Joint Commission Clarifies Leadership Responsibilities for Providing Access to Prescription Drug Monitoring Program (PDMP) Databases

PUBLISHED: Jul 29, 2019
Relevant to: Ambulatory Care, Hospitals, Office-Based Surgery

The Joint Commission has issued a Frequently Asked Question (FAQ) providing clarification on the responsibilities of leadership in providing access to Prescription Drug Monitoring Program (PDMP) Databases.

Joint Commission standard LD.04.03.13. EP 6 requires accredited Hospital, Ambulatory Care and Office-Based Surgery organizations to facilitates practitioner and pharmacist access to the Prescription Drug Monitoring Program databases. Note: This element of performance is only applicable in states that have a fully functioning Prescription Drug Monitoring Program (PDMP).

According to TJC, “facilitating access to the PDMP…” is demonstrated through an implemented process that provides both ease of access and consistent access to the PDMP. Some examples provided by TJC include:

  • Embedding links into electronic health records
  • Providing shortcuts on computer desktops
  • Providing education on how to access the PDMP
  • For states that required PDMP access before discharge, creating prompts in the electronic health record (when state law requires accessing before hospital discharge).

TJC further clarifies that:

  • Organizations should define who is responsible for accessing the PDMP. Individuals will vary based on patient care settings
  • Each state that requires use of the PDMP will have regulations outlining the criteria for use. These state regulations must be consulted.
  • During TJC surveys, compliance will be assessed through tracer activities, interviews with staff, practitioners, pharmacists, etc.
  • TJC makes clear that, “The requirement does NOT apply to patients receiving short term opioid medications DURING the hospital encounter, unless required by State Law.”

Included with today’s notice is an example policy for pain management services.

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