Changing the default quantity for opioid medications in the electronic medical record was found to change prescribing habits and reduce overall quantity prescribed.
- Integrated healthcare system/network
- Opioid use in the United States has reached epidemic proportions. According to the Department of Health and Human Services, in 2016 11.5 million people misused prescription opioids, and 116 people died every day from opioid-related drug overdoses.
- Community awareness of the danger of opioid use is increasing, but it remains the responsibility of health care practitioners to ensure safety of their patients while providing guidance in managing pain.
- While awareness is an important component to reducing opioid use, this strategy is dependent on a great number of stakeholders (prescribers and patients alike) becoming aware of the dangers and changing behavior.
- There is an active workgroup in Minnesota, the MN Health Collaborative, convened by the Institute for Clinical Systems Improvement (ICSI) that is collaborating across organizations to identify best practices for use of opioids and reduce opioid use overall. (For more information, visit https://www.icsi.org/mn_health_collaborative/)
- A challenge has been that current guidelines recommend thresholds of morphine equivalent doses (MED), yet our medical record as it is currently structured does not support identifying MED by day at the point of prescription.
Patient Population Served and Payor Information
- This intervention impacts all patients who are to be prescribed an opioid.
- HealthPartners serves 1.2 million patients with a diverse payer mix including Medicare and Medicaid.
- Physician co-chairs of a pain steering committee (paired pain champion physician and senior leader physician), which existed prior to the intervention and worked for several years before deciding on this particular intervention.
- The pain steering committee includes representatives from primary care, medical and surgical specialties, behavioral health, and pain programs.
Research + Planning
- In order to come close to matching guidelines that are MED-based, our physician steering team debated whether a quantity of pills could be defaulted to improve from our current state. Ultimately 10 pills was selected because it came close to recommended thresholds for MED at the prescription level for most opioid medications.
Tools or Products Developed
- In November 2016, the default quantity for opioid medications in the electronic medical
record was changed systemwide to 10 pills.
- Previously, the default typically was 30 pills or no default was set.
- While prescribers have the ability to change the quantity as necessary, setting the default
to a lower quantity was a way to make the right thing to do the easy thing to do
- Communication of the technical change via regular mass email updates to all Epic users.
- Because clinicians would still be able to change an individual prescription anytime it was needed, we opted to communicate less rather than more (knowing that the change would become evident at the point of use). There was no significant backlash to the project’s implementation.
Team Members Involved
Included <100 hours of IT work in Epic
Where We Are
Implemented November 2016, ongoing.
- Change in prescription habits
- Within 6 months of implementation, the most commonly prescribed quantity for new start opioid medications was found to decrease from 30 to 10 (the new default quantity) (Figure 1).
- The average quantity of pills in a new start prescription dropped from 29.14 in March 2016 to 22.24 in February 2018, a 24% reduction (Figure 2).
- On average, the number of new start prescriptions dropped by about 700 per month in year 2 (Mar17-Feb18) compared to year 1 (Mar16-Feb17) from 7131 to 6407, a 10% reduction.
- The total number of pills in new start prescriptions also dropped dramatically, from on average almost 200,000 per month in year 1 to about 160,000 per month in year 2 (Figure 3). This translates to roughly 500,000 pills reduced from new opioid prescriptions annually.
Figure 1: Change in prescribing patterns of most commonly prescribed quantity for opioid prescriptions for those patients with no previous opioid script in the prior 6 months, March 2016-May 2018
Figure 2: Change in prescribing patterns of average quantity of pills prescribed for opioid prescriptions for those patients with no previous opioid script in the prior 6 months, March 2016-May 2018
Figure 3: Reduction in total number of pills in opioid prescriptions to patients with no previous opioid script in the prior 6 months, March 2016-May 2018
Continued reduction in opioid prescribing
- Nearly 5,000 fewer patients per month are receiving an opioid prescription today each month than was the case 2 years ago (of those, 700 are patients who would otherwise have been receiving a new prescription).
- Patients are less likely to get an opioid prescription if not needed, and if they do receive opioids, they are more likely to get an appropriate minimal amount to address acute pain and limit the risk of becoming addicted.
- We had difficulty achieving consensus on the appropriate default to set (ultimately it was most important to start somewhere, regardless of the imperfection of any starting point)
- Finding the right people on our technical team to support the Epic build necessary to make this change possible was difficult. Identifying champions with the authority and ability to make the changes was a very important factor in the intervention’s success.
Amber Larson. Driving Down Opioid Prescribing. Poster Presentation at IHI National Forum 2018: Orlando, FL