pdmp 5 hopkins dreyzehner_o_leary

PDMP  Track:  Lessons  Learned  From  Manda3ng  Prescriber  Compliance    

David  Hopkins,  KASPER  Program  Manager,  Office  of  Inspector  General,  Kentucky  Cabinet  for  Health  and  Family  Services  

John  J.  Dreyzehner,  MD,  MPH,  Commissioner,  Tennessee  Department  of  Health  

Terence  O’Leary,  Director,  Bureau  of  NarcoOcs  Enforcement,  New  York  State  Department  of  Health    

Moderator:    John  L.  Eadie,  Director,  PrescripOon  Drug  Monitoring  Program  Center  of  Excellence,  Brandeis  University    

Disclosures  

•  David  Hopkins  has  disclosed  no  relevant,  real  or  apparent  personal  or  professional  financial  relaOonships.  

•  John  J.  Dreyzehner  has  disclosed  no  relevant,  real  or  apparent  personal  or  professional  financial  relaOonships.  

•  Terence  O’Leary  has  disclosed  no  relevant,  real  or  apparent  personal  or  professional  financial  relaOonships.  

Learning  ObjecOves  

1.  Demonstrate  the  strategies  in  mulOple  states  that  are  effecOve  in  reducing  diversion  of  controlled  substances.    

2.  Judge  outcomes  from  mulOple  states  following  their  decision  to  mandate  prescriber  compliance  of  PDMP  data.    

3.  Assemble  tools  for  prescribers  and  dispensers  to  incorporate  uOlizing  PDMP  data  into  their  pracOce.  

Mandatory Prescriber Use of the

Kentucky All Schedule Prescription Electronic Reporting

System (KASPER)

David Hopkins KASPER Program Manager Office of Inspector General Kentucky Cabinet for Health and Family Services

Agenda

•  Background •  Kentucky’s Mandatory KASPER

Registration and Usage Legislation –  2012 House Bill 1 –  2013 House Bill 217

•  Implementation Challenges •  Results

Background

The Political Climate

•  Opioid abuse a national epidemic •  Controlled substance misuse and

abuse on the rise in Kentucky •  Opioid overdose deaths on the rise in

Kentucky •  Legislators viewing medical community

as not addressing the problem

Cabinet  for  Health  and  Family  Services  

Prescription Drug Abuse in Kentucky •  6.6% of Kentuckians (ages 12+) reported using

prescription pain relievers for nonmedical reasons in past year. (KY tied for second in nation) – National average = 4.9%

•  Kentucky prescription opioid pain reliever overdose death rate was 17.9 per 100,000 of population (KY ranked sixth in the nation) – National average was 11.9 per 100,000 of

population Source:  Data  from  the  2007,  2008  and  2009  NaOonal  Surveys  on  Drug  Use  and  Health,  published  by  the  U.S.  Substance  Abuse  and  Mental  Health  Services  AdministraOon  (SAMHSA),  Center  for  Behavioral  StaOsOcs  and  Quality.  

KASPER Usage December 31, 2011

Law Enforcement = 1.5% (13% of KY LE had

accounts)

Prescribers = 94.9% (32% of KY prescribers had accounts)

Pharmacists = 3.5% (26% of KY

pharmacists had accounts)

Judges, Other = .1%

Kentucky’s Mandatory KASPER Registration and Usage Legislation

2012 House Bill 1 2013 House Bill 217

Cabinet  for  Health  and  Family  Services  

KASPER Reporting KRS 218A.202

• Controlled substance administration or dispensing must be reported within one day effective July 1, 2013

Cabinet  for  Health  and  Family  Services  

KASPER Accounts – KRS 218A.202

•  KASPER registration is mandatory for Kentucky practitioners or pharmacists authorized to prescribe or dispense controlled substances to humans.

Cabinet  for  Health  and  Family  Services  

KASPER Prescriber Usage - KRS 218A.172 •  Query KASPER for previous 12 months of

data: –  Prior to initial prescribing or dispensing of a

Schedule II controlled substance, or a Schedule III controlled substance containing hydrocodone

–  No less than every three months –  Review data before issuing a new prescription or

refills for a Schedule II controlled substance or a Schedule III controlled substance containing hydrocodone

•  Additional rules/exceptions included in licensure board regulations

KASPER Regulations – Licensure Boards •  201 KAR 5:130

–  Kentucky Board of Optometric Examiners KASPER requirements

•  201 KAR 8:540 –  Kentucky Board of Dentistry KASPER requirements

•  201 KAR 9:260 –  Kentucky Board of Medical Licensure KASPER

requirements •  201 KAR 20:057

–  Kentucky Board of Nursing KASPER requirements •  201 KAR 25:090

–  Kentucky Board of Podiatry KASPER requirements.

JusOce  &  Public  Safety  Cabinet  

Exceptions •  After surgery •  Patients in hospitals and long term care

facilities – Hospitals and long term care facilities can

establish facility accounts and request reports on behalf of the facility

•  Patients in Hospice care or being treated for cancer pain

•  Single doses of anxiety medicine prior to a procedure

•  As a substitute within 7 days of initial prescribing

JusOce  &  Public  Safety  Cabinet  

Implementation Challenges

User Registration

•  Implemented temporary paperless registration process

•  Increased administrative staff to handle emails and calls – Went from one to three administrative

staff – Engaged four temps

JusOce  &  Public  Safety  Cabinet  

Cabinet for Health and Family Services

KASPER Master Accounts 12/31/2011   04/24/2012   07/20/2012   02/24/2014  

Doctor*   5,470              5,680            11,923            17,807    

APRN   690                    781                1,523                2,150    

Pharmacist   1,385              1,450                3,602                5,363    

Total   7,545              7,911            17,048            25,320    

*Includes  physicians,  denOsts,  optometrists  and  podiatrists  

Technology

•  Less than three months to prepare – Had to rely on existing system

capacity •  Initial system outages •  Increased technology Help Desk

staff from one to four • Created web-based KASPER

tutorial

JusOce  &  Public  Safety  Cabinet  

Cabinet  for  Health  and  Family  Services  

KASPER Reports

Policy

•  Complexity of 2012 licensure board regulations – Simplified in 2013

•  Confusion on who to contact with questions/issues – KASPER – Licensure Boards

•  Proliferation of misinformation •  HB1 Legislative Oversight Committee

JusOce  &  Public  Safety  Cabinet  

Results

Cabinet for Health and Family Services

Controlled Substance Dispensing – One Year Comparison

Drug   August  2011  through  July  2012  

August  2012  through  July  2013  

Change  

Hydrocodone        239,037,354          214,349,392     -­‐10.3%  

Oxycodone            87,090,503              77,022,586     -­‐11.6%  

Oxymorphone                1,753,231                  1,138,817     -­‐  35.0%  

Alprazolam            71,669,411              62,088,568     -­‐13.4%  

Methylphenidate            10,659,840              11,454,025     +  7.5%  

Amphetamine            13,795,147              15,065,833     +  9.2%  

All  Controlled  Substances        739,263,679          676,303,581     -­‐8.5%  

Figures  shown  in  doses  dispensed  

Cabinet  for  Health  and  Family  Services  

Cabinet  for  Health  and  Family  Services  

Cabinet  for  Health  and  Family  Services  

Cabinet  for  Health  and  Family  Services  

Cabinet  for  Health  and  Family  Services  

Cabinet  for  Health  and  Family  Services  

Cabinet  for  Health  and  Family  Services  

Cabinet  for  Health  and  Family  Services  

House Bill 1 Impact Study •  Comprehensive assessment of HB1’s impact on

patients, prescribers, and other stakeholders •  Overall goals:

–  Evaluate the impact of HB1 on reducing prescription drug abuse and diversion in Kentucky

–  Identify unintended consequences associated with implementation of HB1 that impact patients, providers and citizens of the Commonwealth

–  Develop recommendations to improve effectiveness of HB1 and mitigate identified unintended consequences

•  Final study report planned for 3Q 2014

David R. Hopkins Kentucky Cabinet for Health and Family Services

502-564-2815 ext. 3333 Dave.Hopkins@ky.gov

John  J.  Dreyzehner  MD,  MPH,  FACOEM  

MANDATED  PDMP  USE  A  Collaborative  Journey  in  

Tennessee  

John  J.  Dreyzehner,  MD,  MPH  Commissioner    

Tennessee  Department  of  Health  

Overview:  Lessons  Learned  in  TN  

1.  As PDMP queries go up, doctor shopping goes down.

2.  Partner with prescribers to establish mandated PDMP checking.

3.  PDMP checking leads to more conversations about Rx drug abuse and referrals to treatment.

4.  Mandated PDMP checking is leading to a plateau in MME

5.  Trilateral approach of PDMP will aid fight against heroin epidemic

34  

Defining  Terms  

•  PDMP = Prescription Drug Monitoring Program

•  CSMD = Controlled Substance Monitoring Database, Tennessee’s PDMP

•  MME = Milligrams of Morphine Equivalent, a standard approach to measuring the total value of opiates prescribed and dispensed

35  

Lesson learned: Lives get saved. Fewer addictions.

As  PDMP  queries  go  up,  doctor  shopping  goes  down  

36  

More  CSMD  Queries,  Fewer  Doctor  Shoppers  

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2010 2011 2012 2013

Hig

h Ut

iliza

tion

Patie

nts

Patie

nt R

eque

sts

(in M

illio

ns)

Number of Searches Made by Prescibers, Dispensers, and Delegates

High Utilization Patients: Patients filled 5 or more prescriptions with different DEA Prescribers at 5 or more different DEA dispensers within 90 days.

Source: Tennessee Department of Health Internal Files, February 2014 37  

Results  from  Prescriber  Survey  

Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses Q6: Answered: 769 Skipped: 37 38  

Lesson learned: Engage prescribers to make them partners in mandating

PDMP checking.

Prescribers  do  not  check  the  PDMP  in  large  numbers  until  it’s  

mandated.  

39  

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

Q2 2013

Q3 2013

Q4 2013

CSMD Searches by Delegates CSMD Searches by Prescibers

Mandating  CSMD  Checking  Resulted  in  More  Queries  

Source: Tennessee Department of Health Internal Files, February 2014

Mandated checking began April 1, 2013

Mandated registration began Jan. 1, 2013

40  

Leveraging  Technology  to  Promote  Collaboration  

•  Easy to see current MME calculation on patient report

•  Linkage of APN and PA accounts to supervising physician to enhance supervision of prescribing practices

•  Near real-time reporting pilot program by pharmacies

•  Easy access to interstate data sharing

41  

Leveraging  Technology  to  Promote  Collaboration  

•  Color-coded risk icons on patient report for:

–  Pharmacy Shopper –  Doctor Shopper –  High MME Dose

•  Automated username and password retrieval •  Batch requests for high-volume clinics

42  

Turning  Data  Into  Information  Helps  •  Comparison to peers by specialty

–  Dynamic report with trend capabilities –  Accessible at any time by prescribers

•  High risk models in development –  High risk patient –  High risk prescriber –  High risk dispenser

43  

Turning  Data  Into  Information  Helps  •  Push reports

–  Upon login to the PDMP, prescriber’s patients who meet risk thresholds are visible on the main screen –  Prescriber then acknowledges viewing the patient alert

Ask  End  Users  How  They  Feel  

•  Survey asked for specific improvements – 11 were implemented within first year

•  Regional forums were held with feedback •  Examples of end user suggested improvements

include: – Supervising physician capability to audit mid-level

providers –  Automated username and password retrieval – Batch request capability –  Enhanced graphics on patient report

45  

Lesson learned: Our PDMP is causing conversations that may have a long-

term beneficial impact.

Prescribers  using  the  PDMP  are  more  likely  to  discus  substance  abuse  with  patients  and  refer  to  treatment.  

46  

Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses Q3: Answered: 766 Skipped: 40 47  

Results  from  Prescriber  Survey  

Results  from  Prescriber  Survey  

Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses Q4: Answered: 768 Skipped: 38 48  

Results  from  Prescriber  Survey  

Source: June 2013 End-User Survey Regarding CSMD, 805 Total Responses Q5: Answered: 765 Skipped: 41 49  

Lesson [hopefully] being learned: In other states, decreasing MME has

been associated with a drop in overdose deaths.

In  TN  our  PDMP  is  very  important  in  achieving  a  plateau  in  MME    

(Morphine  Milligram  Equivalents)  

50  

Morphine  Milligram  Equivalents  (MME)  Dispensed  and  Reported  to  TN  CSMD,  2010-­‐2013  

8.2

8.4

8.6

8.8

9.0

9.2

9.4

9.6

9.8

10.0

2010 2011 2012 2013

MM

E in

Bill

ions

MME Reported by Newly Reporting Dispensers MME Reported by All Other Sources

2013 = First year of data from newly reporting dispensers

Source: Tennessee Department of Health Internal Files, February 2014 51  

Slowing  the  Growth  of  Controlled  Substances  Prescribed  in  TN  

Year Rx’s Per Capita (TN Rank – lower is better)

Percent Change in Filled Rx’s from Previous Year (TN Rank – lower is better)

2008 TN: 0.53/person (4) US: 0.39/person

N/A

2012 TN: 0.64/person (2) US: 0.41/person

TN: 7.4% (23) US: 7.0%

2013 TN: 0.68/person (2) US: 0.42/person

TN: 0.3% (31) US: 0.7%

C-II Controlled Substances

Source: IMS Health, Inc. 52  

Lesson learned: Success is found by focusing trilaterally on treatment,

control, and prevention.

All  partners  must  work  together  to  constrain  the  market  on  opiate  

addiction.  

53  

Supply  and  Demand:  The  Substance  Abuse/Misuse  Market  Triangle  

54  

Substance  Abuse/Misuse:  Constraining  the  Market  

PDMP Addresses All Three

55  

Summary:  Lessons  Learned  in  TN  1.  As PDMP queries go up, doctor shopping goes

down. 2.  Partner with prescribers to establish

mandated PDMP checking. 3.  PDMP checking leads to more conversations

about Rx drug abuse and referrals to treatment.

4.  Mandated PDMP checking is—in our opinion—leading to plateau in MME

5.  Trilateral approach of PDMP will aid fight against heroin epidemic

56  

Thank  You  

New  York’s  Prescrip3on  Drug  Reform  Act  

Part  A:  I-­‐STOP      (Internet  System  to  Track  Over-­‐Prescribing)  

Part  B:  Electronic  Prescribing  Part  C:  Schedule  Changes  Part  D:  Work  Group  Part  E:  Safe  Disposal  Program  

I-­‐STOP  • Required  NYS  Department  of  Health  to  update  exisOng  PMP  • Requires  more  Omely  data    • Makes  addiOonal  data  available  • Allows  informaOon  to  be  shared  with  addiOonal  appropriate  enOOes  • Requires  consultaOon  of  the  PMP  Registry  

PracOOoners  are  required  to  consult  the  registry  in  most  cases  prior  to  prescribing  or  dispensing  any  controlled  substance  listed  in  Schedule  II,  III,  or  IV.    

ExcepOons  are  limited  to  specific  circumstances  or  a  waiver  granted  by  Department  of  Health.  

Duty  to  Consult  

As  part  of  I-­‐STOP  legislaOon,  the  Ome  frame  for  dispensers  to  submit  data  changed  from  once  a  month  to  within  24  hours  from  when  the  prescripOon  was  dispensed.    

To  help  facilitate  Omely  reporOng  New  York  implemented  a  new  PMP  Data  CollecOon  Tool  

To  increase  accuracy  of  data,  the  number  of  criOcal  error  fields  were  expanded.  

Data  Collec3on  

Why  can’t  I  find  my  paOent’s  data  in  the  PMP?  

Data  entry/submission  error,  record  is  awaiOng  correcOon,  incorrect  search  terms  were  entered,  prescripOon  was  filled  out-­‐of-­‐state  

Why  is  the  prescriber  informaOon  is  incorrect?  

Usually  a  data  entry  error.      

Isn’t  this  law  a  violaOon  of  HIPAA?  

Nope.      

Common  Ques3ons  from  Prac33oners  

My  doctor  charges  me  $5  to  check  PMP;  

My  doctor  said  I-­‐STOP  requires  me  to  come  into  the  office  every  month  to  pick  up  my  prescripOon.  

My  doctor  said  the  Department  of  Health  has  red-­‐flagged  me  and  won’t  let  him/her  prescribe  any  medicaOons  to  me.  

Isn’t  this  law  a  violaOon  of  HIPAA?  

Common  Complaints  from  Pa3ents  

Beginning  on  March  27,  2015,  all  prescripOons  in  New  York  State  must  be  transmired  electronically.  

ExcepOons  include    •  power  failure;  •  paOent  safety  ;  •  PracOOoners  who  have  received  a  waiver  from  

the  Department  of  Health  based  upon  a  showing  of  technological  limitaOon  outside  of  his/her  control  or  other  excepOonal  circumstances.      

Electronic  Prescribing