Online prescribing or internet prescribing refers to a provider prescribing a drug to a patient based upon an interaction that has taken place online. (E-Prescribing is the act of a provider sending a prescription electronically to a pharmacy, such as through an EHR, and should not be confused with online or internet prescribing.) A concern with online prescribing is that the patient-provider relationship is solely established by an online encounter. There must be a patient-provider relationship, presumed to be established in an in-person encounter, before a prescription can be written. By having all interaction occur online, questions are raised regarding whether the provider has enough information to make an informed decision regarding treatment. Questions include whether adequate information of the patient’s health status and history has been obtained and confirmation that the patient is accurately representing himself or herself. In some states, a patient-provider relationship based solely on internet interactions is prohibited.
INTERNET PRESCRIBING BACKGROUND
In 2008, the Ryan Haight Online Pharmacy Consumer Protection Act was passed by Congress, which prohibits dispensing controlled substances via the Internet without a “valid prescription.”
For a prescription to be valid, it must be issued for a legitimate medical purpose in the usual course of professional practice, meaning that, with limited exceptions, a doctor must conduct at least one medical evaluation of the patient in person or via telemedicine.
The Act provides a definition for the “practice of telemedicine,” which would allow prescribing to take place even if there was no physical encounter if certain conditions are met. The practice of telemedicine is defined as the practice of medicine by a practitioner who is at a location remote from the patient and is communicating with the patient or health professional treating the patient via a telecommunication system so long as the patient “is being treated by, and physically located in, a hospital or clinic” or “while the patient is being treated by, and in the physical presence of, a practitioner.”
The Drug Enforcement Agency (DEA) is the federal agency responsible for enforcement of the Controlled Substance Act (CSA). Among its duties is overseeing the distribution of controlled substances over the Internet. The Ryan Haight Act of 2008 added to the CSA and placed under DEA jurisdiction controlled substances prescribed via telemedicine.
The onset of the opioid epidemic and potential for telehealth to be used to deliver aspects of Medication Assisted Therapy (MAT) (which combines behavioral therapy and medication to treat opioid use disorder) has sparked some recent interest and legislation aimed at relaxing rules on controlled substances, specifically for methadone and buprenorphine, both controlled substances that can be used in MAT to treat opioid use disorder. In the 2018 legislative session, HR 6, the Support for Patients and Communities Act was signed into law, which requires the Attorney General (AG)to promulgate final regulations to specify the limited circumstances in which a telemedicine special registration may be issued to prescribe controlled substances and the procedure for obtaining a special registration within a year of enactment. The AG was previously required to promulgate regulations related to the telemedicine special registration process under the Ryan Haight Act, but had no deadline as to when a final rule must be issued.
STATE LAW & PRESCRIBING
States maintain a large amount of control over internet prescribing. Whether a prescription can be written based solely on an internet or online interaction can be impacted in several different ways. One of the primary considerations is whether an online consultation is adequate enough to establish a patient-provider relationship when one did not exist before. Until that relationship is established, a prescription cannot be made. Other requirements that states may place on online prescribing is the need for an in-person physical examination prior to writing a prescription. CCHP provides overview information on the subject in the 50 State interactive map. State medical boards have information online regarding prescribing standards, laws and regulations.