#PNN Prescription

Beginning on January 1, 2022 almost all prescriptions written in California must be transmitted electronically. Physicians who have not yet implemented electronic prescribing in their practices should begin the process now. 

The electronic prescribing mandate was contained in a law passed by the California State Legislature in 2018. The bill (AB 2789) had a three-year delayed implementation to allow physicians and other prescribers the opportunity to select and implement an electronic prescribing platform. But the delay ends at the end of this year.  

The law is partially based on the Medicare electronic prescribing for controlled substances (EPCS) requirement, which is also set to take effect on January 1st.  The Centers for Medicare and Medicaid Services (CMS) has proposed in the 2022 Medicare Physician Fee Schedule to delay implementation of the EPCS requirement for an additional year, to January 1, 2023, but that does not have any direct effect on the state requirement. Much of the language of the requirement was copied straight from the federal regulations.  

Unlike the Medicare requirement, however, the state mandate applies to almost all prescriptions, not just those for controlled substances. In that respect, the state mandate is much broader than the Medicare one and will affect many more physicians. 

The California Medical Association (CMA) opposed AB 2789 when it was being debated in the legislature and offered the author possible amendments that would have created some accommodations in the law. But the proposed amendments were rejected, as the Legislature saw AB 2789 as just an extension of the Medicare requirement. 

Understanding the Electronic Prescribing Mandate 

As physicians approach coming into compliance with the electronic prescribing mandate, it is important to understand a few major facets of the law. CMA has based the following on conversations with many physicians over the past few months. 

Exceptions 

The following types of prescriptions are exempt from the electronic prescribing mandate: 

  • Controlled substances prescriptions for use by a patient who has a terminal illness. 

  • E-prescribing is not available due to a temporary technological or electrical failure.  

  • The prescribing physician is issuing a prescription to be dispensed by a pharmacy located outside California. 

  • The prescription is issued in a hospital emergency department or urgent care clinic and either the patient resides outside California, the patient resides outside the geographic area of the hospital, the patient is homeless or indigent and does not have a preferred pharmacy 

  • the prescription is issued at a time when a patient’s regular or preferred pharmacy is likely to be closed. 

  • The prescription is issued by a veterinarian. 

  • The prescription is for eyeglasses or contact lenses. 

  • The prescribing physician and the dispenser are the same entity. 

  • The prescription is issued by a prescribing physician under circumstances whereby the physician reasonably determines that it would be impractical for the patient to obtain controlled substances from an e-prescription in a timely manner, and the delay would adversely impact the patient’s medical condition. 

  • The prescription that is issued includes elements not covered by the latest version of the National Council for Prescription Drug Programs’ SCRIPT standard.  

If a physician believes that one of the above exceptions apply, they must document it in the patient record within 72 hours of filing the prescription. 

Practice Exemptions 

While some specific prescriptions are exempted from the electronic prescribing mandate, there are no exemptions in the law for physician practices. CMA receives many questions from physicians about hardship exemptions, considerations for retired (or semi-retired physicians), low volume prescribers, physicians in safety net settings, and rural physicians. All of the above are subject to the law, and there is no provision in the law for a practice to request an exemption. 

Enforcement  

Physicians who fail to comply with the law will be referred to the Medical Board of California. The Medical Board has published several physician communications outlining the requirements of the law but has not proposed any specific enforcement actions they might take. 

An enforcement action by the Medical Board under this law would be triggered by a complaint. The most likely scenario is that a physician is referred to the Medical Board by either a patient or a pharmacist.  

Importantly, the law does not create private right of action. That is, physicians cannot be sued for failing to comply with the law. 

Product Selection and Implementation 

For physicians who have an electronic health record (EHR) system, implementing electronic prescribing may be as simple as turning on an embedded electronic prescribing module. Any EHR that is certified by the Office of the National Coordinator for Health IT (ONC) must have the capability to transmit prescriptions, including controlled substances, electronically. Physicians with an EHR should contact their vendor for more information. 

For paper-based practices, selecting the right technology platform will be a little more complicated. A stand-alone electronic prescribing system (that is, not tied to an EHR) will likely be much cheaper and easier to implement than a complete EHR system. Most paper-based practices will likely look to one of these systems. 

While CMA does not endorse any particular electronic prescribing system, there are a few recommendations for physicians who are in the market. First and foremost, if the practice does any prescribing of controlled substances, the system must have the ability to do EPCS and query the CURES database. Not all commercially available systems can do both of these, so practices should ask perspective vendors before investing in a system. 

Also, practices should strongly consider electronic prescribing systems that are connected to the SureScripts network. SureScripts is the largest electronic prescribing network in the country. Vendors on their certified product list will give physicians and patients the largest number of pharmacies from which to choose. 

CMA Resources 

To help physicians make this transition, CMA has developed the following resources, available only to CMA members: 

  1. CMA Frequently Asked Questions: California’s Electronic Prescribing Mandate 

  1. Webinar: Preparing for California’s Electronic Prescribing Mandate (archived; available for on-demand viewing) 

CMA members are also always welcome to call the CMA Member Helpline at (800) 786-4262 to request one-on-one assistance. 

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