BILL ANALYSIS                                                                                                                                                                                                    �







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        |Hearing Date:August 26, 2014       |Bill No:SB                         |
        |                                   |204                                |
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                      SENATE COMMITTEE ON BUSINESS, PROFESSIONS 
                               AND ECONOMIC DEVELOPMENT
                              Senator Ted. W. Lieu, Chair
                                           

                         Bill No:        SB 204Author:Corbett
                      As Amended:June 10, 2014      Fiscal:   Yes

        
        SUBJECT:  Prescription drugs: labeling.

        SUMMARY:  Requires the Board of Pharmacy to conduct a survey of  
        pharmacists and vendors of electronic health records to gather  
        information about the utilization of, and the obstacles to, the use of  
        the Board's standardized directions for use on prescription drug  
        labels.

         NOTE  :  The Assembly amendments create a  new bill  and this measure has  
        been referred to the Committee pursuant to Senate Rule 29.10 (d) for  
        consideration.  The Committee may, by a vote of the majority, either:  
         (1) hold the bill, or (2) return the bill to the Senate floor for  
        consideration of the bill as amended in the Assembly.
        
        Existing law:
        
        1) Provides for the practice of pharmacy and the licensing and  
           regulation of pharmacies and pharmacists by the Board of Pharmacy  
           (Board) within the Department of Consumer Affairs (DCA).

        2) Specifies certain requirements regarding the dispensing and  
           furnishing of dangerous drugs and devices, and prohibits a person  
           from furnishing any dangerous drug or device except upon the  
           prescription of a physician, dentist, podiatrist, optometrist,  
           veterinarian or naturopathic doctor.  (BPC � 4059)

        1) Requires that each prescription dispensed by a pharmacist must be  
           in a container complying with state and federal law and correctly  
           labeled as specified, including:  (BPC � 4076)






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           a)   Unless otherwise ordered by the prescriber, the manufacturer's  
             trade name of the drug or the generic name and the name of the  
             manufacturer, as specified.

           b)   The directions for the use of the drug.

           c)   The name of the patient or patients.

           d)   The name of the prescriber, as specified.

           e)   The date of issue.

           f)   The name and address of the pharmacy, and prescription number  
             or other means of identifying the prescription.

           g)   The strength of the drug or drugs dispensed.

           h)   The quantity of the drug or drugs dispensed.

           i)   The expiration date of the effectiveness of the drug  
             dispensed.

           j)   The condition for which the drug was prescribed if requested  
             by the patient and the condition is indicated on the  
             prescription.

           aa)       The physical description of the dispensed medication,  
             including its color, shape, and any identification code that  
             appears on the tablets or capsules.

        2) Requires the Board to promulgate regulations on or before January  
           1, 2011, for a standardized, patient-centered, prescription drug  
           label on all prescription medication dispensed in the state. (BPC �  
           4076.5 (a))
         
        3) Requires the Board to hold public meetings statewide in order to  
           seek information on a standardized label from groups representing  
           consumers, seniors, pharmacists, the practice of pharmacy, other  
           health care professionals, and other interested parties.  (BPC �  
           4076.5 (b))

        4) Requires the Board, when considering the requirements for  
           prescription labels, to consider: (BPC � 4076.5 (c))

           a)   Medical literacy research.






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           b)   Improved directions for use.

           c)   Improved font types and sizes.

           d)   Placement of information that is patient-centered.

           e)   The needs of patients with limited English proficiency.

           f)   The needs of senior citizens.

           g)   Technology requirements necessary to implement the standards.

        This bill:

        1)Requires the Board to conduct a survey of a representative sample of  
          licensed pharmacists to determine the utilization of the  
          standardized directions in current law. 

        2)Requires the survey to  address, but not be limited to, the  
          following:

           a)   Whether the pharmacist utilizes the standardized directions;

           b)   How often the pharmacist utilizes the standardized directions;

           c)   Challenges or barriers to utilizing the standardized  
             directions; and,

           d)   Other directions utilized by the pharmacist.

        1)Requires the Board to conduct a survey of vendors that provide  
          electronic health records (EHRs) to pharmacies and prescribers to  
          determine the type of directions included in the vendor's EHR  
          programming. 

        2)Requires the survey to address, but not be limited to, the  
          following:

           a)   Whether California's standardized directions are included in  
             the vendor's EHR programming;

           b)   Challenges or barriers to utilizing the standardized  
             directions in the vendor's EHR programming; and,

           c)   Other directions utilized by the vendor in its EHR  
             programming.





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        5)Authorizes the two surveys to be conducted with other routine  
          surveys conducted by the Board during its regular course of  
          business.

        6)Requires the Board to report the findings of the two surveys at its  
          July 2016 meeting and publish the findings on its Internet Web site,  
          as specified.

        7)Repeals the above provisions on January 1, 2020.
        
        FISCAL EFFECT:  This bill is keyed "fiscal" by Legislative Counsel.   
        According to the Assembly Committee on Appropriations analysis dated  
        July 2, 2014, this bill will result in $50,000 in estimated costs to  
        the Contingent Fund of the Board to contract for the mandated surveys.
        
        COMMENTS:
        
        1. Purpose.  This bill is sponsored by the  California Pan-Ethnic  
           Health Network (CPEHN)  .  The Author states that according to the  
           U.S. Pharmacopeial Convention, the main cause for medication errors  
           and patient misunderstanding is a lack of universal standards.  The  
           Author notes that in 2010, the Board of Pharmacy adopted  
           regulations to develop a patient-centered prescription label and  
           standardized directions for use and that despite taking this very  
           important step towards reducing dosage errors, the Board does not  
           know how many pharmacies are using these standardized directions,  
           nor do they have any method for determining whether or not  
           pharmacies are utilizing them.  The Author adds that the Board also  
           does not know, nor does it have a method for determining, if the  
           vendors of electronic health records are using the standardized  
           directions for use in the products that they market to prescribers  
           and pharmacies.  

           The Author states that this bill directs the Board to gather this  
           important information to determine if the standardized directions  
           are being used and what the barriers there are to using the them in  
           prescriptions and electronic health records for prescribers and  
           pharmacists. The Author believes that these surveys will provide  
           the Board with the necessary data to determine how to better ensure  
           the use of this important aspect of the patient-centered  
           regulations.

        2. Background. 

           a)   Medication Errors and Legislative Response.  According to  





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             the Journal of the American Medical Association, 46 percent  
             of adults cannot understand the information listed on their  
             prescription drug labels.  Furthermore, the Institute of  
             Medicine of the National Academies indicates that medication  
             errors are among the most common medical errors, harming at  
             least 1.5 million people annually.  Families USA reports that  
             90 percent of Medicare patients take medications for chronic  
             conditions with nearly half of them taking five or more  
             medications a day.  Given the large numbers of prescriptions  
             that may be prescribed, it is not easily discernable what the  
             purpose for each of these medications is.  This increases the  
             chances that a patient may take the wrong medication  
             increasing the likelihood of serious injury or death.  

             SCR 49 (Speier, Resolution Chapter 123, Statutes of 2005)  
             established the Medication Errors Panel (Panel) which  
             published a report in March 2007 entitled, "Prescription for  
             Improving Patient Safety: Addressing Medication Errors."  The  
             report listed six general goals to reduce medication errors.   
             Under each goal were recommendations (12 in all) and methods  
             to accomplish each recommendation.  The Panel report states  
             that "the information that consumers need to know about  
             regarding their medication is often complex and may include  
             unfamiliar language or concepts.  Expecting a consumer to  
             retain all the pertinent knowledge from a brief verbal  
             encounter may not be reasonable in many instances."  Although  
             the Panel did not come to consensus on the most important  
             subset of consumers that are at "high risk" for medication  
             errors, it did acknowledge that there are a variety of  
             factors which may increase an individual's risk for  
             experiencing a medication error.  These include:  i) low  
             health literacy; ii) limited English proficiency; iii)  
             cultural incongruence with healthcare providers; iv)  
             physical, cognitive and/or other impairments that make  
             understanding and/or complying with medication instructions  
             difficult; v) age at either end of the age spectrum (the  
             variability of a medication's response, metabolism and dose  
             increases in children and seniors); 
             vi) multiple medications; vii) multiple prescribers; viii)  
             non-prescription medication use (including herbals, dietary  
             supplements, alcohol, and tobacco); and, 
             ix) medication procurement from more than one pharmacy  
             including mail-order. The Panel did state that these factors  
             must be taken into consideration in the development of any  
             consumer education efforts.  






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             One bill was pursued in response to the Panel report.   SB  
             472  , The California Patient Medication Safety Act, (Corbett,  
             Chapter 470, Statutes 2007) sought to deal with the lack of  
             uniformity in prescription drug labels throughout the state  
             and the resulting confusion and medication errors that may  
             arise.  Much of the conversation during the SB 472 debate  
             focused on the fact that individual pharmacies design and  
             format their own labels, resulting in a lack of standards  
             across all pharmacies which adversely affects medication  
             users who are elderly, suffer from poor vision, have  
             difficulty reading and understanding instructions on labels  
             or have limited English proficiency. 

             The bill required the Board to promulgate regulations on or  
             before January 1, 2011, that require a standardized,  
             patient-centered, prescription drug label on all prescription  
             medicine dispensed to patients.  Additionally, the Board was  
             required to report to the Legislature by January 1, 2010, on  
             its progress in implementing these regulations.

             This measure is a follow-up to the Author's SB 472 which  
             created the patient-centered label standard.  
        
           b)    Affordable Care Act (ACA).  The passage of the federal  
             Patient Protection and Affordable Care Act has the potential  
             to require greater numbers of health professionals throughout  
             the nation and state, particularly pharmacists who are well  
             placed in communities, to provide medication therapy  
             management services.  The Author also provided background  
             information highlighting the impact of implementation of the  
             federal ACA.  As a result of the ACA, anywhere from 
           4 to 7 million more Californians will be eligible for health  
             insurance.  

        1. Implementation of a Standardized Prescription Drug Label by the  
           Board of Pharmacy.  California is the first state to require  
           redesigned prescription container labels to emphasize  
           information most important to consumers offering an element of  
           safety and consistency since prescription labels are the key  
           source of patients' reference for information when taking  
           medications in their homes.  Part of this current requirement  
           also ensures that oral interpreter services are available to  
           limited English speaking patients in pharmacies, to insure such  
           patients have access to information about how to take their  
           medications.






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           The Board was charged with promulgating regulations that  
           require a standardized, patient-centered prescription drug  
           container label for all prescription drugs dispensed to  
           patients in California.  The Board reported on its efforts in a  
           January 2010 report to the Legislature.  The Board established  
           a "SB 472 Medication Label Subcommittee" in January of 2008, to  
           conduct public forums and to work with organizations and  
           individuals to develop recommendations to implement the  
           provisions of the law to establish a patient-centered  
           prescription drug label.  In May 2008, the Board developed an  
           open-ended prescription label survey for distribution at public  
           outreach events.  A total of 606 consumers completed the  
           surveys.  

           When asked what to change on the prescription label, the top  
           responses were:

              1.      Print should be larger or darker = 30.1%

              2.      Nothing needs to be changed on the label =24.6%

              3.      Include purpose of drug = 12%

           The Board concluded that most consumers participating in the  
           survey requested larger and bolder type font on prescription  
           labels to increase readability.  Many participants suggested  
           that if a generic drug is provided, the prescription label  
           should state the name of the generic drug name and the  
           brand-name it is generic for.  They also noted that color  
           printing and highlighting on labels brings attention to  
           important information. Some participants suggested that the  
           labels themselves be color-coded to help differentiate between  
           multiple medications and family members.  Many consumers  
           responded that they want to know "what the drug is for" and  
           suggested that "the purpose of drug" be printed directly on  
           prescription labels. 

           The Board approved a regulation per the requirements set forth  
           in SB 472 after engaging in a lengthy process.  The Board  
           conducted outreach, hearings and information gathering sessions  
           throughout 2008, to collect data from the public on  
           prescription labels and standards for those labels.  The Board  
           considered testimony and information provided from the public,  
           the pharmaceutical industry, pharmacy professionals and  
           literacy subject matter experts on medical literacy research,  
           improved directions for use, improved font types and sizes, the  





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           placement of information that is patient-centered, the needs of  
           patients with limited English proficiency, the needs of senior  
           citizens, and technology requirements necessary to implement  
           the standards developed.  Board members were also provided with  
           research articles on designing patient-centered labels.  In  
           2009, the Board discussed the requirements of the regulation at  
           regularly scheduled meetings.  

           Throughout early 2010, the Board held regulation hearings to  
           adopt the proposed regulation, a new section at Title 16  
           California Code of Regulations Section 1707.5 - "Requirements  
           For Patient-Centered Prescription Container Labels."  The  
           regulation outlines that the following items must be clustered  
           into one area of the label that comprises at least 50 percent  
           of the label, using at least 10-point font using sans serif  
           typeface, listing these items in the following order: 

                     Name of the patient.
                 
                     Name of the drug and strength of the drug.  ("Name  
                of the drug" means either the manufacturer's trade name,  
                or the generic name and the name of the manufacturer.)

                     Directions for use.

                     Purpose or condition, if entered onto the  
                prescription by the prescriber, or otherwise known to the  
                pharmacy, and its inclusion on the label is requested by  
                the patient.  

           The regulation also requires pharmacies to have policies and  
           procedures in place to help patients with limited or no English  
           proficiency, understand the information on the label in the  
           patient's language.  The pharmacy's policies and procedures  
           must be specified in writing, and must include, at minimum, the  
           selected means to identify the patient's language, and to  
           provide interpretive services in the patient's language.   
           Pharmacies must provide, at minimum, interpretive services in  
           the patient's language, if interpretive services in such  
           language are available, during all hours that the pharmacy is  
           open, either in person by pharmacy staff or by use of a  
           third-party interpretive service available by telephone at or  
           adjacent to the pharmacy counter.  
           Since the adoption of the regulation, the Board has continued to  
           evaluate the implementation of the requirements provided under SB  
           472.  When the Board initially promulgated the regulation, a  





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           requirement was included for the Board to reevaluate the regulation  
           by December 2013.  In April 2013, the Board's Public Education  
           subcommittee began its review of the regulation.  As a result of  
           discussions at these subcommittee meetings (which are presented to  
           the full Board for further discussion at Board meetings), in April  
           2014 the Board initiated a new rulemaking request to change the  
           font size to a minimum of 12-point, rather than the current  
           10-point.  Additionally, the new rulemaking request requires that  
           only four items be clustered into one area of the label that  
           comprises at least 50 percent of the label.  The Board continues to  
           discuss the directions for the use component of the standardized  
           label at its Public Education subcommittee meetings.

        1. Related Legislation.  SB 205  (Corbett) of 2013 would have required  
           the information on the prescription label to be printed in at least  
           a 12-point sans serif typeface.  (  Status:   The bill was vetoed by  
           Governor Brown who indicated in his veto message that "the Board of  
           Pharmacy is required to provide an update of its 2010 labeling  
           guidelines to the Legislature next month. I prefer to wait for  
           their findings before mandating such a change.")

            AB 396  (Fox) of 2013 would have required every prescription to  
           include a legible, clear notice of the condition or purpose for  
           which the drug is prescribed, unless the patient or prescriber  
           requests that this information be omitted. Also, would have  
           required that every prescription container be correctly labeled to  
           include that information, if indicated on the prescription, unless  
           the patient or prescriber requests that this information be  
           omitted.  (  Status:   The bill was never heard in a policy  
           committee.)

            AB 1136  (Levine, Chapter 304, Statutes of 2013) required a  
           pharmacist to include a written label on the drug container  
           indicating that the drug may impair a person's ability to operate a  
           vehicle or vessel.   
            
           SB 1390  (Corbett) of 2010 would have repealed the requirement that  
           the Board promulgate regulations requiring a standardized,  
           patient-centered, prescription drug label on all prescription  
           medications dispensed to patients in California on or before  
           January 1, 2011, and instead established statutory requirements for  
           standardized, patient centered prescription drug labels.  (  Status:    
           The bill failed passage in the Assembly Committee on Business,  
           Professions and Consumer Protection.)   

            SB 470  (Corbett, Chapter 590, Statutes of 2009) permitted, if  





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           requested by patients, the purpose of the prescribed medication to  
           be listed on prescription drug labels. 

            SB 472  (Corbett, Chapter 470, Statutes of 2007), the California  
           Patient Medication Safety Act, required the Pharmacy Board to  
           promulgate regulations that require a standardized,  
           patient-centered, prescription drug label on all prescription  
           medication dispensed to patients in California.  Additionally, the  
           Board was required to report to the Legislature by January 1, 2010,  
           on its progress in implementing these regulations. 
            
           AB 1276  (Karnette, 2007) would have required medication prescribers  
           to ask a patient if they wanted the intended use on the  
           prescription label.  (  Status:  The measure failed passage in the  
           Assembly Committee on Business and Professions.)
            
           SCR 49  (Speier, Resolution Chapter 123, Statutes of 2005) created a  
           panel to study the causes of medication errors and recommend  
           changes in the health care system that reduces errors associated  
           with the delivery of prescription and over the counter medication  
           to consumers.  This resolution required the panel to convene by  
           October 1, 2005, and to submit to the Assembly Committee on Health  
           and the Senate Committee on Health, a report on its finding by June  
           1, 2006.
            
           AB 657  (Karnette, 2005) would have required prescription drug  
           labels to include the intended purpose of the drug, if indicated on  
           the prescription, and required prescribers to ask the patient or  
           the patient's authorized representative, if the patient is either  
           incapacitated or a minor who cannot provide informed consent,  
           whether to indicate the intended purpose of the prescription on the  
           label.  (  Status:   The bill was held in this Committee at the  
           request of the Author.)
            
           AB 288  (Mountjoy, 2005) would have amended the prescription  
                                                                  labeling requirement to include the condition for which the drug is  
           prescribed unless the patient, physician or legal guardian  
           requested that the information be omitted.  (  Status:  The measure  
           was held in the Assembly Committee on Business and Professions at  
           the request of the Author.)
            
           AB 2125  (Levine, 2004) would have required a physician and surgeon  
           to indicate the patient's diagnosis on each prescription written,  
           unless directed otherwise by the patient and amended the  
           prescription labeling requirement to require that the condition be  
           included on the label unless otherwise directed by the patient.   





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           (  Status:  The bill was held in the Assembly Committee on Business  
           and Professions at the request of the Author.)
            
           SB 292  (Speier, Chapter 544, Statutes of 2003) required  
           prescription labels to include a physical description of the drug,  
           including the color, shape, and any identification code that  
           appears on the tablet or capsule.
            
           AB 2099  (Epple, Chapter 397, Statutes of 1993) required that the  
           condition for which the drug is being prescribed must be included  
           on the label if the patient requests that information on the label.

        2. Arguments in Support.  The  AllCare Alliance  writes in support of  
           this bill, stating that it represents an important step toward  
           quality - and linguistically competent - health care.  
           
           According to the  California Alliance for Retired Americans (CARA),   
           "with an estimated 
           7 million limited English proficient Californians and studies  
           showing that only about 2/3 of California pharmacies are providing  
           translated directions on prescription labels upon request, it is  
           unlikely that limited English proficient patients can properly read  
           and follow their medication directions."  CARA believes this bill  
           will help this population of Californians so they can read and  
           understand the directions on their prescriptions medication labels.

           The  California Pan-Ethnic Health Network (CPEHN)  asserts that "a  
           patient's first and best source of information about their  
           medication is the prescription container label."  CPEHN believes  
           that the data provided through this bill about how pharmacists and  
           vendors of electronic health records utilize standardized  
           instructions for use, as well as barriers that may impede their  
           use, will help ensure the needs of California consumers are being  
           met while also preventing cost and health risks associated with  
           adverse drug events.

           According to the  Latino Coalition for A Healthy California  , studies  
           show that a large percentage of patients misunderstand dosage  
           instructions on their labels and that simple, explicit and specific  
           instructions can help with patients' misunderstanding.  

           The  Western Center on Law and Poverty  believes that the information  
           collected through surveys provided under this bill will be  
           especially useful in determining a streamlined way to provide  
           translated medication instructions to meet the needs of  
           California's limited English proficient patients.  





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        3. Arguments in Opposition.  The  Board of Pharmacy  writes in  
           opposition to this bill, stating that it would require the Board to  
           perform two surveys: one on pharmacies' use of the standardized  
           directions for use as specified in Board regulations, and another  
           of electronic health record vendors to determine the types of  
           standardized directions included in software. The Board states that  
           it is unable to absorb the cost of conducting these surveys,  
           estimated to be approximately $50,000. According to the Board,  
           "while the Board opposes Senate Bill 204, the Board has directed  
           staff to collect information during its compliance inspections from  
           pharmacies on the use of the standardized directions for use."   
           Additionally, the Board writes that it "has committed to continue  
           its work to determine ways that drug labels can be improved so that  
           patients can have better health outcomes through medication  
           adherence."   
        

        SUPPORT AND OPPOSITION:
        
         Support:
         
        California Pan-Ethnic Health Network (Sponsor)
        AllCare Alliance
        California Alliance for Retired Americans
        Latino Coalition for a Healthy California
        Western Center on Law and Poverty

         Opposition:  

        Board of Pharmacy



        Consultant: Sarah Mason