Opioid misuse and overdoses are rising at an alarming rate. The crisis is due in part to wider use of prescription opioids, despite the risk for addiction and lack of evidence about long-term effectiveness to treat pain. It will require a comprehensive response from many stakeholders to stem the tide of the devastation from opioid abuse.
This content is sponsored by Allscripts.
Health IT has a role to play in helping clinicians respond with more precision to this public health crisis. Instead of aiming for the overall reduction of opioid prescriptions, and risk potentially under-treating patients who legitimately need them, technology enables health systems to refine their response and tailor it for their patient populations.
Understand prescribing patterns
Before designing an intervention, health systems must first understand their own opioid prescribing patterns. They need to analyze data from prescribers to understand frequency, opioid type, quantity, reason for prescribing and other factors. This data can be used to monitor prescribing over time.
"We have a client taking a closer look at prescribing data in the emergency department, and it validated what the physicians had been doing for years – prescribing opioids appropriately and in limited quantities," David Hurwitz, MD, general internist, hospitalist and Allscripts Medical Director of Clinical Analytics, said. "In other cases, prescribers may underestimate the frequency of opioid prescribing, and data can be useful to help educate and change prescribing behavior."
University Hospitals in Cleveland is committed to combating the opioid crisis in northeast Ohio. Through multidisciplinary teams and collaboration with the community at large, University Hospitals has armed itself with data from its EHR when designing a response to the crisis. Leading these efforts is Randy Jernejcic, MD, the appointed Vice Chair of Clinical Integration for University Hospitals, Chair of the Opioid Patient Safety Steering Committee at University Hospitals, and 2018 Chair of the Northeast Ohio Hospital Opioid Consortium Executive Committee.
"We're pulling data from the EHR, starting with primary care, where the bulk of opioid prescribing occurs at University Hospitals," Dr. Jernejcic said. "The data has helped us understand some of our opioid prescribing patterns and we can now visualize where we want to go. We developed a documentation toolkit to help providers gather more data points and design more precise interventions for our community."
Secure the prescribing process
Another early step health systems should take is to implement electronic prescribing of controlled substances. Areas where clinicians regularly use EPCS have seen significantly less prescription fraud and abuse.
"Most physicians have stories about altered paper prescriptions. For example, editing a quantity from '3' to '30,'" Michael Blackman, MD, Allscripts Medical Director, Population Health and Analytics, said. "Electronic prescribing of controlled substances can help mitigate some of these risks by ensuring that the pharmacy receives what, and only what, was prescribed."
Unfortunately, even though the technology is widely available, it is only required in select states and is not widely adopted. While more than 90 percent of all pharmacies are EPCS-enabled, only 14 percent of controlled substances are prescribed electronically.
Provide clinical decision support
Evidence-based prescribing guidelines can help clinicians stay current on the most up-to-date research findings. These guidelines can recommend quantity limits, fast-acting versus extended-release medications, protocols for additional and alternative therapies, and expanded educational material and content. University Hospitals has made a commitment to train all prescribers on best practices for opioid prescribing by the end of 2018.
Clinical decision support can give prescribers assessment tools at the right place within EHR workflows. Well-placed information helps clinicians to engage in more effective conversations with patients, make informed decisions and create optimal treatment plans.
"One of our clients is providing information about MME [morphine milligram equivalents] of prescriptions being written in the emergency department, as higher doses are directly correlated with a higher overdose risk," Dr. Blackman said. "This enables a prescriber to quickly see what they are prescribing in a standardized way."
Simplify access to prescription drug monitoring programs
PDMPs are state-level databases that collect, monitor and analyze e-prescribing data from pharmacies and prescribers. Integration of state PDMPs into the EHR workflow helps inform prescribers about a patient's prior opioid prescriptions. Review of PDMP data is a requirement in many states prior to prescribing an opioid.
"These systems can help identify 'doctor shopping' patients or substantiate a history of legitimate opioid use," Dr. Hurwitz said. "Currently I do not have access to the Florida PDMP within my EHR, which makes review of this data extremely cumbersome and time consuming in an already very time-intensive hospitalist workflow."
Unfortunately, technical and data standards vary greatly across the 50 PDMPs, which makes it a fragmented source of information. The College of Healthcare Information Management Executives has called for better EHR-PDMP integration, and policy efforts could help simplify the process of connecting PDMP information with prescribers.
"Knowledge is power," Dr. Blackman said. "Prescribers should have access, within their workflow, to a patient's history with controlled substances through state PDMP databases, no matter where that patient was seen."
Predict risk for addiction and death
Using big data and algorithms can help health systems better identify at-risk patients and reveal prescription patterns that most often lead to abuse, overdose and death. Research on this is just beginning and early insights are compelling.
Dr. Jernejcic anticipates expanded uses of data at University Hospitals. "For example, tracking suspected opioid overdoses in emergency departments for real-time, communitywide tracking — as well as [using] data to better predict who is at risk for addiction and death from overdose and provide that information to prescribers."
When these insights are delivered at the point of care, prescribing patterns can change. "Data can inform prescribers, who might then consider a non-opioid alternative when treating pain," Dr. Hurwitz said.
How do we measure success?
With a complex issue like opioid misuse, it can be challenging to come up with the right metrics to mark progress. Dr. Blackman cautions against striving for perfection. "We're not realistic if we try to develop a system where physicians never, ever prescribe an inappropriate opioid," he said. "In that situation, there is a substantial chance of undertreating some patients who would genuinely benefit."
At University Hospitals, the long-term goal is to lower rates of opioid-related death and addiction, but the coalition recognizes this will take some time to achieve. In the meantime, the organization set concrete short-term goals, initially to reduce opioid prescriptions. From October 2017 through March 2018, University Hospitals has seen a 13 percent drop in opioid prescriptions by family practice physicians and a 21 percent drop by internal medicine physicians.
"We measured our progress in terms of pill count and potency," Dr. Jernejcic said. "These metrics are strong, basic surrogates to monitor and address opioid abuse and misuse. However, we soon recognized that this approach would not be enough to make meaningful change."
In other words, reducing the overall number of prescriptions could end up withholding opioids from patients who legitimately need them to manage pain. Instead, health systems should focus on delivering the right interventions to the right patient at the right time.
As the University Hospitals opioid response matures, the organization is evaluating process metrics and digging into more complex facets of opioid prescribing, such as referral patterns. For example, University Hospitals is measuring if patients who are taking certain levels of MMEs are getting appropriate referrals for pain management and the consults they need from behavioral health.
"Process metrics are more difficult to measure than pill counts and MMEs, but they are more sophisticated and precise indicators that we are attacking the opioid problem where it is causing the most damage," Dr. Jernejcic said.
Combatting opioid abuse will be a long, complex journey. Harnessing technology can help healthcare systems design more precise interventions to reduce inappropriate prescriptions, and ultimately, the devastating toll opioids are taking on our communities.
Learn more about how Allscripts will help fight the opioid abuse in 2018.