Double- Doctoring
From "Practice Q&A", Mar/April 2001 Pharmacy Connection
A third party payer has phoned and requested patient information. Can I provide this information over the phone?
Pharmacists should take the utmost care to ensure patient confidentiality and be cautious about divulging information over the phone. In responding to phone requests, it is your responsibility to ensure that the party on the phone is who they claim to be. It would not be considered unreasonable to request verification before providing any information as per any third party agreement.
You will find an article by Tina Langlois, OCP Manager of Legal Services and Patient Relations Programs, on the confidentiality of patient informatin in the July/August 1997 issue of Pharmacy Connection, p. 19. Also, watch for the information on the Provincial Health Information Privacy Act in an upcoming issue. Reprinted here for your information is the Pharmacy Q&A from May/June 1998:
Under what conditions can I share patient information with a physician, another pharmacist, or some other third party?
Principle three of the Code of Ethics states:
The pharmacist preserves the confidentiality of information about individual patients acquired in the course of his or her professional practice and does not divulge this information except where authorized by the patient or required by law.
Pharmacists protect their patients by serving them in a private and confidential manner. Pharmacists do not divulge information that identifies the patient - except in instances where (in the pharmacists's professional judgement) sharing information will protect the patient or another person from harm, or where it is authorized by the patient or required by law.
When considering whether to release patient information, you must decide:
- Do I have the patient's consent? If a patient has consented to the release, directly or as part of a contractual agreement with a third party, you may release the information.
- Is the information required by law?
- Am I exercising my professional judgement to protect the patient or another from harm?
- This issue is complicated through cases of double-doctoring. Remember, it is not a crime to see more than one physician for a narcotic or controlled drug, but the patient must inform the physician that he/she has received a narcotic or controlled drug within the last 30 days.
If you are presented with a prescription and you have first-hand knowledge that the patient is double-doctoring, under certain circumstances you may release information to the prescriber. (First-hand knowledge would be if the patient filled the other prescription at your store, or if you received information from a third party, e.g., ODB DUR message.)
With this knowledge you need to decide what steps to take. Discussing the issue with the patient directly would be appropriate and the patient would then be involved with the outcome. This outcome could include calling the physcian who wrote the prescription to confirm that he/she still wishes to authorize its release.
If double-doctoring is confirmed, you may contact the Drug Control Unit or police, or discuss the issue with the patient. If a prescription is confirmed to be fraudulent, the details of this forged document may be shared with the police, physician and other pharmacists. Patient confidentiality is not an issue, since this is not a valid prescription.
Alternatively, if a prescriber calls with a prescription and asks what other medications the patient is taking to prevent an interaction, in the absence of patient consent, you must exercise professional judgement before releasing the information.
You should not release a patient's medication history to a physician who is calling to update patient records. (The physician should already have this information. ) Any time you exercise professional judgement you should document it.
A doctor has just called in a prescription for Ativan 1 mg and requested "no substitution". Can I take a verbal authority for "no substitution"?
According to the Drug Interchangeability and Dispensing Fee Act (DIDFA), Section 4, (6), (a), (b):
4. (6) Subsections (1),(2),(3), and (5) do not apply to a prescription that includes,
- in the case of a written prescription, the handwritten words "no sub", "pas de rempl", "no substitution" or "pas de remplacement"; or
- in any other case, a direction recorded by the dispenser that there be no substitution. R.S.O. 1990, c.P.23,s.4(6).
A pharmacist can accept a verbal order for no substitution as long as the appropriate documentation is recorded on the prescription. If patients request no substituion on a prescription, pharmacists should ensure that there is supporting documention.
I cannot emphasize enough the importance of documentation. In the case of interchangeable products, where there is no documentation to indicate otherwise, there is no authority to dispense the brand name.
The Act states that on a written prescription, the order for no substitution must be handwritten. Indicating no substitution in the physician's own handwriting was agreed to by the Ontario Medical Association and the College of Physician and Surgeons after dialogue with the Ontario Pharmacists' Association and the Ministry of Health, and was addressed in the April 1993 OCP Council Report.
Pharmacists are reminded to check the specific rules for no substitution on various third party plans, as other criteria may be required, e.g., adverse drug reaction reports.
