Using CDS Alerts to Drive Patient Safety, Opioid Stewardship

Healthcare organizations are looking to improve opioid stewardship as harm related to opioid use continues to escalate.

CDC data shows that opioid overdose deaths increased by more than 36 percent in 2020.

While the opioid epidemic has affected every corner of the country, certain areas have been hit especially hard by the opioid epidemic, such as rural communities.

Take Jefferson County, Wisconsin, for example. Between 2015 and 2017, the county death rate in Jefferson County due to opioid overdose nearly tripled.

Further, in 2017 alone, the county death rate from opioid abuse exceeded the entire state of Wisconsin by 31 percent.

"There's been an increase everywhere, but particularly in our county, we had seen higher rates than we had before," Jennifer Winter, MD, a pediatrician and internist at Fort Healthcare in Jefferson County, told EHRIntelligence in an interview.

Fort HealthCare is Jefferson County's only hospital and local resource for opioid stewardship.

In 2018, the hospital had a standard opioid treatment agreement (OTA). An OTA is a written document that lists expectations for opioid therapy to support patient education, facilitate mutual agreement about treatment course, and outline terms of monitoring for safe opioid use.

Patients often must sign OTAs to receive controlled pain medications for chronic non-oncological pain. The documents to promise to not give pills to others, use illegal drugs, or seek controlled medications from health care providers. IHowever, it presented several challenges.

For instance, clinicians had difficulty finding OTAs within patient charts at the point of care.

"When we were in the process of prescribing, we didn't always have time to search around and find the agreement," explained Winter, who also serves as the hospital's CMIO.

As a result, clinicians were often unaware of an active OTA. The OTA also depended on voluntary patient disclosure, which presented a significant social barrier for those patients who might be uncomfortable self-reporting opioid usage.

"We really needed more support with our opioid stewardship to improve outcomes for our patients and reduce the complications that come from having opioids in our practice," Winter said.

The hospital looked to clinical decision support to help improve opioid prescribing practices. Winter noted that the system from EHR vendor Oracle Cerner alerts prescribers when a patient has an active OTA.

"The alerts come up when you're prescribing to make you aware if a patient may have a history of drug abuse or misuse of medications," Winter said. "In that way, we can start to review the safety of the medications and make sure that it is the right prescription for them and that we have safety nets in place."

Additionally, the system sends an alert to all providers that a patient sees to ensure all care team members are on the same page.

"If a patient is seen in the emergency department, or with an orthopedic provider, a surgeon, or someone else, the alert will also pop up for them so they're aware that there may be concerns about prescribing controlled substances to a patient if they have an agreement with someone else," Winter said. "That way, they're aware that they need to be careful about prescriptions."

The toolkit also includes alerts for the appropriate prescription of naloxone, a medication designed to reverse opioid overdose rapidly.

"We wanted to increase our naloxone prescription so that people who were taking our opioids could have a safety net, should they need it," Winter explained.

The alert for naloxone provisioning responds to the patient prescription history and trend analytics to notify physicians and care team members when a patient is under an OTA and could be considered vulnerable.

"The alerts help us get closer to our goal of making sure that our patients who are on 50-milligram equivalents of morphine and medical equivalents daily can get their naloxone prescription," she added. "I think the more we see it, the more we'll remember to talk about it and prescribe it."

Additionally, Winter noted that the alerts inform clinicians if a patient is on benzodiazepine prescriptions, a type of sedative commonly prescribed for anxiety or insomnia. The use of these medications with opioids increases the risk of overdose. In 2020, 16 percent of overdose deaths involving opioids also involved benzodiazepines.

"These kinds of alerts really help us prescribe more safely for our patients," Winter underscored.

The system also notifies providers if a patient has other risk factors for complications from opioids, such as depression or chronic health conditions.

Since implementing the toolkit, Fort Healthcare has experienced a 53 percent decline in the number of patients with opioid prescriptions. The hospital also saw an increase in naloxone prescriptions and a decrease in prescriptions for combined opioids with benzodiazepines.

"It's really made an impact on how we are thinking about the patient as a whole," Winter said.