The opioid crisis that has killed more than 200,000 Americans rages on today because, in large part, U.S. health care is hooked on broken processes that guide how patient care is provided.
When it comes to tackling the crisis, a crucial part of the solution is already in place in every hospital — the clinical processes that have been built into every electronic health record (EHR) system that tell doctors, nurses and other clinicians how to deliver care to patients.
When the U.S. government approved $787 billion of economic stimulus spending in 2009, that package included $19 billion to subsidize the cost of equipping health-care providers with modern EHR systems. Those systems now guide and track clinicians on routine patient care, but could be doing so much more if used to full capacity.
For health systems to improve clinical effectiveness, the data captured in these systems needs to be put to work to dramatically improve the delivery and quality of care that patients receive.
The data and trends in these EHRs can significantly improve the clinical treatment of pain and decrease the variability in how opioids are prescribed. These changes can be both proactive — directing hospital staff protocols — and reactive, identifying where data opioids are overused. Put simply, fixing the processes built into the EHR could fix the problem.
Some experts believe that our opioid crisis has its roots in standards issued in 2001 about pain management from the Joint Commission — the body that accredits nearly 21,000 U.S. health-care organizations and programs.
Many providers interpreted the revised standards as a mandate to treat pain as a vital sign to be monitored in patients. (Previously, there were four vital signs measured — temperature, pulse, respiration rate, and blood pressure.) The Joint Commission says it never intended pain to be elevated to vital sign status, but as more and more hospitals did just that. Hospital administrators began measuring patient pain levels and sought to reduce those numbers by implementing clinical processes designed to aggressively treat pain.
The end result was a spike in painkiller prescriptions such as morphine, oxycodone and hydrocodone: Between 1999 and 2016, sales of prescription opioids quadrupled and overdose deaths involving these prescriptions increased five-fold. In that period, over 200,000 people died in the United States from overdoses related to prescription opioids.
The fact of the matter is that a lot of hospital systems’ leaders in the country have little to no specific visibility into the exact mechanisms by which their methods for managing pain have inadvertently contributed to the crisis. But the message is getting out. Last summer, physicians, nurses and executives from five hospital systems gathered for a summit to begin addressing the problem and to grasp the industry’s role in the crisis.
The participants — LifePoint Health, Tenet Healthcare, Community Health Systems, HCA’s TriStar Health division in Nashville and Scripps Health — committed to making organizational changes by increasing awareness and education about pain management with clinicians and patients. They will gather data and scientific evidence to refine surgical recovery protocols.
It is exactly the right approach. Once you realize the opioid crisis largely stems from broken processes that by default guide clinicians to write too many prescriptions, you also realize getting hold of a process to change that is critical. In the United States, reducing those prescriptions should start with better use of the capabilities in EHR systems.
Improving the use of EHR systems in the following five ways would make significant inroads in cutting the endemic overuse of opioids:
1. Review clinical protocols. EHR systems are configured to include clinical protocols, or best practice road maps for clinicians. Now that reducing opioid abuse has been flagged as a national imperative, updating EHR systems with the latest protocols will reduce the use of these highly addictive pharmaceuticals. Newer treatments limit the use of opioids, preferring the use of non-addictive drugs such as powerful nonsteroidal anti-inflammatories, as well as such things as local injections of corticosteroids directly into joints for targeted pain relief, the use of certain local anesthetics during surgery and physical therapy. EHR systems should ensure opioids are used appropriately.
2. Change order sets. Order sets — groups of prepackaged orders for treating a certain diagnosis that allow clinicians to issue a range of orders with just a few mouse clicks — should not default to having an opioid prescription pre-selected. Instead, if the clinician opts to treat a certain patient with opioids, that choice should be actively made as the orders are being written rather than passively included in a pre-populated group of orders. Order sets should also include other treatment options on the pain management pathway.
3. Reduce flexibility and change alerts. When a doctor writes a prescription, often nurses are given significant dispensing flexibility. For example, a prescription for one to two pills every four hours may leave the interval between doses to the nurse’s judgment, when the nurse is not ultimately responsible as the prescribing physician. Eradicating that flexibility with precise orders would reduce prescription abuse. Similarly, verbal prescriptions where nurses call doctors (not on site to physically examine the patient) for approval, should be discouraged. EHR systems also often have alerts that flag when a nurse records high levels of patient pain. These alerts drive significant, routine opioid use and should often be modified or turned off.
4. End open-ended prescriptions. Doctors often issue open-ended prescriptions that persist for several days. Hospitals can automatically stop opioid prescriptions, perhaps after 24 hours, then requiring that a doctor reevaluate the patient before continuing those drugs, which would otherwise be open to abuse.
5. Analyze data. Systems can alert administrators, almost in real time, of how opioids are being prescribed across a health-care network, and if standards that have been set are being adhered to. That analysis will flag certain departments, and specific clinicians, that are prescribing more opioids than is appropriate. Even when EHR systems populate doctors’ workflows with a specific protocol, some clinicians will be outliers, doing things the way they have always preferred. Clinical leaders with instant, highly actionable insights can identify those outliers and, armed with that knowledge, can take appropriate action.
The U.S. health-care system is so huge that it can take a decade or more to bring about real change. So acting now to better leverage EHR workflows to end the over-prescription and misuse of opioids is crucial.
Reducing the variability in how opioids are prescribed and improving, standardizing and better controlling clinical processes are two important ways to stem the country’s opioid crisis. By doing those two things, we can hope to properly manage pain while minimizing the risk of addiction — and death.
Better use of EHR systems and the workflows in them guiding care is the key to getting there. The solution is straightforward: Fix the process, fix the problem.
Patrick Yoder is co-founder and chief executive officer of LogicStream Health.