Best Practices: Prescription Monitoring and

Narcotic Guidelines1

WSHA Presenters

2

Carol Wagner Senior VP,Patient Safety

Amber TheelDirector,Patient Safety

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Additional PresentersWashington State

Department of Health

Chris Baumgartner, DirectorPrescription Monitoring Program

Sacred Heart Medical Center

Dr. Darin Neven, ED Physician

Susan PetersonAssociate Director, Legislative, Regulatory and Legal Affairs

Washington State Medical Association

Web Conference Objectives• Background on ER is for Emergencies• Best Practice: Prescription Monitoring

Program and Narcotic Guidelines• What is PMP?• How does it work?• How can we help?• Questions and comments

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An Opportunity

Redirecting Care to the Most Appropriate Setting

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Partnering for Change

• Washington State Hospital Association • Washington State Medical Association• Washington Chapter of the American College

of Emergency Physicians

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State Approaches to Curbing ER Use

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When What Impact Status Original proposal

3-visit limit on unnecessary use

Cuts payments to providers

Won lawsuit; policy abandoned

Revised proposal

No-payment for unnecessary visits

Cuts payment to providers

Delayed by the Governor just prior to implementation

Current policy

Adoption of best practices

Improves care delivery and reliance on ER as source of care

Passed in latest state budget

If Unsuccessful

Revert to the no-payment policy.

$38 million in annual cuts!

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Seven Best Practices

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The Seven Best Practices

• Electronic health information• Patient education• PRC client information/identification• PRC client care plans• Narcotics guidelines• Prescription monitoring• Use of feedback information

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E) Narcotic Guidelines

Goal: Reduce drug-seeking and drug-dispensing to frequent ER users• Implement ACEP guidelines for prescribing and

monitoring of narcotics• Direct patients to better resources• Track data and follow-up with

providers who excessively prescribe

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How to Accomplish

• Change hospital policy to conform with ACEP guidelines: – Prohibit long-acting opioids and discourage injections– Screen patients for substance abuse– Refer patients suspected of Rx abuse to treatment– Other

• Train ER prescribers in narcotic guidelines

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How to Accomplish, continued

• Consider joining this “oxy-free” movement

• When guidelines have been implemented, hospitals have seen significant drop in visits

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F) Prescription Monitoring

Goal: Ensure coordination of prescription drug prescribing practices• Enroll providers in Prescription Monitoring Program:

electronic online database with data on patients prescribed controlled substances

• Target enrollment for ER providers : – 75% by June 15, 2012– 90% by December 31, 2012

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How to Accomplish

• WSMA and WA/ACEP encourage members to sign up

• Educate and encourage medical staff to enroll• Hospitals track enrollment of ER prescribers to

report to HCA by June 15 and December 31, 2012

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Washington State Prescription Monitoring Program:

Background and History

Carl Nelson, Director of Political AffairsWashington State Medical Association

PMP Legislative History• HB 3320 by Rep. Hinkle in 2006.• HB 1553 by Rep. Hinkle, Rep. Morrell and

others in 2007.• SB 5930 The Blue Ribbon Commission. • 2007 Session Laws, Chapter 259, section 42

through 45.• Providers oppose licensure tax.• Funding source remains issue.

WA Prescription Monitoring ProgramChris Baumgartner, Director

Overview - 2012

Washington State Hospital Association

Unintentional and Undetermined Intent Drug Overdose Death Rates by State,

2007

3.1-9.0 9.1-11.4 11.5-21.1

Age-adjusted rate per 100,000 population

8.2

8.2

7.4

4.8

8.7

3.1

3.7

4.1

5.3

10.5

7.1

10.0

7.6

10.8

17.9

9.8

20.4

10.2

9.2

10.0

16.8

8.6

7.111.715.1

9.9

9.7

18.4

10.5

12.5

11.1

14.2

12.7

21.1

12.3

12.5

10.5

13.6

10.4

16.0

9.0

NH 11.7VT 7.9MA 12.5RI 11.1CT 11.1NJ 7.5DE 9.8MD 12.5DC 8.8

9.4

Non-medical Use of Pain Relievers

12 or Older, 2007 & 2008

Source: National Survey on Drug Use & Health, SAMSHA

The PMP Solution:An Overview

• Designed to improve patient safety and prevent prescription drug abuse by keeping records of all dispenser transactions

• Store and evaluate records for illicit use of prescription drugs

• Generate reports to aide prescribers, dispensers, law enforcement, and licensing entities in stopping illicit use

Status of Prescription Drug Monitoring Programs (PDMPs)

Research is current as of April 26, 2012

AK

AL

AR

CACO

ID

IL INIA

MN

MO

MT

NENV

ND

OH

OK

OR

TN

UT

WA

AZ

SD

NM

VA

WYMI

GA

KS

HI

TX

ME

MS

WINY

PA

LA

KYNC

SC

FL

NHMARICTNJDEMD

DC

VT

WV

Operational PDMPs

Enacted PDMP legislation, but program not yet operational

Legislation pendingGU

Implementation Update

• Begin Data Collection – October 1

• Begin Mandatory Reporting – October 7

• Begin DOH/PMP Staff/Licensing Board Access – October 26

• Begin Oversight Agencies Access – November 15

• Begin Pilot Data Requestor Access – December 1

• Begin Data Requestor Access – January 4

• Begin Law Enforcement/Prosecutorial Agencies Access – January 4

• Begin Medical Examiners/Coroners Access – February 1

• Operations, Maintenance, Enhancements – ongoing

2011 2012

DOH’s Goals for Washington’s PMP

• To give practitioners an added tool in patient care

• To allow prescribers and dispensers to have more information at their disposal for making decisions

• To get those who are addicted into proper treatment

• To help stop prescription overdoses

• To educate the population on the dangers of misusing prescription drugs

• To make sure that those who do need scheduled prescription drugs receive them

• To curb the illicit use of prescription drugs

System Overview

State PMP

Dispensers

Prescribers

Law Enforceme

nt& Licensing

Pharmacists

Data Submitted

Reports

Sent

Reports

SentReports

Sent

*Other groups may also receive reports other than those listed

- Weekly Submission

- Schedules II-V

- ASAP 4.1

Who Isn’t Required to Submit Data

• Prescriptions provided to patients receiving inpatient care at hospitals

• Practitioners who directly administer a drug• A licensed wholesale distributor or manufacturer• Pharmacies operated by the Department of

Corrections• VA or other federally operated pharmacies• Canadian pharmacies that are not licensed to

dispense in Washington

Who Has Access• Prescribers & dispensers - in regards to their patients

• Licensing boards – in regards to investigations

• Individuals – in regards to any prescription dispensed to them

• DOH/Vendor – in regards to program operation

• Law Enforcement/Prosecutor – for bona fide specific investigations

• Medical Examiner/Coroner – cause of death determination

• HCA (Medicaid), L&I (Worker’s Comp), DOC (Offenders)

• De-identified information may be provided for research and education

Highest Number of Scripts Per Person by County

County Scripts Population Scripts Per PersonColumbia 10,810 4,040 2.68Garfield 2,810 2,101 1.34Stevens 44,544 42,334 1.05Ferry 7,858 7,520 1.04Clallam 72,285 71,413 1.01Lincoln 9,967 10,248 0.97Benton 162,763 168,294 0.97Spokane 452,149 468,684 0.96Asotin 20,240 21,432 0.94Pend Oreille 12,177 12,946 0.94

• Data pulled 03/30/12, Jan2011-Feb2012, US 2009 Census Estimates

Top 10 Drugs by Rx Count

Rank Generic Name Number of RX Total QTY Total Days Supply

1 HYDROCODONE /ACETAMINOPHEN 944,575 49,889,601 11,135,234

2 OXYCODONE /ACETAMINOPHEN 302,243 16,867,961 3,428,399

3 ZOLPIDEM 285,167 8,845,839 8,455,383

4 OXYCODONE 270,425 25,736,912 4,722,338

5 ALPRAZOLAM 200,471 10,524,485 4,601,852

6 LORAZEPAM 189,683 8,650,802 3,880,719

7 CLONAZEPAM 155,956 9,284,932 4,501,441

8 AMPHETAMINE 135,177 7,273,681 4,012,796

9 METHYLPHENIDATE HCL 119,464 6,322,550 3,650,637

10 MORPHINE SULFATE 97,552 7,337,202 2,272,666

* Data pulled 03/30/12 covers CY 2011

Just Two Months of Prescriptions!(January – February 2012)* Data pulled 3/30/12

# of individuals with CII Rxs

# of individuals with CIII Rxs

# of individuals with CIV Rxs

# of individuals with CV Rxs

# of individuals with CII and CIII Rxs

# of individuals with CII, CIII, CIV Rxs

# of individuals with State Controlled Rxs

296,718 383,557 336,677 63,381 54,403 19,447 2,011

Generated Reports

• A series of reports can be developed as data collection progresses. Reports include:▫ Patient history reports

▫ Reports that show that patients have exceeded a threshold considered a safe level of dispensing

▫ Prescriber history reports

▫ De-identified reports for research/education

▫ Other reports can be generated for specialized interests and needs

Sub-accounts for Prescribers

• The rule allows for “licensed health care practitioner authorized by a prescriber” to access information as a delegate

• Any health professional licensed by the department can have a sub-account

• Prescribers will be able to link sub-accounts to their main account to make requests on their behalf

Two Factor Authentication

• Virtual tokens authenticate a user’s device (process is similar to online banking)

• The device can be a desktop, laptop, tablet, or smart phone

• Once a device is enrolled the user can simply login with their username and password

• Additional computers can be enrolled

PMP Registration: 5,204 Total Prescribers

• Pharmacists – 1,681• Medical Doctor – 2,706• Medical Limited – 71• Physician Fellowship – 0• Teaching/Research – 2• Osteopathic Physician –

239• Osteopathic Limited – 6• Physician Assistant –

519• Osteopathic PA – 13

• Nurse Practitioner – 753• Dentist – 770• Dental Com. Resident –

0• Dental UW Resident – 1• Dental Faculty – 0• Podiatric Phys. – 37• Naturopaths – 34• Optometrist – 40• Veterinarian - 13

Provider Requests(as of 4/12/2012)

• 95,794 patient history requests have been made

• 2,043 prescriber history requests have been made

Provider Quote"Now that I've started using this system, it's almost hard for me to imagine how I was practicing medicine without it. Whenever I prescribe scheduled meds now, I routinely search the Prescription Monitoring Program database, to ensure that the patient isn't getting similar meds from another provider. It is amazing to me how often this search reveals that the patient actually was getting such meds somewhere else, and just not providing this information. Finding this out helps prevent abuse of the system and thus keep costs down for everyone. Most importantly, it helps to keep patients safe and allows us to get them the help that they truly need."

www.wapmp.org

Uses for Prescribers/Pharmacists

• Prescription history of a current or a new patient• Check for addiction or undertreated pain

• Check for misuse, multiple prescribers

• Check for drug interactions or other harm

• Use reports for compliance with pain contracts

• Prescription history of transactions linked to a DEA number• Check for fraudulent scripts

• Regular monthly reporting

PMP Education Materials Timeline

Brand design - DONEDispenser Requirement Factsheet -

DONEPublic factsheet - DONEProvider factsheet – DONEFAQs – DONEQuick Tips - DONE

Future Enhancements

• Share data with other State PMPs

• Interface with the Emergency Department Information Exchange

• Education programs

• Health information exchange

• Outcome evaluation

• Chris Baumgartner, Program Director• Phone: 360.236.4806• Email: prescriptionmonitoring@doh.wa.gov• Website:

http://www.doh.wa.gov/hsqa/PMP/default.htm

Program Contact

Experience in the Hospital

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Sacred Heart Medical Center

• How are the ER providers incorporating the narcotic guidelines into their practice at Sacred Heart?

• How does the prescription monitoring program assist them in their efforts?

• What are the challenges?

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Next Steps

How We Will Help

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Review: What Do You Need to Do?Reduce drug-seeking and drug-dispensing to frequent ER users and coordinate prescription drug prescribing practices•Implement ACEP guidelines for prescribing and monitoring of narcotics•Direct patients to better resources•Track data and follow-up with providers who are outliers• Enroll ER physicians in Prescription Monitoring Program

– 75% by June 15, 2012– 90% by December 31, 2012

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Quick Action Needed!

Hospitals must submit

attestations and best practice

checklists to HCA by June 15, 2012

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For More Information

Carol Wagner, Senior VP, Patient Safety(206) 577-1831, carolw@wsha.org

Amber Theel, Director, Patient Safety Practices(206) 577-1820, ambert@wsha.org

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Questions and Comments

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