Opioid Challenge Leadership Roundtable – Balancing Cost, Technology, and Governance
Oracle Health hosted a roundtable of top healthcare IT experts to share insights on how technology fits into the healthcare industry’s efforts to address the opioid crisis.
CHIME President and CEO Russ Branzell guided the discussion between panelists:
Participating CHIME members:
- Chani Cordero, CIO, Brooke Army Medical Center
- Chris Plaisance, CIO, Black River Memorial Hospital
- Liz Johnson Retired CIO
- Mike Ward, SVP & CIO, Covenant Health
- Tressa Springmann, SVP & CIDO, Lifebridge Health
- Rusty Yeager, SVP & CIO, Encompass Health
- A former CIO of a hospital system in the Northeast
Joining form Oracle Health:
- Doug Reorda, Sr Director of Strategic Growth
Finding a solution to the growing opioid crisis is as challenging as finding its root cause. Technology is expected to play a role in addressing this epidemic, but it can’t singlehandedly solve issues with policy, funding, education, and governance, as well as the lack of available services to help people manage opioid abuse risk factors. However, there are ways providers can use technology to make a positive impact on opioid use and substance use disorder (SUD), including bringing together various data sources and applying technologies to help manage opioid prescriptions, improving the care and data around patients’ mental health, and collectively advocating for more attention and funding from the government for opioid use management.
Opioid addiction and overuse are in every nook and cranny of society, and the emotional and financial costs are enormous. In the United States, drug overdose deaths numbered more than 100,000 during the 12-month period ending in April 2021, a 28.5% increase from the prior year, according to the US Centers for Disease Control and Prevention (CDC). It’s estimated 75,673, or about 75% of those overdose deaths, were opioid related.
Substance use disorder (SUD) impacts family and work life, including routines, responsibilities, social life, and finances. At home, more than eight million children under the age of 18 live with at least one adult who has a SUD, and most of these are under 5 years of age. Such kids are at a greater risk of being abused and of developing their own SUD later in life. At work, lost productivity and absenteeism are key impacts. In a National Safety Council (NSC) survey, 75% of employers reported opioid use has impacted their workplaces. Further, workers with SUD miss about 50% more workdays than their peers (NSC), which strains the remaining workforce.
THE ROLE OF PRESCRIPTION OPIOIDS
Prescription opioid-involved deaths increased by 17% between 2019 and 2020, according to the CDC. Opioid prescribing increased in the 1990s, the CDC noted, and overdose of prescription opioids—natural and semi- synthetic opioids and methadone—have been on the rise since 1999.
The government’s approach to addressing the prescription aspect of this crisis includes increasing awareness of the problem to both the healthcare industry and the public, improving prescription monitoring, and providing health systems, providers, and payers with the data, tools, and guidance they need to better manage opioid prescribing and patient safety.
As a former systems engineer, Black River Memorial Hospital CIO Chris Plaisance is familiar with the need to close the loop (e.g., a self-regulating system) and highlighted the importance of providing clinicians feedback data in the moment. “Whether they are prescribing formulas they like to use or whether it’s treating drug seekers, a decision support system that would flag improper prescribing could help care providers stop and rethink in that moment,” he explained.
Retired CIO Liz Johnson detailed the longitudinal records her team created for care teams, which she now knows were missing some critical information. “When I think back on it, there was nothing in this record about whether the patient was flagged as someone who primarily seeks drugs on a routine or frequent basis, or who is struggling with mental illness.”
Rusty Yeager, SVP and CIO, Encompass Health, said with an average patient age of 77 years, his system isn’t dealing with classic drug seekers. But by focusing on appropriate prescribing of opioids, Encompass has been able to limit their use by exposing over-prescribing. “We don’t want to send somebody home with a bunch of stuff that may be abused by somebody in the family or in the home,” he stated.
During the COVID-19 Public Health Emergency (PHE), the US Drug Enforcement Administration (DEA) adopted policies allowing DEA-registered practitioners to prescribe controlled substances without in- person interaction with patients. This helped ensure uninterrupted pain and opioid treatment with buprenorphine (Schedule III) and Narcan/naxolone (Schedule IV). With the COVID-19 PHE ending May 11, 2023, the controlled substance prescription allowances would have expired, but the DEA issued proposed regulations to extend the telemedicine prescribing allowance for narcotic and non-narcotic Schedule III drugs including buprenorphine to treat opioid disorder, and naloxone for opioid overdose. They didn’t extend the allowance for telemedicine prescribing of Schedule II drugs including opioids.
THE MOVE TO ELECTRONIC PRESCRIBING
The move to electronic prescribing for controlled substances (EPCS) is one of healthcare’s recent achievements in addressing the opioid and related SUD crises. The DEA published an interim final rule in 2010 to provide practitioners the option to prescribe these drugs electronically and to lay out requirements for pharmacies and EPCS software. CMS recognized EPCS has many benefits such as improved patient safety and workflow efficiencies, fraud deterrence, adherence management, and reduced burden. Section 2003 of the SUPPORT Act generally mandates that Schedule II-V controlled substances under Medicare Part D prescription drug plans and Medicare Advantage prescription drug (MA-PD) plans use EPCS. CMS e-prescribing rules require use of software applications that meet DEA requirements.
Certain US states, including Pennsylvania and California, mandate electronic prescribing for Schedule II-V controlled substances—opioids are Schedule II drugs. In New York, which is among the states requiring electronic prescribing for both controlled and non-controlled substances, the mandate reduced opioid prescriptions by 53% (Journal of Emergency Medicine) and the rate of overdoses involving natural and semi-synthetic opioids by 22% (Journal of Economics and Human Biology).
THE DATA CONUNDRUM: AVAILABILITY AND ACCESS
The data that providers and clinicians need to better tackle the opioid crisis can come from many places, both internal and external, including EHR vendors, prescription drug monitoring programs (PDMPs), health Information exchanges (HIEs), and many smaller provider and community networks. However, most behavioral health/SUD records are not yet digitized — only six percent of behavioral health facilities and 29% of substance use disorder treatment centers in the US utilize EHRs (MACPAC Report to U.S. Congress).
Data availability within provider systems and even statewide networks can be decent. Black River Memorial Hospital is a critical access hospital (CAH) located between Milwaukee and Minneapolis. The Wisconsin provider is an Oracle Health CommunityWorks hospital, which allows such facilities with fewer than 250 beds to have access to the Oracle Health EHR network.
Plaisance said his IT team at Black River created an interface between CareQuality and CommonWell that helps them see if patients are seeking care—including medications—at other state systems, such as St. Gundersen’s in LaCrosse or Mayo Clinic in Eau Claire.
The state’s PDMP, which is connected to the state’s HIE—Wisconsin Statewide Health Information Network (WISHIN)—is another data resource Black River uses to track prescribing information.
However, one provider’s experience is not necessarily another’s.
Based on her 15+ years in healthcare, a former hospital system CIO concluded the core problem with the data on prescribing and patient prescription fill histories is that the information isn’t readily available in most instances and can be expensive. “PDMPs are not technologically where they need to be unless they are closely working with HIEs.” Even when they do work together, it can take a significant amount of time for the integration into a provider’s EHR, she noted. “If the data is not in your clinical workflow, physicians are not going to use it.”
Another tool is electronic prescribing of controlled substances (EPCS), which was mandated for Medicare Part D by the SUPPORT Act passed by Congress in October 2018. The idea was EPCS can help providers integrate prescription drug information more directly into EHRs to improve patient safety and limit fraud.
Despite this promise, the reality of this electronic prescribing requirement may be in what a provider does to augment or enhance the core of the technology.
“We have taken the base offering and built more around it to deliver an effective, working solution. Now that we are to this point, our focus will be continued improvement, to learn and mature much further than where we are today,” asserted Mike Ward, SVP and CIO of Covenant Health, noting challenges to such maturity include accessibility of the data, as well as integration ability from the primary solution or the other solutions around the edge. “I think EPCS works for us because we’ve integrated the technology and defined associated processes to deliver an overall solution.”
GETTING THE RIGHT DATA TOOLS TO WORK TOGETHER
With so much data available from different sources, interoperability is a big factor in making it easier for providers to utilize information to better manage opioid use.
Having to jump out of one system and into another isn’t ideal, Plaisance said, explaining this process is challenging for many providers who might not have time for all the system jumping.
Ward’s team has faced these challenges. “But last year, we put some great integration in place between Oracle Health, and so it’s all within the physician workflow, the in-context workflow of the providers,” he reported.
Ward is the president of the local HIE called ETHIN, the East Tennessee Health Information Network. Noting this advantage, he said, “Just by the press of a button in our Oracle Health screen, we bring in all the community data that we have access to.”
Further, Covenant has a very active emergency department (ED) in the tourist-heavy Gatlinburg, TN, area and has found CommonWell, a nationwide health information alliance, helpful with caring for such visitors from outside of the area. It also uses the SureScripts health information network to provide physicians with important information on patient histories, including prescription opioids.
Most of the CIOs supported the creation of a national patient identifier. “Until we’re able to collect data under a single place, we can’t do the rest of it,” Johnson argued. “We need a patient identifier.” As providers continue to provide care with whatever data they have, policymakers must provide the avenues for unique identifiers for patients while simultaneously providing policy that addresses the opioid/fentanyl/drug crises in America, she concluded.
Doug Reorda, senior director of strategic growth at Oracle Health, agreed that making real progress on the opioid crisis and data conundrum starts with identifying the patient, but also by de-duplicating them and making the system more intelligent. “This ultimately solves the time constraint and allows the physician, the clinician, the care coordinator, and the community to be more intelligent,” he said. “We as a health IT (HIT) vendor need to continue to lead towards a single identifier and promote an open ecosystem for data exchange regardless of technology. Enabling the right data at the right time will ultimately improve the overall clinical and care experience.”
In addition to a patient identifier, Plaisance liked the idea of a common EHR. “I think it could be blended into a common nationwide HIE,” he continued. “PDMPs, and pharmaceutical and insurance companies would have to enter data in there, so you get a clear picture of the patient health record post visit and have a summary of a patient and their care holistically. This is what needs to happen.”
Branzell backed the patient identifier wish and called for an absolute standardized data dictionary and nomenclature that anybody working in healthcare is required to follow.
Chani Cordero, CIO of Brooke Army Medical Center, backed the patient identifier as a good start, followed by shifting the ownership of the patient’s record from the physician to the patient.
Along these lines, Yeager called for a personal health record (PHR) that’s funded and structured, and patients can elect to participate or not. “You’d have a portable medical record and a full continuity of care,” he explained. “We all should have workflow systems, but we have EMR systems. I’ve got like 12 million records, but if a patient sees us more than once in a lifetime it is a true anomaly.”
WORKFLOW SUPPORT NEEDS IMPROVEMENT
Physicians, nurses, and other clinicians already receive vast information and data they struggle to fit into their workflows, observed Russ Branzell, president and CEO of CHIME. “They really don’t have time in a small episodic environment to take everything in mentally, to really be able to see all the data and to make a decision while they’re dealing with something that may not be even closely related to an opioid issue,” he explained. “But at the same time, somehow tangentially they have to consider this as part of an overall problem.”
Yeager called for additional workflow support. For instance, when looking at medication reconciliation between the phases of care—home, acute stay, and post-stay—he suggested concentrating only on opioids is probably not the right approach. “Maybe we should do medication reconciliation across the patient’s continuity of care, which would improve their healthcare, as well as monitoring their use of opioids and other medications.”
Physicians commonly service high numbers of patients and have limited time to spend with each one. Reorda referenced continued innovation within the clinical workflow that will improve the deluge of data that interoperability has created. “Much of the last decade has been focused on getting the patients data to and from the local record, ultimately creating the burden on the clinician when attempting to reconcile across the various care venues. The focus needs to be on the usability of the data and how the EMR system is empowering more time for the clinician through added innovation.”
Tressa Springmann, SVP and CIDO for Baltimore-based Lifebridge Health, noted Maryland’s PDMP is part of its state HIE, for which she is a longtime board member. “We have single sign-on for Oracle Health and other EMRs, and there are flags and indicators for opioids and prescription refills,” she said. “It’s all within the workflow.”
The healthcare industry needs to do better on the opioid problem, she said, and pointed to lack of profitability and supporting public health as key factors.
FUNDING OPIOID MANAGEMENT
Revamping the reimbursement model is one way to help with the opioid crisis. “My vote would be to level the playing field for nonprofits,” Springmann stated. “Our system of reimbursement hardens many of today’s backward behaviors across the industry,
incenting the wrong behaviors and paying for overuse. For-profit entities pass along their high prices to those who are desperate (for coverage, to feed their addiction, etc.) as community-based nonprofits and public health scrounge to find the resources most at need in these at-risk communities.“
Ward would turn his attention to the payers, the insurance companies. “There’s enough money in healthcare to pay for all these initiatives that we we’ve talked about,” he reasoned. “Instead of all the corporate profits and the organizational arrogance, we ought to be able to use the money to solve the healthcare crisis in the United States.”
Funding and expanding nationwide services featured in one former CIO’s proposed three-step plan, which starts with democratizing the data, making it widely available. “I’m specifically talking about prescription fill history and prescription ordering history,” she explained. Next would be putting more money toward physician training, educating them on the options available in the community, and their own health systems for treating the patients without the use of opioids. “This needs to be universally available across all the health systems, from a humanistic perspective,” she said. Lastly, would be investing money in communities to make more programs available, including CAHs, community health clinics, and substance abuse programs. “The pandemic has exacerbated mental health and behavioral health issues, as well as pain and opioid use,” she said. “We don’t have the mechanisms and the ability to treat all these people in our country.”
THE POWER OF POLICY
Maryland has a different reimbursement model, according to Springmann, who further noted abundant grant funding has helped address public health gaps. “On their own, without the power of policy to support the greater good, many other health systems are left to solve these gaps system by system by system,” she said. “Ten percent of care takes place in hospitals, and the other 90% is in the community. When it comes to a public health crisis, it is important to reach that 90% and do whatever we can to advance policies and standards.”
Branzell added that in Atlanta, 90% of the lack of primary and routine care is in 10% of the community. “This isn’t an Atlanta metro area issue, but it is a subset of a widespread problem,” he stated.
Johnson, who has spent retirement digging deeper into policy, agreed. “We have finally persuaded people to quit thinking of this as a drug problem in the slums of their cities,” she said. “This is a problem that is a pandemic and endemic across all populations.”
Unfortunately, the problems with opioids and associated data may not have Washington’s ear. “To be blunt, I have not seen where the opiate crisis and drug problem in general is really on the top of anyone’s list,” Johnson reported. She further asserted the rules and regulations implemented thus far have only scraped the surface of what is needed. “They’re not looking at the practicality of the information that’s being used or how it’s being used.” She acknowledged there are several efforts underway to go deeper.
In her view, infrastructure and interoperability get more chatter in policy circles, including on Capitol Hill, but there is a lack of knowledge on these terms. “You see those two words used interchangeably, but they’re not the same thing,” she said.
Despite the perceived current lack of federal priority, there’s an opportunity to use the increased attention among policymakers on the growing fentanyl problem to gain new ears for the role healthcare and tech can play in solutions to the opioid crisis. “We may be able to jump on that bandwagon as the policy people and share information with policymakers and stakeholders,” Johnson suggested.
Ward wondered if there is an opportunity to lobby the government for funding toward data providers to make this data available at low or no cost. “We [care systems] have to provide a lot of uncompensated care,” he reminded.
BEYOND PRESCRIPTIONS: USER DEMAND AND MENTAL HEALTH IN FOCUS
People who seek drugs will get them somewhere, Yeager assured. “As we tighten up prescribing, where will they go next to access these drugs? It’d be great to try to knock down demand. Demand is the problem.”
Cordero agreed monitoring of prescribing trends is only one part of the equation. “The ideal is not to just stop prescribing narcotics,” she declared. “The ideal is to address the root issue of what is making these people seek these types of drugs.” Some alternative approaches may include screening to identify certain behaviors. “This is an area where artificial intelligence (AI) may be able to help,” she suggested, “Much how we use AI to identify comorbidities.”
Branzell recalled the prophetic words of Stanford Children’s Health CIO Ed Kopetsky, whose family were the inspiration for CHIME’s Opioid Task Force: “If we treat this as just a prescribing issue, we will fail miserably because we will force an entire cared-for population in a prescribed world into an uncared-for environment where they will get no support.”
One way to address the issue is to concentrate on the stigma around mental health. “As long as there’s a stigma attached to any kind of mental health issue or asking for help, people aren’t going to come to us for care,” Johnson reasoned. The industry needs to figure out non-threatening ways to assess people for mental health risks, she advised.
“I think there is a lot of stigma associated with mental health data, as well as mental health-associated use of opioids and drugs associated with that spectrum,” added a former CIO of a large health system. “Stigma exists not only in terms of who sees the data etc., but also in terms of patients receiving the care needed.”
She further explained how a primary care physician may well notice a patient is using a drug more than they are supposed to be, but such physicians aren’t necessarily trained to address this from a humanistic perspective. “If they shun the relationship, the patient will go somewhere else; this is not resolving the problem at the point of care,” she said, adding physicians need the tools and training to know how to provide such patients with humanistic care options, including bringing in a care navigation team to help communicate options with the patient. “Unfortunately, these are not universally available in most health systems.”
She noted health plans are starting to provide more robust care options, as they are required by CMS and the SUPPORT Act to have a pharmacy program and put together care teams—including care navigators, social workers, and even behavioral health therapists—to monitor these patient populations that are potentially having the drug abuse problems.
“Perhaps other providers have these programs in place, but it is reaching our level now, the critical access hospitals,” Plaisance reported, noting Black River is setting up a substance abuse program as part of its behavioral health clinic. He noted a robust program requires the right tools to implement proactive patient engagement. Otherwise, you’re “just doing peer review.”
Covenant Health’s network of hospitals, outpatient and specialty services, and physician services is using proactive engagement, according to Ward, who said they are pulling in the relevant data and providing it to the physicians at the point of care. Training, monitoring, and re-education are key elements of Covenant’s approach.
Springmann noted outcomes from opioid use can be different from person to person, as one person ends up with addiction while another ends up with just pain relief. AI might be useful here, she suggested, possibly via use of risk algorithms. “As we mature on more personalized and genetically targeted therapeutics, our clinical platforms need to be ready to manage that,” she said, stressing that the human genome needs to be accessible. “This is a whole different level of sophistication.”
The United States is among the worst at treating the physical and mental bodies differently, Branzell stated. “We do not truly have holistic medicine here.”
The healthcare industry focuses on the disease and not the preventive. It’s one thing to monitor people who are already misusing drugs, but there are other people at-risk of addiction or misuse.
Springmann pointed out the industry’s drive to specialize has created silos and it isn’t treating the individual person, who has idiosyncrasies, tendencies, and social structures. “Has our system of health in the US, whether through reimbursement or not, unintentionally made healthcare so complex, with so many sub- specializations that people are losing sight of the big picture of a person?”
Reorda suggested ensuring that the patient’s record follows their care may be helpful. “One of the challenges today is that we (the industry) are creating too much noise within the clinical workflow, forcing the clinician to spend more time in front of a computer as opposed to time with their patient,” he noted.
Johnson added the patient’s record should be comprehensive, including sleep data and diet information, etc. “Even if we are collecting more information on patients, we don’t have it all,” she reminded, there may an opportunity to improve data exchange and completeness by taking advantage of knowing that a high percentage of our patient population have smartphones.
“Even if the data exists—we all fill out questionnaires asking about alcohol consumption—what happens to the data?” asked a former CIO of a large health system. “Nobody even looks at it, unless there is a huge problem.” She expressed a lack of confidence that providers are leveraging the data points to adequately trigger flags and alerts and bring together all the aspects, risks, and behaviors of the patient to formulate holistic care plans.
LOOKING FORWARD: LIMITING OPIOID MISUSE, REDEFINING HEALTH CARE
The healthcare industry’s technological approach to the opioid problem centers on the availability of useful data—information on patients’ risk factors and history with certain medications, as well as prescribing data from systems and clinicians—and being able to use such data to limit misuse and overuse of opioids. Along the way, these efforts to use technology to improve the opioid situation are challenged by costs, the ability of end users (i.e., physicians and related staff) to use the data in a timely and effective way, and the interoperability of the systems maintaining and using the data.
Some ways providers can limit opioid misuse and redefine care associated with pain relief and medication, include:
Make it a priority. Making a positive impact on the opioid crisis and on the lives of your patients with SUD and their families requires an investment of time and resources. Identify goals and the personnel, technologies, tools, resources, and partners needed to meet these goals.
Accessing the data. EHRs, ECPS, PDMPs, HIEs and other sources can provide valuable data across your region that can contribute to improving medication management and care of patients on opioids. The new rules on information blocking apply to not just providers but also HIEs and health information networks (HINs). Learning what data you have the right to access (ONC info blocking page) will help you provide your staff all the available information that can impact patient care related to opioids. Utilize your EHR’s interoperability specialists to ensure your organization is connected to key networks in your region so your patients’ records are more comprehensive.
Integrating quality data. Automated, timely data integrated into the workflow can provide clinicians with actionable information to impact patients’ opioid use. Work with your EHR to determine opportunities to optimize your use of outside data.
Consider SUD risk factors. Beyond managing prescribing across facilities and regions, providers can analyze data on the root causes of opioid use. For instance, AI may help identify comorbidities that may make a patient more susceptible for opioid misuse. Also, addressing and destigmatizing mental health by talking to patients and offering treatment options as necessary. This also becomes an important part of the patient’s data record for purposes of overall SUD identification and care.
Training staff to use the data and tools. Offering training and tools to help clinicians recognize patients’ risks and use trends at the point of care is only helpful if these end users know how to use these tools, including what can be offered in terms of alternative medications, additional care resources, and other next steps.
Care navigation. Establish care navigation teams that can help patients dealing with or at risk of SUD. These teams can talk to patients about issues they’re dealing with, including pain, as well as provide options such as community resources and substance abuse programs.
Drive policy and funding change. Making your voice heard is key to gaining attention from the policymakers. Speak louder and wider. Utilize resources from trade associations such as CHIME, which has been active on the patient identifier and other key healthcare issues. Call, write, and visit regulators, legislators, and other key officials. Highlighting the impact on constituents and districts is an effective way to drive home the importance of issues such as opioid abuse and ways the healthcare industry can help.
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