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At its annual meeting in Chicago last month, the American Medical Association (AMA) highlighted the problem of on-line prescribing by calling on government regulators, state medical societies, and licensing boards to step up efforts to investigate physicians who dispense drugs to patients over the Internet without benefit of a face-to-face examination.
Anecdotal evidence suggests that at least some state medical boards already have made this practice a top investigative priority. Recently, for example, the Illinois Department of Professional Regulation in Chicago suspended the license of a physician who prescribed Viagra on-line to patients he never examined. The department also imposed a $1,000 fine. At least 10 other state boards are investigating Internet prescribing.
In Kansas, the Board of Healing Arts in Topeka took an even bolder step, filing petitions in district court against two out-of-state physicians who had dispensed drugs to patients in Kansas without an examination.
The physicians were charged with practicing medicine without a license in the state of Kansas. The board won an injunction against the physicians.
"Theoretically, a criminal case could have been filed," says Mark Stafford, JD, the board’s general counsel. "But realistically, it would have been a Class B misdemeanor, and it’s hard to get extradition for something like that. The formalities are incredible."
The Kansas case highlights the problems inherent in taking action against such prescribing schemes, since many are conducted by fly-by-night organizations that use the Internet to hide their identity and location.
One Web site mentioned by the AMA, "get-it-on.com," which sold Viagra, already has folded. What remains at the site is a link to cybrxpress.com, which advertises itself as "the premier online source for Phentermine, Meridia, Xenical, Valtrex, and Zyban." The main page boasts that "no visit to your doctor’s office or pharmacy" is necessary and that there’s "no charge if you are not approved for the medication." A counter on the site indicates that it’s received almost 50,000 hits.
According to the AMA, at least 14 Web sites are probably involved in sight-unseen on-line prescribing.
"In many of these cases, there is no real physician involvement," Stafford says. "In some of the cases we’ve dealt with, the physician involvement was in name only. The order comes in for the drug and the marketing company simply fills the order. The doctor doesn’t normally see the patient information."
Patricia Beatty, assistant vice president of communications at the Federation of State Medical Boards in Euless, TX, notes that boards can’t take action against a physician simply for issuing prescriptions over the Internet. "They would have to take an action for unprofessional conduct, depending on how they define that in their board order," she says. Besides, she says, the real problem is the lack of physician-patient relationships, and even regulating that can pose problems for medical boards and state and federal lawmakers.
"It’s written in a lot of medical practice acts that you have to have a good faith exam or [establish] a physician-patient relationship," Beatty says. "But how that’s defined becomes a gray area." Most statutes are very specific about what’s required, primarily because, before the Internet came along, it was difficult to prescribe drugs or otherwise treat a patient without a face-to-face encounter. Even now, enacting effective legislation is difficult "because it would have to get very specific, and might not stand the test of time as technology continues to change."
Currently, a committee established by the Federation of State Medical Boards is examining the issue and preparing recommendations it hopes will be generic enough to be used by all state medical boards. The recommendations will be presented at the federation’s next house of delegates meeting in April 2000.