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


KASPER Reporting KRS 218A.202

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


KASPER Accounts – KRS 218A.202

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


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


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



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



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


Results


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


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 [email protected]

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 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


TN: 7.4% (23) US: 7.0%


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

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