Integra(ng	
  PDMP	
  Data	
  into	
  the	
  Clinical	
  Workflow	
  
Dr.	
  Jinhee	
  Lee	
  
Public	
  Health	
  Advisor,...
Disclosure Statement
•  Jinhee	
  Lee	
  has	
  no	
  financial	
  rela/onships	
  with	
  proprietary	
  en//es	
  that	
 ...
Objectives
•  Define	
  current	
  tools	
  that	
  are	
  in	
  place	
  for	
  prescribers	
  and	
  dispensers	
  to	
  ...
Over	
  prescribing	
  for	
  various	
  reasons……..	
  
Obj. 2 Evaluate effectiveness of current PDMP programs
to optimally manage patients……………………
in the clinical environment.	
...
Clarification of Acronyms
•  Controlled Substance Monitoring Database (CSMD)
•  Controlled Substance Monitoring Program (C...
Intent of PDMP
“Two intents depending on the origination of legislation and
the state of origination”
•  Practitioner driv...
Use of the PDMP
•  The PDMP database is a tool and NOT definitive evidence of a
crime!
•  The database should be used to p...
Two Major components of the PDMP
1.	
  	
  	
  	
  pa/ent	
  tracking	
  of	
  records	
  
	
  2.	
  	
  	
  prescriber	
 ...
Limitations
•  pa/ent	
  names-­‐spellings	
  
•  addresses	
  
•  date	
  of	
  birth	
  	
  
•  accurate	
  NDC	
  codes...
Basic Observations of the PDMP Report
•  early refills
•  multiple pharmacies – (be cautious, many patients swap pharmacie...
Sometimes more importantly…..
What’s	
  not	
  on	
  the	
  report!	
  
12	
  
What’s Not on the Report
•  prescriber	
  verbal	
  changes	
  
•  is	
  the	
  DEA	
  Valid?	
  
•  fixed	
  errors	
  
• ...
Optimizing PDMP Report Reviews:
Running the PDMP Report
•  In	
  todays	
  busy	
  medical	
  offices	
  and	
  community	
 ...
Strategies to consider
•  The	
  most	
  important	
  factor…..train	
  your	
  staff	
  on	
  how	
  to	
  run	
  
the	
  ...
Facilita(ng	
  Work	
  Flow	
  with	
  the	
  PDMP	
  Tool;	
  When	
  to	
  
Run	
  the	
  Report	
  
•  State	
  mandate...
Case Points:
Prescribers	
  /	
  pharmacists	
  should	
  not	
  spend	
  lots	
  of	
  /me	
  interpre/ng	
  	
  
“gray	
...
Evaluating the Printout
•  Pick	
  drug	
  
•  Note	
  QTY	
  
•  Note	
  Dates	
  
•  Note	
  Prescribers	
  
•  Note	
  ...
State XXX= BOARD OF PHARMACY – PATIENT PROFILE
Date 4/15/2012 Date of Birth 12-10-1966 Beginning Date: 04-01-11 =nbsp Endi...
Findings
•  Early	
  Refillers	
  	
  (professional	
  judgment	
  	
  vs.	
  negligence)	
  
•  Dr.	
  Shoppers	
  
•  Pa/...
Clarification, Verification and Documentation of
the Prescription or Whether to Even Prescribe
•  Calling the prescriber(s...
Findings and anomalies should lead to further questions by
the prescriber, pharmacist (not technician), or investigator
• ...
Key Considerations:
Prescribers	
  and	
  pharmacists	
  are	
  making	
  on	
  the	
  spot	
  	
  real	
  /me	
  “clinica...
Complications and Barriers……
•  Corporate	
  policies	
  and	
  procedures	
  
•  Lack	
  of	
  training	
  is	
  big	
  a...
Repor(ng	
  Clinical	
  Findings	
  
•  Law	
  Enforcement	
  
•  Prescribers	
  
•  Colleagues	
  
Case	
  2	
  
First	
  Name	
   Address	
   Zip	
   Fill	
  date	
   Rx	
  no.	
   Product	
  Name	
   Strength	
   Qty	
 ...
Summary
•  PDMP	
  is	
  an	
  amazing	
  and	
  evolving	
  tool!	
  
•  The	
  PDMP	
  is	
  NOT	
  evidence	
  of	
  a	...
Integra/ng	
  PDMP	
  Data	
  Into	
  the	
  
Clinical	
  Workflow	
  
Jinhee	
  Lee,	
  PharmD	
  
Division	
  of	
  Pharm...
Status of State
Prescription Drug Monitoring Programs (PDMPs)
AK
AL
AR
CA
CO
ID
IL IN
IA
MN
MO
MT
NE1
NV
ND
OH
OK
OR
TN
UT...
The	
  Story	
  So	
  Far	
  
Stakeholders
Organizations
White	
  House	
  
Roundtable	
  on	
  
Health	
  IT	
  	
  
&	
 ...
PDMP	
  Workflow	
  Today	
  	
  
and	
  in	
  the	
  Future	
  
•  PDMPs	
  today	
  
–  primarily	
  standalone	
  
syste...
Ac(on	
  Plan	
  Implementa(on	
  
•  SAMHSA	
  provided	
  funding	
  for	
  implementa/on	
  of	
  
the	
  Ac/on	
  Plan...
•  Goal:	
  Increase	
  /mely	
  access	
  to	
  PDMP	
  data	
  in	
  an	
  effort	
  to	
  
reduce	
  prescrip/on	
  drug...
Improve	
  clinician	
  
workflow	
  by	
  connec(ng	
  
PDMPs	
  to	
  health	
  IT	
  
Support	
  (mely	
  
decision-­‐ma...
Phase	
  1	
  Pilots:	
  Overview	
  	
  
36	
  
Phase 2 Pilots - Overview
State	
   End	
  User	
   Pilot	
  Summary	
  
Illinois	
  
Emergency	
  
Department	
  
•  Auto...
•  Enhancing	
  Access”	
  Pilot	
  White	
  Papers:	
  	
  Eight	
  papers	
  detailing	
  each	
  pilot’s	
  design,	
  ...
SAMHSA	
  -­‐	
  PDMP	
  EHR	
  Coopera(ve	
  Agreements	
  
•  FY	
  12	
  –	
  Provided	
  2	
  year	
  funding	
  for	
...
PDMP	
  EHR	
  Coopera(ve	
  Agreement	
  State	
  
Updates	
  
•  Illinois*	
  	
  
–  Currently	
  connected	
  to	
  An...
PDMP	
  EHR	
  Coopera(ve	
  Agreement	
  State	
  
Updates	
  (cont)	
  
•  Kansas*	
  
–  Integra/on	
  at	
  Via	
  Chr...
Now	
  and	
  Then	
  
Enhancing	
  Access	
  to	
  PDMPs	
  using	
  Health	
  IT	
  project	
  –	
  Phases	
  1	
  &	
  ...
PDMP	
  Ecosystem	
  
Pharmacy
PMPi /
RxCheck PDMP
Other	
  State	
  PDMPs	
  
NCPDP	
  Script	
  
PDMP
Portal
Switches
NC...
PDMP	
  Interoperability	
  Challenges	
  
•  One	
  of	
  the	
  current	
  technical	
  barriers	
  to	
  interoperabili...
45	
  
•  A	
  collabora/ve	
  community	
  of	
  par/cipants	
  from	
  the	
  public	
  and	
  
private	
  sectors	
  wh...
ONC Standards and Interoperability
(S&I) Framework Lifecycle
Our Missions
»  Promote a sustainable ecosystem that drives i...
PDMP	
  &	
  Health	
  IT	
  Integra(on	
  Ini(a(ve	
  
Purpose	
  &	
  Goals	
  
•  The	
  purpose	
  of	
  this	
  ini/a...
PDMP	
  &	
  Health	
  IT	
  Integra(on	
  Ini(a(ve	
  
Stakeholder	
  Community	
  
10%	
  
15%	
  
6%	
  
13%	
  
11%	
 ...
Phase	
   Planned	
  Ac(vi(es	
  	
  
Pre-­‐Discovery	
   •  Development	
  of	
  Ini/a/ve	
  Background	
  
•  Developmen...
50	
  
•  1.0	
  Preface	
  and	
  Introduc(on	
  
•  2.0	
  Ini(a(ve	
  Overview	
  
–  2.1	
  Ini/a/ve	
  Challenge	
  S...
While it is understood that there are various workflows that can take place when a
Healthcare Professional queries a PDMP ...
SDO	
  Ballo(ng,	
  RI	
  &	
  Pilots*	
  
Standards	
  &	
  
Harmoniza(on	
  Process	
  
The	
  Harmoniza/on	
  Process	
...
Standardiza(on	
  Development	
  &	
  
Harmoniza(on:	
  Workflow	
  
Outputs	
  
1.  Validate	
  candidate	
  
standards	
 ...
Harmoniza/on	
  Timeline	
  
Week	
  
Target	
  
Date	
  
(2014)	
  
All	
  Hands	
  WG	
  Mee(ng	
  Tasks	
  
Review	
  &...
PDMP Project Timeline
Kick-­‐off	
  	
  (11/14)	
  
Pre-­‐Discovery,	
  Call	
  for	
  
Par/cipa/on	
  
Jan	
  14	
  
June	...
Join	
  us!	
  	
  
•  The PDMP & Health IT Integration Initiative is open for anyone
to join
•  This community meets each...
PDMP	
  &	
  Health	
  IT	
  Integra(on	
  Ini(a(ve	
  
Resources	
  
57	
  
•  Initiative Wiki Homepage
–  http://wiki.si...
PDMP	
  &	
  Health	
  IT	
  Integra(on	
  Ini(a(ve	
  
Support	
  Leads	
  
•  For questions, please feel free to contact...
Thank	
  you!	
  
Jinhee	
  Lee,	
  PharmD	
  
jinhee.lee@samhsa.hhs.gov	
  
The findings and conclusions in this report a...
Pdmp 3 lee oneil
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Pdmp 3 lee oneil

  1. 1. Integra(ng  PDMP  Data  into  the  Clinical  Workflow   Dr.  Jinhee  Lee   Public  Health  Advisor,  Division  of  Pharmacologic  Therapies  Center,  Center  for  Substance   Abuse  Treatment,  Substance  Abuse  and  Mental  Health  Services   Dr.  Michael  O’Neil   Drug  Diversion  and  Substance  Abuse  Consultant   South  College  School  of  Pharmacy   RxSummit    2014  
  2. 2. Disclosure Statement •  Jinhee  Lee  has  no  financial  rela/onships  with  proprietary  en//es  that   produce  health  care  goods  and  services.   •  Michael  O’Neil  has  no  financial  rela/onships  with  proprietary  en//es  that   produce  health  care  goods  and  services.  
  3. 3. Objectives •  Define  current  tools  that  are  in  place  for  prescribers  and  dispensers  to                 incorporate  PDMPs  through  electronic  health  informa/on  sources.   •  Evaluate  effec/veness  of  current  PDMP  programs  to  op/mally  manage   pa/ents.   •  Outline  opportuni/es  to  enhance  the  access  and  effec/veness  of  PDMP   programs.   3  
  4. 4. Over  prescribing  for  various  reasons……..  
  5. 5. Obj. 2 Evaluate effectiveness of current PDMP programs to optimally manage patients…………………… in the clinical environment.   •  basic  clinical  applica/ons   •  limita/ons   •  prescriber  /  pharmacist  vs.  law  enforcement   approaches     •  example  cases  
  6. 6. Clarification of Acronyms •  Controlled Substance Monitoring Database (CSMD) •  Controlled Substance Monitoring Program (CSMP) •  Controlled Substance Monitoring Program Database (CSMPD) •  Prescription Monitoring Program (PMP) •  Controlled Substance Database (CSD) •  Prescription Drug Monitoring Program (PDMP) CSMD=CSMP = CSMPD = PMP = CSD = PDMP 6  
  7. 7. Intent of PDMP “Two intents depending on the origination of legislation and the state of origination” •  Practitioner driven with specified allowances to law enforcement / health professional boards •  Law enforcement driven with specified allowances for specific healthcare professionals •  The differences are BIG!!! 7  
  8. 8. Use of the PDMP •  The PDMP database is a tool and NOT definitive evidence of a crime! •  The database should be used to pose further questions to the patients, prescribers or law enforcement. •  “………then where does the crime come in?” 8  
  9. 9. Two Major components of the PDMP 1.        pa/ent  tracking  of  records    2.      prescriber  tracking  of  records    3.      surveillance  /  monitoring  /  Research   •   review  for  today  is  on  pa/ent  data   9  
  10. 10. Limitations •  pa/ent  names-­‐spellings   •  addresses   •  date  of  birth     •  accurate  NDC  codes   •  accurate  prescribers  /  accurate  pa/ents….legal  ramifica/ons   •  lazy  pharmacists  /  techs   •  reversing  errors  (reversing  transac/ons)   •  current  state  interfaces………GeVng  beWer!  But…….   •  diagnosis  unknown   •  error  accountability?   •  federal  data…..  VA  Medical  Centers?   •  repor/ng  should  go  where?   •  Internet  capabili/es  /  servers   10  
  11. 11. Basic Observations of the PDMP Report •  early refills •  multiple pharmacies – (be cautious, many patients swap pharmacies due to financial incentives for every prescription transferred) •  ?multiple doctors (sometimes hard to tell) -cross cover prescribers -prescription renewals -is it the same address? •  persistent or continued randomness of similar medications including escalating- deescalating doses, variation in products •  Combinations (Soma, Oxys, Xanax) Example: e.g. oxycodone, morphine, hydromorphone, oxymorphone (Indication?) 11  
  12. 12. Sometimes more importantly….. What’s  not  on  the  report!   12  
  13. 13. What’s Not on the Report •  prescriber  verbal  changes   •  is  the  DEA  Valid?   •  fixed  errors   •  controlled  substances  NOT  picked  up   •  wrong  entries   •  federal  prescrip/ons  (VA  Medical  centers),  data  waived   •  methadone  /  buprenorphine  under  federal  programs   13  
  14. 14. Optimizing PDMP Report Reviews: Running the PDMP Report •  In  todays  busy  medical  offices  and  community  pharmacies…..  unless  you   get  more  help…rarely  do  new  processes  actually  facilitate  workflow!   •  Individual  prescribers  and  pharmacist  should  have  their  “own”  access   codes.   •  Most  states  allow  sharing  of  access  codes  up  to  2-­‐3  individuals  (nurse   manager,  pharmacy  technician,  medical  assistant,  etc.)   •  As  pa/ent  records  are  pulled  by  assistants  for  appointments  or  technicians   for  filling  prescrip/ons.  “Flags”  should  be  part  of  the  assistants  /  techs   workflow  that  prompts  running  the  PDMP.  
  15. 15. Strategies to consider •  The  most  important  factor…..train  your  staff  on  how  to  run   the  report.  If  you  don’t  know….  learn.  Designate  staff!   •  Request  your  local/regional  professional  agencies  to  provide   CEs  as  part  of  PDMP  training.   •  At  LEAST  login  to  the  PDMP  rou/nely.              -­‐forgoWen  or  expired  passwords  cost  significant    loss  of  /me                -­‐familiarity  with  PDMP  formaVng  helps!  
  16. 16. Facilita(ng  Work  Flow  with  the  PDMP  Tool;  When  to   Run  the  Report   •  State  mandated  reports  (chronic  opioids  or  benzodiazepines),  opioids  >   than  3  months   •  Annually  with  chronic  controlled  substances?   •  The  report  does  not  need  to  be  run  for  every  pa/ent!                                    (unless  otherwise  mandated  by  the  state)   •  Flags:  new  pa/ents,  unknown  pa/ents,  pa/ents  that  travel  long  distances,   unusual  cocktail  prescrip/ons.   •  Recommended  to  go  back  At  LEAST  6months….1  year  is  usually  op/mal.  
  17. 17. Case Points: Prescribers  /  pharmacists  should  not  spend  lots  of  /me  interpre/ng     “gray  areas”.   •  Rarely  is  this  ever  about  1  or  2  prescrip/ons   •  Occasionally  “extra  scripts”   •  Den/sts,  ER  visits   •  Frequently  there  are  “clinically  relevant”  jus/fica/ons.              Clinical  judgment  is  frequently  warranted  and  reports  should                be  confirmed  via  phone  calls,  emails,  etc.   •  Prescribers  and  pharmacists  are  not  looking  for  subtle/es   Everyone  is  looking  at  trends  or  paYerns   18  
  18. 18. Evaluating the Printout •  Pick  drug   •  Note  QTY   •  Note  Dates   •  Note  Prescribers   •  Note  addresses   19  
  19. 19. State XXX= BOARD OF PHARMACY – PATIENT PROFILE Date 4/15/2012 Date of Birth 12-10-1966 Beginning Date: 04-01-11 =nbsp Ending Date: 04-15-12 First Name: MIKE Last Name: =OWEN First   Name   Address   Zip   Fill  date   Rx  no.   Product  Name   Strength   Qty   Doctor   Name   Doctor  Dea   Pharm   Name   Pharm  Dea   Ph  Zip   MIKE   319  LOWER   25526   4/2/2011   11222   APAP/HYDRO   500MG-­‐10 MG   180   SMITH  JOE   DH0267890   TOM’S   PHARM   GF1234567   25526   MIKE   319  LOWER   25526   5/3/2011   19976   APAP/HYDRO   500MG-­‐10 MG   180   SMITH  JOE   DH0267890   TOM’S   PHARM   GF1234567   25526   MIKE   319  LOWER   25526   5/27/2011   23466   APAP/HYDRO   500MG-­‐10 MG   180   SMITH  JOE   DH0267890   TOM’S   PHARM   GF1234567   25526   MIKE   319  LOWER   25526   6/4/2011   31111   APAP/HYDRO   500MG-­‐10 MG   180   SMITH  JOE   DH0267890   TOM’S   PHARM   GF1234567   25526   Case  1   1.  Early  Refill?   2.  How  many  days  of  medica/on?   3.  Change  of  prescriber?   20  
  20. 20. Findings •  Early  Refillers    (professional  judgment    vs.  negligence)   •  Dr.  Shoppers   •  Pa/ent  cocktails   •  Mul/ple  medica/ons  (polypharmacy)   •  Mul/ple  prescribers   •  Aberrant  paWerns  of  prescribing  medica/ons   •  Escala/on  of  doses  /  de-­‐escala/on  of  doses   •  Changes  in  medica/ons   •  Acute  medica/ons  and  Chronic  medica/ons   •  Disease  state  knowledge   Frequently  requires  clinical  judgment……..   21  
  21. 21. Clarification, Verification and Documentation of the Prescription or Whether to Even Prescribe •  Calling the prescriber(s) - validating patient - validating prescription - quantity - validating indication •  Questioning the patient - previous prescriptions - other practitioners - indication •  Documentation of the query / discussion / intervention 22  
  22. 22. Findings and anomalies should lead to further questions by the prescriber, pharmacist (not technician), or investigator •  When  was  last  refill  for  drug  X   •  Have  you  had  any  other  scripts  for    drug  X?   •  Indica/ons    for  drug  X  /  Hx?   •  Do  the  other  Drs  Know?   •  Distance  Travelled?   •  What  other  medica/ons  do  you  take…….where  are  they  filled?   •  OK  to  call  prescriber?   23  
  23. 23. Key Considerations: Prescribers  and  pharmacists  are  making  on  the  spot    real  /me  “clinical   decisions”  with  the  PDMP.  Law  enforcement  is  not.   Law  Enforcement  is  usually  accessing  the  PDMP  AFTER  some  report,   probable  cause  or  inves/ga/on  of  diversion,  etc.  has  been  reported.   Poor  PROFESSIONAL  judgment  by  a  prescriber  is  NOT  CRIMINAL!   So  prosecu/ons  are  very  difficult,  labor  intensive,  last  forever  and  costs  big   bucks…..open  have  minimum  outcome.   State  professional  boards  MUST  step  up  enforcement  for  professional   “misbehaviors”,  poor  prac/ces  and  errors.   24  
  24. 24. Complications and Barriers…… •  Corporate  policies  and  procedures   •  Lack  of  training  is  big  across  the  board!   •  Who  to  report  is  some/mes  confusing,  frustra/ng,  difficult   •  Manpower   •  $$$$$   •  …and  we  haven’t  even  seen  the  lawyers  yet…..   25  
  25. 25. Repor(ng  Clinical  Findings   •  Law  Enforcement   •  Prescribers   •  Colleagues  
  26. 26. Case  2   First  Name   Address   Zip   Fill  date   Rx  no.   Product  Name   Strength   Qty   Doctor  Name   Doctor  Dea   Pharm  Name   Pharm  Dea   Ph  Zip   MIKE   319  LOWER   25526   4/2/2011   11222   APAP/HYDRO   500MG-­‐10MG   180   SMITHJOE   0267890   TOM’S  PHARM   FT1234567   25526   MIKE   319  LOWER   25526   4/9/11   19986   Oxymorphone  ER   20MG     60   SMITH  JOE   CS0267890   TOM’S  PHARM   FT1234567   25526   MIKE   319  LOWER   25526   4/27/2011   23466   APAP/HYDRO   500MG-­‐10MG   180   SMITH  JOE   CS0267890   TOM’S  PHARM   FT1234567   25526   MIKE   319  LOWER   25526   5/4/2011   31111   Oxycodone  ER   40  MG   45   SMITH  JOE   CS0267890   TOM’S  PHARM   FT1234567   25526   MIKE   319  LOWER   25526   5/12/2011   44445   hydromorphone   4mg   80   JONES  BILL   CJ9839432   TOM’S  PHARM   FT1234567   25526   MIKE   319  LOWER   25526   5/9/11   59986   Oxymorphone  ER   20MG     60   SMITH  JOE   CS0267890   TOM’S  PHARM   FT1234567   25526   MIKE   319  LOWER   25526   5/23/2011   69976   APAP/HYDRO   500MG-­‐10MG   180   SMITH  JOE   CS0267890   TOM’S  PHARM   FT1234567   25526   MIKE   319  LOWER   25526   5/27/2011   23466   Morphine  sulf  liq     10mg/5ml   100   SMITHJOE   CS0267890   TOM’S  PHARM   FT1234567   25526   MIKE   319  LOWER   25526   5/4/2011   31111   Oxycodone  ER   40  MG   45   SMITH  JOE   CS0267890   TOM’S  PHARM   FT1234567   25526   27  
  27. 27. Summary •  PDMP  is  an  amazing  and  evolving  tool!   •  The  PDMP  is  NOT  evidence  of  a  crime!   •  Usually  involves  blatant,  repe//ve,  and  illegal  behaviors.   •  Flags  and  strategies  can  be  ini/ated  that  help  minimize   interrup/on  of  clinician’s  work  flow.   •  Enforcement  of  the  PDMP  is  also  s/ll  evolving   28  
  28. 28. Integra/ng  PDMP  Data  Into  the   Clinical  Workflow   Jinhee  Lee,  PharmD   Division  of  Pharmacologic  Therapies     Center  for  Substance  Abuse  Treatment   Substance  Abuse  and  Mental  Health  Services  Administra/on  
  29. 29. Status of State Prescription Drug Monitoring Programs (PDMPs) AK AL AR CA CO ID IL IN IA MN MO MT NE1 NV ND OH OK OR TN UT WA AZ SD NM VA WY MI GA KS HI TX ME MS WI NY PA LA KY NC SC FL NH MA RI CT NJ DE MD VT WV 1  The  opera/on  of  Nebraska’s  Prescrip/on  Monitoring  Program  is  currently  being  facilitated  through  the  state’s  Health  Informa/on  Ini/a/ve.    Par/cipa/on  by  pa/ents,   physicians,  and  other  health  care  providers  is  voluntary.   2  The  Mayor  of  D.C.  has  approved  the  legisla/on  but  it  is  pending  a  30-­‐day  review  process  by  Congress.   States with operational PDMPs States with enacted PDMP legislation, but program not yet operational States with legislation pending © 2014 The National Alliance for Model State Drug Laws (NAMSDL). Headquarters Office: 215 Lincoln Ave. Suite 201, Santa Fe, NM. 87501. This information was compiled using legal databases, state agency websites and direct communications with state PDMP representatives. D.C.2 30  
  30. 30. The  Story  So  Far   Stakeholders Organizations White  House   Roundtable  on   Health  IT     &  Prescrip(on   Drug  Abuse   June  3,  2011   Federal & State Partners State Participants Action Plan Slide  31  
  31. 31. PDMP  Workflow  Today     and  in  the  Future   •  PDMPs  today   –  primarily  standalone   systems   –  Separated  from  rest  of   health  IT  ecosystem     –  accessed  via  web  portals   –  Human-­‐centric  process   •  PDMPs  tomorrow   –  Integrated  with  other   health  IT  in  the  pa/ent   workflow   –  Machine-­‐centric  process   Page    32  
  32. 32. Ac(on  Plan  Implementa(on   •  SAMHSA  provided  funding  for  implementa/on  of   the  Ac/on  Plan  through  the  “Enhancing  Access  to   PDMPs  through  Health  IT  Project”.   – SAMHSA  partnered  with  ONC,  ONDCP,  &  the  CDC.   – ONC  has  management  oversight  of  the  effort.   Slide  33  
  33. 33. •  Goal:  Increase  /mely  access  to  PDMP  data  in  an  effort  to   reduce  prescrip/on  drug  misuse  and  overdoses.   –  Explore  ways  to  use  HIT  to  link  prescribers  and   dispensers  with  the  valuable  data  in  PDMPs.   –  Main  issue:  How  to  make  this  informa/on  more   available  to  three  key  groups  of  clinical  decision   makers:     Enhancing  Access  to  PDMPs   through  Health  IT  Project  
  34. 34. Improve  clinician   workflow  by  connec(ng   PDMPs  to  health  IT   Support  (mely   decision-­‐making  at  the   point  of  care   Establish  standards  for   facilita/ng  informa/on   exchange   Provide  recommenda/ons   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   Enhancing  Access  to  PDMPs   through  Health  IT  Project  
  35. 35. Phase  1  Pilots:  Overview     36  
  36. 36. Phase 2 Pilots - Overview State   End  User   Pilot  Summary   Illinois   Emergency   Department   •  Automated  query  via  intermediary  and  interstate  hub  to  PDMP  upon  pa/ent   admission  to  ED   •  PDMP  data  integrated  into  EHR  as  a  PDF  via  a  Direct  message   Indiana   Emergency   Department   •  Automated  query  via  HIE  to  mul/ple  states’  PDMPs  upon  pa/ent  admission  to  ED   •  Pa/ent  risk  score  and  PDMP  data  integrated  into  EHR   Kansas   Providers   •  Unsolicited  report  of  at-­‐risk  pa/ents  sent  via  Direct  to  EHR-­‐integrated  mailboxes   Michigan   Providers   •  Automated  query  via  e-­‐Prescribing  sopware  to  mul/ple  states’  PDMPs    and  result   integrated  in  pa/ent’s  medica/on  history   Nebraska   Emergency   Department   •  Automated  query  via  HIE  to  PDMP  upon  pa/ent  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  represen/ng  the  PDMP  data   Tennessee   Pharmacy   •  Real-­‐/me  repor/ng  of  dispensing  controlled  substance  data  to  the  PDMP  using  an   exis/ng  network   Slide  37  
  37. 37. •  Enhancing  Access”  Pilot  White  Papers:    Eight  papers  detailing  each  pilot’s  design,   technical  configura/on,  outcomes,  and  plans  for  expansion.    The  white  papers  also   highlight  various  personal  anecdotes  from  the  par/cipants  who  wrote  about  how  they   integrated  PDMP  data  into  their  clinical  workflow  and  the  success  it  had  on  their   prac/ce.   •  The  Road  to  Connec+vity:    A  roadmap  for  connec/ng  to  PDMPs  through  health  IT.   •  Work  Group  Recommenda+ons–Final  Report:    Stakeholders  iden/fied  challenges  and   recommended  solu/ons  to  increase  /mely  use  of  PDMP  data  by  clinicians.  More  than   94  people  across  53  organiza/ons  formed  work  groups  to  define  barriers  and  rapidly   finalize  recommenda/ons  to  address  the  problem.   •  Videos:  Pilot  par/cipants  detail  their  individual  baWles  against  prescrip/on  drug  abuse,   recalling  the  advantages  of  their  state’s  PDMP  including  real-­‐/me  repor/ng  and  how   they  used  health  IT  to  connect  clinicians  to  this  important  database.   •  PDMPConnect:  A  website  providing  a  forum  for  connec/ng  members  of  the  PDMP   community  to  share  valuable  experience,  informa/on,  and  resources  wherever  they   are.   **All  resources  available  at:  www.healthit.gov/pdmp   Enhancing  Access  to  PDMP  using   Health  IT     Phases  1&2:  Resources  
  38. 38. SAMHSA  -­‐  PDMP  EHR  Coopera(ve  Agreements   •  FY  12  –  Provided  2  year  funding  for  9  states:   FL,  IN,  IL,  KS,  ME,  OH,  TX,  WA,  WV   •  FY  13  –  Provides  2  year  funding  for  7  states:        KY,  MA,  ND,  NY,  RI,  SC,  WI   –  Purpose:    1)  Improve  real-­‐/me  access  to  PDMP  data  by  integra/ng   PDMPs  into  exis/ng  technologies  like  EHRs  (FY12,13)   2)    Strengthen  currently  opera/onal  state  PDMPs  by   increasing  interoperability  between  states    (FY12)   3)    Evaluate  whether  these  enhancements  have  an  impact  on   prescrip/on  drug  abuse  (FY12)   Slide  39  
  39. 39. PDMP  EHR  Coopera(ve  Agreement  State   Updates   •  Illinois*     –  Currently  connected  to  Anderson  Hospital.     •  Over  700  requests  per  week  to  IL  PMP   •  Requests  triggered  upon  pa/ent  presenta/on  or  admission  to  ER.   •  PMP  report  returned  and  presented  on  select  worksta/ons  in  the  ER  and  immediate  care   loca/ons   –  Plans  to  integrate  with  a  EMR  sopware  company  that  is  used  by  many   opioid  treatment  programs.   •  Tes/ng  to  begin  within  the  next  30  days   –  Plans  to  bring  another  hospital  online  within  the  quarter   –  Within  the  next  6  months,  three  hospitals  fully  implemented  and  five   hospitals  in  the  tes/ng  stage   •  West  Virginia   –  Planning  with  a  clinic,  hospital  and  the  West  Virginia  Health  Informa/on   Network  con/nues.     Slide  40   *Murzynski,  Stanley.  “Illinois  PMP  SAMHSA  Grantee  Mee/ng  on  Data  Integra/on.”  PowerPoint  presenta/on.  SAMHSA,  Rockville,  MD.  19  Feb  2014.  
  40. 40. PDMP  EHR  Coopera(ve  Agreement  State   Updates  (cont)   •  Kansas*   –  Integra/on  at  Via  Chris/  Hospital  fully  func/onal   •  K-­‐TRACS  is  integrated  into  the  physician’s  workflow   •  VC  currently  has  267  users  +   –  Integra/on  with  LACIE  (Lewis  And  Clark  Informa/on  Exchange)   •  Tes/ng  successfully  completed   •  Hospital  pilot  an/cipated  by  end  of  this  month   •  An/cipate  3-­‐4K  users  in  the  KC  metro   –  Integra/on  with  major  pharmacy  chain   •  Ohio**   –  Currently  integrated  into  the  EMR  of  22  hospitals  and  6  primary  care   prac/ces   –  Plans  to  expand  and  integrate  into  over  200  community  pharmacies,   addi/onal  hospitals,  and  15  ambulatory  clinics   Slide  41   *Singleton,  Marty.  “Kansas  PDMP  Status  Update.”  PowerPoint  presenta/on.  SAMHSA,  Rockville,  MD.  19  Feb  2014.   **Garner,  Chad.  “Bringing  Ohio’s  PMP  Into  the  Clinician  Workflow.”  PowerPoint  presenta/on.  CADCA,  Na/onal  Harbor,  MD.  4  Feb  2014.  
  41. 41. Now  and  Then   Enhancing  Access  to  PDMPs  using  Health  IT  project  –  Phases  1  &  2       •  September  2011  -­‐  March  2013   •  Pilots  demonstrated  proof  of  concept.     •  Various  non-­‐standard  approaches  were  also  used  that  need  to  be  refined  or  harmonized   with  the  exis/ng  porzolio  of  standards  and  implementa/on  specifica/ons.     •  Abbreviated  S&I  Ini/a/ve  (Jan  –  March  2013)     Did  not  iden/fy,  evaluate  and  harmonize  standards  for  the  exchange  of  informa/on  from   PDMP  to  EHRs  or  HIEs.     Valuable  feedback  from  stakeholders  but  only  iden/fied  where  standards  were  needed   and  the  poten/al  standards  that  could  be  used.   PDMP  &  Health  IT  Integra>on  Ini>a>ve  –  Phase  3   •  November  2013  –  TBD   •  Full  S&I  Framework  Ini/a/ve     •  Assess  the  current  PDMP  infrastructure  and  available  standards  that  could  be   harmonized  to  allow  interoperable  communica/ons  between  PDMPs  and  health  IT   systems.    
  42. 42. PDMP  Ecosystem   Pharmacy PMPi / RxCheck PDMP Other  State  PDMPs   NCPDP  Script   PDMP Portal 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)  
  43. 43. PDMP  Interoperability  Challenges   •  One  of  the  current  technical  barriers  to  interoperability  is  the   lack  of  standard  methods  to  exchange  and  integrate  the   prescrip/on  drug  data  available  in  PDMPs  into  health  IT   systems.     –  Lack  of  common  technical  standards  and  vocabularies  to   enable  PDMPs  to  share  computable  informa/on  with  the   EHR  that  providers  can  use  to  support  clinical  decision-­‐ making.     •  To  achieve  interoperability,  consistent  and  standardized   electronic  methods  need  to  be  established  to  enable  seamless   data  transmission  between  PDMPs  and  health  IT  systems.  
  44. 44. 45   •  A  collabora/ve  community  of  par/cipants  from  the  public  and   private  sectors  who  are  focused  on  providing  the  tools,   services  and  guidance  to  facilitate  the  func/onal  exchange  of   health  informa/on.     •  Creates  a  open  and  transparent  process  where  healthcare   stakeholders  can  focus  on  solving  real-­‐world  interoperability   challenges.     •  Is  a  consensus-­‐driven,  coordinated,  incremental  standards   process.     Each  S&I  Ini/a/ve  focuses  on  narrowly-­‐defined,  broadly  applicable   challenge,  tackled  through  a  rigorous  development  cycle,  and  provides   input  to  Federal  Advisory  CommiWees  for  considera/on.   The Standards & Interoperability (S&I) Framework:
  45. 45. ONC Standards and Interoperability (S&I) Framework Lifecycle Our Missions »  Promote a sustainable ecosystem that drives increasing interoperability and standards adoption. »  Create a collaborative, coordinated, incremental standards process that is led by the industry in solving real world problems. »  Leverage “government as a platform” – provide tools, coordination, and harmonization that will support interested parties as they develop solutions to interoperability and standards adoption. 46   Tools and Services Use Case Development and Functional Requirements Standards Development Support Certification and Testing Harmonization of Core Concepts Implementation Specifications Pilot Demonstration Projects Reference Implementation Architecture Refinement and Management
  46. 46. PDMP  &  Health  IT  Integra(on  Ini(a(ve   Purpose  &  Goals   •  The  purpose  of  this  ini/a/ve  is  to  bring  together  the  PDMP  and  health  IT   communi/es  to  standardize  the  data  format,  and  transport  and  security   protocols  to  exchange  pa/ent  informa/on  between  PDMPs  and  health  IT   systems  (e.g.,  EHRs  pharmacy  systems).   •  The  specific  goals  are:   –  Iden/fy  exis/ng  connec/ons  that  consume  PDMP.   –  Iden/fy,  evaluate,  and  harmonize  the  data  format(s)  sent  from  PDMPs  to  EHRs.   –  Evaluate  and  select  transport  protocol(s)  systems  support.   –  Evaluate  and  select  security  protocol(s)  systems  support.   –  Map  selected  health  IT  standards  to  standards  already  in  use  for  PDMP-­‐to-­‐PDMP   interstate  exchange.   •  The  results  of  this  work  would  enable  health  care  providers  to  make  more   informed  clinical  decisions  though  /mely  and  convenient  access  to  PDMP   data  in  an  effort  to  reduce  prescrip/on  drug  misuse  and  overdose  in  the   United  States.     47  
  47. 47. PDMP  &  Health  IT  Integra(on  Ini(a(ve   Stakeholder  Community   10%   15%   6%   13%   11%   45%   HIT/EHR,  Vendors/PHR  and   Associa/ons   Provider/Provider  Organiza/ons   SDOs/Analy/cs/Research   Federal/State/Local  Agencies   Other   State  PDMP/PMP/Or  Affiliate   48   •  This  is  an  open  government  ini/a/ve.  To  succeed,  the  S&I  Framework  works   with  a  set  of  mo/vated  organiza/ons  and  individuals  who  share  the  mission   and  goals  of  care  delivery  transforma/on  through  improved  interoperability.     Stakeholder  Par(cipa(on  by  Industry   (n=190)  
  48. 48. Phase   Planned  Ac(vi(es     Pre-­‐Discovery   •  Development  of  Ini/a/ve  Background   •  Development  of  Ini/a/ve  Charter   •  Defini/on  of  Goals  &  Ini/a/ve  Outcomes   Discovery     •  Crea/on/Valida/on  of  Use  Cases,  User  Stories  &  Func/onal  Requirements   •  Iden/fica/on  of  interoperability  gaps,  barriers,  obstacles  and  costs   •  Review  of  Vocabulary   Implementa(on   •  Crea/on  of  aligned  specifica/on     •  Documenta/on  of  relevant  specifica/ons  and  reference  implementa/ons  such  as   guides,  design  documents,  etc.   •  Valida/on  of  Vocabulary   •  Development  of  tes/ng  tools  and  reference  implementa/on  tools   Pilot   •  Valida/on  of  aligned  specifica/ons,  tes/ng  tools,  and  reference  implementa/on  tools   •  Revision  of  documenta/on  and  tools   Evalua(on   •  Measurement  of  ini/a/ve  success  against  goals  and  outcomes   •  Iden/fica/on  of  best  prac/ces  and  lessons  learned  from  pilots  for  wider  scale   deployment   •  Iden/fica/on  of  hard  and  sop  policy  tools  that  could  be  considered  for  wider  scale   deployments   S&I  Framework  Phases  &     PDMP  &  Health  IT  Integra/on  Ac/vi/es   49   We are Here
  49. 49. 50   •  1.0  Preface  and  Introduc(on   •  2.0  Ini(a(ve  Overview   –  2.1  Ini/a/ve  Challenge  Statement**   •  3.0  Use  Case  Scope   –  3.1  Background**   –  3.2  In  Scope   –  3.2  Out  of  Scope   –  3.3  Communi/es  of  Interest  (Stakeholders) **     •  4.0  Value  Statement**   •  5.0  Use  Case  Assump(ons   •  6.0  Pre-­‐Condi(ons   •  7.0  Post  Condi(ons   •  8.0  Actors  and  Roles   •  9.0  Use  Case  Diagram   PDMP  &  Health  IT  Integra(on  Ini(a(ve   Use  Case  Outline   •  10.0 Scenario: Workflow –  10.1 User Story 1, 2, x, … –  10.2 Activity Diagram o  10.2.1 Base Flow o  10.2.2 Alternate Flow (if needed) –  10.3 Functional Requirements o  10.3.1 Information Interchange Requirements o  10.3.2 System Requirements –  10.4 Sequence Diagram •  11.0 Dataset Requirements •  12.0 Risks, Issues and Obstacles •  Appendices –  Privacy and Security Considerations –  Related Use Cases –  Previous Work Efforts –  References ** Leverage content from Charter
  50. 50. While it is understood that there are various workflows that can take place when a Healthcare Professional queries a PDMP (see full context diagram), for the purposes of this use case, we will be focusing on the transactions originating from the HIT to the next end point, which would be the PDMP, a Hub, or HIE/Pharmacy Intermediary •  Scenario  #1  –  HIT  to  In-­‐State  PDMP   •  Scenario  #2  –  HIT  to  Hub   •  Scenario  #3  –  HIT  to  HIE/Pharmacy  Intermediary   EHR  or   Pharmacy   System   EHR  or   Pharmacy   System   Hub   EHR  or   Pharmacy   System   HIE/   Pharmacy   Intermediary   51   PDMP  &  Health  IT  Integra(on  Ini(a(ve   Use  Case  Scenarios  -­‐  examples  
  51. 51. SDO  Ballo(ng,  RI  &  Pilots*   Standards  &   Harmoniza(on  Process   The  Harmoniza/on  Process  provides  detailed  analysis   of  candidate  standards  to  determine  “fitness  for  use”   in  support  of  Ini/a/ve  func/onal  requirements.     The  resul/ng  technical  design,  gap  analysis    and   harmoniza/on  ac/vi/es  lead  to  the  evalua/on  and   selec/on  of  drap  standards.    These  standards  are   then  used  to  develop  the  real  world  implementa/on   guidance  via  an  Implementa/on  Guide  or  Technical   Specifica/on  which  are  then  validated  through   Reference    Implementa/on  (RI)  and  Pilots.     The  documented  gap  mi/ga/on  and  lessons  learned   from  the  RI  and  Pilot  efforts  are  then  incorporated   into  an  SDO-­‐balloted  ar/fact  to  be  proposed  as   implementa/on  guidance  for  Recommenda/on.   *Depending  on  the  ini>a>ve  the  SDO  Ballo>ng,  RI  &  Pilot  ac>vi>es  may  occur  prior  to  the  recommending  a  harmonized   standard,  this  also  means  that  ongoing  pilots  can  provide  feedback  to  draK  standards  or  specifica>ons;  May  not  be   applicable  to  the  PDMP  &  HIT  Integra>on  Ini>a>ve   Leveraged  from  previous  S&I  Ini+a+ves   52 Implementa(on  Guidance  for   Real-­‐World  Implementers   Drar  Harmonized  Profile/ Standard   Evalua/on    and  Selec/on    of   Standards   Valida/on  of   Standard  Harmonized  Profile/Standard  for   Recommenda(on   Use  Case   Requirements   Candidate   Standards   Technical   Design   Standards  &   Technical  Gap   Analysis  
  52. 52. Standardiza(on  Development  &   Harmoniza(on:  Workflow   Outputs   1.  Validate  candidate   standards  list   2.  Map  UCR  to   candidate  standards     3.  Analyze  mapped   standards  per  HITSC   criteria  to  narrow   down  any  conflic(ng     standards  resul/ng   from  the  UCR-­‐ Standards  mapping   4.  Perform  technical   feasibility  of  analysis 5.  Review  with   community   Use  Case  Requirements   Crosswalk   1.  Develop  gap   mi/ga/on  plan   2.  Drap  Solu/on     diagram   3.  Validate  solu/on   plan   2.  Confirm  data  model   approach   4.  Modify/harmonize   exis/ng  standard(s)   to  produce  final   standards   5.  Achieve  community   consensus  or   agreement   Final  standards   1.  Using  final   standards,  develop   Implementa/on   Guide  document   2.  Document  IG   Conformance   Statements  in  RTM   3.  Develop  Examples   to  inform   implementers   4.  Validate  examples   5.  Achieve  community   consensus  or   agreement   Implementa(on  Guide   1.  Survey  SDO  or   standards   organiza/on   op/ons   2.  Select  ballo/ng   approach   3.  Align  /meline  with   ballot  cycles   4.  Submit  documents   informing  SDO  of   intent  to  ballot   5.  Submit  content  to   SDO   6.  Conduct  ballo/ng   cycle  &   reconcilia/on  per   SDO  guidelines   Balloted  standards   Evaluate   Standards   Plan  for  Solu(on   and  Final   standards   Develop   Implementa(on   Guide   *SDO  Ballo(ng   53
  53. 53. Harmoniza/on  Timeline   Week   Target   Date   (2014)   All  Hands  WG  Mee(ng  Tasks   Review  &  Comments  from  Community  via  Wiki   page   due  following  Monday  @  12  noon   1   3/25   Harmoniza(on  Kick-­‐Off  &  Process  Overview   Introduce:    Overview  of  UCR-­‐Standards  Mapping   Review:  N/A   2   4/1   Introduce:  Candidate  Standards  List  &  UCR-­‐Standards  Mapping   Review:  Candidate  Standards  List   3   4/8   Finalize:  Candidate  Standards  List   Review:  UCR-­‐Standards  Mapping   Review:  UCR-­‐Standards  Mapping   4   4/15   Review:  UCR-­‐Standards  Mapping   Review:  UCR-­‐Standards  Mapping   5   4/22   Finalize:  Outcome  of  UCR-­‐Standards  Mapping   Introduce:  Gap  Mi(ga(on  Plan   Review:  Gap  Mi(ga(on  Plan   6   4/29   Finalize:  Gap  Mi(ga(on  Plan   Introduce:  HITSC  Evalua(on   Review:  HITSC  Evalua(on   7   5/6   Review:  HITSC  Evalua(on   Review:  HITSC  Evalua(on   8   5/13   Finalize:  Full  Review  of  HITSC  Evalua(on,  Total  Ra(ngs,  List  of   Final  Standards  for  Solu(on  Plan   Introduce:  Solu(on  Plan   Review:  Solu(on  Plan   9   5/20   Review:  Solu(on  Plan   Review:  Solu(on  Plan   10   5/27   Finalize:  Solu(on  Plan   Introduce:  Implementa(on  Guide  (IG)  Template   Review:  Implementa(on  Guide  Template   11-­‐15   6/3  –  7/1   Review:  Implementa(on  Guide   Review:  Implementa(on  Guide   16-­‐17   7/8  –  7/15   End-­‐to-­‐End  Community  Review  of    Implementa(on  Guide   End-­‐to-­‐End  Review  of  Implementa(on  Guide   18   7/22   Consensus  Vote  
  54. 54. PDMP Project Timeline Kick-­‐off    (11/14)   Pre-­‐Discovery,  Call  for   Par/cipa/on   Jan  14   June  14   Discovery Ini(a(ve  End   55   Nov  13   July  14  Mar  14   Implementation Pilot User  Stories,  Use  Cases,   Func/onal  Requirements   Standards  Gap   Analysis   Harmonized   Specifica/ons   Technology  Evalua/ons   Reference  Model   Implementa/on   &  Valida/on   Use  Case  Kick  Off   Use  Case  Consensus   Standards  and  Harmoniza(on  Kick  Off   Pilot  Kick  Off  
  55. 55. Join  us!     •  The PDMP & Health IT Integration Initiative is open for anyone to join •  This community meets each week on Tuesday from 12:00-1:30 pm ET by webinar and teleconference. •  We use Wiki pages to facilitate discussion. Information on how to join the Community can be found on the PDMP & Health IT Integration Initiative: •  http://wiki.siframework.org/PDMP+%26+Health+IT+Integration +Homepage •  In order to ensure the success of our initiative and the subsequent pilots, we encourage broad and diverse participation from the community. •  This is your chance to have an impact on the creation and implementation of pilots that will use selected standards in transactions between PDMPs and Health IT systems. 56  
  56. 56. PDMP  &  Health  IT  Integra(on  Ini(a(ve   Resources   57   •  Initiative Wiki Homepage –  http://wiki.siframework.org/PDMP+%26+Health+IT+Integration +Homepage •  Become a Community Member –  http://wiki.siframework.org/PDMP+%26+Health+IT+Integration+Join +the+Initiative •  Project Charter –  http://wiki.siframework.org/PDMP+%26+Health+IT+Integration +Charter+and+Members •  Standards and Interoperability(S&I) Framework –  http://wiki.siframework.org/Introduction+and+Overview •  S & I Calendar of Events –  http://wiki.siframework.org/Calendar
  57. 57. PDMP  &  Health  IT  Integra(on  Ini(a(ve   Support  Leads   •  For questions, please feel free to contact our support team: –  Initiative Coordinators: •  Johnathon Coleman jc@securityrs.com •  Sherry Green sgreen@namsdl.org –  ONC Leads: •  Jennifer Frazier Jennifer.Frazier@hhs.gov •  Helen Caton-Peters Helen.Caton-Peters@hhs.gov –  SAMHSA Leads: •  Jinhee Lee Jinhee.Lee@samhsa.hhs.gov •  Kate Tipping Kate.Tipping@samhsa.hhs.gov –  Support Team: •  Project Management: –  Jamie Parker jamie.parker@esacinc.com –  Ali Khan Ali.Khan@esacinc.com (Support) •  Use Case Development: –  Presha Patel presha.patel@accenture.com –  Ahsin Azim Ahsin.Azim@accenture.com (Support) •  Vocabulary and Terminology Subject Matter Expert: –  Mark Roche mrochemd@gmail.com 58  
  58. 58. Thank  you!   Jinhee  Lee,  PharmD   jinhee.lee@samhsa.hhs.gov   The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Substance Abuse and Mental Health Services Administration. Slide  59  

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