Opioid Epidemic & Health IT

This section of the Playbook provides background on the role health IT plays in fighting the opioid epidemic in the United States. It presents health IT strategies that clinicians can use to address the problem. Healthcare practitioners, administrators and physician practice owners, and practice staff can also find a variety of health IT resources in this section. These strategies and resources can help improve opioid prescribing practices, inform clinical practice, protect patients at risk for opioid use disorder, and reduce diversion.

Learn about:

• Opioid Epidemic from the Centers for Disease Control and Prevention (CDC)
• Providers' Clinical Support System for Opioid Therapies from Providers' Clinical Support System for Opioid Therapies (PCSS-O)

How can health IT help?

Health IT is increasingly used to improve the quality and efficiency of healthcare delivery, patient safety, care coordination, and patient-centered care. This includes offering strategies to address the opioid epidemic. The use of health IT has been demonstrated to improve adherence to opioid prescribing guidelines and physician adherence to treatment protocols, increase the safety of prescribing for controlled substances, enhance clinician access to prescription drug monitoring programs (PDMPs), expand access to addiction treatment and recovery supports, and much more.

As the opioid epidemic escalates, clinicians are actively seeking tools and resources to help prevent and detect opioid misuse, abuse, and diversion by their patients. The following sections of the Playbook describe in detail how various health IT solutions are being used by clinicians on the frontlines to address the opioid crisis in their practices.

Where can I access health IT tools to support opioid prescribing?

What is a prescription drug monitoring program (PDMP)?

PDMPs are one of the most promising tools available to address prescription opioid misuse and abuse. PDMPs are state-run electronic databases operating in every state that collect data from pharmacies on Drug Enforcement Agency (DEA) controlled substances prescription drugs dispensed to patients. Pharmacists (and some dispensing physicians) report to a PDMP each time a prescription is filled for a controlled substance medication.

PDMP information data can give a prescriber or pharmacist critical information regarding a patient's controlled substance prescription history. This, in turn, can help clinicians distinguish between patients who legitimately need opioid medications for pain treatment and those who may be seeking to misuse or divert (i.e., channeling drugs into illegal use) these powerful drugs. Reviewing PDMP data before prescribing also provides an opportunity to intervene early if there are signs of misuse or abuse. Additionally, licensing and regulatory boards can use PDMP data to identify unusual prescribing patterns by prescribers; state Medicaid Programs can use PDMP data for patient reviews; and state public health officials can use aggregated PDMP data to inform the development and implementation of targeted public health interventions, such as prescriber education campaigns.

Who can use PDMP information?

Access to PDMP information is determined by state law. All states with a PDMP allow prescribers and pharmacists to obtain prescription history information on patients under their care. A majority of states allow prescribers to authorize certain members of their healthcare teams such as nurses or pharmacy technicians to access the PDMP on their behalf. Such delegation can save time, reduce the burden on prescribers and encourage greater PDMP use.

Many states enable PDMP access to other end users as well, such as law enforcement, medical licensing and regulatory boards, state Medicaid programs, and medical examiners or coroners. Some PDMPs are also authorized to release de-identified data (i.e., data that is stripped of all personally identifying information, or PII) for research and prevention purposes.

Are PDMPs effective?

Growing evidence supports the value of PDMPs as an effective clinical tool to improve patient care and safety while reducing the negative health outcomes associated with the medically unnecessary use of controlled substances.¹

Evidence suggests that when PDMP data are readily accessible, prescribers, clinicians, and pharmacists are empowered able to take actions that could lead to reductions in the risks of prescription drug opioid abuse and diversion.^{2, 3, 4} In this way, use availability of PDMP data in PDMPs can potentially:

• Improve prescribing practices
• Give clinicians a more complete picture of their patient’s medical history
• Reduce “doctor shopping” to obtain prescriptions from multiple clinicians
• Reduce rates of abuse (which results in lower rates of admissions for substance use treatment)

The requirements for and the actual use of PDMP data by clinicians and prescribers varies significantly based on state laws and requlations. A 2014 national survey found that 72% of primary care physicians surveyed were aware of their state’s PDMP, but only 53% used it, and many did not use it routinely. Another study found that physicians checked the PDMP only 14% of the time prior to prescribing an opioid.⁵ That means that 86% of opioid prescriptions were written without a prescriber ever checking the patient’s prescribing history. Physicians have stated that PDMPs are too time-consuming and difficult to access, often requiring prescribers to sign out of their electronic health record systems and into another database.

An AMA study showed a 5 fold increase in PDMP queries, from 61 million to over 300 million, across the country between 2014 and 2017, and a more than 3 fold increase of providers registered and using PDMPs as states implement and strengthen mandatory PDMP check requirements.⁶

How can PDMP usage be improved?

A promising strategy to address the prescription opioid epidemic is optimizing PDMPs through integration with health IT systems. Although PDMPs are designed to improve opioid prescribing practices and protect patients at risk for misuse and abuse, prescriber utilization is low. Reducing the clinician burden required to access PDMP data is critical for increasing its use. Clinicians, in most cases, have limited time to retrieve and review their patient’s controlled substance prescription history in the PDMP before prescribing or dispensing. The non-integrated approach to PDMP checking requires clinicians to exit their normal clinical workflow and log into the PDMP system which can be a time consuming and cumbersome process.

How is health IT improving prescription drug monitoring programs (PDMPs)?

Despite the benefits of PDMPs, their use in clinical care remains low. States have implemented policies to strengthen and improve use of these programs. Due to the escalating opioid crisis, the majority of states now mandate that clinicians check the PDMP (in certain circumstances) before writing for controlled substances with known potential for abuse or dependence. Integrating PDMPs with health IT systems can increase PDMP use and drive the success of these mandatory use requirements by reducing the burden placed on clinicians. Lack of interoperability also contributes to the low usage rates of PDMPs, however there are emerging capabilities that hold promise for increased PDMP use in the future.

Health IT is an essential part of the solution to improving clinician access to PDMP data and ensuring that the right information is available at the right place and time to help inform clinical decision-making. Integrating PDMP information with health IT systems like electronic health records (EHRs) makes it easy for clinicians to quickly check a patient’s PDMP report before prescribing or dispensing powerful prescription pain medications. Since clinicians already typically work within an EHR, health information exchanges (HIEs), or pharmacy management systems, making PDMP data seamlessly available in these systems results in minimal disruption to their normal workflow. It also reduces the time and resources wasted by having multiple user accounts and system logons.

For additional resources on PDMPs, visit section 4.5.

How can electronic prescribing of controlled substances help reduce fraud and abuse?

To help combat the current opioid epidemic, healthcare clinicians need up-to-date tools and technology that support appropriate prescribing of prescription opioids. Electronic prescribing of controlled substances (EPCS) allows physicians to leverage technology to issue prescriptions to patients in a secure manner necessary to prevent over-prescribing.

States are increasingly embracing EPCS to help address the prescription opioid crisis. EPCS enables healthcare clinicians to play a critical role in decreasing opioid fraud and abuse. When its full capabilities are used, EPCS allows clinicians to see patients’ medication histories at the point of care, which helps identify patients who may be “doctor shopping” or exhibiting other behaviors associated with drug abuse.

EPCS also ensures that prescriptions are securely transmitted from clinician to pharmacy without the risk of forgery or alteration. Drug diversion, or the obtainment of prescription drugs for illicit use, is a significant concern for controlled substances, where between 3% and 9% of diverted drugs are tied to fraud or forgery of paper prescriptions. Strong security requirements and clinician access controls implemented through EPCS significantly decrease the risk of these powerful prescription drugs falling into the wrong hands.

What are the benefits of EPCS?

Prescribing controlled substances electronically offers many benefits for patients, clinicians, and the healthcare system as a whole. All of these factors will reduce clinician burden and create a safer environment for patients.

Using EPCS:

• Enhances Patient Safety by providing alerts to prevent drug-to-drug and drug-to-allergy interactions, inappropriate dosing, and duplicate therapies and patient status — such as pregnancy or breast-feeding.
• Improves Accuracy by reducing errors inherent in paper-based prescribing, including illegible handwriting, misinterpreted abbreviations, and unclear dosages.
• Reduces Fraud and Drug Diversion by ensuring prescriptions are securely transmitted from clinician to pharmacy without the risk of forgery or alteration.
• Reduces Drug Misuse and Abuse by allowing clinicians to see patients’ medication histories at the point of care, which helps them determine if patients are “doctor shopping” or are exhibiting other behaviors associated with drug abuse.
• Improves Workflow Efficiencies by streamlining all prescribing into a single workflow, eliminating the need to switch between workflows (electronic for some medications and paper for others).

Where is EPCS allowed?

EPCS is now legal in all 50 U.S. states.

In the past, federal law required the issuance of a paper prescription for controlled substances. In 2010, the U.S. Drug Enforcement Administration (DEA) passed new regulations making it legal to send controlled substances electronically. By 2015, all states had changed their rules to allow EPCS.

Even though EPCS is now legal in every state, it has not yet been widely adopted. On average, just 23.6% of all U.S. practitioners are currently EPCS-enabled compared to 90.6% of retail pharmacies. The majority of prescribers are sending electronic prescriptions,¹ but far fewer prescribers are using this capability for prescribing controlled substances — even though such medications make up about 13% of the prescription market.

National EPCS availability is a key step in combating prescription drug fraud and abuse. To promote widespread use of this technology, some states, are taking legislative action to mandate electronic prescribing. ONC is working to educate the healthcare community on the benefits of electronic prescribing and importance of EPCS as a tool to support improved opioid prescribing.

Learn about mandatory electronic prescribing in New York and Ohio and Kentucky.

Since 2009, lawmakers, federal agencies, states, and local jurisdictions have developed a number of strategic policy initiatives which include the use of health IT and support public health and population health management. Two major initiatives at the federal level include the policies established in the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

CMS EHR Incentive Programs (HITECH Act)

The Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs require participants to demonstrate Meaningful Use of certified EHR technology to accomplish a range of actions related to clinical processes and care coordination. In 2017, the EHR Incentive Program for Medicaid eligible professionals requires public health and clinical data registry reporting. Eligible professionals, eligible hospitals, and critical access hospitals can send data to a PDMP in their jurisdiction to meet public health requirements of the EHR Incentive Program.

CMS has stated that a PDMP can be considered a specialized registry, if the PDMP has declared itself a specialized registry. In addition, clinicians must demonstrate “active engagement” with the PDMP which means the participant is 1) engaged in registration and onboarding, 2) engaged in testing and validation, and/or 3) engaged in submitting production data (i.e., real clinical data).

For additional information about meeting the Medicaid EHR Incentive Program’s public health and clinical data registry reporting requirements, refer to the CMS Specification Sheet. In addition, this CMS FAQ provides guidance for using PDMP connectivity to fulfill part of the EHR Incentive Program public health and registry reporting requirements.

To determine if your jurisdiction has an active PDMP, refer to the resources in section 4.2.

CMS Quality Payment Program (MACRA)

The new Medicare payment program will replace the Sustainable Growth Rate (SGR) that was repealed in 2015. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) emphasizes improving quality of care for patients and moving away from a fee-for-service payment system.

Under MACRA, Medicare eligible clinicians have 2 options for participating in the Quality Payment Program: the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

To learn more about the Quality Payment Program, visit the Value-Based Care section.

In the MIPS Advancing Care Information category, a participant can earn up to 5 points for the use of an EHR to support active engagement with a PDMP that has declared itself as a specialized registry.

In the MIPS Improvement Activities category, a participant can earn points through 2 improvement activities related to preventing opioid misuse.

Safe opioid prescribing

• National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain [PDF – 1.1 MB]
  The National Pain Strategy outlines the federal government’s first coordinated plan for reducing the burden of chronic pain that affects millions of Americans. Developed by a diverse team of experts from around the nation, the National Pain Strategy is a roadmap toward achieving a system of care in which all people receive appropriate, high quality and evidence-based care for pain.
• CDC Guideline for Prescribing Opioids for Chronic Pain
  The Centers for Disease Control and Prevention (CDC) has developed and published guidelines for prescribing opioids for chronic pain. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.
• Minimizing the Misuse of Prescription Opioids in Patients with Chronic Nonmalignant Pain [PDF – 509 KB]
  This educational module introduces health professions students to a standardized approach to managing patients with chronic pain. It integrates techniques for the prevention and detection of prescription opioid misuse.
• Pathways to Safer Opioid Use
  This training uses the principles of health literacy and a multimodal, team-based approach to promote the appropriate, safe, and effective use of opioids to manage chronic pain. The training is based on recommendations from the National Action Plan for Adverse Drug Event (ADE) Prevention, which identifies opioids as a major contributor to ADEs.
• Opioid & Pain Management CMEs
  The National Institute on Drug Abuse (NIDA) presents a resource for medical professionals to find continued medical education courses (CMEs) related to opioid prescription and pain management.
• Safe Opioid Prescribing
  The Indian Health Service (IHS) presents information comparing different prescription opioids, summarizing the principles of safe prescribing, and outlining opioid therapy exit strategies.