New focuses for_pdm_ps_efforts_final

New Focuses for PDMP’s Efforts Jennifer Frazier, MPH

Office of the Na7onal Coordinator for Health Informa7on Technology

Jinhee Lee, PharmD Substance Abuse and Mental Health Services

Administra7on

Len Young Epidemiologist, MassachuseIs Department of Public

Health

Mike Small Department of Jus7ce Administrator II, California

Department of Jus7ce

Learning Objec7ves

1.  Outline strategies to enhance exis7ng programs’ abili7es to analyze and use collected data to iden7fy drug abuse trends.

2.  Explain how to enhance exis7ng programs’ ability to analyze and use collected data.

3.  Outline new opportuni7es for PDMP to effec7vely iden7fy doctor shoppers.

Disclosure Statement

•  Jennifer Frazier has no financial rela7onships with proprietary en77es that produce health care goods and services.

•  Jinhee Lee has no financial rela7onships with proprietary en77es that produce health care goods and services.

•  Len Young has no financial rela7onships with proprietary en77es that produce health care goods and services.

•  Mike Small has no financial rela7onships with proprietary en77es that produce health care goods and services.

FEDERAL HEALTH IT INTERVENTIONS TO COMBAT PRESCRIPTION DRUG ABUSE &

OVERDOSE

Jennifer Frazier, MPH Office of the National Coordinator for Health Information Technology

Jinhee Lee, PharmD Substance Abuse and Mental Health Services Administration

Outline

•  PDMPs: The Context •  SAMHSA PDMP RFA

•  ONC-‐SAMHSA Project –Phase I

•  ONC-‐SAMHSA Project –Phase II

•  Next Steps

1. PDMPS: THE CONTEXT

The Problem

•  The Centers for Disease Control and Preven7on (CDC) declared that deaths from prescrip7on painkillers now outnumber deaths from heroin and cocaine combined

•  Prescrip7on drug abuse deaths is one of the fas7ng growing public health epidemics, outpacing deaths from traffic fatali7es

Past Month Illicit Drug Use among Persons Aged 12 or Older: 2011

Numbers in Millions

0.3

0.6

1.0

1.4

6.1

18.1

22.5

0 5 10 15 20 25

Heroin

Inhalants

Hallucinogens

Cocaine

PsychotherapeuXcs

Marijuana

Illicit Drugs (8.7%)

(7.0%)

(2.4%)

(0.5%)

(0.4%)

(0.2%)

(0.1%)

1

1 Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescrip7on-‐type psychotherapeu7cs used nonmedically (pain relievers, s7mulants, tranquilizers, seda7ves). Source: 2011 NSDUH

Past Year IniXates of Specific Illicit Drugs among Persons Aged 12 or Older: 2011

2,617

1,888

1,204 922

719 670 670

358 178 159 48

0

500

1,000

1,500

2,000

2,500

3,000 Numbers in Thousands

Marijuana

Pain Relievers

Tranquilizers

Ecstasy

Inhalants

Cocaine

SXmulants

LSD

Heroin

SedaXves

PCP Note: Numbers refer to persons who used a specific drug for the first 7me in the past year, regardless of whether ini7a7on of other drug use

occurred prior to the past year. Source: 2011 NSDUH

Numbers in Thousands

360+ 415+ 424+

466+

547 565 604

736 761

726

0

100

200

300

400

500

600

700

800

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

+ Difference between this es7mate and the 2011 es7mate is sta7s7cally significant at the .05 level. Source: 2011 NSDUH

Received Most Recent Treatment in the Past Year for the Use of Pain Relievers among Persons Aged 12 or Older: 2002-‐2011

Federal Strategy to Address the Problem of PrescripXon Drug Abuse

•  In 2011 ONDCP released the Prescrip7on Drug Abuse Preven7on Plan, which includes 4 major areas of ac7on to reduce prescrip7on drug abuse:

– Educa7on, – Monitoring, – Proper Disposal, and – Enforcement

•  PDMPs are at the core of the Monitoring ac7vi7es.

Source: Epidemic: Responding to America’s Prescrip7on Drug Abuse Crisis, (2011), retrieved from hIp://www.whitehouse.gov/sites/default/files/ondcp/policy-‐and-‐research/rx_abuse_plan.pdf

SAMHSAs Strategic Ini7a7ves

•  Preven7on of Substance Abuse & Mental Illness

•  Trauma and Jus7ce

•  Military Families

•  Recovery Support •  Health Reform

•  Health Informa7on Technology

•  Data, Outcomes, and Quality

•  Public Awareness and Support

ONC’s Strategic Plan

Goals:

•  Achieve adopXon and informaXon exchange through meaningful use of health IT

•  Support health IT adop7on and informa7on exchange in long-‐term/post-‐acute care, behavioral health and emergency sehngs.

•  Improve care, improve popula7on health, and reduce health care costs through the use of health IT

•  Inspire confidence and trust in health IT

•  Empower individuals with health IT to improve their health and health care system

•  Achieve rapid learning and technological advancement

13

2. SAMHSA PDMP GRANT PROGRAM

PDMP EHR Coopera7ve Agreements

•  Provided two year funding for 9 states (FL, IN, IL, KS, ME, OH, TX, WA, WV)

•  Purpose – 1)improve real-‐7me access to PDMP data by integra7ng PDMPs into exis7ng technologies like EHRs and 2) strengthen currently opera7onal state PDMPs by increasing interoperability between states

•  Evaluate whether these enhancements have an impact on prescrip7on drug abuse

Enhancing Access to Prescrip<on Drug Monitoring Programs

3. ONC/SAMHSA PROJECT: PHASE 1

The Story So Far

Stakeholders

Organizations

White House Roundtable on

Health IT & PrescripXon Drug Abuse June 3, 2011

Federal & State Partners

State Participants

Action Plan

Situa7on Today •  Providers and dispensers need prescrip7on drug history

informa7on to improve clinical decision making

–  They don’t receive the data they need from PDMPs

•  Health IT is the link to connect prescribers and dispensers with the valuable data in PDMPs

•  From the local to na7onal level – never a greater 7me of ac7on centered around PDMPs and their value

•  Increasing number of projects centered on PDMPs and health IT connec7vity

Project Structure and Objec7ves

Improve clinician workflow by connecXng PDMPs to health IT

Support Xmely decision-‐making at the

point of care

Establish standards for facilita7ng informa7on

exchange

Provide recommenda7ons and pilot input

Test the feasibility of using health IT to enhance PDMP access

Reduce prescrip<on drug misuse and overdose in the United States

19

PDMP Impediments

Emergency Department Prescriber

Ambulatory Prescriber

Dispenser

Low Usage

Limita7ons on Authorized Users

Current Processes Do Not Support Clinical Workflows

Low Technical Maturity to Support Interoperability

Lack of Business Agreements

Work Groups Number/Name Purpose

1: Data Content and Vocabulary

To determine the data content and vocabulary necessary to support data exchange between Prescrip7on Drug Monitoring Programs (PDMP) and recipients.

2: Informa7on Usability and Presenta7on

To determine how PDMP informa7on will be presented in the user interfaces for pharmacy systems and provider and ED Electronic Health Records (EHR) to maximize the value of this data for the treatment and dispensing decision-‐making processes.

3: Transport and Architecture

To explore and develop the technical specifica7ons for data transmission (e.g., REST, SOAP, Direct) between PDMPs and a variety of recipient systems and intermediaries.

4: Law and Policy To explore legal and policy issues in support of program objec7ves, including PDMP data access within various recipient sehngs, use of intermediaries to enable PDMP data exchange and specific Pilot Program scenarios in the context of specific state(s).

5: Business Agreements for Intermediaries

To analyze the current business environment relevant to the use of intermediaries (e.g., Switches, HIEs) to route transmissions between PDMPs and data recipients.

21

Work Group Recommenda7ons Summary

Automate/streamline registra7on process

Expand authorized user pool

Appoint delegates Increase protec7on

PEOPLE

Info for clinical decisions Workflow-‐based

Improve unsolicited repor7ng

USEFULLNESS

Integrate access with EHR System-‐level access Standardize PDMP

interfaces

INTEGRATION

Standard set of data Adopt data exchange standard (NIEM-‐PMP)

Real-‐7me transmission

DATA

Business Agreements Business Associate

Agreements

AGREEMENTS

48 Findings and 11 Products

Pilot States and Summary

23

Pilot States and Summary

Indiana (IN1)

Emergency Department

Automated query to PDMP upon pa7ent admission to ED

PDMP data integrated into EHR

Automated query and response, streamlined workflow for physicians

Indiana (IN2)

Provider Unsolicited PDMP reports sent via Direct Safer, more secure transmission of unsolicited reports

Pilot States and Summary (cont.)

North Dakota (ND)

Pharmacy

Automated query to PDMP using an exis7ng benefits management switch and return results to Indian Health Service pharmacy

Leveraged exis7ng benefits transmission technology

Michigan (MI)

Provider Automated query to PDMP to create integrated prescrip7on history and alerts

Partnered with e-‐prescribing

Pilot States and Summary (cont.)

Washington (WA)

Opioid Treatment Program

Hyperlink to PDMP within EHR Streamlined access to PDMP

Ohio (OH) Provider

Automated query to PDMP upon appointment scheduling and pa7ent check-‐in; pa7ent risk score displayed in EHR

Automated query and response, streamlined workflow for physicians

Pilot Results   Immediate improvement to the

patient care process after connection

  Streamlined the user workflows by leveraging technology to enable PDMP query and processing tasks.

  Prescribers and dispensers were the most satisfied with their new workflows when technology automated the majority of workflow tasks.

In their own words…   “I have to say that this is probably one of the

more genius moves of the 21st century . . . having easy access to [the PDMP] without going to a totally different website and have it pop up instantly has taken a lot of time off of decision making for me.” –  Emergency Department Physician

  “Yes, much easier. Especially like being able to click on the report and be taken directly to the patient’s report without having to enter the patient’s name, date of birth, and zip code (this was very time consuming and sometimes prevented me from looking up the information in the past).” –  Ambulatory Family Physician

Enhancing Access to Prescrip<on Drug Monitoring Programs

4. ONC/SAMHSA PROJECT: PHASE 2

Phase 2 Overview

29

LEARN CHANGE

EQUIP

From Phase I By empowering others

Technology Framework

Share the News

Build the community

Evolve the vision

Pilots

Phase 2 Pilots - Overview State End User Pilot Summary

Illinois Emergency Department

•  Automated query via intermediary and interstate hub to PDMP upon pa7ent admission to ED

•  PDMP data integrated into EHR as a PDF via a Direct message

Indiana Emergency Department

•  Automated query via HIE to mul7ple states’ PDMPs upon pa7ent admission to ED

•  Pa7ent risk score and PDMP data integrated into EHR

Kansas Providers •  Unsolicited report of at-‐risk pa7ents sent via Direct to EHR-‐integrated mailboxes

Michigan Providers •  Automated query via e-‐Prescribing sopware to mul7ple states’ PDMPs and result integrated in pa7ent’s medica7on history

Nebraska Emergency Department

•  Automated query via HIE to PDMP upon pa7ent admission to ED

•  Easy access to PDMP with SSO

•  PDMP data integrated into EHR

Oklahoma Emergency Department

•  Established PDMP access directly though an HIE

•  Developed a SSO from the EHR through the HIE to the PDMP

•  Alert flag represen7ng the PDMP data

Tennessee Pharmacy •  Real-‐7me repor7ng of dispensing controlled substance data to the PDMP using an exis7ng network

Technical Framework

PDMP S&I Community Focus/Scope

Pharmacy

PMPi / RxCheck PDMP

Other State PDMPs

NCPDP Script

PDMP

Por

tal

Switches

NCPDP Telecom

ASAP

Pharmacy Benefits Mgmt

Provider

EHR System

NIEM-‐PMP NIEM-‐PMP

Provider

EHR System

Provider

EHR System Data Out

Needs for standards (data format and content; transport and security protocols)

Compelling Vision

Articulating a Compelling Vision

Evidence and AnalyXcs

Roadmaps

Workflows

User Stories

EducaXon

Pilot Progress

Tech Development

Building a COMMUNITY through development of a resource center that

includes:

Oklahoma & Indiana Videos

Roadmap Workflows •  Goals

–  To connect and engage stakeholders

–  Accelerate adop7on and use of PDMPs

•  Key features –  Models the connec7on –  Technology workflows –  Project plan –  Implementa7on –  Evalua7on and op7miza7on

PDMP Resource Center

About PDMPConnect PDMPConnect seeks to inform and unite the community of physicians, providers, pharmacists, and health IT organiza7ons and professionals in one forum to discuss and share ideas about enhancing access to pa7ent prescrip7on drug informa7on stored in PDMPs using health IT technologies at the point of care.

1. “Map Filter” Filter by interest:

•  Federal Govt, Grants, PDMPS, etc "

2. “Featured Contributors” “Tear drop” icons =

•  Key PDMP players •  Pilot participants •  Others

3. “Other Contributors” info “Small bubble” icons =

•  State PDMP specific information •  FY2012 pilots

“Featured Contributors” Page •  Displays custom content and resources

from these contributors

•  Includes information that is relevant to that individual or group

•  Conversation feed is sorted based on tweets from the individual/group

•  Individually follow each of these contributors on Twitter

5. NEXT STEPS

Collabora7on and Funding

•  Coordinate with BJA Harold Rogers PDMP Grants

•  Con7nue collabora7on with other federal partners (i.e. ONC, ONDCP, CDC, BJA, NIDA, FDA, etc.)

•  Future funding to extend project goals

Looking toward the Future…

•  Prescrip7on drug misuse and abuse con7nues to be a challenge in the U.S.

•  A balance must be maintained between the benefits of properly managed pain medica7on and the poten7al for abuse of that medica7on.

•  A holis7c response must include a combina7on of educa7on, monitoring, control, and enforcement.

THANK YOU.

The Team

Jennifer Frazier, ONC, [email protected]

Jinhee Lee, SAMHSA, [email protected] Kate Tipping, SAMHSA, [email protected]

Chris Jones, CDC, [email protected]

Cecelia Spitznas, ONDCP, [email protected]

Lisa TuIerow, MITRE, [email protected]

Jeffrey Hammer, MITRE, [email protected]

Outreach to Prescribers Who Have a High Number of

Doctor/Pharmacy Shopper PaXents

April 2 – 4, 2013 Omni Orlando Resort

at ChampionsGate

Massachusejs PrescripXon Monitoring Program

Massachusejs Department of Public Health Bureau of Health Care Safety and Quality

Drug Control Program


•  All presenters for this session have disclosed no relevant, real or apparent personal or professional financial rela7onships.

OVERVIEW

• MA PMP Background

•  Individual (Pa7ent) Level Analysis • Electronic Alerts • Prescriber Level Analysis

BACKGROUND MA PRESCRIPTION MONITORING PROGRAM (MA PMP)

•  MA PMP

 promotes safe prescribing and dispensing,

 helps prevent drug diversion and abuse.

•  MA PMP collects data on Schedule II-‐V prescrip7ons dispensed in MA ambulatory pharmacies and from out-‐of-‐state pharmacies delivering to pa7ents in MA.

•  Over 12 million Schedule II-‐V prescrip7on records were reported to MA PMP in CY 2012.

MA PMP PROGRAM ENHANCEMENTS

•  New Pa<ent Iden<fiers: Prior to January 2009, MA PMP only collected customer iden7fiers (e.g., drivers license numbers). Aper regula7on change the MA PMP began collec7ng pa7ent iden7fiers (i.e., names and addresses).

•  Expanded Schedules: Originally the MA PMP only collected data on Schedule II prescrip7ons. In January 2011, MA PMP expanded monitoring requirements to include Schedule III-‐V prescrip7ons.

•  Unsolicited Reports: In February 2010, MA PMP began providing unsolicited (paper) reports to prescribers, iden7fied as prescribing to individuals mee7ng or exceeding a pre-‐determined threshold for suspected ques7onable ac7vity (i.e., poten7al doctor/pharmacy shopping).

•  MA Online PMP: In December 2010, the MA Online PMP became opera7onal.

DEFINING THE PROBLEM

•  Individuals who are dependent on, maybe becoming dependent on or who are diver7ng prescrip7on opioids may visit many different providers (prescribers and pharmacies) in order to obtain mul7ple, open overlapping, and dangerous quan77es of prescrip7ons of the same or similar opioid drugs.

•  Prescribers may inadvertently serve these individuals because of lack of informa7on about their prescrip7on histories.

1 Popula7on includes all individuals (iden7fied by customer ID) who received at least one Schedule II opioid prescrip7on in a fiscal year.

2 Ques7onable ac7vity is defined as having received Schedule II opioid prescrip7ons from a minimum of 4 providers and 4 pharmacies during the reported fiscal year.

EsXmated Number of Individuals per 100,0001 Showing QuesXonable AcXvity2 by Fiscal Year in MA

7,411 (0.85%)

Individuals

121,238 (5.8%)

Prescrip7ons

ADDRESSING THE PROBLEM

1.  Focus on individuals receiving the prescrip=on controlled substances

  Sending unsolicited reports to prescribers

  Referring “highly suspicious” individuals to law enforcement

2.  Focus on the health care providers who are prescribing the controlled drugs

  Target for ini7al outreach (i.e., educa7on and invita7on to enroll in the MA Online PMP) prescribers who have a large number of pa7ents exhibi7ng ques7onable ac7vity.

  Con7nue to reach out and aIempt to follow-‐up with those prescribers who do not enroll in the MA Online PMP and con7nue to prescribe to large numbers of pa7ents with ques7onable ac7vity.

FOCUSING ON INDIVIDUALS Unsolicited Report Analysis

•  MA PMP evaluated the impact of unsolicited reports on the prescrip7on controlled substance use of individuals who met specified thresholds of ques7onable ac7vity for whom such reports were sent.

•  A non-‐interven7on comparison group was included to provide more accurate measures of the impact of unsolicited reports.

Preliminary Findings

cases: n = 84, controls: n = 84

† Sta<s<cally significant at p < 0.05

FOCUSING ON INDIVIDUALS Electronic Alerts

•  Unsolicited report analysis provides empirical evidence that aler7ng prescribers can reduce doctor/pharmacy shopping ac7vity over 7me.

•  MA Online PMP system allows for electronic alerts to be sent out to prescribers and dispensers based on established thresholds (e.g., min # prescrip7ons, prescribers, pharmacies, within a specified 7me frame).

•  MA PMP has conducted some pilot tests of these electronic alerts and is in the process of establishing appropriate thresholds for full implementa7on.

FOCUSING ON PROVIDERS MA PMP IniXaXve

•  Iden7fy prescribers who have significant numbers of pa7ents with ques7onable ac7vity (i.e., doctor/pharmacy shopping) based on pre-‐specified criteria (described in methodology).

•  From the list of prescribers iden7fied above determine who are not already enrolled in the MA Online PMP.

•  Send an “outreach” leIer to those prescribers with significant numbers of pa7ents with ques7onable ac7vity who have not enrolled in the MA Online PMP encouraging poten7ally “at risk” prescribers to enroll in the MA Online PMP.

•  This ini7a7ve resulted in 150 leIers sent to non-‐enrolled prescribers in CY 2012 and approximately 40 percent of these prescribers are currently enrolled in the MA Online PMP.

PRELIMINARY ANALYSIS

•  A small pilot analysis was conducted to evaluate possible impacts of prescriber enrollment to the MA Online PMP

•  Time Period: July 1 through December 31 (2010 and 2011)

•  The top 50 prescribers (i.e, prescribers with the highest number of individuals who met the doctor/pharmacy shopper threshold) were used for a preliminary analysis:

–  Those prescribers who enrolled in the MA Online PMP (n=12) had a 26 percent decline in individuals who met the ques7onable ac7vity criteria from 2010 to 2011.

–  Those prescribers who were not enrolled in the MA Online PMP (n=38) had a 7.5 percent decline in individuals who met the ques7onable ac7vity criteria at the 7me of this evalua7on.

EXPANDED PRESCRIBER ANALYSIS Methodology

•  Based on the posi7ve findings of the pilot evalua7on, a larger analysis was undertaken.

•  Time Period: Data queried from CY 2009-‐2012

•  For purposes of this ini7a7ve, ques7onable ac7vity is defined as an individual who receives Schedule II-‐V opioid prescrip7ons from 4 or more different providers and fills such prescrip7ons at 4 or more different pharmacies during the calendar year.

•  Prescribers with reported hospital DEA numbers were excluded from this evalua7on.

•  In order to be included in the analysis a prescriber must have had 10 or more individuals who met the ques7onable ac7vity criteria during at least 1 of the 4 calendar years evaluated and a minimum of at least two non-‐zero data points during the 4 calendar years.

EXPANDED ANALYSIS Results

*Online Users -‐ prescriber must have conducted a minimum of one pa7ent search since being enrolled in the MA Online PMP.


•  Online Users > 1 year: The “high doctor/pharmacy shopper” prescribers enrolled in the MA Online PMP for at least one year (n=20) had a 50 percent decline in the number of doctor/pharmacy shopper pa7ents (Avg # = 103.3 pa7ents [2009-‐2010] versus 51.7 pa7ents [2011-‐2012]).

•  Not-‐Enrolled Prescribers: The “high doctor/pharmacy shopper” prescribers not enrolled in the MA Online PMP (n=70) had a 31 percent decline in doctor/pharmacy shopper pa7ents during the same 7me period (Avg # =73.7 pa7ents [2009-‐2010] versus 53.4 pa7ents [2011-‐2012]).


1 Ques7onable ac7vity is defined as having received Schedule II opioid prescrip7ons from a minimum of 4 providers and 4 pharmacies during the calendar year.

2 The "average" percentage of all pa7ents prescribed a Schedule II-‐V controlled drug who meet the ques7onable ac7vity threshold within each prescriber category analyzed.


•  Among the 3 groups of prescribers analyzed:

 Online “High” Users > 1 Year: Those prescribers who have been enrolled in the MA Online for over 1 year PMP (n=25) and are among the top 25 enrolled prescribers in number of pa7ents searched (an average of about twice as many searches as the “Online Users > 1 year” group) had a 71.9 percent decrease (13.9 to 3.9) in the percentage of all pa7ents prescribed a Schedule II-‐V controlled drug who met the ques7onable ac7vity criteria from 2009 to 2012.

 Online Users > 1 Year: The “high doctor/pharmacy shopper” prescribers enrolled in the MA Online PMP for at least one year (n=20) had a 64.8 percent decline (from CY 09-‐10 to 11-‐12) in the number of doctor/pharmacy shopper pa7ents.

 Not Enrolled Prescribers: The “high doctor/pharmacy shopper” prescribers not enrolled in the MA Online PMP (n=70) had a 35.1 percent decline (from CY 09-‐10 to 11-‐12) in the number of doctor/pharmacy shopper pa7ents.

CONCLUSIONS

•  Prescribers who are enrolled and use the MA Online PMP have exhibited a larger decrease in the number and propor7on of their pa7ents who have been prescribed controlled drugs and who meet the specified doctor/pharmacy criteria compared to non-‐enrolled prescribers.

•  More frequent use of the MA Online PMP by prescribers results in greater decreases in doctor/pharmacy shopper ac7vity among their pa7ents.

Prescription Monitoring Program Acknowledgement

•  Portions of this project were supported by grants awarded by the U.S. Bureau of Justice Assistance. Points of view or opinions in this presentation are those of the author and do not represent the official position or policies of the United States Department of Justice.

CONTACT INFORMATION

Len Young

MA Department of Public Health Drug Control Program Phone: 617-‐983-‐6705

Email: [email protected]

PDMP Powerful Tool for MulXple

ModaliXes

April 2 – 4, 2013 Omni Orlando Resort

at ChampionsGate

Learning Objec7ves

Imbue PDMP colleagues with the noXon we can and should do much more.


This presenter reports no relevant financial interests.

“During the spring and summer of 2001, U.S. intelligence agencies received a stream of warnings that al Qaeda planned, as one report put it, “something very, very, very big.”

The Director of Central Intelligence said, “The system was blinking red.”

Execu=ve Summary, The 9/11 Commission Report, Page 6

The FBI’s approach to counterterrorism inves7ga7ons was, “case-‐specific, decentralized, and geared toward prosecu7on.”

Execu=ve Summary, The 9/11 Commission Report, Page 13

“Each agency’s incen7ve structure opposes sharing, with risks (criminal, civil, and internal administra7ve sanc7ons) but few rewards for sharing informa7on.”

The 9/11 Commission Report, Page 417

The 9/11 Commission’s boIom-‐line recommenda7on was for a…

Unity of Effort

One fight, one team.

2,390 Pearl Harbor Deaths

2,973 9/11Deaths hIp://www.cbsnews.com/2100-‐224_162-‐2035427.html

>15,500 PrescripXon Painkiller Overdose Deaths

CY 2009 hIp://www.cdc.gov/vitalsigns/MethadoneOverdoses/

Current PDMP Systems

PDMPs serve the public health and the public safety.


PDMPs, generally, serve two principal clients:

  Health Care Prescribers and Dispensers

  Law Enforcement Police and Sheriff Agencies Investigative Agencies (DEA, DOJ, Coroner, etc)

District Attorneys & DA Investigators Regulatory Board Investigators (Medical, Osteopathic, Pharmacy, Podiatry, Veterinary, Dental, etc.)


Generally, relevant provisions of laws for the PDMPs are:

  Health Insurance Portability and Accountability Act (HIPAA) & AIendant Regula7ons

42 U.S.C. §§ 1320d to 1320d-‐8, and 45 CFR 164, et seq.

  A State Confiden7ality of Medical Informa7on Act   A State Informa7on Prac7ces Act

  State PDMP Legisla7on


  Pharmacists are required to report dispensaXons scheduled controlled substances at a frequency prescribed by statute.

  Use of the PDMP by prescribers and dispensers for prescripXon abuse prevenXon/intervenXon is voluntarily in many states.


Many states presently limit law enforcement PDMP queries to a single name/date of birth search with and only with an acXve case number.

LICENSE ALERT

On July 23, 2012, the Orange County Superior Court issued a PC23 Order that suspended the license of JOHN DOE, M.D., with an address of record in Laguna Beach, CA. He shall cease and desist from the prac7ce of medicine, as a condi7on of bail, or own recognizance release, during the pendency of the criminal ac7on un7l its final conclusion and sentence.

The Privacy and Security Rules apply only to covered en<<es.

Individuals, organizaXons, and agencies that meet the definiXon of a covered enXty under HIPAA must comply with the Rules' requirements to protect the privacy and security of health informaXon and must provide individuals with certain rights with respect to their health informaXon.

If an en<ty is not a covered en<ty, it does not have to comply with the Privacy Rule or the Security Rule.

hNp://www.hhs.gov/ocr/privacy/hipaa/understanding/covereden==es/index.html

A Health Care Provider

This includes providers such as: Doctors Clinics Psychologists Den7sts Chiropractors Nursing Homes Pharmacies

...but only if they transmit any informa7on in an electronic form in connec7on with a transac7on for which HHS has adopted a standard.

A Health Plan

This includes:

Health insurance companies

HMOs

Company health plans

Government programs that pay for health care, such as Medicare, Medicaid, and the military and veterans health care programs

A Health Care Clearinghouse

This includes en77es that process nonstandard health informa7on they receive from another en7ty into a standard (i.e., standard electronic format or data content), or vice versa.

HIPAA Privacy and Security Rules Covered EnXXes

www.hhs.gov/ocr/privacy/hipaa/understanding/covereden==es/index.html

Entities not required to comply with HIPAA’s Privacy and Security Rules include:

•  Life Insurers

•  Employers

•  Workers Compensation Carriers

•  Many Schools and School District

•  Many State Agencies like Child Protective Services

•  Many Law Enforcement Agencies

•  Many Municipal Offices

http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Two major law enforcement operaXonal objecXves:

1.   Discern Crime

2.   InvesXgate Crime

InformaXon-‐led policing discerns crime.

Atlan=c Monthly, March 1982

In their now famous 1982 article, Broken Windows, social scientists James Q. Wilson and George L. Kelling stated: “Just as physicians now recognize the importance of fostering health rather than simply treating illness, so the police – and the rest of us – ought to recognize the importance of maintaining, intact, communities without broken windows.”

PDMP data value for law enforcement:

  Inves7ga7ve leads to evidence (prescrip7ons)

  Indicia for inves7ga7ve targe7ng

  Indicia for suspicious death inves7gators

  Raw informa7on for inves7ga7ve analy7cs

AnalyXc-‐oriented inquiry capabiliXes that could greatly benefit law enforcement:

  Pa7ent, Prescriber, and Pharmacy Reports by Date Range Parameters

  Method of Payment

  Pa7ent Distance to Prescriber

  Pa7ent Distance to Pharmacy

AnalyXc-‐oriented inquiry capabiliXes that could greatly benefit law enforcement (conXnued):

  Top Prescribers by Date and Region

  Top Pa7ents by Date and Region

  Top Pharmacies by Date and Region

  Overdose Surveillance: Histories of Decedents’ Prescribers; Histories of the Prescribers’ Top Pa7ents


New England Journal of Medicine 2012; 366:2341-‐2343, June 21, 2012, DOI: 10.1056/NEJMp1204493 Jeanmarie Perrone, M.D., and Lewis S. Nelson, M.D.

Drs. Perrone and Nelson noted barriers to today’s PDMPs include:

  Time and access issues.

  Complicated applica7on and notariza7on procedures

  Prescribers will have to be educated about PDMPs if voluntary compliance is to be improved and rou7ne use encouraged.

PDMPs need to integrate and interoperate with the major health care systems in their regions.

PDMP data can be rendered by the health care system to be presented with the EHR when the prac77oner walks into the exam room to see the pa7ent.

IntegraXon / InteroperaXon

IntegraXon / InteroperaXon

Integra7on/Interopera7on leverages a trust arrangement that the various interopera7on partners vet their respec7ve members.

Integra7on/Interopera7on can facilitate peer-‐to-‐peer collabora7on.

Integra7on/Interopera7on can facilitate a “watch” flags across member systems.

3rd Party Payers

EsXmated Savings from Enhanced Opioid Management Controls through 3rd party Payer Access to the Controlled Substance UXlizaXon Review and EvaluaXon System (CURES) California Workers’ Compensa7on Ins7tute January, 2013 Alex Swedlow & John Ireland

3rd Party Payers

The study states that access to a PDMP system,

“…coupled with enhanced medical cost containment strategies including medical provider networks (MPN) monitoring and u7liza7on review (UR) – could significantly reduce the average number of prescrip7ons and the average dose levels of workers’ compensa7on claims that u7lize opioids.”

3rd Party Payers

The CWCI study es7mates the cost savings to AY 2011 California workers’ compensa7on claims to be $57.2 million.

The CWCI study states a California workers’ compensa7on system investment in PDMP

would realize an es7mated $15.5:$1 return-‐on-‐investment.

3rd Party Payers

3rd Party Payer PDMP access could:

Help promote adherence with accepted chronic pain management guidelines.

Provide another mutually advantageous check point against poten7ally dangerous prescrip7ons.

Save rate payers money.

Health Care Administrators

Health care system administrators rou7nely monitor professional performance for quality of care assurance, protocol adherence, cost control and liability mi7ga7on.

Certainly PDMP access would allow health care system administrators to deal with outliers at the system level before a great public health and/or public safety peril takes hold.

Mental Health Crisis IntervenXonists

PDMP data can well serve mental health clinicians and behavorial professionals who must determine likely causes of an individual’s mental crisis as well as a best course of treatment.

Thank You!


New focuses for_pdm_ps_efforts_final

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