How a Health System Cut Opioid Prescribing Rates, Clinician Burden

With an opioid prescribing rate 38 percent higher than the rest of the nation, the opioid epidemic has hit Kentucky hard. Although the state passed a law in 2012 requiring physicians to check the state’s prescription drug monitoring program (PDMP) database, roughly 1,000 Kentuckians are passing away from drug overdoses and this number continues to climb.

The PDMP assembles pharmacy and patient data from Drug Enforcement Agency (DEA) controlled substances and prescription drugs. PDMPs help prescribers keep track of patients at high risk of becoming opioid-dependent.

But although the statewide PDMP database was in place, Steven Heilman, senior vice president and chief health innovation officer at Norton Healthcare, said the previous method would take clinicians up to 10 minutes to check both Kentucky’s and its neighboring state, Indiana’s, PDMP databases for each prescription.

This lengthy process resulted in clinician burden and a high prescribing rate.

“Typically, the ER doctors would have to stop working what they're doing in the EHR, log into the state's registry, put in all the patient information, wait for a return to come back in, and then look at it,” Heilman said in an interview with EHRIntelligence.

“That could take anywhere from five to 10 minutes, typically, depending on how much time the provider took to put everything in.”

Norton Healthcare, which serves as Kentucky’s largest health system, put together a narcotics task force to help look at the prescribing habits and behaviors of its employees and clinicians to see if there were areas where they could improve prescribing practices.

“We wanted to help streamline the clinician's ability to look at the PDMP databases if they were going to prescribe narcotics and get a better understanding of a patient's history and to make sure that they weren't doctor shopping,” Heilman said.

Due to an alarming clinician burnout rate, Heilman assigned medical assistants to help clinicians with this lengthy process.

“In some of the clinics, there were proxies who were assigned so that if a patient came in, the proxy would go ahead and complete all that information and then slide the printout into the chart or hand it to the physician so they could take a look at it,” Heilman said. “They had to acknowledge that they had searched the PDMP and put that in the chart as well.”

To decrease the number of clicks, minimize the need for medical assistants, and to keep the clinician within a singular workflow, Heilman and his team integrated a tool from Appriss Health into its EHR platform that allows users to query the database without opening up a new window.

“Having the tool integrated into the EHR helped with the workflow for clinicians,” Heilman said. “We’re now able to look the information up without having to log out of the EHR, log into the state's website, then log into multiple registries because we're on the southern border of Indiana as well to look up a patient's previous habits and their database history in the PDMP.”

Now with all the information passed directly from the EHR to the PDMP database, the former proxy access issues are a thing of the past, Heilman said. Since integration, the prescription numbers at Norton Healthcare fell more than 51 percent from last year.

“It was a multi-pronged approach,” Heilman said. “Yes, we have seen about a 50 percent decline in narcotic prescribing, but that's based on both ease of access of the tool and the task force looking at online order sets that we utilize and educating physicians who typically prescribed large portions of narcotics at initial visits so, a lot of orthopedic procedures or painful procedures.”

“A lot of our providers were writing for 120-day supplies and we knock those down to 90 or less,” Heilman continued. “We've seen a significant reduction with everything that we've done. Whether it’s modifying order sets, educating per clinician, or making ease of access to the PDMP. We've also seen the number of clicks have gone down dramatically within the last year.”

Although the EHR integration occurred without any issues, Norton had to work with the state to iron out specifics.

“Some of the identifiers that this tool uses were not the same identifiers that the state utilizes,” he explained. “We had to position the state to accept what we were going to send them in terms of identifying who the patients are and who they match, but it was not complicated when you've had a good conversation with the state. They agreed and it worked.”

Heilman said he’s looking forward to January 1, 2021, when a federal mandate will require e-prescribing for all narcotics, which he said will help further reduce the number of prescriptions and force providers into compliance with utilizing the PDMP tool.

“That's probably one of the biggest things coming in the future and it’s going to be very helpful,” Heilman concluded. “We’ll continually look to monitor prescribing behaviors. Then, we also have a dashboard that we monitor how often each provider is prescribing and educate our providers on what is appropriate and what may be excessive.”