The opioid crisis is not news to most in this country. But the way Overlake Medical Center & Clinics in Bellevue, Washington, is customizing its Epic electronic health record to combat the opioid crisis is.
Multidisciplinary teams have customized the EHR to include: tracking when a patient agreement goes into Epic; tools for assessing risk of diversion or addiction; the state provider database; and more.
“The opioid epidemic obviously has myriad contributing causal factors,” said Dr. Tom Miller, medical director, quality and safety, at Overlake Medical Center & Clinics. “As our community’s healthcare convener, we developed a plan to address some of these factors we could influence from our vantage point.”
First, a pain management committee
To that end, the provider organization formed a pain management committee, which is composed of multiple specialty and primary care providers, as well as nursing, pharmacy, physical therapy and information technology staff members.
The committee sought to identify the following key pieces of information:
- How are prescribing patterns and workflows aligning with best practices?
- How can the organization use its EHR to leverage and support adoption of best practices?
- Where are the opportunities to address non-compliance with individuals or specialty groups?
- How does the organization track and trend compliance with guidelines and demonstrate improvement?
- How can the organization structure resources for providers and the community to allow ease of access?
Epic-specific technology solutions have included:
- Embedding the Washington state prescription monitoring program (PMP) database access into the Epic EHR such that PMP data is automatically available to providers without a separate log-in being necessary. This is available for hospital as well as outpatient clinic providers.
- Collecting prescribing data on all discharge prescriptions written on the Epic platform in inpatient and outpatient settings. This information is then made available to providers in blinded format so that anyone can see their prescribing amounts per patient compared with their colleagues and their own trend over time. Medical directors are able to see unblinded data.
- Changing the Epic nursing workflow sheet for pain management to include suggestions for non-pharmacologic interventions for pain listed first, followed by non-narcotic pharmacologic options and, finally, narcotic pharmacopoeia.
- Revising the information text in the after-visit summary regarding opioid medication that automatically loads when the patient is given an opioid prescription. This includes warnings regarding addiction, co-use medication risks, and safe disposal sites for unused medication in addition to other information.
Other work included standardization of physician order entry for all pain medications contained in order sets for hospital patients to reinforce the aforementioned change in the Epic nursing workflow sheet, said Dr. Jamie Kim, chair of the Epic Governance Group and medical director of information services at Overlake Medical Center & Clinics.
Real-time safety alerts
“Epic morphine equivalent daily dose calculation is currently live for ambulatory and will go live for inpatient this fall,” Kim said. “This allows all clinicians to quickly view a patient’s ordered MEDD and will also display in real time as they order additional/reduction of opioid medications. MEDD will also be used to trigger real-time safety level alerts to providers to consider reduction in dosages/frequency, need for rescue medications and other therapies.”
Overlake Medical Center & Clinics’ aim in another project was to leverage Epic to assist physicians, nurse practitioners and physician assistants in operationalizing the Washington state opiate guidelines to support safe opioid prescribing without the risk of underprescribing to those who are appropriate. These approaches are specific to the outpatient setting, while the aforementioned approaches apply more to the inpatient setting.
“As our community’s healthcare convener, we developed a plan to address some of these factors we could influence from our vantage point.”
Dr. Tom Miller, Overlake Medical Center & Clinics
“The design constraints were to develop multiple approaches that could function in multiple venues to assure safe opioid prescribing with minimum burden on the provider,” said Dr. Michael Hatzakis Jr., chair of the Overlake Clinics Operations and Information Technology Committee and director of musculoskeletal medicine at Overlake Medical Center & Clinics.
“Practitioners already perceive their interactions with EHRs as overly burdensome,” he explained. “From an individual and organizational surveillance standpoint, we wanted to impact safe prescribing at the point of care and at the level of clinic staff workflow, as well as provide individual education to patients.”
The most significant challenge was to make the approach as accessible as possible to Epic users and prescribers, while not being burdensome or intrusive, he added. Also, the provider organization needed to leverage a methodology that allowed it to track activity and measure processes at an organizational, departmental and individual user level.
‘Health maintenance’ clinical reminder functionality
“We chose to use Epic’s ‘health maintenance’ clinical reminder functionality as our vehicle for point of care,” he explained. “We developed an organization opioid registry for clinic use, surveillance of performance using Tableau, and Epic order sets and templates to support documentation requirements. We also leveraged the after-visit summary for patient education.”
However, one of the biggest challenges using health maintenance is alert fatigue as there are already many of these alerts for physicians, physician assistants and nurse practitioners, he added.
The organization initially chose five health maintenance items to track in its initial implementation, including: presence of an opiate agreement, accesses to the Washington state prescriber database, performance of an opioid risk tool, urine specimen screening, and prescription for Naloxone for an accidental overdose.
“We felt that tracking these measures was our most effective first step rather than tracking prescribing volume or number of prescriptions,” Hatzakis explained. “Tracking these measures represented steps that a physician could take to reduce inadvertent opiate addiction or misuse and would not provide any downward pressure on appropriate prescribing.”
The complexity of the logic
One of the next, most significant challenges in operationalizing the health maintenance measures was the complexity of the logic, he stated.
“The frequency of measurement of the above measures was dependent on opioid risk stratification, which represented a significant programming challenge,” he said. “In addition, calculation of opioid equivalent dosing had to be tested and had to be accurate to properly stratify prescription dosing so as to inform the timing of the health maintenance items. Ultimately, all five measures were implemented into Epic and were piloted first in the musculoskeletal medicine clinic.”
Once these five measures were built and tested, the organization then interfaced with Tableau technology to provide an easily accessible visual Interface, he said.
“The Tableau interface allowed each of the physicians in our clinic to compare their rates of adherence to the above measures against expectations and against their peers in the clinic,” Hatzakis explained.
“Furthermore, the Epic registry functionality was implemented so as to allow clinic staff to assess the daily patient panel: who needs agreements, specimen screening and review of PDMP data. Two of the opioid measures were then applied to the physicians in the clinic as part of their quality expectation.”
Five venues to assure safe prescribing
Overlake Medical Center & Clinics now has five venues to help assure safe and consistent prescribing: health maintenance alerts for physicians at the point of care, opioid registry for clinic staff, Tableau reports to benchmark organizational, departmental, individual and peer prescribing, Epic documentation templates, and education sheets in the after-visit summary.
“My advice to other organizations: It is important to make sure that variables that are measured and presented to prescribing staff represent the values of their organization and the needs of the patients,” Hatzakis said. “For example, it is problematic to measure absolute doses of opioids or number of prescriptions without proper risk adjustment for a particular prescriber’s population or without understanding the prescriber’s venue.”
“The design constraints were to develop multiple approaches that could function in multiple venues to assure safe opioid prescribing with minimum burden on the provider.”
Dr. Michael Hatzakis Jr., Overlake Medical Center & Clinics
Otherwise, there will be either subtle or even an overt pressure to underprescribe in appropriate situations, he said. Overlake chose to emphasize safety measures as opposed to volume of opioid prescribing as it believes that safe and appropriate prescriptions are more centered on patients’ needs than numbers of prescriptions, he added.