Although Minnesota has historically compared favorably to many of its U.S. state peers—notably in the Southeast and Midwest—in the number of opioid-related overdose deaths, it has hardly been spared. In fact, the state’s opioid overdose death rate increased 12 percent from 2015 to 2016, with about half of the opioid-related deaths associated with prescription medications.
As it has been for so many patient care organizations, the growing opioid public-health crisis was becoming a major cause of concern for providers and administrators at Allina Health, a 12-hospital integrated delivery system serving patients throughout Minnesota and western Wisconsin. Clinical and IT leaders at the health system realized they needed to minimize excessive quantities of opioids remaining after care and thus prevent opioid misuse within the community. Allina further recognized a need to evaluate how it managed acute non-cancer pain for the 4.8 million annual visits to its more than 90 health clinics, particularly among opioid-naïve patients.
From there, as organization executives detail, a project around combating opioid abuse with data-driven prescription reduction was born—an initiative built on collaboration, change management and leveraging robust data analytics. As a result of this leading-edge work, Allina Health was one of two health systems that received co-second-place recognition in the 2019 Innovator Awards Program, from Healthcare Innovation, for using data and IT to combat the opioid crisis.
Like their peers at Bon Secours Mercy Health, the other co-second-place winner in this year’s program, Allina Health leaders knew they needed to change their strategies around reducing the number of opioids their providers were prescribing. They believed if they were able to reduce opioid availability, opioid dependency would also be reduced.
How it all began
While clinical guidelines for acute pain management were initially in place at Allina—with help from the Institute for Clinical Systems Improvement (ICSI), an organization that helps providers in Minnesota and elsewhere address major health topics such as opioid misuse and addiction—it was not producing a noticeable reduction in the number of opioids prescribed, the health system’s officials recall.
The issue was that while providers were aware of the negative impact of prescribing high numbers of opioids for acute pain after a procedure, some were not aware of the ICSI guideline recommendations, leading to unintended variation in prescribing practices. In short, providers did not have the data they needed on how their prescribing practices compared to the prescribing practices of their peers.
In response, an interdisciplinary acute pain committee was formed in 2015 which included clinicians, program directors, pharmacists, educators, and other leaders from across Allina. The committee, that is still in place today, first conducted a review of the latest literature as well as a comprehensive review of internal prescribing data. From that came the implementation of system-wide clinical guidelines, with the goal of ensuring appropriate, standardized management of acute pain, while working to prevent overuse, abuse, and addiction, officials say.
The clinical guidelines specifically include items such as: conditions for which opioids are not prescribed; assessment for which alternative therapies may be used; screening for risk of misuse and adverse outcomes; conditions or cases where prescribing opioids is higher risk; advisory against long-acting opioids for acute pain; recommendation to prescribe less than or equal to 20 pills, or a maximum of five days of opioids, per prescription for acute pain; and recommended use of the Minnesota Prescription Monitoring Program (PMP), a database of controlled substances previously prescribed to patients.
Data transparency is critical
In 2016, the health system developed a care goal around opioid prescribing, similar to the care goals it already had around hypertension, diabetes and healthy weight. From there, explains Kathleen Keller, R.N., project management coordinator at Allina, team members began to measure the actual opioid pills prescribed. With the help of Utah-based analytics vendor Health Catalyst, reports were developed that gave Allina leaders important chronic and acute care information, “such as what our physicians were writing at discharge, what they were giving patients for procedures at discharge, how many opioid-naïve patients there were, and how many patients were on opioids and benzos [benzodiazepines] combined,” recalls Keller.
The Health Catalyst reports increase the ability to look at trends from many different lenses, Keller notes, adding that through the collaboration with ICSI, Allina could work with other organizations that were also affiliated with the firm, and share its data with them so that comparisons could be done, and opioid tables for certain procedures could be created. As a result of these reports, providers can distinguish the standard number of opioid pills that they would prescribe following a single-level cervical fusion, for example, Keller offers.
Speaking further to the data transparency element, Keith Olsen, D.O., regional medical director at Allina, notes, “Physicians are scientists by nature; they want to see data. It’s an old [maxim] that if you can’t measure it, you can’t improve it. So we had to come to the providers with provider-level specific data on their prescribing habits,” he says. Olsen adds, “For many providers, having that transparency of the data and seeing their prescribing habits compared to their peers was helpful in driving their improved behavior on prescribing.”
Using the reports generated from Health Catalyst that drilled down into prescribing data, the top five procedures with the highest volume of opioid prescriptions at discharge were identified, and shared with service line leaders, who then partnered with physician leaders to provide education and take appropriate action. This regular communication and teamwork added needed transparency, officials say.
Murray McCallister, clinical director of pain services for Courage Kenny Rehabilitation Institute, part of Allina Health, says that when the health system started getting the data in, they had conversations on how they could properly compare themselves to other patient care organizations. “Each of us started doing research around what the published [evidence] shows, but there really isn’t any. In some respects, we’re very early on in the process. How do we compare ourselves? We don’t quite know yet,” he admits.
What’s more, Allina also created a structured order set and progress note in its EHR (electronic health record), inclusive of the ICSI template, which providers were asked to review. The order sets in the EHR included prescribing recommendations to: limit the number of opioid pills for a single acute pain prescription to a three-day supply or 20 pills; limit the morphine milligram equivalents (MME) for a single acute pain prescription to 200 MME total; and standardize MME ranges by procedure type, according to the project’s senior leaders.
A new pain management approach
As part of the transformation process, the way in which providers traditionally have managed patients’ pain would have to be changed. And there are multiple layers to this alteration, Allina executives contend.
For one, ensuring that acute and post-surgical patients are managed in a rational way that prevents people from transitioning to chronic use of opioids “has been our big target so far,” says McCallister. But a second key consideration involves more than just reducing the number of opioid prescriptions.
“The question becomes, what do you replace opioids with? And the truth is that there are a number of non-narcotic ways of managing pain,” says McCallister. “So in acute or post-surgical conditions, you might use opioids very briefly and then ideally transition toward non-narcotic pain management,” he says, noting that this area has been a core focus for ICSI as it continues to update its pain management guidelines. “Opioids, overall, are [just part] of pain management; it’s a subset of the larger whole and we need to expand the conversation around how to improve pain management in general,” McCallister asserts.
Keller describes how Allina’s pain management steering committee—whose membership includes physician leadership, nursing leadership, pharmacists, quality specialists, and data analysts—has given providers and nursing staff recommendations, including beginning initial pain management with non-opioid prescriptions and alternative treatments, such as physical therapy, massage, or acupuncture.
Impressive outcomes, already
In just one year, Allina’s leaders call out the following improvements as most noteworthy:
- More than 3.8 million fewer opioid doses prescribed in Allina’s outpatient facilities in 2018 compared to 2017, including pills and other forms of opioid medications
- 3,441 fewer patients (with acute or chronic pain) receiving eight or more opioid prescriptions from 2015 through 2018
- 13,391 fewer patients receiving opioid prescriptions for more than 20 pills in one year, a 13 percent relative reduction
- 15,730 fewer opioid pills prescribed at discharge in one year, and a 16 percent relative reduction in the number of opioid pills prescribed per admitted patient.
Olsen adds that the data-driven nature of this project has enabled clinical and IT leaders to go into surgical service meetings and openly discuss with individual providers the number of opioids they are prescribing for a particular procedure. “Let’s have a discussion about why doctor X is prescribing 50 percent more [opioids] than doctor Y. That’s the transparency we need and that’s what is going to drive prescribing reductions,” he attests.
