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 [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 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