The first prescription without a doctor
Utah now lets software choose a patient's first prescription for acne; the terms for withdrawing the doctor's review will outlast the acne, and physicians should write them.
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read by an AI voiceOn Oct. 5 a startup called Nolla Health began a pilot in Utah in which software, rather than a doctor, chooses a patient's first prescription. Adults in the state with mild to moderate acne open its app, answer a questionnaire that takes 10 to 15 minutes, scan their face and receive a treatment the software picks from eight topical formulas listed in the company's agreement with the state. The service costs $4.99 a month during the pilot, with the medicine extra. Utah's earlier agreements, with Doctronic and Legion Health, let software renew only prescriptions that a clinician wrote first.
The acne is the least important part of the arrangement. What matters is the taper, the schedule on which a doctor's review of the software's choices is withdrawn. Its terms were settled between the company and two offices of the state's commerce department, the AI office and the licensing division, and they will be read as precedent for drugs that matter far more than acne cream. Physicians should write the criteria for such tapers before regulators and vendors settle them one agreement at a time.
Utah has posted Nolla's agreement, signed Sept. 22, on its AI office's list of authorized pilots. For at least four weeks and 100 patients, two Utah-licensed physicians review each prescription before it goes out. If the software agrees with their choices at least 95% of the time, misses none of the conditions that should stop it and records no serious adverse event, it then sends prescriptions itself, and a physician reviews every case afterward, at least weekly, for at least eight weeks and until 500 patients have been treated. After that, physicians review a monthly sample of at least 10% of enrollment, and every case involving an adverse event or an escalation in full; any serious adverse event triggers a pause. The decision to advance rests with the state: the agreement says each advance will be "conducted in coordination with the State of Utah," and it bars Nolla from starting a new stage without the prior written approval of the AI office.
Oddly, the pilot that starts treatments steps back after fewer patients than the ones that only renew them. Doctronic's agreement had physicians review the renewals of its first 250 patients before anything reached a pharmacy and check those of the next 1,000 afterward, then a monthly sample of 5% to 10%; Legion Health's terms use the same numbers, counted in renewal requests rather than patients. Doctronic must also complete at least 250 renewals in each of nine drug classes before it can move on, telehealth.org reported in April. Nolla's later sample, at least 10% a month, is no smaller than Doctronic's. But it is hard to see why starting a treatment should earn independence sooner than renewing one.
What the tests measure matters as much as how long they last. Nolla says licensed clinicians agree with its treatment choices in more than 96% of real-world cases; its agreement says the figure, about 96%, comes from the last 1,000 treatments in its existing app, as judged by its current clinicians. Utah's report on Doctronic's first months gives percentages without totals: reviewing physicians agreed with its renewals 91% of the time. Agreement with a reviewer is a measure of process. And a run of 100 or even 500 patients without a serious adverse event says little about an error that strikes one patient in a thousand, which is the kind a physician's review is there to catch.
Acne is a sensible place to start. It is common and rarely dangerous, and one of its standard drugs, adapalene, was approved for sale over the counter in 2016. Nolla leaves out oral drugs and isotretinoin. Yet even creams carry an error that a review after the fact cannot undo: some topical retinoids, such as tazarotene, are contraindicated in pregnancy, and a check a week later finds that mistake after the exposure. The protection there lies in the screening questions and the drug list. Nolla's agreement leaves tazarotene off the list and stops the software when a patient reports being pregnant, trying to conceive or breastfeeding, a screen that rests on what the patient says. All eight formulas are compounded preparations that patients may buy from Nolla itself, so the software is also choosing among products its company sells.
The medical profession's formal role has been advisory. After Doctronic began, the state's Medical Licensing Board urged that it be suspended, saying it learned of the agreement only once the service was available; the state replied that the board serves in an advisory capacity and that medical professionals had reviewed the pilot before launch. The board now has a working group supporting the AI office's review of health care applications, Nolla says it worked with the board before its own launch, and Utah says it will require third-party audits of companies' claims. California, by contrast, has a new law, signed Sept. 30, that bars health facilities, clinics and physicians' offices from using AI to perform on its own any clinical function the law reserves for a licensed professional.
Medicine already knows how to hand over decisions in stages, with the terms set before the handover begins. Residents earn independence through levels that the accreditation rules define: a supervisor present or watching live, then one immediately available, then one who reviews the care afterward, each step granted by the program director and faculty. Colorado's pharmacists may prescribe birth control under a protocol approved by the state's pharmacy board, with a screening questionnaire, a fixed algorithm, the federal eligibility criteria and a process for informing the patient's own doctor. An autonomous system that screens for diabetic eye disease in primary care was authorized in 2018 after a prospective trial in 10 primary care sites, and it decides only who needs to see an eye doctor.
The strongest objection is that criteria written by physicians will protect physicians. The American Medical Association says there generally should be a human in the loop for medical decisions, and the Federation of State Medical Boards calls failing to apply human judgment to AI's output a violation of a physician's duties. Meanwhile patients with acne treat themselves or wait; Nolla says the average wait to see a dermatologist in Utah is 61 days. Caution has costs too: reviewing physicians judged nearly a third of Doctronic's escalations overly cautious. That is all fair, and it argues for criteria that can say yes. But a yes should rest on outcomes counted by someone other than the vendor, and on a taper that reverses when the numbers turn.
The principle that matters most is reversibility. Software should be handed only decisions whose worst likely mistake can be noticed and undone before it does harm; where it cannot be, as with a drug that harms a pregnancy, a human check belongs on that branch however good the average looks. The measure that matters most is what happens to patients. Harms, treatment failures, missed escalations and patients' own reports, compared with usual care, say far more than whether the software agrees with the company's reviewers, and the targets should be fixed in advance, as the eye-screening trial's were. Everything a pilot relies on, from the drug list to the numbers needed to move from one stage to the next, should be public before the first patient, as Utah's posted agreements for Doctronic and Nolla show is possible.
Just as important is who keeps the score. Someone independent of both the company and the office that approved the pilot should do the counting; Utah's auditors, vetted by its AI office, are a start. Each step back should need the approval of a named body that includes practicing physicians in the specialty. Nolla's agreement already pauses the pilot after any serious adverse event; a rise in harms, complaints or escalations short of that should put a doctor back in front of every prescription automatically, without a negotiation. And the company should carry malpractice insurance for its software's decisions, as Utah expects of the companies in its program. A specialty society, a state medical society or a hospital's medical staff could adopt such rules, and Utah's AI office, which must report to the legislature every year, is an obvious place to press them.
Acne cream is a modest beginning, and Utah has handled it with some care. But Nolla's website already lists birth control and urinary tract infections among the conditions for a women's service it marks as coming soon, and when software starts drugs like those, the terms agreed for acne will be the precedent. Physicians should write the next terms themselves, before a company and a commerce department do it for them.
- Nolla Health announced on Oct. 5, 2026, that Utah had approved its pilot for AI to issue initial prescriptions; the pilot, developed with the Utah Office of Artificial Intelligence Policy, launched that day through the Nolla Derm app. The agreement was signed on Sept. 21 and 22, 2026, by the AI office, the Division of Professional Licensing and Magic Health, Inc. and Magic Health Services, LLC, which operate Nolla, and runs for 12 months from its commencement date. The pilot is open to Utah residents 18 and older with mild to moderate acne, who complete an informed consent process, a 10- to 15-minute questionnaire and a face scan; the system "can only select between pre-approved treatment pathways" and directs a patient to a licensed physician when it "cannot confidently select a treatment" (company). The agreement lists eight compounded topical formulas, each paired with a non-compounded product (tretinoin, adapalene, clindamycin with benzoyl peroxide, benzoyl peroxide and azelaic acid); patients who choose a compounded formula pay Nolla directly. It excludes oral medications, systemic hormonal therapies and isotretinoin, makes self-reported pregnancy, aiming to become pregnant or breastfeeding a hard stop, and sends every prescription under the overseeing physician's NPI. The pilot costs $4.99 a month, with medication separate (MobiHealthNews). The company says licensed clinicians agree with its treatment recommendations "in over 96% of real-world cases"; its agreement with Utah puts the figure at about 96% of the last 1,000 treatments in its app. "The AI can't improvise," said Dr. Zaid Fadul, the company's chief medical adviser. Becker's reported that Nolla worked with the Utah Medical Licensing Board before launch.
- Utah's agreement with Magic Health, Inc. and Magic Health Services, LLC, which operate Nolla (signed Sept. 21 and 22, 2026, and posted on the AI office's list of authorized pilots), sets three stages. Stage 1 lasts at least four weeks and 100 patients: the overseeing physician reviews and approves every prescription before submission, and each is reviewed by two independent Utah-licensed physicians; to advance, the system needs at least 95% concordance, no missed hard stops, no serious adverse events and 100% pre-review. Stage 2 lasts at least eight weeks and 500 patients in all: the AI submits directly and a physician reviews all cases retrospectively at least weekly; the gate adds no adverse safety trends. Stage 3 begins at 750 patients in all: a monthly sampling-based review of at least 10% of enrollment volume, with full review of any case involving an adverse event or escalation. Any serious adverse event "triggers immediate review and pause," and progression "may be paused or reversed at any stage if safety concerns arise." Advancement is "conducted in coordination with the State of Utah," and the participant "shall not commence any succeeding phase without the prior written approval of the Office" (section 20). MobiHealthNews reported the schedule in these terms. Nolla's announcement and Becker's describe a physician approving every prescription for the first 100 patients, a daily review after the fact through the first 500 and a weekly sample after that.
- Utah and Doctronic announced on Jan. 6, 2026, the first state-approved program allowing an AI system to take part in decisions on prescription renewals. Its agreement provides for physician review of every AI-generated renewal for the first 250 patients before it reaches the pharmacy, retrospective review of the next 1,000 and then a monthly review of 5% to 10% of renewals; AI-generated renewals are identified to pharmacists, who may escalate any of them to a physician. Legion Health signed an agreement on March 19, 2026, for renewals of non-controlled psychiatric maintenance drugs, with review of the first 250 requests before completion, intensive retrospective review of the next 1,000 and ongoing monthly sampling. Utah's AI office says it expects companies in the program to maintain medical malpractice insurance that covers AI liabilities, and Nolla's agreement requires professional liability coverage. Telehealth.org reported in April that Doctronic was still in Phase I, according to the AI office's director, and that moving to later phases requires at least 250 renewals in each of nine drug classes. MobiHealthNews reported that Utah has also approved a renewal pilot by August AI.
- Utah's summary of Doctronic's first months (dated May 19, 2026) reports that the AI recommended renewal in 72% of cases and escalated 28% to a physician, that 69% of physician reviews agreed the escalation was appropriate and the other 31% found it overly cautious, and that the reviewing physician agreed a renewal was appropriate in 91% of cases; it gives no totals and notes the pilot is still in Phase One. The Utah Medical Licensing Board recommended suspending the pilot, saying it became aware of the agreement after it was available for use (KSL, Apr. 27, 2026); the Division of Professional Licensing and the AI office replied that the board serves in an advisory capacity. Fox13 reported on Oct. 5, 2026, that "The board now has a working group supporting the AI policy office's review of health care applications"; a board member, Dr. Bill Hamilton, said it is not a blanket approval of AI pilots. In the New England Journal of Medicine, Ravi Parikh, Sara Gerke and I. Glenn Cohen raised the risks for drugs that need frequent dose changes and asked whether such systems need FDA review.
- Utah's Artificial Intelligence Policy Act took effect May 1, 2024, and created a learning laboratory in which the state may grant regulatory mitigation agreements. S.B. 332 (2025) extended the act to July 1, 2027. H.B. 320, effective May 6, 2026, caps an initial agreement's demonstration period at 12 months, with up to two extensions. The act, as amended, requires the office to report each year, before Nov. 30, to the legislature's Business and Labor Interim Committee, a duty it has carried since 2024. On Oct. 5, 2026, Utah announced a healthcare pillar for its AI initiative, new pilots and partnerships with third-party evaluators; STAT reported that the state "will require third-party audits of company claims." Nolla's agreement provides that de-identified data from the pilot will be shared with auditors vetted by the AI office.
- California's AB 1979, signed Sept. 30, 2026, prohibits a health facility, clinic, physician's office or group practice from using AI to independently perform any clinical function that the law requires a licensed person to perform. The Federation of State Medical Boards (April 2024): "the physician is ultimately responsible for the use of AI" and "failure to apply human judgement to any output of AI is a violation of a physician's professional duties." The AMA (November 2024): developers of autonomous AI "must accept" liability for system failure, and "there generally should be a human in the loop" in medical decision making. FDA's clinical decision support guidance (January 2026) exempts from device rules only software whose recommendations are intended for a health care professional; its example of patient-facing software that calculates an insulin dose is a device function. The Healthy Technology Act of 2025 (H.R. 238) would let AI prescribe if FDA has authorized it and the state allows it. The New York Times reported on Sept. 14, 2026, citing a person involved, that officials have discussed whether AI physicians should be paid as much as 60% to 80% of what human physicians earn for the same service.Sources: CalMatters Digital Democracy (AB 1979), Office of the Governor of California, Federation of State Medical Boards, American Medical Association, FDA (clinical decision support guidance), Rep. David Schweikert, Becker's Hospital Review (on The New York Times report), The New York Times (via The Philadelphia Inquirer)
- ACGME's common program requirements (effective July 1, 2026) define direct supervision, indirect supervision and oversight, in which the supervising physician reviews care after it is delivered, and say progressive authority must be assigned by the program director and faculty. Colorado's statewide protocol (updated November 2016) lets trained pharmacists prescribe hormonal contraception to people 18 and older using a self-screening questionnaire, a standard algorithm and the CDC's medical eligibility criteria, and requires a process for communicating with the patient's primary care provider. The autonomous diabetic retinopathy system IDx-DR (FDA De Novo DEN180001, 2018) was studied in a prospective trial in which 900 participants were enrolled at 10 primary care sites; it exceeded all pre-specified endpoints, and FDA reported sensitivity of 87.4% and specificity of 89.5%. The study was funded by the company. The AMA's CPT Appendix S sorts AI into assistive, augmentative and autonomous work, with three levels of autonomy.
- Adapalene gel 0.1% was approved for over-the-counter sale in the United States in July 2016, for people 12 and older (Galderma). The American Academy of Dermatology's guideline covers topical therapies including benzoyl peroxide, topical retinoids, topical antibiotics, clascoterone, salicylic acid and azelaic acid. Tazarotene cream's label lists pregnancy as a contraindication and calls for a negative pregnancy test within two weeks before therapy. Isotretinoin is dispensed under the iPLEDGE program, which requires pre-treatment pregnancy tests in a medical setting for patients who can become pregnant.