October 2014

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Comments

Norman Yee

I also received the sample secure rx paper yesterday. Nice idea and is a product extension of their rx pads. My 2 most immediate thoughts were too expensive and too difficult to use different paper trays for my in-room printers (1 for rx, 1 for all the other stuff I print).

Currently, I print my rx from my EMR and sign with blue ink. This makes it less likely that someone will easily copy it. True that they can scan and print in colour, or colour copy, but that shows some level of determination that we are not going to get around. Even with the secure rx paper, someone could just use regular paper and print off an rx saying that the doc said to say he ran out of the usual secure paper. In fact, the determined fraudster can just copy, print, fax, call the rx's into whichever pharmacy with very little challenge. Fortunately, this doesn't happen very often in established practises where we have a better 'feel' of our patients and the usual pharmacists are familiar with us and the patients.

Security should be improved with electronic rx networks, but we can't even do digital signatures at this time due to yet-to-be-updated federal legislative restriction.

Anyway, I happily trudge along with our current system of print and sign. There's not enough problems around here to change the fantastic convenience and organization of using an electronic database.

Norm

stephen

The unique identifier on the e-Rx takes our EMR rxs one security step further than we had in the paper world.
To date we have had one attempt to counterfeit our e-Rx that we know of compared to many in the paper world.
The printers we use serve multiple output purposes and separate trays / printers is not desirable. We must keep it simple.
The paper world has not gone to great lengths to secure Rxs.
As we encourage others to utilize EMR let's be careful not to build obstacles, especially ones that we haven't brought forward in the paper world.

Peter Hutten-Czapski

Unique identifiers (serial numbers) are a good idea but the pharmacist has no way of checking on his end and you can do better. The route I have gone for narcotics and restricted drugs (Ritalin)is to have the default perscription typed as "Tylenol #3 S: one or two q 4h prn pain M:40(fourty) **to be valid the perscriber has to rewrite details by hand**" and I scrawl T3#40, circling the fourty and sign my name in a non standard colour ink that is not sold locally and I control in the office. Less work than custom paper, clarity of typing, and no counterfits that our pharmacists have caught yet after 5 years on the system. Yes a colour photocopy would be close, but it would lack the ballpoint indent.

Alan Brookstone

Reading through the comments, it appears that physicians adopt a very practical approach towards prescription fraud for scheduled drugs in terms of writing the prescriptions by hand, using blue ink,indenting the paper etc. Until one has a single integrated electronic network with electronic signatures and workflows that are designed for electronic prescribing, it appears that we will be living in a hybrid setting. Printing some prescriptions via EMR and filling out triplicate or duplicate pads by hand.

In British Columbia, we have a duplicate prescription program for scheduled drugs that is administered by the College of Physicians and Surgeons. All of the pads are numbered and traceable back to the ordering physician.

Some of the resistance to using counterfeit-resistant computer paper is simply a matter of practicality. At this time, in BC it is required that all physicians prescribe scheduled drugs using the official prescription pad provided by the College. I believe this applies in other provinces that require these programs. Most printers in doctor's offices would not be multitray printers, meaning that a physician would need to store the paper in a separate location (drawer perhaps - likely need to be locked for security) and change the paper when printing a scheduled drug. Or alternatively if the counterfeit resistant paper was left in the printer, it would potentially be subject to theft. This is an issue that currently adds an additional level of complexity to the use of paper on a routine basis.

There is no doubt that the trend towards more stringent control of scheduled drugs is something that is going to become more prevalent in provinces/territories in Canada as well as in the US states. Unless there is some creative thinking regarding the process, physicians will be stuck with doing some prescribing electronically and then reaching into a cabinet to hand-write the scheduled prescriptions on counterfeit resistant pads.

Alan Brookstone

The following examples of prescription fraud were forwarded to me by RxSecurity:

One Ontario clinic explained that one of their patients didn’t just make a copy of a prescription, but made their own pad from photocopies of the clinic’s script;

A hospital from B.C. communicated that they have at least one attempt a week (that they know of) to make changes to prescriptions that have been written by their physicians;

A Saskatchewan doctor stated that they didn’t think that prescription drug abuse was an issue in their area until a particularly vigilant drugstore from a neighbouring town started calling. Patients had been going to other pharmacies with photocopied scripts;

An Ontario practice stated: "We had no idea that patients were abusing prescriptions from this office until we got a call from the local police. Multiple copies of a script were located along with a large stash of prescription medication, a patient had been copying, filling and selling prescription medication over the course of several months."

Krzysztof Wierzchoslawski, Miramichi, NB

I use Nightingale as my primary EMR, it is run on the tablet PC so I can sign each Rx seperatly and send via Fax, I use HP 3015 combined with jetdirect HP ew2400 and this goes wirelessly to Patient's pharmacy of choice, as well same system is used for most of my requisitions and consults.

Kris W

Alan Brookstone

This is a research letter published in the electronic version of CMAJ entitled "Changes in illicit opioid use across Canada". To read the article, go to:

Link: Changes in illicit opioid use across Canada -- Fischer et al. 175 (11): 1385 -- Canadian Medical Association Journal.

Jack Behrmann

I have a semi-electronic medical record in my office. This is a self designed system. Over the past year I have been faxing prescriptions directly to the pharmacies. The requirement of the College of pharmacists of British Columbia is that a unique identifier be placed on each prescription that is faxed. This should not been known to my office staff want toanyone else. It has to be changed every three to four months. In addition to that I also put a serial number on the prescription. With each prescription I send a cover page to the pharmacy notifying them of the latest unique identifier. If someone calls my office to authenticate the prescription they speak to me and I can confirm the unique identifier. This makes it impossible for anyone else but myself to fax the prescription to the drugstore. Over the past year I have not had any problems in this regard. In the office I simply print out a prescription and sign it. The prescriptions that are printed in my office do not have the unique identifier on it.

Jack Behrmann

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