Opioid Epidemic: Integrating Electronic Medical Records and Prescription Monitoring Programs Bryant thomas Karras, MD, Chief Informatics Officer Chris Baumgartner, Drug Systems Program Director Dan Bolton PhD, Applied Public Health Informatics Fellow

States with more opioid pain reliever sales tend to have more drug overdose deaths Death rate, 2011, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and Consolidated Orders System

Unintentional Prescription Opioid Overdose Deaths Washington 1995-2015 There was a coding change that became effective in 2009, which included tramadol as an opioid code. Deaths with tramadol as the only opiate were excluded prior to 2009. In 2009, there were 9 such deaths. It is likely that the decline from 2008 to 2009 would be slightly larger if tramadol only deaths had been included previously. Source: Washington State Department of Health, Death Certificates 3

Trends in the Rate of Opioid Overdose Deaths*, WA State 2006–2015 718 deaths in 2015 Source: DOH Death Certificates * Includes all intent of drug-related deaths with the additional ICD-10 codes of T40.0, T40.1, T40.2, T40.3, T40.4, or T40.6 Note: Intentional self-poisonings account for ~9% of all opioid overdose deaths

The PMP Solution- An Overview PMPs are designed to improve patient safety and protect public health with the goal of reducing overdose deaths, hospitalizations, and other related prescription drug abuse issues Records for dispensing of controlled substances are submitted to a central database by pharmacies and other dispensers Providers and other authorized users can register for access, and once approved, can view information through a secure web portal PMP information helps providers avoid duplicative prescribing and dangerous drug interactions, and helps identify substance abuse or pain management issues The PMP is a patient safety tool available to prescribers and pharmacists making dispensing records of controlled substances available for evaluation in patient care avoiding instances of duplicative prescribing and dangerous drug interactions and helps to identify substance abuse and pain management issues.

The Epidemic & Provider Utilization Currently about 30% of prescribers are registered to use the PMP as it is voluntary in Washington To adequately address the Rx epidemic we need more use of the system The key issue found when surveying out prescribers as to why they don’t use the PMP: Ease of access

Value proposition Providers Patients Public PMP More confidence that they can treat pain without endangering health of the patient or others Patients Can be treated for serious pain without provider deciding to err on the safe side Public Reduction in opportunities to abuse opioids and in costs associated with abuse PMP More effective operation and availability of data

Existing IHE profiles and risks There has been a national effort to develop PMPs as part of efforts to reduce opioid abuse There have not been consistent or uniform efforts to ensure that PMP data are easily available If PMP data are not easily available, there is a danger that resources invested in implementing PMPs will not yield effective tools for addressing the problem

Common facts for use cases Patient presents at clinic or ED with significant pain Provider logs on to EHR to check previous treatment and document patient care Patient requests, or provider considers, an opioid pain reliever Provider should investigate patient’s history of opioid use to check on possible abuse through overuse or diversion

Current use case To check on patient’s prescribing history, provider must consult PDMP or rely on patient’s reporting about use To use the PDMP, provider must: Have previously registered with the PDMP Log on to PDMP separately with user id and password Some states require providers to register PDMP log on is separate from EHR

Proposed use case At the beginning of the patient encounter, provider logs on to EHR As part of patient treatment, provider checks on patient’s opioid prescribing history: Working within the EHR, provider sends a request via the state HIE to the PDMP Data on patient’s opioid history is sent back to the provider via the HIE Provider then recommends a treatment plan based on review of information and discussion with patient

Proposed standards and identified systems EHR HIE PMP or PDMP system vendor National Council for Prescription Drug Programs version 10.6 (NCPDP script 10.6) Medication Dispense History Query Request/Response Standard ONC conducted a Standards and Interoperability (S&I) Framework (http://wiki.siframework.org/PDMP+%26+Health+IT+Integration+Homepage). Most of the pilots used NCPDP 10.6 as their standard for this medication history request/response. PMIX SOAP

Level of effort to develop profile NCPDP as the official standard for e-prescribing (see https://www.cms.gov/Medicare/E-Health/Eprescribing/Adopted-Standard-and-Transactions.html). So it is available in current Certified Electronic Health Record Technology (CEHRT) systems for medication reconciliation already Same as Surescripts uses so most will already have the interface type developed

Prescription Monitoring Program In WA state, the Health Information Exchange (HIE) is One Health Port (OHP) WA PMP is connected to OHP WA organizations and heath care facilities - such as hospitals, clinics, and pharmacies – can build their connection to OHP This will allow the facility to connect with the PMP and integrate PMP records with their own Electronic Health Record (EHR). This will put PMP information into the provider’s workflow rather than the provider having to login to the PMP separately.

HIE Message Handling

Piloting the Connection The EDIE system connects all of the emergency departments in our state to ensure patients do not visit multiple EDs for the same problem. They can work to coordinate care and prevent ED overutilization. PMP data is now connected to this system so ED providers can see controlled substance use along with ED visit history. 2016 ONC Annual Meeting: Committed to Better Health through IT

Current accessibility 15 states are now HID PDMP clients Alabama     Arkansas     Colorado     Delaware     Florida     Hawaii     Kentucky     Maine     Maryland     Minnesota     New Hampshire     North Carolina     Oregon     Washington     Wisconsin

S&I Epic Pilot Emergency Department Connection

PMP Pilot with Epic Standard & Interoperability Framework – sponsored by the Office of the National Coordinator (DHHS) Washington chosen as a pilot site Began work with Epic in April 2015 Completed pilot in October 2015 Epic has released the update and it is available to Washington customers The purpose of this initiative is to bring together the PDMP and health IT system communities to standardize the data format, transport, and security protocols to exchange patient controlled substance history information between PDMPs and health IT systems. Doing so would enable health care professionals to make more informed clinical decisions through more timely, effective and convenient access to PDMP data in an effort to reduce prescription drug misuse and overdose in the United States. The specific goals are: Define use case requirements and implementation guide to securely and appropriately communicate patient controlled substance data from PDMP to HealthIT system Identify existing stakeholders and methodologies for accessing PDMP data. Identify, evaluate, and harmonize the data format(s) sent from PDMPs to Health IT systems Define standard transactions between the HealthIT system and the PDMP Identify standards that allow the Health IT system the ability to query the PDMP Identify gaps in selected standards and work with standards organizations to fill in those gaps Evaluate and select transport protocol(s) systems support. Evaluate and select security protocol(s) systems support.

Epic Use Case (From S&I) Pre-Step: Healthcare Professional logs into Health IT System PDMP & HIT Integration Use Case Scope 1. Sends query to state PDMP State HIE Healthcare Professional receives requested information 2. PDMP sends query response

Current Status As of October 2016: 80 hospitals have gone live with their PMP connection Over 2 million queries were submitted in 2015 via HIE to the PMP We average only 700,000 or so queries via our online portal Listed as an EP & EH Public Health Measure-Specialized Registry 92 facilities registered including 1051 total clinics through August 2016 Several Hospitals and Clinic systems in Queue for Epic PMP interface

Quote from End User (benefits of automated HIE query) "Just as creating a PMP was a game changer in its relationship to coordinating the care of our most at risk patients in WA State, pushing that information without provider bias, without burdensome hurdles, now pretty much mandates providers be aware of these patient's special needs and risks.  It's the next level that all of the nation can learn from."

Contact Bryant Karras, MD bryant.karras@doh.wa.gov Chris Baumgartner chris.baumgartner@doh.wa.gov Dan Bolton dan.bolton@doh.wa.gov