CC

QI Spotlight: Opioid Management: Physician Drug Monitoring Program to Identify Multiple Opioid Prescriptions and Contraindicated Drugs

This month our QI Project Spotlight was submitted by Tram Nguyen, MD and Hoyman Hong, MD. After meeting during residency at Stanford, they are now partners at a private practice in San Mateo, California.

"For a period of time, I was heavily involved in a MedTech startup that remotely monitored patients' controlled medication compliance and adherence. In addition, California implemented a new statute that required physicians to check the state PDMP or CURES system when first prescribing an opioid. Those factors, combined with my practice in which I prescribe controlled medications for chronic pain conditions, led me to develop this QI project." - Dr. Hong

Thank you for submitting your project, Dr. Nguyen and Dr. Hong!

The QI Project Spotlight is a periodic feature on the ABPMR News Center to highlight exemplary Quality Improvement projects submitted by your fellow diplomates (or residents) for continuing certification (CC) credit. Diplomates can use the QI Project Spotlight as a tool to plan their own QIs or as a way to connect with other diplomates doing similar work.

What is the problem you are trying to solve?

1. Incorporate California PDMP/CURES reports into the current patient care workflow.
2. Eliminate overprescribing from multiple providers of opioid pain medications for patients with chronic and acute pain.
3. Mitigate the potential risk of opioid overuse, diversion, and overdose.
4. Improve adherence to opioid prescribing guidelines.

What data (objective measurements) do you have that supports this as a problem?

1. California's PDMP, also known as CURES (Controlled Substance Utilization Review and Evaluation System) is not integrated into any EMR/EHR and must be run separately before appointments and saved as a PDF. This task takes approximately 5-7 min to complete.

2. Per the California Dept of Consumer Affairs, which runs the state's PDMP, there is no ability for the system to audit when the physician has accessed the system or run a CURES report.

What is your opportunity statement? State the goal you hope to achieve.

GOAL#1: For CURRENT patients receiving an opioid prescription, our goal is to check our California PDMP or CURES >90% of the time for each patient encounter.

GOAL #2: For CURRENT patients receiving an opioid prescription, our goal is to meet the minimum standard of checking the California PDMP or CURES at least once per quarter in >90% for each patient.

GOAL#3: For NEW patients receiving a NEW opioid prescription, our goal is to check our California PDMP or CURES in 100% of cases.

What is the underlying cause of the performance/quality problem?

1. No technology integration between California PDMP/CURES and current EMR/EHR.

2. Staffing: We did not have the staffing levels needed to run the PDMP/CURES reports for all medication appointments. We must devote dedicated staffing resources to run the reports and save them as a PDF to the EHR as part of the appointment preparation.

3. Training/Education: New and current staff did not know which patients or which medications required CURES reports. Staff also did not understand the medical decision impacts of not having the reports for new patient and follow-up appointments.

4. Policy implementation and staff responsibility were not clearly stated on who will run the CURES report and which patient requires it in the chart.

5. Provider unable to personally run reports due to time constraints, prioritizing treatment, patient Q/A, documentation of care.

What change(s) did you implement?

1. Hired new staff to address administrative deficiencies in the practice.
2. Assigned 2 admin to evenly divide the tasks of running CURES reports the before every appointment and save it to the chart. These were to be part of chart preparation and complied 1-2 days before patient's scheduled appointments.
3. Did three in-service staff meetings to educate the new staff members, providing an overview of the clinical context and Quality implications for PDMP/CURES reports.
4. Implemented a provider training to attach PDF to the encounter as part of workflow.

Did you achieve your goal or target from your opportunity statement? What data do you have to support your conclusion?

Yes. In the beginning of 2022, the practice was short staffed, everyone became ill with COVID. Starting at the end of the Q2 of 2022, we hired new staff and embarked on attaining our new goal of having a PDMP or CURES report saved for every patient encounter. A random data sample of 10 patients on chronic medication management was reviewed. The 2022 data is as follows:

GOAL #1: Checking PDMP/CURES Report for every appointment Q1 (Jan-Mar): 27% Q2 (Apr-Jun): 45% Q3 (Jul-Sept): 94% Q4 (Oct-Dec): 90%

GOAL #2: Meeting the minimum standard of running a PDMP/CURES report once per quarter for every patient: Q1 (Jan-Mar): 30% Q2 (Apr-Jun): 90% Q3 (Jul-Sept): 100% Q4 (Oct-Dec): 100%

GOAL #3: For NEW patients receiving a NEW opioid prescription our 2022 data was as follows: Q1 (Jan-Mar): 100% Q2 (Apr-Jun): 100% Q3 (Jul-Sept): 100% Q4 (Oct-Dec): 100%

Overall we met our goal of achieving >90% compliance.

How will you maintain the success of your project going forward?

COVID made communication very difficult and inconvenient due to reduced face to face interactions. This complicated developing and implementing policies and forced the practice to communicate better and to engage the team more.

Our goals were met with the participation of team members, Physicians, Physician Assistants, MAs and Admin team, communicating the goals of the practice and engaging the group to identify the problems and then come up with solutions we could implement.

Moving forward, we will continue to have our monthly staff meetings where we check in on practice goals, policies, workflows etc. and discuss what is working or needs improvement.