Overview

This program at an urban community hospital utilized implementation of evidence-based opioid therapy best practices including EHR prompts and prescription drug monitoring database integration to improve opioid management.

Organization Name

Valley Medical Center, Renton, WA

Organization Type

• Academic Medical Center
• Community hospital
• Community outpatient clinic
• Safety net hospital

National/Policy Context

• About 25% of patients prescribed opiate therapy for chronic pain develop chronic opioid use disorder.
• Treatment of chronic pain is a challenge as it is often associated with psychological conditions and risk of addiction.
• About 1.7 million people suffered from substance abuse disorders associated with prescription opioid pain medication in 2017.
• Opioid overdoses increased by 30 percent in 45 states of the United States between 2016 and 2017.

Local/Organizational Context

(Via written correspondence with Dr. Sahana Ingale)

• Improving safety of patients and opioid stewardship was identified as an organizational priority by VMC board. The national attention to opioid epidemic and the WA state law on opioid prescribing and safety provided further impetus for change. 

Patient Population Served and Payor Information

 (Via written correspondence with Dr. Sahana Ingale)

• All patients with chronic pain identified by their primary care provider as chronic opioid therapy-prescribed patients.
  • The team used the CDC and Bree Collaborative definition to identify patients on chronic opioids. 
    • Any patient on opioids for at least 60 days in the last 90 days period would be identified as a Chronic Opioid patient. 

Leadership

(Via written correspondence with Dr. Sahana Ingale)

• The Chief Quality Officer was the sponsor of Ambulatory Care Pathways work. 
• The team identified a physician champion to lead the pathway development and implementation.
  • The role involved reviewing and synthesizing national clinical guidelines, developing standard work recommendations, leading provider education, creating of Epic tools and workflows. 

Funding

(Via written correspondence with Dr. Sahana Ingale)

• There was no external funding for this project.
  • The organization has teams and structures developed to support care pathway development and implementation.
  • This includes a full time care pathways coordinator role, medical director (lead physician) for care pathways committee, reporting analyst time, EHR analyst time and care pathway physician champion time. 

Research + Planning

• Evidence-based guidelines for opioid prescription and chronic pain management were reviewed by a group of primary care providers, specialists, pharmacists and other allied health professionals. Selected guidelines were adapted from:
  • Centers for Disease Control and Prevention guidelines for prescribing opioids
  • Washington State Agency guidelines for prescribing opioids
  • Department of Veterans Affairs guidelines for opioid therapy
• These guidelines were added to the clinical workflow via EHR (Epic).

Tools or Products Developed

• Morphine equivalent daily dose (MEDD) calculator: An automatic calculator was developed to calculate the morphine equivalent dose of opioids using the active medication list of the patient in the EHR system.
• Oswestry Disability Index (ODI) flowsheet: The ODI was incorporated as a flowsheet into the EHR (Figure 1) to assess the patient’s pain and functional status. The flowsheet includes patient’s chronological responses at each visit to the pain questionnaire and hence aids in assessing ongoing response to pain treatment.
• Prescription drug monitoring database: The EHR is integrated with the state of Washington’s prescription drug monitoring database to verify prescriptions and detect misuse directly from Epic.
• EHR alerts: 
  • Alerts for urine drug screenings and medication agreements prompt the providers to administer the urine test and use updated agreements according to current guidelines.
  • An alert for naloxone was created to remind the provider to prescribe the drug if the patient is on more than 50 morphine equivalent dose (MED) of opioids.

Training

• Providers and care team members were educated on evidence based guidelines for current treatment of chronic pain.

Tech Involved

• Electronic medical record
• Epic

Team Members Involved

• MAs
• Pharmacist
• Physicians
• Primary Care Physicians
• Specialists

Workflow Steps

• Patients with chronic pain who are prescribed opioid therapy for pain management are enrolled in the opioid Care Pathway, which was designed with the help of physicians and clinical pharmacists.
• The morphine equivalent dose (MED) calculator is used to assess the dose of opioids the patient is currently taking.
• If the patient is taking 90 MED or more of opioids daily, he/she is referred to a pain specialist.
• If the patient is taking between 15-89 MED of opioids, the provider and the patient complete and sign a medication agreement annually. The patient is educated about the risks of opioids.
• The agreement is scanned and saved in the Media section of the EHR (Epic). It is flagged by the medical assistant or the provider with a note listing the following information:
  • Medication agreement
  • Provider name
  • Date the agreement was signed
  • Name of medication(s)
• A follow-up appointment is scheduled 3 months later. The ODI form is given to the patient by the MA at the beginning of the visit and a urine toxicology screen is ordered by the provider. 
• The data from the patient filled ODI form and all drug screens are entered into the EHR and reviewed by the physician at every visit.
• Naloxone alert appears to prompt physicians to prescribe naloxone to patients on >50 MED.

Budget Details

The following sources of costs were estimated by the CareZooming team:

• Costs associated with staff time spent updating EHR with alerts, prompts, and integrating the state’s prescription drug monitoring database

Where We Are

• Date (Month/Year) Project Described Started: January 2018
• Date (Month/Year) Poster Presented: April 2019
• This project is ongoing.

Outcomes

• The following outcomes were measured over the course of one year:
  • Pain assessments completed: The number of ODI assessments increased by 15% over the year the study was conducted.
  • Patients with a valid drug screen: The number of patients who successfully completed a valid drug screen increased by 33%.
  • Patients with valid medication agreements: The number of patients with valid medication agreements increased by 7%.
  • Patients with high risk co-prescriptions: The number of patients with high risk prescriptions decreased by 17%.
  • Patients with more than 50 morphine equivalent doses (MED) on Naloxone: The number of patients who qualify for Naloxone based on their MED increased by 42%.

Future Outcomes

• The adoption of the Pain, Enjoyment, General Activity (PEG) tool for ongoing assessment of pain and functional status will be evaluated.
• The adoption of the opioid risk tool to assess the risk of opioid abuse by the patient will be evaluated.
• A tapering strategy for patients on high doses of opioids will be devised with the help of clinical pharmacists.
• Plan-do-study-acts will be conducted to improve adoption of workflows.

Benefits

• The Care Pathway changes that were implemented resulted in improvements in compliance to the standard methods of treatment of chronic pain and hence may have lowered the chances of opioid abuse and addiction.
• A significant change in the culture of the organization occurred due to sensitive data transparency.
  • The culture change was mainly referring to data transparency and sharing sensitive prescriber level data to our providers. This has helped our teams prioritize improvement efforts and conduct PDSAs to test change. Also, sharing data on process and outcome measures has provided more clear guidance for teams on what are some key value added activities that will ensure safety for these patients. (Via written correspondence with Dr. Sahana Ingale)

Unique Challenges

(Via written correspondence with Dr. Sahana Ingale)

• Variation in adoption of the care pathway recommendations, prioritizing timelines for provider education, and creating EMR tools/workflows among other competing priorities were other challenges. 

Sources

• This primer was developed by the CareZooming team based on our interpretation and analysis of a poster presentation and with consent and permission of the author and/or their representatives. Authors and/or their representatives were able to review the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
• Ingale S., Herner K., Dalton T., Chacko S. (2019, April). Impact Analysis of Ambulatory Care Pathway for Chronic Opioid Safety. Poster session at the Institute for Healthcare Improvement Patient Safety Summit, San Francisco, CA.
• Washington State Agency Medical Directors’ Group. (2015). Interagency Guideline on Prescribing Opioids for Pain (3rd edition). Retrieved from: http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
• National Institute on Drug Abuse. (2019). Opioid Overdose Crisis. Retrieved from: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
• National Institute on Drug Abuse. (2019), Opioid Summaries by State. Retrieved from: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state