I-STOP: What You Need to Know

Lyuba Konopasek, MD Designated Institutional Official NewYork-Presbyterian Hospital

August 26, 2013

Objectives • What is I-STOP?

• Why is I-STOP necessary and how is it relevant to me?

• How do I register for an HCS account?

• How do I use the PMP database system?

• Do I need to document in the chart?

• What if I notice suspicious prescribing practices?

• How are our residents, fellows, and supervising attendings impacted?

What is I-STOP and why is it necessary?

• The I-Stop act was signed into law by Governor Cuomo in response to concerns over the abuse and diversion of controlled substances obtained via prescription.

• It goes into effect August 27, 2013.

• The new law requires all prescribers to consult the Prescription Monitoring Program (PMP) prior to prescribing Schedule II, III and IV controlled substances.

• Failure to consult the PMP may effect your current licensure or ability to get a license in the future.

Does this affect me?

• I-STOP affects EVERYONE who writes orders and prescriptions for Schedule II, III and IV controlled substances or supervises someone who writes orders and prescriptions for Schedule II, III and IV controlled substances.

• Most resident physicians are not licensed and thus, will not be able to access the PMP themselves for the next month until they are registered to do so

– a licensed provider will have to access the PMP for any unlicensed provider writing a prescription for the next month.

What is the Prescription Monitoring Program?

• The PMP registry is a tool to help enhance understanding of a patient’s controlled substance utilization, guide management, and improve quality of care.

• For questions about the PMP call: 1-866-811-7957

• The New York American College of Physicians website is also an excellent resource for more info on I-STOP and the PMP.

– http://www.nyacp.org/i4a/pages/index.cfm?pageid=3700

How do I access the PMP?

• The PMP is an application within the Health Commerce System (HCS), which is a secure online communications system operated by the NYS Department of Health.

• You must have an individual HCS account to gain access to the PMP registry.

How do I get an HCS account and access the PMP if I am a

licensed provider?

• If you do not have an HCS account, register on-line at: https://apps.health.ny.gov/pub/cgi-bin/applinks/pubforms/medprof • You will receive a form by email within a couple of hours

• The form must be notarized and mailed back

• You will then receive your HCS ID and password by mail

• If you already have an HCS account, access the PMP at:

https://commerce.health.state.ny.us

More on HCS accounts

• If you have an HCS account with an expired password, it can be reset immediately by calling (866) 811-7957

• If you are not sure if you have an HCS account, call (866) 811-7957 BEFORE applying on-line

• If you have mailed back the notarized form and have not received the final authorized form with your password and ID, call the number on the back of the notarized form you sent in and you will get immediate access

HCS Update 8/26/13

• If you have made a good faith attempt to apply for an HCS account but it has not yet been processed, you should continue prescribing controlled substances as per usual without accessing the registry

• The period between August and October is considered a transition period.

• If you do have an HCS account, you must start accessing the PMP as of August 27th, 2013.

• Please see below for additional details

– http://www.health.ny.gov/professionals/narcotic/prescription_monitoring/

How do I get an HCS account and access the PMP if I am an

unlicensed provider?

• You need to be registered for an HCS account by an NYPH HCS coordinator

– We are in the process of assigning HCS coordinator status to your Program Coordinators

• Until you have you have your own HCS account, you will need to have your supervising attending or another licensed physician access the PMP for you

• Once you have an HCS account, you will be able to access the PMP “on behalf of NYPH” and check it yourself

Some Exemptions

• You do not need to consult the PMP to order and dispense controlled substances for patients being treated in an in-patient setting but must document this exemption in the chart.

• You do not need to consult the PMP for patients being treated and discharged from the ED with a prescription for 5 days or less. This exemption does not apply to any other area of the hospital.

• The exemption of not having access to the PMP does not apply to NYP! This exemption addresses remote rural areas without appropriate IT resources. There should always be someone at NYP with access to the PMP.

How do I access the PMP?

• After logging into your HCS account, the PMP can be accessed by clicking onto the blue and white NYS PMP logo at the top of the screen.

How do I search for patients in PMP?

• Enter patient information

– First name

– Last name

– Gender

– DOB

• Review the Frequently Asked Questions within the application for further information

When should I check the PMP registry?

• The PMP must be checked no more than 24 hours before the prescription is written.

– The PMP is updated on a daily basis, so if you check it greater than 24 hours prior to checking the PMP it will not be up to date.

• The PMP must be checked for all Schedule II, III, and IV drugs when writing discharge scripts or writing scripts in the ambulatory setting.

• The PMP must also be checked when writing scripts in the ED for greater than 5 days. Again, the 5 or less rule only applies in the ED.

The PMP and HIPAA

• Information contained on the PMP is considered protected health information, therefore, only practitioners involved in the care and treatment of the patient may access the patient’s information on the PMP

– If you are looking at the PMP to assist a colleague without an HCS account this is considered participating in the care of the patient

• There is a record of all access to the PMP

Documentation in the Chart

• If you prescribe or write an order for a Schedule II, III, or IV controlled substance, you must either document that the PMP was consulted or document the relevant exemption (eg. Prescribed for 5 days or less in the ED, Order written for in-patient)

• We are working to include drop down menus for this in the EMR but these will not be functioning on August 27.

• There will be a record of your access activity in the PMP but you still must document in the chart

How do I know I need to consult the PMP?

• In Rx Writer, if you write for a Schedule II, III, or IV prescription drug, an ALERT will appear that you must consult the PMP and a link to the HCS from which you can access the PMP

• At this point there is no hard stop for consultation of the PMP

Examples of what might indicate suspicious activity on the PMP

• Multiple prescriptions for controlled substances from different providers in a short time period

• Multiple prescriptions for large numbers of controlled substances from the same provider

What do you need to report? • Suspicious activity for an individual patient

– Report to Bureau of Narcotic Enforcement by clicking button on PMP

• Suspicious activity by a physician

– Unlicensed providers do not have a duty to report but should advise their supervising physician

– Report to Bureau of Narcotic Enforcement by clicking button on PMP

– Report to OPMC • you may consult risk management in the event the suspicious

activity involves an NYP employee or medical staff member

• There is no requirement that you tell the patient or the physician that you are reporting them

If you note possible suspicious activity on the PMP…

• Go to the patient and elicit more information with open-ended questions

– “By a new state law when prescribing a controlled substance, like (name of med prescribing), I needed to consult the Prescription Monitoring System and noticed that (…) Can you please tell me about that?”

• If the history is indicative of a substance abuse problem, consult Social Work as well as reporting it via the PMP

• If the history is indicative of possible criminal activity, report it via the PMP

If you are a resident…

• Be sure to consult with your supervising attending prior to reporting suspicious activity through the PMP

• If you are an unlicensed resident and do not yet have an HCS account, you can still write scripts under the institutional DEA but you must have a licensed physician with an HCS account check the PMP and you need to document this

– “PMP checked by….”

• During the transition period from August to October if your supervising physician does not have an account, you may continue prescribing controlled substances as per usual without accessing the registry.

If you are a supervising physician…

• If unlicensed, your resident will likely not have access to the HCS account for the next month while they are registered

• If your resident needs to write a script for a controlled substance for your patient, please access the PMP and let the resident know so that they can document that the PMP has been consulted

• If you do not have an HCS account, let the resident know so that they can document it

• Once the resident has an HCS account, they can consult the PMP “on behalf of NYPH”

Should this effect the scope of my practice?

• Your clinical decision making should not be effected by I-STOP

– You should never fail to treat a patient’s pain because of this new program

• For example, even if you suspect that a hospitalized patient is abusing you should still prescribe appropriate therapy and treat their pain, as well as reporting them to the PMP

– In fact, you may need to write for a higher dose to treat their pain adequately

Questions?

• GME:

– Lyuba Konopasek Lyk2003@nyp.org

• Columbia campus:

– John Evanko evankoj@nyp.org

• Weill Cornell campus:

– Ralph Slepian ras2009@med.cornell.edu

• Ambulatory Care Network:

– Steven Kaplan stk2002@nyp.org