- Identifying ways to curb the nationwide opioid epidemic is a top priority among state health departments and federal entities including CMS and ONC.
An opioid roadmap released by CMS earlier this summer listed several strategies for reducing opioid overuse through prevention, treatment, and health data utilization. Prescribers are better-equipped to leverage health data to address the opioid epidemic as more and more hospitals and health systems connect to state prescription drug monitoring programs (PDMPs) through EHR systems, which provide prescribers with complete patient prescription histories.
In addition to enabling connections with PDMPs, EHR systems can also help to promote safe opioid prescribing practices by streamlining communication between providers, care teams, and prescribers for better-informed clinical decision-making.
Nurse and Director of Clinical Applications at HSTpathways Maura Dent Cash recently spoke to EHRIntelligence.com about how EHR adoption and use has improved prescribing practices in emergency departments and ambulatory surgery centers (ASCs) in ways that were unprecedented in the days of paper-based processes.
“For years, it was standard practice to just scribble out a prescription and hand it to the patient at discharge,” Cash told EHRIntelligence.com. “They would fill it and go home and take all of them or take part of them, and put the rest in the cabinet, and no one would really follow up.”
“And if a patient just said, ‘Hey, I need some more,’ prescribers would write some more because no one really understood the epidemic and the proportion of the epidemic that was going on,” she added. “When I started in ASCs the prescription pads were still being used in ASCs, and nobody had electronic prescribing.”
Paper-based prescribing practices were common in ASCs long after inpatient hospitals began adopting EHR technology.
“That is not a problem of their own making,” said Cash. “ASCs were not part of the original incentive package for electronic health records. And it’s partly because it’s such a fast-paced environment with rapid turnover and very short cases. There wasn’t really an EHR out there that suited the needs of ambulatory centers for a while.”
While EHR technology was more common in inpatient care settings in the early days of EHR adoption, a 2017 HIMSS Analytics study found the vast majority of hospital-owned outpatient practices had implemented an EHR system by 2017.
One of the most commonly-used EHR functionality is computerized prescriber order-entry (CPOE). Eligible hospitals and critical access hospitals (CAHs) participating in meaningful use — recently rebranded Promoting Interoperability (PI) — have been incentivized to use CPOE since 2012.
“Now, electronic prescribing particularly of narcotics is prevalent,” said Cash. “Prescribers can run patients through a vast database and find out a patient’s prescription history. They can see what they’ve already been prescribed, the last time they had a prescription.”
“It's a really great way of keeping track of the amount of opioids that the patient is getting, who's prescribing it for them, and the last time they took them,” she continued.
Through CPOE, providers must utilize standardized order sets to fill prescriptions. This baseline standardization ensures providers across care settings can access, view, and prescribe medications using similar terminology and values for more efficient communication between clinicians.
“When you have an EHR, you come up with standardized order sets,” said Cash. “When you have those standardized sets even for the anesthesia providers, for in-house PACU, post-op care, those types of standard order sets, you don't have one group or one physician prescribing a lot more than everyone else.”
“It sort of goes through a process of review so that everybody is on the same page,” emphasized Cash. “Having a standard set of orders is important. If somebody called it the generic name and somebody else called it a different name for that medicine, you'd have to sift through those different variations.”
EHR use also bolsters communication by allowing clinicians to engage in concurrent charting. Concurrent charting is especially important in the fast-paced ASC setting.
“With concurrent charting you have everyone looking at the same patient at the same time,” Cash said. “You can be aware of their pain assessment, their vital signs, what medication was administered, when it was — it's all right in front of you on the screen.”
Different members of the patients care team in the ASC setting — including anesthesiologists and prescribers — can communicate quantifiable values and indicators of pain more effectively and precisely through EHR systems.
“When you have an electronic health record, the provider can bring that case right up in front of him,” said Cash. “He can look at the vitals, the pain assessment, what was given, when it was given. He can read quick review of that patient's history, which can be important.”
Certain social determinants of health data within patient EHRs can quickly signal to providers that a patient may be more susceptible to opioid addiction than others.
“Do they have a history of recreational drug use?” said Cash. “Do they have a history of alcohol use? Or will they be a hard patient to control their pain? You have all those facts right in front of you and not just a request for pain on the fly.”
In an ASC setting where the rate of patient turnover is high, EHR use can also help to streamline discharge processes.
“Your discharge instructions sets are in electronic health records,” said Cash. “You can have a massive amount of instructions loaded into your electronic health record, and you can cherry pick the ones that are appropriate for every single patient.”
“You don't give everybody the same discharge instructions for their knee arthroscopy,” she continued. “You can have a set for a patient who is discharged home who's had a nerve block on that knee, or somebody who doesn't have an opioid, or someone who does, but needs very careful instructions about that opioid.”
Thorough EHR clinical documentation throughout a patient’s stay in the ASC ensures providers who see the patient in follow-up appointments or at other hospitals in the future have a comprehensive, transparent understanding of how that patient responded to certain medications.
“The EHR provides a cumulative account of all the medication that the patient received when they were in the hospital,” said Cash. “It's very easy to see in the electronic health record how much a patient received right on the patient summary page. It gives providers totals of every medication a patient got.”
With complete prescription histories available to clinicians in surgery centers and outpatient practices, providers can avoid opioid over-prescribing, negative drug-on-drug interactions, and other potential problems in environments where word-of-mouth provider communication can be hurried.
“When you coordinate care through the EHR, you don’t have to worry about saying, ‘I didn't get to talk to the anesthesiologist before they brought the patient back,’” said Cash. “Because you can make all of those entries available, and concurrent, and have those fields that the anesthesia knows to look for.”
“They can look in the EHR and say, ‘This is the area,’” she added. “This is the documentation block that has the information I need to know what the patient needs for anesthesia.”
Ultimately, promoting EHR use in ASCs and other environments where pain management is an imperative during care delivery can help to lower opioid doses during crucial points early-on in a patients treatment plan.
“You can't fix a problem unless you've identified it, tracked it, and followed it,” said Cash. “EHRs are going to play an increasingly critical role in that for opioid prescribing. And ASCs can now be part of this bigger picture.”