1. PDMP Track:
PDMPs as User-Friendly Clinical
Decision Support Tools
Presenters:
• Christi Hildebran, LMSW, CADC III, Research Manager,
Acumentra Health
• Gillian Leichtling, Research Project Manager, Acumentra
Health
• Peter W. Kreiner, PhD, Senior Scientist, Institute for Behavioral
Health, Brandeis University
Moderator: Jinhee J. Lee, PharmD, CDR, Senior Public Health
Advisor, Division of Pharmacologic Therapies, Center for Substance
Abuse Treatment, Substance Abuse & Mental Health Services
Administration, & Member, Rx Summit National Advisory Board

2. Dislosures
• Christi Hildebran, LMSW, CADC III, has disclosed no relevant, real or
apparent personal or professional financial relationships with
proprietary entities that produce health care goods and services.
• Gillian Leichtling, BA, has disclosed no relevant, real or apparent
personal or professional financial relationships with proprietary
entities that produce health care goods and services.
• Peter W. Kreiner, PhD, has disclosed no relevant, real or apparent
personal or professional financial relationships with proprietary
entities that produce health care goods and services.
• Jinhee J. Lee, PharmD, CDR, has disclosed no relevant, real or apparent
personal or professional financial relationships with proprietary
entities that produce health care goods and services.

3. Learning Objectives
1. Describe how prescribers currently integrate PDMP
data into patient care in Oregon.
2. Advocate the use of guidelines and training to
optimize prescriber use of PDMPs in patient care.
3. Outline nine state projects designed to integrate
PDMP reports with electronic health record systems
and pharmacy dispensing software.
4. Evaluate the effectiveness of those state projects’
interventions on prescriber and pharmacist use of the
PDMP and on their respective prescribing and
dispensing behaviors.

4. PDMPs as User-Friendly Clinical Decision
Support Tools
Christi Hildebran, LMSW, CADC III
Gillian Leichtling, BA
Acumentra Health
Portland, Oregon

5. Disclosure Statement
Christi Hildebran, LMSW, CADC III and
Gillian Leichtling, BA
have disclosed no relevant, real or apparent
personal or professional financial relationships
with proprietary entities that produce health
care goods and services.

6. Learning Objectives
1. Describe how prescribers currently integrate
PDMP data into patient care in Oregon.
2. Advocate the use of guidelines and training
to optimize prescriber use of PDMPs in
patient care.

7. NIDA-funded Study
“Use of Prescription Monitoring Programs
to Improve Patient Care and Outcomes”
Supported by the National Institutes of Health, National Institute for Drug Abuse through Grant # 1 R01
DA031208-01A1, and by the National Center for Research Resources and the National Center for Advancing
Translational Sciences, through grant UL1RR024140.

8. Study Aims
AIM 1:
Determine the prevalence and characteristics of
PDMP users and non-users
AIM 2:
Determine how providers use PDMP data;
formulate recommendations for clinical guidelines
AIM 3:
Determine whether PDMP use improves patient
outcomes and reduces apparent diversion
and abuse

9. Background
• PDMPs increasingly used for public health:
reduce drug abuse, improve patient safety
• Many clinicians who prescribe
controlled drugs do not use PDMPs
• Little known about clinician responses
to PDMP information (what is communicated
to patients, what decisions are made)

10. Methods
• Surveyed a sample of all Oregon clinicians
with DEA license (MD, DO, PA, NP, Dentists,
Naturopaths; not Pharm)
• Randomly selected 650 frequent users
(>1 query per month)
• Of 358 frequent users who returned a survey,
212 agreed to a follow-up interview
• Follow-up telephone interviews (n=33)

11. Interview Participants
Specialty N
Primary Care (PCP) 16
Emergency Medicine 7
Procedural Specialist (dental, surgical) 6
Other (pain, psychiatry, addictions) 4
Total 33

12. Results
1. Workflow
2. Communication
3. Decision-Making

13. Workflow Topics
• Circumstances in which clinicians check
PDMP
–Routine versus triggered by red flag or
suspicion
–New Rx/patient versus existing patient

14. Results: Workflow
• Inconsistent use of routine PDMP checks
–Some emergency and procedural specialists
check routinely when controlled substance
requested; others rely on red flags such as
patient behavior
–Many PCPs check routinely with new
patients; for ongoing monitoring with
existing patients, some rely on red flags

15. Quotes: Routine vs. Triggered Checks
“If somebody immediately starts negotiating their pain
medicine or telling me they’ve lost a prescription
and/or they’re new to town ― and usually they would
say several of those things ― that’s clearly a red flag.
But it wouldn’t even take something that overt. If
they’re hinting at…they’re low on their medication, and
it’s the weekend and they haven’t been able to get in
with their doctor, that’s all it usually takes to prompt
me to consider or just go ahead and use the
Prescription Drug Monitoring Program.”
– Emergency Room Physician

16. Quotes: Routine vs. Triggered Checks
“I started trying to be less discriminating. If pain is the
issue and if I think pain medications are going to be a
question, I’ve tried to start doing it almost across the
board with those people before I walk into the room.
I’m not going to try to pick and choose so much, I’m
going to try to do it on most if not all of the people I’m
seeing.”
– Emergency Room Physician

17. Quotes: New vs. Existing Patients
“The new patient that's coming in asking for opiates is
going to get at least checked immediately. With existing
patients, it will depend on the situation. If I see them
frequently wanting medications, maybe after the first
or second time, I'll check them. It really depends on
what they're asking for. It depends on the feel that I’m
getting from the patient. I don’t have a thing I do for
every patient.”
– Primary Care Clinician

18. Communication Topics
• Ways in which providers discuss worrisome
reports with patients
• Policies or guidelines that
influence checking the PDMP
and/or prescribing
• Ways in which providers discuss
PDMP information to assess patient
medication compliance and ongoing care

19. Quotes: Ways Providers Discuss
Worrisome Reports with Patients
• Openly discussing and sharing PDMP results
with the patient
“For me, it’s a chance to be hopefully less judgmental…
and an opportunity to broach the topic. And in an
objective, non-judgmental way, to say, “Look at this ―
you’re 20 years old and I see you’ve gotten 160 Vicodin
over the last month.”
– Emergency Room Physician

20. Quotes: Ways Providers Discuss
Worrisome Reports with Patients
• Withholding PDMP results and keeping it a
secret
“It’s a cat and mouse thing. I keep it secret as much as
possible because it’s better used if it’s kept quiet. I can
catch the patient unaware…It’s much better for me to
have information and I can discover things that are
happening. You have to be a bit of a detective.”
– Primary Care Physician

21. Quotes: Ways Providers Discuss
Worrisome Reports with Patients
• Avoid discussing the PDMP results with the
patient
“I never confront them with the evidence from the
PDMP. I write it up in the chart, so the chart indicates
18 prescriptions for controlled substances, from six
providers over the last year…I’ll flag his chart as drug
seeking and that will be his number one diagnosis.”
– Primary Care Physician

22. Quotes: Policies or Guidelines that
Influence Checking the PDMP and/or
Prescribing
• Discussing PDMP as part of agency policy or
guideline
“I tell them that as part of our clinic policy, I need to log in
and see if they’re getting these prescriptions from another
prescriber. It also helps me to tell them about the policy,
the contract that we will have them sign if they start getting
them long-term from us.”
‒ Primary Care Clinician

23. Quotes: PDMP Information
Communicated as a Tool to Assess
Patient Medication Usage
• Discusses PDMP results routinely as part of the
visit
“I communicate much of the time that, ‘It looks like you’ve
been filling your Ambien about two weeks late, so it looks
like you haven’t been using it every night. What have you
been doing to help yourself sleep on the nights that you
don’t take it?’”
‒ Psychiatrist

24. Decision-Making Topics
• Prescribing decisions in light of worrisome
PDMP profile
– New/episodic patients
– Existing patients
• Referrals
– Emergency/procedural specialist referral to PCP
– Referrals to behavioral health provider
• Discharge from care

25. Results: Prescribing and New Patients
• Clinicians generally won’t prescribe for new
patient with worrisome profile
– Some PCPs/clinics had policies against prescribing
at first visit or until specific conditions met
• Clinicians will prescribe for verifiable acute
condition (e.g., broken bone) regardless
– Emergency and procedural specialists generally
won’t prescribe for chronic pain conditions unless
authorized by PCP

26. Quotes: New Patients
“I just say, ‘I see you’ve gotten multiple scripts filled
from multiple providers. I just need to look into this
some more, and I’ll see you back in X amount of time,
hopefully when I’ve gotten the records, and we can
figure out what else we’re going to do for your anxiety
or pain management.”
– Primary Care Clinician

27. Quotes: New Patients
“I’ll bring the PDMP report back with me and I’ll say,
‘I want to get clear on the information we discussed.
You told me you take a Vicodin once in a while, but I
have access to your prescription history and when I
looked it up, I see you’re getting a regular prescription
for this many from Dr. So-and-So, and that’s more than
once in a while. So I want you to know before we do
treatment, I will not be able to prescribe you any
narcotics in addition to what you're already getting.’”
– Dentist

28. Results: Prescribing and Existing
Patients
• Some clinicians discontinue ongoing Rx
automatically at worrisome profile
– Violation of medication agreement
• For some, depends on patient circumstances
– If continue Rx: revisit medication agreement,
more frequent monitoring, shorten refill/visit
schedule, behavioral health visit
• If discontinue Rx: some taper, others do not

29. Quotes: Existing Patients
“If they’ve gone to other prescribers, I’ve found it’s
most commonly dentists and they don’t think of it as
the same thing…I am aware of the kind of mistakes that
people make, but when somebody has been to an ER
three times in the last month and hasn’t told me, and
got prescriptions every time, I simply say, ‘That’s a
violation and I can no longer prescribe for you.’”
– Primary Care Clinician

30. Quotes: Existing Patients
“It depends on their history and the risk of addiction
and abuse. We do a risk evaluation when they first
come in, so they’re either a mild, moderate, or high-risk
patient. If they’re a high-risk patient and something
happens, then it’s a lot more severe what I do. If
they’re a moderate or low-risk patient, chances are I
might not be as controlling. I might just say ‘Okay, you
did this ― now we’re reiterating that this is our policy.
You can’t do this again.’ Then I’ll watch their drug
monitoring program a lot closer and maybe do urine
drug screens more frequently.”
– Primary Care Clinician

31. Results: Referral and Discharge
• Some emergency and procedural specialists
refer patient to primary prescriber/PCP, or
may contact PCP to ask about prescribing
• PCPs and clinicians who provide ongoing
prescribing had varied responses
– Some may discharge if worrisome report; others
will not
– Most offer referrals and/or alternatives

32. Quotes: Referral to PCP/Pain Specialist
“If I feel like they have a legitimate reason for wanting
more, sometimes I will call their medical doctor or
whoever’s been prescribing all the other pain medicine,
and talk to them to see if they feel comfortable with
me giving the patient more, or ask them if the patient
has a legitimate reason for being out.”
– Dentist

33. Quotes: Referral to PCP/Pain Specialist
“We are not going to manage medications,
narcotics at least, for long periods of time. So when
I get into situations like that, I would rather refer
them to somebody that is better suited to handle a
longer-term situation. Or if I think that they’re
going to be a problem, somebody that needs to be
monitored a little more closely with urine drug
screens and things like that.”
– Surgical Specialist

34. Quotes: Discharge
“Usually the people I choose to discharge from my clinic are the ones
who have been getting narcotics multiple other places and haven’t
been honest with me.”
– Primary Care Clinician
“You have to be a really bad person to get discharged from our
practice…I think as clinicians, a lot of times we hide behind the
Hippocratic Oath or behind this side that we don't want to hurt
anybody. Well, we already got all those patients on these medications.
It's best that you work with them to turn the ship.”
– Primary Care Clinician

35. Conclusions: Workflow
• Routine use of PDMP vs. triggered by red flags
– Some emergency and procedural specialists not
checking routinely
– Some PCPs checking routinely only with new
patients; for ongoing monitoring rely on red flags
• Need for guidance:
– What policies or guidelines support optimal use of
PDMP?

36. Conclusions: Communication
• Some discuss PDMP results openly; others
hold back PDMP results to unearth patient
dishonesty
• Need for guidance:
– What works best in engaging patient?
– What should be the role of episodic providers in
discussing concerns with patient?

37. Conclusions: Decision-Making
• Clinicians likely not to prescribe for new
patients with worrisome profile
• Decisions related to existing patients varied
• Need for guidance:
– For existing patients, when to taper, discontinue,
or continue prescription?
– What is the optimal care related to discharge in
response to a worrisome profile?

38. Next Steps
• Understand when it is optimal to access PDMP
• Understand how the various ways of
communicating PDMP results may affect
provider-patient relationship and ongoing
patient engagement
• Understand how clinic policies or guidelines
may affect provider actions

39. Contact Information
Christi Hildebran
 childebran@acumentra.org
Gillian Leichtling
 gleichtling@acumentra.org
Project Funding:
National Institute on Drug Abuse, 1R01DA031208-01A1
For more information, please visit:
http://www.acumentra.org/PDMP/

40. PDMPs as User-Friendly Clinical
Decision Support Tools
Evaluation of SAMHSA’s PDMP EHR
Integration and Interoperability
Expansion Projects

41. Disclosure Statement
Peter Kreiner, Ph.D., has disclosed no relevant,
real, or apparent personal or professional
financial relationships with proprietary entities
that produce health care goods and services.

42. Learning Objectives
• Describe how prescribers currently integrate PDMP
data into patient care in Oregon.
• Advocate for the use of guidelines and training to
optimize prescriber use of PDMPs.
• Outline nine state projects designed to integrate PDMP
reports with electronic health record systems and
pharmacy dispensing software.
• Evaluate the effectiveness of those state projects’
interventions on prescriber and pharmacist behaviors

43. Presentation Outline
• Overview of SAMHSA’s PEHRIIE Program
• Review of evaluation objectives and design
• Review of evaluation progress to date
• Preliminary evaluation findings and
recommendations
• Future work

44. Prescription Drug Monitoring Programs
(PDMPs): Challenges to Effective Use
• Data are not sufficiently timely
– In most states, pharmacies are only required to report
dispensed prescriptions weekly or biweekly.
• Data are incomplete
– Not all states require reporting of all controlled substances
– Data is not shared between many state PDMPs.
• Data are not easily accessible
– Manual registration processes, notarization requirements.
– Difficult and time-consuming to access, especially in an ED.

45. SAMHSA’s PDMP EHR Integration and
Interoperability Expansion (PEHRIIE) Program
• History
 Grew out of Enhancing Access to PDMPs – A National Effort to Reduce
Prescription Drug Abuse and Overdose Through Technology and Policy
 Work groups to gather information and provide recommendations
(2011)
 Pilot Projects to test the feasibility of using health information
technology (HIT) to enhance PDMP access (Feb – Sept 2012)
 October 2012: SAMHSA funded larger-scale integration and
interoperability projects in nine states using PPHF funds (PEHRIIE
Cohort 1)
 October 2013: SAMHSA funded PEHRIIE projects in seven additional
states (PEHRIIE Cohort 2)

46. About SAMHSA’s PEHRIIE Program
• Primary Objectives:
• Increase integration of and access to PDMP data
within electronic health records (EHRs) and/or
pharmacy dispensing software (PDS) systems.
 Goal: Improved PDMP accessibility
• Increase interoperability of state PDMPs across state
lines.
 Goal: Improved PDMP data quality & comprehensiveness
CDC Role: Design and execute a comprehensive
process and outcomes evaluation of the Cohort 1
PEHRIIE projects

47. RxCheck
Data Hub
WA Prescription
Review
(Vendor: HID)
University of
Washington
Network
All WA State
Emergency
Depts
EDIE HIE
(Operated by Collective
Medical Technologies)
Washington DOH
(Oversight Agency)
OneHealthPort
(Tech Partner =
CyberTrust)
Pharmacies
(PharmNet EHRs)
Ambulatory
Clinics
(Epic EHRs)
Emergency Depts
(Cerner FirstNet
EHRs)
Ambulatory Clinics
(Cerner Powercharge
EHRs)
Pharmacies
(Cerner Etroby
EHRs)
Other
States’
PDMPs
HID RxSentry
Data Hub
Other Medical
Site Trading
Partners
*S&I Framework
Pilot with EPIC EHRs

48. Anticipated Outcomes of the
PEHRIIE Program
• Initial Outcomes:
– Increased provider registration with the PDMP
– Increased provider use of the PDMP
• Intermediate Outcomes:
– Decreased inappropriate prescribing/dispensing
practices
• Impacts:
– Decreased risky patient behaviors relating to
prescription drug misuse and abuse
– Improved health outcomes

49. EVALUATING SAMHSA’S PEHRIIE
PROGRAM

50. Evaluation Objectives
• To determine if successful completion of the two
primary objectives of the PEHRIIE program resulted in
changed provider behavior and impacted prescription
drug-related health outcomes.
• To identify cross-cutting barriers to and facilitators of
successful implementation of sustainable HIT
integration and interstate interoperability projects.
• To document important lessons for other states as they
expand their PDMPs’ HIT integration and interstate
interoperability.

51. Evaluation Design
• Multi-component, observational and case-comparison
approach
Conclusions
Quantitative Data
Three Data Types:
• PDMP Usage Data
• State PDMP Data
• Health Outcomes Data
Two planned data collections:
• Baseline
• Follow-Up
Qualitative Data
• Annual interviews with project
directors
• One time interviews with project
stakeholders
• One time interviews with clinical
end users
• Observations
Annual Document Reviews
• Grantees’ Proposals
• Grantees’ Progress Reports
• Other information sources

52. PEHRIIE Evaluation Progress To Date
• Developed a detailed evaluation plan and
disseminated it to funded states1
• Qualitative Information Collection:
– Stakeholder interviews in six of nine states
– End User interviews in two of five states
– Regular phone calls with project directors
1 OMB Control Number 0920-1008 (Expires January 31,2016)

53. PEHRIIE Evaluation Progress To Date
• Quantitative Data Analysis:
– Baseline data request (March 2014)
• Preliminary PDMP data from two states
• Preliminary metrics from one state
– Negotiation of data sharing agreements with
remaining states
– Developed final data request (to be sent in May
2015)
• Quarterly data, July 1 2010 – March 31, 2015
• PDMP data and usage metrics

54. PEHRIIE Evaluation Progress To Date
• Document Review:
– Baseline review of project proposals, legal
statutes, and other relevant documents
– Annual progress report reviews

55. PEHRIIE EVALUATION PRELIMINARY
FINDINGS AND RECOMMENDATIONS

56. Preliminary Evaluation Findings
• Significant differences in project approach and
management across states
– Statewide vs regional HIEs vs direct integration at end user sites
– Single Sign On vs full integration
– Project management approach
• Interoperability
– Steady growth of interstate data sharing within some of the
data sharing hubs
– Pending “within hub” universal data sharing MOUs have slowed
data sharing in other hubs
– Pending hub-to-hub data sharing is also delaying some
expansion efforts

57. Preliminary Evaluation Findings
• EHR Integration
– End User adoption of new systems has been slower than
anticipated
• Pharmacy Integration
– Generally, this piece has been the slowest to be completed
across states
– Commercial pharmacies prefer to work with multiple states at
once
• Working through organizations like the National Association of
Boards of Pharmacy (NABP)
• Project plans must meet standards and adhere to policies in
multiple states simultaneously, which extends the time needed for
this work

58. Preliminary Evaluation Findings
• PDMPs, as part of state governments, have traditionally
interacted with other governmental agencies, or with
entities (e.g., pharmacies) controlled by state laws or
regulations
• Integrating PDMP reports with HIT and interstate data
sharing require different kinds of boundary-spanning:
– Interacting with commercial entities (HIE, EHRs)
– Interacting with agencies outside of focal state (interstate
interoperability)
– These boundary-spanning efforts may require different kinds of
skills than prior PDMP interactions

59. Preliminary Evaluation Challenges
• Quantitative Data Availability
– Data availability varies widely across states
• Prescription and patient data elements available
• Provider-level usage data available
• Years of data available
– Limited ability to identify implementation sites vs. non-
implementation sites within PDMP and usage data
• Final end user sites are still unknown
• No individual implementation sites because project is state-wide
• Prescribers practice at multiple sites within one state
• All queries assigned to medical director at some sites
• Is automatically-called PDMP report the same as a query?
– Underestimated the legal documentation required for data
release from most states

60. Preliminary Recommendations
• Multiple strategies may be most effective for
maximizing PDMP utilization by providers
– “Push” strategies like integrated EHR access to simplify
workflow
– “Pull” strategies like unsolicited reporting to increase
provider awareness
– Legal strategies such as requiring PDMP use as a best
practice and mandating PDMP registration

61. Preliminary Recommendations
• New boundary-spanning skills and structures may
be needed, such as:
– Technical training and advisors
• IT technical solutions and jargon
• IT security requirements
• Legislative processes for statutory and rule changes
– An implementation steering committee including
representation from all stakeholder groups

62. Remaining Work
Apr May June July Aug Sept
Qualitative
Complete stakeholder & end user
interviews
Quantitative
Disseminate
final data
request
Final data collection and
analysis
Doc Review
Final progress
report review
General
Final
report
writing

63. Interim and Final Reports
• State-specific interview summary report
– Following completion of all stakeholder interviews for that state
– Factual review by the project coordinator
• State-specific comprehensive report
– Will include findings from qualitative interviews, document
review, and quantitative analyses
– Can be disseminated to other interested parties
• Final Evaluation Report
– Will examine cross-cutting issues, successes, and lessons
learned from all participating states
– Qualitative, quantitative, and document review results will
be included

64. PEHRIIE Evaluation Team Members
CDC Evaluation Team Lead:
• Jan Losby
CDC Research Fellows:
• Kristen Cincotta
• Wesley Sargent
• Brian Manns
CDC Statistician:
• Rose Rudd
Subject Matter Experts:
• Peter Kreiner, Brandeis
University
• Cindy Parks Thomas,
Brandeis University
CDC PDO Team Lead:
• Debbie Dowell

65. Thank You
The findings and conclusions in this report are those of the author and do not necessarily
represent the views of the Centers for Disease Control and Prevention.