How Broken Pharmacy Systems Are Failing
New York’s Most Vulnerable

Last week, I took my 91-year-old father to our local pharmacy after a series of hospital stays that left his medication list changed again and again. He has trusted this pharmacy for decades. But this time, instead of reassurance, I walked away shaken.

The pharmacist told me something that floored me: “No one’s on the same system. Pharmacies (CVS, Walgreens, independents), hospitals (UHS, Guthrie, etc.), and federal systems (like the VA) all use their own electronic health records (EHRs) and pharmacy management systems.

These systems are often not interoperable meaning they don’t talk to each other smoothly. .

” They continued to tell me that when a doctor lowers a prescription, say from 40 mg of Crestor to 20, pharmacies have to guess: is it in addition, or instead of? If the doctor doesn’t call back, they’re left to figure it out with the patient.

Guesswork.
Dealing with medications that keep people alive.

New York State does have a prescription monitoring program, known as I-STOP (Internet System for Tracking Over-Prescribing). It was designed in 2013 to help curb opioid abuse. But here’s the problem:

I-STOP only tracks controlled substances like opioids, benzodiazepines, and stimulants.

It does not include everyday drugs like cholesterol medications, blood pressure pills, blood thinners, or antidepressants, the very medicines most seniors depend on.

Pharmacies, hospitals, and federal agencies like the VA each use their own electronic systems, and these systems don’t fully talk to one another.

This means that while a patient can’t easily “doctor shop” for extra opioid prescriptions, they can absolutely be double-prescribed or dangerously underdosed on common medications and the system won’t catch it.

And here is an extra risk that no one wants to talk about. Pharmacists told me they often call doctors to confirm changes, but many times those calls go unanswered. They are then forced to ask the patient or guess. That guess can mean:

Overdosing a frail elderly patient who now gets 40 mg and 20 mg of a medication.

Underdosing a heart patient who suddenly drops from 40 mg to 20 mg when the intent was for both.

Confusing patients with dementia or mental illness, who cannot be relied on to clarify complex dosing instructions.

The result: an invisible epidemic of medication errors that never makes headlines but could be quietly killing people every single day.

This puts my father and thousands like him at risk. My father’s medications change frequently. After every hospital stay, new orders come down, old prescriptions were canceled or were supposed to be.

But no one system reflects those changes clearly. It’s left to pharmacists, already overworked, to interpret. It’s left to families like mine to cross-check pill bottles, discharge papers, and pharmacy records.

He shouldn’t need me to play detective. At 91, he deserves certainty and safety.

The Moral and Policy Questions

Why hasn’t New York expanded I-STOP to cover all medications, not just controlled substances?

Why aren’t pharmacy systems, hospital EMRs, and VA software interoperable so changes show up in real time statewide?

Why are pharmacists meant to dispense, educate, and protect being forced into risky clinical judgment calls without full access to patient records?

What Needs to Change

1.  Expand I-STOP statewide to include every prescription drug.

2.  Mandate interoperability across all healthcare platforms for private, state, and federal.

3.  Require clear electronic cancellation of old prescriptions when dosages are reduced or changed.

4.  Relieve pharmacists and patients from bearing the burden of incomplete information.

When I walked out of the pharmacy with my father that day, I realized just how fragile our safety net is.

And again, this is not just confined to NYS it is a federal problem. We are surviving on guesses. And guesses are not good enough when lives hang in the balance.

So I ask you would you help Informed NY to fight this injustice, this silent killer. If so please write us at lisa@informedny.com and say you want to help.