Transparency Key for Default Opioid Dosing EHR Interventions

EHR interventions to change default dosing settings for opioid prescriptions may be feasible to implement in various surgical populations, especially if the new settings are evidence-based, according to a study published in JAMA Network Open.

Researchers implemented an intervention at a tertiary medical center that lowered the default number of opioid doses in an EHR system for adolescents and young adults undergoing tonsillectomy to an evidence-based level.

One-year post-implementation, the researchers conducted semistructured interviews with otolaryngology physicians who had cared for adolescents and young adults undergoing tonsillectomy.

None of the 16 participants knew that the default number of doses had decreased from 30 to 12. However, 10 participants wrote one or more prescriptions with 12 doses after this change, and some of these providers mistakenly believed that they had not done so.

Some participants in the study credited the power of default dosing settings to the fact that it was easier to comply with these settings rather than take the time to override them. Others indicated that they trusted that the EHR dosing settings signaled the appropriate behavior.

Notably, some participants thought the normative power of default dosing settings would be the greatest for inexperienced clinicians.

“In potential support of this notion, a 2018 study found that after implementation of a systemwide default number of doses for opioid prescriptions, surgical residents were the least likely to deviate from the new defaults,” the authors pointed out.

“These considerations suggest that ensuring the appropriateness of default dosing settings may be an important goal for resident training, as inappropriate settings might create false perceptions of what constitutes appropriate care,” they added.

Participants recognized several factors that might improve clinician support for efforts to change default dosing settings for opioid prescriptions.

Some participants noted that clinicians should not automatically trust default settings. They emphasized the importance of understanding how the settings were developed. Several participants were reassured when the researchers informed them that the new default settings were based on patient-reported opioid consumption and were not arbitrarily created.

Additionally, some participants expressed concerns that lowering the default number of doses in opioid prescriptions could increase refill requests.

“This finding suggests that carefully monitoring for changes in refills may be important to secure clinicians’ support,” the authors wrote. “To further enhance support, those responsible for changing the default dosing settings could educate surgeons on the large body of literature showing that postoperative opioid prescribing can be decreased without increasing refills.”

Participants had mixed thoughts on whether the EHR should require clinicians to justify overriding a new default dosing setting for opioid prescriptions. Some reported that this requirement would be a good check on their decision-making, while others were concerned that it would impede workflow.

“Further research is needed to evaluate whether requiring justification to override defaults affects clinician burden, opioid prescribing, and patient outcomes,” the authors wrote.

The researchers noted two limitations to their study.

First, the transferability of findings is unclear, as the study assessed one surgical population at a single institution. However, most participants were confident that other surgical populations and institutions could use evidence-based default dosing settings for opioids.

“Second, we ideally would have only interviewed participants who were exposed both to the original and updated order set, but we were unable to do so owing to the limited number of otolaryngologists at our institution,” the authors pointed out. “However, nearly all eligible otolaryngologists participated, increasing confidence in the validity of the findings.”