PDMP Strategy Survey Results

CHIME Opioid Task Force – PDMP Strategy Survey

The College of Healthcare Information Management Executives (CHIME) Opioid Task Force is developing a playbook to assist our membership in addressing the substance abuse crisis.  Keys to every provider’s strategies are reducing opioid prescribing for pain management, employing alternative forms of pain management and facilitating patients’ addiction recovery efforts.

Chapter 6 of the playbook focus is identifying at-risk patients through access to the Prescription Drug Monitoring Programs (PDMP) used by most states.   The chapter includes information on how the key electronic prescribing solution vendors are approaching access to PDMP’s from their EPCS solution and assessment of patients’ risk to abuse and addiction.

CHIME asked the numerous EHR Vendors to share their strategies.  The following firms were able to complete the survey and their responses follow;

• Allscripts
• Cerner
• First
• EPIC
• MEDITECH
• Next Gen

What is your overall strategy responding to the opioid crisis (in addition to PDMP integration)?

Allscripts has developed and communicated, both internally and externally, an overall approach that brings to bear our resources to address the Opioid Epidemic.  In short, these tools are focused on four areas:

• EPCS to help fight fraud and abuse
• PDMP Integration to provide seamless and transparent retrieval of patient data
• Informed Decisions through alerts, scores, and dashboards (analytics)
• Clinical Guidelines and Tools

This article provides an overall summary of Allscripts’ public commitment:

https://www.healthcareitnews.com/blog/how-technology-can-help-fight-against-opioids

What is your overall approach to PDMP integration?

Point-to-point or hub-and-spoke?

Hub-and-spoke:  Allscripts has integrated with various PDMP aggregators and state PDMPS to enable one-click access to a patient’s PDMP data within the EHR workflow.  We continue to work on expanding our functionality in this area, as the market is evolving quickly, including requirements from the state regulators.

Where in workflow?  EPCS or Other – for example: all encounters vs EPCS only

All Encounters.  Allscripts has taken a unique approach wherein the PDMP data is requested and retrieved for every patient encounter (not just when a controlled substance is being prescribed and not just on demand) so that providers will have this important data available at all times.  In that way, providers will be alerted to potential problems even when the patient is presenting for routine or other visits that might not normally prompt a prescription for a controlled substance.

What are your plans and progress in interoperability with state PDMPs?

Allscripts has entered into relationships with various partners and states to provide PDMP integration across all states.  Where it is allowed, Allscripts will be deploying functionality at a future date to increase integration of the data from PDMPs into our EHRs.

Allscripts – PDMP Strategy Survey

What is your interoperability with Appriss?

• Do you offer / resell NarxCare?

• Allscripts has a relationship with Appriss that provides access to all their supported states (currently at 48). Allscripts has worked very closely with Appriss to implement a unique technology approach to enable rapid retrieval and response with data.
• Do you offer any alternate risk models and analytics availability? If so, please describe.
• Native development and/or 3^rd party vendors (e.g. PastRx)
• Not at this time. Allscripts does enable providers to easily link to state PDMPs that provide this level of analytics, and we are in the process of developing native analytics capabilities.
• Do you link directly to PDMP?
• Whether Appriss or other vendors, we link from within our EHRs to the PDMPs. Allscripts also displays a PMDP-sourced report that is presented to the provider within the EHR workflow.
• Data import from PDMP?
• Our ability to import data is affected by state laws and regulations, given that a large number of states prohibit such data consumption by the EHR. Where it is allowed, Allscripts will be deploying functionality at a future date to increase integration of the data from PDMPs into our EHRs.

Do you have interoperability with alternate PDMP solutions?  Have you developed integrations with;

• State portal(s)
• RxCheck/PDMP Assist
• Logicoy
• HIE as link to Appriss or others.
• Other
  • Answers above speak to Allscripts’ interoperability with each of these vendors or vendor types.

If you can, please share any specific client case studies – include 2-3 representative client examples

• Allscripts is seeking the appropriate permissions from clients so that we may share such information. We will do so when they are available.

Optional: If you are able, please share the economic model in provision of these services to your provider clients. 

• As part of its commitments to provide relevant IT solutions that are responsive to the critical Opioid crisis, Allscripts has chosen not to charge clients any additional fees related to PDMP. All related PDMP functionality is included with a client’s EPCS subscription.

Overall strategy responding to the opioid crisis (in addition to PDMP integration)

Facing the complex, global opioid crisis, Cerner Corporation has a holistic strategy to support patients, practitioners and health systems in the mission to prevent and manage opioid use disorder. Though the industry has previously emphasized reducing opioid over-prescribing and access to prescription drug monitoring programs (PDMP) as keys to managing the opioid crisis, Cerner coach health systems on balancing the Three Pillars of Opioid Management:

• Opioid Safety – Tenaciously identify and mitigate risks of opioid use while utilizing evidence-based opioid prescribing practices
• Pain Management – Maintain excellence in pain management, support chronic pain populations with proactive connection with the right providers and services to manage their underlying disorders, and address variance in pain management
• Opioid Use Disorder – Tenaciously maximize patient engagement at every state in the Cascade of Care for opioid use disorder, and support care teams and providers with the training and resources they need to be successful in helping individuals manage their opioid use disorder

Achieving excellence in opioid management requires a strategic approach each of the Three Pillars with a focus on how the people, processes, and technologies support each other in a common mission. Though much focus has been given in the industry on “don’t do” clinical decision support, such as alerts to prevent prescribing of opioids beyond a certain number of days’ supply, Cerner Corporation is working with health systems and their providers to use technology to truly support clinical decision making.

For example, the Cerner Opioid Toolkit includes a collection of CDS to help providers identify person-specific risks prior to prescribing an opioid. It even includes analytical tools that go beyond prescribing rates to determine where opioid treatment agreements and proactive naloxone education can be used more effectively to mitigate patient risk. The opioid crisis is obviously complex, and while many providers feel a sense of duty to help, most are in want of resources that can help. A very simple place to start is to help providers know where a patient can go for treatment of their substance use disorder.

SAMHSA offers a free online treatment locator; which Cerner has integrated into EHR workflow using Cerner MPages technology so that providers can see up-to-date locations of different types of providers based on the patient’s preferred zip code for service.

Cerner Corporation – PDMP Strategy Survey

Though these provide a few examples of specific technologies supporting providers, it is important for health systems to not “throw the kitchen sink” at the problem of opioid misuse. No two states or health systems experience the opioid use disorder epidemic the same way. There are disparities in access to care for populations, differences in the prevalence of fentanyl in illicit sources of opioids, state strategies and community engagement. In 2018, Cerner created the Opioid Management Value Advisory to work in partnership with its clients, taking a data-driven, value-based approach to the opioid crisis. The methodology yields a sustainable process of continuous improvement in both preventing and managing opioid-related harm.

Overall approach to PDMP integration

• Point to point, hub and spoke
  • No different than any other EHR – current options are limited. Cerner is connected to Appriss who connects to PMPi.  Cerner currently support connecting to both WA and IL PDMPs which is a point to point connection.
• Where in workflow?
  • General workflow integration. Workflows in Cerner can are configured Linearly and can be contextual to Role, Venue, and specialty.  PDMP integration can be placed/ ordered right before or after the home medication list is reviewed and reconciled.
  • EPCS

Other – for example: all encounters vs EPCS only

• Practitioner access to prescription drug monitoring programs is ideally part of EHR workflows to bolster utilization of the PDMP. When left to tediously access the PDMP via a state web portal, many a practitioner has confessed that they “look the patient up in the PDMP only if they look like a junkie”. This leads to under-identification of individuals engaging in opioid misuse since, for example, individuals with a substance use disorder may not have an appearance or demeanor that matches the practitioner’s conception and may, in fact, appear and be a high-functioning individual. The utility of PDMPs to the practitioner and the patient are improved by including PDMP access easily within common EHR workflows for providers who prescribe or manage opioid medicines.At a minimum, providers of primary care, pain medicine and emergency medicine should have access to PDMP data accessible prior to medication order entry and/or in relation to their medication reconciliation workflow. State law(s) and opioid prescribing guidelines should be consulted for additional guidance.

Plans and progress in interoperability with state PDMP’s

State-specific successes and challenges

• Cerner is working to connect all state and territory PDMP to allow for integration of the PDMP report inside clinical and prescriber workflows. Cerner was the first to connect EHRT to the Appriss API and first to have a Provider organization realize the benefits of workflow integration.  Due to connection to Appriss, Cerner supports most states that support Appriss integration.  Cerner also currently supports workflow integration of 2 states that do not support Appriss – WA and IL.  Currently Cerner is working to connect to CA and other states that do not support Appriss integration.  This has been a challenge due to lack of standards (API specifications and content format that is delivered.

Interoperability with Appriss.

• Formal agreement?
  • Yes, Cerner Resales Appriss connectivity however recognizes no margin.
• NarxCare resale?
  • Yes, same as above.
• Alternate risk model and analytics availability? Describe.
  • Native development and/or 3^rd party eg PastRx
  • The component that launches the Appriss report is native Cerner Developed and supported. Appriss delivers HTML which is not modified merely launched in a window for clinical user to review.
• Direct link to PDMP?
  • Connected to Appriss API. Also connect to WA API offered by OneHealthPort and IL via API supported by Logicoy
• Data import from PDMP? Describe.
  • No, data from Appriss API is HTML and not delivered in discrete format like XCPDP. Report level saving is also not offered.  Very few states allow saving of report so have not invested in capability although newer Appriss spec can deliver an alternative format that is more conducive to saving to EHRT.

Interoperability with alternate PDMP solutions

• Custom integration with state portal(s)
  • WA through OneHealthPort.
• RxCheck/PDMP Assist
  • No
• Logicoy –
  • Yes, in IL
• HIE as link to Appriss or others.
• Other

Client case studies – include 2-3 representative client examples

• Atrium Health reduced prescribing rates for opioids and benzodiazepines after the implementation of EHR-based clinical decision support to identify person-specific risks of use.
• Cook County
• Intermountain Health Care reduced opioid prescribing rates by about 40% (compared to 2016 rate) through a combined effort of provider collaboration, implementing an opioid stewardship committee, and EHR-based clinical decision support.

Optional: Economic model in provision of these services to the provider client

Overall strategy responding to the opioid crisis (in addition to PDMP integration)

• MME Equivalent
• Alerts customizable by enterprise, such as the 6-6-5 alert.
• Benchmarking dashboards

Overall approach to PDMP integration

• Point to point, hub and spoke
  • Both
• Where in workflow?
  • At point of e-prescribing
  • Available at any point in encounter

Plans and progress in interoperability with state PDMP’s

• State-specific successes and challenges
  • Integrated with APPRISS
  • In Nebraska we are the state PDMP
  • Also, have direct connect with some states

Interoperability with Appriss.

• Formal agreement?
  • As they bring up a state we integrate
• NarxCare resale?
  • Not Clear on this question. We integrate with Narxcare but are not a reseller.
• Alternate risk model and analytics availability? Describe.
  • Native development
• Direct link to PDMP?
  • In all e-prescribing apps there are numerous integration points. By clicking PDMP is displayed and prescriber is given credit with the state for checking.
• Data import from PDMP? Describe.
  • In states that allow data will become part of the medhx.

Interoperability with alternate PDMP solutions

• Custom integration with state portal(s)
  • yes
• RxCheck/PDMP Assist
• Logicoy
• HIE as link to Appriss or others.
  • Yes, already integrated with a number of HIEs
• Other

EPIC – PDMP Strategy Survey

Overall strategy responding to the opioid crisis (in addition to PDMP integration)

• Epic established a Company Wide Initiative to prioritize software development across applications to help our customers address the opioid epidemic. Some of the functionality from this CW include PDMP integration, morphine equivalency calculations, and decision support at prescribing to account for quantity, duration, and morphine equivalence. A registry was developed for reporting on quality metrics. A predictive model to assess risk of opioid abuse is in development.
• We created an opioid safety taskforce that includes representatives from R&D, technical services, and other roles to help ensure customers understand and use the opioid-related enhancements. This group serves as evangelists to assist with adoption of existing opioid-related functionality and workflows, and as a point of contact for new development requests. This group identifies Epic customer success stories to share with others in the Epic community.
• Epic provides venues for our customers to collaborate and share their opioid-related initiatives and learn about our plans for development. This includes frequent webinars with customers to communicate our development progress and for customers to share their outcomes. We have a focus group for opioid safety at our annual Users’ Group Meeting, as well as a dedicated forum on our intranet, the UserWeb, for customers to share ideas regarding opioid management.

Overall approach to PDMP integration (Point to point, hub and spoke? Where in workflow?

• EPCS, Other – for example: all encounters vs EPCSonly
• Epic customers connect to the PDMP using single sign-on (SSO) to pass user and patient credentials to the PDMP portal or using an NCPDP interface. Epic is PDMP vendor neutral, which means that we can integrate with different states’ PDMPs, regardless of which technology they use (3^rd party, HIE, home grown, etc.).
• The user can query the PDMP at any time in a patient encounter, not just during order entry. Epic customers report that this process takes only seconds. The query can happen automatically prior to the MD seeing the patient, if state rules allow. Decision support at the point of order entry can be used to remind the prescriber to check the PDMP if they have not done so already.
• Epic will track whether the prescriber checked the PDMP.

Plans and progress in interoperability with state PDMPs

• Our goal is for all Epic community members to integrate with the PDMP as their state allows, typically NCPDP interface, SSO, or both. As state PDMPs are interconnected, they will often also provide prescription dispense information from other states, depending on their regulations.
• We recommend industry standard integration for more complete adoption. If a state is considering a non-industry standard method of PDMP integration, we will provide feedback on the benefits on using an industry standard method.

Interoperability with PDMP Vendors.

• Epic is vendor neutral. The state determines how a healthcare system’s EHR will integrate with their PDMP database. This could be direct integration with the PDMP, or via a 3^rd party such as Appriss, Logicoy, or NIC. Regardless of the method of integration chosen by the state, Epic customers can integrate with the PDMP using the industry standard NCPDP interface or SSO integration methods.
• Epic does not resell NarxCare or similar 3 ^rd party products. Instead, Epic customers can purchase those products directly from the 3 ^rd party as needed.

Client case studies – include 2-3 representative client examples

• In 2018, there were 6 HIMSS Davies Award winners that presented an opioid-related use case. Five of those 6 HIMSS Davies Award winners use Epic. The presentations are available here: https://www.himssconference.org/education/best-practices-opioids- symposium

The organizations are:

• Ochsner Health Systems: Leveraging EHR for Opioid Stewardship
• Duke: Perioperative Care, Enhanced Recovery After Surgery and Reducing Opioid Dependency
• Bon Secours Mercy Health: Leveraging Analytics to Change Opioid Prescribing Behavior
• Rush University: Standardizing Opioid and Drug Abuse Referrals to Rehabilitation
• Sparrow Hospital: Anticipating and Preventing ADEs: Decreasing the Need to Rescue Hospitalized Patients from Opioid-related Complications

Several Epic organizations have demonstrated at least 50% reduction in opioid prescribing:

• Geisinger
• Anne Arundel Medical Center
• Yale New Haven Health System
• MetroHealth
  • Project DAWN (Deaths Avoided with Naloxone) is a program that provides naloxone kits to those at high risk of overdose. MetroHealthreports over 1,200 lives saved with Project DAWN.
  • They’ve also reduced opioid prescriptions by over 33% over the course of 18 months. They attribute some of their success to PDMP integration with Epic, opioid abuse screening questionnaires in Epic, and reports in Epic for monitoring provider prescribing habits.

• Henry Ford Health System integrates with Michigan’s PDMP. When clinicians order a schedule II-V drug, the system automatically queries the Michigan Automated Prescription System at the same time to see previous opioid prescriptions the patient

Overall strategy responding to the opioid crisis (in addition to PDMP integration)

MEDITECH is committed to providing our customers – all of whom are healthcare organizations – with tools that support their efforts in reducing opioid-related harm.  With this vision in mind, MEDITECH has launched an Opioid Stewardship Toolkit, providing both evidence-based and experience-based tools and optimal workflows which align with the 12 CDC recommendations for prescribing opioids as it pertains to chronic pain management. These tools, along with optimal workflow recommendations include:

• • In-workflow access to Prescription Drug Monitoring Programs
  • Collaborative solution for Electronic Prescribing of Controlled Substances
  • Embedded opioid risk tool
  • Chart review tools for longitudinal tracking
  • Streamlined order sets to guide appropriate therapies
  • Templates for tracking the patient’s opioid use and outcomes in the physician’s note
  • Patient registries to identify patients and monitor compliance
  • Patient education provided in departure packet and accessible via patient portal
  • Opioid treatment agreements accessible via patient portal
  • Outcomes monitoring (including opioid prescribing patterns) available in MEDITECH’s Business and Clinical Analytics solution

Overall approach to PDMP integration

Point to point, hub and spoke

MEDITECH is addressing physician concern over laborious reporting of controlled substances by integrating direct, one-tap access to the Prescription Drug Monitoring Program (PDMP), directly within MEDITECH Expanse. Leveraging our relationship with DrFirst for PDMP integration, MEDITECH created an integrated PDMP link, accessible to prescribers throughout their EHR navigation to provide on-demand access to a patient’s-controlled substance history.

Where in workflow?  EPCS, Other – for example: all encounters vs EPCS only

Providers using MEDITECH and DrFirst are able to immediately access a patient’s PDMP report throughout their chart review and e-Prescribing workflow. MEDITECH has created an integrated PDMP link, available in the chart and patient reference region of MEDITECH Expanse. Providing multiple access points, such as in the reference region, allows prescribers the ability to access the PDMP wherever the prescriber navigates within the patient’s chart. The PDMP link can be accessed from the patient’s chart whether on an active visit or not.  Prescribers have expanded views of a patient’s-controlled substance history with a multiple-state PDMP view as allowed by cooperating states, within the EHR prior to transmitting prescriptions. The immediate access removes the need to link separately to multiple PDMP’s and is crucial for improving workflow and clinical decision making, and safely managing patient drug use.

Plans and progress in interoperability with state PDMP’s

State-specific successes and challenges

• The goal of MEDITECH and DrFirst’s PDMP collaboration is to provide a PDMP solution for all states, regardless of data source, regardless of the changing regulatory landscape, with the same seamless interface for the user. To accomplish this, DrFirst has created a data source-agnostic platform that is seamlessly integrated into MEDITECH Expanse. MEDITECH and DrFirst currently have available integration with 35 states and growing, to obtain PDMP data from both Appriss and non-Appriss data sources. Recent connectivity to California CURES 2.0 PDMP represents a key success as this was a new program run specifically by the state with a new infrastructure.
• The constantly changing PDMP landscape involving differing requirements, formats, and jurisdictions remains the most difficult challenge to overcome. DrFirst maintains an assertive regulatory outreach program and development process with the ultimate goal of nation-wide PDMP data coverage.

Interoperability with Appriss.

Formal agreement?  Describe.  NarxCare resale?

• DrFirst has a long-standing and valued relationship with Appriss and provides data from all of their supported states to MEDITECH Expanse. DrFirst continues to work closely with Appriss to expand the availability of data and to refine the registration and provisioning processes necessary to connect clinical users nationwide. DrFirst is in the late stages of securing an agreement to provide NarxCare and expect to have it available shortly.

Alternate risk model and analytics availability? Describe.

Native development and/or 3^rd party eg PastRx

• Utilizing PDMP data to perform analytics and provide clinical decision support would be of high value. At this time, states which provide discrete PDMP medication data and allow long-term storage and analytics to be performed on that data are extremely limited. MEDITECH and DrFirst continue to weigh in and provide input on the changing regulatory landscape in order to support such valuable tools in the future.

Direct link to PDMP?  Describe.

• Our MEDITECH/DrFirst connection to Appriss supports the ability to receive an HTML report pre-formatted by Appriss which is presented for display within MEDITECH Expanse.

Data import from PDMP? Describe.

• Our MEDITECH/DrFirst connection to non-Appriss states such as California, Illinois, and Maryland support the ability to receive discrete PDMP medication data. We request and display the data upon demand within the prescriber workflow, but do not store it long-term in MEDITECH Expanse due to state requirements.

Interoperability with alternate PDMP solutions

• As stated above, MEDITECH and DrFirst’s goal is to provide a PDMP solution that is supplier-agnostic, easy-to-access, and seamlessly integrated. DrFirst has designed their solution to scale and adapt as state, federal, and other initiatives continue to evolve. Their multi-data source architecture already accommodates state data sources that do not work with Appriss. DrFirst maintains custom integrations to state platforms and will continue to support and grow these as the market dictates.

Custom integration with state portal(s)

• DrFirst has direct, state-specific connections in California and Maryland and is actively working with other states. These PDMP connections are therefore accessible in MEDITECH Expanse.

RxCheck/PDMP Assist –

• MEDITECH and DrFirst are interested in connecting to additional data sources in pursuit of our goal to obtain nationwide coverage, but no official agreements to report at this time.
  • Logicoy –
    MEDITECH via DrFirst is connected to Logicoy in Illinois.
  • HIE as link to Appriss or others.
  • Other
    MEDITECH has been speaking to Collective Medical about their ED notifications which incorporate state PDMP data.

Client case studies – include 2-3 representative client examples
We will note 3 key client examples here:

• The first MEDITECH customer to go live with in-workflow, one-click PDMP integration was War Memorial Hospital in Sault Ste Marie, Michigan, in June 2018. Prescribers at War Memorial are accessing PDMP data from both ambulatory and acute care settings.
  See published success story: https://blog.meditech.com/integrated-prescription-drug-monitoring-supports-smarter-opioid-prescribing
• The first MEDITECH Expanse customer to go live with the Illinois PDMP (which uses Logicoy) was Swedish Covenant Hospital in Chicago, Illinois.
• Salinas Valley Memorial Hospital (in Salinas Valley, California) is currently testing the new connection to CURES 2.0 in California. Dr. Kasting from Salinas Valley was a major proponent of this initiative and is actively involved in testing.
  See published article:
  https://www.drfirst.com/news/drfirst-launches-californias-first-ever-integrated-technology-to-tackle-the-opioid-epidemic-across-the-healthcare-continuum/

All of our physician users have noted a significant time savings when accessing PDMP data from within their workflow in MEDITECH Expanse as opposed to logging into and searching the state PDMP web sites manually.  We are working with our clients to collect metrics to further validate.

Optional: Economic model in provision of these services to the provider client

• MEDITECH does not charge for PDMP integration. DrFirst fees vary from state to state as the state data charges vary.

Overall strategy responding to the opioid crisis (in addition to PDMP integration)

• NextGen NGCare enables us to manage populations of patients that are considered high risks for opioid abuse.
• New behavioral health content enables provider to appropriately screen patients that are high risk for Opioid abuse.
• Internal task force commissioned within NextGen to establish a strategy and communication plan to address the crisis.

Overall approach to PDMP integration

• Point to point, hub and spoke
  • NextGen Enterprise (NGE) EHR supports point-to-point connections from EHR to Appriss. In the coming Spring 2019, we will be offering a proxy server between EHR and Appriss which will handle two-way SSL.
• Where in workflow?

EPCS

• NGE EHR offers an automatic report retrieval before a user sends a controlled substance.
  • Other – for example: all encounters vs EPCS only
• NGE EHR offers ad-hoc PDMP reports available for any user with proper credentials.

Plans and progress in interoperability with state PDMP’s

State-specific successes and challenges

• Due to scalability, NextGen’s focus has been on establishing a centralized connectivity to various state registries through Appriss. We do have some direct points of connectivity with various state registries who are not connected thru Appriss. Those connections can often be complex since many states have established their own proprietary methods of connectivity, so these connections are established on a case-by-case bases and may come at a higher cost to the client.

Interoperability with Appriss.

• Formal agreement?
  • NGE has integration with Appriss. Clients pay Appriss directly for licenses.
• NarxCare resale?
  • Appriss sales NarxCare directly to NGE clients as a value-added-service.
• Alternate risk model and analytics availability? Describe.
  • Native development and/or 3^rd party eg PastRx
• Direct link to PDMP?  None
• Data import from PDMP? None

Interoperability with alternate PDMP solutions

• Custom integration with state portal(s)
  • None
• RxCheck/PDMP Assist
  • None
• Logicoy
  • State-specific solutions are available for NGE EHR clients residing in states where Logicoy has a contract with the state to offer access to the PDMP.
• HIE as link to Appriss or others.
• Other

Client case studies – include 2-3 representative client examples

• At this time, NextGen has not conducted case studies on PDMP connectivity.

Optional: Economic model in provision of these services to the provider client

• NextGen does not require clients to license or pay for additional services to integrate with the standard connectivity through Appriss, however, clients may be subjected to licensing charges directly by the state PMP.