It’s quite remarkable to think
Transcript of It’s quite remarkable to think
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It’s quite remarkable to think
back to our humble beginnings ...when a group of ambitious, young clinicians, not being satisfied with the services available to
the public, relentlessly lobbied for a new hospital to better meet the needs of the community.
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This building is not a
private enterprise …
It is a great, public
compassion. Here is a
living monument to the
heart of the people.
“
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Who We Are Today
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MISSION:
HEALTHHOPE HEALINGA N D A D VA N C E
E L E VAT E
T O I M P R O V E
- FOR ALL
VISION:TO BE THE FIRST AND BEST CHOICE FOR CARE
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37,800 Patient Encounters
25,000 Physician Visits 3,900 ED Visits 700 Home Health Visits
475 New Primary Care Patients 14,000 Virtual Care Encounters
$5.6 MillionEach day in uncompensated care
and other benefits to our community.
In One Day at Atrium Health
(1 every 2 seconds)
91 Babies Delivered 635 Surgeries
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Size & Scope
$11.1 BillionNet Operating Revenue
$2.9 BillionIn last 5 years
Invested into renovations, new care
locations, equipment upgrades and other
capital projects
69,800+ Teammates 50 Hospitals
44 Urgent Care Locations 45 EDs 25 Cancer Care Locations
4,650+ Physicians 17,000+ Nurses
*Includes Joint Venture and Affiliated Enterprises
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2019 Facilities & Locations
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FOR ALL
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REPUTATION OF EXCELLENCE
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Local Problem: Utilizing Clinical Decision Support to
Assist in Opioid Prescribing
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Staggering Statistics
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63,600Overdose deaths in 2016 making it the
leading cause of death
170 MILLIONOpioid prescription
increase from 1992 to 2012
236 MILLIONOpioid prescriptions
written in 2016
4 / 5Heroin users started out
using prescription painkillers
94%In opioid addiction carechose to use heroin dueto expense and access
504 BILLIONIn economic costs
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Local Impact
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Full Administrative Support
Opioid Steering Committee
Quality, Safety & Patient Experience (QSPX)
Patient Safety Subcommittee
SVP & Chief Medical Officer
Research
Medication
Safety
Clinicians Pharmacy
Information
& Analytics
Services
Behavioral
Health
Pain
Management
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Integration of Clinical Need with Research and Quality`
Original PRIMUM Study Funded by the
CDC
2014
2015
PRIMUM Alert Launched in the
EMR
CDC Guideline for Prescribing Opioids for Chronic Pain
Released
23,000 High-Risk Prescriptions Cancelled
2016
2017
Awarded CDC Grant for Operationalization of
CDC Guideline
Controlled Substance Review Component
Launched
Opioid Dashboard Launched
Awarded CDC R01: IMPROVE
Cerner made PRIMUM available
2018
Over 43,000 High-Risk
Prescriptions Cancelled and
Counting
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Publication
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PRIMUM Platform
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Silent Phase
• Anticipated workflow impact was high• Concern for alert fatigue• Ran the rules in the background• After 1 month – the impact was substantial • Go/No-Go decision was made• Response was far less than anticipated
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Phase 1 - Alerting
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Impact of Phase 1
In 6 months
3,860opioid prescriptions
2,857benzodiazepine prescriptions
prevented
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Phase 2 – Alerting Advances
Provider receives alert
when extended
release opioid is
prescribed without a
30-day history of
previous prescription
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Phase 2 – Naloxone Co-Prescribing
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Phase 2 – Therapy > 90 Days
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Rapid Increase in Alerting
• Noted an increase in opioid alerting • High rate of cancelation beyond expected• Physicians ordered non-indicated opioids in order
to trigger the alert for the purpose of getting the information
• Then cancelling the order
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Opioid Widget – Workflow
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Opioid Widget – MME & Active Rx
Displays all active prescriptions and 30 day history of onsite administrations
Calculates total MME per day. Displays green if <50, yellow if 50-89, and red if >90
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Opioid Widget – 3 or More & Benzo
Indicates whether patient hashad 3 or more prescriptions inpast 30 days. Displays green ifno, red if yes.
Indicates if patient has active opioid and benzodiazepine prescriptions. Displays green if no, red if yes.
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Opioid Widget – Pain Agreement
Displays total MME prescribed
Indicates whether patient has current pain agreement. If so, displays date. Includes hyperlink to launch pain agreement for all patients.
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Opioid Widget – Pain Agreement
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Opioid Widget – Connection to State PDMP
Indicates if patient has history of overdose or positivetoxicology screen. Displays green if no, red if yes.
Hyperlinks to NC and SC -Prescription Drug Monitoring Program
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Opioid Widget – Bypassing Alerts
Bypass the alerting
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Impact
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Provider Education Online
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Discharge Instructions
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Clinical Implications
• Increase the number of illegal drug narcotic users?• Results in a higher rate of death?• Prescribe more Narcan?• Will the patients hate it?
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Heroin Overdose
0
200
400
600
800
1000
1200
2014 2015 2016 2017 2018 2019
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Heroin Deaths
0
2
4
6
8
10
12
14
16
2014 2015 2016 2017 2018 2019
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Naloxone Prescriptions
0
500
1000
1500
2000
2500
3000
3500
4000
4500
2014 2015 2016 2017 2018 2019
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Patient Satisfaction
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
2014 2015 2016 2017 2018 2019
Top
Bo
x %
Atrium HealthOverall Rating of Care
ED IP Med Practice
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Benzodiazepine Prescriptions
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Making an Impact
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Value Derived
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Opioid Prescription Dashboard
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Dashboard
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Dashboard Trends
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Original PRIMUM Study Funded by the
CDC
2014
2015
PRIMUM Alert Launched in the
EMR
CDC Guideline for Prescribing Opioids for Chronic Pain
Released
23,000 High-Risk Prescriptions Cancelled
2016
2017
Awarded CDC Grant for Operationalization of
CDC Guideline
Controlled Substance Review Component
Launched
Opioid Dashboard Launched
Awarded CDC R01: IMPROVE
Cerner made PRIMUM available
2018
Over 43,000 High-Risk
Prescriptions Cancelled and
Counting
Integration of Clinical Need with Research and Quality
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National Outcome
• Direct connection to the NC PDMP
• Understanding administrative data delivery
• Determining best visual for ongoing alerting• Discern Alert
• Smart Zone
• Partnership with our national vendors
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Value Questions
• What meaningful metrics to focus
• We had to pull the Rx data out to a data mart• Necessary details needed
• Apply Morphine Milligram Equivalent (MME) calculation
• For us volume is an issue – 50,000 Rxs a month
• Connections to the medications needed
• Attaching to all providers (NNPs and PAs)
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Technical Challenges
• Adherence to the standard Mpage code
• No MME calculations standard• Working through all the meds
• Multum update now has MME
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Challenges
• Medication duration problematic
• Determining acute vs. chronic
• Connection to PDMP
• Standardizing pain agreement
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Key Learnings
Big build and lots of time required
Power BI was important for information display
Needed to connect and include:
Geography
Specialty
Administrative line
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Lessons Learned
• It is important that CDS alerts are tested and tuned sufficiently to minimize
alert fatigue.
• The engagement of key stakeholders supported by an appropriate
governance structure is key to the success.
• Data evaluation and alert development will require adequate resources
• Collaboration is paramount in tackling the opioid epidemic
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In Summary
Local problem: Atrium Health created a taskforce in 2017 to focus on the development of standard tools and resources to support the appropriate use of opioids. Global Collaboration
Design and Implementation: Atrium Health built an alerting system to address prescribing patterns of opioids by providing critical, objective information at the point of care. The CDS alerts were built and ran silently in the background in order to appreciate the impact prior to exposing the alert. The development of the opioid alert was dependent upon the alert requirements being consistently and accurately documented in the EHR in a specific location that could be searched in an automated way. The ultimate goal of this intervention was not to achieve a cancellation for all at-risk patients; rather, we aimed to provide information to prescribers for them to use to inform their clinical decision-making. Iterative
Healthcare IT: EHR, CDS, CPOE, Dashboards, analytics, development of PRIMUM platform – Solution Backbone
Value derived: Improved information at the POC for appropriate opioid prescribing. Without Negative Consequences
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Questions??