and potential risks. Identifying unexpected outcomes early and encouraging self reporting decreases the actual number of errors that reach the patient. According to Dr. Don Lighter, Shriners' assistant chief medical officer, “One of Deming's 14 principles mandates is the elimination of rework and inspection by designing quality improvement into each process; the Cost of Quality analysis is an effective tool to achieve this goal.” This principle is the cornerstone in designing our systems and processes.
Having a detection system incorporates a robust occurrence capturing and reporting system. Physician led committees and thorough peer review is crucial to sharing data with the PCA committees, internally and externally. The ability for every provider to report unexpected outcomes, basically, at the point of care is what makes the process work so well. The provider can notify the PCA Coordinator via written communication, voice messaging or through committee that they have identified a potential or actual unexpected outcome.
The process of communicating the findings and improvements is very important to sustain effective reporting. The providers need follow-up and a reassurance that their contributions to patient safety have meaning. Making the workforce more involved in the process while rewarding self reporting leads to improved retention. Additionally our systematic means of identifying, preventing, and eliminating unexpected outcomes through “driving out fear” (Deming) of reporting errors proves to be a key role in reducing unexpected outcomes while promoting a free to report culture. This process is interdisciplinary and connects departments from the Board of Governors to the Medical Staff to Nursing, to Pharmacy to Performance Improvement and everyone in between.
By “driving out fear” and interconnecting departments we not only reduce unexpected outcomes, but get to the root cause of quality care issues and system errors.
We knew that if we could capture more of the potential errors that we could have a positive impact on eliminating errors before they reach the patient. It was necessary to have the assistance of the entire workforce to create a culture free to report. In keeping with the philosophy of Ronald Tompkins, M.D., our chief of staff, “patient safety has to be everyone's focus. And we have to drive out the fear of reporting.”
Shriners Hospital — Boston is a 30 bed acute and reconstructive surgical hospital of the international hospital system of Shriners Hospitals for Children and is a verified burn center. This article was contributed by Rosemary Hargreaves, R.N., B.S.N., director of Performance/Risk Management and a patient care assessment coordinator.
Reprinted from the online version of First Do No Harm, a publication of the Patient Care Assessment Division, Massachusetts Board of Registration in Medicine.
MICHIGAN
MICHIGAN RECEIVES MORE THAN $2 MILLION IN COMPETITIVE PUBLIC HEALTH GRANTS
In February 2008, the Centers for Disease Control and Prevention (CDC) made available $24 million in competitive funds to enhance pandemic influenza preparedness. Michigan received an award of more than $2 million.
The Michigan Department of Community Health (MDCH) Office of Public Health Preparedness will provide the oversight and distribution to three sub-recipient projects: a Michigan Care Improvement Registry (MCIR) expansion, a new electronic mortality reporting system, and a pilot project through the Spectrum Healthcare System, designed to ensure delivery of essential health care services during a pandemic. The grant period is Sept. 30, 2008, to Sept. 29, 2009.
These projects support the state's strategic enhancement of public health and health care preparedness. The MCIR All Hazards Enhancement Project, developed through MDCH's Bureau of Epidemiology, expands the use of the registry to achieve timely reporting, data aggregation, and data exchange in the event of an influenza pandemic. The new PHIN-compliant electronic mortality reporting system, developed through MDCH's Bureau of Local Health and Administrative Services, enables the exchange of mortality data with federal partners and enhances integration with existing disease reporting systems. The final project, developed through Spectrum Health of Grand Rapids, develops a set of planning and operations guidelines to identify and provide essential health care while also caring for large numbers of hospitalized and home-bound patients during a pandemic.
States, counties, cities, and U.S. territories were encouraged to apply for the competitive grant based on policy innovation and potential for nationwide replication in one or more of the following areas:
engaging the public in public health decision-making
enhancing electronic laboratory data related to pandemic influenza surveillance
developing statewide public health information network (PHIN)-compliant electronic mortality reporting,
integration of state-based immunization information systems
developing preparedness among identified at-risk populations
distribution strategies for isolated or quarantined persons
Reprinted from the Michigan Department of Community Health website.
TEXAS
MEDICAL BOARD IMPLEMENTS FAST-TRACK PROCEDURE FOR MINOR VIOLATIONS
The Texas Medical Board has adopted a new “fast-track” enforcement procedure that will allow doctors facing discipline for relatively minor administrative violations to quickly resolve the matter rather than undergoing a lengthy investigation. Diverting administrative cases into the new streamlined procedure will allow the board to free up investigative resources that can then be redirected to more serious violations involving inadequate patient care or unprofessional conduct.
Physicians who choose to participate in the new fast-track system can agree to administrative charges and pay a fine, rather than undergo a full investigation and the resulting stress and expense. A licensee who disputes the charges can contest the violation in writing and the case will be reviewed by a board committee, or a physician may opt out of fast-track entirely and contest the charges through the board's traditional investigation and litigation process.
“This will benefit both the medical community and medical consumers in Texas,” said Donald W. Patrick, M.D., J.D., the board's former executive director. “Doctors will be able to dispose of relatively minor administrative violations quickly. Consumers benefit because the board will be able to concentrate its limited investigative resources to more serious cases.”
Administrative violations punishable only by a fine, with no other allegation, will be eligible for fast-track consideration. These include failure to provide medical records in a timely manner, failure to file a change of address with the board, failure to sign a death certificate in a timely manner, failure to obtain required continuing medical education, and other administrative violations. Violations arising from inadequate patient care or unprofessional conduct are not eligible for fast-track consideration.
The number of times a licensee may opt for fast-track consideration will be limited to three times, and only once for a given violation.
Prior to the adoption of the new procedure, all complaints believed to be a probable violation resulted in an investigation that could last 180 days, followed by an additional 180 days of litigation procedures, culminating in a hearing before a panel of board representatives. Cases considered under the new procedure can be concluded in as few as 60 days, said Mari Robinson, the board's director of enforcement.
“We thought these administrative violations should be handled more like traffic tickets and less like full-scale investigations,” Robinson said. “The initial reaction from the medical community has been very positive.”
Reprinted from the Texas Medical Board website.
WEST VIRGINIA
2008 LEGISLATIVE UPDATE
Senate Bill 317 was enacted during the recent legislative session and took effect on June 4, 2008. It removes outmoded and expired language in the portion of the law pertaining to licensing requirements for physicians and podiatrists. It provides for a period of 10 years for applicants to pass all steps of the licensing examination, and requires an appearance before the board for any applicant who has failed to pass any step of the licensing examination in three attempts for a determination as to any further education, evaluation and training which may be required for further consideration of licensure. It permits a restricted license to be issued in certain specified instances in extraordinary circumstances, and requires the board to propose a rule to establish and regulate the restricted license.
S.B. 317 specifies that the board may not issue a license to a person not previously licensed in West Virginia whose license has been revoked or suspended in another state until reinstatement of the license in the other state. Com. Sub. for S.B. 349 was enacted as well, and it authorizes three board rules, all of which went into effect July 1, 2008. These rules relate to continuing education for physicians and podiatrists, collaborative pharmacy practice, and radiologist assistants. The rules are all on the board website, www.wvdhhr.org/wvbom. Effective July 1, 2008, at least 30 of the 50 hours of continuing education required every two years must be related to each physician's or podiatrist's specialty area(s).
Com. Sub. for H.B. 4144 also was enacted during the recent legislative session and took effect on June 4, 2008. It is related to physician assistants, updates language to conform to national changes, and specifies that a supervising physician must be fully licensed without restrictions or limitations. It allows for a temporary license to be granted between board meetings for qualified applicants who have passed the National Commission on Certification of Physician Assistants (NCCPA) examination, as well as for those who have not yet taken the examination. A $50 temporary license fee is now required. Other fees have been raised and added. If a licensed physician assistant fails a recertification examination of the NCCPA and is no longer certified, the physician assistant is required to immediately notify the supervising physician(s) and the board, shall immediately cease practicing, the license will automatically expire and terminate, and the P.A. is not eligible for reinstatement until a passing score on the examination is obtained.
Com. Sub. for H.B. 4129 was passed and is now in effect. This bill authorizes special volunteer licenses for several different health professionals free of charge. Physician assistants who are retiring or retired from practice may apply to the board for a special volunteer physician assistant license to donate their expertise for the medical care and treatment of indigent and needy patients in a clinic where health care services are delivered without charge. If the clinic maintains liability coverage of not less than one million dollars per year and has an agreement with the physician assistant to provide voluntary uncompensated medical services to patients of the clinic under the control of the clinic, the physician assistant may have immunity from liability except in instances of gross negligence or willful misconduct. Application forms are available at the board's office. Contact Charlotte Jewell at extension 210 or at [email protected].
Reprinted from Volume 12, issue 1, of the West Virginia Board of Medicine Quarterly Newsletter, published by the West Virginia Board of Medicine.
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