Pdmp 5 hopkins dreyzehner_o_leary

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PDMP: Lessons Learned From Mandating Prescriber Compliance - Dr. John Dreyzehner, David Hopkins and Terence O'Leary

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Pdmp 5 hopkins dreyzehner_o_leary

  1. 1. PDMP  Track:  Lessons  Learned  From   Manda3ng  Prescriber  Compliance     David  Hopkins,  KASPER  Program  Manager,  Office  of  Inspector  General,   Kentucky  Cabinet  for  Health  and  Family  Services   John  J.  Dreyzehner,  MD,  MPH,  Commissioner,   Tennessee  Department  of  Health   Terence  O’Leary,  Director,  Bureau  of  NarcoOcs  Enforcement,   New  York  State  Department  of  Health     Moderator:    John  L.  Eadie,  Director,  PrescripOon  Drug  Monitoring   Program  Center  of  Excellence,  Brandeis  University    
  2. 2. Disclosures   •  David  Hopkins  has  disclosed  no  relevant,  real   or  apparent  personal  or  professional  financial   relaOonships.   •  John  J.  Dreyzehner  has  disclosed  no  relevant,   real  or  apparent  personal  or  professional   financial  relaOonships.   •  Terence  O’Leary  has  disclosed  no  relevant,  real   or  apparent  personal  or  professional  financial   relaOonships.  
  3. 3. Learning  ObjecOves   1.  Demonstrate  the  strategies  in  mulOple  states   that  are  effecOve  in  reducing  diversion  of   controlled  substances.     2.  Judge  outcomes  from  mulOple  states   following  their  decision  to  mandate   prescriber  compliance  of  PDMP  data.     3.  Assemble  tools  for  prescribers  and  dispensers   to  incorporate  uOlizing  PDMP  data  into  their   pracOce.  
  4. 4. Mandatory Prescriber Use of the Kentucky All Schedule Prescription Electronic Reporting System (KASPER) David Hopkins KASPER Program Manager Office of Inspector General Kentucky Cabinet for Health and Family Services
  5. 5. Agenda •  Background •  Kentucky’s Mandatory KASPER Registration and Usage Legislation –  2012 House Bill 1 –  2013 House Bill 217 •  Implementation Challenges •  Results
  6. 6. Background
  7. 7. The Political Climate •  Opioid abuse a national epidemic •  Controlled substance misuse and abuse on the rise in Kentucky •  Opioid overdose deaths on the rise in Kentucky •  Legislators viewing medical community as not addressing the problem
  8. 8. Cabinet  for  Health  and  Family   Services   Prescription Drug Abuse in Kentucky •  6.6% of Kentuckians (ages 12+) reported using prescription pain relievers for nonmedical reasons in past year. (KY tied for second in nation) – National average = 4.9% •  Kentucky prescription opioid pain reliever overdose death rate was 17.9 per 100,000 of population (KY ranked sixth in the nation) – National average was 11.9 per 100,000 of population Source:  Data  from  the  2007,  2008  and  2009  NaOonal  Surveys  on  Drug  Use  and  Health,  published  by  the   U.S.  Substance  Abuse  and  Mental  Health  Services  AdministraOon  (SAMHSA),  Center  for  Behavioral   StaOsOcs  and  Quality.  
  9. 9. KASPER Usage December 31, 2011 Law Enforcement = 1.5% (13% of KY LE had accounts) Prescribers = 94.9% (32% of KY prescribers had accounts) Pharmacists = 3.5% (26% of KY pharmacists had accounts) Judges, Other = .1%
  10. 10. Kentucky’s Mandatory KASPER Registration and Usage Legislation 2012 House Bill 1 2013 House Bill 217
  11. 11. Cabinet  for  Health  and  Family   Services   KASPER Reporting KRS 218A.202 •  Controlled substance administration or dispensing must be reported within one day effective July 1, 2013
  12. 12. Cabinet  for  Health  and  Family   Services   KASPER Accounts – KRS 218A.202 •  KASPER registration is mandatory for Kentucky practitioners or pharmacists authorized to prescribe or dispense controlled substances to humans.
  13. 13. Cabinet  for  Health  and  Family   Services   KASPER Prescriber Usage - KRS 218A.172 •  Query KASPER for previous 12 months of data: –  Prior to initial prescribing or dispensing of a Schedule II controlled substance, or a Schedule III controlled substance containing hydrocodone –  No less than every three months –  Review data before issuing a new prescription or refills for a Schedule II controlled substance or a Schedule III controlled substance containing hydrocodone •  Additional rules/exceptions included in licensure board regulations
  14. 14. KASPER Regulations – Licensure Boards •  201 KAR 5:130 –  Kentucky Board of Optometric Examiners KASPER requirements •  201 KAR 8:540 –  Kentucky Board of Dentistry KASPER requirements •  201 KAR 9:260 –  Kentucky Board of Medical Licensure KASPER requirements •  201 KAR 20:057 –  Kentucky Board of Nursing KASPER requirements •  201 KAR 25:090 –  Kentucky Board of Podiatry KASPER requirements. JusOce  &  Public  Safety  Cabinet  
  15. 15. Exceptions •  After surgery •  Patients in hospitals and long term care facilities – Hospitals and long term care facilities can establish facility accounts and request reports on behalf of the facility •  Patients in Hospice care or being treated for cancer pain •  Single doses of anxiety medicine prior to a procedure •  As a substitute within 7 days of initial prescribing JusOce  &  Public  Safety  Cabinet  
  16. 16. Implementation Challenges
  17. 17. User Registration •  Implemented temporary paperless registration process •  Increased administrative staff to handle emails and calls – Went from one to three administrative staff – Engaged four temps JusOce  &  Public  Safety  Cabinet  
  18. 18. Cabinet for Health and Family Services KASPER Master Accounts 12/31/2011   04/24/2012   07/20/2012   02/24/2014   Doctor*   5,470              5,680            11,923            17,807     APRN   690                    781                1,523                2,150     Pharmacist   1,385              1,450                3,602                5,363     Total   7,545              7,911            17,048            25,320     *Includes  physicians,  denOsts,  optometrists  and  podiatrists  
  19. 19. Technology •  Less than three months to prepare – Had to rely on existing system capacity •  Initial system outages •  Increased technology Help Desk staff from one to four •  Created web-based KASPER tutorial JusOce  &  Public  Safety  Cabinet  
  20. 20. Cabinet  for  Health  and  Family   Services   KASPER Reports
  21. 21. Policy •  Complexity of 2012 licensure board regulations – Simplified in 2013 •  Confusion on who to contact with questions/issues – KASPER – Licensure Boards •  Proliferation of misinformation •  HB1 Legislative Oversight Committee JusOce  &  Public  Safety  Cabinet  
  22. 22. Results
  23. 23. Cabinet for Health and Family Services Controlled Substance Dispensing – One Year Comparison Drug   August  2011   through   July  2012   August  2012   through   July  2013   Change   Hydrocodone        239,037,354          214,349,392     -­‐10.3%   Oxycodone            87,090,503              77,022,586     -­‐11.6%   Oxymorphone                1,753,231                  1,138,817     -­‐  35.0%   Alprazolam            71,669,411              62,088,568     -­‐13.4%   Methylphenidate            10,659,840              11,454,025     +  7.5%   Amphetamine            13,795,147              15,065,833     +  9.2%   All  Controlled   Substances        739,263,679          676,303,581     -­‐8.5%   Figures  shown  in  doses  dispensed  
  24. 24. Cabinet  for  Health  and  Family   Services  
  25. 25. Cabinet  for  Health  and  Family   Services  
  26. 26. Cabinet  for  Health  and  Family   Services  
  27. 27. Cabinet  for  Health  and  Family   Services  
  28. 28. Cabinet  for  Health  and  Family   Services  
  29. 29. Cabinet  for  Health  and  Family   Services  
  30. 30. Cabinet  for  Health  and  Family   Services  
  31. 31. Cabinet  for  Health  and  Family   Services   House Bill 1 Impact Study •  Comprehensive assessment of HB1’s impact on patients, prescribers, and other stakeholders •  Overall goals: –  Evaluate the impact of HB1 on reducing prescription drug abuse and diversion in Kentucky –  Identify unintended consequences associated with implementation of HB1 that impact patients, providers and citizens of the Commonwealth –  Develop recommendations to improve effectiveness of HB1 and mitigate identified unintended consequences •  Final study report planned for 3Q 2014
  32. 32. David R. Hopkins Kentucky Cabinet for Health and Family Services 502-564-2815 ext. 3333 Dave.Hopkins@ky.gov
  33. 33. John  J.  Dreyzehner   MD,  MPH,  FACOEM   MANDATED  PDMP  USE   A  Collaborative  Journey  in   Tennessee   John  J.  Dreyzehner,  MD,  MPH   Commissioner     Tennessee  Department  of  Health  
  34. 34. Overview:  Lessons  Learned  in  TN   1.  As PDMP queries go up, doctor shopping goes down. 2.  Partner with prescribers to establish mandated PDMP checking. 3.  PDMP checking leads to more conversations about Rx drug abuse and referrals to treatment. 4.  Mandated PDMP checking is leading to a plateau in MME 5.  Trilateral approach of PDMP will aid fight against heroin epidemic 34  
  35. 35. Defining  Terms   •  PDMP = Prescription Drug Monitoring Program •  CSMD = Controlled Substance Monitoring Database, Tennessee’s PDMP •  MME = Milligrams of Morphine Equivalent, a standard approach to measuring the total value of opiates prescribed and dispensed 35  
  36. 36. Lesson learned: Lives get saved. Fewer addictions. As  PDMP  queries  go  up,   doctor  shopping  goes  down   36  
  37. 37. More  CSMD  Queries,  Fewer  Doctor  Shoppers   0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 2010 2011 2012 2013 HighUtilizationPatients PatientRequests(inMillions) Number of Searches Made by Prescibers, Dispensers, and Delegates High Utilization Patients: Patients filled 5 or more prescriptions with different DEA Prescribers at 5 or more different DEA dispensers within 90 days. Source: Tennessee Department of Health Internal Files, February 2014 37  
  38. 38. Results  from  Prescriber  Survey   Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses Q6: Answered: 769 Skipped: 3738  
  39. 39. Lesson learned: Engage prescribers to make them partners in mandating PDMP checking. Prescribers  do  not  check  the   PDMP  in  large  numbers  until  it’s   mandated.   39  
  40. 40. 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 CSMD Searches by Delegates CSMD Searches by Prescibers Mandating  CSMD  Checking  Resulted  in  More  Queries   Source: Tennessee Department of Health Internal Files, February 2014 Mandated checking began April 1, 2013 Mandated registration began Jan. 1, 2013 40  
  41. 41. Leveraging  Technology  to  Promote  Collaboration   •  Easy to see current MME calculation on patient report •  Linkage of APN and PA accounts to supervising physician to enhance supervision of prescribing practices •  Near real-time reporting pilot program by pharmacies •  Easy access to interstate data sharing 41  
  42. 42. Leveraging  Technology  to  Promote  Collaboration   •  Color-coded risk icons on patient report for: –  Pharmacy Shopper –  Doctor Shopper –  High MME Dose •  Automated username and password retrieval •  Batch requests for high-volume clinics 42  
  43. 43. Turning  Data  Into  Information  Helps   •  Comparison to peers by specialty –  Dynamic report with trend capabilities –  Accessible at any time by prescribers •  High risk models in development –  High risk patient –  High risk prescriber –  High risk dispenser 43  
  44. 44. Turning  Data  Into  Information  Helps   •  Push reports –  Upon login to the PDMP, prescriber’s patients who meet risk thresholds are visible on the main screen –  Prescriber then acknowledges viewing the patient alert
  45. 45. Ask  End  Users  How  They  Feel   •  Survey asked for specific improvements –  11 were implemented within first year •  Regional forums were held with feedback •  Examples of end user suggested improvements include: –  Supervising physician capability to audit mid-level providers –  Automated username and password retrieval –  Batch request capability –  Enhanced graphics on patient report 45  
  46. 46. Lesson learned: Our PDMP is causing conversations that may have a long- term beneficial impact. Prescribers  using  the  PDMP  are  more   likely  to  discus  substance  abuse  with   patients  and  refer  to  treatment.   46  
  47. 47. Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses Q3: Answered: 766 Skipped: 4047   Results  from  Prescriber  Survey  
  48. 48. Results  from  Prescriber  Survey   Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses Q4: Answered: 768 Skipped: 3848  
  49. 49. Results  from  Prescriber  Survey   Source: June 2013 End-User Survey Regarding CSMD, 805 Total Responses Q5: Answered: 765 Skipped: 4149  
  50. 50. Lesson [hopefully] being learned: In other states, decreasing MME has been associated with a drop in overdose deaths. In  TN  our  PDMP  is  very  important   in  achieving  a  plateau  in  MME     (Morphine  Milligram  Equivalents)   50  
  51. 51. Morphine  Milligram  Equivalents  (MME)  Dispensed   and  Reported  to  TN  CSMD,  2010-­‐2013   8.2 8.4 8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0 2010 2011 2012 2013 MMEinBillions MME Reported by Newly Reporting Dispensers MME Reported by All Other Sources 2013 = First year of data from newly reporting dispensers Source: Tennessee Department of Health Internal Files, February 2014 51  
  52. 52. Slowing  the  Growth  of  Controlled   Substances  Prescribed  in  TN   Year Rx’s Per Capita (TN Rank – lower is better) Percent Change in Filled Rx’s from Previous Year (TN Rank – lower is better) 2008 TN: 0.53/person (4) US: 0.39/person N/A 2012 TN: 0.64/person (2) US: 0.41/person TN: 7.4% (23) US: 7.0% 2013 TN: 0.68/person (2) US: 0.42/person TN: 0.3% (31) US: 0.7% C-II Controlled Substances Source: IMS Health, Inc. 52  
  53. 53. Lesson learned: Success is found by focusing trilaterally on treatment, control, and prevention. All  partners  must  work  together   to  constrain  the  market  on  opiate   addiction.   53  
  54. 54. Supply  and  Demand:  The  Substance  Abuse/Misuse   Market  Triangle   54  
  55. 55. Substance  Abuse/Misuse:  Constraining  the  Market   PDMP Addresses All Three 55  
  56. 56. Summary:  Lessons  Learned  in  TN   1.  As PDMP queries go up, doctor shopping goes down. 2.  Partner with prescribers to establish mandated PDMP checking. 3.  PDMP checking leads to more conversations about Rx drug abuse and referrals to treatment. 4.  Mandated PDMP checking is—in our opinion— leading to plateau in MME 5.  Trilateral approach of PDMP will aid fight against heroin epidemic 56  
  57. 57. Thank  You  
  58. 58. New  York’s  Prescrip3on  Drug  Reform  Act   Part  A:  I-­‐STOP      (Internet  System  to  Track  Over-­‐Prescribing)   Part  B:  Electronic  Prescribing   Part  C:  Schedule  Changes   Part  D:  Work  Group   Part  E:  Safe  Disposal  Program  
  59. 59. I-­‐STOP   • Required  NYS  Department  of  Health  to   update  exisOng  PMP   • Requires  more  Omely  data     • Makes  addiOonal  data  available   • Allows  informaOon  to  be  shared  with   addiOonal  appropriate  enOOes   • Requires  consultaOon  of  the  PMP  Registry  
  60. 60. PracOOoners  are  required  to  consult  the   registry  in  most  cases  prior  to  prescribing   or  dispensing  any  controlled  substance   listed  in  Schedule  II,  III,  or  IV.     ExcepOons  are  limited  to  specific   circumstances  or  a  waiver  granted  by   Department  of  Health.   Duty  to  Consult  
  61. 61. As  part  of  I-­‐STOP  legislaOon,  the  Ome  frame  for   dispensers  to  submit  data  changed  from  once  a   month  to  within  24  hours  from  when  the  prescripOon   was  dispensed.     To  help  facilitate  Omely  reporOng  New  York   implemented  a  new  PMP  Data  CollecOon  Tool   To  increase  accuracy  of  data,  the  number  of  criOcal   error  fields  were  expanded.   Data  Collec3on  
  62. 62. Why  can’t  I  find  my  paOent’s  data  in  the  PMP?   Data  entry/submission  error,  record  is  awaiOng  correcOon,  incorrect   search  terms  were  entered,  prescripOon  was  filled  out-­‐of-­‐state   Why  is  the  prescriber  informaOon  is  incorrect?   Usually  a  data  entry  error.       Isn’t  this  law  a  violaOon  of  HIPAA?   Nope.       Common  Ques3ons  from  Prac33oners  
  63. 63. My  doctor  charges  me  $5  to  check  PMP;   My  doctor  said  I-­‐STOP  requires  me  to  come  into  the   office  every  month  to  pick  up  my  prescripOon.   My  doctor  said  the  Department  of  Health  has  red-­‐ flagged  me  and  won’t  let  him/her  prescribe  any   medicaOons  to  me.   Isn’t  this  law  a  violaOon  of  HIPAA?   Common  Complaints  from  Pa3ents  
  64. 64. Beginning  on  March  27,  2015,  all  prescripOons  in  New   York  State  must  be  transmired  electronically.   ExcepOons  include     •  power  failure;   •  paOent  safety  ;   •  PracOOoners  who  have  received  a  waiver  from   the  Department  of  Health  based  upon  a   showing  of  technological  limitaOon  outside  of   his/her  control  or  other  excepOonal   circumstances.       Electronic  Prescribing  
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