1. Prescription Safety In the Technological World Angela JW Smithson MD MPH U of MN St Johns Family Medicine Residency Emily Day MD, Chief Resident

2. Disclosures None

3. Objectives Identify potential security concerns in EMR printed prescriptions for restricted medications Adopt improvements for safe prescription printing and pick up process. Implement consistent documentation around high risk medications.

4. Printing Prescription Background What needs printing? –Schedule II-V drug issues (high risk for misuse, diversion) Why print instead of electronically prescribe? –Regulations exist for printing and signature authentication –Pharmacy issues: location, indecision –Patient preference –Electronic/equipment downtimes

5. Government Regulations Title 21 Code of Federal Regulations –Part 1306 Prescription requirements –Part 1311 Electronic prescribing options Two factor authentication (2 of the 3 required) –Password or challenge question –Iris/fingerprint scan –Hard token State regulations and statutes vary

6. http://www.deadiversion.usdoj.gov/21cfr/cfr/index.html

9. Phalen Process Start Case of Identified Prescription Fraud –Studied issues around narcotic safety –Reviewed our prescription process –Identified our weak areas Unknown duplication of a prescription –Possible because script not secured, unattended, undocumented time, undocumented person pick up Lack of documentation and inconsistent and unsecure process

10. Safe Prescribing Problems Prescription fraud Unsecure Process Inadequate Documentation Issues

11. Anti-fraud Security Features Falsifying drug concentration, quantity, refills Numbers printed and written Refill restrictions Falsifying person Photo ID Falsifying signature Blue Ink DEA verification Signature reference Falsifying entire prescription Script ID numbers Microprint Blue Ink Special paper

12. Prescription Security Features Prescription ID # Written and numerical documentation Blue ink Microprint

13. Print Process Problems and Solutions IssueSecurity Process RiskSolution Printed duplication of same script Multiple identical scripts given to same individual 1. Documenting reprint reason 2. Code or badge printer 3. Designated printer Unattended or printed and forgotten scripts Staff or patients can pick up and fraudulently use Duplicated scripts may be printed and given 1.Code or badge secure printer 2. Route to a single printer Equipment failuresPatient gets handwritten script, possibly insecure, possibly undocumented 1. Standard documentation process. 2.Scripts with carbon copy

14. Phalen Print Process Implementations IssuePhalen Solution Script Duplication1. Standard documentation on reason for reprint 2. Checking all printers beginning and end of shift 3.Request to change printing routing Unattended/forgotten scripts1. Checking all printers beginning and end of shift 2. Request to change printing routing Equipment failuresStandard phrase about handwritten script being used

15. Pick up Process Problems and Solutions IssueSecurity RiskSolution Undocumented patient/designee pickup Fraudulent diversion1.Photo ID for pick up 2. Documentation of time/date Duplication due to miscommunication/lack of documentation “I never got my script” Multiple scripts possibly given to patient 1.Documentation if given during visit. 2.Documentation at time of pick up Lost prescriptions in the clinic Staff and providers at risk for accusations and or fraud. 1. Locked box, secured envelope, 2. Process documentation in chart.

16. Phalen Pick up Process Implementations IssuePhalen Solution Undocumented patient/designee pickup Photo ID for pick up Documentation of time/date Duplication due to miscommunication/lack of documentation “I never got my script” Documentation for office visits when script given to patient Lost prescriptions in the clinicLocked box, secured envelope, Documentation in chart

17. Important Document Issues Documentation Times –Duplicated printing –Handed to patient/designee –Shredded prescription

18. Implemented Process

19. Phalen Pick up Secure Envelope Process

20. Phalen Original Pick up Documentation DATE: PATIENT NAME: D.O.B : NAME OF MEDICATION: DATE MEDICATION WAS PICKED UP: Print Name: SIGNATURE: STAFF INITIALS:

21. Phalen Revised Print and Pick up Process Documentation

22. Phalen Current Pick up In Chart Documentation

23. Phalen Disposal Documentation

24. Phalen Visit Documentation

25. Phone Request Documentation

26. Process Update Current stats –Zero-Four scripts/day picked up –Still found script fraud Next phase –Monitor Schedule 2 and 3 prescribing –Route printing to single printer in secure location –Consider alternate print security features –Improve standardization and utilization of documentation phrases

27. Summary Take responsibility for safe and secure printed prescription Demand robust print security features Develop secure print and pick up processes Improve process documentation and reduce process variation

28. Please evaluate this session at: stfm.org/sessionevaluation