E2: A Data-Based Approach

This is OnePath with Metrohealth, your toolkit for helping to combat the opioid epidemic as a member of the medical community with empathy, mindfulness, and a big-picture perspective. I’m Libbey Pelaia, educator within Metrohealth’s department of Opioid Safety. Thanks for joining us.

Last episode, we talked with Dr. Bob Smith about the basic psychology of addiction and the stigma surrounding opioid use disorders. He gave us some practical advice for gaging the needs of patients experiencing addiction from a humanistic, interpersonal standpoint.

And today, we’re pivoting to the digital: MetroHealth’s electronic health record tools AND opioid safety Epic dashboard, as a case study in what hospital systems can do to increase ease of safer prescribing measures in the everyday practices of doctors.

MetroHealth has a comprehensive system of dashboards and tools within their electronic health records to aid providers in making informed choices when it comes to prescribing for their patients.

And who better to orient us within those systems than Dr. Jonathan Siff, the associate chief medical informatics officer for Metrohealth, and Karolyn Tibayan, the director of the office of opioid safety.

We wanted to start by establishing the role that electronic health systems play in influencing provider behavior, particularly as a tool for opioid safety.

Dr. Jonathan Siff: So, the purpose of any electronic health system is to augment the provider's ability to care for patients and with respect, particularly to opioids, the things that we can do to help those providers are we can present data in a way that's meaningful to them, we can make sure that tttdata is available to them at the point of care, and that we have easy access to context, appropriate tools. This would be things like making sure they have the right doses for ordering and to guide them to the state and federal requirements around opioid providing, and to make sure that when they're doing a function in the system, that they are able to clearly understand what the system expects and to address it simply without having to fully disrupt their workflow.

Karolyn Tibayan: When we created these tools and these best practices, our ultimate goal is really to create tools and resources and supports to allow prescribers and providers to make the best and safest decision and make it the easiest decision to make.

There are a number of ways that comprehensive, integrated electronic health records can help providers make better choices for their patients.

Dr. Jonathan Siff: First is at the point of care, which is that the electronic health record allows us to, again, guide providers to correct dosing, correct medications. It helps us guide providers to non-opioid alternatives for patient's pain. It also allows providers to quickly access information such as the state PMP database to see if patients have had multiple prescriptions in the past, or have a concerning pattern of a controlled substance use. We also allow providers to review data longitudinally so they can see how their prescribing practices compare to their peers and physicians are nothing if not competitive, and they don't want to be the worst at anything. So if they see that their numbers are not in line with their peers, this is often actually a great catalyst for change.

One of the most important elements of the dashboard created by metrohealth are co-prescribing alerts-- simple notifications that bring attention to potentially nasty prescription combinations that providers may not be aware of.

Dr. Jonathan Siff: Co-prescribing alerts refer to alerts that the providers get within the system around their prescribing habits. This may be because the dose of the opioid is too high to be safe, or in some cases because the patient is already on a benzodiazepine, a sedative medication, which in combination with opioids can be extremely dangerous or also commonly we have co-prescribing alerts around prescribing Naloxone when you prescribe opioids. Naloxone is the antidote to opioid overdose, and there's good literature that shows that when patients have Naloxone available in the community, that it saves lives. And so we've really tried to push our providers to provide Naloxone with opioid prescriptions, along with other education to try and reduce the morbidity and mortality of our prescribing.

The promotion of Naloxone prescribing among providers has led to direct, concrete positive outcomes for patients and their communities at large.

Dr. Jonathan Siff: Metrohealth has a long history of distributing a Naloxone, and I'll let Carolyn speak to that in a second, with respect to within the electronic health record, we've been providing prompts since early in 2019 and have seen over a thousand fold increase in our prescribing of Naloxone to patients when we co-prescribe opioids.

Karolyn Tibayan: Yes. Like I mentioned before, this is kind of a prescriber do the right thing, order set.And we've seen once we've incorporated this order set close to a 71% increase with prescribing Naloxone and to our patients.

Another tool that Metrohealth uses to make strides towards greater opioid safety is the opioid registry.

Dr. Jonathan Siff: The opioid registry is an automated system that collects information on patients who are prescribed opioids, things like when was it prescribed, who prescribed it, how long was the prescription for as well as other measures that are important to providers, and lets us easily report on them in dashboards. We have made a number of dashboards available to providers at their individual level, and we also have administrative dashboards that let department chairpersons and our senior leadership look at how the organization is doing at a whole and drill down into individual departments or individual providers, if there's concerns.

We also need to be able to look as an organization and see, how are we doing? Are we prescribing too many pills? Are we prescribing to the right people? So we use the opioid registry and dashboards in combination to help us answer those questions.

For those experiencing opioid use disorder, medical assisted treatment, or MAT, can be a huge part of their recovery. We’ll have an entire episode about MAT later on in this series, but know this: MAT is a life-changing and life-saving option for those experiencing opioid addiction, and an option that some providers may not necessarily think to utilize without being prompted to do so.

Dr. Jonathan Siff: We have implemented a number of things within the electronic health record to try and help the MAT providers do this more easily. We have, for the emergency department an MAT order set, which allows providers in the emergency department who may not prescribe it as often, more easily follow the rules and put the right sets of orders in for patients and ensure that patients are appropriate for MAT at the time of care. We've also created a MAT registry, which allows us to easily track patients who received MAT and feed information back to the MAT providers. This is important because the way the licensing for MAT works, providers have limitations on how many patients they can concurrently treat, and this dashboard and registry information helps them keep track of that.

Another tool available to providers is the MEDD calculator, which stands for Morphine Equivalent Daily Dose.

Dr. Jonathan Siff: This is a measure of how much opioid medication the patient is getting and helps us make it equivalent across all the various formulations of opioids. The key to the use of the MEDD calculator is that the system can actually calculate for the provider, both what the patient's existing dose is, and if they are planning to prescribe, how that prescription would change that. And there are certain thresholds that have been set up by the government where we have different alerts and different requirements of how to treat patients and manage them.

Dr. Jonathan Siff: So the calculator quickly allows the provider to see, okay, the patient is currently at 30 MEDD, if I give this new prescription, they'll now be at 80, 80 is a trigger point. If I had hit 80, if I'm going to go ahead with this prescription, here are the things I additionally need to do.

And we make this available all throughout the EHR. We make it available in the patient header. We make it available during order entry. Again, we want providers to have key information at the right point in their workflows, they don't have to leave prescribing and go look for a piece of information, then go back.

Karolyn Tibayan: We’re able to determine opioid pills and pills per 100 counters, drilled down to the provider name and determined that they decrease with our tools and resources and supports within the EHR. At the same time, we've noticed the MAT prescriptions have subtly increased. So that's also another nice way to look at this data, to determine we're going down in prescriptions, but we're going up in MAT medications and the support for our patients that are suffering from opioid use disorder.

Perhaps the most time-saving and comprehensive element of the opioid dashboard at metrohealth is the opioid snapshot, a conglomerate of patient data and data surrounding their prescriptions.

Dr. Jonathan Siff: So the opioid snapshot is our primary method of aggregating information for providers. We have an opioid peer review committee that was spending an inordinate amount of time combing through charts, looking for the information they needed to appropriately review providers prescribing. And to try and make that a more seamless process, I created a snapshot that brings in the patient's prescriptions, their toxicology reports, and a variety of other pieces of information key to those evaluations. And what we discovered was the information was not only valuable to our peer review committee, but to individual providers when looking at a patient and trying to get an overall picture quickly of that individual patient's opioid history. So we made that snapshot available to all providers at the point of care and it's really been a nice tool for them to be able to quickly visualize a patient's information. When you add that in with the data from the PMP, it really gives a provider an overall picture of, is this patient appropriate for opioids? And are there other things I can do if they're already taking opioids to reduce their dependence on those medications.

Opioid risk scoring is the next step beyond the opioid snapshot-- a tool created to help providers estimate the potential negative outcomes of prescribing a given patient an opioid.

Dr. Jonathan Siff: With respect to the opioid risk scoring, we have a number of tools in our electronic health record that allow providers to create a score, giving them an idea of the risk of providing opioids to a certain patient. These tools can be used both in primary care and by our pain management providers. We are also currently working on predictive analytics to predict which patients may be at risk for opioid dependence if we do prescribe for them, which will hopefully give us an opportunity to not prescribe to patients who may be high risk, where there's other options and prevent future addiction.

Even though Metrohealth may have been one of the first adopters of this sort of technology, Dr. Siff says that many health organizations are now using similar tools, and their respective communities are reaping the benefits of a streamlined process for prescribers.

Dr. Jonathan Siff: We realized that if we didn't make it easy for providers to do the right thing, unfortunately, oftentimes they would not. I’ve been around the country talking on some of these topics… our governance practices attract a lot of interest. We inspect what we expect of our providers and how we ensure that things are happening the way we want them to so that we're getting those great changes in our numbers, that Carolyn mentioned, a decrease in prescribing of opioids and an increase in a MAT and treatment for our patients. And that's really key to any of this is that you have to ensure that what you are helping to happen, through your electronic health record implementation is actually making a difference. And if it's not, then you need to adjust your course.

If you’re listening to all of this and you’re working for a health system that doesn’t yet have these types of tools in place, you may be wondering how implementing similar systemic changes can happen. Dr Siff says that it’s relatively simple.

Dr. Jonathan Siff: The basic functionality which we discussed can be implemented in any electronic health record, certainly for customers of the Epic electronic health record, Epic has made efforts to create standard or foundation versions of most of these alerts. And most of these dashboards that customers can then customize to their own needs. For others using non Epic electronic health records, I think that their vendors are willing to be engaged and should be engaged to try and help the organizations quickly and efficiently implement these types of efforts. But all the major electronic health system vendors have functionality similar to what we've discussed, it's just a matter of making sure that you implement it in your electronic health systems version in a way that makes sense for your providers and your workflows.

Another person who has been instrumental in creating digital tools for promoting opioid safety at MetroHealth is Peter Lawson, manager of business intelligence within the department of operations and research analytics.

LAWSON: The work that I do with the office of opioid safety is both part of my job, but from the beginning has been really a labor of love and part of my kind of commitment and passion for improving the lives of the patients we take care of.

I think at the top line, we look at the number of pills prescribed just as a way of looking at just with a goal of saying we should be working every day to minimize the number of doses of opioids that ultimately are making their way into the community. We also measure the percentage of patients who are receiving an opioid. And we look at some various ways of looking at how well the prescribing sort of aligns with our expectations based on guidance from CDC and others.

Peter told us that in addition to co-prescribing alerts and MEDD, there’s another use for the data compiled by the opioid safety dashboard.

And finally we look at how providers are doing in documenting their use of the system, which is the Ohio pharmacy data that says what else is this patient being prescribed based on that statewide database to look for other indications that the patient might already be getting opioids elsewhere, or isn't having their care for pain well managed centrally.

Peter explains that all of this opioid data isn’t only used to provide more cultivated and personalized care for patients, but also to inform decisions made by leadership at MetroHealth.

Our executive leadership gets a monthly scorecard that takes the system as a whole and reports those measures, and it reports how we're doing in the current month. It trends it against how we were doing in this period last year. And we look at it all of them over time. And in terms of clinical leadership department chairs or division directors also have access to a dashboard that shows just their clinicians and gives a more granular clinician centric view of comparing that group of providers to one another and how they're performing in these various metrics.

From the beginning of his collaboration with the Office of Opioid Safety, Peter says that a top priority was creating a data-first approach to combating the opioid epidemic.

If we're trying to change behavior fundamentally to make patients safer, to make the organization safer, to make individual providers and prescribers to make their practices safer. We really should be looking to say, how are we communicating? How are we partnering? Looking for bad actors puts everyone in a defensive posture and look trying to identify those who've done wrong. As somebody who has knowledge, expertise in public health, I don't pretend to understand what it is, how a given clinician should be caring for a given patient. I think that relationship borders on the sacred, right?

What I've always wanted to do is make sure we steer the conversation towards providing information and context to providers to say, this is a way for you to see patterns in what you're doing with your patients to see patterns that maybe you can't see even in the day-to-day grind of caring for so many. In a moment to moment, we all make the best decisions that we can, we make the decisions we think are our best for that individual patient at the time. Middle of the road and their prescribing patterns were very much sort of right in line, might find that they are in one of the the edges of the distribution in terms of how much, or how frequently, or at what levels, and while that can make anyone feel uncomfortable.

I think in the moment as partners in this change and really ultimately in partners in trying to make sure that the community is well-served and the organization is well-served going forward. We're really trying to see more accurately understand things in context, and then just make sure that the measures we're presenting are based on the latest guidelines and are based on science. And while they're not meant to dictate behavior of the providers or the prescribers they're meant to put that individual decision into some kind of context that can help them see what else might be possible.

These are extraordinarily well-trained compassionate, caring individuals who went into this profession with the desire to help and to heal. And so our message and our tools should all be aligned with things that can help them achieve their part of that mission.

And for Peter-- like many of the folks at Metro and other hospital systems in Ohio-- this work does cross into personal territory.

My own life, my own family's lives have been touched by addiction and this crisis, and as have many of us, and I think that human component of how much suffering and how much continues to be how much stigma and shame surrounds issues of addiction and mental health. And the notion that none of that should be transferred onto the medical profession as a some like a guilty party to be kind of blamed for this. It's just the idea that there's so much suffering and we have a unique and privileged position to try to address that and address the roots of it

These are lives made better or worse by the decisions that patients make about the decisions that providers make. Yeah, and it's a bundle of human tragedy that I think even doing something small, even doing something just compassionate empathic for me personally, it's why doing this work has been more than just a job for me. It's really been something that I've spent many extra hours and nights working on data sometimes seeing things and understanding kind of the depth of the crisis from a human patient level that I don't know, it's changed me. And it's also the work that I feel I'm the most proud of in my professional life. So, if it ever seems that the numbers are bad, and this reports, or these things are being used punitively, or it's mistrusted, and certainly it can always be improved, but at least for my part. I think that we're all in this together.

Next time on OnePath with Metrohealth…

We talk with Medical Director of the Office of Opioid Safety Dr. Joan Papp on the peer review process within the MetroHealth system.

OnePath with Metrohealth is a production of Evergreen Podcasts, produced, written, and engineered by Hannah Rae Leach and mixed by Sean Rule-Hoffman. Special thanks to Mike Tobin, Karolyn Tibayan, Joan Papp, Joya Riffe, and the entire Department of Opioid Safety in making this show possible.