Much has been written about the opioid epidemic in recent years. While it has certainly garnered a great deal of attention, the abuse of prescription drugs, particularly opioids, is not new. Health professionals have known for decades that the difference between medical opioids and street opioids is that medical opioids have been recognized by the U.S. Food and Drug Administration and are intended for use in the treatment of disease in humans or animals. The chemical structures of heroin, morphine, and oxycodone are nearly identical. Therefore, the human body’s opioid receptors produce the same results regardless of the source of the drug.
Because legal opioids are used in medicine, prescribers and dispensers of these drugs are required to keep detailed records of acquisition and distribution. Pharmacy dispensing records are the most accessible healthcare record of legal drug acquisition and distribution. These records are used both by healthcare practitioners and by government agencies as a reliable source of information for investigating violations of professional practice or drug-related crimes. States and jurisdictions created prescription monitoring programs (PMPs) or prescription drug monitoring programs (PDMPs) to maintain centralized prescription records, which have come to be critical in the fight against opioid abuse. It should be noted that opioids are not the only prescription drugs of abuse; therefore, PMPs contain records of numerous drugs that are subject to abuse, including stimulants for the treatment of attention deficit disorder, sleeping pills, anti-anxiety drugs, and some of the nonopioid pain relievers.
The purpose of every PMP is to provide a prescription drug history to help healthcare providers and regulatory officials monitor use of controlled substances and other drugs of abuse. This information is essential to the provision of appropriate healthcare by healthcare professionals and the investigation of illegal activity by regulatory officials. However, the data was never intended to be a primary record nor absolutely correct in every regard. It was intended to be another tool in a professional’s toolbox to identify trends in prescription drug use or misuse.
As PMP records are used more and more often, the errors and omissions in the data come to light. The PMP record consists of selected data fields within the data required for prescription record keeping. However, whenever humans are involved, errors will occasionally occur.
PMP errors can occur throughout the process of filling a prescription and are the result of omission or commission. Errors of commission are the result of inaccurate data being submitted to the PMP. Errors of omission result from data that is never submitted to the PMP or incorrect data that is never corrected.
It is important to understand where errors arise or could arise in order to accurately interpret a PMP report. While errors may exist in any data field, patient identity and prescriber identity are the most problematic. The identity of the dispensing pharmacy is a critical piece of information that the reviewer of a PMP report may need if further details are necessary.
Prescriber name or prescriber identification is the most frequently identified error in PMP databases. It comes to light in several ways. A prescriber or pharmacist may be reviewing PMP data with a patient and the patient denies ever having been treated by a particular prescriber. In other cases, a prescriber receives communication from his or her state PMP or a regulatory agency about one or more prescriptions attributed to him or her. The prescriber has no record of the patient and denies that he or she authorized the prescription. In either case, the dispensing pharmacy must be contacted. The pharmacy staff reviews the original document and finds some of the following:
- The wrong DEA or NPI number was entered or selected at the time of dispensing.
- The prescriber on the prescription cannot be identified (such as an emergency department prescription).
- There is an error in the database of prescribers that the pharmacy uses.
The first scenario occurs most frequently and is easily corrected by the dispensing pharmacy. However, it should be noted that, as with many PMP errors, the pharmacy might correct its own record but fail to amend the PMP record.
Patient Name — Person Identification
There’s a common misperception that any person in the United States can be identified by first name, last name, and date of birth. If you Google someone, even with a relatively uncommon name, you often find multiple people. Even adding the date of birth does not narrow the search sufficiently. I personally know of two women with the same first name, last name, and date of birth who live three miles apart, in the same state. PMP data is unlike health insurance data, credit card data, and many other large databases because there is no unique identifier that can be assigned. Based on my experience as a PMP director, even Social Security numbers (SSNs) are not the answer. Today there are very sophisticated algorithms that use a wide variety of details and extraneous data sets to match patient identities. Still, this is not perfect.
Patient identity is probably the most prone to error and arguably the most critical data field for understanding all the rest of the information. The reasons for patient identity errors are numerous:
- Women change or hyphenate their last name upon marriage or divorce.
- People use nicknames, which occasionally morph over time.
- Nicknames may bear no semblance to a given name. For example, Bob is usually a nickname for Robert, but Bubba or Sissy can be an affectionate term for any first name.
- Some people are called by their middle name instead of their first name, and few people realize that fact.
- Some cultures reverse the last name/family name and the first name/given name.
- Twins often have very similar first names along with the same date of birth, and for many years have the same address.
- Similar-sounding names may be spelled differently.
The identity of the dispensing pharmacy is seldom an issue, since data is submitted to the PMP by the dispensing pharmacy. Yet sometimes prescription records may be duplicate or nearly duplicate. It is not uncommon for a prescription to be delivered via phone, fax, or e-prescribing to a pharmacy, and the prescription will be prepared. Later, the patient chooses to pick up the prescription at a different pharmacy. Then the original prescription information will be transferred to the second pharmacy, which creates its own record of dispensing. The original pharmacy usually makes all the appropriate and legally required changes or amendments to its own record, but often fails to amend the record that has already been sent to the PMP. The result is two prescription records in the PMP, but the patient only received one prescription.
While patient, prescriber, and dispensing pharmacy are not the only sources of errors in PMP reports, they usually cause the most concern and are the most highly visible inaccuracies.
The key to evaluating PMP information is critical thinking:
- Does the information provided match or support what I already know about the person?
- If there are outliers, can I verify the accuracy of the outlier or determine that the information should be excluded?
- What does the patient say? Ask for details in an open-ended manner such as “Tell me about the visit to Dr. X on a specific date.” or “Did you see a dentist or go to an emergency room back in June?”
- Look at the prescribers. Are they local? What is their specialty? Are they associated with a major medical center or a teaching hospital? Does the patient regularly travel to other states?
It is also helpful to remember that PMP reports are tools to identify trends. The report cannot be used in isolation; it must be combined with additional information about the persons involved to properly assess the situation.
As more and more states require prescribers and dispensers of controlled substances to review a patient’s PMP report prior to prescribing or dispensing, the identification of real and potential errors is increasing. Pharmacists and their staff should be cognizant that their data is no longer maintained in a silo for their own use but is commingled with data from all pharmacies, and errors in record keeping can require labor-intensive corrections in the future. CT
Danna E. Droz, J.D., R.Ph., is the prescription monitoring program liaison for the National Association of Boards of Pharmacy in Mount Prospect, Ill. She can be reached at email@example.com.