We are DREM Consulting. A health IT consulting group with a focus on interoperable systems and health care system education models for opioid abuse awareness and prevention.
Overview of Hospital System and Case
Overview of Goals
Overview of HealthIT Solutions
Actions and Execution Elements
The Prescription Opioid Crisis In and Around Pulaski County, VA
Over six percent (6.3%) of Virginians, or 530,706 residents, received an opioid prescription. In 2011, Virginia drug treatment admissions for opiates (including prescription drugs) surpassed admissions for heroin and cocaine.
Virginia Prescription Drug Rate
Steady increase in all age groups with largest spike in 25-34 group.
Highest At Risk Population in VA
Pulaski County had 42 emergency room visits for unintentional overdose by opioid and has a 134.1 per 100 persons prescription rate of opioids.
In 2016, there were 1,130 opioid-related overdose deaths in Virginia (13.5 deaths per 100,000 person). The national average for that year was 13.3 deaths per 100,000 persons.
The Crisis As It Stands Today
Overview of Riney Regional Health Systems (RRHS)
A smaller healthcare system located in Pulaski County, VA. Serving predominately middle class individuals who are mature or elderly.
Front Office Staff
Overview of Goals
Within one year identify the “at risk” population and provide information on the “at risk” of opioid addiction to the care delivery team of clinical providers.
Within two years implement delivery system changes within the necessary data flow and health IT infrastructure to support the data/information flow for the delivery system changes.
Virginia Policy & Legal Issues
Under Virginia Law, strength of an opioid is limited to less than 50 MME. For both acute and chronic pain the regulation requires the provider query the Virginia PMP when more than 7 days supply of opioids will be prescribed. For chronic pain prescribed strengths over 50 MME a medical justification in the medical record and strengths over 120 MME need a reasonable justification or consultation with a pain management specialist.
Opioid Prescription Regulations
The Virginia PMP is law 54.1-2522.1 under the Code of Virginia (Virginia Law). All prescribers of controlled substance in the state of Virginia have to be registered with the PMP (Virginia Law). The Virginia PMP is compliant with HIPAA.
Virginia PMP &
Under 45 C.F.R. §164.512. a pharmacy (covered entity) may disclose protected health information for certain public health activities and purposes. The specific purpose will be preventing or controlling disease, injury, or disability.
Virginia PMP would also be compliant with 42 CFR part 2 (42 CFR 2.1 - Statutory authority for confidentiality of substance use disorder patient records.). Under 42 CFR 2.53, disclosure can be made without consent to as ongoing audit to meet requirements of Center for Medicare & Medicaid Services-regulated organization (42 CFR 2.53 - Audit and evaluation.).
45 & 42 CFR
Since the PMP is HIPAA compliant and all EHR systems must also be HIPAA compliant, there is no need to address HIPPA in terms of the IT solution. All medical providers with the ability to prescribe opioids will be required by VA state law to register with the PMP.
Using a shared value of the patient first, we will train your staff to use the new system as well as recognize "at risk" populations. This will allow all providers to effectively communicate with and educate those who are prescribed opioids.
Our IT solution will allow the EHR system to query the VA PMP. Where providers are not required to register with the PMP yet, they will be soon. Getting your healthcare system ahead of the requirements and providing a solution that will be interoperable and adjust to your EHR system will not only satisfy state law, but also help patients who are at risk for opioid abuse.
EMR Opiates Module
The system will have the ability to build a more complete data set in the PMP.
Reduce Time Waste
Reduce physician time spent interacting with the PMP.
This program will improve regulatory compliance.
Track patient's daily Morphine Milligram Equivalents (MME) from all sources.
Acute Pain Management
Chronic Pain Management
Suggest non-opioid alternatives
Quarterly opioid rationale documentation
Prompt for regular opioid abuse evaluation
Regulatory-Based Decision Support in the EMR
All acute pain management considerations
Client EMR & PMP
Physician Responsible for 1 Time Registration with PMP
Automatically Query PMP When Opiate is Ordered
If Opiate is Prescribed, Submit Prescription to PMP Automatically
Change Management Model
The plan devised to maintain and build competitive advantage.
The way the organization is structured and who reports to whom.
The daily activities and procedures that staff members engage in to get the job done.
The style of leadership adopted.
The employees and their general capabilities.
The core values of the company that are evidenced in the corporate culture and the general work ethic
The actual skills and competencies of the employees working for the company.
1. Address Core 3
2. Address Specifics of last 4
Decrease in prescription opioid abuse rates for Pulaski Country as well as increased value to hospital system and patients.
Implementation of the new system has the potential to disrupt workflow until new habits can be formed and change is accepted.
Shared Value : create a shared value of wanting lasting patient wellness, not immediate relief only.
Style: Open and effective communication between all levels.
Skills and Staff: Trained and knowledgable about identification and resources.
Strategy: Use new interoperability health IT to increase ability to identify at risk populations by requiring over the current standard.
Structure: Create a prescription system that requires data collection
Systems: Create a training program to allow staff members to effectively interact with the program and identify at risk populations before prescription.
Training Programs Outline
Using the shared value of the patients overall well-being, we will train your physicians and staff to use the new system as well as recognize "at risk" populations. All levels that provide care will be given a "working" tour of the new system that allows them to use a fake case to run through scenarios and understand data input and data extraction.
Additionally, providers will be taught to use “teach back method” when meeting with patient to ensure the understanding of all drug medication the patient is taking such as reinstating why they are taking it. Interoperability (EHR/EMR) will be used for communication to obtain patients medical history, patient referrals, and data/charting to allow for better understanding of that particular patient and the best way to approach them about opioid use and abuse.
All patients will be given an iPad with educational material and video as educational aspects. The total length of this education module on the iPad will last no longer than 10 minutes and will outline prescription policy, abuse risks, and drug disposal amount others. A consent form must be signed on the iPad at the end of the material before prescription can take place.
RRHS will be set up with a community outreach centers that supplies patients with education material for themselves, their families, or anyone they feel to be at risk. The community outreach center swill be located in the hospital and at each clinic but will also go to events to spread awareness. Patients will be able to use the outreach center as a place to return unused opioids. The center will be monitored at all times and any returning prescriptions must be entered in the EHR under the patients chart and then placed in the provided locked container to be sent to the hospital pharmacy for proper returning/destroying.
iPads will be provided during check-in with a new patient tab pre-set on each iPad. The front office coordinator is responsible for ensuring each patient receives a iPad populated to the patients portal updating patients portals at each visit. (any recent changes in medication, address changes, any insurance updates etc.).
Each patient will then be required to watch a short educational video on opioids use and administration, side effects, and danger of misuse if are if they are prescribed medications such as (OxyContin, Vicodin, Lorcet etc.) Implementing take home brochures for follow up information and any common questions.
The “teach back method” will be an especially important form of communication for the elderly as they are often Polypharmacy patients (administration of many drugs at one single setting). The knowledge of the patient's past drug history will also be helpful with this population when determining the best "teach back method" approach.
Initial barrier cost to RRHS of implementing the system and training.
Potentially higher barriers to the patient as it could cost more should the physician suggest long term main management without opioids. This might create a barrier for the program as you could meet patient resistance.
Within the 1st year we suggest applying for grants and budgets as the system collects "at risk" data. By year 3, full integration of the system and training should be in place or complete and RRHS should slowly integrate budget allotments that allow for additional outreach programs investing $1 per patient in the program.
Virginia saves $7 for every $1 invested in treatment.
" The Federal Government awards competitive grants to help states in their efforts to reduce drug use and its harmful consequences"
Viriginia Drug Control Update
Health Care Innovation Aware (HCIA): $856,695
Medical Assistance Program - Grants to States for Medicaid To Treat Substance Abuse: $25,194,250
There is a $3 million grant from PurduePharma that will allow the Department of Health Professions to connect the state PMP with electronic health records (EHR ) used by Virginia doctors and pharmacies.
Biennial Report on Substance Abuse Services Per Code of Virginia § 37.2-310(pp. 11-24, Rep.). (2015). VA: Virginia Department of Behavioral Health & Developmental Services.
Emergency Department Visits for Overdose by Opioid, Unspecified Substance and Heroin Among Virginia Residents(pp. 3-10, Rep.). (2016). VA: Virginia Department of Health. Retrieved September 1, 2018, from
Levine, M. J., MD MPH. (2017, June 8). The Opioid Addiction Emergency in Virginia[PPT]. Virginia Department of Health.http://www.pwcgov.org/news/Documents/opioid_presentation.pdf
Mastrangelo, D. (2018, July 16). 'Unfettered greed': Pulaski County seeks damages for opioid crisis from Big Pharma. Retrieved September 1, 2018, from https://www.roanoke.com/news/local/pulaski_county/unfettered-greed-pulaski-county-seeks-damages-
Mandatory Prescribing Regulations for Treating Pain and Addiction. (2018, August 8). Retrieved September 01, 2018, from https://www.msv.org/opioidregulations
National Institute on Drug Abuse. (2018, March 02). Virginia Opioid Summary. Retrieved September 1, 2018, from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/virginia-opioid-summary
Opioid Overdose. (2017, July 31). Retrieved September 3, 2018, from https://www.cdc.gov/drugoverdose/maps/rxcounty2016.html
PressRelease_Jan2017-1[PDF]. (2017, January 1). Governor of Virginia.
The McKinsey 7-S FrameworkEnsuring That All Parts of Your Organization Work in Harmony. (n.d.). Retrieved September 1, 2018, from https://www.mindtools.com/pages/article/newSTR_91.htm
Virginia Drug Control Update[PDF]. (2013, January 1). Washington, DC: Office of National Drug Control Policy.https://obamawhitehouse.archives.gov/sites/default/files/docs/state_profile_-_virginia_0.pdf
Virginia Law. (n.d.). Retrieved September 01, 2018, from https://law.lis.virginia.gov/vacode/54.1-2522.1/
Virginia Prescription Monitoring Program Quarterly Report(pp. 1-4, Quarterly Report). (2018). VA: Virginia Department of Health Professions. Retrieved September 1, 2018, from
Virginia Prescription Monitoring Program. (n.d.). Retrieved September 01, 2018, from https://www.dhp.virginia.gov/dhp_programs/pmp/“
Virginia Prescription Monitoring Program Frequently Asked Questions.” DHP Case Decisions History, www.dhp.virginia.gov/dhp_programs/pmp/faq.asp.
45 CFR 164.512 - Uses and disclosures for which an authorization or opportunity to agree or object is not required. (n.d.). Retrieved September 01, 2018, from https://www.law.cornell.edu/cfr/text/45/164.512#b_1
42 CFR 2.1 - Statutory authority for confidentiality of substance use disorder patient records. (n.d.). Retrieved September 01, 2018, from https://www.law.cornell.edu/cfr/text/42/2.1
42 CFR 2.53 - Audit and evaluation. (n.d.). Retrieved September 01, 2018, from https://www.law.cornell.edu/cfr/text/42/2.53