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, MPHOffice of the National Coordinator for Health InformationTechnologyJinhee Lee, PharmDSubstance Abuse and Mental Health ServicesAdministration
Outline • PDMPs: The Context • SAMHSA PDMP RFA • ONC-‐SAMHSA Project –Phase I • ONC-‐SAMHSA Project –Phase II • Next Steps
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 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
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
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
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
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 Federal & State Partners Action Plan State Participants Stakeholders White House Roundtable on Health IT & PrescripXon Drug Abuse Organizations June 3, 2011
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 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
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
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
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
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
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
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
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.
Enhancing Access to Prescrip<on Drug Monitoring Programs 4. ONC/SAMHSA PROJECT: PHASE 2
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
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
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
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
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 • Others3. “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
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.
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.
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.
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.
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]).
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.
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.
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: firstname.lastname@example.org
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.
Disclosure Statement 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
Current PDMP Systems PDMPs serve the public health and the public safety.
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.)
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
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.
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.
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
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
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
Two major law enforcement operaXonal objecXves: 1. Discern Crime 2. InvesXgate Crime
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
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.
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.
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.