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Policies and Procedures for the Electronic Prescribing of Controlled Substances

Brown and Toland Physicians is a multi-specialty IPA in San Francisco, CA with over 250 physician members. The IPA wished to implement electronic prescribing of controlled substances (EPCS) for all users of its EHR. It asked Sujansky & Associates to help design and operationalize a set of the policies and procedures to ensure adherence with the complex federal regulations for EPCS.

Sujansky and Associates worked with Brown and Toland to understand its specific clinical and administrative workflows and map them to the regulatory requirements for identity-proofing clinicians, issuing two-factor authentication credentials, managing access control for prescribers, and performing required auditing and reporting tasks. The resulting policies and procedures were documented in a comprehensive reference manual that now enables Brown and Toland Physicians to consistently adhere to EPCS regulatory requirements while minimizing additional administrative workload on physicians and staff.

Relevant documents:

Policy & Procedure Manual for Electronic Prescribing of Controlled Substances (PDF)
Overview of Federal Regulations for Electronic Prescribing of Controlled Substances (PDF)
Guidelines for the Electronic Prescribing of Controlled Substances (PDF)

Sujansky & Associates' role in this project included:

  • Educating the clinical, administrative, and I.T. staffs regarding the federal regulatory requirements for EPCS.

  • Analyzing the existing clinical and I.T. workflows at Brown and Toland, as well as the specific e-prescribing features and configuration of its EHR.

  • Determining the appropriate policies and procedures for operationalizing EPCS at Brown and Toland, given the local workflow, environment, and preferences.

  • Authoring a formal Policies and Procedures Manual that documented this information for reference by all Brown and Toland staff.



A comprehensive Policies and Procedures Manual was developed to help the medical group fully and consistently adhere to complex federal regulations for EPCS.

A number of options were assessed to determine the ideal form of two-factor authentication for the medical group's clinical staff and budget.

Careful analysis of existing staffing and workflow was required to identify the appropriate personnel to grant and approve clinicians' access to EPCS.