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    Christian Green
    Christian Green, MA

    An Oct. 16 MGMA Stat poll asked healthcare leaders if there has been a shift in their practice's approach to prescribing opioids. The majority of respondents said there has been a shift, while 23% said there has not and 9% said they do not prescribe opioids at all in their practice. MGMA Stat is a national poll that addresses practice management topics, the impact of new legislation and related topics. Participation is free and open to all healthcare leaders.
    When MGMA data and content teams convened to create the MGMA Research & Analysis report: Combating the Opioid Epidemic: Effective Policies and Communication Strategies earlier this year, one of the key areas identified for successfully modifying prescribing policies for pain patients was the need for technological solutions to integrate disparate systems that are essential to maintaining compliance and delivering quality care.
    MGMA's research led us to Sunrise Community Health, a Federally Qualified Health Center (FQHC) in northern Colorado's Weld and Larimer counties with 50 primary care providers in 10 clinics. As a FQHC focused on comprehensive integrated primary care, Sunrise often has patients come to them because their pain medications have been cut off by other practices. As such, there is a better chance that these patients may display aberrant behavior or develop an opioid use disorder.
    About a decade ago, one of Sunrise's physicians saw a need to create a plan of action for prescriptions, according to Lesley Brooks, MD, a family medicine physician and chief medical officer at Sunrise. As Brooks recalled, the physician noted a lack of standardization around their opioid prescribing practices: "We have a patient population who are behaving outside the boundaries of safety and we need to address that with safer opioid prescribing."
    To address this need, Sunrise established its Opiate Oversight Committee (OOC), composed of physicians, case managers, behavioral health consultants and the pharmacy director. As Brooks noted, the OOC was designed to streamline the review of all chronic opioid therapy patients. The behavioral health consultants, for example, are employed by mental health centers in the area, creating a direct connection between Sunrise's patients and the care they may need at these facilities, e.g., mental health evaluations and therapy.
    Sunrise's providers were asked to manage acute pain for 90 days, log information for those patients and then notify the OOC. Beginning with patients receiving the highest doses of pain medication, the committee conducted chart reviews designed to answer some of the following questions:

    • Do patients have an appropriate musculoskeletal diagnosis for opioid therapy?
    • What are their comorbid medical conditions?
    • Do those conditions contribute to risk for opioid therapy?
    • What are their psychiatry comorbidities and are those well controlled?
    • How compliant have they been to the regimen or are there early refills or lost or stolen prescriptions? 

    At the time, Sunrise used the Opioid Risk Tool (ORT) and the Diagnosis, Intractability, Risk, Efficacy (DIRE) tool to evaluate aberrant behaviors and the risk of opioid abuse among its patient population, while also determining which patients were eligible for long-term opioid therapy. The OOC would then send recommendations to the providers. This process worked well for several years, leading to safer opioid prescribing and more informed providers, but patient education needed improvement. As a response, Sunrise added group visits and began educating its patients about safe prescribing. This was another significant step toward comprehensive practice transformation for Sunrise, leading to a more informed patient population and a robust way to respond to increased risk among patients on chronic opioids. But, according to Brooks, Sunrise needed a way to support its process, particularly because chart reviews and overall management of this patient population can be so time consuming.
    The solution came in the form of OpiSafe, a tool that promotes safe and effective opioid prescribing adherent to CDC guidelines. OpiSafe, when fully implemented, makes it possible for providers to be more efficient by providing:

    • Easy integration: Before enrollment, patients can answer required assessment questions in minutes.
    • Quick access to PDMP reports: Generates patient reports in seconds without having to log in to state PDMP databases.
    • Detailed assessment and risk stratification: Provides comprehensive information on patient use, pain level, misuse risk, as well as data on anxiety, comorbid depression and sleep disorders via an accompanying app. Also, this provides risk stratification, as determined by patient factors.
    • Automated monitoring: Via their smartphones or the web, patients can provide continuous feedback. Pain, function and risk assessments and medication diary questions can be used to generate easily measurable summaries.
    • Automated urinalysis: Provides randomized UA screenings for patients, along with information on how and where they can get screened.
    • Customized notification: Providers and staff can be alerted when specific patient events occur.

    OpiSafe is HIPAA compliant and SAS 70 Type II and SASE-16 certified.
    For Sunrise, which has used OpiSafe since January 2018, the biggest obstacle for implementation has been overcoming the organization's (internal) limited resources. As Brooks noted, "It's the technical integration, made more challenging because inside FQHC we don't have a super large IT staff. There are competing priorities for their time." Additionally, when Sunrise started its association with OpiSafe, the health center was using LabCorp for its diagnostic solutions and OpiSafe had not yet established a relationship with them. "We did not want to walk away from LabCorp because we had done a lot of work to put lab testing into our EHR, and to get those labs flowing into our EHR, we wanted this to follow the same model," Brooks stated. Since then, OpiSafe has worked to interface with LabCorp, and urine drug testing data are automatically fed into the OpiSafe dashboard.
    Unlike some practices whose providers may work directly in OpiSafe, Sunrise has three OOC case managers devoted to its chronic pain/chronic opioid prescribed population. "Those case managers are in and out of OpiSafe daily because they are preparing for group visits, which entails a urine drug screen along with a PDMP check," Brooks said.
    Although Sunrise's providers are at the frontline of opioid oversight, it's the health center's case managers who analyze patient information. "Our case managers are at a micropopulation level; we really needed our case managers to have a 20,000-foot view of a small population and be able to manage that," Brooks stated.
    Brooks believes that tracking and monitoring patient opioid use will become much more efficient, with less time spent combing through patient charts. In turn, she believes this will help improve patient communication. "Chronologically putting that info together and doing it every single time is hard and time-consuming," she said. "That makes a difference for how you communicate with patients because if the clinical plan is going to change, you better be really clear about why it's going to change. Having a tracker like OpiSafe that helps consolidate that information really helps to streamline the message."
    For Sunrise, OpiSafe has been the final piece of the puzzle in helping to make the review of its chronic pain/chronic opioid prescribed population more efficient. "As a tool and as an idea of what could be, it's super exciting," Brooks said.

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    Christian Green

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