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Managing patients’ pain, not just their opioid prescriptions

The opioid crisis is tearing lives apart. At University Hospitals, we’re seeing its effects in our primary care practices, hospitals and emergency rooms, as well as medical surgical units, specialty practices, dental offices and across our entire system. Nearly everyone personally knows someone who has been affected by this powerful, often tragic, addiction.

Ohio has been markedly affected by the opioid crisis, and northeastern Ohio has been hit especially hard. According to the Centers for Disease Control (CDC), Ohio has the second-highest rate of death due to drug overdose, and continues to see significant increases year over year. In the Cleveland area, we estimate as many as one in four people have been affected by the epidemic.

This public health crisis is vast and complex. To make progress requires collaboration from every discipline within University Hospitals and the community at large.

Start with strong leadership and teams

We’re fortunate at University Hospitals to have a chief executive officer and board members who are fully engaged with our response to the opioid crisis. Early on, University Hospitals had physician leadership and participation from a multidisciplinary team – including nursing, pharmacy, physicians – as well as non-clinical disciplines such as legal and human resources. In the fall of 2017, this group formed the Opioid Patient Safety Committee.

Beyond our system, collaboration is the only way to drive true outcome changes across a community. To that end, University Hospitals is one of five hospital systems, alongside the regional hospital association, that formed the Northeast Ohio Hospital Opioid Consortium. It is the first coalition of its kind in the nation, and it builds on years of dedicated work by community and hospital leaders to fight opioid addiction, save lives and create a healthier community.

Early results of using technology to address the crisis

Many of our early efforts at University Hospitals have been wrapped around the electronic health record (EHR) and analytics. Through the EHR, for example, we have made our opioid prescribing guidelines available to providers when and where they need them at the point of care.

We’re pulling data from the EHR, starting with primary care, where the bulk of opioid prescribing occurs at University Hospitals. The data has helped us understand some of our opioid prescribing patterns and we can now visualize where we want to go.

We developed a documentation toolkit to help providers gather more data points and design more precise interventions for our community. It helps clinicians measure patients’ functional capacity, pain scales, history of addiction and depression and more. The toolkit can help clinicians fill in gaps in the patient record, initiate important conversations and identify people who may be at greater risk for addiction.

Our goal is to lower rates of opioid-related death and addiction, but these long-term outcomes will take time to achieve. We needed a concrete short-term goal to track our progress and, initially, set our sights on reducing opioid prescriptions. We measured our progress in terms of pill count and potency, otherwise known as Milligram Morphine Equivalents (MMEs).

From October 2017 through March 2018, University Hospitals has seen a 13% drop in opioid prescriptions by family practice physicians and a 21% drop by internal medicine physicians. The average MME has also declined during the same period.

Why curbing prescriptions isn’t enough

These metrics are strong, basic surrogates to monitor and address opioid abuse and misuse. However, we soon recognized that this approach would not be enough to make meaningful change.

Some patients legitimately need opioids to manage pain. If we “shut off the faucet” by reducing the number of opioid prescriptions, we risk unintended consequences such as undertreating patients. These early efforts make a difference in the short term, but for long-term success we need processes that get the right intervention to the right patient at the right time. In light of our maturing strategy, our Opioid Patient Safety Committee has shifted to a broader focus and become a more holistic Pain Management Institute.

As our vision evolves, our measurements must change, too. We’re looking at process metrics and digging into more complex facets of opioid prescribing, such as referral patterns. Are patients who are taking certain levels of MMEs getting appropriate referrals for pain management? Are they getting the right consults they need from behavioral health? Process metrics are more difficult to measure than pill counts and MMEs, but they are more sophisticated and precise indicators that we are attacking the opioid problem where it is causing the most damage.

The next steps in the University Hospitals journey

We have just scratched the surface in the fight against opioid abuse, and there is much more to do. Here are just a few of the steps University Hospitals has planned for the near future:

  • Train all prescribers on the latest evidence-based guidelines for opioid prescribing by the end of 2018.
  • Replicate some of the primary care data analysis in the inpatient setting and evaluate emergency department prescribing and referral patterns.
  • Improve interoperability and reduce barriers with our state’s prescription drug monitoring program (PDMP), the  Ohio Automated Rx Reporting System (OARRS).
  • Explore opportunities related to telemedicine to safely deliver Medication-Assisted Treatment (MAT) for patients who are unable to physically come into the office.
  • Eventually use data – for example tracking suspected opioid overdoses in emergency departments for real-time, communitywide tracking – as well as use data to better predict who is at risk for addiction and death from overdose and provide that information to prescribers.

We’ve learned a lot since we started this journey about the complexity of the opioid crisis. It’s not enough to reduce the number of opioid prescriptions; we will continue to collaborate with our community, and remain focused on a holistic, patient-centered approach to pain management.

Editor’s note: Learn more about Allscripts’ response to the crisis in 5 ways Allscripts will fight opioid abuse in 2018.

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