Sometimes a doctor has no idea whether a patient is abusing or selling prescription painkillers until it’s too late.
Even known abusers of the drugs are gaining access to more pills. One recent study, out of Boston Medical Center, found that about 91 percent of those who overdosed on opioids continued to receive a supply of pills from their doctors.
Hospitals are seeking new ways to sound the alarm for physicians in these cases, before a prescription is even written.
One such organization, Carolinas HealthCare System, just added alerts within its electronic health records that are triggered by selected risks for abuse. These red flags might include whether the patient previously had OD’d on an opioid, or whether he or she had tested positive for marijuana or cocaine in a toxicology screening.
Rachel Seymour, associate director of Carolinas’ orthopedic clinical research, tells us more about the system.
“The idea really is to package all of the relevant information that’s already in the EMR and put it right in front of the physician at the point of care, rather than having busy physicians digging through charts trying to find the pieces of information while they’re trying to get through a busy shift,” she says.
Five Red Flags
A Carolinas HealthCare System doctor prescribing opioids or benzos is alerted by the electronic health record when a patient's history shows one of five red flags. Physicians can choose to either cancel or continue with the prescription, with medical validation. Those red flags are:
- Three or more active narcotic or benzodiazepine prescriptions received in the last 30 days.
- Greater than 50 percent of the prescribed medication remains from at least one narcotic or benzo prescription.
- Those two drugs have been administered during an emergency department or urgent care visit two or more times in the last 30 days.
- Patient shows any history of a positive toxicology screen for marijuana or cocaine, or a positive blood alcohol content test.
- Record indicates a diagnosis of a narcotic or benzo overdose.
Seymour says that after launching last fall, they’ve already implemented the system in all care sites that use their Cerner electronic health record system, such as emergency departments, urgent care and outpatient clinics. She’s now working with colleagues to publish some of the initial results but, in the early going, they’ve found that about 20 percent of patients being prescribed opioids have at least one of the five red flags in their records [see sidebar].
Physicians, already plagued by alarm fatigue, may have been skeptical about PRIMUM at first. But after putting it in place, doctors have come around quickly and seen how helpful these alerts have proven in bolstering their prescribing habits. Animita Saha, M.D., specializing in internal medicine at Carolinas HealthCare and an associate professor at UNC Medical School, tells us more.
“I’ll tell you, since these alerts have gone up, and they’ve been there for quite some time now, we don’t hear any complaints that this has been an interference," she says. "When people started using it, they saw how good it was.”
Along with publishing findings later this year, Seymour eventually hopes to integrate the alert system with North Carolina’s prescription drug monitoring program, or PDMP. Such databases allow doctors to see when patients are shopping around across the state from hospital to hospital, attempting to get more pain pills. As of today, Carolina’s doctors must pull up a second screen, outside of the EHR, to check that info.
"Getting access to the database is really not at all difficult. It takes a few steps, but it’s not difficult," Saha says. "The problem comes when it is one more thing to open up. You have to sign up on the database, put in the patient's name, date of birth before you get the history. It does take five to seven minutes to go through that so, I think for physicians, it is a barrier. Even though we try to work with our residents and physicians to say that you need to have absolutely accessed the database in order to do chronic pain care with opiates, I have seen that that particular time factor is a constraint for doctors during a busy day when they have a lot of patients.
Removing that barrier and improving such integration is a key area of interest for federal agencies like the Office of the National Coordinator for Health Information Technology, or ONC. They’re striving to ensure that state databases can connect with hospital IT systems by implementing what they call a “standards and interoperability framework.” Currently, there are no uniform standards that allow PDMPs and EHR systems to communicate. The ONC also has run several pilot projects in recent years to test possible standards that enable such information sharing. They're also developing a guide to assist vendors with creating such functionality in hospital IT systems.
Elise Sweeney Anthony, director of the ONC’s policy office, is pleased with the progress made thus far.
"I think, as the recognition has grown around the importance of PDMPs as part of the effort to address prescription drug abuse and drug diversion generally, the landscape is really a place where progress is happening and we’re thrilled to see that," she says. "I think there are other pieces that are really exciting as well. One of the things that we work with here at ONC is obviously around the health information technology. So, thinking about how health information technology systems can integrate more smoothly with PDMPs, we’re excited about the progress we’re seeing there as well. We are trying to help state PDMP systems, to work and integrate with hospital IT systems and, for simplicity purposes, [to communicate in] a common language. So, we’ve been doing a lot of work around that, and we’re excited to see that some of that is coming to bear, and that vendors are actually thinking about how to incorporate that information.
The CDC has been investing millions to aid states with these efforts. Communicating across borders is also critical, and Anthony notes that at least 40 states are now tackling this endeavor. They’re doing so by connecting to interstate data-sharing hubs that allow for the safe and secure transfer of PDMP information across state lines.
One recent study out of Vanderbilt University found that about 600 overdose deaths could be avoided each year if every state deployed a robust PDMP, one that monitors four or more drug schedules, for instance, and updates its data at least weekly. Currently, every state except Missouri has a database, but each varies greatly in its rules and effectiveness. Stephen Patrick, M.D., lead author of the study and an assistant professor of pediatrics and health policy at Vanderbilt, believes the evidence is clear.
"I would encourage hospital leaders that PDMPs appear to be an effective tool to combat the rising prescription opioid epidemic," he says. "We're seeing increasingly in our hospitals throughout the nation an increase in neonatal abstinence syndrome (babies born having opioid drug withdrawal), emergency department visits, inpatient admissions. And so, I think as members of our community and as physicians and hospitals, it’s incumbent upon us to do our part to help limit the scope and the reach of the prescription opioid epidemic.
Experts like Patrick caution that health tech tools such as databases and clinical decision support are just a small piece of the puzzle in addressing this opioid epidemic.
"Prescription drug monitoring programs are one part of the solution, but they’re certainly not the only part of the solution," he says. "We need a public health approach that begins with thinking through primary prevention, improving access to treatment and looking at this as a health system overall, and I think hospitals and physicians are part of that public health solution."