Maryland Prescription Drug Monitoring Program

The Maryland Prescription Drug Monitoring Program (PDMP) is run by Chesapeake Regional Information System for our Patients (CRISP).  Maryland launched the PDMP in late 2014, allowing physicians to access information online to assist them in identifying at-risk patients and help them prevent dangerous drug interactions.  The Maryland PDMP also includes data from several other states.

Clinical access to PDMP data is provided through the CRISP web-based query portal.  CRISP also administers the statewide health information exchange (HIE).  All Controlled Dangerous Substances prescribers are required to be registered with PDMP.  To register, complete the process that begins on the CRISP website.  A step-by-step guide to prescriber registration is available.

If you don’t remember whether you registered or can’t find your Registration Confirmation Code, go to the PDMP Auto-Registration front page (https://crisphealth.force.com/crispregkeydata), select Physician for Member Title, and enter license and DEA numbers.  Then enter the red characters displayed in the gray window and hit “Submit.”  If you are already registered, the system will show your PDMP Registration Confirmation Code and your email account on record will also be emailed a copy of your Confirmation Code.

PDMP use before prescribing opioids or benzodiazepines is mandatory in most cases.  Prescribers must, with some exceptions, query, review and assess their patient’s PDMP data prior to initially prescribing an opioid or benzodiazepine AND at least every 90 days thereafter if the course of treatment continues to include prescribing an opioid or benzodiazepine.  Prescribers must document the PDMP data query and review in the patient’s medical record.  MedChi explains exceptions to PDMP query requirements for prescribing opioids and benzodiazepines.

A Note of Caution regarding the PDMP 

Because of the confidentiality restriction for people receiving treatment from programs for substance use disorders (42 CFR Part2), controlled medications dispensed or prescribed from such programs (including methadone and buprenorphine) mostly do not get included in the PDMP.  This means the only way to know is to ask or test the patient.  The PDMP website notes that certain types of pharmacies, clinics and practitioners are EXEMPT from reporting CDS that are dispensed to patients

RESOURCES FOR PDMP USE

Prescriber Insights Report allows prescribers to see trends in their prescribing history and compare their prescribing history with that of their peers.  This educational report can support prescribers in better understanding their prescribing habits. Please see the letter for complete details.

Buprenorphine Comparison Report lists the number of patients receiving buprenorphine for substance use disorder treatment formulas with a comparison to peers. This educational report can support prescribers in better understanding their prescribing habits. Please see the letter for complete details.

CDC has mobile app that helps prescribers apply its guidelines for opioids.  PDMPs can alert you to provide potentially lifesaving information and interventions. Take action to improve patient safety.

Maryland Addiction Consultation Service offers consultation to primary care and mental health prescribers across Maryland, supporting them in the identification and treatment of Substance Use Disorders.  Services include:

• Free phone consultation for clinical questions, resources, or referral information
• Education and training opportunities related to substance use disorders
• Assistance with identification of addiction and behavioral health resources that meet the needs of the patients in your community

Call 1-855-337-MACS

SAMHSA’s treatment locator can help identify sources for treatment that is outside your scope of practice.

Maryland PDMP Best Practice and Clinical Usage is an online CME presentation that describes the PDMP, when PDMP query is required and what the query portal looks like.  It also outlines the data available from other states through the PDMP, establishes how to use the PDMP as a clinical tool and identifies safe opioid prescribing resources.

Maryland Board of Physicians has adopted guidance for Maryland physicians and physician assistants to consider when determining whether and how to prescribe opioids.

SAMHSA also has a mobile app to assist with treatment for opioid use disorder.

 

 

RISK MANAGEMENT TIPS FOR PDMPs

Introduction

A Prescription Drug Monitoring Program (PMP) is a state-run electronic database that stores and analyzes information on the prescribing and dispensing of specific controlled substances.[1]    The general purpose of a PMP is two-fold:  1) to reduce misuse and diversion of controlled substances and 2) to improve patient safety.[2]

These programs, found in the majority of states, specify the following:

• the scheduled substances to be monitored, typically Schedule II, III, and IV drugs (drugs of concern or nonscheduled drugs may also be included), and
• those who are authorized to access and use PMP data (authorized users typically include prescribers and dispensers; law enforcement agencies; representatives of professional or occupational boards, directors of state commissions or agencies; and individuals whose prescription history has been captured by the database).

Legal and Clinical Implications

What are the legal and clinical ramifications of PMPs for physicians prescribing controlled substances? Legally, physicians must know what state law requires of them, in particular, whether physicians are required to access the data. New York became the first state to create a duty for practitioners to review PMP data prior to prescribing Schedule II, III, and IV controlled substances.[3]  Some states, such as Kentucky,[4] set forth certain circumstances under which a prescriber must check the database, while most states currently allow the practitioner to determine when the data is needed. However, more states may begin to require PMP review following New York’s lead.   Even if review of PMP data is not required by law, the fact that the capability to do so exists may impact the standard of care.

Physicians should also know that their prescription histories will be tracked, as over-prescribers are targets of increased scrutiny.  Two other legal issues to be aware of are that some states permit physicians to delegate authority to access PMP data to another person under their direct supervision and, at the present time, PMP laws do not require physicians to notify law enforcement of suspicious behavior on the part of the patient.

Clinically, a patient’s prescription history may be valuable information to have when prescribing.  For example, a new patient wants a prescription for stimulants.  Upon reviewing the PMP data, you note that the patient just filled such a prescription three days prior to her first visit with you.  Given this information, you decide not to prescribe at that visit and to clinically address the issue with the patient.  States are beginning to share PMP data, which should prove clinically useful to psychiatrists with patients who cross state lines to obtain prescriptions.  States are also striving to move to real-time reporting so that practitioners can get the most current information on their patients.

Risk Management Advice

Legal and Professional Obligations:  Familiarize yourself with the PMP in your state and its requirements, if any, for prescribers.  [Maryland’s Prescription Drug Monitoring Program]

Inform your patients:  Some states, such as Virginia, require that prescribers provide notice to their patients that they will access PMP data.[5] You may want to do this even if not required to by the state as part of educating and informing your patients.  Remember, however, that you do not need patient authorization to access the PMP.  Moreover, you should not seek patient authorization to access the PMP as doing so may lead patients to believe they can prevent you from reviewing it when they cannot.

Proper Prescribing and Monitoring of Medications:  Consider whether applying for access to and using the data might assist you in making decisions on prescribing controlled substances.  Incorporating review of the data into your practice may be particularly useful when seeing new patients who request prescriptions for controlled substances.  Having the data may also make it easier to initiate a conversation with your patients on proper use of controlled substances, the risks of abuse and diversion, and the availability of substance abuse programs.  We know that allegations of improper prescribing and monitoring of medications form the basis for a significant majority of lawsuits filed against our insured psychiatrists.  Use of PMP data may minimize the risks of those allegations being made against you with regard to controlled substances and may indicate when a treatment relationship needs to be terminated.

Documentation:  We suggest reviewing your practice state’s PMP laws and regulations, as well as those relevant to prescribing controlled substances, for any documentation requirements.  For example, in New York, the law only requires noting that a review of the PMP registry was done or that it was not done along with the applicable exception.  Not only does this approach align with the law, it respects the highly confidential nature of the information and the potential legal consequences attached to it.  So our general advice is for your documentation to reflect that the PMP data was reviewed.  Due to the highly protected nature of PMP data and the stiff penalties for improper disclosure, unless required by state law, we advise against including a copy of the PMP report in the medical record.  If the PMP reports are printed for review, a policy and procedure for secure shredding of the documents after review should be in place and followed.

Conclusion

As PMP laws and regulations continue to evolve, our risk management advice will as well.    In states where physicians are required to access and use PMP data, the standard of care will also require that they do.  In states without such a mandate, the issue is not as clear.   Understanding the general purpose of PMPs and your state’s specific requirements, will ensure that you are in compliance with the applicable legal and professional standards.  Incorporating the review of PMP data into your practice may serve to inform prescribing practices, enhance patient safety, and minimize your professional liability risk.

[1] US Dept. Justice Office of Diversion Control, State Prescription Drug Monitoring Programs. Accessed online at www.deadiversion.usdoj.gov/faq/rx_monitor.htm#1.
[2] Id.
[3] N.Y. Pub. Health Law § 3343-a(2)(2013).
[4] KASPER (Kentucky All Schedule Prescription Electronic Reporting.  Accessed online at http://www.chfs.ky.gov/os/oig/KASPER.htm.
[5] 18 Va. Admin. Code 76-20-70 (2014).

Written by Professional Risk Management Services, Inc. (PRMS)

PRMS, Manager of The Psychiatrists’ Program
Medical Professional Liability Insurance for Psychiatrists
1-800-245-3333
Email: TheProgram@prms.com
www.psychprogram.com