What practical steps are the leaders of patient care organizations taking right now, in the nationwide battle against opioid addictions and opioid abuse? Many patient care organizations across the U.S. are in fact taking active steps, moving forward on what inevitably is a complex and challenging path to intervention in the crisis.
On July 16 at the Grand Hyatt Denver, during day two of the Rocky Mountain Healthcare Innovation Summit, sponsored by Healthcare Innovation, two clinician leaders shared from their organizations’ journeys in this area, in the session entitled “Optimizing Health Information Technology to Promote Opioid Stewardship.” Joanne Hatfield, PharmD., lead pharmacist, pain management, at Truman Medical Centers in Kansas City, Missouri, and James Hellewell, M.D., medical director, care transformation information systems at Intermountain Healthcare, Salt Lake City, shared from their organizations’ experiences in this area.
Truman’s Hatfield presented first. At the time that she and her colleagues began their initiative, she told the audience, no inpatient pain management service existed outside of the palliative care area. But senior leadership rounds were able to uncover the pain management concerns on the part of patients and their families, and how those concerns were impacting overall patient satisfaction. Meanwhile, the organization’s outpatient pain clinic requested pharmacist involvement in an interdisciplinary clinic.
Hatfield was able to focus her time and energy on this initiative, leading an opioid stewardship effort, while also offering inpatient and outpatient pharmacy pain management consults. Looking back on what’s been accomplished so far, she said, “We’ve taken a lot of what’s been done with microbial stewardship, and applied it to opioid stewardship. Within our organization, we asked ourselves which patients were at highest risk for addiction? We determined that those on schedules for prescriptions were at the highest risk. Also, are those being adequately treated for pain? We also used other functionalities” to address the issue of adequate pain management, while moving forward to modify the prescribing of opioids, she said.
Hatfield noted that “Missouri is the only state without a statewide database for the reporting of controlled substances; hopefully, that will happen in the next year,” she said. Fortunately, she added, “We now have a secure messaging application we use; that’s been great.” Further, in analyzing the situation clinically, she said, “We decided to adjust the order of discharge sequence,” to focus on patient education, in order to ensure that it was being included in the discharge process. Importantly in that regard, she said, “You have to integrate this into clinicians’ normal workflow, into the EHR [electronic health record], to get them to see it. And lastly,” she said, “it’s important to integrate opioid education process into the discharge process for patients.”
Much progress has been made in the past two years at Truman Medical Centers, Hatfield told the audience. Starting in 2017, pharmacists began reviewing opioid management with every prescription order. And, after an initial pilot in this area that began in January 2017, the program was rolled out across the entire organization. Importantly, she reported, “We’ve achieved a reduction of about 30 percent in the prescribing of parenteral opioids since then.” Meanwhile, at the start of 2017, about 4,000 short-acting opioid prescriptions were ordered every month; “we’re down to about 3,500 now,” she reported. “Some of this decrease has certain been connected to the national spotlight on the national spotlight on the opioid epidemic, but we’d like to think it also relates to our continuous education process.” Another sign of progress? Before the initiative, only 2 percent of opioid prescriptions were being written for a five-day supply, the shortest standardized order for such prescriptions; now, she noted, that figure is 19 percent. “That’s progress.”
Meanwhile, Hatfield said, “Our pharmacy consult services continue to grow. Our physicians request about 17 consults with me for opioid management per month on the inpatient side. And on the outpatient side, the number of physicians asking for consults continues to grow at a regular pace. “Overall,” she said, “the volume of interventions ebbs and flows; but the acceptance rate is about 95 percent.” Importantly, she said, “Clinicians do listen” to consultative pharmacists in this area.
What’s been learned? Among other things, Hatfield told the audience, “One key is developing a multifaceted, pharmacist-led pain management program. I’ve been cochair for our corporate pain management committee. We’ve done a lot of education of multiple disciplines,” she testified. “And we’ve managed opioid shortages.” Staffing remains a challenge; she herself remains the only pharmacist dedicated to this work, in the organization.
Meanwhile, analytics has proven to be very vital to the success of the initiative so far. As just one practical example, Hatfield said, “Previously, I was manually running a report on the previous 24 hours on patients who were on IV or parenteral opioid management. The report would run after midnight, and would miss people” whose treatment began after midnight but before 8 AM. “Now,” she said, “we’re able to cover every patient. We found that patients were often more or less automatically prescribed parenteral opioids upon admission to the hospital. Often, they could be put on a pill.” And reducing the automated ordering of longer-term refills, she added, has been key. The Food and Drug Administration, she noted, suggests automated refill orders for no longer than five to seven days. So Hatfield and her colleagues established a protocol based on five day-orders and no longer. That protocol can always be overridden, she noted, and there is no attempt to substitute automated prompts for clinical judgment. But, in a care delivery environment in which most prescribers are medical residents, guiding prescribing choices has made a great deal of sense. In the end, she said, “We’re trying to ingrain better prescribing practices.”
At Intermountain, tackling co-prescribing and order-default issues
Things are moving forward in this area, too, at the 23-hospital, 170-clinic, 37,000-caregiver Intermountain Healthcare in Utah, Dr. Hellewell told the audience. Indeed, though Utah was only one of nine states nationwide to record a decrease in opioid overdose deaths from 2016 to 2017, tragedy did not escape that state, as 360 people died of an opioid-related overdose death in Utah in 2017.
Dr. Hellewell said that one of the areas that he and his fellow clinicians at Intermountain have focused on is the issue of co-prescribing opioids and benzodiazepines (a class of drugs that includes the commonly prescribed drugs known by their commercial names Valium and Xanax), citing research that has found that more than 30 percent of overdoses involving opioids also involve benzodiazepines. Indeed, he noted, a cohort study in North Carolina found that the overdose death rate among patients receiving both types of medications was 10 times higher than among those receiving only opioids.
“In mid-2017,” Hellewell told the audience, “our CEO made a commitment to reduce the prescribing of opioids for pain. We set a goal of a 40-percent reduction” of opioid prescriptions—and, impressively, the organization has already achieved a 30-percent reduction in two years. Very importantly, he said, “A lot of what is involved here is not really about technology. It involves people, process, and technology, and technology is the last of those three elements.” Still, he said, data analytics has been critical in defining and tracking progress.
As at Truman Medical Centers, the clinician leaders at Intermountain realized early on that one area of real potential involved clinical protocols around the prescribing of opioids. “There’s an area known as short-acting opioid order sentences,” he explained to the audience. “We found that we had room to improve in that area.” Within their EHR, he said, the default order sets were very high. A recommended amount of pills, he noted was 8 to 12. As he explained, “When a provider orders, they generally start with a default order. One thing that we did was that we reduced the dispense amount from as high as 60 or more to 8 and 12. You can change it on an individual level, but the defaults, have been changed. We also took away one of the functions to automatically calculate a 30- or 90-day supply. That’s really not applicable when prescribing for acute pain.”
What’s more, Hellewell said, “In addition, we’ve changed the therapy type: it can be acute or maintenance. Maintenance prescriptions are really meant to be refilled every month; acute prescriptions are really meant for a particular period of time. We default to a specific period of time, with a stop date for the prescription. That’s important, because you could imagine a patient going back in, showing up at the physician’s office, and the physician might think it’s a chronic case, and offer to fill it.”
And, he added, “Another thing we did, perhaps the boldest move at all: we looked at the order sentences that providers created for themselves. As a provider you can create a favorite folder form.” Very encouragingly, he noted, 4,230 prescribing clinicians changed their therapy types from maintenance to acute therapy,” meaning that they are now prescribing more rigorously and in effect, monitoring opioid use more carefully. Importantly, he said, speaking of the cultural changes involved, “We paused [the initiative] for some time, to discuss things and to engage with prescribers; we needed for them to be on board, because they could easily have changed their favorites back. But in the end, we were able to make changes, changing the therapy type from acute to maintenance” as the default choice. “We also got rid of refills on those favorites.” What’s more, he reported, “Only about 5 percent of the favorites have been changed back. That’s pretty impressive; it gives you an idea of how effective these defaults can be.”
Alerts--a necessary set of interruptions
In addition, Hellewell told the audience, “We’ve also put some alerts in place. Alerts should be considered a last resort, because you’re interrupting people. We did find a few spots where we thought it was worthwhile. One was the dispense amount alert. We set up an alert that would fire the threshold of 12 pills, and would let them know that they were prescribing more than the norm. It’s a soft alert, but it gives them the chance to think twice about it and change the dispense amount. We found that over time, fewer providers changed. That’s to be expected, because you’re learning the behavior,” he added.
Another very important alert is the opioid/benzodiazepine alert that Intermountain Healthcare clinician leaders have put in place. And it works whether a single clinician is about to order an opioid and a benzodiazepine, or if a second clinician is ordering one of those medications after a first clinician ordered one of the two types of medications. And a third important alert put into place has been an inpatient opioid order alert, based on the fact that, as Hellewell noted, “When you have jointly managed patients, you’re at risk for a situation in which one group is ordering or prescribing medications, and the other doesn’t know. In the case of opioids and benzodiazepines, there is the risk of too much sedation. This alert will warn or caution a surgeon about to order a sedating agent or opioid, to contact the pain services team.” They’ve also been working on standardizing measurements for morphine dosages.
As for the 30-percent reduction already achieved in just two years, Hellewell said, “We’ll get pretty close to that 40 percent reduction in opioid prescription for acute pain” that the organization’s CEO has committed the organization to. And, in addition to the overall 30-percent reduction already achieved in opioid prescribing, a full 3.8 million fewer opioid tablets were prescribed in 2018.
Both of these organizations continue to move forward in this complex, challenging area, and Hatfield and Hellewell assured their audience that they will continue to make additional progress over time, at a time when patient safety and community well-being are in focus more than ever.