This blog explores health informatics—a collaborative activity connecting people, process, and technologies to produce trusted data for better decision-making.
Editor’s note: This is the first part of a two-part series.
By Barbara A. Ryznar, RPh, MSHI, RHIA, CHDA, CPHI, CPHIMS, CAPM
The opioid crisis has generated much data to monitor the problem and analyze its scope and trends. Statistics can describe the demographics of the opioid addict, describe the source and type of drug abuse, and aggregate data to assess the extent of the opioid crisis. The Centers for Disease Control and Prevention (CDC) databases are a source of such data, and the WONDER query tool can be used to filter the data to desired parameters for review. Many common aspects are present in both charts and tables at the CDC website, among others. Perhaps the best starting point is the National Institute on Drug Abuse (NIDA) or the Substance Abuse and Mental Health Services Administration (SAMSHA), additional sources of aggregated data beneficial in assessing factors of the opioid crisis.
Among the most notable numbers to gain public attention are the overdose death statistics. For 2017, NIDA estimated reported drug overdose deaths at 72,000 people. To put this estimate in perspective, drug overdoses represent the leading cause of accidental death in the United States. This data comes from individual death certificates listing information on primary and contributing causes of death using ICD codes. It is important to realize that this drug overdose total must be broken down to identify opioid-related overdose. Further defining of the specific drug entity to legal drugs or illegal status becomes more complicated when a mix of drugs is present or is unspecified. The granularity of ICD-10 coding allows the definition of the drug entity and becomes a filtering parameter for query and data analysis. Accurate documentation is necessary in order to assign the appropriate code on the death certificate. So, data is available to track the deaths, but data to track the extent of the problem may be more elusive. The ICD-10 codes again can be used within the electronic health record (EHR) with supportive documentation to assign F11 codes (F11.1, Abuse; F11.2, Dependence; and F11.9, Use) and emergency department (ED) hospital billing data on opioid-involved overdoses become markers to address scope and trends but are points for intervention with treatment. The potential for EHRs to facilitate targeted case management or to deploy other resources or follow-up interventions is a resource that has yet to be tapped for its full potential through interoperability.
The Centers for Medicare and Medicaid Services’ (CMS) FY 2019 IPPS Rule is an important step forward in addressing the opioid crisis. Among the Promoting Interoperability (PI) programs are two optional programs directed to do just that by augmenting requirements for legal opioid monitoring:
- Verify Opioid Treatment: allows a prescriber to verify that an opioid agreement is present when prescribing
- Query of Prescription Drug Monitoring Program (PDMP): allows the provider to review a snapshot of the patient’s opioid prescription history before prescribing
Of the two, I think that Query of PDMP stands to have an impact from the benefit of having real-time prescription history from aggregate sources at the time of e-prescribing. It is a means of linking the realm of pharmacy prescription history data to the EHR using claims and reporting data sources. This program is optional for FY 2019 but required for 2020, so facilities have time to adopt this policy and address factors that impact clinical workflow and interoperability. Unless the system is integrated into the EHR and established as part of the prescribing process, the reluctance of providers to use the system and reap the benefit of this measure cannot be maximized.
Recently, I renewed my pharmacy license. New requirements this year included continuing education credits needed for opioid medications and verification of access to the state PDMP. I have been using the PDMP for over two years in retail pharmacy. I can say that so far, it seems to have been effective. The results that I have observed include smaller quantities per prescription for acute pain and fewer prescriptions for narcotics from ED visits with a reflex increase in nonnarcotic (such as NSAID medications) pain relievers. In the two years of its use, I have found the PDMP technology to be rapidly evolving in usability factors, but it is not integrated with our pharmacy software yet. I must step away and use another computer, log in to assess the PDMP, and enter patient data again. Needless to say, this disrupts the workflow and lacks efficiency, but interoperability of the PDMP for all affected provider locations is a current focus in my state. I expect interoperability is our next step, too.
The PDMP is one of the measures introduced to curtail the availability of legal opioids to prevent diversion with initiatives for monitoring and controlling the legal drug supplies. However, the CDC attributes the sharp increase in overdose deaths to illicit and highly potent semi-synthetic opiates such as fentanyl entering the country rather than prescription opioids. The PDMP falls short with data for this sector. So, efforts to combat drugs on this front are needed, too. Federal and state initiatives to prevent deaths by increasing patient access to naloxone as a nasal spray have the potential to reduce the death rate from opioid overdoses as this drug acts to reverse the effects of opiates. This will logically yield a more favorable number for opioid-related drug overdose deaths—but with little impact on the underlying problem. Congress is expected to pass the Opioid Crisis Response Act toward the end of 2018. Its many and diverse provisions, which range in scope from blister packaging of pain medications to developing new nonnarcotic pain medications, are designed to curb the flow of illegal drugs into the country, support the treatment of addiction, and address long-term solutions to the opioid crisis.
Part two of this two-part series, publishing later this month, will address how Big Data is being leveraged to find innovative solutions for the prevention and treatment of opioid addiction.
CDC. “U.S. drug overdose deaths continue to rise; increase fueled by synthetic opioids.” Press release. March 29, 2018. https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html.
CMS. Fiscal Year (FY) 2019 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Prospective Payment System Final Rule (CMS-1694-F). August 2, 2018. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2019-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute-0.
NIDA. Overdose Death Rates. Revised August 2018. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
SAMSHA. Opioids. https://www.samhsa.gov/atod/opioids.
United States Senate. Opioid Crisis Response Act of 2018. https://www.help.senate.gov/imo/media/doc/The%20Opioid%20Crisis%20Response%20Act%20of%202018%20summary.pdf.
Barbara A. Ryznar is a community pharmacist at a Medicine Shoppe Pharmacy and a part-time adjunct instructor in the MSHI program at University of Cincinnati.