Roy, writing at Shrink Rap, has a post about the
prospect of online access to prescription records in the State of
California. The attorney general is proposing a database of
all prescription records, that could be accessed by doctors and
pharmacists.
href="http://psychiatrist-blog.blogspot.com/2008/06/online-access-to-prescription.html">Online
Access to Prescription Medication History
Posted by Roy at 8:02 AM
I saw a href="http://www.latimes.com/news/local/la-me-drugs5-2008jun05,0,2974326.story">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).
Roy has some good suggestions on how to set up such a thing, to strike
the correct balance between privacy and good patient care. I
won't repeat them here. Rather, I urge anyone interested to
go read what Roy has to say. I just have a few comments to
add.
First of all, the problem with drug diversion is very real.
But the newspaper article fails to mention one thing.
It is not merely a problem of individual patients talking
doctors into writing prescriptions. The big problem comes
from organized gangs that have operatives, whom they coerce
into getting these prescriptions. They coach them, learn
which techniques are most effective, and which doctors are most
susceptible. This also occurs in situations of domestic
violence, in which the victim is coerced into obtaining prescriptions
for the abuser.
Without access to a prescription database, there is no defense against
this kind of thing. That is because they learn what kinds of
things raise suspicion, and coach the people to avoid raising those red
flags.
Second, although I am a big fan of online databases, I don't think it
is a good idea to disseminate this information over the Internet.
Imagine, if people knew that Briney Spears' prescription
records were out there, what kind of hacker firepower would be directed
at getting that information. The defenses will fail,
eventually. Especially in California.
Of course, any system will fail eventually, but the Internet is
well-suited to anonymous attacks. I would be more in favor of
a fax-back system, in which doctor's offices would have to register fax
numbers, and verify that the fax is secure. I think it would
be easier to track down security breaches that way. Michigan
happens to have system for controlled substances, which
operates on a fax-back basis. The problem is the turnaround
time. It
is fairly quick, usually within 24 hours, but it would be more useful
if it could respond within a few minutes.
Third, such a system should not contain direct identifying information
about the prescribing physicians and dispensing pharmacies.
The reason is that it is desirable to limit the impact of any
leaks that may occur. If unauthorized access occurs, the
perpetrator would not be able to see what doctor's offices or
pharmacies to raid, for more information. They would have to
jump through an additional hoop or two to get that.
Fourth, I really do think it should be an opt-in system.
Patients would have to affirm that they want to participate.
They could specify which providers would have access to the
information, and be able to specify a time limit. They also
should receive automatic notification when their records are accessed.
Personally, I think this should be a standard feature for all
personal information: driver's license records, voter registration,
credit reports, etc. It would be easy to implement, and would
greatly improve the security. Yes, this would reduce the
usefulness of the system somewhat, but not very much. It
would be perfectly reasonable for physicians writing prescriptions to
ask their patients to opt in, and to ask why not, if a patient refuses.
It might be a little uncomfortable, but doctor-patient
relationships sometimes have to withstand a little discomfort.
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In my state, we have a system that allows providers to pull up narcotic prescription records on patients. This system in invaluable.
One of my jobs is at a clinic with lots of walk-ins, and people ask for "refills" of their vicodin, etc all the time. We can actually check to see what they've been getting and if their record is suspicious. It protects the provider and the patient.
In the case of electronic prescription records, I think safety should trump any of our uniquely American privacy concerns. My e-prescribing system checks for drug interactions, etc, increasing patient safety dramatically.
"First of all, the problem with drug diversion is very real."
Is it really? The posting you link to quotes a 5000% mark-up for the recreational drug resale business. That indicates an extremely steep price-demand curve, which is likely to be minimally affected by moving the supply chain from retail sources to substitutes and wholesale sources. (Much like gasoline consumption has changed only a few percent in the last two years despite the price doubling.) Moreover, to the extent that there is a meaningful goal to drug politics, it is to minimize long-term morbidity and mortality, an aim that could be harmed if even a small fraction of recreational drug users were to switch from comparatively safe opioids to substitutes like meth and alcohol.
Dan, I'm a little dense, perhaps, and didn't really understand your comment. Would you mind clarifying? At least around here, we have a lot of prescription drugs ending up on the street, and people can get them quite easily. Many of the sketchy requests we get are people trying to get pills to sell.
BTW, Michigan's system is now online (no fax required) and has a turn-around time of a few minutes--huge improvements.
Thanks for linking, Joseph. I like the idea of an immediate fax-back, rather than on the screen. It would enhance the ability to track who accessed the record, though the risk would be that the fax winds up in the wrong hands.
And I agree with some element of opt-in, with the opt-outs taking the risk of increased scrutiny. The downside: say you are on Adderall and want that confidential, so you opt out. Then the pharmacist may refuse you and you feel like a criminal. Just because you exercise the right to privacy.
"The posting you link to quotes a 5000% mark-up for the recreational drug resale business. That indicates an extremely steep price-demand curve, which is likely to be minimally affected by moving the supply chain from retail sources to substitutes and wholesale sources."
That all depends on the initial cost of the pill. Generic hydrocodone and diazepam are extremely cheap, so a high mark-up is still going to keep them affordable. A quick search shows me that a 5mg hydrocodone can be purchased from drugstore.com for $0.23. At $5 a pop, that's not 5000%, but its a handy profit, and more than enough to keep people coming to the ER to try to score some vics.
Though with regard to this idea: LOVE IT!!!!! Oddly enough, I could give a rats left nad about the people who are diverting and doctor shopping (it won't stop them, they will just drag their family into the game.) Don't get me wrong, I would use it for that too. But that's not what what makes it the best idea evah!
It is FREAKING AWESOME because when the little old lady who passed out comes to the ER and says she takes a white pill for her blood pressure, a pill for her nerves, a blood thinner, and a medicine for her heart that is just a tiny pill so it must not be important.... I can figure out that she is taking diltiazem, lithium, coumadin, and digoxin.
This would be like christmas, my birthday, and June 17th (I'm getting hitched) all rolled into one!
British Columbia has had this for years...
http://www.health.gov.bc.ca/pharme/pharmanet/netindex.html
as a part time EMT I'll second Nick's comments about ER access and add...
"not only can it tell what meds you are taking...but (often more importantly) what meds you have been prescribed, and haven't taken"
I don't know if that's frightening or cool, but it sure can be handy...