Real behavior change can happen only when physicians truly understand their prescribing tendencies. This requires awareness of prescribing habits that is informed by trustworthy data clearly presented in the dashboard. This is the first step to performance assessment and eventually to performance improvement. Some physicians may be convinced when a physician leader puts the data in front of them. Others may resist, insisting their professional experience validates their prescribing practices. One way to disprove their misconceptions (see Table 1) is to counter the assertions made with verifiable information backed up by factual data.
A physician-written article in the Harvard Business Review stated that “physicians are mesmerized by data and cannot look away.” It cited a strategy by Brent James, MD, executive director at the Institute for Health Care Delivery at Intermountain Healthcare: “Rather than make a frontal attack on physicians’ autonomy, he wears down their resistance to change by showing them how their practice varies from the norm.”
Arming providers with data and appropriateness measures can help them determine whether their prescribing behavior for opioids is consistent with peer-developed guidelines. Making prescribing data available to physicians allows them to self-correct without bringing their clinical judgment into question.
Proven steps used to self-assess prescribing behaviors and how they may align with norms are:
- Assess clinician perception by getting data on the current state through surveys or interviews about how opioids are used across the system, whether they are overused, underused and used appropriately
- Determine the opinions on the effectiveness of opioids relative to other pain management options and the safety of opioid prescription
- Ensure that the data presented to physicians is uniform and reliable so that organizational leaders can push for standardization of best practices
- Have the Opioid Stewardship Committee identify pain management studies from the literature and present the findings to the relevant service lines
- Develop reports and dashboards that analyze prescribing data that can be used by medical directors to share with clinicians to identify improvement opportunities by service line
It is recommended that the Opioid Stewardship Committee, staffed with physician leaders, develop an educational program that:
- Engages all physicians no matter what their prescription patterns are; the educational program should be developed to create change using face-to-face, one-on-one conversation
- Includes examples or patient stories to highlight the historical pain management culture that you are trying to change
- Engages naysayers and those who resist with additional personal training, providing them time to talk in person
- Includes analytics to drive discussions on standards, guidelines and reduce variability; reports should include benchmarking data about prescribing practice compared to physician peers
- Incorporates training into annual compliance/training program for all staff to ensure awareness
- Includes not just physicians but all clinical workforce; the educational program should include the organization’s vision and commitment to ending the opioid crisis
- Makes it local and personal; engage frontline staff about the opioid epidemic and how your health system can play a role in reversing it
- Takes a wide approach to education, offering training through online training modules, system-wide forums, peer-to-peer discussions, educational podcasts and lunch and learns
- Understands and addresses barriers by administering a “culture assessment” survey to attending physicians, residents and fellows, pharmacists and pharmacy residents, and advanced practice providers to identify issues, barriers and where prescribers need support the most
- Adds awareness and alerts into the EHR so standards are integrated into the physician’s workflow
- Launches an opioid awareness campaign focused on providers to boost engagement and awareness; campaign should partner with marketing to include newsletters, intranet communication, email blasts and community partners
- Provides CMEs and is disseminated at medical staff meetings, executive medical meetings, grand rounds
How to Achieve Permanent Behavior Change
Education often is not enough. Real changes require permanent behavior modification, especially in physician practices where concepts and practices have remained in place for years and have become habitual. Even now with the opioid crisis fully recognized, physicians may lack awareness and familiarity with the most recent guidelines or may lack confidence to execute change. Many practicing physicians were trained in an era with set clinical methods in place with an emphasis on adequate treatment of pain and have valid concerns about harming patients by failing to prescribe sufficient analgesics.
“Educating physicians is less likely to alter their practice if it contradicts patients’ preferences. Physicians may indeed oppose any mechanism that they perceive as threatening their sense of competence or autonomy, but such threats may be overcome if the patient is the agent of change.” James L. Wofford, M.D., M.S. Wake Forest University, Winston-Salem, NC 27157-1051
“Doctors have historically seen themselves as their patients’ sole advocates, with the rest of the world divided into those who are helping and those who are in the way. Resistance in the pursuit of patients’ interests was acceptable behavior. ”
Source: “Turning Doctors into Leaders,” Harvard Business Review
To effectively change prescribing behavior, physicians must believe that the action is good for their patients, is based on best practices and can be incorporated into their practice without significant barriers. The Theory of Planned Behavior is a good model for understanding physician clinical behaviors. (See Resources for more on the Theory of Planned Behavior.)
This theory recommends using a bottom-up approach that engages physicians. The approach emphasized influence rather than authority by not threatening the physician clinical and personal autonomy. Unlike a top-down approach that needs groups of physicians to reach a consensus on new approaches to care, the bottom-up approach involves leaders using their influence to construct a vision and build a case for change that doctors can buy into. It is a more inspirational method requiring participation of the Opioid Stewardship Committee rather than imposed by administration and senior leaders. This approach coupled with data analysis brings positive behaviors that enable the outliers to achieve success. Healthy competition method stimulates physicians to work toward goals and avoids the frustration of asking physicians to reach consensus. Research demonstrates that most physicians undergo stages of change in adopting new behaviors. (See Table 4)
|Table 4: Stages of Change
|1. Present facts, data and knowledge. Physicians require information about new data or new practice guidelines that advocate a change in practice behavior. Studies has also shown that information by itself is not enough.
|2. Recognize that most physicians entered the profession because they want to do good. Appeal to their altruistic nature.
|3. Once physicians know about and accept the behavior, they must have the ability to implement it. Enthusiasm by itself is insufficient if there is a lack of time, resources, staff, training or equipment.
Constraints imposed by office or clinic operations, practice leadership, information systems, regulations and insurance coverage can impede change.
|4. Finally, like all people, physicians need reinforcement to maintain behaviors. It is human nature to forget, overlook or lose interest over time. The most committed physician needs reminder systems to remember when to implement guidelines, tracking systems to identify patients who need follow-up, and encouragement from practice leaders, systems of care and patients that their efforts are appreciated.
Guidelines and Prescribing Standards
Many professional and governmental organizations have published guidelines that reflect the most up-to-date research on pain management with best practices for opioid prescribing. The list in the Resources section provides material that assists providers through the various phases of pain management, suggests alternative therapies and recommends appropriate types and levels of medication when needed. Adoption of nationally recognized standards of care will enable clinicians to align their prescribing patterns with industry-wide best practices.