Creating an Opioid Stewardship Committee

Creating an Opioid Stewardship Committee is one of the critical first steps for hospitals and health systems seeking to play a more active and formal role in combatting the national opioid epidemic. This multidisciplinary internal committee serves as the underlying foundation to the hospital or health system’s overall opioid stewardship effort, providing important structure, leadership and accountability.

Within individual health systems, many efforts are led by multi-disciplinary safety committees composed of physician leadership, pharmacists, and other health system leaders. These teams identify problematic trends, assess evidence, and craft interventions that can be broadly implemented within different health settings. While there is no single method for designing a comprehensive health system approach to safe prescribing, examples of coordinated approaches often incorporate provider education, prescribing guidelines, risk-assessment tools, monitoring and coordination through electronic medical record (EMR) integration, and interventions to positively change provider or patient behavior.

“Strategies for Promoting the Safe Use and Appropriate Prescribing of Prescription Opioids,” Duke Margolis Center for Health Policy, February 2018

Although there is no shortage of recommendations and guidance about opioid stewardship programs in general – including toolkits from the American Hospital Association and others – far less has been published to date around considerations and strategies when establishing the internal opioid stewardship committee.

Part of the reason for this gap is likely due to the fact the structure of the committee (oversight, participants, responsibilities, subgroups, etc.) depends heavily on several factors that are unique to the hospital or health system:

• The overall goals of the opioid stewardship program
• The scope of the effort (i.e., broad vs. targeted)
• The specific needs of the community

Although published examples of best practices when creating an opioid stewardship   are somewhat anecdotal – limited to a slide in a presentation or a few sentences in a report – one commonality is the multidisciplinary nature of the team. In addition to support and engagement from C-level executives, pharmacy leadership is almost always actively involved on the committee, as are representatives from departments that prescribe opioids (primary care, surgery, etc.) or that treat addiction. Participation from nursing leadership and behavioral health stakeholders is also common.

Given that technology and data are foundational to virtually any aspect of an opioid stewardship program – whether it is identifying at-risk patients or building dashboards to monitor opioid prescribing practices – it is critical that IT be engaged from the start. IT leadership should have a formal role on the hospital or health system’s opioid stewardship committee, and there should be active IT participation and representation in any relevant subgroups or “task forces” that report up to the stewardship committee. IT’s involvement on the committee will be essential to succeed with opioid stewardship efforts such as:

• Performing risk modeling to identify vulnerable patients
• Building dashboards and decision support tools to monitor opioid prescribing practices
• Providing standard and/or customized educational content to patients about opioid use
• Developing and implementing order sets and care plans
• Configuring alerts at the point of care to notify clinicians about potential opioid misuse
• Implementing electronic prescribing for controlled substances (EPCS)
• Integrating with the state’s prescription drug monitoring program (PDMP) database

Geisinger’s efforts to reduce prescription opioid abuse began in 2015, when the opioid crisis started to become prevalent in Pennsylvania. Analytics played a significant role in helping drive the need to act.

A Geisinger committee of key physician leaders (representing 10 physician “councils” across the entire organization) decided to establish an Opioid Task Force to respond to the growing opioid epidemic in the region. The executive sponsor of the Opioid Task Force is Geisinger’s chief pharmacy officer, and the team includes representation from physician leadership as well as IT (specifically the Epic Ambulatory Leader). The purpose of Geisinger’s Opioid Task Force is to support the needs of the 10 physician councils, each of which is focused on a different aspect of Geisinger’s Opioid Stewardship Program (e.g., pain management, clinical decision support tools, community outreach, etc.). The Opioid Task Force initially met on a weekly basis when Geisinger was planning and implementing the core components of its Opioid Stewardship Program; currently the team meets once a month.

IT involvement in Geisinger’s Opioid Task Force was essential given the role that data plays in Geisinger’s opioid stewardship efforts. In addition to being responsible for the reporting and analytics needed to support the opioid stewardship program (much of which is done using an external “big data” platform), IT also worked closely to collaborate with Geisinger stakeholders across the organization to link the provider dashboard to Geisinger’s enterprise EHR, leverage information from the Pennsylvania state PDMP database, implement electronic prescribing for controlled substances (EPCS), and integrate data from Geisinger’s pain app into the EHR and provider dashboard.

Information technology is a powerful tool, but its effectiveness is limited without buy-in from clinicians and administrators…Technology is not the silver bullet to solving this problem; there is no single silver bullet.

– John Kravitz, Corporate CIO, Geisinger,
Source: Healthcare Informatics, 4/27/18

Geisinger’s Opioid Stewardship initiative has resulted in reducing the number of opioid prescriptions per month by half, from an average of 60,000 prescriptions per month down to 31,000 per month by April 2018. The downward trend has continued since then.

Keys to Success:

• A passionate executive sponsor.
• Engagement from clinical and administrative leaders.
• Patience. Kravitz notes: “Creating the right governance structure and implementing
  changes to curb opioid abuse takes a lot of diligence; it took us two full years to actually
  achieve results.”
• Focus on knowledge and analysis. “We found that giving data back to our providers was
  critical to success; they absolutely respond to data and relative metrics,” says Kravitz.
• Create peer pressure among physicians.
• Employ change management methods (skills, techniques, disciplines).

Geisinger’s approach to opioid stewardship governance reflects the organization’s holistic, multifaceted, and data-driven strategy for
responding to the opioid crisis:

• Encourage effective, non-opioid therapies
• Leverage the Pennsylvania state PDMP
• Link provider dashboard to EHR
• Document findings in patient’s medical record
• Integrate data from the Geisinger pain app into the dashboard and the
  patient’s medical record
• Enable electronic prescribing for controlled substances (EPCS)

Source: “Geisinger’s Approach to the Increasing Opioid Epidemic,” CHIME
Webinar, April 2018

At UChicago Medicine, opioid management falls under the scope of the organization’s pain care stewardship efforts. According to Samantha Ruokis (director, Quality Performance Improvement at UChicago Medicine), the decision to focus more broadly on pain care was very deliberate. “The message we want to send is that we are trying to provide the safest and most comprehensive pain care possible,” says Ruokis. “Reducing opioid prescriptions is certainly a critical part of that, but we also want to make sure we don’t lose sight of other important components of pain care that need to be included across the care continuum.”

The multidisciplinary Pain Care Stewardship Committee at UChicago Medicine was established in the fall of 2016. The Pain Care Stewardship Committee reports directly to the Medical Center Quality Committee, the same group that has oversight over a number of other key quality initiatives at UChicago Medicine (such as the Readmissions Task Force).

The structure of UChicago Medicine’s Pain Care Stewardship Committee is designed to be flexible and agile, with committee responsibilities and activities largely driven by the pain care stewardship workplan. Initiatives defined in the workplan dictate the work that needs to be done, and the committee implements the structure needed to ensure all related tasks are completed.

Participation on the Pain Care Stewardship Committee is intentionally broad to ensure that a variety of different perspectives on pain care are represented. Pharmacy was heavily involved from the start, as were pain experts across the organization. However, UChicago Medicine also engaged clinicians from many different disciplines outside of pain care, particularly those involved in interventions at the point of care (capturing data, receiving alerts, etc.)  The goal was to achieve multidisciplinary participation and representation across all UChicago Medicine encounters and types of pain (acute, chronic and abuse disorders).

IT – along with the Clinical Informatics team at UChicago Medicine – also played a large role, with formal representation on the Pain Care Stewardship Committee and early involvement in planning the implementation of many of the interventions. According to Quality Improvement Project Manager Leslie Wiora:

Getting our technology and informatics folks engaged as early as possible was essential; a lot of our pain care initiatives and opioid-specific interventions heavily involved IT.” Adds Ruokis: “Collaboration between IT and the Pain Care Stewardship Committee was critical to ensure we had high fidelity data on pain and pain management from our EHR. It isn’t just about getting our clinicians the actionable data they need at the right time, it is also about ensuring that data is easy to understand and actionable across disciplines and across teams.

Keys to Success:

• Leadership support and buy-in to make pain care stewardship an organizational priority – including support from IT, informatics and quality department leaders.
• Engagement from clinicians at all levels in the organization. “No matter how much leadership wants to make pain stewardship a priority, if you don’t have engagement from pain care experts in the organization and the clinicians involved at the point of care, you will struggle to be successful,” says Ruokis.
• Formal IT and informatics representation on the Pain Care Stewardship Committee – and early involvement from IT and informatics around planning and implementing opioid-specific interventions.
• Not being content with the status quo. According to Wiora, “We are constantly asking ourselves: ‘Where are we today? Where are the gaps we need to address?’ Continuing to move forward with innovative thoughts and ideas about pain care stewardship is critical.”

At CalvertHealth (Prince Frederick, MD), opioid stewardship planning efforts first began in December 2015. An Opioid Stewardship Task Force was officially established in 2016, with a mission of ensuring safe and appropriate use of opioids. In terms of oversight, the Opioid Stewardship Task Force reports to the CalvertHealth Medication Usage and Safety Team (MUST), and meeting minutes are sent to CalvertHealth’s Medical Executive Committee.

CalvertHealth deliberately took a well-rounded, inclusive approach to membership on the Opioid Stewardship Task Force. The group is co-chaired by Kara Harrer (CalvertHealth director of pharmacy) and Drew Fuller, MD, (a CalvertHealth ED physician), with wide representation from across the CalvertHealth system, including stakeholders from hospital leadership, nursing, quality and public relations. (See below.) Notably, the Opioid Stewardship Task Force includes participants from outside CalvertHealth as well, such as representatives from the County Health Department and physician practices in the community. According to Harrer, “It was important to us that we collaborated with our allied health partners and educated them on what we were doing to tackle the crisis. We wanted to do our best to ensure everyone was on the same page and that opioid stewardship efforts in the community were as aligned as possible.”

The Task Force made data and reporting a high priority, including metrics such as total opioid orders in the emergency department per month, total opioid IV doses per month and total opioid tablets prescribed per month. “Focusing on data and reporting was essential for us to track progress on our initiatives, communicate the impact of our stewardship efforts to the board, and educate our physicians and allied health partners,” says Fuller.

IT worked actively with the Opioid Stewardship Task Force to build the reports and track the defined metrics in the EHR. Ensuring accurate data was critical, especially in terms of engaging and educating clinicians. “Physicians are very accustomed to being measured – they just want to be measured fairly,” says Fuller. “Access to the right data can be really powerful. Just being able to show a physician that they are prescribing two-three times more opioids compared to their peers is enough to change behavior.”

According to Phil Campbell, CIO/ vice president of information services at CalvertHealth, one of IT’s most important functions in supporting the Opioid Stewardship Task Force is to look for opportunities to make things more efficient. “The physicians know the diagnoses and treatments, the pharmacists know the drugs and the IT team knows the EHR application and what it is capable of,” says Campbell. “It is critical that the CIO stay plugged in with the needs and priorities of an Opioid Stewardship Committee. IT can often make things more efficient in ways end users may not even realize.”

Keys to Success:

• Take a well-rounded, inclusive approach to forming an Opioid Stewardship Committee. According to Harrer, “We wanted to ensure we involved all stakeholders in the discussion – including the public.”
• Make an upfront investment in reporting. Fuller advises: “Avoid vagueness. Define clear metrics that can accurately communicate information. Focus on measurable outcomes.”
• Early – and ongoing – communication between the Opioid Stewardship Committee and IT.
• Adopt and endorse best practice prescribing standards. “There is a myth that physicians don’t like guidelines, but we found that our doctors greatly appreciated them,” says Fuller.

The rapid escalation of the national opioid epidemic has resulted in an increasing number of hospitals and health systems formalizing action plans in the last few years. However, some provider organizations have actually been tackling problems with opioid abuse and addiction for over a decade. One example is Gundersen Health System (GHS) in Wisconsin, which began its efforts back in 2008 amid concerns from ambulatory physicians about an increasing volume of opioid prescriptions and changes in patient behavior.

Gundersen Health System (which includes a 325-bed teaching hospital and 30 primary care clinics) employed a very targeted and ambulatory-focused strategy, centered on creating an organizational approach to pain management. According to Marilu Bintz, MD (senior vice president, Population Health and Strategy at GHS), “Growing concerns about patient behavior was one of the primary factors that caused us to take action in 2008, but we didn’t have any way to actually identify the patients we needed to track and monitor. We decided the first thing we needed to do was build a registry of chronic pain patients where we could put the chronic pain agreements, DIRE (Diagnosis, Intractability, Risk and Efficacy) scores and urine toxicology screening results, as well as a template for medication refills.”

A Chronic Pain Committee was established in 2009 to lead the effort. The makeup of the multidisciplinary team reflected the targeted, ambulatory-centric nature of GHS’s approach.  Committee members included GHS stakeholders from primary care, pain medicine, addiction medicine, nursing, legal, patient education, quality improvement and pharmacy. IT – which was responsible for building the registry of chronic pain patients and creating the electronic flow sheet and measures – also had formal representation on the Committee, particularly clinical data services staff.

The Chronic Pain Committee was put under the Disease Management Steering Committee at GHS. As Bintz notes, “Because we were building a registry of chronic pain patients, we treated it as a disease. Having the Chronic Pain Committee fall under our existing Disease Management Steering Committee was consistent with how we approach planning and implementation of other registries and internal disease management initiatives.” Holly Boisen RN (system project manager at GHS) adds, “The Chronic Pain Committee was actually fairly autonomous, empowered to make important decisions independently and do what was necessary to keep the effort moving forward. When we needed help with something like organization-wide messaging or communication though, we could turn to the Disease Management Steering Committee for support.”

Figure 1. Gundersen Health System’s Chronic Pain Committee

Keys to Success:

• Begin with a defined, narrow focus. GHS took a targeted approach that started with the development of a registry of chronic pain patients. The narrow, ambulatory-centric scope of that effort was reflected in the way the Chronic Pain Committee was structured (participants, oversight, etc.)
• Strong clinician champions. “This is a difficult topic, and you need someone who is willing to have those important conversations in a constructive, respectful manner,” says Bintz.
• Accurate data. According to Boisen, “Report validation, which required collaboration between IT and Quality, was critical. You really can’t put data out there if it isn’t accurate.”
• A good CIO partner. IT played an important role right from the start to build GHS’ chronic pain registry and create the electronic flow sheets and measures. As IT transitioned into more of a supporting role, both Boisen and Bintz point out the value of open, regular communication with IT stakeholders – and the importance of a good, collaborative partnership with the CIO.

Opioid stewardship committees are by no means exclusive to large academic medical centers and integrated health systems. Many smaller organizations – such as Healdsburg District Hospital, a critical access hospital in Healdsburg, Calif. – have also set up the internal structure and governance needed to support the specific scope of their respective opioid stewardship programs.

The Opioid Crisis and Pain Management Task Force at Healdsburg District Hospital (HDH) was established in July 2018 to “promote and standardize safe opioid use in pain management in the acute care setting and help combat the opioid crisis within surrounding communities.” The group – which meets every month – is chaired by the hospital’s pharmacy director, with the CNO serving as the executive sponsor. The CIO is a formal member of the task force, and there is participation from emergency physician group, district education coordinator and perioperative clinical leaders as well. The Opioid Crisis and Pain Management Task Force is responsible for a quarterly report that goes to the HDH Quality Committee and Pharmacy & Therapeutics/Medication Safety Committee, as well as a bi-annual report that goes to the hospital’s Medical Executive Committee.

Having the CIO actively involved on the Task Force right from the start was critical to HDH being able to quickly implement a number of key IT-related changes in support of their goal to reduce opioid prescriptions and standardize pain management. For example, in just the first few months alone, HDH has been able to successfully:

• Build – and modify – pain management standardized order sets in the EHR
• Identify current opioid prescribing patterns within the organization and establish a baseline to measure outcomes of the task force’s initiatives
• Implement a “pass through” in the EHR so physicians can directly access the California PDMP database at the point of care
• Implement and build a standardized Suboxone treatment protocol (in coordination with ED physician group) in EDIS (the EHR in the Emergency Department) to initiate treatment in opioid-withdrawal patients

When asked his advice to CIOs at similar-sized hospitals establishing an opioid stewardship committee, HDH CIO Bill Cioffi says, “Build a coalition – both internally and in the community – and rely on appropriate resources. IT alone can only drive the effort so far. There must be strong leadership and engagement among physicians, nursing and pharmacy, since that is ultimately where the changes and interventions take place.”

One of the biggest challenges for small hospitals – especially compared to academic medical centers and integrated health systems – is the lack of resources. However, as Cioffi points out, smaller organizations also have some advantages that CIOs should keep in mind when establishing an opioid stewardship committee. “There is usually much less bureaucracy at smaller organizations,” says Cioffi. “Here at Healdsburg District Hospital, our leaders are very accustomed to wearing many different hats and taking on new kinds of responsibilities.  Active, candid communication is just part of the culture. In many ways, we can implement meaningful change much more quickly than a large organization.”

• Kaiser Permanente Southern California took a “comprehensive” approach to combat the opioid epidemic, creating “prescribing and dispensing policies, monitoring and follow‐up processes, and clinical coordination through electronic health record integration.” According to a 2017 study in the Journal of Evaluation in Clinical Practice, “Kaiser Permanente Southern California’s intervention was developed and overseen by a multi‐disciplinary team composed of physician administrative leaders, primary care, pain management and addiction medicine physicians, pharmacists, information technology leaders, and education specialists… This structure provides the critical framework needed to develop, communicate, implement, and sustain the initiative.” Results from implementing the interventions included “a 30% reduction in prescribing opioids at high doses” and “a 98% reduction in the number of prescriptions with quantities greater than 200 pills.”
• At University of Kentucky HealthCare, the opioid stewardship committee is modeled after the antimicrobial stewardship committees in many hospitals.  According to Phillip Chang, MD (CMO at UK Kentucky HealthCare), the committee is responsible for “monitoring the prescribing patterns and educating physicians, nurses and pharmacists about the rules around prescribing.”

Measuring Success

Key Success Factors When Establishing an Opioid Stewardship Committee

• Clear mission statement and goals
• Well-defined accountability structure
• C-Suite engagement and support
• Multidisciplinary participation on the committee, especially from pharmacy leadership and departments that prescribe opioids or treat opioid addiction
• Formal involvement of IT leadership on the opioid stewardship committee, as well as IT participation and engagement in any applicable opioid stewardship committee subgroups or task forces
• Protected time for leaders to participate on opioid stewardship committee-related tasks

Key Takeaways

• Creating an opioid stewardship committee that is positioned to succeed requires support and engagement from C-level leadership
• Multidisciplinary participation on the opioid stewardship committee is also key
• IT should play a significant role on the opioid stewardship committee – both at the leadership level as well as engagement in committee subgroups and task forces
• The specific structure of the opioid stewardship committee (stakeholders involved, subcommittee tasks, overall oversight, etc.) should reflect the unique goals and scope of the opioid stewardship program as well as the needs of the community

Resources 

• NQF “Playbook” on Opioid Stewardship (March 2018)
• “Strategies for Promoting the Safe Use and Appropriate Prescribing of Prescription Opioids,” Duke Margolis Center for Health Policy, February 2018
• “Stem the Tide: Addressing the Opioid Epidemic,” American Hospital Association, 2017
• “Safer and more appropriate opioid prescribing: a large healthcare system’s comprehensive approach.” Losby JL, Hyatt JD, Kanter MH, Baldwin G, Matsuoka D. J Eval Clin Pract. 2017;23:1173–1179.