Evidence-Based Practices to Optimize Prescriber Use of PDMPs

Evidence-Based Practices to Optimize Prescriber Use of PDMPs Sheri Lawal, MPH, CHES Senior Associate, Substance Use Prevention and Treatment Initiative, The Pew Charitable Trusts Thomas Clark Research Associate, Institute for Behavioral Health at the Heller School for Social Policy and Management, Brandeis University Jean Hall ekasper Integration Project Manager, Kentucky Cabinet for Health and Family Services

Overview Background Methodology Overview of report findings Select practices Perspective from Kentucky Q&A

Background PDMPs valuable patient care and public health tools Opportunity to increase prescriber use of PDMPs Median enrollment rate, 2014: 31.7% 1 22% of primary care physicians did not know whether their state had a PDMP 2 Only 53% reported ever using the PDMP 2 1 Survey conducted by Brandeis University PDMP Center of Excellence and The Pew Charitable Trusts from November to December 2015 2 Rutkow et al., Health Affairs 34, no. 3 (2015): 484-92,.

Report Overview Released December 2016 Examined 8 evidencebased practices to increase prescriber use of PDMPs Case studies of states that have implemented practices Additional and emerging practices

PDMP Practices Evaluated Prescriber use mandates Delegation Unsolicited reports Data timeliness Streamlined enrollment Educational and promotional initiatives Health information technology integration Enhanced user interfaces

Methods Literature review Search of PDMP-related websites Selection of state case studies on implementing PDMP practices Survey of states on practices, enrollment, and utilization External peer review of paper by PDMP staff and other stakeholders

Survey Goal: get snapshot of states on practice implementation and prescriber utilization Received data on practice implementation from 48 of 50 operational PDMPs Received data on prescriber/delegate enrollment and utilization from 42 of 50 operational PDMPs Variation among states in practice adoption, prescriber enrollment and utilization Variability among PDMPs in capacity to report enrollment and utilization measures

Limitations Few published studies on practices to increase PDMP utilization Multiple concurrent practices and interventions make assessment of impact difficult Surveys, process and outcome data suggest efficacy of practices Variation in evidence: prescriber mandates have clearest measurable impact Moving target: states continually enhancing their PDMPs with novel and updated practices

Report Findings Prescriber use mandates rapidly increase PDMP utilization and can have an immediate impact on prescriber behavior Delegate accounts, daily dispenser reporting, and streamlined enrollment are practical solutions that are feasible to implement Unsolicited reporting and educational and promotional initiatives encourage use of PDMPs Health IT integration and enhanced user interfaces address barriers to using PDMPs

Mandates

Mandates: Evidence of Effectiveness Reductions in the number of opioid prescriptions NY: 8.7% decrease in the year following the mandate Increases in registration and utilization of the PDMP NY: increase from 11,000 to 1.2 million queries Reductions in multiple provider episodes NY: 91.2% decrease between the 4 th quarter of 2012 and the fourth quarter of 2015

Mandates: Implementation Challenges and Solutions Challenge: Additional workload Solutions: Allow ample time to implement the mandate Increase PDMP staffing Shift to paperless online registration Challenge: Increased demand on IT systems Solution: Upgrade the software and system hardware

Mandates: Implementation Challenges and Solutions Challenge: Concern from prescriber communities Solutions: Allow for exceptions for required checking of the PDMP Allow delegates to obtain reports Engage prescriber organizations to develop provisions Prescriber education

Delegation

Delegation: Evidence of Effectiveness Increases PDMP use OR: delegates accounted for ¼ of PDMP queries and overall PDMP use increased by 30% KY: delegates accounted for 42% of accounts, but requested ~64% of reports Reductions in multiple provider episodes Reductions in controlled substance prescriptions

Delegation: Implementation Challenges and Solutions Challenge: Administrative burden to register delegates Solutions: Allow delegates the ability to register online Hold prescribers responsible for verifying their delegates Challenge: Protecting patient privacy and confidentiality Solution: Limit delegate accounts to licensed staff

Delegation: Implementation Challenges and Solutions Challenge: Reducing prescriber s burden Solutions Allow prescribers ability to view and download a report of delegates activity Allow prescribers ability to audit multiple delegates with a single query

Health information technology (HIT) integration

HIT Integration: Evidence of Effectiveness Users report data are easier to access Indiana ONC pilot #1: 97% of participating prescribers (N=243) reported that automatic queries to database made PDMP data easier to access Increased workflow satisfaction from having each patient s prescription information as part of the medical record Increases PDMP utilization Indiana ONC pilot #2: with PDMP access via HIE, total queries to the Indiana PDMP increased 59 percent over the prior month Washington state s ED Information Exchange (EDIE): automated queries made up nearly 60% of total queries to PDMP in 2015

HIT Integration: Implementation Challenges and Solutions Challenge: Need for resources to develop and test data systems Solutions: Federal grant programs (ONC, SAMHSA, CDC, BJA) Meaningful Use incentive program for EHRs State funding to providers, pharmacies and vendors Challenge: Secure data access and monitoring Solutions: Develop policies for EHR data storage Maintain audit trails for individual end-users User authentication from different access points

HIT Integration: Implementation Challenges and Solutions Challenge: Interoperability of disparate systems Solutions: Use small pilots to develop interface protocols, then scale up Compare direct-to-ehr vs. HIE-mediated approaches Learn from early adopters what does and doesn t work Challenge: Present clinically useful data Solutions: Pop-up prescription history reports in EHR, e.g., PDFs Only show report if patient meets risk threshold (EDIE) Display data using analytical tools (e.g., NARxCHECK)

Enhanced user interfaces

Enhanced Interfaces: Case Studies California: CURES 2.0 includes a high-risk alert dashboard Lists patients meeting risk thresholds when logged in: Over 100 MME/day >6 prescribers or >6 pharmacies in last 12 months Over 40 mg methadone daily Over 90 days of continuous opioid Rx Concurrent opioid and benzo Rx Generates patient safety alerts, enables peer communication Evaluation: will assess prescriber use of the dashboard, recommend modifications to assure maximum effectiveness

Enhanced Interfaces: Case Studies New Jersey: Developed first PDMP mobile phone app to view patient data Incorporates standard mobile security and functionality View same data elements as computer access Works independently of PDMP web portal Receives push alerts from PDMP, e.g., re fraudulent Rx Start up: $95,000 in development costs Regulatory and data sharing hurdles overcome 545 users had downloaded app as of November 2015; promotion underway as of 2016

Enhanced Interfaces: Case Studies Indiana: Implemented NARxCHECK analytical tool ONC Enhancing Access two-phase pilot: ED, then hospitals Tool includes Composite patient risk score MME data Graph of Rx history showing overlapping prescriptions Full patient report available 4,259 PDMP/NARxCHECK reports generated in one month 6% of reports suggested at risk patients: score >500 75% of at risk patients did not receive an opioid prescription 25% did receive opioids

Evidence-Based Practices to Optimize Prescriber Use of PDMPs A Kentucky Perspective Jean Hall, KASPER Integration Project Manager Kentucky Cabinet for Health & Family Services January 25, 2017

Kentucky Perspective Overview Recommended Practices State Kentuck y PDMP start date Unsolicit ed reports Delegati on Streamlin ed enrollme nt Prescrib er use mandat e Educatio nal and Promotio nal activities Mandat ed training Health IT integrati on Enhance d user interfac es Dispens er reportin g interval 1999 X p X p p p X p Daily Statute does not permit Initially for HB1 p

Prescriber Use Mandates House Bill 1 - passed on April 24, 2012 and was effective July 20, 2012. ekasper Accounts KRS 218A.202 ekasper registration is mandatory for Kentucky practitioners or pharmacists authorized to prescribe or dispense controlled substances to humans. ekasper Prescriber Usage KRS 218A.172 Query ekasper for previous 12 months of data: Prior to initial prescribing or dispensing of a Schedule II controlled substance, or a Schedule III controlled substance containing hydrocodone No less than every three months Review data before issuing a new prescription or refills for a Schedule II controlled substance or a Schedule III controlled substance containing hydrocodone Additional rules/exceptions included in licensure board regulations

Prescriber Use Mandates What if I cannot query ekasper? If ekasper indicates manual process (Manual processed reports are reviewed by a staff member before release) Record the ekasper report request number in the patient s chart If the ekasper system is unavailable or Internet access unavailable Document circumstances why ekasper could not be queried If ekasper outage, record the date and time, and ekasper system outage logs will confirm lack of system availability

Prescriber Use Mandates ekasper Query Exceptions In an emergency situation Within 14 days of surgery or within three days of oral surgery Patients in hospitals and long term care facilities Patients in Hospice care or being treated for cancer pain Single doses of anxiety medicine prior to a procedure

Results of Prescriber Use Mandates HB1 July 20, 2012 2.39 2.43 2.65 2.65 2.72 2.72 2.47 2.43 2.41 Number of Controlled Substance Prescriptions per Person

Results of Prescriber Use Mandates Controlled Substance Dispensing Comparison Number of prescriptions dispensed as reported to KASPER

Multiple Provider Episodes

Delegation Delegates KRS 218A.202e Allows an employee of the practitioner's or pharmacist's practice acting under the specific direction of the practitioner or pharmacist, who requests information and certifies that the requested information is for the purpose of: 1. Providing medical or pharmaceutical treatment to a bona fide current or prospective patient;

Delegation Institutional Accounts for Hospitals and Long Term Care Facilities KRS 218A.202f Allows a chief medical officer, an employee designee who is working under the specific direction of chief medical officer or a physician designee if the Facility has no chief medical officer to designate delegates. Requires execution of an agreement: Institutional Account Agreement Institutional Account Agreement for Integration

Number of Reports in Thousands Results of Prescriber Use Mandates & Delegation HB1 July 20, 2012 6,871 7,354 4,587 4,992 2,691 362 418 708 811 2008 2009 2010 2011 2012 2013 2014 2015 2016

Data Timeliness Must be reported no later than the close of business on the business day immediately following the dispensing In house data collection effective March 2017

Educational and Promotional Initiatives Require 7.5% of CME in addiction, pain management or KASPER Grants allowed us to make CMEs available at no cost through University of Kentucky CE Central Publish promotional literature (brochures, fact sheets, signs, etc.) Provider Dispenser Law Enforcement Public Regularly provide educational and promotional presentations

Educational and Promotional Initiatives

Educational and Promotional Initiatives

Educational and Promotional Initiatives

Health Information Technology Integration Current The Kroger Company In Progress Kentucky Health Information Exchange Other potential initiatives DrFirst SpeedScript

Enhanced User Interface In-house development and support of ekasper KASPER Advisory Council feedback Provides guidance on potential ekasper enhancements Provides guidance on identifying potential inappropriate or illegal controlled substances prescribing Additional reports available to prescribes CS prescribers can obtain an ekasper report on themselves: To review and assess the individual prescribing patterns To determine the accuracy and completeness of information contained in ekasper To identify fraudulent prescriptions Summary report To review individual and delegate request history Peer Review Report Enhanced report features (e.g. Morphine Milligram Equivalents)

Active Cumulative Morphine Equivalent

Active Cumulative Morphine Equivalent

Other Keys to Success Strong leadership support, strong leadership Strong partnership between the business owners, Office of Inspector General and the technical team, Office of Administrative and Technical Services Successful partnerships at many levels Kentucky Office of Drug Control Policy Licensure Boards Professional Associations Stakeholder engagement

Jean Hall KASPER Integration Project Manager Cabinet for Health and Family Services #12 Mill Creek Park Frankfort KY 40601 Jean.hall@ky.gov 502.564.0105 x2499 KASPER Web Site: www.chfs.ky.gov/kasper

Thank You Sheri Lawal, The Pew Charitable Trusts, slawal@pewtrusts.org Tom Clark, Institute for Behavioral Health, Heller School, Brandeis University, twclark@brandeis.edu Jean Hall, Kentucky Cabinet for Health and Family Services, jean.hall@ky.gov

Email: info@pdmpassist.org Telephone: (781) 609-7741 Website: www.pdmpassist.org