Making Over PAT

Lawmakers Look to Improve Texas' Prescription Drug Monitoring Database

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Legislative Affairs Feature — March 2015 

Tex Med. 2015;111(3):37-41.

By Amy Lynn Sorrel
Associate Editor

When Texas' prescription monitoring database, Prescription Access in Texas (PAT), went offline for a few weeks, Garland pain management specialist C.M. Schade, MD, couldn't see what turned out to be obvious signs of doctor-shopping. A patient whom police eventually arrested had already been to multiple doctors for the same pain medicine prescription. 

Designed to rein in drug trafficking and abuse, PAT allows physicians and other authorized users — like pharmacists, midlevel practitioners, and law enforcement personnel — to see patients' prescription drug history for the last 12 months. Pharmacists must report prescription data within seven days of filling an order.

"It made me look bad, like I wasn't doing anything about the problem," said Dr. Schade, a past president of the Texas Pain Society (TPS) and member of the Texas Medical Association's Interspecialty Society Committee. 

But he also has patients with legitimate needs and wants to be able to prescribe safely. Some of his patients travel from Oklahoma or Louisiana to see him because they don't have access to specialty care in their areas. 

Even when PAT is up and running, however, Dr. Schade must play detective to figure out the difference. He hunts through the system's unwieldy spreadsheets because PAT does not alert him when patients obtain or fill similar prescriptions from multiple doctors. 

Almost three years after the system's launch, he prints out patients' prescription histories and stores them separately because PAT cannot connect with his electronic medical records. And to prescribe in the first place, physicians and other prescribers must get a state controlled substances registration (CSR) certificate — another process that fails to run smoothly — in addition to their federal prescribing license from the Drug Enforcement Administration (DEA). 

Dr. Schade says physicians should be vigilant, and if someone is suspected of doctor-shopping or stealing his prescriptive identity, "Tell me. I want to know." 

But physicians also must be able to practice medicine efficiently and effectively, he says. And for doctors to more readily and widely make use of PAT, the system needs a makeover. "Texas is far behind the curve. Other states are already doing these things."

Texas has come a long way in the fight against prescription drug abuse and misuse, ranking 44th in the nation for prescription opioid overdose deaths per year. (See "Texas Tackles Prescription Drug Abuse.")

But the state still has a ways to go, ranking 12th for nonmedical use of prescription opioids.  

That's the gist of a pair of Senate and House committee reports that recommend improvements to PAT as one of several strategies to fight diversion. (See "Fixing PAT.") The reports, likely to spur legislation, are the result of the Senate Health and Human Services and House Public Health committees' interim charges to find ways to better tackle the problem, particularly among high-risk populations like pregnant women. 

Moving PAT to the Board of Pharmacy

As an important first step, the committees agree that transferring the operation and oversight of PAT from the Texas Department of Public Safety (DPS) to the Texas State Board of Pharmacy (TSBP) would enhance the program's usefulness. 

"PAT has the potential to be a very effective tool in the state's fight against prescription drug abuse, but is currently not reaching its full potential," the Senate panel wrote. "DPS is responsible for the monumental tasks of combating crime and terrorism, assisting with statewide emergency management, and ensuring public safety. The agency does not have the bandwidth to focus their attention on prescription monitoring, and the online program has not progressed in terms of usability or interactive features since its creation in 2012."

The House committee report notes also that TMA-backed House Bill 1803 from the 2013 legislative session linked renewal of physicians' CSR permits to their medical license renewal; and Senate Bill 1643 authorized pathways for doctors to access prescription information through a health information exchange and electronic medical records. 

"None of these legislative initiatives from 2013 have been implemented by DPS," House members wrote. 

Senate Bill 195, introduced this year by Sen. Charles Schwertner, MD (R-Georgetown), would shift PAT from DPS to TSBP by Jan. 1, 2016, and pave the way for system updates. Those updates include allowing Texas to participate in the national prescription monitoring program InterConnect to track drug diversion across state lines — another strategy agreed upon by the House and Senate panels. 

"Prescription drug abuse and misuse is a serious problem in Texas. As a practicing physician I've seen that firsthand, and the state of Texas does need to be more diligent in monitoring" the problem, Senator Schwertner told Texas Medicine. "We already have a prescription drug monitoring program, and in my opinion, these types of programs are best administered by a health agency."

TMA supports the legislation as part of its crusade to cut through the reams of red tape enveloping physician practices and detracting from patient care. Through those efforts, TMA wants to ensure PAT remains a user-friendly risk-management tool that gives doctors the flexibility to use it in ways suitable to their practices.

The pharmacy board also welcomed the potential move, and the proposal gathered speed this year with TMA's support, says TSBP Executive Director Gay Dodson. All states now have a prescription monitoring program, and all but five house those databases within a health-related agency, she adds. 

"This needs to be housed somewhere that has some knowledge of prescribing and prescribing habits to be able to help doctors and pharmacists make better decisions when writing prescriptions," Ms. Dodson said. "This is not really a law enforcement issue. We're not here to catch crooks. This [PAT] is a tool to help doctors and pharmacists make better decisions. And if you have better tools to make better decisions, that's also a therapeutically better decision for the patient." 

Working With Other States

Looking to advance Texas' PMP, the pharmacy board and TMB also researched other state strategies and found most use push notifications that proactively alert physicians and pharmacies when a patient fills a prescription for a controlled substance from more than one doctor. Physicians would receive an email, or an alert when they log into the system, for example.

Other states also make multiple reports available, "and we [the pharmacy board] would intend to get as much flexibility for practitioners to get the information they need so they can see what patients are getting from other doctors, and pharmacists can see what patients are getting at other pharmacies, too," Ms. Dodson said.

Those reports would be more robust with out-of-state data from InterConnect, allowing physicians to see a more complete history of patients' controlled substance prescriptions. 

The program, run by the National Association of Boards of Pharmacy, links participating state PMPs so users in Texas, for example, could access interstate data from the roughly 30 participating states to see prescriptions written in one state and filled in another. Texas could join the grant-funded program at no cost. 

DPS did not respond to Texas Medicine's requests for comment. But at hearings last year, agency officials told House and Senate committee members they continue to work on improvements to PAT, and the number of physicians, pharmacists, and other eligible health professionals using the database is approaching 100,000. 

DPS leaders and some lawmakers also suggested that requiring physicians to query the database before prescribing could help cut down on illicit doctor-shopping before it leads to widespread criminal activity. 

Finding a Balance 

TMA President Austin King, MD says such a mandate would be "disastrous" for patient care. 

The head and neck surgeon from Abilene doesn't access the database often because he knows his patients, "and most have an excellent reason why they are in severe pain," he said. "If someone comes to see me with terminal head and neck cancer, why in the world should I have to do that? All it does is interfere with the patient-physician relationship. Can you imagine an oncologist, every time someone walks in the office, having to check the database to prescribe pain medication?" 

On the other hand, some of his colleagues, when on call in the emergency department, shy away from prescribing narcotics to patients who have legitimate needs when they do not have access to the patient's medical history. 

"If we had easy access to a database, we wouldn't have to do that," Dr. King said. "What we need to do is move on to the next level of making this pharmacy- and physician-friendly so that it can be more easily and more widely utilized." 

A mandate is also impractical for physicians and for the system, adds Dr. Schade, who pilot-tested PAT before its launch. 

"It's like saying everybody has to have a lab test because somebody might be sick. Is it more logical that all physicians check every time for the 99 percent of patients who are good, or that the computer, like other states, looks for the 1 percent who are bad? Which one works well, and which is cost effective?" he asked. "And it's a fact: The system will crash if everyone queries it. It's not robust enough to handle that volume of traffic, and it makes it expensive."

Nor would transferring oversight of PAT to the pharmacy board interfere with any of DPS' law enforcement authority, Ms. Dodson says. The board still could provide information to DPS to aid in relevant investigations. But for the most part, "the medical board and the pharmacy are doing that, and we have stepped up and are doing a good job of policing and talk often."

During hearings, TMB Executive Director Mari Robinson told lawmakers that existing laws have enabled the board to prosecute legitimate criminal activity, levying roughly 100 actions over the past two years for nontherapeutic prescribing. 

She also cautioned that simply running a report on the volume of every physician's prescribing does not present the whole picture. Physicians working with hospice or terminal cancer patients, for example, are likely to be higher prescribers. 

"What we are doing is working, but we have to continue doing it and trying to improve it as best we can," she said. "We are on to the next generation of how do we make the system work for regulators and for physicians who are trying to do the right thing, which, remember, is 99 percent of the population."

Senator Schwertner called mandatory use the wrong path. 

"Physicians can get into a cycle of continuing to write for prescription drugs and unknowingly facilitate a bad situation. So we do need checks and balances, and this [PAT] allows us to have that information," he said. "But we already have tremendous amounts of hurdles and regulations and issues we have to face in our challenge to treat patients as best we can. Education and utilization are very important. But making it mandatory is not the right path."

CSR Frustrations Persist

Instead, to encourage use, the Senate health committee report recommends automatically registering physicians and other users in PAT when they renew their CSR permit. 

But many physicians remain frustrated with the CSR process, pointing to the bureaucratic bungling of earlier red-tape reduction efforts to streamline the requirements and help avoid care interruptions. 

In response to persistent backlogs at DPS, the TMA-backed HB 1803 from last session was supposed to make the process part of physicians' biennial online medical license renewal at TMB starting Jan. 1, 2014. TMB made the necessary technological updates, but DPS has yet to follow through. 

The agency says programming changes are under way and has since offered a temporary solution to automatically renew CSR permits at no charge. 

But physicians seek a long-term solution that would completely eliminate the hassles that have caused some to lose their prescribing authority and hospital privileges. Texas physicians' ability to prescribe medications hinges on a valid state CSR, which is also necessary to obtain a prescribing permit from DEA. 

Dr. Schade, speaking on his own behalf, called the duplicative state process "outdated," adding many states require only a DEA license to prescribe.

And the delays at DPS have nothing to do with quality of care, and instead impede it, adds Dr. King. "This has nothing to do with determining whether you [physicians] are competent to prescribe narcotics. This is because DPS hasn't cashed your check to pay a fee." 

At press time, lawmakers had not proposed legislation to eliminate the CSR permit.

Instead, Senate Bill 196 by Senator Schwertner seeks to synch CSR renewal for advanced practice registered nurses and physician assistants with their respective license renewal processes, similar to what HB 1803 did for physicians in 2013.

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

All articles in Texas Medicine that mention Texas Medical Association's stance on state legislation are defined as "legislative advertising," according to Texas Govt. Code Ann. §305.027. That law requires disclosure of the name and address of the person who contracts with the printer to publish the legislative advertising in Texas Medicine: Louis J. Goodman, PhD, Executive Vice President, TMA, 401 W. 15th St., Austin, TX 78701.


Fixing PAT

The Senate Health and Human Services and House Public Health committees made several recommendations to improve Texas' prescription monitoring program (PMP), Prescription Access in Texas (PAT), as part of a larger strategy to fight prescription drug abuse in Texas.  

  • Transfer PAT and associated appropriations from the Department of Public Safety to the Texas State Board of Pharmacy (TSBP).
  • Give TSBP authority to join the national PMP, InterConnect.
  • Make PAT more user-friendly by providing push notifications, integration with electronic medical records, and other incentives for physicians and others to use the program without interference with patient care. 
  • Make prescribing information available in real time. 
  • Automatically enroll prescribers in PAT when they renew their controlled substances registration (CSR) permit to encourage use. 
  • Align CSR renewal for advanced practice registered nurses and physician assistants with their respective license renewal processes, similar to that achieved for physicians in House Bill 1803 in 2013. 

Read the full reports online: Senate Health and Human Services Committee and House Public Health Committee.

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Texas Tackles Prescription Drug Abuse

  • 2009: To weed out so-called "pill mills," lawmakers require all pain management clinics to register with the Texas Medical Board (TMB). 
  • 2010: The Texas Department of Insurance Division of Workers' Compensation adopts a closed formulary that requires prior authorization for certain pain drugs. 
  • 201l: The legislature creates criminal penalties for doctor shopping and increases penalties for illicit distribution of prescription drugs. 
  • 2012: The Department of Public Safety (DPS) makes the state's prescription monitoring program, Prescription Access in Texas, available online for easier access. 

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