Monday, February 23, 2015

State-by-State Doctor Shopping Prevention Silos

By Doug Brockway
February 23, 2015

PMPs as currently designed and governed cannot look beyond state lines and thus cannot stop doctor shopping across state lines.

Because PMPs do not operate across state lines, multiple prescriptions can be written in one state and filled a very short time later in another state with no-one the wiser.

In the North East this is a big problem.  In Eastern Massachusetts, where I am at this moment, I can be in New Hampshire in 20 minutes, in Rhode Island in less than an hour, and in Connecticut, Vermont or Maine in less than two hours.  New York State is less than three hours away.

But even in the middle of the US the lack of inter-state controls over doctor shopping endanger us all.  Take St. Louis, for example.  According to the firm Inbound Logistics, Items shipped by truck from the bi-state region reach 70 percent of the U.S. population within 48 hours. A doctor shopper can do the same.  A doctor shopper with an airline ticket is faster.

Of all the reasons that PMPs cannot fully respond to Doctor Shopping this one requires inter-state cooperation.  It requires that an easy-to-use, fast method be developed for a doctor or pharmacist to see all the PMP records of an individual. 

This means a cross-state method of identifying patients (for personal security reasons it cannot be the social security number) and a way to use that identifier to collect from and deliver doctor shopping relevant information to doctors and pharmacists. 

The credit card networks do this today.  A similar capability exists as an overlay for existing PMPs.  Solutions like these are needed in order to provide sufficient integration across PMPs that interstate doctor shopping is slowed if not prevented.

Thursday, February 5, 2015

In Opiate Abuse Prevention, PMP Timeliness is Godliness

By Doug Brockway
February 5, 2015

PMP data are collected monthly, or at best in some states weekly.  This is not sufficient to capture diversion, which can be done intraday with patients getting prescriptions from multiple doctors and filling them at multiple pharmacies in very short periods of time.

An enterprising “patient” can visit a doctor and get a prescription for a pain in the back, leave that office, go to another doctor, perhaps just doors down the hall, and get a prescription for a pain in the leg, and so on.  Perhaps a more frequent situation is the phantom patient that approaches a series of emergency rooms and clinics in an attempt to gain medication for phantom pains?

Then, or alternately, the enterprising patient can visit many pharmacies; a Walgreens at 10:00 AM, a CVS at noon.  Each with a different prescription, and keep doing this for some time, at least a week, before being found out.

Even if one believes that the only role of PMPs is aiding physicians in properly advising patients regarding their use of opiates there is something of a functional gap in the systems.  By not collecting activity in real-time the PMPs are forced to assist doctors and pharmacists with incomplete and thus inaccurate data.

From a process engineering perspective the penalty we all pay for this is not that we miss the opportunity to stop that last attempt at diversion that allows a patient to take the fateful step into addiction.  That we allow any such attempts because we haven’t made data collection (and use) real time we have permitted a diversionary environment.  This helps make PMPs, as currently implemented, inadequate to the tasks of prevention of doctor shopping and diversion.

Friday, January 30, 2015

Closing the In-state PMP Loop

By Doug Brockway
January 30, 2015

A key weakness with Prescription Monitoring Programs, PMPs, is they do not capture and immediately make use of the act of writing a prescription. There is no PMP record of a prescription as it is written.  With PMPs data are only collected by the pharmacist for prescriptions filled.  The pharmacy often has a week, usually more time, to enter the data.

As a result a PMP cannot detect potential diversion prior to dispensing.  One doctor hears you have back difficulties, the next is told that your shoulder hurts.  Each can write you a prescription without knowing of the other’s action. You can see doctor after doctor for at least a week before anyone notices. 

If in your state the pharmacist has more than a week to submit information on a prescription the window for mischief is wider. Sometimes the doctor shopping is done by an individual trying to satisfy an addiction or generate some cash.  More insidiously are the diversions done by coordinated groups intent on the resale of prescription pain killers to the innocent and the unsuspecting.

As noted elsewhere, PMPs are not notable for their user experience.  They cause significant delay in process when only used for look-up purposes by doctors.  What is needed is a very efficient-for-the-user method to capture prescriptions, in real time, and feed that data to a central data base, presumably a PMP, for use in closing the in-state PMP loop. 

This either means wholesale re-write/replacement of PMPs or the use of a “surround strategy;” putting a superior data collection capability, a “wrapper” around the existing systems[1].  If this is done then PMPs will be far more suitable to our goals of opiate abuse prevention than they are now.

[1] Capabilities of this sort, CMS-tested, are available:

Thursday, January 29, 2015

Design Prescription Monitoring for Operability

By Doug Brockway
January 29, 2015

A key reason that Prescription Monitoring Programs (PMPs) are inadequate to the task of prevention of opiate abuse is a matter of consistent, enthusiastic participation and use.  People will flock to technology based products or services with superior user experiences.  The Apple suite is a commonly cited example that takes advantage of what is known as “design thinking.”  In contrast, PMPs are user-experience clunkers, designed for data analysis, not for quick, easy, universal use in an active medical office.

When considering prescribing prescription pain killers PMPs oblige doctors and pharmacists to manually examine a data base. According to recent testimony from the Massachusetts Medical Society (MMS) each lookup takes 3 to 7 minutes. This doesn’t sound like much unless you’re in the middle of a busy day at a medical practice or in an emergency room or any one of a number of situations where speed is important.

It’s as if in your day-to-day life when buying clothes at a store the sales clerk stops the sale to check your credit history.  They’d have to be sure you’re the person referred to on the screen, so they’d ask you a set of authentication and validation questions, then they’d look at your credit history and make their decision whether you’re able and willing to pay for those pants.

Instead they swipe a card (or use a mobile service like Apple Pay) and all that is done in seconds by an independent, objective, consistent third party. If on-average each retail purchase was 5 minutes longer than it is today sellers and buyers would be unhappy, grumpy, and un-cooperative with the process and each other.

With many uses of pain killers the 5 minute investment in the PMP is easily seen as too burdensome. The hospice setting is one.  So are small amount prescriptions, especially for patients well known to the physician. Emergency care, many inpatient settings so-called “immediate treatment” also might fall in this category.  Policy makers and the medical community spend much time discussing how to manage the efficiency of the process for such situations.

A process engineer will tell you that excepting uses is not advisable.  You want to collect all uses of pain killers and do your analyses from there.  You can’t/shouldn’t presume to know where the patterns are.  That same process engineer will tell you that putting a multi-step, multi-minute process in front of all data collection will sink under its own weight. This is a big part of the reason, in the case of retail, the data collection is just a swipe of a card.  For PMPs to be widely used and widely accepted in all prescription writing and fulfilling they need to create a similar capability. 

Monday, January 26, 2015

Prevention Effectiveness Requires Transactional Consistency

By Doug Brockway
January 26, 2015

As discussed in this related post there is a minority of doctors and pharmacists that are consciously and intentionally involved in the diversion of prescription drugs will not turn themselves in based on what is shown in a PMP data base.  On the other side of the transactions are patients who intentionally take advantage of inconsistencies in our prevention systems and processes to gain access to drugs they should not have.  These are the doctor shoppers that PMPs are trying to stop.

Key goals of PMPs include the ability to review a patient’s prescription history, avoid duplication of drug therapy or possible drug interactions, and enable appropriately coordinated care across providers. But PMP data are subject to error in the interpretation by myriad physicians and pharmacists each applying their individual interpretations and doing it with different levels of diligence each time. This contributes to PMPs, as currently engineered, to being inadequate to the task of preventing opiate abuse.

One key issue with PMP data in this regard is that there are spelling, keying errors and missing information.  The PMP may have data for John Q. Public, John Public, J.Q. Public and more.  The underlying records for the patient are not likely the same.  In the terms of systems security, the physician must authenticate and verify the identity of the patient, decide which records to use, and then make a series of interpretations before deciding whether a patient is at risk for doctor shopping.

Another key issue is the delay or “float” in PMP data.  The most ambitious states require data to be submitted by pharmacists within a week of fulfillment, most are less strict.  When a patient who is not doctor shopping visits a doctor it will more likely not be within that one week window.  Their PMP record will be up-to-date.  A doctor shopper is more pressed by time, will see many providers within a week.  Their histories of opiate use will be out-of-date.

Combined, these weaknesses create a system that either is not repeatable in its application or, since it uses incomplete data, is repeatably evaluating incorrectly.  We need a system and process that is both repeatable and accurate.

Having a doctor or pharmacist interpret PMP data to evaluate if a patient is doctor shopping can be viewed as akin to a clothing salesperson or store manager interpreting your credit history to see if you should be able to buy that sweater you like.  The same salesperson will react differently to different customers, even to the same customer at different times and under different circumstances.  In the case of retail the basic analysis is done via computer separate from and agnostic to the sale, not by the person doing the selling.  Crucially, this is done in real-time with the swipe of a credit card or, more recently, with the presentation of an Apple Pay or similarly enabled mobile payment device.  Real time is important because if the checking is too time consuming and burdensome then the checker will often put in a less than stellar effort.

We’re all familiar with and depend on second opinions from doctors when we seek care.  We want to be sure that all possible diagnoses and proscriptions are considered and the best course of action is available to us.  A patient who is doctor shopping also relies on this variance but for dark purposes.  They want to use or sell pain killers. These doctor shoppers use the inconsistencies in doctors’ attention to, thoroughness regarding and interpretations of need for care to see multiple doctors until they get the outcome they want, additional opiates.  PMPs will be more effective when they are able to tighten the loopholes, make data (and thus interpretations) more consistent and up-to-date, and provide basic analysis of PMP data in real time at the point of care.

Wednesday, January 21, 2015

The Fox is in the PMP Henhouse

By Doug Brockway
January 21, 2015

Before we get into the meat of this post suffice it to say that as a group of individuals there is absolutely no indication that doctors or pharmacists are less honest and upright than the average person.  In fact, someone who takes on those jobs, with the tasks, cases and experiences that are involved, and the work and sacrifice needed to succeed and thrive, is likely, on average, to be more honorable than most.

Still and all it takes almost no effort to do a search regarding health care fraud and find many, many cases of doctors and pharmacists engaged in all manner of unethical, fraudulent and illegal activities.  There are bad apples, what the Boston DEA’s SAC Ferguson has called “rogue” doctors and pharmacists.  When it comes to stopping doctor shopping and thus much opiate abuse the preferred systems technology, PMPs, put these rogue providers, these foxes in the henhouse.

We have previously made the case that PMPs are inadequate to the task of preventing opiate abuse. A key reason is that the only people examining a patient’s history of drug use in the PMP are doctors and pharmacists. PMPs are populated by having pharmacists enter into a data base all opiate prescriptions, all Schedule II and III drugs, that they fill.  They enter data identifying the patient, the doctor who wrote the prescription, the nature of the prescription (how many units of what drug), and the pharmacist filling the prescription. Requirements vary but in most states pharmacists have one week to submit the data after providing the drugs to the patient.

The rules and usage vary by state but doctors and pharmacists then inquire this data base prior to writing or filling a prescription for someone with existing, open, conflicting prescriptions or showing a pattern of over consuming opiates. When the provider is, per usual honest, the PMP can be effective. But it is known that the minority of doctors writes the broad majority of illegal prescriptions. PMPs can only work in these cases if “rogue” doctors and/or “rogue” pharmacists turn themselves in.

This is a major fault. With PMPs as they are, the largest sources of fraudulent prescriptions are created and then filled by the one minority that has a vested interest in the fraud[1].  Until this “loophole” is closed there will be foxes in the opiate abuse henhouse.

[1] Fortunately, there are methods to do the checking for the provider not by the provider

Thursday, January 15, 2015

PMPs Are Inadequate to the Task

By Doug Brockway
January 15, 2015

A bit of background to make sure we’re on the same or similar pages.  Especially accelerating in the past few years, opioid abuse, the over use of prescription pain killers, has become a major economic and health issue in the US and a major cause of death.

Opiates, which are crucial to alleviating pain for many patients have been mismanaged and misused to our shared loss.  There are many places to get numbers.  Here’s a fairly net summary from The Incidental Economist, Austin Frackt[1].

In the summary Frackt makes two points key to this post:
  • Most opiate overdose deaths and growth in them can be traced back to prescriptions: “4 in 5 of people today who start using heroin began their opioid addiction on prescription opioids.” Clamping down on the supply of heroin alone will not address the problem.
  • U.S. clinicians “write more prescriptions for opiate painkillers each year than there are adults in the United States.”
A common and concerning trope is that average citizens are often prescribed opiates in large or refillable dosages after injury.  This often leads to dependencies.  When the prescriptions run out and/or the costs get out of hand, the much more available and cheaper street drugs, mostly heroin, become the outlet for the addict’s need.  From here we move to petty crime to support the addiction and death from misuse and overdose (see chart above).

Much has been and must continue to be done to help people recover from their addictions.  In terms of preventing them in the first place, besides public awareness, education, training within the medical, policing and treatment communities, the tool that is almost universally cited as an aide to prevention is something called a Prescription Monitoring Program (PMP). 

Operating on a state-by-state basis in almost all states PMPs require pharmacists to record into the system the data/time of fulfilling a prescription for Schedule II or III drugs (opiates), the name of the patient, who picked up the prescription, the name of the doctor, and key data about the prescription itself.

Once the data are in the PMP then doctors have the opportunity to, increasingly they are required to, look at the PMP data base to see if the patient has outstanding, repeated or high numbers of opiate prescriptions prior to writing a new one.  Similarly, the pharmacist can see the same information to help guide if a prescription should be filled based on patterns implied in the PMP data.  In this way PMPs have shown some effect in reducing “casual” or “unthoughtful” prescription of opiates, but the effect is minor compared to what should be[2].

Especially given the size and scope of the epidemic, the nature of the death and destruction that opiate addiction brings with it, Prescription Monitoring Programs as currently structured are inadequate to the task.  PMPs’ significant shortcomings include:

  • ·    The Fox is in the PMP Henhouse - When doctors and/or pharmacists are involved in the fraud the PMP is not a defense. This is a major failing of relying on PMPs.  Although very few doctors participate in scams, if, as the Boston DEA’s SAC Ferguson says, “there are too many rogue doctors and pharmacists” then we are not being diligent enough if we ask rogue doctors and pharmacists to check on themselves
  • ·    Prevention Effectiveness Requires Transactional Consistency - PMP data is subject to error in the interpretation by myriad independent physicians and pharmacists each applying their individual interpretations and doing it with different levels of diligence each time
  • ·    Design Prescription Monitoring for Operability - PMPs oblige doctors and pharmacists to examine a data base, manually, with each patient, causing delay, frustration and cost in the office. It’s as if when buying clothes at a retailer the sales clerk stops the sale to check your credit score
  • ·    Closing the In-state PMP Loop - With PMPs data are only collected for prescriptions filled, not prescriptions written.  The PMP cannot detect potential diversion prior to dispensing.  You can see doctor after doctor for at least a week before anyone notices
  • ·    In Opiate Abuse Prevention, PMP Timelinessis Godliness - PMP data are collected monthly, or at best in some states weekly.  This is not sufficient to capture diversion, which can be done intraday with patients getting prescriptions from multiple doctors and filling them at multiple pharmacies in very short periods of time
  • ·    State-by-State Doctor Shopping Prevention Silos - Because they vary, technically, by state, and because laws governing their data and use are written without sharing across state lines in mind, PMPs do not operate across state lines.  Multiple prescriptions can be written in one state and a very short time later, often minutes, filled in a nearby state with no-one the wiser.

Opiate addiction and its health and related effects is particularly destructive to people, families and communities.  Nationwide groups, towns, counties and states are trying to stem and turn the tide.  PMPs as structured are not adequate to the task.  Fortunately, there are methods to do the checking for the doctor not by the doctor, operate without new office technology and very little process change for doctors, capture prescription writing and dispensing, operate in real time, and operate across state lines.

[1] If you have the time I strongly urge you to read the insightful conversation between Harold Pollack and Keith Humphreys that Frackt links to
[2] Perhaps this is only the Hawthorne Effect where the act of looking itself changes the behavior, not the analysis of the doctor or pharmacist