Prescription Monitoring & Standard of Care

I wrote about my early experience with the state of Washington's new program that allows prescribers to monitor patients' prescriptions from other prescribers here. Questions about use of the program continue to emerge:

• How often should prescribers perform searches?
• What should we do when we discover undisclosed prescribing by other prescribers?
• Can we contact other prescribers without the patient's authorization?
• When should we discharge patients who have withheld information from us?
• Can we rely upon a negative search?
• Can we charge a fee for performing a search?
• How will we redefine standard of care in light of this new capability?

If we define standard of care as that which is "reasonable and prudent," as an expert witness I believe I would consider that a prescriber must conduct at least one search in order to meet standard of care. There can be little question whether a prudent provider would want to inquire as to what controlled substances a patient might have been prescribed. Such information can aid in diagnosis and may help prevent dangerous drug interactions. We know patients sometimes lie about drug use. The patient who does so should retain some responsibility for misleading a physician, but with this new tool the prescriber assumes more responsibility.

Whether standard of care requires repeated searches may depend on other factors, perhaps most import among them the results of the first search. If a search produces no positive result a prescriber may not need to  repeat the process for a year or more in some patients. After a positive search, however, the prescriber must take action. She should confront the patient and establish contact with any other prescribing providers to coordinate which provider will assume responsibility for addressing which problems and prescribing which classes of drugs. Too many chefs spoil the broth. Prescribers should consider discharging patients who do not cooperate.

Prescribers should repeat searches more frequently after a positive result, not only to determine whether other prescribers adhere to mutual plans, but also to determine whether the patient has sought prescriptions from other providers, each time taking appropriate action on positive results.

The increase in transparency afforded by prescription monitoring enables us to provide better care, but only if we access the information and act on it.