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PDMP Workshop-2 …

PDMP Workshop-2
New Focuses for PDMP's Efforts
National Rx Drug Abuse Summit
April 2-4, 2013
Jennifer Frazier, Jinhee Lee, Len Young and Mike Small

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  • 1. 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        
  • 2. 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.  
  • 3. 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.    
  • 4. FEDERAL  HEALTH  IT  INTERVENTIONS  TO   COMBAT  PRESCRIPTION  DRUG  ABUSE  &   OVERDOSE  Jennifer Frazier, MPHOffice of the National Coordinator for Health InformationTechnologyJinhee Lee, PharmDSubstance Abuse and Mental Health ServicesAdministration
  • 5. Outline  •  PDMPs:  The  Context  •  SAMHSA  PDMP  RFA  •  ONC-­‐SAMHSA  Project  –Phase  I  •  ONC-­‐SAMHSA  Project  –Phase  II  •  Next  Steps  
  • 6. 1.  PDMPS:  THE  CONTEXT  
  • 7. 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    
  • 8. Past  Month  Illicit  Drug  Use  among  Persons     Aged  12  or  Older:  2011   Illicit  Drugs  1   22.5   (8.7%)   Marijuana   18.1   (7.0%)   PsychotherapeuXcs   6.1   (2.4%)   Cocaine   1.4   (0.5%)   Hallucinogens   1.0   (0.4%)   Inhalants   0.6   (0.2%)   Heroin   0.3   (0.1%)   0   5   10   15   20   25   Numbers  in  Millions  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  
  • 9. Past  Year  IniXates  of  Specific  Illicit  Drugs  among  Persons   Aged  12  or  Older:  2011     Numbers  in  Thousands   3,000   2,617   2,500   2,000   1,888   1,500   1,204   1,000   922   719   670   670   500   358   178   159   48   0   Pain  Relievers   Ecstasy   Cocaine   LSD   SedaXves   Marijuana   Tranquilizers   Inhalants   SXmulants   Heroin   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  
  • 10. Received  Most  Recent  Treatment  in  the  Past  Year  for  the  Use  of  Pain   Relievers  among  Persons  Aged  12  or  Older:  2002-­‐2011   Numbers  in  Thousands   800    761      736      726     700    604     600    547      565     500    466+      415+      424+     400    360+     300   200   100   0   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  
  • 11. 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  
  • 12. 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  
  • 13. 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  
  • 14. 2.  SAMHSA  PDMP  GRANT  PROGRAM  
  • 15. 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  
  • 16. Enhancing  Access  to  Prescrip<on  Drug  Monitoring  Programs  3.  ONC/SAMHSA  PROJECT:  PHASE  1  
  • 17. The  Story  So  Far   Federal & State Partners Action Plan State Participants Stakeholders White  House  Roundtable  on   Health  IT    &  PrescripXon   Drug  Abuse   Organizations June  3,  2011  
  • 18. 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  
  • 19. Project  Structure  and  Objec7ves   Improve  clinician   workflow  by  connecXng   Provide  recommenda7ons   PDMPs  to  health  IT   and  pilot  input   Support  Xmely   decision-­‐making  at  the   point  of  care   Test  the  feasibility   Establish  standards  for   of  using  health  IT  to   facilita7ng  informa7on   enhance  PDMP  access   exchange   Reduce  prescrip<on  drug  misuse  and  overdose  in  the  United  States   19  
  • 20. PDMP  Impediments   Low  Usage  Emergency  Department   Prescriber   Limita7ons  on  Authorized  Users   Current    Processes      Do  Not  Support     Clinical    Workflows  Ambulatory  Prescriber   Low    Technical    Maturity    to  Support     Interoperability   Lack  of  Business  Agreements   Dispenser  
  • 21. Work  Groups  Number/Name   Purpose  1:  Data  Content  and   To  determine  the  data  content  and  vocabulary  necessary  to  support  data  exchange  Vocabulary   between  Prescrip7on  Drug  Monitoring  Programs  (PDMP)  and  recipients.  2:  Informa7on  Usability  and   To  determine  how  PDMP  informa7on  will  be  presented  in  the  user  interfaces  for  Presenta7on   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   To  explore  and  develop  the  technical  specifica7ons  for  data  transmission  (e.g.,  REST,  Architecture   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   To  analyze  the  current  business  environment  relevant  to  the  use  of  intermediaries  Intermediaries       (e.g.,  Switches,  HIEs)  to  route  transmissions  between  PDMPs  and  data  recipients.   21  
  • 22. Work  Group  Recommenda7ons   Summary   PEOPLE   DATA   AGREEMENTS   Automate/streamline   registra7on  process   Standard  set  of  data   Business  Agreements  Expand  authorized  user  pool   Adopt  data  exchange   Business  Associate   standard  (NIEM-­‐PMP)   Agreements   Appoint  delegates   Increase  protec7on   Real-­‐7me  transmission   USEFULLNESS   INTEGRATION   Info  for  clinical  decisions   Integrate  access  with  EHR   Workflow-­‐based   System-­‐level  access   Improve  unsolicited   Standardize  PDMP   repor7ng   interfaces   48  Findings  and  11  Products  
  • 23. Pilot  States  and  Summary   23  
  • 24. Pilot  States  and  Summary   Automated  query  to  PDMP  upon  Indiana   Emergency   pa7ent  admission  to  ED     Automated  query  and  response,   (IN1)   Department   streamlined  workflow  for  physicians   PDMP  data  integrated  into  EHR   Indiana   Safer,  more  secure  transmission  of   Provider     Unsolicited  PDMP  reports  sent  via  Direct   (IN2)   unsolicited  reports  
  • 25. Pilot  States  and  Summary  (cont.)   Automated  query  to  PDMP  to  create  Michigan   Provider     integrated  prescrip7on  history  and   Partnered  with  e-­‐prescribing   (MI)   alerts   Automated  query  to  PDMP  using  an   North   exis7ng  benefits  management  switch   Leveraged  exis7ng  benefits   Dakota   Pharmacy   and  return  results  to  Indian  Health   transmission  technology     (ND)   Service  pharmacy    
  • 26. Pilot  States  and  Summary  (cont.)   Automated  query  to  PDMP  upon   appointment  scheduling  and  pa7ent   Automated  query  and  response,  Ohio  (OH)   Provider   check-­‐in;  pa7ent  risk  score  displayed  in   streamlined  workflow  for  physicians   EHR   Opioid   Washington   Treatment   Hyperlink  to  PDMP  within  EHR   Streamlined  access  to  PDMP   (WA)   Program  
  • 27. Pilot  Results    Immediate improvement to the In their own words… patient care process after   “I have to say that this is probably one of the more genius moves of the 21st century . . . connection 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  Streamlined the user workflows decision making for me.” by leveraging technology to –  Emergency Department Physician enable PDMP query and processing tasks.   “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  Prescribers and dispensers were (this was very time consuming and the most satisfied with their new sometimes prevented me from looking up the information in the past).” workflows when technology –  Ambulatory Family Physician automated the majority of workflow tasks.
  • 28. Enhancing  Access  to  Prescrip<on  Drug  Monitoring  Programs  4.  ONC/SAMHSA  PROJECT:  PHASE  2  
  • 29. Phase 2 Overview   EQUIP   Pilots  LEARN   Technology  Framework   CHANGE  From  Phase  I     By  empowering  others   Share  the  News   Build  the   Evolve  the   community   vision  29  
  • 30. Phase 2 Pilots - Overview State   End  User   Pilot  Summary   •  Automated  query  via  intermediary  and  interstate  hub  to  PDMP  upon  pa7ent   Emergency   Illinois   admission  to  ED   Department   •  PDMP  data  integrated  into  EHR  as  a  PDF  via  a  Direct  message   Emergency   •  Automated  query  via  HIE  to  mul7ple  states’  PDMPs  upon  pa7ent  admission  to  ED   Indiana   Department   •  Pa7ent  risk  score  and  PDMP  data  integrated  into  EHR   Kansas   Providers   •  Unsolicited  report  of  at-­‐risk  pa7ents  sent  via  Direct  to  EHR-­‐integrated  mailboxes   •  Automated  query  via  e-­‐Prescribing  sopware  to  mul7ple  states’  PDMPs    and  result  Michigan   Providers   integrated  in  pa7ent’s  medica7on  history   •  Automated  query  via  HIE  to  PDMP  upon  pa7ent  admission  to  ED   Emergency  Nebraska   Department   •  Easy  access  to  PDMP  with  SSO   •  PDMP  data  integrated  into  EHR   •  Established  PDMP  access  directly  though  an  HIE   Emergency  Oklahoma   Department   •  Developed  a  SSO  from  the  EHR  through  the  HIE  to  the  PDMP   •  Alert  flag  represen7ng  the  PDMP  data   •  Real-­‐7me  repor7ng  of  dispensing  controlled  substance  data  to  the  PDMP  using  an  Tennessee   Pharmacy   exis7ng  network  
  • 31. Technical Framework
  • 32. PDMP S&I Community Focus/Scope Needs  for  standards  (data  format  and  content;  transport  and  security  protocols)   NCPDP  Script   Pharmacy EHR System EHR System EHR System ASAP   Data  Out   NCPDP   Telecom   Portal PDMP Provider   Switches Provider   Provider   NIEM-­‐PMP   NIEM-­‐PMP   Pharmacy PMPi / Benefits Mgmt RxCheck PDMP Other  State  PDMPs  
  • 33. Compelling Vision
  • 34. Articulating a Compelling Vision Evidence  and   Roadmaps   AnalyXcs   Workflows   Building  a  COMMUNITY  through   development  of  a  resource  center  that   includes:   User  Stories   Pilot  Progress   EducaXon   Tech  Development  
  • 35. Oklahoma & Indiana Videos  
  • 36. 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  
  • 37. 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.    
  • 38. 1. “Map Filter” Filter by interest: •  Federal Govt, Grants, PDMPS, etc "2. “Featured Contributors” “Tear drop” icons = •  Key PDMP players •  Pilot participants •  Others3. “Other Contributors” info “Small bubble” icons = •  State PDMP specific information •  FY2012 pilots
  • 39. “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
  • 40. 5.  NEXT  STEPS  
  • 41. 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  
  • 42. 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.  
  • 43. THANK  YOU.  
  • 44. The  Team   Jennifer  Frazier,  ONC,  Jennifer.Frazier@hhs.gov     Jinhee  Lee,  SAMHSA,  Jinhee.Lee@samhsa.hhs.gov     Kate  Tipping,  SAMHSA,  kate.7pping@samhsa.hhs.gov     Chris  Jones,  CDC,  cjones@cdc.gov     Cecelia  Spitznas,  ONDCP,   Cecelia_M_Spitznas@ondcp.eop.gov    Lisa  TuIerow,  MITRE,  ltuIerow@mitre.org    Jeffrey  Hammer,  MITRE,  jmhammer@mitre.org    
  • 45. Outreach  to  Prescribers     Who  Have  a  High  Number  of  Doctor/Pharmacy  Shopper  PaXents   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  • 46. Massachusejs  PrescripXon   Monitoring  Program   Massachusejs  Department  of  Public  Health   Bureau  of  Health  Care  Safety  and  Quality   Drug  Control  Program  
  • 47. Disclosure  Statement  •  All  presenters  for  this  session  have  disclosed   no  relevant,  real  or  apparent  personal  or   professional  financial  rela7onships.  
  • 48. OVERVIEW  •  MA  PMP  Background    •  Individual  (Pa7ent)  Level  Analysis  •  Electronic  Alerts  •  Prescriber  Level  Analysis  
  • 49. 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.  
  • 50. 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.  
  • 51. 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.  
  • 52. 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  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.    
  • 53. 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.  
  • 54. 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.  
  • 55.  Preliminary  Findings    cases:  n  =  84,  controls:  n  =  84  †  Sta<s<cally  significant  at  p  <  0.05  
  • 56. 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.  
  • 57. 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.  
  • 58. 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.  
  • 59. 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.  
  • 60. EXPANDED  ANALYSIS    Results  *Online  Users    -­‐  prescriber  must  have  conducted  a  minimum  of  one  pa7ent  search                                                                  since  being  enrolled  in  the  MA  Online  PMP.    
  • 61. EXPANDED  ANALYSIS   Results  •  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]).  
  • 62.  EXPANDED  ANALYSIS   Results  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.  
  • 63. EXPANDED  ANALYSIS     Results  •  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.  
  • 64. 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.  
  • 65. 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.
  • 66. CONTACT  INFORMATION  Len  Young  MA  Department  of  Public  Health  Drug  Control  Program  Phone:  617-­‐983-­‐6705  Email:  leonard.young@state.ma.us  
  • 67. PDMP  Powerful  Tool  for  MulXple   ModaliXes   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  • 68. Learning  Objec7ves  Imbue  PDMP  colleagues  with  the  noXon  we  can  and   should  do  much  more.  
  • 69. Disclosure  Statement  This  presenter  reports  no  relevant  financial  interests.      
  • 70. “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
  • 71. 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  
  • 72. The  9/11  Commission’s  boIom-­‐line   recommenda7on  was  for  a…   Unity  of  Effort  
  • 73. One  fight,  one  team.  
  • 74. 2,390  Pearl  Harbor  Deaths   2,973  9/11Deaths   hIp://www.cbsnews.com/2100-­‐224_162-­‐2035427.html  
  • 75. >15,500  PrescripXon  Painkiller   Overdose  Deaths     CY  2009   hIp://www.cdc.gov/vitalsigns/MethadoneOverdoses/  
  • 76. Current  PDMP  Systems  PDMPs  serve  the  public  health  and  the  public  safety.  
  • 77. Current  PDMP  Systems  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.)
  • 78. Current  PDMP  Systems  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  
  • 79. Current  PDMP  Systems    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.  
  • 80. Current  PDMP  Systems  Many  states  presently  limit  law  enforcement  PDMP  queries  to  a  single  name/date  of  birth  search  with  and  only  with  an  acXve  case  number.  
  • 81. 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.    
  • 82. 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  
  • 83. HIPAA  Privacy  and  Security  Rules  Covered  EnXXes   A  Health  Care  Provider   A  Health  Plan    A  Health  Care     Clearinghouse   This  includes  providers     This  includes:   such  as:   This  includes  en77es        Doctors      Health  insurance     that  process        Clinics              companies   nonstandard  health        Psychologists     informa7on  they        Den7sts      HMOs   receive  from  another      Chiropractors   en7ty    into  a  standard        Nursing  Homes      Company  health  plans   (i.e.,  standard  electronic        Pharmacies   format  or  data  content),        Government  programs     or  vice  versa.   ...but  only  if  they  transmit        that  pay  for  health  care,     any    informa7on  in  an        such  as  Medicare,     electronic  form  in  connec7on  with   edicaid,  and  the        M a  transac7on  for  which        military  and  veterans     HHS  has  adopted  a  standard.      health  care  programs  www.hhs.gov/ocr/privacy/hipaa/understanding/covereden==es/index.html  
  • 84. Entities not required to comply with HIPAA’s Privacy andSecurity 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 Officeshttp://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
  • 85. Two  major  law  enforcement  operaXonal  objecXves:   1.     Discern  Crime   2.     InvesXgate  Crime  
  • 86. InformaXon-­‐led  policing   discerns  crime.   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.” Atlan=c  Monthly,  March  1982  
  • 87. 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  
  • 88. 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  
  • 89. 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  
  • 90. One  fight,  one  team.  
  • 91. 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.    
  • 92. 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.  
  • 93. IntegraXon  /  InteroperaXon  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.  
  • 94. 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.  
  • 95. 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  
  • 96. 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.”  
  • 97. 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.    
  • 98. 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.  
  • 99. 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.  
  • 100. 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.    
  • 101. One  fight,  one  team.   Thank  You!