Although opioid-related fatalities are slowly decreasing across the U.S., emergency department (ED) physicians still are faced with the great challenge of treating patients who present with an overdose. And those statistics continue to trend upward—by as much as 30 percent at some EDs, including Connecticut’s largest provider, Yale New Haven Hospital (YNHH).
With growing evidence that people who have had an overdose are more likely to have another, being seen in the ED is an opportunity for action. But in order to take meaningful action, physicians need accurate data in real-time to aid clinical decision making and safely manage treatment.
One tool that’s helped some hospitals in this area has been state prescription drug monitoring programs (PDMPs) that help clinicians find patient history by collecting prescription data for Schedule II through Schedule V drugs into a centralized database. Healthcare providers and pharmacists can then use the tool in the active treatment of their patients since, in theory, they are presented with a complete picture of a patient’s controlled substance use, including prescriptions by other providers. Currently 49 states have PDMPs that are operational, with Missouri as the lone exception.
Interestingly, however, in Connecticut, providers have struggled with using the state’s PDMP tool, the Connecticut Prescription Monitoring and Reporting System (CPMRS), says Vivek Parwani, M.D., the medical director at YNHH’s adult emergency department. From his perspective specifically, he says he could remember at least a half-dozen occasions when he had to recreate a new password, go into his email, and then back to the database just to check a patient’s prescription history. This process took over 15 minutes, and sometimes, a patient’s controlled substance history was never checked due to the technology burden.
“This was all during the course of a shift in a busy ED. I see 300 to 400 patients a month, but I was only checking the PDMP [here and there]. It’s effectively a useless website; occasionally you can get what you want, but it requires a lot of work to do so,” he says.
Undoubtedly, the need for quicker data access was mounting. With 955 opioid overdose deaths in 2017 in the state, Parwani knew the hospital needed to have quick, easy and integrated access to controlled substance prescription history. As a solution, the hospital implemented NarxCare, a substance use disorder platform developed by the Louisville, Ky.-based Appriss Health, and now Parwani says that clinicians have an easier view of the patient profile within the electronic health record (EHR).
Appriss Health officials have stated that its NarxCare platform allows for the integration of the state’s PDMP information directly into the EHR. As a result, clinicians are presented with interactive, visual representations of controlled substance prescribing information, advanced analytic insights, risk scores, and red flags directly in their EHRs, officials said.
According to Parwani, the NarxCare platform enables ED physicians to do exactly what the PDMP was created for without wasting valuable time logging into the state dashboard to find patient history, only to then have to log back into the EHR. Indeed, the integration between the Appriss product and the organization’s EHR is where the real value is seen, he says. “It’s part of our header in the Epic EHR. So you can see if a patient has a primary care physician, their allergies, and in the same place, the patient’s ‘Narx Score’ score pops up,” explains Parwani.
Produced via a patented algorithm that analyzes controlled substance data from PDMPs, the Narx Score quantifies risk with a three-digit score, ranging from 000-999. According to Appriss officials, in general, the score is a weighted combination of multiple variables such as drug equivalents, number of providers, potentiating drugs, number of pharmacies, and number of overlapping prescription days. The score is intended to create a composite risk index, which increases as the value of one or more of the risk factors in a PDMP report increases.
Narx Scores have been computed for three different drug types; specifically, narcotics, sedatives, and stimulants. Officials note that about 75 percent of scores will fall below 200, about 5 percent will be above 500, and only 1 percent will be above 650. The score’s last digit represents the number of active prescriptions that a patient will have if medications are taken as directed, and that’s the key number that Parwani pays attention to, he says.
During a recent shift, he recalls, a patient presented with severe abdominal pain and trauma, which was presumed to be gastritis or stomach inflammation. The NarxCare tool immediately showed the patient had a high Narx Score, but without the ability to view that information in real-time, Parwani admits he would have prescribed this patient a small amount of opiates. The hospital’s EHR does have a preset number of pills that it limits a physician to prescribe, but even a small amount for a patient who has a high score could be dangerous, he notes.
On another recent shift, Parwani saw 30 patients in eight hours, and about one-third of them had a non-zero Narx Score, meaning they had an active controlled substance prescription. “In a few of those cases, having that type of integration made a palpable difference,” he says.
At the same time, Parwani acknowledges that he’d be much more comfortable prescribing opiates to a patient with a low score. In the context of ED physicians’ prescribing patterns, “it’s really a critical to have easy and quick access within the EHR as it could definitely make a difference in getting pain medications to the right patient,” he says. And that is an key point, he adds; some people could be harmed by getting a few days of narcotics whereas others wouldn’t be. “Getting the right [amount] of medications to the right patients is critical.”
