Web prescribing: How to set the standards

The AMA has guidelines that make clear the way to prescribe online.

Editorial. Sept. 1, 2003.

The reputation of Internet prescribing is often framed in terms of the seemingly endless number of shady sites ready to ship drugs in return for little more than a credit card number and the click of a mouse.

It shouldn't be this way. Internet prescribing can be an effective tool for physicians and a worthwhile service to patients, but there must be proper standards. With that in mind, the American Medical Association House of Delegates recently approved a report that offers guidance to physicians in how to handle Internet prescribing. The guidance covers not only online interactions with patients, but also online interactions with pharmacies.

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The guidance stands in sharp contrast to the actions of the disreputable sites on the Web, which operate on the basis of sham exams, anonymous doctors and other practices that are at odds with responsible prescribing. It is clearly in the interest, and the purview, of the medical community to establish the rules of physician conduct, advising doctors on good uses of the Web while medical boards and others try to root out the bad.

A central idea behind the guidance, based on recommendations from the AMA Council on Medical Service, is the same notion that the Association and others have propagated since Internet prescribing first emerged: No physician should prescribe any drug to a patient whom that physician has not examined. As with any prescription, it should be provided in the course of treatment to a patient whom a physician has seen, has discussed treatment options and risks with and, as necessary, will then be followed up to assess the therapeutic outcome. Doing otherwise carries the direct risk of conduct that is unprofessional and outright dangerous.

Medical boards are getting more aggressive about disciplining physicians who prescribe blindly. Witness California, which fined out-of-state physicians who prescribed to patients in that state, whom they had never seen.

There are exceptions within the context of accepted medical practice: treatment provided in consultation with another physician who has an ongoing relationship with a patient and will oversee that patient's treatment, or on-call or cross-call coverage where a physician has access to a patient's medical record.

In any case, the guidelines point out that physicians prescribing online should be licensed in the states where their patients live, unless the patient's state allows electronic prescriptions from out-of-state doctors.

The guidance also stresses that physicians send prescriptions, whether directly to the patient or to the patient's pharmacy, over a secure network, meaning there are provisions for password protection, encryption or authentication techniques similar to the AMA Internet ID. It's sensible to ensure that both parties on the end of the e-mail line are who they say they are. And with HIPAA electronic transaction standards a reality, ensuring patient privacy is more than sensible -- it's a legal must.

The guidance also declares that any electronic prescription should be a part of the patient's medical record. And it says that a physician who prescribes via a Web site should disclose physician-identifying information, including about everything except license and DEA numbers.

These guidelines are not meant to push physicians to prescribe online. That's an individual doctor's decision. But they do give physicians interested in using the Internet a framework to ensure that the technology works to serve and to protect both doctor and patient. The guidelines also are a warning, stating that physicians "may increase liability exposure by prescribing medications solely through online interactions."

Shady pill-pushers should not define the practice of Web prescribing.

These guidelines provide timely and practical advice on the way it should be done.