Beyond Adopting Prescribing
GuidelinesMonitoring & Strengthening the
Prescribing Patterns of Clinicians
June 6, 2019
11:00am -12:00pm Pacific Time
Opioid Safe Hospital Designation 2019 Webinar Series – 2 of 5
Cal Hospital Compare
Beyond Adopting Prescribing Guidelines: Monitoring and Strengthening the Prescribing Patterns of Clinicians
Online Live Webinar
June 6, 2019
The planners and faculty of Cal Hospital Compare have indicated no relevant financial relationships to disclose in regard to the
content of their presentations with the exception of:
Dr. Steve Tremain is a stockholder of Allergan. This presentation has been reviewed and found to contain no bias. Dr. Tremain
has no other relevant financial relationships to disclose in regard to the content of this presentation.
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the
Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American Board of Quality
Assurance and Utilization Review Physicians, Inc. and Cal Health Compare. The American Board of Quality Assurance and
Utilization Review Physicians, Inc. is accredited by the ACCME to provide continuing medical education for physicians.
The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live online webinar for a
maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
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BRN Contact Hours
• If you are interested in claiming BRN Contact Hours for attending this webinar, please register, complete the post webinar survey, including your contact information and your certificate will be emailed within 10 days.
• Provider approved by the California Board of Registered Nursing, Provider Number CEP 15958, for 1 contact hour.
Using Zoom
4
All lines MUTED upon
entry, UNMUTE
yourself as needed
Recommend calling in
via phone; link using
unique participant ID
Click “chat” to
open the chat box
Select To: “all
panelist and
attendees”
Meeting is being
recorded
Recording available on
calhospitalcompare.org
Meeting Objectives
Considered the value of attaining the Opioid Safe Hospital
Designation & identified the steps your hospital will take to apply for
the designation using the Opioid Safe Hospital Self-Assessment
Analyzed your hospital’s performance on the implementation of opioid
safe discharge prescribing guidelines across service lines
Examined the CDCs guideline for prescribing opioids for chronic pain
Heard from two peer hospitals the steps they have taken to partner
with physicians, staff, and patients to implement opioid safe discharge
prescribing practices
Communicated how CHC can support hospital progress over the next
three webinars
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Cal Hospital Compare
About: For more than a decade, Cal Hospital Compare (CHC) has been providing
Californians with objective hospital performance ratings. CHC is a non-profit
organization that is governed by a multi-stakeholder board, with representatives
from hospitals, purchasers, consumer groups, and health plans. In effort to
accelerate improvement and recognize high performance by California hospitals,
CHC publishes an annual Patient Safety Honor Roll and Low-Risk C-section Honor Roll.
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Facilitators
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Alex Stack
Director, Programs & Strategic Initiatives, CHC
Aimee Moulin
Co-Director ED Bridge
Steve Tremain
Physician Improvement Advisor Cynosure Health
Guest Speakers
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Sharon Tsay, MD
Medical Officer, Opioid Overdose Health Systems Team, CDC
Angela Rosenblatt
System Director of Pharmacy Clinical Services, Co-Chair, Opioid Stewardship
Committee, Scripps Health
Mary Beth Chambers,CNS
Pain Management, UCLA Health
POLL: What type of hospital do you work at?
What is your average daily census?
What is your role?
Opioid Safe Hospital DesignationProgram Overview
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Frequently Asked Questions
11
• All California, adult, acute care hospitals are eligible to apply for the Opioid Safe Hospital Designation.
Who can participate in the Opioid Safe Hospital Designation?
• Annual complimentary 5-part webinar series
• Tactical and other resources available on CHC website & mapped to Opioid Safe Hospital Self-Assessment
What resources are available to support improvement efforts?
• May 13 – September 18, 2019
• Each hospital must submit responses and any supporting documents via e-survey here
When is the assessment window?
Source: Opioid Safe Hospital Designation Frequently Asked Questions
CHAT: What questions do you have?
POLL: What is the first step you will take, by next
Thursday, to apply for the Opioid Safe Hospital
Designation?
Beyond Prescribing Guidelines
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Why Prescribing Matters
15Source: Characteristics of Initial Prescription Episodes and
Likelihood of Long-Term Opioid Use — United States, 2006–2015
Discharge Prescribing Guidelines
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Source: Opioid Safe Hospital Self-Assessment
POLL: What level best describes your work in this area?
Guest Speakers
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Sharon Tsay, MD
Medical Officer, Opioid Overdose Health Systems Team, CDC
Angela Rosenblatt
System Director of Pharmacy Clinical Services, Co-Chair, Opioid Stewardship
Committee, Scripps Health
Mary Beth Chambers,CNS
Pain Management, UCLA Health
CDC Guidelines
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National Center for Injury Prevention and Control
CDC Guideline for Prescribing Opioids for Chronic Pain
andHealth System Implementation Efforts
Sharon Tsay, MD Medical Officer
Opioid Overdose Healthcare Systems TeamDivision of Unintentional Injury Prevention
Cal Hospital Compare
Opioid Safe Hospital Designation Webinar Series, 2019 – 2 of 5
June 6, 2019
Nearly400,000
people have died from an
opioid overdose
since 1999
Three Waves of the Rise in Opioid Overdose Deaths
Rapid Increase in Drug Overdose Death Rates by County
SOURCE: NCHS Data Visualization Gallery
Conduct surveillance and research
Empowerconsumers to make
safe choices
Build state, local, andtribal capacity
Support providers,health systems,and payers
Partner withpublic safety
CDC’s Approach: Opioid Overdose Prevention
➢ Primary care
➢ Patients > 18 Years with chronic pain
➢ Outpatient settings
➢ Outside of active cancer, palliative, and end of life care
Organization of Guideline Recommendations
12 recommendations grouped into 3
conceptual areas:
CDC Prescribing Guideline Update
• Plan to update the CDC Guideline for Prescribing Opioids for Chronic Pain
• Agency for Healthcare Research and Quality (AHRQ) systematic review of the evidence for:
– Acute pain management
– Chronic pain management
• Update the 2014 systematic review on opioids for chronic pain
• Update the 2018 systematic review focusing on non-pharmacologic treatment of chronic pain
Comprehensive Implementation Approach for the CDC Prescribing Guideline
Translation & Communication
Education & Training
Insurer
Interventions
Health System Interventions
Translation & Communication
APP includes:– MME Calculator– Prescribing Guidance– Motivational
Interviewing
Education & Training
Online training modules & webinars for clinicians (earn CE/CME credits)
Clinical Outreach and Communication Activity (COCA) Free Webinars1. Overview of Guideline 2. Nonopioid Treatments for Chronic Pain3. Assessing Benefits and Harms of Opioid
Therapy4. Dosing and Titration of Opioids5. Opioid Use Disorder—Assessment and
Referral6. Risk Mitigation Strategies7. Effective Communication with Patients
To learn more: emergency.cdc.gov/coca/calls/2016/index.asp
To learn more: www.cdc.gov/drugoverdose/training/index.html
Interactive Trainings:1. Addressing the Opioid Epidemic: Recommendations from CDC2. Treating Chronic Pain Without Opioids3. Communicating with Patients4. Reducing the Risk of Opioids5. Assessing and Addressing Opioid Use Disorder6. Dosing and Titration of Opioids: How Much, How Long, and
How and When to Stop7. Determining Whether to Initiate Opioids for Chronic Pain8. Implementing CDC’s Prescribing Guideline into Clinical
Practice9. Opioid Use and Pregnancy10. Motivational Interviewing11. Collaborative Patient-Provider Relationship in Opioid Clinical
Decision Making
Insurer Interventions
Easier to prescribe
non-opioid pain medications
Pay forpatient
counseling, coordination of
care, and checking PDMP
PeerReview
PeerReview
Cover evidence-based non-pharmacologic therapies like exercise and cognitive behavioral therapy
Make it easier to prescribe non-opioid pain medications
Reimburse patient counseling, care coordination, and checking PDMP
Promote more judicious use of high dosages of opioids using drug utilization review and prior authorization
Remove barriers to evidence-based treatment of opioid use disorder
1
2
3
4
5
Health Systems Interventions
➢ Clinical decision support (CDS) tools embedded in electronic health records (EHRs)
➢ EHR and PDMP (prescription drug monitoring program) Integration
➢ Clinical Quality Improvement and Care Coordination
Encourage careful and selective use of opioid therapy and to facilitate actual implementation of the CDC Guideline for
Prescribing Opioids for Chronic Pain
Help health systems and primary care providers integrate quality improvement (QI) measures into their clinical practice
CDC Resources
CDC Guideline for Prescribing Opioids for Chronic Pain:https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Resources for patients:https://www.cdc.gov/drugoverdose/patients/index.htmlhttps://www.cdc.gov/rxawareness/index.html
Resources for providers:https://www.cdc.gov/drugoverdose/providers/index.html
QI and Care Coordination resources:https://www.cdc.gov/drugoverdose/prescribing/qi-cc.html
COCA Calls:https://emergency.cdc.gov/coca/calls/2016/index.asp
Online Training Series for Healthcare Providers:https://www.cdc.gov/drugoverdose/training/index.html
CDC Publications:https://www.cdc.gov/drugoverdose/pubs/index.html
Clinical Decision Support resources:*Implementation guide output: http://build.fhir.org/ig/cqframework/opioid-cds/
*Source for the implementation guide: https://github.com/cqframework/opioid-cds
*Supporting Java packages for the CQL-to-ELM translator and CQL Engine: https://github.com/cqframework/opioid-cds-logic
Contact:
Jan L. Losby, PhD
Telephone: 770-488-8085
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Contact:Sharon [email protected]
CHAT/UNMUTE TO TELL US:
What questions do you have?
Local Approaches
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Opioid Stewardship The Scripps Health Experience
Angela Rosenblatt, MS, PharmD, BCPS, BCNSP, APh
System Director of Pharmacy, Clinical Services Scripps Health
Co-Chair Opioid Stewardship Program
With special thanks to:
Valerie Norton, MD, FACEP, Physician Operations Executive Scripps Mercy Hospital, San Diego
Ole Snyder, MD, Scripps Coastal Family Medicine; Medical Director, Scripps Health Opioid Stewardship Program
THE BURNING PLATFORM
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If severe pain warrants opioid use and opioids are not contraindicated, prescribe the smallest amount needed for a limited duration (3-7 days) to prevent chronic use
Reset patient expectations: goal is to reduce suffering & return patients to normal functioning, NOT to eliminate all pain
If patients need opioids on discharge, prescribe no more than 30 immediate-release tablets in opioid-naïve patients with acute pain (many patients will do well with 10-20 tablets)
Educate patients on risks of opioids, safe storage and proper disposal; Provide patients a tapering schedule
Opioid Stewardship Program
Our Vision
• To promote safe and effective opioid prescribing and multi-modal pain management techniques
• To prevent new dependencies and addictions in the community
• To identify gaps in therapy and adequately treat those already suffering with chronic pain or opioid addiction
• To provide support to clinicians to combat the opioid crisis
Opioid Stewardship Program
Accomplishments• Created Opioid Stewardship Steering Committee –Vision –Phases for implementation
• Developed two Patient Education Brochures –Acute Pain Management, Post-Op Pain
• Developed Opioid Tapering Schedules for acute pain
• Developed Prescribing Standards for Acute Pain
• CME Lectures –Grand Rounds, Department Meetings
• LMS Learning Modules created for Physicians, Pharmacists, and Nurses
• Promotion of Multi-modal pain Management/Integrative medicine
• Drug Take Back Kiosks Implemented
• Opioid Stewardship Resource Center Implemented on Scripps IntraNet
• Continuous and Ongoing Prescriber Education, Rx Tracking
• Facilitated EPIC experience: CURES, Naloxone, Ordersets and defaults
• $260,000 Grant to treat OUD in ED
• Health Trust Grant ($50,000) Patient Videos professionally produced for Acute Pain and Post-
op Pain Management
Scripps Opioid Prescribing – 25% Reduced
82 77
75 71 71 71
66 63 64
60 62 62
-
10
20
30
40
50
60
70
80
90
FY18: Mean Number of Pills Per Opioid Prescription by Month
25% decrease over 12 months
Prevent new opioid starts
Measure Intent Level 3 (1 pt.) Safe
Level 2 (2 pts) Safer
Level 1 (3 pts) Safest
Steps Taken:
Discharge
Prescribing
Guidelines
Develop and
implement evidence-
based discharge
prescribing guidelines
across multiple service
lines to prevent new
starts on long-term
opioid treatment (with
exceptions for
palliative care).
Service lines may
include ED, Medical
IP, General Surgery,
and/or OB, etc.)
Your hospital has
developed and
implemented
evidence-based
discharge prescribing
guidelines in 1 service
line (e.g. ED, Medical
IP, General Surgery, or
OB, etc.)
Your hospital has
developed and
implemented
discharge prescribing
guidelines in 2 service
lines (e.g. ED, Medical
IP, General Surgery,
and/or OB, etc.)
Your hospital has
developed and
implemented
evidence-based
discharge prescribing
guidelines for at least
3 service lines
including ED and
General Surgery (e.g.
Medical IP, and/or OB,
etc.)
Extra credit (+1 pt.):
Procedure specific
prescribing guidelines
•Prescriber
education
•ERAS
•Default quantity
to lower quantity
(5, 10)
•Prescriber will
need to change
for higher
quantities
•Limited to
immediate
release solid oral
formulations
Tools for Provides and Patient Care
Prescribing Standards for Opioid Naïve Patients, Acute Pain
Tracking Individual Metrics
Procedure Specific Metrics and Feedback
Implementation of opioid safe prescribing guidelines in
the hospital setting
UCLA Health
Baseline self-assessment scoring:
2
Step #1 Improve rate of e-Prescribing
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• Started 2018
• In-servicing for
• NP’s
• Amb pharmacy Dir.’s
• Communications within dept’s
• Updated monthly
• Current – 69%
Electronic prescribing bill
goes into effect January 1,
2022:
1) requires health care
practitioners authorized
to issue prescriptions
to have the capability
to transmit electronic
data transmission
prescriptions
2) requires pharmacies to
have the capability to
receive those
transmissions.
3) requires those health
care practitioners to
issue prescriptions as
an electronic data
transmission
prescription, unless
specified exceptions
are met.
Step # 2: Develop MD Opioid Pocket guide
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Step #3 Focus on Stakeholder Management• General surgical guideline for common procedures:
• Reviewed by Med Staff, key stakeholders and surgical groups
• Currently being built in EMR as point of reference for prescribers when discharging opioid naive patients
• Distributed to prescribers during credentialing and re-appointment process and residency program
• Review of specialty prescribing practices currently underway:
• Discharge Prescribing Guidelines being used for: neurosurgery, total joint, colorectal, donor nephrectomy, gyn/onc and cystectomy.
• Leveraging role of 15 Physician Informaticists to tailor approach to specialty/ improve “buy in”
• Metrics being built to capture prescribing variance
Step #4 Mitigation Plan for Unintended Consequences
• Palliative care and end of life patients
• Workgroup with members from oncology and palliative care chartered by UCLA Pain Management Steering Committee to:
• Review key proposed prescribing and workflow changes for possible unintended impact on quality of pain management for at risk populations (*HCAHPS pain management satisfaction questions removed from reporting and pending dc 10/19).
Step #5 Review
• Prescribing data/ variance to be presented at Steering Committee meetings
• Based on review will determine whether/ what type of additional “nudge” enhancements in EMR are recommended. Target determination for enhancement is 1/1/2020.
CHAT/UNMUTE TO TELL US: What questions do you have?
Wrap up
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POLL:
What do you want to know more about that would help to close a gap in your work?
Webinar ScheduleAll calls start at 11:00am PT
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July 10
• Initiating MAT in the hospital: Unique aspects from the ED and inpatient settings
August 27 (Topic TBD)
• Using Alternatives to Opioids: overcoming resistance to non-opioid analgesics
• The nuts and bolts of dispensing naloxone to high-risk patients and their support systems
September 12 (Topic TBD)
• Understanding and eliminating stigma with OUD
• Emerging measures in the hospital setting for safe opioid management in the hospital
Register at calhospitalcompare.org
Resources & Follow Up Materials
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Source: Cal Hospital Compare Website – About – Opioid Safe Hospital Designation
Questions?
Alex Stack
Director, Projects & Special Initiatives
Cal Hospital Compare
Aimee Moulin
Central Valley Regional Coordinator
ED-BRIDGE Central Valley
Steve Tremain
Physician Improvement Advisor
Cynosure Health
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Thank you!Please give us the gift of feedback and complete the event evaluation
65
