Pharmacy Clinical Decision Support Tools for Improving Opioid Safety LTC Mark Maneval, RPh, PhD Chief, Pharmacy Clinical Decision Support Enterprise Intelligence and Data Solutions (EIDS) PMO Deputy Assistant Director for Information Operations Defense Health Agency
CPE Information and Disclosures Mark Maneval declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of the Army, Defense Health Agency, Department of Defense, nor the U.S. Government. The American Pharmacist Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
CPE Information Target Audience: Pharmacists and Pharmacy Technicians ACPE#: 0202-0000-18-216-L04-P/T Activity Type: Knowledge-based
Learning Objectives Explain how to use the Opioid Registry to identify opioid patients who naloxone 1. may be indicated. Identify clinical, medication, MEDD and encounter based factors associated 2. with a higher probability of opioid induced respiratory depression. State how to quickly and easily screen patients for risk of opioid induced 3. respiratory depression at the pharmacy using the Patient Lookup Tool.
Self-Assessment Questions What is the fastest way to estimate the probability of opioid induced respiratory 1. depression and obtain a recommendation for who may need naloxone? a. Ask the patient at the pharmacy window what their risk factors are and calculate it by hand b. Milsuite c. Opioid registry in Carepoint d. Patient Lookup Tool in Carepoint
Self-Assessment Questions Which of the following are risk factors used in the Opioid Registry’s predictive 2. model for opioid induced respiratory depression? a. A health care visit (outpatient, inpatient, or ED) involving opioid dependence b. Currently consuming an ER/LA formulation of an opioid with a long or variable half life (Oxycontin, Methadone, Fentanyl patch, etc.) c. MEDD >100 d. Had 1 or more ED visits in the past 6 months
Self-Assessment Questions The Patient Look-up Tool requires special equipment and training to access and 3. use. a. True b. False
Do we have an opioid problem?
Pharmacist’s Responsibilities: 1985-2018 “Pharmacists now must consider the best interests of patients and provide consultation to patients and/or prescribers if prescribed medications pose preventable risks for patients.” David Brushwood, JD, column coordinator, and Professor Emeritus of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville www.pharmacist.com/evolving ‐ responsibilities ‐ pharmacy downloaded 28 Sep 2018
Pharmacy Value
Digital Platform for a Learning Health System
Information Underload Problem: Patient information is lacking at point of care Hypothesis: Better Information → Better Care → Better Outcomes Solution: Display patient information at point of care
What is “CarePoint”? Information Sharing: Apps Personalized Gallery Items Collections Sites Enhanced Landing Page and Navigation Enhanced Search and Filters Community Contribution https://carepoint.health.mil
Navigate to the Population Health Portal https://carepoint.health.mil
Navigate to the Patient Look-up Tool
Select your duty location
Select your duty location
Navigate to Clinical Registries
Real Patient
Real Patient: Clinical Decision Support Used
Clinical Decision Support Not Used, No Naloxone 28 APRIL: ADMITTED FOR OPIOID INDUCED RESPIRATORY DEPRESSION
More Information is Available
More Information is Available
Methodology Documents
VA led the way
Procedural Instruction
Opioid Measure Perspectives Patient Level (released) • Opioid Registry and Data Dictionary • Opioid Patient Summary Report • ORCA Clinical Guidance Report • Patient Lookup Tool • Pharmacy Level (released) • Patient Lookup Tool Dashboard • Prescriber Level (in development) • Prescriber Trend Report • Facility Level (in development) • Enrollment Based •
Patient Level Clinical Decision Support Tools
Pharmacy Level Dashboard
Reporting and Evaluation Tools
Provider Level Trend Report
Facility View (in development)
Facility View (in development) Measure Construct DoD Definition/Description Long ‐ Term Opioid Therapy (LOT) LOT Use Among DoD Beneficiaries Number of patients on LOT during reporting period. LOT is defined as 90 days of continuous opioid therapy without a gap in therapy of >= 30 days. Might be reported as percentage of enrolled population by enrollment DMIS. Long ‐ Term Opioid Therapy (LOT) <=30 Years Old Among LOT Patients Of the LOT patients, number & proprtion <= 30 years of age Any Opioid Usage Any Opioid Usage Among DoD Beneficiaries Presence of any opioid Rx during the reporting period among DoD beneficiaries Any Opioid Usage Long vs Short Acting Opioids Of the patients receiving opioids, breakdown of long vs short acting opioids Concomitant Medications Concurrent Use of Opioids & Benzodiazepines Percentage of individuals 18 years and older with concurrent use of prescription opioids and benzodiazepines.
Facility View (in development) Measure Construct DoD Definition/Description Morphine Equivalent Daily Dose (MEDD) Median Morphine Equivalent Daily Dose (MEDD) for LOT Patients The median MEDD value for patients identified as LOT users during the measurement period at each level of care from the MHS down to the provider level Morphine Equivalent Daily Dose (MEDD) >= 90 MEDD Among LOT Patients Of the LOT patients, number and proportion of patients with >= 90 MEDD Morphine Equivalent Daily Dose (MEDD) 20 ‐ 50 MEDD Among LOT Patients Of the LOT patients, number and proportion of patients with an MEDD value of 20 ‐ 50 mg Naloxone Naloxone Use Among LOT Patients Proportion of patients on long term opioid therapy (LOT) who have received naloxone. The proportion of LOT patients who meet the following criteria: 1) Have received naloxone over the past 12 months OR 2) Have an average morphine equivalent daily dose (MEDD) ≥ 50 mg and have received naloxone in the past 12 months OR 3) Have an average morphine equivalent daily dose (MEDD) ≥ 90 mg and have received naloxone in the past 12 months Naloxone Naloxone Dispensings Among High RIOSORD/STORM Population Number and percentage of opioid users with RIOSORD >32 or STORM scores in the 'high' or 'very high' categories that were dispensed Naloxone
Facility View (in development) Measure Construct DoD Definition/Description Risk Scores Mean RIOSORD Score Mean RIOSORD score among LOT patients during reporting period Risk Scores Mean STORM Score Mean STORM score during reporting period Risk Scores High RIOSORD Score Population Number and percentage of opioid users with a RIOSORD score > 32 Risk Scores High STORM Score Population Number and percentage of opioid users with a STORM score in the 'high' or 'very high' categories Mental Health PTSD Among LOT Patients Presence of PTSD diagnosis among LOT users in the past year Mental Health Depression Among LOT Patients Presence of depression diagnosis among LOT users in the past year Mental Health Suicide Risk Among LOT Patients Presence of suicide related diagnosis among LOT users in the past year Urine Drug Testing (UDT) Urine Drug Testing in LOT Users Presence of opioid related UDT among LOT users in the past year Therapy Duration Median Duration of Opioid Therapy Among Long ‐ Term & Short ‐ Term Users Median number of prescription opioid therapy days during the measurement year for (1) LOT users and (2) short ‐ term users Therapy Duration Comparison of Patients on Long vs Short Acting Opioids Average length of therapy among patients on long vs short acting opioids
Way Ahead MHS Validated OIRD Risk Model: • o 2-stage logistic regression o Machine Learning (ML) model using advanced analytics (Python/SAS Enterprise Miner) o Integrate the ML model into MHS Genesis using SMART on FHIR app Increased visibility for VA providers: • o Opioid JIF o Improve continuity during transition Expand the point of care based functionality to other disease states and purposes: • Diabetes • Hypertension • Dyslipidemia • Tobacco cessation • Benzo reduction • Deprescribing • Medication Synchronization • Potentially Deployment Limiting Conditions/Medications •
Key Points Pharmacy is the most frequent touchpoint in the healthcare system Pharmacy is not a count, lick, stick and pour business anymore The Patient Lookup Tool provides a pharmacy based clinical decision support tool that identifies risk of respiratory depression and potential need for naloxone Access the Opioid Registry, Patient Look-up Tool and Dashboard thru the CarePoint Information Portal at https://carepoint.health.mil Clinical pharmacy integration of CarePoint registries and reports aligns with the DHA Quadruple Aims: Better Care, Better Health, Lower Cost and Improved Readiness
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