Patient privacy and the security of electronic data remain key issues in the ongoing debate over a statewide prescription drug monitoring program in Missouri, but if legislators don't pass a bill this session, county programs are poised to fill the void.
Missouri, still the only state without its own Prescription Drug Monitoring Program (PDMP), could enact a statewide version in 2017 after roughly 12 years of trying. For now, however, the operative word continues to be “could.”
As it has been in years past, a key issue is one familiar to virtually anyone with a computer, a cellphone, or the ability to stream movies or play multiplayer video games — privacy.
Two statehouse officials continue to have differing views of what constitutes privacy in a PDMP in a virtual world.
They also have their own bills: House Bill 90, known in the state Senate as Senate Bill 231, introduced by state Rep. Holly Rehder, R-Sikeston; and SB 74, sponsored by state Sen. Rob Schaaf, R-St. Joseph.
Both have tangled over the issue of a program before, sitting down in a room together two years ago in an effort to resolve differences. In order for this year to be different, change will have to come by May 30 when the state Legislature adjourns. Regardless of whether a state PDMP is enacted, however, one county is taking matters into its own hands.
HB 90 would require the state Department of Health and Senior Services (HSS) to establish and maintain a program to monitor dispensing of all Schedule 2 through Schedule 4 controlled substances; require dispensers to notify HSS within 24 hours of filling a prescription, either electronically or by paper; and let HSS contract with any other state agency or private vendor running a narcotics control program.
Known as the Narcotics Control Act, it would require collection of information about patients’ prescriptions including quantity, dosage and whether a prescription is new or a refill. The bill would also require collection of a patient’s name, address, date of birth and “identification number,” which could include but not be limited to a driver’s license number, or government or insurance ID number.
It would keep all prescription information confidential and not subject to public disclosure, with specified exceptions; and make unlawfully and knowingly accessing or disclosing private information — regardless of whether a person is authorized to handle such information — a Class E felony.
The bill, which has received its second reading in the House, would also fine dispensers $1,000 for failing to notify HSS that a prescription has been filled, or for providing incorrect information.
It would also require HSS to notify authorities if it believes the law has been violated or professional standards breached. It would keep dispensation information from being used to deny anyone the right to get or own a firearm; and allow the department to release “non-personal, general information for statistical, educational or research purposes.”
HHS could also provide data to people in and outside Missouri who are “authorized to prescribe or dispense controlled substances”; to law enforcement under subpoena; to state boards including the pharmacy board; and to people requesting their own prescription information.
Naturally, Rehder said she thinks her bill is the better choice.
“This is an extension of electronic medical records. It’s simply giving medical professionals the information they need, their patients’ histories,” Rehder told Government Technology. “What we’re trying to do is, we’re trying to recognize abuse, we’re trying to curb abuse, we’re trying to save these kids. We’ve had story after story given of divorces, of men losing their jobs, people having surgery and never getting off prescription pills."
And just as understandably, Schaaf said his bill, the Prescription Drug Monitoring Act, is the one his fellow legislators should pass to create a PDMP.
Senate Bill 74 would also empower HSS to create a PDMP, using “an existing data aggregation platform through the state data center within the office of administration” — and hold it responsible for ensuring the privacy and security of personal information.
Schaaf’s bill calls on HSS to only aggregate “necessary and appropriate information related to the prescribing or dispensing of Schedule II through Schedule IV controlled substances,” to keep that information segregated from other data sources, and to keep all prescription and dispensation information confidential with specified exceptions.
It cleared the state Senate’s Health and Pensions Committee on Thursday, Jan. 26, and has been calendared for “perfection” and printing before a third reading.
SB 74 charges HSS with keeping all prescription and dispensation information confidential with specified exceptions; and starting Aug. 28, 2019, would let the department keep prescription and dispensation information no more than 180 days before deleting it.
The bill would require prescribers — and specifically all “prescribers who hold themselves out to the public as pain management specialists” — to electronically file information with HSS on each prescription or dispensation of Schedule 2 through Schedule 4 substances. HSS would be required to pay their costs to file the information.
Like Rehder’s bill, it would hold out the possibility of letting prescribers that can’t submit information electronically do so on paper, and be funded by appropriations, but also by federal or private money.
Also like HB 90/SB 231, it would criminalize inappropriate handling and use of private medical information, making it a misdemeanor to unlawfully or knowingly access or disclose prescription or dispensation monitoring information, failing to submit such information, or submitting incorrect information.
SB 74 would also make it a felony for people who have access to private medical information to knowingly disclose it or use it in violation of the act — and give people whose information has been improperly disclosed “a private cause of action” and the potential to recover damages including liquidated damages of $25,000.
Schaaf’s bill also requires HSS to provide an annual report to the state general assembly on dispensations and fraudulent prescriptions; to implement educational courses on the act’s provisions; and to work with associations for impaired professionals to ensure the intervention, treatment and monitoring of people identified as addicted to substances monitored by the act.
The state senator said he believes his bill to be more protective of online privacy than Rehder’s legislation.
“With my bill, people would log on to a database, and all of the data would only ever be seen by a handful of people,” said Schaaf, who said he believes Missourians remain greatly concerned about keeping their personal medical information private.
“I would have bet you, if you put my bill to a vote of the people of Missouri, they would still say, ‘We don’t want our drugs on a government database,’” he added.
Rehder said privacy is a key issue for her as well, and her bill merely provides doctors, pharmacists and others with a valuable tool to use in providing medical care.
“Privacy is always a concern. Your medical history is not something you see hackers going after,” she said. “This is an extension of electronic medical records. It’s simply giving medical professionals the information they need — their patients’ histories.”
Dr. Sam Page, a St. Louis County Council member who testified Wednesday to a state Senate committee in support of Rehder’s bill, said he believes increased, albeit controlled, access is what’s needed in a statewide PDMP.
“The alternative bill that’s been offered by Sen. Schaaf limits physicians’ access to information that they need to make good decisions. It may wave the flag of privacy, but the limited access severely limits the ability of the PDMP to do any good at all,” said Page, who testified at the state capitol to the Senate Committee on Health and Pensions.
“Privacy is a flag that always goes up with any electronic medical record. We go to great pains to secure the information, and PDMPs have a great track record of privacy in the U.S. Most of the questions about privacy have been about what might happen, with no good evidence that a PDMP isn’t secure,” Page added. “The people who have access to medical information are medical professionals who are used to dealing with it. It’s not that different than looking at your chart in a hospital."
Schaaf questioned whether, at its core, the issue isn’t just “a power thing.”
“It’s the people who run the PDMPs are more concerned about having the, you know, the access to the data … than they are actually stopping deaths from opioids,” he said. “The thing is, if you really want to stop deaths from opioid abuse, you’ve got to get doctors not to put people on prescription opioids longer than the recommended [duration], and you’ve got to get them to take people off them when they’re not working."
The opioid epidemic continues to be an issue of high concern and some debate nationwide even in states with their own PDMPs. At least two governors — Bill Walker of Alaska and Nathan Deal of Georgia — called on their legislators to strengthen existing PDMPs in their State of the State addresses.
And in Missouri, the drive for PDMPs has become localized with St. Louis County — joined by six member areas — beginning its own PDMP later this year.
Sarah Patrick, deputy director for St. Louis County's Department of Public Health, confirmed the county will have its own program up and running during the second quarter of 2017, at a cost of roughly $320,000.
Technology provider Appriss Inc., a major provider for PDMPs nationwide, will stand up St. Louis County's program, after a position paper on heroin and opioid deaths last year documented the opioid effort and recommended multiple steps including launching such an effort.
Member areas — county-level jurisdictions elsewhere in the state — will pay St. Louis County $7 per registered user to join, including physicians, physicians assistants, dentists and pharmacists.
Reporting parties and members of the medical community wanting to access information will have to conclusively prove they are who they say they are. Members of the law enforcement community wanting to access information will have to be working on an active case and have a subpoena.
Adding a further layer, Appriss will have the ability to track all reported information, Patrick said.
"There have been rumors that there are all these people looking at data and that’s just not true. We’re very comfortable with the system that was picked and how we will be able to protect the privacy of individuals," Patrick said. "I guess one of the benefits of being last is that a lot of these problems have been worked out elsewhere."
By year's end, Page estimated a “great portion” of the state could be covered by the county program — that is, unless it’s also covered by a statewide PDMP.
“I think we’ve got more momentum than we’ve had in the past, and bill sponsors in the House and Senate are strong leaders. But it’s competing with a lot of other ideas and has a lot of other pieces of legislation, and the session ends in May,” Page said of a statewide PDMP's chances.
In the wake of Gov. Eric Greitens' recent announcement of more than $146 million in state budget cuts, Patrick agreed it's possible a statewide PDMP may not happen ... again.
"That’s not usually a good indication of expansion to new programs," Patrick said.