“A Penny for Your Thoughts”-or What Would Rod Serling Say About E-prescribing?

October 24, 2016

What does mandated electronic prescribing have to do with that old show, Twilight Zone?

[[{"type":"media","view_mode":"media_crop","fid":"53119","attributes":{"alt":"","class":"media-image","id":"media_crop_1870143955841","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6614","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]Ever since New York State mandated electronic prescribing, I have had flashbacks of a 1961 Twilight Zone episode, “A Penny for Your Thoughts.” In 25 minutes, the TV show traced the events that transpired in a day in the life of a shy and self-effacing bank clerk. He was too meek and mild to ask his boss for a raise. He could not approach the coworker he wanted to date-until he gained temporary telepathic powers because the nickel he paid for his morning newspaper landed on its side.

When the nickel stood upright, the clerk could hear unspoken thoughts of those around him. The secret yearnings of the woman he admired from afar and the daydreams of a rival at work became transparent. The women’s thoughts inspired him to ask for a raise-and to ask her out.

His newfound powers persisted until he accidentally knocked the nickel down on his way home from work. As he tossed another coin into the news seller’s bin, to purchase the newspaper’s evening edition, his telepathic abilities vanished as magically as they had started. The upright nickel had opened the window to another dimension . . . and now that window had closed.

My e-prescribing program, mandated as of March 27, 2016, also allows me to see unspoken thoughts-and acts-concerning my patients’ prescription histories, and much more. Like the protagonist in Rod Serling’s television show, I am intrigued-but also chagrined-to find information that was left unsaid.

"My e-prescribing program, mandated as of March 27, 2016, also allows me to see unspoken thoughts."

E-prescribing was in the incubator since 2013, when the I-STOP law went into effect. I-STOP requires prescribers to check the PMP (prescription monitoring program) before prescribing controlled medications. Organized psychiatry initially objected to adding benzodiazepines and stimulants (the controlled medications that psychiatrists are most likely to prescribe) to I-STOP regulations, arguing that the initiative purported to stem the raging opioid epidemic. Some psychiatrists secretly celebrated the amped-up PMP database that replaced the anemic prescription registry of the past.

It was no surprise that I-STOP revealed some irregularities, even for those of us who pride ourselves on knowing our patients, reviewing old records, and phoning pharmacists directly when needed. Some “irregularities” that came to the surface were hurtful-yet ultimately helpful. Seeing that a longtime patient surreptitiously filled short-acting scheduled sleeping aids from 6 other physicians was painful, especially after she supposedly confided her innermost secrets and the details of her divorce. In the long run, however, this revelation probably saved her life, making I-STOP a success-even if the issue was not opioids.

There are many I-STOP stories to tell, but most are not so sentimental. I will not tell those stories now, because I-STOP did not rattle me as much as the revelations that came by way of Surescripts. Surescripts accesses almost all prescriptions, not only controlled prescriptions. It lists names and doses of medications, names and degrees of prescribers, and the names of pharmacies that filled them and when. E-prescribing adds another dimension to I-STOP, which can be gamed by patients who misspell their names, provide false dates of birth, or fill prescriptions in another state. Some pharmacies are not always efficient when entering required data into I-STOP, but virtually all pharmacies keep track of their “claims.” Mail-order pharmacies, discount pharmacies, and cash purchases do not necessarily show up on the Surescripts clearing house that supplies data to electronic databases and pharmacy benefit plans.

E-prescribing data are humbling, if nothing else, because they show how little we really know about our patients, in spite of our best efforts-and because they suggest that our hubris is often undeserved.

In one instance, a new patient assured me that she had never seen a psychiatrist before. She emphasized how hard she worked to muster her courage to make an appointment, given her culture’s disapproval of psychiatric care. (In hindsight, it was an example of “the lady doth protest too much.”)

Yet when I registered her in the electronic prescription database and clicked on the “claims” button that shows prescriptions written by other physicians, I recognized the names of 4 different psychiatrists who prescribed her antidepressants in the past few months. The prescriptions were innocuous-compared to the opioids that interest the PMP-but it’s not just the prescription, it’s the principle.

Another young man listed “0” for alcohol intake on his intake form. He confirmed that he did not drink, not now or in the past. Knowing that there is often a reason for zero alcohol use-medical, religious, an aversion because of parental alcohol use, or avoidance because of past alcohol problems-I asked more. He elaborated, stating that he never drank because his father had such serious alcohol issues. As for him, he just needed something “mild” for sleep and anxiety-but no benzodiazepines, which could be addicting, he said. I was not one to argue with such a request, and so we agreed on gabapentin.

To my amazement, he had prescriptions galore for gabapentin in the database, along with claims for disulfiram, naltrexone, and acamprosate-and not just one prescription, but a year’s worth-prescribed by a well-known addiction subspecialist from an equally well-known alcohol program. Looking perplexed, I printed the page from the e-program, handed it to him, and asked him how this could be. The patient then recanted his original history and said that he did not want to take chances, given his family history. And that was the reason why he got repeated prescriptions to prevent alcohol use.

Another time, a pop-up refill request appeared on my “dashboard”-with the name of a patient who had terminated treatment a year earlier, when she returned to her home country after losing her job and her J-1 visa. Again, this medication was not controlled and not known to be misused. It was too inexpensive to merit any resale value. The refill might have flown under the radar, had I not remembered the patient and wondered what happened after she returned to her war-torn country.

Expecting everyone to remember everything is unrealistic, and not necessary with newer technology.

At her last appointment, she received a 90-day prescription to tide her over until she found local treatment. I closed her paper chart in my office. Her electronic prescription “chart” showed that the same medication had been refilled monthly for an entire year. I called the pharmacist, who said that someone telephoned refill requests every 90 days for the past year. I knew it was not me-and the pharmacist knew that she did not enter refill requests that bore initials of a long-gone pharmacist. Mysterious.

Not every revelation was so disheartening, and some unexpected findings improved clinical care (at the same time that they instilled skepticism). On more than a few occasions, unmentioned prescriptions for thyroid medications appeared in the database of an anxious patient. Knowing that my initial intakes cover all medications and all medical conditions-and not only psychiatric or substance-related conditions-I asked the patient how we missed this medication. She said that she did not deem it important enough to mention, since she did not expect a psychiatrist to prescribe those medications. In return, I explained how excessive thyroid medications can induce anxiety-and how important it is to review labs and adjust thyroid replacements before resorting to her requested antianxiety medications.

More and more often, I see prescriptions for prednisone in the database, typically for someone who complains of mood instability but sometimes from patients who present with depression. Seeing evidence of on-off treatment with steroids is critical data when deciding on treatment for mood disorders-yet, typically, patients do not mention treatments prescribed by popular walk-in clinics because they seemed “insignificant” or because they simply forgot about this single quick visit.

In one case, a tearful new patient bemoaned his “worst depression ever”-but was relieved when I pointed out a month’s worth of steroid medication, which went unmentioned because treatment ended. The steroid dose was substantial, but it was lowered quickly, shortly before his psychiatric symptoms worsened. To date, no one who entered my office since the e-prescribing law went into effect has admitted knowledge about the mood-altering effects of corticosteroids. In contrast, psychiatrists are well aware of steroid-induced psychosis and of less dramatic mood and energy changes that accompany starting and stopping steroid use. Getting this history is essential to good treatment. Expecting everyone to remember everything is unrealistic, and not necessary with newer technology.

So where does this 1961 Twilight Zone episode mentioned above come into play? Let me explain.

When the Twilight Zone aired in 1961, psychiatrists-and society-were infatuated with Freud. We lionized insight and intuition. Today’s evidence-based medicine and data-driven decisions were not on the radar. Contemporary electronic databases and I-STOP remind us that “insight” and intuition cannot compete with cold hard facts-and that psychiatrists’ oracle-like abilities, once mythologized in movies, are little more than myths. That switch in values is insulting to many psychiatrists (and perhaps to other physicians), because it overrides belief systems that were once inculcated into budding psychiatrists.

Psychiatrists are well aware of steroid-induced psychosis and of less dramatic mood and energy changes that accompany starting and stopping steroid use.

Speaking of changing times, as I was writing this article, an electronic newsletter arrived in my inbox, decked with screen shots and memorable quotes from several decades of television medical shows. The goal was to demonstrate shifts in depictions of doctors. Drs. Kildare, Casey, Welby, and Quincy were earlier entries, all vestiges of the days when screen media romanticized MDs.

How well I remembered Ben Casey, the earnest neurosurgical resident who probed patients’ psychological reactions as thoroughly as their cerebral cortex. Ben Casey fretted about everyone and everything and had the furrowed brow to prove it. Dr. House arrived much later. A troubled medical character who developed an opiate dependency, House’s most memorable quote is “Everybody lies.”

Dr. House’s cynical quip certainly sums up the secrets revealed by Surescripts. Suddenly, I realized why I was so shocked: I was stuck in the Ben Casey stage (which premiered in 1961, when “A Penny for Your Thoughts” aired). Times had changed. I kept current with journal reading and CME-but I had fallen behind on small screen media, which could have prepared me for dark secrets revealed by Surescripts.

To compensate for my media lapses, I clicked on my Netflix subscription. Netflix recommended Person of Interest for me. I clicked again, and, lo and behold, the series revolves around a secret machine that monitors our every move-and deliberate the morality of such electronic omniscience, which can be used for good or bad. Eerie, but Freud himself admitted that “poets” (screenwriters) perceive psychological insights first.