implementing cdc opioid guidelines and state prescription ......electronic chronic pain questions...

©Copyright 2016 Clinical Content Consultants, LLC All rights reserved. ©Copyright 2016 Clinical Content Consultants, LLC All rights reserved.

Implementing CDC Opioid Guidelines and State

Prescription Drug Monitoring Programs

John Janas, M.D.

Christy L. Moe

©Copyright 2016 Clinical Content Consultants, LLC All rights reserved.

Presenters QuadMed

Quad/Graphics

• John Janas, M.D. – Board Certified Internal

Medicine and Pediatrics 1987 – Creighton University School of

Medicine, Omaha, NE, 1983 – Baystate Medical Center,

Springfield, MA 1987 – President/CEO of

Clinical Content Consultants (CCC)

– Founder Clinical Quality Improvement Collaborative (CQIC)

Clinical Content Consultants

• Christy L. Moe – IT – Clinical Systems

Supervisor – QuadMed – A Subsidiary of

Quad/Graphics – Sussex, Wisconsin


Objective 1

• Be able to educate their providers and staff on the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain


Objective 2

• Be able to implement workflows to comply with their States Prescription Drug Monitoring Programs (PDMP)


Objective 3

• Be able to rapidly administer, document, and track Chronic Pain Assessments for their patients with Chronic Pain as recommended in the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain


IMPORTANT NOTE • Controlled Substance

Management and the “2016 CDC Guideline for Prescribing Opioids for Chronic Pain” are PRIORITY CQIC PROJECT

• EXTRA SLIDES for TRAINING!


CQIC Controlled Substance/Opioid Project

• Educate Providers & Staff –CQIC WebEx Presentations

–PowerPoints

–Videos

–Handouts


Transforming the Delivery of Healthcare

Experience. Solutions. Results. 8

©Copyright 2016 Clinical Content Consultants, LLC All rights reserved. Experience. Solutions. Results. 9

INCEPTION OF QUADMED

Healthcare Crisis. • Soaring healthcare costs • Growing dissatisfaction with

insurers and HMOs • Inconsistent quality and

access to care

1971 | Quad/Graphics is founded.

Create a better healthcare strategy, in-house.

• Improve employee health, well-being and productivity

• Provide higher quality and better access to medical care

• Lower healthcare spend

• Eliminate the bureaucracy


NATIONAL PRESENCE

• 25 years of success

• 700+ QuadMed employees

• Over 100 clients

• More than 90 health centers

• Across 22 states

• 380,000+ lives served

• 98.1% patient satisfaction

• First ambulatory healthcare provider to achieve AAAHC Network Accreditation



PARTNERS

We’re proud to call these prestigious and world-renowned organizations our partners in transforming healthcare.


©Copyright 2016 Clinical Content Consultants, LLC All rights reserved. Experience. Solutions. Results. 12

Training Team IT/Informatics work closely with the training team during the design phase

Train the trainer sessions

Lunch n Learn Open sessions with compliance team to discuss the policy and demonstrate the technology

Recorded Sessions Session were recorded by the Provider Lead and posted internally

Informatics Members have access to our development domain to showcase the build to their assigned health centers

Clinical News Updates Distributed to the organization before and after the changes were applied

Training Strategy


References - Links • CDC Guideline for Prescribing Opioids for Chronic Pain — United

States, 2016 http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

• Opioid Check List-CDC: http://stacks.cdc.gov/view/cdc/38025

• CDC Injury Prevention & Control: Opioid Overdose http://www.cdc.gov/drugoverdose/prescribing/resources.html

• Guidelines Fact Sheet http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf

• Non-Opioid Alternatives http://www.cdc.gov/drugoverdose/pdf/alternative_treatments-a.pdf

http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm


http://stacks.cdc.gov/view/cdc/38025


http://www.cdc.gov/drugoverdose/prescribing/resources.html

http://www.cdc.gov/drugoverdose/prescribing/resources.html

http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf




http://www.cdc.gov/drugoverdose/pdf/alternative_treatments-a.pdf





References - Links • Assessing Benefits and Harm http://www.cdc.gov/drugoverdose/pdf/assessing_benefits_harms_of_opioid_therapy-a.pdf

• Calculating Total Daily Dose http://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf

• PRESCRIPTION DRUG MONITORING PROGRAMS (PDMPs) http://www.cdc.gov/drugoverdose/pdf/pdmp_factsheet-a.pdf

• WHY GUIDELINES FOR PRIMARY CARE PROVIDERS? http://www.cdc.gov/drugoverdose/pdf/guideline_infographic-a.pdf

http://www.cdc.gov/drugoverdose/pdf/assessing_benefits_harms_of_opioid_therapy-a.pdf





http://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf





http://www.cdc.gov/drugoverdose/pdf/pdmp_factsheet-a.pdf




http://www.cdc.gov/drugoverdose/pdf/guideline_infographic-a.pdf





CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016





• “recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care”

1. when to initiate-continue opioids for chronic pain

2. opioid selection, dosage, duration, follow-up, and discontinuation

3. assessing risk and addressing harms of opioid use





• “intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death.

• CDC has provided a checklist for prescribing opioids for chronic pain http://stacks.cdc.gov/view/cdc/38025 as well as a website http://www.cdc.gov/drugoverdose/prescribingresources.html with additional tools to guide clinicians in implementing the recommendations.





http://www.cdc.gov/drugoverdose/prescribingresources.html






Benefits and Harms of Opioid Therapy

• “multiple prescribers and high total daily opioid dosage, both important risk factors for overdose (124,146) that are available to prescribers in the PDMP (124).”

• “limited evaluation of PDMPs at the state level has revealed mixed effects on changes in prescribing and mortality outcomes (28).”




Clinician and Patient Values and Preferences

• “Clinicians do not consistently use practices intended to decrease the risk for misuse, such as PDMPs (161,162), urine drug testing (163), and opioid treatment agreements (164).”

• “Challenges-registering for PDMP access and logging into the PDMP (interrupt normal clinical workflow if data are not integrated into electronic health record systems) (165), competing clinical demands, perceived inadequate time to discuss the rationale for urine drug testing and to order confirmatory testing, and feeling unprepared to interpret and address results (166).”




Assessing Risk and Addressing Harms of Opioid Use

• 9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.

• Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months. (recommendation category: A, evidence type: 4)





• Create Controlled Substance Form – Urine Drug Screen

– Random Controlled Substance Pill Count

– Prescription Drug Monitoring Program Review

– Medication Contract on File

– Opioid Risk Assessment/Calculator

– MME Calculator (new functionality)


Controlled Substance Mmgt-CCC Form

• Available since 2012

• As new State and Federal Requirements for Opioid Prescribing and Controlled Substance Monitoring become LAW, more and more CQIC sites are asking if CCC has anything to help providers comply with these requirements


Controlled Substance Monitoring

• Penobscot Community Health Care

• John Patten, DO / Deb Durant

• Workflow (Form) to document and track compliance with federal and state requirements for Controlled Substances


Controlled Substance Mgmt-CCC Form

Indications

Co-morbidities

Prior Evaluation

Pain Rating: best, worst, & current

Urine Drug Screen

Random Pill Count

Rx Monitoring Program

Contract on File

Opioid Risk

ADLs

Management




ADLs

Opioid Risk Tool




Management

Displays Medications

by Class

Prior Treatments

Titration Schedule




• Implement workflows to comply with their States Prescription Drug Monitoring Programs (PDMP) –STATE SPECIFIC PDMP LINKS based on

LOC_DOCUMENT or LOC_STATE_ABBREV


Q2-2016 CQIC Enhancement

• 05-25-16: CCC-fndef-site-specific-1.ccc (date of last edit: 04-14-16)

• Added NEW TAG FOR 4th ARGUMENT: 'LOC_STATE_ABBREV' for Controlled Substance and other State Specific requirements (Immunization Registries)


NEW TAG FOR 4th ARGUMENT • Case Uses: Controlled Substance Mgmt-CCC

• Physician Drug Monitoring Program (PDMP) URL links based on Location of Care or State of Location of Care

• State of Location of Care requires fewer options (see next slides)


PDMP URL’s by State Document LOC



Prescription Monitoring

Program Review

Go to Website

Based on State

Location of Care



KQ2: Harms

• KQ2: Additional harms include:

–opioid dosages ≥20 MME/day (Morphine Milligram Equivalent = MME) were associated with increased odds of road trauma among drivers (74)




Morphine Milligram Equivalent (MME) Calculator

http://www.nyc.gov/html/doh/html/mental/MME.html







MME Risk • Dosages >=20 MME/day can also

increase overdose risk compared to dosages of 1-20 MME/day, however the overdose risk is even higher for dosages >=100 MME/day.

• Integrated MME Calculator !!!


Controlled Substance Mgmt-CCC Form Workflow

• Calculate MME

• Reminder on 1st Tab: Monitoring

• If OBSNOW does not contain value, glows YELLOW

ccc_ConSub_exec("CALCULATE_MME_OBS","D","MMECALCULATE","")

Clicking OPENS new MME Tab




• New MME Tab

• Current Narcotic Medications Data Display

• If on Med List appears in Data Display

• Select Drug Name

• Strength

• Quantity

• Days

• Units & Multiplier extract from user-edit file-MME calc

Displays based on CPOE Drug Class values defined in CCC-fndef-CPOE.ccc File ccc_CPOE_Rx_CL_exec("Analgesics-Narcotics only") fn ccc_CPOE_Rx_class_4(){"65"}




• New MME Tab

• Current Narcotic Medications Data Display

• Added (Generic) display

• Select ‘New Row’ if more than 1 Opioid

• NOTE: Fentanyl and Buprenorphine patch ‘adjusted’ for days

• Details in “Informational Display”




• Enter in Strength

• NOTE: units and multiplier automatically populate data display based on user-edit file

• PLUS for Fentanyl and Buprenorphine patch the qty. and days automatically insert ‘adjusted’

• Calc. MME

• Total MME (sums)




Informational

Display

• Data Display

• User-Edit



CALCULATE_MME_OBS

• New obs term requested from GE

• MMECALCULATE

• Auto-populates when value calculated



Informational

Display

• Data Display

• User-Edit



Controlled Substance Mgmt-CCC

• Updated form with MME Calculator and Informational Displays in the Q2/Q3-2016 CQIC CDSS Update Release

• July 18, 2016

• Additional Controlled Substance CDSS for VAP or Informational Action Buttons in Q3 per Workgroups!



• eCPQ14 Chronic Pain Assessment Integration

– Chronic Pain Assessment

– When to initiate-continue opioids for chronic pain



• “Chronic pain has been variably defined but is defined within this guideline as pain that typically lasts >3 months or past the time of normal tissue healing (5).”





• “Evidence supports short-term efficacy of opioids for reducing pain and improving function in noncancer nociceptive and neuropathic pain in randomized clinical trials lasting primarily ≤12 weeks (9,10), and patients receiving opioid therapy for chronic pain report some pain relief when surveyed (11–13).”





• “Few studies have been conducted to rigorously assess the long-term benefits of opioids for chronic pain (pain lasting >3 months) with outcomes examined at least 1 year later (14).”




All Centricity Users

• eCPQ14 Chronic Pain Questionnaire Centricity Tool Kit

–Step by Step Implementation of eCPQ14 with Conditional Action Metric (CAM) Reminders for ALL Centricity EHR Users (CPS/CEMR)


Electronic Chronic Pain Questions (eCPQ*)

Score: ≥ 3 Score: < 3

Consider Neuropathic Pain

Consider Nociceptive Pain

“Mostly Yes” Consider

Sensory Hypersensitivity

What was your average pain over

the last week?

(0–10 NRS Scale)

Thinking of the past week… How much did pain interfere with your usual activities?

How much did pain interfere with your sleep? How much did pain interfere with your mood?

(0–10 NRS Scale for each item)

CHRONIC PAIN? PAIN INTENSITY & LOCATION IMPACT ON FUNCTION, SLEEP, & MOOD

No = Exit

Yes

Other information to help diagnose sensory hypersensitivity can be derived from medical history and other eCPQ questions. It includes:

• Widespread pain from body map image / locations? (Y/N)

• Marked impairment of mood, sleep, and function? (Y/N)

• Medical history of ≥1 other sensory hypersensitivity condition? (Y/N)

PAIN QUALITY & TYPE

Where is your pain?

(Diagram)

Have you had pain most days in

the past 3 months?

(Y/N)

ID PAIN® Screener

Did the pain feel like pins and needles? (Y/N)

Did the pain feel hot/burning? (Y/N)

Did the pain feel numb? (Y/N)

Did the pain feel like electrical shocks? (Y/N)

Is the pain made worse with the touch of clothing or bed sheets? (Y/N)

Is the pain limited to your joints? (Y/N)

“Sensory Hypersensitivity” or Fibromyalgia-like Pain

Did you have trouble thinking or remembering in the past week?

Were you sensitive to bright lights, loud noises, or smells in the past week?

(0–10 NRS Scale for each item)

*For the purposes of this presentation, the eCPQ questions have been paraphrased. NRS, numeric rating scale.


Traditional Pain Assessment Problems

• No structured, systematic means for capturing chronic pain data that is widely adopted* –*Masters ET et al. ISPOR

CONNECTIONS. 2013;2(19):8-10.

• Considered a symptom of multiple conditions and never a disease in itself


Pain data are rarely recorded. When done, it is usually in the

open notes fields in most EHRs, making extraction,

reporting, and analysis difficult

Structured data fields exist for diabetes information

in most EHRs, making extraction, reporting, and

analysis easy

Diabetes patient visit to HCP

Captured in structured data fields

HbA1c

Blood pressure

LDL

Retinopathy

Nephropathy

Neuropathy

NOT Captured

in structured data fields1

Pain severity or intensity2

Pain location and duration2

Impact of pain on patient’s

function, mood, and sleep2

Pathophysiologic type

of pain (nociceptive,

neuropathic, or sensory

hypersensitivity)2

Unlike Patient Data in Other Chronic Diseases, Chronic Pain Assessment and Data Are Not Captured Systematically in

EHRs

1. Masters ET et al. ISPOR CONNECTIONS. 2013;2(19):8-10. 2. IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.



• 3 Main Types of Pain are not easily assessed —no simple test or widely adopted tool – NOCIOCEPTIVE

– NEUROPATHIC

– SENSORY HYPERSENSITIVITY - Fibromyalgia Like

• Validated scales for pain assessment are not broadly utilized


Three Main Types of Pain Pathophysiology

NOCICEPTIVE

PAIN

NEUROPATHIC

PAIN

SENSORY

HYPERSENSITIVITY

Pain related to damage of somatic or visceral tissue, due to

trauma or inflammation

EXAMPLES: rheumatoid arthritis, osteoarthritis, gout

Pain related to damage of peripheral

or central nerves

EXAMPLES: painful diabetic

peripheral neuropathy, postherpetic neuralgia

Pain without identifiable nerve or tissue damage; thought to result from

persistent neuronal dysregulation

EXAMPLE: fibromyalgia

Phillips K, Clauw DF. Best Pract Res Clin Rheumatol. 2011;25(2):141-154.



• EHR data capture solutions offered by some EHR vendors fall short of health system needs

• Integrated delivery networks and medical groups view existing EHR pain modules as too long and cumbersome

• The modules are not used because they do not offer a clear path on integration into current workflows


eCPQ14 Objectives • Designed to enable

systematic, structured collection of discrete data on pain in a format that allows for extraction, analysis, and aggregation

• Designed to enable physicians to more appropriately and efficiently assess chronic pain and to help clinicians better diagnose, treat, and monitor patients with chronic pain


eCPQ14 What it IS

• Recommended set of questions to help support chronic pain assessment

• Electronic module/workflow for data capture (structured)

• Based on existing guidelines EVIDENCE!

What it IS NOT • Clinical Diagnostic Tool

or treatment pathway

• Mobile device

• HOWEVER, the eCPQ14 can be sent by secure messaging for patient to complete


Structured Data Collection • Allows for Extraction, Analysis, and

Aggregation for clinical outcomes and quality measurement

• Rapidly Assess and Accurately Classify the 3 Main Types of Pain

• Appropriately Treat and Manage Chronic Pain


Patient completes paper eCPQ in waiting room when checking in at

each visit

Nurse/MA inputs patient answers into

eCPQ form in EHR

Provider can see individual longitudinal eCPQ results during

each patient visit

eCPQ Workflow Case Example Implementation at a large integrated pain clinic in the Midwest

Office feedback: Does not interrupt normal workflow and takes only a few minutes

Integration into GE Centricity EHR System

• Results beneficial at individual patient visits, as well as from a population perspective

– Periodically (every 6 months) eCPQ aggregate results analyzed from an entire clinic population perspective

– Results provide information on how well clinic is managing patients with chronic pain, (pain, functioning, mood, and sleep)

Note: This is one example of how an office has implemented the eCPQ into its EHR system; the process can be customized for

individual practices, institutions, and EHR systems.


CAM reminder -> Print -> Patient Completes

eCPQ Completed


NOTE: sites using Secure Messaging can send electronically to patient to

complete PRIOR or DURING visit!

eCPQ Completed


eCPQ14 Chronic Pain Questionnaire Entry Form

Template

eCPQ DATA Entered


NOTE: sites using Secure Messaging can RETRIEVE and

automatically populate!

eCPQ Completed


Chronic Pain Questionnaire-eCPQ14 Flowsheet (Option)

eCPQ DATA Entered


eCPQ14 Chronic Pain Questionnaire Entry Form

Template

eCPQ DATA Review


Chronic Pain Questionnaire-eCPQ14 Flowsheet (Option)

eCPQ DATA Review


eCPQ14 Chronic Pain

Clinical Quality Reports

eCPQ DATA Review


Score: ≥ 3 Score: < 3

Consider Neuropathic Pain

Consider Sensory Hypersensitivity

Consider Nociceptive Pain

“Mostly Yes”

What was your average pain over

the last week?

(0-10 NRS Scale)

Thinking of the past week… How much did pain interfere with your usual activities?

How much did pain interfere with your sleep? How much did pain interfere with your mood?

(0-10 NRS Scale for each item)

Electronic Chronic Pain Questions Module (eCPQ) Questions* CHRONIC PAIN?1 PAIN INTENSITY & LOCATION2 IMPACT ON FUNCTION, SLEEP & MOOD3-4

No = Exit

Yes

ID PAIN® Screener5 “Sensory Hypersensitivity” or Fibromyalgia-like Pain

Did you have trouble thinking or remembering in the past week? (Y/N)

Were you sensitive to such things as bright lights, loud noises, or smells in the past week? (Y/N) In addition to:

• Widespread pain from body map image / locations? (Y/N)

• Marked impairment of mood, sleep, and function? (Y/N)

• Medical history of ≥1 other sensory hypersensitivity condition? (Y/N)

PAIN QUALITY & TYPE

Where is your pain?

(Diagram)

Have you had pain most days in

the past 3 months?

(Y/N)

Did the pain feel like pins and needles? (Y/N)

Did the pain feel hot/burning? (Y/N)

Did the pain feel numb? (Y/N)

Did the pain feel like electrical shocks? (Y/N)

Is the pain made worse with the touch of clothing or bed sheets? (Y/N)

Is the pain limited to your joints? (Y/N)

* For the purposes of this presentation, the eCPQ questions have been paraphrased.

1. Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. 21st ed. Philadelphia: W.B. Saunders; 2000:104. 2. Jensen MP, Karoly P. “Self-report scales and procedures for assessing Pain in adults.” In: Turk DC, Melzack R, editors. Handbook of Pain Assessment. New York: The Guilford Press, 2011:19–41. 3. Data on File. Pfizer Inc, New York, NY. [Chronic Pain Assessment EMR Tool: Fibromyalgia Patient Research Findings. June 12, 2013.] 4. World Health Organization. Scoping Document for the WHO Treatment Guideline on Chronic Non-Malignant Pain in Adults, Adopted in WHO Steering Group on Pain Guidelines, October 14, 2008. http://www.who.int/medicines/areas/quality_safety/Scoping_WHOGuide_non-malignant_pain_adults.pdf. Accessed November 12, 2013. 5. Portenoy R. Development and testing of a neuropathic pain screening questionnaire: ID Pain. Curr Med Res Opin. 2006;22(8):1555-1565.


eCPQ14_annual_Entry CAM

• Click ‘Yes’ -> PRINTS ‘Chronic Pain Questionnaire-eCPQ14’ and Loads ‘eCPQ14 Chronic Pain Questionnaire’


Click ‘Yes’ -> PRINTS ‘Chronic Pain Questionnaire-eCPQ14’ ObsNow ‘ECPQ14PRINT’: ‘eCPQ14 printed’ Loads ‘eCPQ14 Chronic Pain Questionnaire’

Chronic Pain Questionnaire-eCPQ14


ObsNow ‘ECPQ14PRINT’: ‘eCPQ14 printed’




Loads ‘eCPQ14 Chronic Pain Questionnaire’



eCPQ14_opioid_Entry CAM

• Triggers if LASTOBSVALUE('CHRONPAINHX') is empty or not updated in last 28 days AND Medication List contains Opioid COND_IGPI|65

• UserYesNo prompt to Load Entry-Wide View-CCC Form with the ‘eCPQ14 Chronic Pain Questionnaire’ template AND print the ‘Chronic Pain Questionnaire-eCPQ14’ – Click ‘yes’ to load & print otherwise ‘no’



• Medication List contains Opioid COND_IGPI|65

• Does NOT trigger unless ALL conditions are met IGPI ‘65’



• Click ‘Yes’ -> PRINTS ‘Chronic Pain Questionnaire-eCPQ14’ and Loads ‘eCPQ14 Chronic Pain Questionnaire’


Click ‘Yes’ -> PRINTS ‘Chronic Pain Questionnaire-eCPQ14’ ObsNow ‘ECPQ14PRINT’: ‘eCPQ14 printed’ Loads ‘eCPQ14 Chronic Pain Questionnaire’



ObsNow ‘ECPQ14PRINT’: ‘eCPQ14 printed’




Loads ‘eCPQ14 Chronic Pain Questionnaire’



Chose an Option or Use BOTH! • Since the CDC Opioid Guidelines call for

a chronic pain questionnaire at the start and within 28 days for patients on an opioid, we recommend all sites use the:

• Opioid Option: All patients with an Opioid on the Med List should have a CPQ documented every 28 days

–eCPQ14_opioid_Entry CAM


eCPQ14 CQI Project

2. Create an “eCQP14" Entry Template plus Calculate function for scoring

• ‘eCPQ14 Chronic Pain Questionnaire’ Entry template available

– Copy & paste from the ‘eCPQ14 Chronic Pain Questionnaire Entry Template’ file in the eCPQ14 Kit into your sites CCCQE-User-Edit-Expanded-Hx-# file (NOTE: Be careful NOT to exceed 64K file size)


eCPQ14 – Question 1

• Have you had pain most days or every day in the past 3 months? (yes, no)

• CHRONPAINHX

• If ‘yes’, answer all questions; if ‘no’ then done



• What was your average pain over the past week? : 0: No Pain,1,2,3,4,5,6,7,8,9,10: Pain as bad it can be

• CHRPAININTEN



• Where is your pain?: head, neck, left shoulder, right shoulder, left arm, right arm, left wrist, right wrist, left hand, right hand, upper back, chest, abdomen, pelvis, lower back, left hip, right hip, left leg, right leg, left knee, right knee, left ankle, right ankle, left foot, right foot, other:

• CHRPAINLOCAT


Questions 1-3 = ‘Minimum’ CPQ

• Chronic Pain (yes or no)

• Pain Intensity (0-10 NRS Scale) 0 = no pain – 10 = pain as bad as it can be

• Pain Location (verbal/text or diagram)


CPQ Questions 4-6: Functional Impact

• Impact on Daily Activities

• Impact on Sleep

• Impact on Mood 0-10 NRS Scale


CPQ Questions 4-6: Functional Impact

• Impact on Daily Activities ISPN INT ACT

• Impact on Sleep ISPN INT SLP

• Impact on Mood ISPN INT MD

• 0-10 NRS Scale


eCPQ Questions 7-12: ID Pain Screener

• Nocioceptive: Ex.: rheumatoid arthritis, osteoarthritis, gout vs.

• Neuropathic: Ex.: painful diabetic peripheral neuropathy, post herpetic neuralgia


eCPQ14 Questions 13-14: Sensory Hypersensitivity or Fibromyalgia-like Pain

• Did you have trouble thinking or remembering in the past week?

• Were you sensitive to bright lights, loud noises, or smells in the past week?

• 0-10 NRS Scale


eCPQ14 Questions 13-14: Sensory Hypersensitivity or Fibromyalgia-like Pain

• Did you have trouble thinking or remembering in the past week?

• Were you sensitive to bright lights, loud noises, or smells in the past week?

– 0-10 NRS Scale


Additional Information Sensory Hypersensitivity or Fibromyalgia-like Pain

Other information to help diagnose sensory hypersensitivity can be derived from medical history and other eCPQ questions: • Widespread pain from body map image / locations? (Y/N) • Marked impairment of mood, sleep, and function? (Y/N) • Medical history of ≥1 other sensory hypersensitivity condition? (Y/N)


Additional Information Sensory Hypersensitivity or Fibromyalgia-like Pain

Other information to help diagnose sensory hypersensitivity can be derived from medical history and other eCPQ questions: • Widespread pain from body map image / locations?

(Y/N) • Marked impairment of mood, sleep, and function? (Y/N) • Medical history of ≥1 other sensory hypersensitivity

condition? (Y/N)


Recommended Medication Classes for Different Conditions/Types of Chronic Pain


eCPQ14 Entry Form Template Workflow

• Rapid documentation of Chronic Pain Assessment with structured data

• Systematic, structured collection of discrete data on pain in a format that allows for extraction, analysis, and aggregation

• Enable physicians to more appropriately and efficiently assess chronic pain and to help clinicians better diagnose, treat, and monitor patients with chronic pain


eCPQ14 CQI Project 3. Create a Centricity Handout of the

eCPQ14 for Centricity Users to Print and Give to Patient NOTE: sites using Secure Messaging can send electronically to patient to complete


Chronic Pain Questionnaire-eCPQ14 CCMe™ Secure Messaging

Patient receives Text Message or email that

they have a secure

message from Provider

Please complete the

attached forms (ECP)

eCPQ14



SAME CONTENT

(QUESTIONS) as in the

ENTRY FORM Template!

ONLY DIFFERENT

USER INTERFACE

SENT SECURE!



SAME CONTENT (QUESTIONS) as

in the ENTRY FORM Template!

CHRONIC PAIN

YES – > Continue

NO –> Stop/Done



SAME CONTENT (QUESTIONS) as in the ENTRY FORM

Template!

CHRONIC PAIN Yes or No

INTENSITY



• SAME CONTENT (QUESTIONS) as in the ENTRY FORM Template!

LOCATION OF PAIN




IMPACT ON

FUNCTION

SLEEP

MOOD




ID PAIN SCREEN




SENSORY HYPER-

SENSITIVITY



ONCE ALL QUESTIONS

COMPETED CLICK TO SUBMIT

RETURNS TO CENTRICITY TO

RETRIEVE & POPULATE FORM!



RETRIEVE

POPULATES ENTRY FORM



RETRIEVE

POPULATES ENTRY FORM

POPULATES OBS TERMS


eCPQ14 CQI Project Requested obs terms from GE for tracking and reporting (Factory not Custom)

CCMDIAGNOSIS Chronic Care Management diagnosis CCMCLINICIAN Chronic Care Management Clinician

CCMELIGIBLE Eligible for Chronic Care Management CCMCONSENT Informed Consent for Chronic Care Management CCMCONTACT Who to contact for Chronic Care Management questions

CCMPLANVISIT Frequency of Planned Future Appointments per year IDPAINSCRQ1 ID Pain Screener question 1

IDPAINSCRQ2 ID Pain Screener question 2





IDPAINSCORE ID Pain Screener Score

IDPSSINTERP ID Pain Screener Score 3 interpretation

ECPQ14Q13 Electronic Pain Questionnaire (eCPQ) question 13





OPIOIDRSKBEN Opioid risks and benefits explained to patient OPIOIDACINCT Informed Consent for acute opioid prescription obtained

OPIOIDACDUR Duration of acute opioid prescription in days PDMPACCESSED Prescription Drug Monitoring Program (PDMP) accessed

MMECALCULATE

morphine milligram equivalents (MME) calculated during current visit; note: not the actual MME but rather was it calculated current visit!

NONOPIOIDRX Non-opioid pharmacologics CSMGMTOTHER Controlled substance prescribing actively managed by another provider ECPQ14PRINT Electronic Pain Questionnaire 14 (eCPQ14) printed administered

SENSHYPERINT Sensory hypersensivity pain evaluation interpretation


eCPQ14 CQI Project Obs Terms

OBSERVATIONS:

• Q1 - CHRONPAINHX – History of chronic pain, yes or no

• Q2 - CHRPAININTEN – intensity

• Q3 - CHRPAINLOCAT - location


eCPQ14 CQI Project Obs Terms

OBSERVATIONS:

• Q4 - ISPN INT ACT - impact on ADLs

• Q5 - ISPN INT SLP - impact on sleep

• Q6 - ISPN INT MD - impact on mood


eCPQ14 CQI Project Obs Terms OBSERVATIONS: ID PAIN SCREEN

• Q7 - IDPAINSCRQ1 - ID Pain Screen question 1 • Q8 - IDPAINSCRQ2 - ID Pain Screen question 2 • Q9 - IDPAINSCRQ3 - ID Pain Screen question 3 • Q10 - IDPAINSCRQ4 - ID Pain Screen question 4 • Q11 - IDPAINSCRQ5 - ID Pain Screen question 5 • Q12 - IDPAINSCRQ6 - ID Pain Screen question 6 • IDPAINSCORE - ID Pain Score • IDPSSINTERP - ID Pain Score Interpretation


eCPQ14 CQI Project Obs Terms OBSERVATIONS: SENSORY HYPERSENSITIVITY

• Q13 - ECPQ14Q13 - Sensitivity Hypersensitivity screen question 1

• Q14 - ECPQ14Q14 - Sensitivity Hypersensitivity screen question 2

• Additional Historical Information (not patient questions)

• 15 - ECPQ14Q15 • 16 - ECPQ14Q16 • 17 - ECPQ14Q17 • Sensitivity Hypersensitivity Interpretation -

SENSHYPERINT


Structured Data Collection • Allows for Extraction, Analysis, and

Aggregation for clinical outcomes and quality measurement

• Rapidly Assess and Accurately Classify the 3 Main Types of Pain

• Appropriately Treat and Manage Chronic Pain


eCPQ14 CQI Project 5. Create Reporting Metric Requirements

CDC Opioid Guidelines recommended that Clinical Quality Measures be developed to track compliance with guidelines in an effort to improve quality of care

• eCPQ14 CQIC Project recommends the following metrics be used for clinical quality measures (CQM) tracking and reporting for evaluation & management of chronic pain


MACRA

MIPS APM PQRS

VBM

MU

ACI 25%

RU 10%

CPIA 15%

Quality QPC 50%

Composite Performance Score ACOs

PCMH

BPMs


Quality Counts for 50% of Score

MIPS Score (year 1): 1. Quality-of-care component 50%

2. Advancing care information accounting 25%

3. Clinical practice improvement 15%

4. Cost 10%

Quality QPC 50%


MIPS Composite Performance Score (CPS) and Categories

• Quality Performance Category: replaces PQRS and the quality component of the Value Modifier Program

• 50 percent of CPS in year 1

• Physicians choose 6 measures – Additional population measures are calculated based on

claims data, with number of measures dependent on group size

• > 200 measures from which to choose; 80% geared to specialists

Quality QPC 50%


CQIC CQM Planning Guide


TABLE E: 2017 Proposed MIPS Specialty Measure Sets

©Copyright 2016 Clinical Content Consultants, LLC All rights reserved. ©Copyright 2016 Clinical Content Consultants, LLC All rights reserved.

John Janas MD - Clinical Content Consultants, LLC

Terry Cross RN - Tallahassee Neurological Clinic

Implementing Actionable Clinical Decision Support (CDSS) Prompts to Improve Quality of Care, Workflow Efficiencies, and Reimbursement


Controlled Substance Contract MAY be Due

• Objectives: If the patient’s Medication List contains an OPIOD pain medication and there is no documented (obs term for tracking & reporting) Controlled Substance Contract, remind provider to review Controlled Substance Mgmt-CCC Form and document review and signing of Controlled Substance Contract


Controlled Substance Contract MAY be Due

Two (2) potential CDSS Workflows

1. CDSS Prompt: Controlled Substance Contract MAY be Due – View All Protocols with or without ClosePage or

Print CVS trigger or Text Component trigger in Document Template

2. CAM (Conditional Action Metric): automatic process when update started


Long-acting Opioids Indication Documentation

• Med List GPI = 651000 (long-acting opioids)


Controlled Substance Contract MAY be DUE CDSS Prompt

Informational Text



Date of last Controlled Substance Contract



Options for User



WORKFLOW OPTION 1

• Print Controlled Substance Contract opens CHL ‘Controlled Substance Contract’

• Can edit using TFE

• Opens custom list to select which contract is appropriate for your site and patient

• NOTE: must check the ‘Reviewed with patient and patient signed’ to populate OBS NARCCONTDTE



WORKFLOW OPTION 1

Print Controlled Substance Contract opens

CHL ‘Controlled Substance Contract’

Can edit using TFE

NOTE: must check the ‘Reviewed with patient and patient signed’ to

populate OBS NARCCONTDTE



WORKFLOW OPTION 1

NOTE: must check the ‘Reviewed with patient and patient signed’ to populate

OBS NARCCONTDTE



NOT INDICATED: terminal care or

hospice

populates obs term

'PAINCNTRCT_N' = 'hospice or

terminal‘

Turns off prompt for

permanently



REMOVE Medication: no longer taking

Opens Medication

Module so user can remove medication

Removing medication

turns off prompt



Alternate Workflow: Go to Controlled Substance Mgmt-

CCC form

For sites that want to do Opioid Risk

Assessments or need to document

additional Controlled Substance Mgmt,

suggest load and go to Controlled

Substance Mgmt-CCC form

Pop-up ONLY

Cannot load-go to form!


Q&A

•Questions?

•Comments?


Contact Information

• John Janas MD

–[email protected]

• Christy Moe –[email protected]

mailto:[email protected]

mailto:[email protected]

implementing cdc opioid guidelines and state prescription ......electronic chronic pain questions...

Documents