Opioid addiction and opioid-related deaths have increased dramatically in the United States in the past decade and healthcare provider organizations across the country are grappling with finding ways to curb the nation’s opioid epidemic.
According to the Centers for Disease Control and Prevention (CDC), deaths from drug overdoses in the U.S. totaled more than 63,600 in 2016, with 42,249 of those deaths attributed to opioids. The death rate from opioid overdoses was five times higher in 2016 than in 1999. In a state-by-state analysis, in 2016 West Virginia had the highest death rate per 100,000 population, followed by Ohio, New Hampshire and Pennsylvania.
During a webinar April 25 sponsored by the College of Healthcare Information Management Executives (CHIME) Opioid Task Force, executive leaders at the Danville, Pa.-based Geisinger Health System outlined a multifaceted, data-driven initiative by health system leaders to address the opioid crisis in Pennsylvania.
“Opioids have been a challenge for us,” acknowledged John Kravitz, CIO at Geisinger Health System, citing the statistic that Pennsylvania’s opioid overdose death rate was the fourth highest in the country. In 2016, there were 4,642 drug-related drug deaths in the state, with 85 percent involving opioids and one in four being prescription opioids. What’s more, many of the counties with the highest death rates in 2016 were served by Geisinger Health System.
Kravitz, along with Richard Taylor, M.D., Geisinger’s chief medical information officer (CMIO) and Michael Evans, Geisinger’s vice president of enterprise pharmacy and chief pharmacy officer, detailed the health system’s effort to utilize data and health IT tools to change providers’ prescribing practices. As a result of this effort, the health system has slashed opioid prescriptions in half, from a monthly average of 60,000 opioid prescriptions to 31,000 prescriptions per month.
Geisinger Health System consists of 12 hospitals and 700 clinics with 2,400 employed physicians and more than 4,000 affiliated physicians. The health system’s reach includes more than 3 million residents in 45 counties in central, south-central and northeast Pennsylvania and southern New Jersey. As an integrated system, Geisinger also operates a health plan with 600,000 members.
According to Kravitz, physician leadership recognized the opioid crisis in its own communities and wanted to reverse the trends. By limiting or eliminating the prescribing of opioids in a clinical setting, physician leadership proposed, Geisinger could minimize or prevent a patient’s exposure to the drugs and the consequent risk of the patient developing an addiction that might lead to an overdose and death.
Physician leaders also recognized that reducing opioid addictions could ease the burden on the health system. An analysis of 942 patients in the Geisinger system who overdosed on opioids found a steep increase in the use of acute care, and especially emergency department services, prior to an overdose, according to Kravitz.
He emphasized that addressing prescription opioid abuse requires a multifaceted, holistic effort that includes encouraging effective non-opioid therapies for pain management. “Technology is not the silver bullet to solving this problem; there is no single silver bullet,” he said.
Kravitz noted that the original intent of the initiative wasn’t to reduce opioid prescriptions, but to ensure appropriate pain management with the recognition than non-opioid therapies would help patients avoid the side effects of opioids and reduce the potential risk of addiction. In the surgical setting, Geisinger leaders designed a pain management program in which patients and their families were counseled to expect some manageable pain after relatively minor procedures. At discharge, providers were encouraged to offer nonaddictive alternatives to opioids for managing pain, such as Tylenol, nonsteroidal anti-inflammatory drugs or other novel medications. If a physician decided an opioid prescription was in the best interest of a patient, the physician was encouraged to use the smallest effective dosage prescribed for three days or less, Kravitz said.
In addition, for chronic pain patients and patients at risk of addiction, Geisinger recommended therapies such as rehabilitation, exercise, cognitive behavioral therapies, yoga and acupuncture rather than opioids. Taylor noted that a Geisinger study found that opioids are not helpful in treating chronic pain, and that side effects of chronic opioid therapy include risk of addiction and depression and other potential health problems.
Geisinger project leaders developed and initiated several approaches that focused on changing physician practice patterns to reduce the prescribing of opioids. Data and IT were foundational to these efforts, as physician leadership developed a provider dashboard linked to the electronic health record (EHR) to identify current practice patterns among Geisinger providers. With this baseline data, Geisinger physician leaders found that providers varied greatly in their opioid prescribing patterns, with a relatively small number being heavy prescribers. They then used that information to first target the outliers and provide them with best practices for pain management.
“Having the dashboard linked into EHR has been critical to success,” Kravitz said. “When we meet with physician provider groups, the typical response is, ‘I had no idea that I was prescribing that much controlled substance, that much opioid.’ It has helped prescribers as they are managing their own patient populations. It shows the fill data around what the patients are doing and the data will tell you if there are patients going to three different providers for three different medications and filled at three different pharmacies.”
The state’s prescription drug monitoring database (PDMP) is another tool providers can use to identify diversions, Kravitz noted, and Geisinger’s IT leaders worked to leverage the state’s PDMP. In Pennsylvania, all prescribers and dispensers (pharmacies) are required to register with the PDMP. Prescribers must query the system each time a patient is prescribed an opioid drug product and dispensers are required to submit data to the PDMP after dispensing a controlled substance.
“We are working with state to get APIs (application programming interfaces) to connect to providers’ workflow, so that it’s in the background. I think we’ll see the delivery of those APIs in the next three months or so. It’s an important step that has to occur, checking the PDMP to see if a patient is a ‘frequent flyer,’ so to speak, and we are working to make that automatic,” Evans said.
Geisinger leaders created tools to track documentation within the EHR and dashboard that indicates that providers reviewed the state-run PDMP, as mandated by the state, and if they considered prescribing a controlled substance. In addition, Geisinger leaders developed a pain app that measures physical activity, patient-reported pain and other metrics and that information is integrated into the provider dashboard and the patient’s medical record as well.
As part of this initiative, Geisinger IT and pharmacy leaders also enabled electronic prescribing for controlled substances (EPCS), noting that written prescriptions pose many challenges, including errors and inaccuracies and the potential for forgeries.
“We set out to identity-proof and authenticate the provider population and we went live last year with EPCS, using a smartphone authentication. We enrolled 1,300 providers on the first day and continue to enroll dozens per month,” Evans said. Currently, 74 percent of controlled medications are being ePrescribed, with 82 percent outpatient adoption and 20 percent inpatient adoption. What’s more, 126 clinics are at 100 percent ePrescribing of controlled substances, Evans said, and 1,662 of Geisinger employed physicians, or 62 percent, are identity-proofed to use the EPCS system.
“We have a vision of no written prescriptions at Geisinger, and we expect to cross that milestone in months, not years. We are targeting every Geisinger provider and we think we can get very close before we have to drop the hammer with a mandate,” he said.
As mentioned above, the initiative has resulted in an almost 50 percent reduction in the number of opioid prescriptions per month, on average. What’s more, Geisinger leaders also reported that the use of e-prescribing for controlled substances created $1 million in savings within five months due to greater efficiencies.
“As I said, there is no silver bullet, but using provider dashboards and with EPCS, we can focus on intervening and we can use the dashboards to help us understand where people are in trouble,” Kravitz said.
He also noted that while the provider dashboard is unique to Geisinger, the underlying processes and strategy involved with this initiative can be replicated by other health systems and hospitals. “We love analytics, and we have two big data platforms, not just one, that we really enjoy utilizing. But, you don’t have to have analytics or big data platforms to identify the prescribing habits of providers,” he said, noting that health systems and hospitals can generate reports on opioid prescribing through their EHRs or clinical order entry systems. “It’s something we can all take part in and dig in and look at practice patterns,” he said.
Taylor adds that, to succeed, organizations will need support from their physician leadership and a commitment to eliminating all unnecessary opioid prescribing. “Information technology is a powerful tool, but its effectiveness is limited without buy-in from clinicians and administrators,” Kravitz said.
