Rx15 pdmp tues_200_1_hildebran-leichtling_2kreiner

PDMP Track: PDMPs as User-Friendly Clinical

Decision Support Tools

Presenters:• Christi Hildebran, LMSW, CADC III, Research Manager,

Acumentra Health• Gillian Leichtling, Research Project Manager, Acumentra

Health• Peter W. Kreiner, PhD, Senior Scientist, Institute for Behavioral

Health, Brandeis University

Moderator: Jinhee J. Lee, PharmD, CDR, Senior Public Health Advisor, Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse & Mental Health Services Administration, & Member, Rx Summit National Advisory Board

Dislosures

• Christi Hildebran, LMSW, CADC III, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

• Gillian Leichtling, BA, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

• Peter W. Kreiner, PhD, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

• Jinhee J. Lee, PharmD, CDR, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Learning Objectives

1. Describe how prescribers currently integrate PDMP data into patient care in Oregon.

2. Advocate the use of guidelines and training to optimize prescriber use of PDMPs in patient care.

3. Outline nine state projects designed to integrate PDMP reports with electronic health record systems and pharmacy dispensing software.

4. Evaluate the effectiveness of those state projects’ interventions on prescriber and pharmacist use of the PDMP and on their respective prescribing and dispensing behaviors.

PDMPs as User-Friendly Clinical Decision Support Tools

Christi Hildebran, LMSW, CADC IIIGillian Leichtling, BA

Acumentra Health Portland, Oregon

Disclosure Statement

Christi Hildebran, LMSW, CADC III and

Gillian Leichtling, BA

have disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health

care goods and services.

Learning Objectives

1. Describe how prescribers currently integrate PDMP data into patient care in Oregon.

2. Advocate the use of guidelines and training to optimize prescriber use of PDMPs in patient care.

NIDA-funded Study

“Use of Prescription Monitoring Programs to Improve Patient Care and Outcomes”

Supported by the National Institutes of Health, National Institute for Drug Abuse through Grant # 1 R01 DA031208-01A1, and by the National Center for Research Resources and the National Center for Advancing

Translational Sciences, through grant UL1RR024140.

Study AimsAIM 1:

Determine the prevalence and characteristics of PDMP users and non-users

AIM 2:

Determine how providers use PDMP data; formulate recommendations for clinical guidelines

AIM 3:

Determine whether PDMP use improves patient outcomes and reduces apparent diversion and abuse

Background

• PDMPs increasingly used for public health: reduce drug abuse, improve patient safety

• Many clinicians who prescribe controlled drugs do not use PDMPs

• Little known about clinician responses to PDMP information (what is communicated to patients, what decisions are made)

Methods

• Surveyed a sample of all Oregon clinicians with DEA license (MD, DO, PA, NP, Dentists, Naturopaths; not Pharm)

• Randomly selected 650 frequent users (>1 query per month)

• Of 358 frequent users who returned a survey, 212 agreed to a follow-up interview

• Follow-up telephone interviews (n=33)

Interview Participants

Specialty N

Primary Care (PCP) 16

Emergency Medicine 7

Procedural Specialist (dental, surgical) 6

Other (pain, psychiatry, addictions) 4

Total 33

Results

1. Workflow

2. Communication

3. Decision-Making

Workflow Topics

• Circumstances in which clinicians check PDMP

–Routine versus triggered by red flag or suspicion

–New Rx/patient versus existing patient

Results: Workflow

• Inconsistent use of routine PDMP checks

– Some emergency and procedural specialists check routinely when controlled substance requested; others rely on red flags such as patient behavior

–Many PCPs check routinely with new patients; for ongoing monitoring with existing patients, some rely on red flags

Quotes: Routine vs. Triggered Checks

“If somebody immediately starts negotiating their pain medicine or telling me they’ve lost a prescription and/or they’re new to town ― and usually they would say several of those things ― that’s clearly a red flag. But it wouldn’t even take something that overt. If they’re hinting at…they’re low on their medication, and it’s the weekend and they haven’t been able to get in with their doctor, that’s all it usually takes to prompt me to consider or just go ahead and use the Prescription Drug Monitoring Program.”

– Emergency Room Physician

Quotes: Routine vs. Triggered Checks

“I started trying to be less discriminating. If pain is the

issue and if I think pain medications are going to be a

question, I’ve tried to start doing it almost across the

board with those people before I walk into the room.

I’m not going to try to pick and choose so much, I’m

going to try to do it on most if not all of the people I’m

seeing.”

– Emergency Room Physician

Quotes: New vs. Existing Patients

“The new patient that's coming in asking for opiates is going to get at least checked immediately. With existing patients, it will depend on the situation. If I see them frequently wanting medications, maybe after the first or second time, I'll check them. It really depends on what they're asking for. It depends on the feel that I’m getting from the patient. I don’t have a thing I do for every patient.” – Primary Care Clinician

Communication Topics

• Ways in which providers discuss worrisome reports with patients

• Policies or guidelines that

influence checking the PDMP

and/or prescribing

• Ways in which providers discuss

PDMP information to assess patient

medication compliance and ongoing care

Quotes: Ways Providers Discuss Worrisome Reports with Patients

• Openly discussing and sharing PDMP results with the patient

“For me, it’s a chance to be hopefully less judgmental… and an opportunity to broach the topic. And in an objective, non-judgmental way, to say, “Look at this ― you’re 20 years old and I see you’ve gotten 160 Vicodin over the last month.” – Emergency Room Physician


• Withholding PDMP results and keeping it a secret

“It’s a cat and mouse thing. I keep it secret as much as possible because it’s better used if it’s kept quiet. I can catch the patient unaware…It’s much better for me to have information and I can discover things that are happening. You have to be a bit of a detective.”

– Primary Care Physician


• Avoid discussing the PDMP results with the patient

“I never confront them with the evidence from the

PDMP. I write it up in the chart, so the chart indicates

18 prescriptions for controlled substances, from six

providers over the last year…I’ll flag his chart as drug

seeking and that will be his number one diagnosis.”

– Primary Care Physician

Quotes: Policies or Guidelines that Influence Checking the PDMP and/or

Prescribing

• Discussing PDMP as part of agency policy or guideline

“I tell them that as part of our clinic policy, I need to log in and see if they’re getting these prescriptions from another prescriber. It also helps me to tell them about the policy, the contract that we will have them sign if they start getting them long-term from us.”

‒ Primary Care Clinician

Quotes: PDMP Information Communicated as a Tool to Assess

Patient Medication Usage

• Discusses PDMP results routinely as part of the visit

“I communicate much of the time that, ‘It looks like you’ve been filling your Ambien about two weeks late, so it looks like you haven’t been using it every night. What have you been doing to help yourself sleep on the nights that you don’t take it?’”

‒ Psychiatrist

Decision-Making Topics

• Prescribing decisions in light of worrisome PDMP profile

– New/episodic patients

– Existing patients

• Referrals

– Emergency/procedural specialist referral to PCP

– Referrals to behavioral health provider

• Discharge from care

Results: Prescribing and New Patients

• Clinicians generally won’t prescribe for new patient with worrisome profile

– Some PCPs/clinics had policies against prescribing at first visit or until specific conditions met

• Clinicians will prescribe for verifiable acute condition (e.g., broken bone) regardless

– Emergency and procedural specialists generally won’t prescribe for chronic pain conditions unless authorized by PCP

Quotes: New Patients

“I just say, ‘I see you’ve gotten multiple scripts filled from multiple providers. I just need to look into this some more, and I’ll see you back in X amount of time, hopefully when I’ve gotten the records, and we can figure out what else we’re going to do for your anxiety or pain management.”

– Primary Care Clinician

Quotes: New Patients

“I’ll bring the PDMP report back with me and I’ll say, ‘I want to get clear on the information we discussed. You told me you take a Vicodin once in a while, but I have access to your prescription history and when I looked it up, I see you’re getting a regular prescription for this many from Dr. So-and-So, and that’s more than once in a while. So I want you to know before we do treatment, I will not be able to prescribe you any narcotics in addition to what you're already getting.’”

– Dentist

Results: Prescribing and Existing Patients

• Some clinicians discontinue ongoing Rx automatically at worrisome profile

– Violation of medication agreement

• For some, depends on patient circumstances

– If continue Rx: revisit medication agreement, more frequent monitoring, shorten refill/visit schedule, behavioral health visit

• If discontinue Rx: some taper, others do not

Quotes: Existing Patients

“If they’ve gone to other prescribers, I’ve found it’s most commonly dentists and they don’t think of it as the same thing…I am aware of the kind of mistakes that people make, but when somebody has been to an ER three times in the last month and hasn’t told me, and got prescriptions every time, I simply say, ‘That’s a violation and I can no longer prescribe for you.’”


Quotes: Existing Patients

“It depends on their history and the risk of addiction and abuse. We do a risk evaluation when they first come in, so they’re either a mild, moderate, or high-risk patient. If they’re a high-risk patient and something happens, then it’s a lot more severe what I do. If they’re a moderate or low-risk patient, chances are I might not be as controlling. I might just say ‘Okay, you did this ― now we’re reiterating that this is our policy. You can’t do this again.’ Then I’ll watch their drug monitoring program a lot closer and maybe do urine drug screens more frequently.” – Primary Care Clinician

Results: Referral and Discharge

• Some emergency and procedural specialists refer patient to primary prescriber/PCP, or may contact PCP to ask about prescribing

• PCPs and clinicians who provide ongoing prescribing had varied responses

– Some may discharge if worrisome report; others will not

– Most offer referrals and/or alternatives

Quotes: Referral to PCP/Pain Specialist

“If I feel like they have a legitimate reason for wanting more, sometimes I will call their medical doctor or whoever’s been prescribing all the other pain medicine, and talk to them to see if they feel comfortable with me giving the patient more, or ask them if the patient has a legitimate reason for being out.”

– Dentist

Quotes: Referral to PCP/Pain Specialist

“We are not going to manage medications, narcotics at least, for long periods of time. So when I get into situations like that, I would rather refer them to somebody that is better suited to handle a longer-term situation. Or if I think that they’re going to be a problem, somebody that needs to be monitored a little more closely with urine drug screens and things like that.”

– Surgical Specialist

Quotes: Discharge

“Usually the people I choose to discharge from my clinic are the ones who have been getting narcotics multiple other places and haven’t been honest with me.”


“You have to be a really bad person to get discharged from our practice…I think as clinicians, a lot of times we hide behind the Hippocratic Oath or behind this side that we don't want to hurt anybody. Well, we already got all those patients on these medications. It's best that you work with them to turn the ship.”


Conclusions: Workflow

• Routine use of PDMP vs. triggered by red flags

– Some emergency and procedural specialists not checking routinely

– Some PCPs checking routinely only with new patients; for ongoing monitoring rely on red flags

• Need for guidance:

– What policies or guidelines support optimal use of PDMP?

Conclusions: Communication

• Some discuss PDMP results openly; others hold back PDMP results to unearth patient dishonesty


– What works best in engaging patient?

– What should be the role of episodic providers in discussing concerns with patient?

Conclusions: Decision-Making

• Clinicians likely not to prescribe for new patients with worrisome profile

• Decisions related to existing patients varied


– For existing patients, when to taper, discontinue, or continue prescription?

– What is the optimal care related to discharge in response to a worrisome profile?

Next Steps

• Understand when it is optimal to access PDMP

• Understand how the various ways of communicating PDMP results may affect provider-patient relationship and ongoing patient engagement

• Understand how clinic policies or guidelines may affect provider actions

Contact Information

Christi Hildebran

[email protected]

Gillian Leichtling

[email protected]

Project Funding:

National Institute on Drug Abuse, 1R01DA031208-01A1

For more information, please visit:

http://www.acumentra.org/PDMP/

PDMPs as User-Friendly Clinical Decision Support Tools

Evaluation of SAMHSA’s PDMP EHR Integration and Interoperability

Expansion Projects

Disclosure Statement

Peter Kreiner, Ph.D., has disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

Learning Objectives

• Describe how prescribers currently integrate PDMP data into patient care in Oregon.

• Advocate for the use of guidelines and training to optimize prescriber use of PDMPs.

• Outline nine state projects designed to integrate PDMP reports with electronic health record systems and pharmacy dispensing software.

• Evaluate the effectiveness of those state projects’ interventions on prescriber and pharmacist behaviors

Presentation Outline

• Overview of SAMHSA’s PEHRIIE Program

• Review of evaluation objectives and design

• Review of evaluation progress to date

• Preliminary evaluation findings and recommendations

• Future work

Prescription Drug Monitoring Programs (PDMPs): Challenges to Effective Use

• Data are not sufficiently timely– In most states, pharmacies are only required to report

dispensed prescriptions weekly or biweekly.

• Data are incomplete– Not all states require reporting of all controlled substances

– Data is not shared between many state PDMPs.

• Data are not easily accessible– Manual registration processes, notarization requirements.

– Difficult and time-consuming to access, especially in an ED.

SAMHSA’s PDMP EHR Integration and Interoperability Expansion (PEHRIIE) Program

• History Grew out of Enhancing Access to PDMPs – A National Effort to Reduce

Prescription Drug Abuse and Overdose Through Technology and Policy

Work groups to gather information and provide recommendations (2011)

Pilot Projects to test the feasibility of using health information technology (HIT) to enhance PDMP access (Feb – Sept 2012)

October 2012: SAMHSA funded larger-scale integration and interoperability projects in nine states using PPHF funds (PEHRIIE Cohort 1)

October 2013: SAMHSA funded PEHRIIE projects in seven additional states (PEHRIIE Cohort 2)

About SAMHSA’s PEHRIIE Program

• Primary Objectives:• Increase integration of and access to PDMP data

within electronic health records (EHRs) and/or pharmacy dispensing software (PDS) systems. Goal: Improved PDMP accessibility

• Increase interoperability of state PDMPs across state lines. Goal: Improved PDMP data quality & comprehensiveness

CDC Role: Design and execute a comprehensive process and outcomes evaluation of the Cohort 1 PEHRIIE projects

RxCheck Data Hub

WA Prescription Review

(Vendor: HID)

University of Washington

Network

All WA State Emergency

Depts

EDIE HIE(Operated by Collective Medical Technologies)

Washington DOH (Oversight Agency)

OneHealthPort(Tech Partner =

CyberTrust)

Pharmacies(PharmNet EHRs)

Ambulatory Clinics

(Epic EHRs)

Emergency Depts(Cerner FirstNet

EHRs)

Ambulatory Clinics(Cerner Powercharge

EHRs)

Pharmacies(Cerner Etroby

EHRs)

Other States’ PDMPs

HID RxSentryData Hub

Other Medical Site Trading

Partners

*S&I Framework Pilot with EPIC EHRs

Anticipated Outcomes of the PEHRIIE Program

• Initial Outcomes:– Increased provider registration with the PDMP– Increased provider use of the PDMP

• Intermediate Outcomes:– Decreased inappropriate prescribing/dispensing

practices

• Impacts:– Decreased risky patient behaviors relating to

prescription drug misuse and abuse– Improved health outcomes

EVALUATING SAMHSA’S PEHRIIE PROGRAM

Evaluation Objectives

• To determine if successful completion of the two primary objectives of the PEHRIIE program resulted in changed provider behavior and impacted prescription drug-related health outcomes.

• To identify cross-cutting barriers to and facilitators of successful implementation of sustainable HIT integration and interstate interoperability projects.

• To document important lessons for other states as they expand their PDMPs’ HIT integration and interstate interoperability.

Evaluation Design

• Multi-component, observational and case-comparison approach

Conclusions

Quantitative DataThree Data Types:

• PDMP Usage Data

• State PDMP Data

• Health Outcomes Data

Two planned data collections:

• Baseline

• Follow-Up

Qualitative Data

• Annual interviews with project

directors

• One time interviews with project

stakeholders

• One time interviews with clinical

end users

• Observations

Annual Document Reviews• Grantees’ Proposals

• Grantees’ Progress Reports

• Other information sources

PEHRIIE Evaluation Progress To Date

• Developed a detailed evaluation plan and disseminated it to funded states1

• Qualitative Information Collection:

– Stakeholder interviews in six of nine states

– End User interviews in two of five states

– Regular phone calls with project directors

1 OMB Control Number 0920-1008 (Expires January 31,2016)


• Quantitative Data Analysis:– Baseline data request (March 2014)

• Preliminary PDMP data from two states

• Preliminary metrics from one state

– Negotiation of data sharing agreements with remaining states

– Developed final data request (to be sent in May 2015)• Quarterly data, July 1 2010 – March 31, 2015

• PDMP data and usage metrics


• Document Review:

– Baseline review of project proposals, legal statutes, and other relevant documents

– Annual progress report reviews

PEHRIIE EVALUATION PRELIMINARY

FINDINGS AND RECOMMENDATIONS

Preliminary Evaluation Findings

• Significant differences in project approach and management across states– Statewide vs regional HIEs vs direct integration at end user sites

– Single Sign On vs full integration

– Project management approach

• Interoperability– Steady growth of interstate data sharing within some of the

data sharing hubs

– Pending “within hub” universal data sharing MOUs have slowed data sharing in other hubs

– Pending hub-to-hub data sharing is also delaying some expansion efforts

Preliminary Evaluation Findings

• EHR Integration– End User adoption of new systems has been slower than

anticipated

• Pharmacy Integration– Generally, this piece has been the slowest to be completed

across states– Commercial pharmacies prefer to work with multiple states at

once• Working through organizations like the National Association of

Boards of Pharmacy (NABP)• Project plans must meet standards and adhere to policies in

multiple states simultaneously, which extends the time needed for this work

Preliminary Evaluation Findings• PDMPs, as part of state governments, have traditionally

interacted with other governmental agencies, or with entities (e.g., pharmacies) controlled by state laws or regulations

• Integrating PDMP reports with HIT and interstate data sharing require different kinds of boundary-spanning:

– Interacting with commercial entities (HIE, EHRs)

– Interacting with agencies outside of focal state (interstate interoperability)

– These boundary-spanning efforts may require different kinds of skills than prior PDMP interactions

Preliminary Evaluation Challenges• Quantitative Data Availability

– Data availability varies widely across states• Prescription and patient data elements available• Provider-level usage data available• Years of data available

– Limited ability to identify implementation sites vs. non-implementation sites within PDMP and usage data• Final end user sites are still unknown• No individual implementation sites because project is state-wide• Prescribers practice at multiple sites within one state• All queries assigned to medical director at some sites• Is automatically-called PDMP report the same as a query?

– Underestimated the legal documentation required for data release from most states

Preliminary Recommendations

• Multiple strategies may be most effective for maximizing PDMP utilization by providers– “Push” strategies like integrated EHR access to simplify

workflow

– “Pull” strategies like unsolicited reporting to increase provider awareness

– Legal strategies such as requiring PDMP use as a best practice and mandating PDMP registration

Preliminary Recommendations

• New boundary-spanning skills and structures may be needed, such as:

– Technical training and advisors

• IT technical solutions and jargon

• IT security requirements

• Legislative processes for statutory and rule changes

– An implementation steering committee including representation from all stakeholder groups

Remaining Work

Apr May June July Aug Sept

QualitativeComplete stakeholder & end user interviews

QuantitativeDisseminatefinal data request

Final data collection and analysis

Doc ReviewFinal progress report review

GeneralFinal report writing

Interim and Final Reports• State-specific interview summary report

– Following completion of all stakeholder interviews for that state– Factual review by the project coordinator

• State-specific comprehensive report– Will include findings from qualitative interviews, document

review, and quantitative analyses– Can be disseminated to other interested parties

• Final Evaluation Report– Will examine cross-cutting issues, successes, and lessons

learned from all participating states– Qualitative, quantitative, and document review results will

be included

PEHRIIE Evaluation Team Members

CDC Evaluation Team Lead:

• Jan Losby

CDC Research Fellows:

• Kristen Cincotta

• Wesley Sargent

• Brian Manns

CDC Statistician:

• Rose Rudd

Subject Matter Experts:

• Peter Kreiner, Brandeis University

• Cindy Parks Thomas, Brandeis University

CDC PDO Team Lead:

• Debbie Dowell

Thank You

The findings and conclusions in this report are those of the author and do not necessarily

represent the views of the Centers for Disease Control and Prevention.

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