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Appl Clin Inform 2022; 13(02): 419-430
DOI: 10.1055/s-0042-1745830
Case Report

Impact of a Vendor-Developed Opioid Clinical Decision Support Intervention on Adherence to Prescribing Guidelines, Opioid Prescribing, and Rates of Opioid-Related Encounters

Robert P. Pierce 
1   Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, Missouri, United States
,
Bernie Eskridge
2   Department of Child Health, University of Missouri School of Medicine, Columbia, Missouri, United States
,
Brandi Ross
3   Tiger Institute, Cerner Corporation, Columbia, Missouri, United States
,
Matthew Wright
4   University of Missouri Health Care, Columbia, Missouri, United States
,
Thomas Selva
2   Department of Child Health, University of Missouri School of Medicine, Columbia, Missouri, United States
› Author Affiliations Funding This study was funded directly by the University of Missouri Health Care.
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Abstract

Background Provider prescribing practices contribute to an excess of opioid-related deaths in the United States. Clinical guidelines exist to assist providers with improving prescribing practices and promoting patient safety. Clinical decision support systems (CDSS) may promote adherence to these guidelines and improve prescribing practices. The aim of this project was to improve opioid guideline adherence, prescribing practices, and rates of opioid-related encounters through the implementation of an opioid CDSS.

Methods A vendor-developed, provider-targeted CDSS package was implemented in a multi-location academic health center. An interrupted time-series analysis was performed, evaluating 30 weeks pre- and post-implementation time periods. Outcomes were derived from vendor-supplied key performance indicators and directly from the electronic health record (EHR) database. Opioid-prescribing outcomes included count of opioid prescriptions, morphine milligram equivalents per prescription, counts of opioids with concurrent benzodiazepines, and counts of short-acting opioids in opioid-naïve patients. Encounter outcomes included rates of encounters for opioid abuse and dependence and rates of encounters for opioid poisoning and overdose. Guideline adherence outcomes included rates of provision of naloxone and documentation of opioid treatment agreements.

Results The opioid CDSS generated an average of 1,637 alerts per week. Rates of provision of naloxone and opioid treatment agreements improved after CDSS implementation. Vendor-supplied prescribing outcomes were consistent with prescribing outcomes derived directly from the EHR, but all prescribing and encounter outcomes were unchanged.

Conclusion A vendor-developed, provider-targeted opioid CDSS did not improve opioid-prescribing practices or rates of opioid-related encounters. The CDSS improved some measures of provider adherence to opioid-prescribing guidelines. Further work is needed to determine the optimal configuration of opioid CDSS so that opioid-prescribing patterns are appropriately modified and encounter outcomes are improved.

Keywords

clinical decision support system - electronic health record - opioids - quality improvement

Protection of Human and Animal Subjects

The University of Missouri institutional review board (IRB) determined that the project was quality improvement activity, not human subject research, and did not require additional IRB review. The requirement for consent was waived.


Supplementary Material



Publication History

Received: 20 September 2021

Accepted: 18 February 2022

Article published online:
20 April 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
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  • References

  • 1 National Institute on Drug Abuse.. Overdose death rates. Accessed April 6, 2020 at: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
    PubMedGoogle Scholar
  • 2 National Institute on Drug Abuse Missouri opioid summary. Accessed April 8, 2020 at: https://nida.nih.gov/drug-topics/opioids/opioid-summaries-by-state/missouri-opioid-involved-deaths-related-harms
    PubMedGoogle Scholar
  • 3 Wilson N, Kariisa M, Seth P, Smith IV H, Davis NL. Drug and opioid-involved overdose deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020; 69 (11) 290-297
    CrossrefPubMedGoogle Scholar
  • 4 Bohnert ASB, Valenstein M, Bair MJ. et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011; 305 (13) 1315-1321
    CrossrefPubMedGoogle Scholar
  • 5 Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016; 65 (01) 1-49
    CrossrefPubMedGoogle Scholar
  • 6 Nuckols TK, Anderson L, Popescu I. et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med 2014; 160 (01) 38-47
    CrossrefPubMedGoogle Scholar
  • 7 Centers for Disease Control and Prevention.. Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain. Atlanta, GA: Division of Unintentinal Injury Prevention, National Center for Injury Prevention and Control; 2018
    Google Scholar
  • 8 Starrels JL, Becker WC, Weiner MG, Li X, Heo M, Turner BJ. Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain. J Gen Intern Med 2011; 26 (09) 958-964
    CrossrefPubMedGoogle Scholar
  • 9 Tournebize J, Gibaja V, Muszczak A, Kahn JP. Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. Pain Pract 2016; 16 (03) 370-383
    CrossrefPubMedGoogle Scholar
  • 10 Losby JL, Hyatt JD, Kanter MH, Baldwin G, Matsuoka D. Safer and more appropriate opioid prescribing: a large healthcare system's comprehensive approach. J Eval Clin Pract 2017; 23 (06) 1173-1179
    CrossrefPubMedGoogle Scholar
  • 11 Huang KTL, Blazey-Martin D, Chandler D, Wurcel A, Gillis J, Tishler J. A multicomponent intervention to improve adherence to opioid prescribing and monitoring guidelines in primary care. J Opioid Manag 2019; 15 (06) 445-453
    CrossrefPubMedGoogle Scholar
  • 12 Dorflinger L, Moore B, Goulet J. et al. A partnered approach to opioid management, guideline concordant care and the stepped care model of pain management. J Gen Intern Med 2014; 29 (Suppl. 04) 870-876
    CrossrefPubMedGoogle Scholar
  • 13 Nielsen J. 10 Usability Heuristics for User Interface Design. Nielsen Norman Group.. Accessed May 17, 2020 at: https://www.nngroup.com/articles/ten-usability-heuristics/
    PubMedGoogle Scholar
  • 14 Boeger MR. 7-Day Opiate Supply for Initial Prescriptions for Acute Pain. Missouri Bureau of Narcotics and Dangerous Drugs. Aug 29, 2018. Available at: https://health.mo.gov/safety/bndd/pdf/7-day-opiate-prescriptions.pdf
    PubMedGoogle Scholar
  • 15 Opioid Oral Morphine Milligram Equivalent (MME) Conversion Factors. Centers for Medicare & Medicaid Services. 2020. HHS-0938-2020-F-5924. Available at: https://www.hhs.gov/guidance/document/opioid-oral-morphine-milligram-equivalent-mme-conversion-factors-0
  • 16 Value Set Authority Center.. NLM Value Set Repository. Accessed April 15, 2020 at: https://vsac.nlm.nih.gov/
    PubMedGoogle Scholar
  • 17 Linden A. Conducting interrupted time-series analysis for single- and multiple-group comparisons. Stata J 2015; 15 (02) 480-500
    CrossrefPubMedGoogle Scholar
  • 18 Lopez Bernal J, Cummins S, Gasparrini A. The use of controls in interrupted time series studies of public health interventions. Int J Epidemiol 2018; 47 (06) 2082-2093
    CrossrefPubMedGoogle Scholar
  • 19 Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf 2016; 25 (12) 986-992
    CrossrefPubMedGoogle Scholar
  • 20 Smart R, Pardo B, Davis CS. Systematic review of the emerging literature on the effectiveness of naloxone access laws in the United States. Addiction 2021; 116 (01) 6-17
    CrossrefPubMedGoogle Scholar
  • 21 Guy Jr GP, Haegerich TM, Evans ME, Losby JL, Young R, Jones CM. Vital signs: pharmacy-based naloxone dispensing—United States, 2012-2018. MMWR Morb Mortal Wkly Rep 2019; 68 (31) 679-686
    CrossrefPubMedGoogle Scholar
  • 22 Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med 2010; 152 (11) 712-720
    CrossrefPubMedGoogle Scholar
  • 23 Chapman L, dela Cruz AM, Hutto J. Opioid treatment agreements: helpful or hurtful?. Am J Psychiatry Resid J 2016; 11 (09) 14-16
    CrossrefPubMedGoogle Scholar
  • 24 McGlothlin AE, Lewis RJ. Minimal clinically important difference: defining what really matters to patients. JAMA 2014; 312 (13) 1342-1343
    CrossrefPubMedGoogle Scholar
  • 25 Hawkins AT, Samuels LR. Use of confidence intervals in interpreting nonstatistically significant results. JAMA 2021; 326 (20) 2068-2069
    CrossrefPubMedGoogle Scholar
  • 26 Osheroff JA. ed. Improving Medication Use and Outcome with Clinical Decision Support: a Step-by-step Guide. Healthcare Information and Management Systems Society; 2009
    Google Scholar
  • 27 Ratwani RM, Savage E, Will A. et al. A usability and safety analysis of electronic health records: a multi-center study. J Am Med Inform Assoc 2018; 25 (09) 1197-1201
    CrossrefPubMedGoogle Scholar
  • 28 Ratwani R, Fairbanks T, Savage E. et al. Mind the Gap. A systematic review to identify usability and safety challenges and practices during electronic health record implementation. Appl Clin Inform 2016; 7 (04) 1069-1087
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Hettinger AZ, Melnick ER, Ratwani RM. Advancing electronic health record vendor usability maturity: progress and next steps. J Am Med Inform Assoc 2021; 28 (05) 1029-1031
    CrossrefPubMedGoogle Scholar
  • 30 Monica K. Cerner Launching EHR-Integrated Opioid Toolkit for Safe Prescribing. Xtelligent Healthcare Media, LLC; 2021 Accessed August 1, 2021 at: https://ehrintelligence.com/news/cerner-launching-ehr-integrated-opioid-toolkit-for-safe-prescribing
    PubMedGoogle Scholar
  • 31 Ross C. Epic's AI algorithms, shielded from scrutiny by a corporate firewall, are delivering inaccurate information on seriously ill patients. STAT.. 2021 Accessed August 1, 2021 at: https://www.statnews.com/2021/07/26/epic-hospital-algorithms-sepsis-investigation/
    PubMedGoogle Scholar
  • 32 Wong A, Otles E, Donnelly JP. et al. External validation of a widely implemented proprietary sepsis prediction model in hospitalized patients. JAMA Intern Med 2021; 181 (08) 1065-1070
    CrossrefPubMedGoogle Scholar
  • 33 Coiera E, Tong HL. Replication studies in the clinical decision support literature-frequency, fidelity, and impact. J Am Med Inform Assoc 2021; 28 (09) 1815-1825
    CrossrefPubMedGoogle Scholar
  • 34 Smith LB, Golberstein E, Anderson K. et al. The association of EHR drug safety alerts and co-prescribing of opioids and benzodiazepines. J Gen Intern Med 2019; 34 (08) 1403-1405
    CrossrefPubMedGoogle Scholar
  • 35 Price-Haywood EG, Burton J, Burstain T. et al. Clinical effectiveness of decision support for prescribing opioids for chronic noncancer pain: a prospective cohort study. Value Health 2020; 23 (02) 157-163
    CrossrefPubMedGoogle Scholar
  • 36 Anderson DR, Zlateva I, Coman EN, Khatri K, Tian T, Kerns RD. Improving pain care through implementation of the stepped care model at a multisite community health center. J Pain Res 2016; 9: 1021-1029
    CrossrefPubMedGoogle Scholar
  • 37 Gregory ME, Russo E, Singh H. Electronic health record alert-related workload as a predictor of burnout in primary care providers. Appl Clin Inform 2017; 8 (03) 686-697
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Melnick ER, Dyrbye LN, Sinsky CA. et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc 2020; 95 (03) 476-487
    CrossrefPubMedGoogle Scholar
  • 39 Committee on Patient Safety and Health Information Technology; Institute of Medicine.. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: National Academies Press; 2011
    Google Scholar
  • 40 Howe JL, Adams KT, Hettinger AZ, Ratwani RM. Electronic health record usability issues and potential contribution to patient harm. JAMA 2018; 319 (12) 1276-1278
    CrossrefPubMedGoogle Scholar
  • 41 Genco EK, Forster JE, Flaten H. et al. Clinically inconsequential alerts: the characteristics of opioid drug alerts and their utility in preventing adverse drug events in the emergency department. Ann Emerg Med 2016; 67 (02) 240-248
    CrossrefPubMedGoogle Scholar