improving opioid prescribing practices · 2019-11-12 · • the average annual death rate in ohio...

Improving Opioid Prescribing PracticesMark Binstock, MD, MPH

Associate Medical Information OfficerGary Grazak, BSCE

Business Intelligence System Engineer

About Us

Our Footprint

• Mercy Health is a Catholic healthcare ministry serving Ohio and Kentucky.

• Mercy Health is one ministry serving seven regions in Ohio and Kentucky, pursuing one Mission to improve the health of our communities, emphasizing people who are poor and under-served. Together, our passion is to make lives better and make healthcare easier.

Our Impact

Communities We Serve• Mercy Health — Cincinnati• Mercy Health — Kentucky• Mercy Health — Lima• Mercy Health — Lorain• Mercy Health — Springfield• Mercy Health — Toledo• Mercy Health — Youngstown

Serving Through Our Partners• Akron — Summa Health

Facts & Stats• Nearly 500 Places to Receive Care • 23 Hospitals• 7 Senior Health and Housing Facilities • 7 Home Health Agencies• Over 33,500 Employees• 1,300 Employed Providers• $10.1 Billion/Year in Economic Impact in Ohio

In 2017:• 6.8 Million Patient Encounters • $6.8 Billion Total Assets • $4.7 Billion in Net Operating Revenue

Our Mission in Action

Investing over $1 million a day

• In 2017, Mercy Health invested $384 million to benefit the communities where we provide care, most of it targeted to help people who are poor and under-served.

–$267 million directly benefited the poor and under-served.–$80 million went to benefit the broader community.

CarePATH Overview

CarePATH is Mercy Health’s branding of Epic

CarePATH is a comprehensive, safety-oriented, patient-centered clinical information system using Epic information technology.

The “PATH” in CarePATH is: Patient-centered Access to Team-based Healthcare

Informatics Governance Structure

• Build is governed by the clinically led CarePATH Informatics Committees

• Recommendations for system changes come from the end users and are vetted with the respective system committees

• Inpatient Informatics is co-chaired by two providers (medical and surgical) and two nurse leaders

• Ambulatory Informatics is co-chaired by both providers and a RN

• Currently have 15 certified Physician Builders, including two from our Connect partner and three working to certify

Recent Accolades

2018 HIMSS Davies Award Recipient

HIMSS Stage 7 Certifications–All Mercy Ambulatory Practices–7 Acute Care facilities

Most Wired Advanced Winner

System Uptime Recognition from Epic

Epic Summa Cum Laude for Honor Roll

Improving Opioid Prescribing Practices

CDC National Guidelines:A foundation for our build and analytics

https://www.cdc.gov/drugoverdose/prescribing/guideline.html

Addressing Opioid Misuse & Diversion Ohio Legislation

• In 2006, the State of Ohio Board of Pharmacy established a Prescription Drug Monitoring Program (PDMP) know as the Ohio Automated Rx Reporting System (OARRS). OARRS collects information on all outpatient prescriptions for controlled substances and can be used to identify drug diversion and abuse

• In 2015, Ohio passed legislation to require that providers must review the OARRS report before prescribing an opioid or benzodiazepine–Providers must document within the chart that this review occurred–Providers must view the OARRS report at least every 90 days after the initial

prescription if the therapy exceeds 90 days

Changing Ohio laws guided the development of workflows supported by the EHR

https://www.ohiopmp.gov/About.aspx

Ohio Opioid prescribing rules (AKA 7/5/30)• No more than seven days of opioids can be prescribed for adults.• No more than five days of opioids can be prescribed for minors and

only after the written consent of the parent or guardian is obtained.• Health care providers may prescribe opioids in excess of the day supply

limits only if they provide a specific reason in the patient’s medical record.• Except as provided for in the rules, the total morphine equivalent dose (MED) of a

prescription for acute pain cannot exceed an average of 30 MED per day.• The new limits do not apply to opioids prescribed for cancer, palliative care, end-of-

life/hospice care or medication-assisted treatment for addiction.

Part 2 of the Acute Prescribing Rules–Starting December 29, 2017 prescribers are required to:–Include the first 4 characters of the diagnosis code or full procedure code on opioid prescriptions.

Since June 1, 2018, the inclusion of the diagnosis/procedure code is required for all other controlled substance prescriptions.

–Indicate the day’s supply on all other controlled substance and gabapentin prescriptions.

http://med.ohio.gov/

Opioids – A national health epidemic

• The drug overdose crisis hit epidemic levels nationally, with Ohio and Kentucky falling among the lowest ranked states in many key opioid-related statistics

• The average annual death rate in Ohio is twice that of the U.S. drug overdose rate (27.7 per 100,000 vs. 14.7 per 100,000)

• Opioids (including prescription opioids, heroin, and fentanyl) killed more than 42,000 people in 2016, more than any year on record. 40% of all opioid overdose deaths involve a prescription opioid (https://www.cdc.gov/drugoverdose/index.html)

• 4 out of 5 people who abuse heroin started with Rx opioids (www.drugabuse.gov)

• The increased prevalence of Opioid abuse necessitated the development of tools and protocols that facilitate improved outcomes and reduced risk for patients presenting to Mercy Health facilities

Our Response to the Opioid Crisis

• As national guidelines and Ohio laws change, new EMR tools are built

• Physician leadership engagement key for workflows & supporting tools

• IT leadership integral to providing access to controlled substance data at the right time in clinical workflows with minimal effort from staff

• Training critical for training new workflows and tools available within EMR

• Clinical best practice is supported by:–Integrating compliance with Ohio laws with current provider workflows–Providers are given the best tools to reduce opioid dependency

Tools to Reduce Opioid Prescribing

Facility Preference List Additions (Browse Mode)

Fully configured compliant orders for selected common acute opioids style guide

Format: generic // (BRAND) // strength // dispqty // frequency// MEDD // day supply

© 2017 Epic Systems Corporation. Used with permission.

Facility Preference List changes (search mode)note difference between base record & fully configured

Providers can use either fully configured orders or select a less configured choice in SEARCH MODE


Tools to Reduce Opioid Prescribing

All opioid containing medications will have a visual indicator of the calculated MEDD within the order composer

Dynamically calculates based on order dose and frequency

–No current support for additional alerts, highlighting, etc

–Does not calculate with free-text sigs

Implemented February 25, 2018


Tools to Reduce Opioid (MEDD) availability Morphine Equivalent Daily Dose (MEDD) availability • Hyperlink in the upper right corner of the Prescription Monitoring

navigator section• Medication activity • Previously Signed Orders within order entry activity


Diagnosis Association Requirement

• Hard stop at order signing• Effective in Ohio on 12/19/2017 for ALL Opioids

–Addition of ALL Controlled Substances on 6/1/2018


Opioid/Controlled Substance Prescription Requirements• Order Validation Points

–Morphine Equivalent Dose and Day Supply Limits–Day Supply Limits


Alert for Extreme MEDD (>80) for Chronic Opioid • Order Validation Point – Offers advice & options

–Controlled substance contract is a new (2019) meaningful use metric–Soft Stop for selected chronic opioid orders–Single Order Threshold of 80 MEDD–Suppression rules being built in based on department/provider specialty, patient diagnosis


Controlled Substance Monitoring SmartformAs a result of the 2015 legislation, a SmartForm was implemented into Mercy’s electronic health record for quick documentation that could be utilized for reports

• Provided attestation button to document within the EMR that the OARRS report was reviewed – a compliance requirement from OARRS

• Any documentation within the form could be pulled into the providers note via a SmartPhrase – “.CONTSUBSDOC”

• Provided a hyperlink out to the OARRS website to perform a manual query

Link to OARRS Website

Attestation documentation


New Limits on Prescription Opioids for Pain• Effective August 31, 2017, Ohio passed new limits for prescribing opioids for acute pain

• Smartform versatility allows additional documentation to the Smartform already in use

• With provider guidance, the Smartform was expanded to accommodate documenting the new limits and exceptions on prescription opioids


Appriss Integration Phase 2: Enhanced report tools and more effective auditing

1

2

3

4

5

6

1. Link to Integration and smartform.

2. Prior recorded SmartformValues

3. MEDD Equivalent Daily Dose Calculations

4. Urine Drug Screenings

5. Scanned Med Contracts

6. Flags related to FYI flags

7. Links to PDMP websites

7

NarxCare Report

• The NarxCare report is the report display from Appriss

–Takes the raw controlled substance data received from multiple state pharmacies and creates scores and graphs

–Providers can quickly tell the patient's history with opioids and likelihood for abuse

Inpatient Order Set Modification

Removal of opioids from a large number of admission order sets and addition of alternative to opiates (ALTO) sections


Build to promote Medication Assisted Therapy (MAT): SmartTexts, SmartSets• Specific Rx: {buprenorphine RX:210780001}

• Phase of treatment: {Phase of Treatment:210780002}

• Buprenorphine treatment initiated {Time; month:10108} {YEAR:304500053}

• For how much longer do you see yourself taking the above Rx? {Duration of Treatment:210780003}

• Dosing/ tolerance/ safety monitoring:

• Current average total daily buprenorphine dose: *** mg

• Adverse effects reported with use of this Rx? {Narcotic Side Effects:210780004}

• Relapse screening:

• Cravings? {Narcotic Craving Assessment:210780005}

• Any admitted lapses (slips) or relapses in use of other opioids? {Lapse vs. Relapse:210780007}

• Admitted use of other substances (including illicit substances or prescribed substances used without own Rx, or not taken according to SIG)? {NO/YES:19833}

• Psychosocial screening:

• Are you currently employed? {EMPLOYMENT STATUS:20021}

• Recent stressors: {Stressors:120012}

• Co-occuring psychiatric disorder(s)? {Co-occurring Psychiatric Disorders:210780008}

• Enrolled in counseling or support group at present? {Dependency Support/Counseling Interest:210780009}

• (Note: patient advised that therapy is more likely to succeed if treatment program includes participation in mutual support group &/or counseling.)

• OBJECTIVE:

• Vitals: @VS@

• Attitude towards examiner: {ATTITUDE:304650264}

• Pupils: {DETAILED PUPIL ASSESS:21906}

• Mood: {Mood:31886}

• LABS:

• Hepatic function tests:

• @LASTLAB(ast)@

• @LASTLAB(alt)@

• Compliance Monitoring:

• Controlled Substances Monitoring: @FLOWCSM(7943,160794301:LAST:1)@

• Urine Drug monitoring:

• @LASTPROCPOC@

• ASSESSMENT:

• @DIAG@

• PLAN:

• {Buprenorphine Follow-up:210780011}

• {MAT Concurrent Therapies:210780015}


Issue: Free Text Opioid Orders

• Over 104,600 free text orders in the past 2 years

• Most can be accommodated directly with discrete frequency


Dose Range Possibilities

• Need to provide way to capture dose ranges


Frequency Range Choices

• Four new discrete frequency range choices (Q3-4H PRN,Q4-6H PRN, Q6-8H PRN, Q8-12H PRN)


Two methods to convey additional detail to pharmacy and/or patient:1. Add additional information

to patient sig (140 total sig character limit for e-prescribing)

2. Note to pharmacy (300 hard character limit)


Opioid/Controlled Substance Prescription Requirements

Day Supply Designation– Effective December 29, 2017– Hard Stop– Number of days will be dynamically appended to

sig when using discrete sigs (default)– Providers will be responsible for indicating a day

supply on any opioid order when electing to utilize free-text sigs

– May write day supply on a printed prescription © 2017 Epic Systems Corporation. Used with permission.

Next Steps - Use Discrete Sig

• Strong suggestion: avoid free text button for opioids• Instead use of (Discrete) Frequency (elimination for our users

slated for 9/1/2018)

Actionable Alert: Special consent

• Special consent form for Opioid prescribing to Minors–Effective 8/8/2018


Next Steps - Overdose Risk Score

• Ingest the APPRISS overdose risk score (predictive analytics) into the EMR for purposes of decision support and outreach.– Two-way VPN set up and a few adjustments in the Epic interface.

Work In Progress

• Concomitant Benzodiazepines & Opioids


Using Analytics

Morphine equivalents

The key to opioid analytics:–Analogy of calories to food–Method of quantifying any opioid order (prescription)–Morphine Equivalent Daily Dose (MEDD) :

–Potency (conversion factor) X dose (milligrams) X frequency per day

–Can also be used at an order, patient, ordering provider, specialty, regional and population level–Potency X dose X dispense quantity

Different opioids have different potencies, or Morphine Equivalents (MEs)

Hydrocodone = 1

Oxycodone = 1.5

Opioid Prescribing – The Problem

• There were 500,000 prescriptions a year out of CarePATH for Vicodin 5-500/Norco 5-325–Each pill contains 5mg hydrocodone = 5.0 MEs–Typical every 4 hour dosing (6 pills/day) = 30 MEs/day

• There were 500,000 prescriptions a year out of CarePATH for Percocet 5 – 325–Each pill contains 5mg oxycodone = 7.5 MEs–Typical every 4 hour dosing (6 pills/day) = 45 MEs/day

These morphine equivalents were over the Ohio limit!

Analytics Methodologies - Core Opioid MetricsTotal Opioid Orders: This is a raw count of narcotic orders within the reporting period

Auth Provider Outlier (Y/N): A value of “1” here indicates that on any of the Sentinel metrics (columns 6, 8, &10 above) the provider scores BELOW the 10 percentile

Avg Percentile for 3 Sentinel Metrics: The mean of the “Percentile” columns (6, 8, & 10)

Total MEQ RX: This represents the cumulative morphine equivalent burden for all narcotic prescriptions ordered within the reporting period. It is the gold standard and takes into consideration potency, dose, frequency, and quantity dispensed

Percentile Auth Provider Total MEQ RX: This represents the percentile score of the provider compared with peers with lower percentiles (in red shades) being associated with higher MEQ and higher percentiles (in green shades) associated with lower MEQ

Rate MEQD GT30 to Acute Opioid Orders: This represents the proportion among narcotic orders placed for acute pain episodes where the morphine equivalent daily dose exceeded 30

Percentile Auth Provider Rate MEQD GT 30 to Acute Opioid Orders: This represents the percentile score of the provider compared with peers with lower percentiles (in red shades) being associated with higher MEQD >30 and higher percentiles (in green shades) associated with lower MEQD>30

Rate MEQD GT 80 to opioid orders: This represents the proportion of all narcotic orders where the morphine equivalent daily dose exceeded 80

Percentile Auth Provider Rate MEQD GT 80 to Opioid Orders: This represents the percentile score of the provider compared with peers with lower percentiles (in red shades) being associated with higher MEQD>80 and higher percentiles (in green shades) associated with lower MEQD>80

Analytics Methodologies - Build• Key software used:

–SQL server 2014 –SQL Server Analysis Services 2016 RTM 1200 –Visual Studio DTS 2015 –Power BI v Oct 2015 –Excel 2016 with Power Pivot –SSIS

• Data sources used:–Epic (Clarity) –Explorys (IBM) –Kyruus–ACO Payors

Acute opioid• Working definition: no preceding opioid order in a 100 day window prior to

the incident opioid order. –Measures not affected by erroneous or absent associated diagnoses

or problem list entries.

• All of these metrics were built in a manner that is not dependent on the use of an Epic registry. –They were set up in a way that was not dependent on, but could

leverage Epic’s method of calculating and storing maximum morphine equivalent daily dose (MEDD)

Two Opioid Key Performance Indicators for 2018

1) Morphine Equivalent daily dose limit for Acute pain prescriptions–Numerator – Number of total outpatient mode prescriptions where

morphine equivalent dose per day greater than 30–Denominator – Acute outpatient opioid orders (in patients with no prior

opiate prescriptions in the last 100 days)

2) Opiate Burden–Numerator - Total opiate burden (morphine equivalents)–Denominator - Total unique patients with one or more selected

encounters

Region Baseline and Targets:

2 metrics:–Rate MEDD > 30 to Acute Opioid Orders–Opioid Burden Rate

2018 targets are 90% of 2017 baseline

Location of Opiate Data Cube

Users guide to Opiate Data Cube

Performance on Metrics by Region

MEDD> 30 for Acute Prescriptions

Opioid Burden (Total MED for opioid prescriptions to # of unique patients)

Rate Morphine Equivalents > 30 (Opioid naïve pts, OH law 8.31.17)

Opioid burden: Total Morphine equivalent divided by patient

2018 Opioid prescribing metrics by Month (two strategic initiatives- red box)

Provider-level graphs

Provider Dashboard (over time with drill down to orders)

Medication Assisted Therapy (MAT)

Lessons Learned

• Engaging a multidisciplinary team in implementation is key• Must have buy-in from top executives and frontline staff• Engage often with internal and external stakeholders• Develop a plan, assign responsibility and hold all involved accountable• Capture the data and tell the story internally and externally• Take full advantage of efficiencies provided by health information technology• Provider involvement and engagement are critical for success• Engagement of multiple state PMDPs and vendors is necessary for successful

integration• Allow enough time for training and education• Monitoring through operational and analytical reporting is vital for providing

feedback to practices

Summary:

The Use of Healthcare IT Improved Mercy Health’s Implementation of National Recommendations on Opioids• From 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain:

–Clinicians should offer or arrange evidence-based treatment (usually medication assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder

–Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose

–When opioids are started, clinicians should prescribe the lowest effective dosage–Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute

pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Summary:

Significant Reductions in Opioid Prescribing Metrics• The following opioid ordering behaviors were substantially reduced

between July 2017 and July 2018:–Total Opioid orders 41,331 to 36,160 [13% reduction]–Rate opioid orders to all medication orders 8.6% to 6.7% [22% reduction]–Rate morphine equivalent daily dose (MEDD) >30 to acute opioid orders 14.7% to

9.6% [35% reduction]–Rate MEDD >80 to opioid orders 3.5% to 3.0% [14% reduction]–Rate supply >7 days to acute opioid orders 23.5% to 13.3% [43% reduction]–Total morphine equivalents prescribed per patient 59.0 to 45.2 [23% reduction]

Key ContributorsGary Grazak

Jedediah Tuten

Nicholas Waggamon

Karen Goda

Anna Lendl

Michael Temple

Marcus Hanna

Lisa Dubois

Matt Rasmussen

Steve Lemaster

Wayne Bohenek

Brian Latham

Rob Quigley

Kelley Recker

• Integration Engineer

• Dir Pharmacy Acute Operations

• Application Coordinator, Willow Pharmacist

• Application Coordinator, Ambulatory

• Application Coordinator, Ambulatory

• Manager CarePATH Research Informatics

• Executive Director Emergency Services

• Application Coordinator, Interfaces

• Integration Engineer II, Cloverleaf

• Application Coordinator, Interfaces

• VP Care Transformation

• Pharmacy Director St. Rita’s Medical Center

• VP CarePATH Ambulatory

• VP CarePATH Operations

improving opioid prescribing practices · 2019-11-12 · • the average annual death rate in ohio...

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