- Under pressure to stall the rising death toll associated with the opioid epidemic, CMS and state regulators have pushed the use of prescription drug monitoring programs (PDMPs) as a way to ensure healthcare providers understand a patient’s full medication history when writing prescriptions.
A CMS opioid roadmap released earlier this year lists PDMP use as a key component of its three-pronged strategy to curb opioid abuse among Medicare beneficiaries. Utilizing PDMP data can help providers ensure opioid use disorder (OUD) prevention and treatment efforts target patient populations who need them most. Additionally, PDMP use can signal to providers which patients may be doctor shopping, or obtaining opioid prescriptions from multiple prescribers.
However, querying PDMPs can be burdensome and inefficient for providers at organizations without access to the databases built directly into their EHR systems.
Requiring providers across care settings to query state PDMPs that lack usability can slow the prescribing process to the detriment of patient satisfaction.
“There is a point to which it becomes more burden than benefit, and that just precludes doctors wanting to prescribe and having to take that extra time,” California Medical Association (CMA) President Theodore M. Mazer, MD, told EHRIntelligence.com.
“What it’s doing in the real-world is driving physicians from prescribing really low level pain medications,” he added.
CMA is a physician advocacy organization representing more than 43,000 physicians in California. CMA has played a significant role in boosting the usability and efficiency of California’s own state PDMP.
The PDMP first debuted as a searchable, user-facing database within California’s Controlled Substance Utilization Review and Evaluation System (CURES) in 2009. By 2012, less than ten percent of providers were using the database.
State regulators and consumer advocacy groups pushed for the passage of state legislation that would require all California physicians and prescribers to query the PDMP before prescribing opioids or other controlled substances.
But rushing a mandate could have negative consequences on clinical efficiency, CMA physicians maintained. The state needed to first optimize the usability of the system.
Boosting PDMP Usability to Reduce Administrative Burden
While CMA supported the use of CURES to promote safe prescribing practices, member physicians wanted to make sure the technology was sufficiently updated and easy to use before requiring all providers to access the system at the point of care.
“We had no objection ever to the use of CURES as a tool to make informed prescribing decisions,” explained Mazer. “What we objected to is that the old version of CURES was very cumbersome, very time-consuming, and inaccessible to the degree that would be necessary for any kind of a mandate. We wanted to make sure the technology was up to speed on a go-live basis.”
Along with the California Department of Justice (DOJ), CMA physicians assisted in financing improvements to CURES that culminated in CURES 2.0.
“We wanted to make sure it was really ready to meet demand, so the requirement that it be certified by DOJ as ready to run with a six-month lead-up to implementation was added,” said Mazer. “We also wanted to make sure the requirements weren’t taking even more time away from physicians taking care of patients without adding benefit to patient safety.”
On April 2, 2018, DOJ certified CURES 2.0 as ready for statewide use. In accordance with CMA’s requirements, the state implemented a mandate requiring that healthcare providers query CURES 2.0 before prescribing Schedule II, III, or IV controlled substances earlier this month.
In addition to optimizing the state PDMP, CMA physicians also contributed feedback to state regulators to ensure PDMP use requirements were effective and conducive to reducing the overprescribing of opioids.
“When the original requirements were burdensome and onerous and not patient safety-related but simply over-response to a demand, we wanted to make sure the requirements on physicians were based on actual, demonstrated benefit to patients,” maintained Mazer.
While modifying PDMP use requirements helped to reduce administrative burden on providers to a certain extent, Mazer maintained there is still more work to be done.
“We still believe the requirements are not helpful when you have to look up short term prescriptions — doing a 3- or 5-day prescription for post-operative pain is not a major contributor to opioid addiction,” he said.
Mazer is not alone in his belief that querying PDMPs before writing short-term prescriptions is more trouble than its worth.
An August 2018 JAMA Surgery study found PDMP use negatively affects clinical efficiency without offering much benefit as a tool for reducing opioid prescribing for patients undergoing elective surgery procedures.
“I generally write 3-5 days of post-operative pain medication, and it’s not a high-end opioid,” said Mazer. “I’ll write those for a limited time. As of last week — and I was doing it before last week — but as of last week I need to go to CURES and make sure no one has prescribed for a short-course of pain medication.”
“We need to watch how this is used and watch where there is reasonable important patient safety information coming in, and that should be done on a pilot-basis first,” he suggested.
Mazer and others at CMA have also urged CMS to require EHR vendors to integrate easily-accessible PDMP links directly into provider EHR systems to further reduce administrative burden.
“If we get what we’ve asked the vendors to have to do with EHRs, that saves us a lot of time,” said Mazer. “We won’t have to back out of one system, open another system, open CURES, and check CURES. When you go to write a script on an EHR, it should automatically query the state database and maybe multiple state databases with one click.”
Improving Interoperability Across Care Sites, State PDMPs
In addition to boosting EHR integration of PDMP links, improving interoperability across the healthcare industry will further optimize the efficiency of the databases.
Improving interoperability between care facilities, EHR systems, and PDMPs will help to ensure physicians and other prescribers are able to seamlessly exchange and access patient medication information without augmenting provider burden unnecessarily.
“We want the Veterans Administration to be part of an interoperable PDMP database,” said Mazer.
Interoperability between PDMPs in different states is also critically important, Mazer said.
“Unless we have all of those databases in there — particularly in cities that border multiple states — it’s not effective,” Mazer maintained.
Some states have already made efforts to improve their level of interoperability with other PDMPs. In March, New York’s PDMP achieved healthcare interoperability with PDMPs in 25 other states and Washington, DC.
Ultimately, Mazer supports EHR integration of PDMP links, improved PDMP interoperability, and tailored PDMP use requirements that target patient populations most at-risk for doctor shopping or opioid overuse as the most effective approaches to addressing the opioid crisis.
“On chronic pain patients, check it the first time you’re prescribing long-term opioids,” suggested Mazer. “And then on a reasonable basis — which I believe under the current mandate is every 4 months — recheck it to make sure there’s not multiple people prescribing.”
“We need to see if we can scroll back requirements on short-term post operative, but if you’re renewing post-operative it’s reasonable to query the database,” he added.
This kind of targeted PDMP use encourages providers to leverage health IT to improve patient care rather than merely fulfill state regulations.
“We need to have proper use where it helps patient safety and isn’t just for a checklist,” said Mazer.