Introduction
The opioid crisis has come to the forefront among our nation’s health emergencies, as declared by President Trump in 2017. At that time, the national rate of deaths involving opioids was 14.6 deaths per 100,000 population – versus Florida, which had 3,245 overdose deaths that year, a rate of 16.3 deaths per 100,000 population (NIDA, 2019). While past endeavors to diminish the social and economic effects of the crisis have fallen short of making significant impacts, health information technology (HIT) has made great strides in mitigating the detrimental effects of opioid abuse and overdose. To understand why HIT made such strides, one must first know the history and be aware of the underlying causes which led to the rise of addiction and resultant deaths from opioid abuse.
Opioid over-prescribing has to date been considered a principal root-cause of the opioid epidemic (HealthIT.gov, 2018). Further expanding on that point, the Substance Abuse and Mental Health Services Administration (SAMHSA) says that more people who misuse prescriptions are doing so to increase the effect that the medication was supposed to achieve (Lipari, Williams, & Struther, 2017). It therefore becomes apparent how over-prescribing of opioids for pain management has not only facilitated but increased the incidence of abuse and overdose-related deaths. Ultimately, the U.S. Department of Health and Human Services (HHS) helped pave the way for HIT to curb deleterious issues of doctor shopping, abuse and overdose-related deaths through the adoption of clinical decision support (CDS), electronic prescribing of controlled substances (EPCS), prescription drug monitoring programs (PDMPs), and the integration of electronic health records (EHRs) with state PDMPs (Wilkins & Gabriel, 2014). All were key elements of the Health Information Technology for Economic and Clinical Health (HITECH) Act to promote the adoption and ensure the eventual meaningful use of HIT (HHS, 2017). Health information technology is integral to fighting the opioid epidemic in the U.S. and many technologies and methods already exist that can be useful in curbing overdoses and misuse but are not universally utilized nor adequately incentivized or funded, limiting their potential impact right now.
Discussion
HIT Solutions: The Basics
HIT has played its key role in the fight against the opioid epidemic through the use of clinical decision support, electronic prescribing of controlled substances, and prescription drug monitoring programs (ONC, 2016). Electronic prescribing of controlled substances or EPCS is when a provider prescribes a controlled substance electronically to prevent diversion of the drug from the intended patient (Terry, 2017). Many barriers exist to electronic prescribing including lack of incentives from state governments and the cost charged by EHR vendors for the capability to electronically prescribe, which can range in the hundreds of dollars per month for a small practice. Some providers find technical issues with prescribing certain drugs and ensuring that the correct pharmacy received the prescription as well as concerns about DEA identity confirmation when sending prescriptions to the pharmacy. While many are familiar with EPCS and PDMPs, which are state-run electronic databases of controlled substance database prescriptions (CDC, 2017), the definition of CDS and its role in the opioid epidemic may not be as easily understood. ONC, the Office of the National Coordinator for Health Information Technology, best defines CDS as a process for improving health-related decisions with organized clinical knowledge and patient information to improve healthcare delivery (Murphy, 2016).
Currently, PDMPs have been the focus to curb overprescribing, doctor shopping, which is the practice of patients seeking treatment from different providers during a single illness episode (Sansone & Sansone, 2012), and to identify those patients most at risk. However, the overall impact has been controversial. One report in Pharmacoepidemiology and Drug Safety (2019) reported New York state experienced a marked decrease in overprescribing as a result of PDMP mandates. Yet, another study in New Hampshire found that among 1,057 post-surgery patients, there was no statistically significant change in the percent decrease of opioid prescribing from six months prior to PDMP mandate versus post-PDMP mandate (Stucke, Kelly, Mathis, Hill & Barth, 2018). Other studies have shown decreased prescribing practices in the emergency room setting as a result of mandated PDMPs. Lastly, state-to-state lines continue to be a barrier, as state-mandated PDMPs – much like law enforcement – remain within their respective states’ jurisdictions.
Florida Mandates Limitations and PDMP: E-FORCSE
As of July 1, 2018, Florida Statutes section 456.44, Controlled Substance Prescribing, was updated to limit opioid prescribing for acute pain to a three-day and seven-day supply. Secondly, prior to issuing new prescriptions, it now requires that prescribers review Florida’s Prescription Drug Monitoring Program (PDMP), called E-FORCSE (Electronic – Florida Online Reporting of Controlled Substance Evaluation Program). E-FORCSE was created in 2009 with a twofold goal: to reduce drug abuse and diversion, which is the illegal transfer of lawful drugs to people not prescribed to have the drugs in question (Berge, Dillon, Sikkink, Taylor, & Lanier, 2012), and to encourage safer prescribing of controlled substances (FloridaHealth.gov, 2018). Such mandates and monitoring have proven effective to reduce overall opioid prescribing in Florida and nationally; still, there remains a gap in interoperability and information exchange between EHRs and PDMPs that has created a substantial barrier to best use.
Trends in EHR-PDMP Integrations: The Missing Link
Currently, PDMPs are seen as an impediment by many providers because the data are not easily retrievable, nor are they standardized; further compounding the issue is a lack of universal patient identifiers as well as, an absence of state-to-state PDMP and PDMP-EHR integration (Davis, 2018). Fortunately, those were initially anticipated as likely issues, and are now being addressed through the emergence of EHR-PDMP integration. One example of that is EHR provider MEDITECH, which in working together with healthcare software developer DrFirst, now has the infrastructure to link with PDMPs (Monica, 2018). Another example is Oregon and Minnesota partnering with Appriss Health, a data analytics firm. They have implemented such integration using Appriss Health’s NarxCare and PMP AWARxE, and the North Carolina Department of HHS (NCDHHS) will use Appriss Health’s PMP Gateway to allow sharing of PDMP data within EHRs, pharmacy systems and Health Information Exchanges (HIEs). (Appriss Health, 2019).
Use of Clinical Dashboards
Clinical dashboards are a relatively new, interactive tool for tracking and monitoring healthcare data, and are designed to improve workflow, reduce errors and reduce reliance on memory when providing care (Bakos, Zimmerman, & Moriconi, 2012). Early dashboards combined early EHRs with existing paper records. With the widespread adoption of EHRs, dashboards have become more advanced and today standards for dashboard designs are set forth by the Agency for Healthcare and Research Quality. Dashboards are particularly effective at aligning care with best practices and increasing the information available to clinicians during a visit. Dashboards can also be used to evaluate care either hospital or practice-wide beyond a single patient.
Over 50 million Americans receive treatment for chronic pain in primary care settings, where resources are often limited and opioids are often prescribed as treatment (Anderson, Zlateva, Khatri, & Ciaburra, 2015). Opioid sales increased by 400% from 1999-2010 in these settings, where chances for diversion and misuse are particularly high. HIT is considered a valuable tool for primary care physicians (PCPs) for reducing prescriptions in unnecessary cases and improving compliance by reducing diversion and misuse among patients. Researchers implemented a clinical dashboard at Community Health Center Inc in Ohio to provide clinical support to PCPs treating chronic by reminding them of guidelines and follow up procedures such as urine screenings, mental health treatments, and formal pain reassessments. Prescriptions issued by all providers in the practice were visible to identify trends. After two years opioid prescribing had a statistically significant decline across the board while over 50% of participating PCPs felt the quality of care when prescribing opioids had increased.
Many clinics and PCPs do not have the resources to implement such an expansive and expensive system (Anderson, Zlateva, Khatri, & Ciaburra, 2015). However, the researchers concluded that using HIT to improve compliance with opioid prescribing guidelines increased quality of care while reducing unnecessary opioid prescriptions, particularly in chronic cases where the medications were ineffective. More research is needed on the use of these dashboards as a tool to improve opioid prescribing, particularly by PCPs. Furthermore, care must be taken not to prevent prescribing medication to those who need it, which is why surveys of physician and patient perceptions of quality of care, like those conducted above, remain important when introducing new innovations.
Dashboards and electronic interventions also have the ability to reduce unnecessary and unsafe polypharmacy within a practice. 30% of opioid overdoses involve a benzodiazepine, leading to FDA black box warnings present on both opioids and benzodiazepines cautioning against concurrent use (NIDA, 2018). Zaman, Rife, Batki, & Pennington (2018) found that using a dashboard for patients prescribed both benzodiazepines and opioids reduced doses and total number of patients prescribed both classes of controlled substances. These findings have huge potential impacts for veterans, who often seek care at the VA system, which can use dashboards to ensure safe prescribing. In addition veterans often suffer from conditions that result in benzodiazepine and opioid prescribing (anxiety, phobias, pain, PTSD, etc). Veterans are also at higher risk of suffering from an opioid overdose, making this a perfect population and system to target for intervention.
Conclusion and Future Study
Further research will need to be done to mark the progress of advancing use of HIT and EHRs for opioid monitoring, along with PDMP to monitor across state lines, so as to curb doctor shopping, diminish abuse, and reduce the incidence of addiction. Many innovations in HIT to combat the opioid epidemic already exist but have not seen widespread or consistent adoption due to lack of adequate incentives, cost of implementation, resistance to change, and varying laws among different states. The federal government has recently allocated more funding for grants for states fighting the opioid epidemic, but state policymakers and experts in the field agree that it is insufficient so far (Vestal, 2019). Many of the HIT strategies for combating the national health emergency, as well as medical treatments, require more funding than is currently available. Lawmakers in some states are considering new taxes to help pay for innovations, some of which have been shown to work on small scales but lack the funding to be universally adopted. Additionally, many of the HIT strategies may have the side effect of limiting prescriptions for those who may legitimately need them, a concern for lawmakers in states across the country. More innovation in HIT, research on the effectiveness of innovations, policy work, and funding is needed to continue making progress against the opioid epidemic.
References
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