Best Practices:
Prescription Monitoring and
Narcotic Guidelines
1
WSHA Presenters
Carol Wagner
Amber Theel
Senior VP,
Patient Safety
Director,
Patient Safety
2
Additional Presenters
Washington State
Washington State
Medical
Department of Health
Association
Sacred Heart
Medical Center
Susan Peterson
Associate Director,
Legislative,
Regulatory and Legal
Affairs
Dr. Darin Neven, ED
Physician
Chris Baumgartner,
Director
Prescription Monitoring
Program
3
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
4
An Opportunity
Redirecting Care to the Most
Appropriate Setting
5
Partnering for Change
• Washington State Hospital Association
• Washington State Medical Association
• Washington Chapter of the American College
of Emergency Physicians
6
State Approaches to Curbing ER Use
When
Original
proposal
What
Impact
3-visit limit on
Cuts payments to
unnecessary use providers
Status
Won lawsuit;
policy abandoned
Revised
proposal
No-payment for Cuts payment to
unnecessary
providers
visits
Current
policy
Adoption of best Improves care
practices
delivery and
reliance on ER as
source of care
Delayed by the
Governor just
prior to
implementation
Passed in latest
state budget
7
If Unsuccessful
Revert to the
no-payment policy.
$38 million in
annual cuts!
8
Seven Best Practices
9
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
10
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
12
How to Accomplish, continued
• Consider joining this “oxy-free” movement
• When guidelines have been implemented,
hospitals have seen significant drop in visits
13
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
14
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
15
Washington State Prescription
Monitoring Program:
Background and History
Carl Nelson, Director of Political Affairs
Washington 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.
Washington State Hospital
Association
WA Prescription Monitoring Program
Chris Baumgartner, Director
Overview - 2012
Unintentional and Undetermined Intent
Drug Overdose Death Rates by State,
2007
12.3
9.7
10.5
3.7
5.3
11.1
7.1
9.2
3.1
9.8
10.5
4.8
4.1
16.0
12.7
8.2 10.8
18.4
8.7
12.5
21.1
11.7
12.5
7.4
7.6
16.8
20.4
10.4
15.1
7.1
10.0
14.2
10.5
9.4
10.0 10.2
8.6
NH
VT
MA
RI
CT
NJ
DE
MD
DC
11.7
7.9
12.5
11.1
11.1
7.5
9.8
12.5
8.8
8.2
17.9
13.6
9.0
9.9
Age-adjusted rate per 100,000
population
3.1-9.0
9.1-11.4
11.5-21.1
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)
VT
ME
WA
MT
ND
OR
MN
SD
ID
MI
WY
NE
NV
UT
CO
CA
AZ
KS
OK
NM
NY
WI
IA
IL
OH
IN
WV VA
NC
TN
AK
G
U
GA
Operational PDMPs
FL
Enacted PDMP legislation,
but program not yet
operational
Legislation pending
HI
Research is current as of April 26, 2012
SC
AR
LA
DC
KY
MO
MS AL
TX
PA
NH
MA
RI
CT
NJ
DE
MD
Implementation Update
2011
• 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
2012
• 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
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
Dispensers
-Weekly Submission
- Schedules II-V
Data
Submitted
- ASAP
4.1
Reports
Sent
Pharmacists
State
PMP
Prescribers
Reports
Sent
Reports
Sent
Law
Enforcement
& Licensing
*Other groups may also receive reports other than those listed
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
Columbia
Garfield
Stevens
Ferry
Clallam
Lincoln
Benton
Spokane
Asotin
Pend Oreille
Scripts
10,810
2,810
44,544
7,858
72,285
9,967
162,763
452,149
20,240
12,177
Population
4,040
2,101
42,334
7,520
71,413
10,248
168,294
468,684
21,432
12,946
•Data pulled 03/30/12, Jan2011-Feb2012, US 2009 Census
Estimates
Scripts Per Person
2.68
1.34
1.05
1.04
1.01
0.97
0.97
0.96
0.94
0.94
Top 10 Drugs
by Rx Count
* Data pulled 03/30/12 covers CY
2011
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
Just Two Months of
Prescriptions!
* Data pulled 3/30/12
(January – February 2012)
# of
# of
# of
# of
individuals
# of
# of
individuals # of
individuals individuals with State
individuals individuals with CIV
individuals with CII and with CII,
Controlled
with CII Rxs with CIII RxsRxs
with CV Rxs CIII Rxs
CIII, CIV Rxs 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 subaccounts 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 - DONE
Dispenser Requirement Factsheet DONE
Public factsheet - DONE
Provider factsheet – DONE
FAQs – DONE
Quick Tips - DONE
Future Enhancements
• Share data with other State PMPs
• Interface with the Emergency
Department Information Exchange
• Education programs
• Health information exchange
• Outcome evaluation
Program Contact
• Chris Baumgartner, Program Director
• Phone: 360.236.4806
• Email: prescriptionmonitoring@doh.wa.gov
• Website:
http://www.doh.wa.gov/hsqa/PMP/default.htm
Experience in the Hospital
42
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?
43
Next Steps
How We Will Help
44
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
45
Quick Action Needed!
Hospitals must
submit
attestations and
best practice
checklists to HCA
by June 15, 2012
46
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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