Mandatory use of NC CSRS

In this episode of MedBoard Matters, host, Jean Fisher Brinkley reviews the STOP Act requirement to check the NC Controlled Substances Reporting System (NC CSRS) before prescribing certain controlled substances which go in effect July 7, 2021.  Jean also talks with Stephanie Johnson, Manager of the PDMP Utilization Project for NC CSRS about recent updates to the system and the ease of practice integration through EHR systems. 

See all of the resources referenced in the episode here.

Host: Jean Fisher Brinkley
Guest: Stephanie Johnson
Producer: Sylvia French-Hodges

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Email your questions to: podcast@ncmedboard.org.

Transcript

Episode 11 – Mandatory Use of NC CSRS

Intro music: 0:00  

Podcast Introduction: 0:08
JFB: It’s been almost four years since the North Carolina General Assembly passed the STOP Act of 2017. The law imposed a whole host of new requirements related to opioid prescribing, which have all gone into effect over the past few years. All, that is, but one. I’m Jean Fisher Brinkley and this is MedBoard Matters. Thank you for joining me. On this episode we are talking about that final provision – the so-called “mandatory use” provision. It goes into effect on July 7. As of that date, controlled substances prescribers must check a patient’s 12-month prescription history before writing a new script for any Schedule II or Schedule III opioid or narcotic. These two schedules include painkillers such as OxyContin, Percocet and Vicodin. The STOP Act aims to prevent inappropriate or excessive prescribing by making the prescriber check a database that lets them see what other controlled substances the patient may already be taking. It’s known as the Controlled Substances Reporting System, or CSRS. Now, CSRS has been around for a while and to be honest medical professionals have mixed feelings about it. Most prescribers acknowledge that knowing what other controlled substances their patient is receiving, and who prescribed them, is useful. But many CSRS users find the system too cumbersome, and say it simply slows them down too much. Complaints of this sort are frankly why it has taken four years for the mandatory use provision to go into effect. It was written right into the STOP Act that mandatory use of CSRS could not be required until the state Department of Health and Human Services made system upgrades. And that’s just what NC DHHS has been working for the past few years. You’ll hear about some of the improvements a little later in the episode. But first, a little CSRS 101 for those of you who may need a refresher.

NC CSRS Review: 2:01
JFB: NC CSRS was authorized by a 2005 state law and the system launched in 2007. Basically, it’s a database of all controlled substances dispensed in outpatient pharmacies across North Carolina. When a pharmacy dispenses a prescription to a patient, the pharmacy sends patient’s name, the drug received, the dose and quantity of pills and the name of the prescriber to CSRS. Pharmacies are encouraged under the law to report this information within 24 hours of dispensing the prescription. That’s how NC CSRS gets the information. When a patient visits a medical professional and controlled substances are considered as a treatment option, the prescriber can look up that patient’s prescription history to see what other controlled substances they have received recently, and from who. The medical professional can use information in the database to assess whether prescribing controlled substances is advisable. For example, if the patient is taking benzodiazepines prescribers generally try to avoid prescribing opioids or narcotics, because taking them together can increase the patient’s risk of overdose. Another scenario could involve a patient who is getting controlled substances from multiple prescribers, which could raise concerns about drug seeking and doctor shopping. The point is for the prescriber to have this information before he or she issues a prescription for controlled substances so they can avoid inappropriate or excessive prescribing. While we are on the topic of doctor shopping, I want to pause and note that CSRS was established as a tool to help clinicians improve quality of care. They can do this again by avoiding inappropriate prescribing and also by intervening to offer substance abuse treatment to patients who need it. CSRS distributes a dos and don’ts flyer that urges prescribers not to use CSRS data to exclude a patient from care, to dismiss a patient from the practice without a referral for treatment, or to report suspected doctor shoppers to the police if CSRS is their only source of information. In the dos column, CSRS advises prescribers to discuss any findings with the patient and asks prescribers to give patients who say CSRS is in error, the benefit of the doubt. Errors happen. CSRS advises contacting the dispensing pharmacy to verify prescription information directly. If that doesn’t resolve the issue email: nccsrs@dhhs.nc.gov. One last tidbit I’d like to share is that while NC CSRS started by providing information only about controlled substances dispensed in North Carolina, it has grown over the years. Today NC CSRS is integrated with 42 other states and the Federal VA system so users can tailor their searched accordingly to see if medications are being obtained outside of North Carolina pharmacies. 

Interview with Stephanie Johnson: 5:00
JFB: I recently had the opportunity to speak with Stephanie Johnson with the North Carolina Controlled Substance Reporting System. Stephanie is manager of the PDMP utilization project for CSRS. Basically, she is in charge of making sure pharmacies and prescribers know how to use the system correctly. I learned a lot about the system upgrades and how they make CSRS faster and easier to use and I hope you will too. One note, Stephanie mentioned several resources including email addresses and websites. You’ll find all of that information on the episode 11 show page which you can visit at www.ncmedboard.org/podcast.

JFB: Stephanie, thank you so much for joining me. I greatly appreciate you taking the time.

SJ: Thank you, thanks for having me. 

JFB: Of course. So, as we've been discussing on the podcast so far, mandatory use goes in effect July 7th. While many prescribers are no doubt already using NCCS Rs, some are not. Let's talk about how a prescriber can get started.

SJ: Absolutely. So, there are two different ways that a prescriber can use the CSRS. So, the 1st way is going to be through PMP aware web portal and then the 2nd way is going to be through the electronic health record integration. So, the state has made it really easy to register and is currently covering the cost of integration for the electronic health record systems via the CSR Gateway.

JFB: OK. That’s great!

SJ: So yeah, so it's a wonderful incentive that they have that will make the prescribers life easier for sure. We can talk about that here in a second on how that works and really about that speed. So, if your practice is not yet integrated, there are a few steps to get the ball rolling. So, first there needs to be the administrative decision maker filling out what we call the integration request form. And then there is an NC prescriber list form. From there…there is also a licensee questionnaire and then just a terms and conditions form. So, in total there are just going to be 4 documents that need to be completed to begin the process of integration. So, we also have provided those links. I believe you said that you're going to be able to share them, so that's going to be…perfect, so that's going to be a fantastic way. Quick and easy click links, right? So, that's always helpful and then some information on kind of how we will be able to assist you during that integration process. How to set it up in general and then further using it as a clinical tool.

JFB: OK, now can you just pause, and I have to admit, I hadn't really thought about the EHR integration piece, so can you? Who is that for? I guess I've as I think about this issue, I think mostly about an individual prescriber registering for access and then using the system. So, are there different pathways for people to use?

SJ: Great question, yes.

JFB: OK.

SJ: Yes. So, you can log in individually through the PMP aware web portal and then perform those searches. You can absolutely do that. It is more cumbersome, and it does take a longer amount of time. So, if…if the hospital systems or the practice has their EHR integrated through our gateway then it is a lot quicker. A lot easier to access. And then yeah, and it's…it's a wonderful tool to make it as seamless as possible.

JFB: Wonderful. OK, so, that would definitely be something you know if hopefully if you practice in a hospital based setting, you know hospitals are communicating with their prescribers about this. But it sounds like you know anyone with EHR could qualify for this integration could and participate that way.  Is that right? 

SJ: Essentially yes, so we are working with a company called Apris and they have done a fantastic job at integrating many…many hospital systems and larger EHR's. And just to see if your EHR is currently compatible then we can get that process going to check. Now the other way around that I can speak on a bit more and that is if you were EHR is not currently accessible by the system, then you can actually use the North Carolina HealthConnex. So, the state HIE, that is also a possibility.

JFB: OK great. Well wow! So, it sounds like there's lots of different ways in and we definitely will provide links to these resources on our podcast show page so that listeners will be able to access that because that would be important for some people. So, I imagine you know some prescribers are going to need a little help getting started. Especially solo practitioners…people in small practices, anyone who's just starting from zero is probably going to need a little help getting started running queries…just learning this system and I wondered if you could talk about some of the resources that are available in that regard?

SJ: Absolutely. So, we have developed two series of support videos and we do have them accessible on our new web page. So, the first series is up and ready to go and that is the tool that will cover how to edit your profile. How to add delegates, how to perform a search and then also how to search for your own prescribing history. Because that's going to be important, right? Being sure that your license is protected. So, it's really a great way to introduce yourself to the system and learn those basic functionalities. So, we run you all the way through that on that video series, but then we also give one on one technical assistance. Within the system once you get in and play around if you have not done that yet, there is some information on quick links that will help with the supporting documentation from the CDC. So, you'll have the overdose risk score on there also known as the NARCS Care Score and how to how to use those right? 'Cause there's a lot of numbers. So, what those numbers mean and then how to use them functionally for the best practice for that patient.

JFB: OK. So, you mentioned one on one assistance. Can you talk a little bit more about that? Because that is something that I know over the years…you know the medical board has received a number of calls and questions. It's a regular topic of inquiry for our licensees. They frequently will contact the medical board because there's not…they’re not sure who to reach out for…for assistance. Tell me about how one on one assistance is going to be available directly from CSRS.

SJ: Yeah, so that is my role…so I will be here to offer one on one technical assistance and that is accessible by just emailing us at csrs.utilization@dhhs.nc.gov. So that's another link that you'll be able to give out to licensees. And not only that, but I have been working with the North Carolina AHEC system on providing education through substances coalition groups and be able to award some CE’s for certain education opportunities. Yes, so…so far, we've delivered education to 13 counties, and I am taking requests to speaking to more. So, if prescribers are members of a coalition or if they want to get to their local health departments or health systems involved, please just send me an email and we will get that going for you and hopefully be able to get you some…some credits as well, 'cause that's always nice. Yeah.

JFB: Great. So, if you're a prescriber, in the listening audience, how would you find out about those opportunities that you just mentioned?

SJ: So, a lot of them are generally discussed within the smaller coalition groups. OK, so I know that for some of the ones that we have done, we've been also working in partnership with the Governor's Institute.

JFB: OK

SJ: So yeah, it's really just through those networking events. 

JFB: OK

SJ: But again, if you just wanted to have them email me, we can set those up and get them going.

JFB: OK, great. But also, people should probably just be keeping their ear to the ground and listening for opportunities in their communities and in their networks.

SJ: Absolutely, and we are looking at other ways that we can push out that information.

JFB: OK, now can you give some examples of the types of challenges or problems that might warrant someone contacting you and asking for one on one technical assistance? I don't know actually how many controlled substance prescribers we have, but I know that the North Carolina Medical Board licenses is more than 50,000 physicians and PA's. You’re one person. I imagine you don't want everybody emailing you, so could you give a little guidance about the types of issues that are sort of most appropriate for one on one assistance?

SJ: So, the majority of the questions for technical assistance that I have received thus far really just involves the system. So, having errors come up when they're trying to navigate through the CSRS. Things like that. We're definitely here to help on that. Yeah, and it's…it's something to where you know, more recently we've had some requests on integration. And really, how it is important throughout all of the ways that we can reach the systems. So, it's interesting because as of our last count, the PDMP is integrated with actually 42 other states as well as the VA and other federal health systems, and that can bring in some differences, right? So, we have had some questions about those type of searches. With the country's population being more transient than in the past, this level of reach has been extraordinary for the continuity of patient prescription case management. But that also applies to search history, so if you're having questions on searching, if you're having questions on delegate searching, then that is what that technical assistance for one on one can be for. 

JFB: Stephanie, you mentioned early on the difference between a practice that's integrated and a practice that's not integrated. I wonder if you could talk a little bit more about that just so that our listeners understand what group they are in and what the implications are?

SJ: Yeah, I can definitely do that, and I think what is most important to take away from…from this question is that being integrated into the system has its advantages. So first and foremost, the biggest advantage of being integrated in with the system through the gateway is that the latest study for patients search time for those that are integrated is only three seconds. Versus a non-integrated search time that would take around 4 minutes. So yes, that's a huge difference, and that plays a part into delegates, right? So, 4 minutes is a long time, especially you know if you're in a tight time frame for that one, on one with the patient, right? So, when we're talking about delegates, delegates can search for you. What is important to know about that is that delegates. So, the other good thing about being integrated into the system is that you don't need delegates to perform the searches for you. So not only is it faster,  perform the search via the web portal and then be able to attach it to a note. So, it just saves even more time not only for the prescriber, but then for the office as a whole so that you can focus more on direct patient care. So again, integrating into the CSR Search with your electronic health record system completely eliminates the need for delegates to search on your behalf, so integrating automatically requests the search and delivers the link to the report straight into the patient's record.

JFB: Wow, that's great! Now,  I feel compelled, though, to sort of pause and talk about delegates because, you know, as I mentioned, you know the medical board...this is a requirement that has been known to our licensees for going on for years now…since the Stop Act was passed. So, the medical board has been encouraging its licensees to go ahead and register and learn the system so that they would be ready. And one of the techniques or strategies that we've been recommending in order to manage the workflow of this, is we've been telling people, don't forget about delegate accounts. So, we've actually been encouraging people to use delegates, but it sounds like with the system upgrades, integration is actually the better option. Is that right?

SJ: Yeah, that's a great point. So, let me talk a little bit about the history of delegates, and where they still would be important.

JFB:  OK

SJ: So, the CSRS began allowing delegate accounts in 2014 where an already approved user could delegate the task of running queries to someone else in the office, right? So, that's typically going to be the RNS, medical assistant, things of that nature. They are labeled in the system as non-licensed, so that's also important to note when you're looking at the supervision aspect. But delegates must register  through the CSRS website, and they must be assigned to a specific prescriber. So, they need to have their own individual username and password, and definitely there is never a scenario where a prescriber would share their username or password for a delegate. Yeah, so there was…it was my understanding, there were some concerns with that, but as of right now those delegates can use the web portal to do patient…patient searches. And then attach them to the notes, right? So, if a practice or a prescriber is not integrated into the system where it is done automatically, like I just discussed, then yes, the delegates would still need to go in and enter it in through the web portal because they don't have that immediate access to the EHR's. So, in those instances, if you are not integrated into the system, then yeah, definitely using delegates to enter in that information will cut down drastically on the speed that you're able to deliver on that one on one patient interaction.

JFB: OK, it's almost, you almost need a decision tree. You know, just sort of be like is this your situation? If this then that. Is this information covered in the resources that CSRS has prepared?

SJ: A lot of them are, yes. I do have a link to…there's a user guide that will help the prescriber know like when those delegates can be used and like how to manage them on your dashboard because that is going to be big so, being sure that your dashboard is up to date with the delegates that you have allocated that responsibility to.

JFB: OK, great. Well Stephanie, that's all I had for you. I always like to ask, you know, is there anything else that I have not asked you that you would like to add?

SJ: I think we cover it up quite a bit and just thank you again for the time. And again, if anyone would like more information, uh, you know I am available. We can do one on one. We can do small practice groups as well as larger coalition groups, so just let me know and we will be here to help however we can.

JFB: That's marvelous. Well thank you very much for joining me and for the work that you're doing to support controlled substances for scribers.

SJ: Thank you Jean.

Resources and wrap up: 20:32
JFB: Again, you can find links to the resources Stephanie mentioned on the podcast show page by visiting www.ncmedboard.org/podcast. Another useful resource is the North Carolina Medical Board’s CSRS page, which you can find at www.ncmedboard.org/NCCSRS. We’ll go ahead and link to it from the show page as well. 

Conclusion: 21:05
JFB: That brings us to the end of this episode of MedBoard Matters. I hope you found the information helpful. If you did, consider telling your friends and colleagues about our podcast or share this episode with them. And remember, your comments, questions and suggestions are always welcome. If you are a controlled substances prescriber, we would especially love to hear from you. Where are you with efforts to integrate mandatory use into your patient care? What have been the biggest challenges? If it’s working well for you, what tips and tricks can you share with your colleagues. Let me know. Email me at podcast@ncmedboard.org. This is Jean Fisher Brinkley. I hope you will join me again.