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
Quotes: Ways Providers Discuss Worrisome Reports with Patients
• 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
Quotes: Ways Providers Discuss Worrisome Reports with Patients
• 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.’”
– Primary Care Clinician
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.”
– Primary Care Clinician
“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.”
– Primary Care Clinician
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
• Need for guidance:
– 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
• Need for guidance:
– 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
Gillian Leichtling
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)
PEHRIIE Evaluation Progress To Date
• 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
PEHRIIE Evaluation Progress To Date
• 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.