The Opioid Crisis, PDMP, and Interoperability

Barbara Mullarky

Barbara Mullarky

Director, Product Management at SRS Health
Barbara has had a successful career in the healthcare industry, working for both vendors and healthcare provider organizations. She has held roles in sales, marketing, product management and professional services, working with EMR and department-focused solutions for the laboratory and imaging.

Prior to becoming the Director of Product Management at SRS, Barbara was with GE Healthcare (now GE Digital), where she held the positions of Senior Product Marketing Manager for Centricity imaging products, Product Marketing Manager and Customer Collaboration Leader for what is now Caradigm, and Upstream Marketing Manager for Centricity Laboratory. Barbara also worked at the University of Arizona Medical Center, where she managed a team that was responsible for implementing and maintaining 27 departmental IT solutions, the ambulatory EMR and the patient safety initiatives.

Originally from New Jersey, Barbara now lives with her husband in Tucson, AZ. She is a graduate of the West Virginia University College of Medicine and is a registered Medical Technologist. When not at work, she loves traveling, taking photographs, watching football and spending time with her two Brittanys.
Barbara Mullarky

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opioid-blog-image-1The National Crisis

The opioid epidemic makes the news at least once a day in my neck of the woods.  Patients, providers and the government talk about the problem and how they’re going to solve it. Drug companies advertise Naloxone as something that you should have on hand as a first response to an overdose, just like having an Epi-pen on-hand is recommended to respond to severe allergic reactions. One of the most talked about solutions for physicians and eligible provides is the PDMP or Prescription Drug Monitoring Program.

What is a PDMP?

A PDMP is a state run system that records data on prescriptions for Schedule II to V narcotics. Currently, 49 states plus the District of Columbia have implemented a PDMP. Missouri is the only state without a statewide PDMP. The contents of each can vary based on the laws of the state, but generally the database is populated by pharmacies when a prescription is dispensed and, in some cases, by the dispensing physician or insurance claims. There are some holes in the databases. In some cases, federally operated pharmacies such as those on military bases, are not required to submit data. In other cases, prescriptions paid for in cash are not submitted. And they only contain the data for prescriptions written in your state. For those of you who live in towns that border neighboring states, your patients may have their prescriptions filled in a different state than where you practice.

While not perfect, PDMPs are one of the best tools available today to help practitioners understand their patient’s drug history and the patient’s potential to be an abuser.  There are documented successes with PDMPs. New York mandated the use of PDMPs in 2013, and in that first year, doctor shopping decreased by 75%, the number of opioid doses dispensed decreased by 10%, and the number of prescriptions for buprenorphine, a drug used to treat opioid addiction, increased by 15%.[1] In 2012, Kentucky became the first state in the nation to pass legislation mandating comprehensive PDMP use. That legislation led to a 13% decline in opioids dispensed, a 25% decline in prescription opioid deaths, and an almost 90% increase in prescriptions for buprenorphine, a medication to treat opioid addiction.[2]

Making connectivity difficult

Today, 39 states require a provider to check the state’s PDMP before they write a prescription for an opioid. Since not all states use the same software (some are homegrown), the ability for EHR vendors to connect to these databases is not easy or simple.  Some states, like New York, are simply not ready for EHRs to connect. This makes your workflow and the workflow of your staff difficult.opioid-blog-image-2

Figure 1 Information current as of January 2019

Is Your Prescribing Workflow Optimized?

Working with our partners at DrFirst, SRS Health now provides a seamless workflow to allow providers to check the PDMP for 35 states. Three other states are in process. With just one click, the patient’s medication history is displayed and the date that the PDMP check was performed is recorded in your state’s database and made available within the EHR’s prescribing application.

Interstate checking of PDMPs is also available for 47 participating states so practices in border towns can see not only their state PDMP data but that in neighboring states as well. Practices just need to request access to other states at implementation. If access is available across states, it will be set up as part of the installation.opioid-blog-image-3

Figure 2 Connectivity as of November 2018

What else will help?

PDMPs are one of the tools available for clinicians to help fight the opioid crisis. Utilizing electronic prescribing for controlled substances is another tool. EPCS prevents prescriptions from being altered or copied and refilled multiple times.  Pharmacists tell stories about how a 30-day supply has become a 130-day supply.

MYTH: Not many pharmacies accept electronic prescriptions for controlled substances. FALSE

According to Surescripts, > 95% of pharmacies in the US are EPCS enabled[3],[4] while physician and provider adoption remains low, with only 31% of providers using EPCS. New York leads the nation with 93.8% of controlled substances prescribe electronically. North Dakota, Maine, South Dakota and Minnesota round out the top five with 57%, 41.2%, 37.3% and 34.2%.[5]

While only 5 states require EPCS (Arizona joined the ranks as of January 1), ePrescribing of opioids is coming. Six more states have passed laws that go into effect from January 1, 2020 through January 1, 2022. In October, 2018, the federal government passed the Opioid Response Act[6]. A portion of the act called the “Every Prescription Conveyed Securely (EPCS) Act will require electronic prescribing for patients covered by Medicare and Medicare Advantage plans of all Schedule II-V narcotics beginning January 1, 2021. Earlier in the year, retail giants Walmart and Sam’s Club announced that they will require EPCS for all controlled substances by 1/1/2020 – less than 12 months from now!

How can you prepare?

For SRS Health EHR users, the answer is simple. We’re ready so you can be ready too. With our new Rx application, powered by DrFirst, we deliver an integrated eRx, EPCS, PMDP access and mobile application that allows you to meet all the state and federal mandates and help improve patient care. Just contact your account manager to learn more.

For non-SRS Health EHR users, check with your EHR vendor to see what capabilities they offer. Contact us if you’d like to learn more, our team is ready to help.

Citations:

[1]  Shatterproof, et al. “Prescription Drug Monitoring Programs: Critical Elements of Effective State Legislation.” March 2016.

[2]  Shatterproof, et al. “Prescription Drug Monitoring Programs: Critical Elements of Effective State Legislation.” March 2016.

[3] Electronic Prescribing for Controlled Substances, Surescripts

[4] E-Prescribing Pharmacies

[5] E-prescribing up more than 500% since 2015. Health Information Technology, May 8, 2018

[6] Senate easily passes sweeping opioids legislation, Washington Post, October 3, 2018

2.02% Reward for Perfect 2017 MIPS Score

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

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final-score-100The results are in! We now know how providers will be rewarded for their 2017 MIPS efforts. You may be disappointed to see that with a perfect score of 100, the 2019 payment adjustment will max out at just slightly above 2%. And, unless a provider exceeded the exceptional performance threshold, thereby qualifying for a share of the $500 million bonus pool, the reward for successful MIPS performance is no more than an approximately 0.3% positive payment adjustment.

A survey of a few SRS Health customers revealed the following correlations between scores and payment adjustments:

2019-positive-payment-adjustments-v3

To summarize, MIPS Medicare payment adjustments fall into the following categories:

chart3

So what happened to the 4% positive payment adjustment “carrot” that the MACRA legislation appeared to offer (even before the bonus)? It vanished when CMS eased the requirements and reduced the threshold for penalty avoidance. Under the mandate of budget neutrality, with fewer providers receiving negative payment adjustments, there will be less money to share among the many providers who merit positive payment adjustments.

This was not unexpected, and a similar result should be anticipated for the next few years. The 2020 payment year (2018 performance year), offers a carrot of 5%, which will be similarly elusive. And the challenge of how to sufficiently motivate and reward providers will continue over the next few years, now that Congress has extended the transition period and relaxed the previously aggressive timetable for increasing the performance threshold.

 


 

Note:  To find out your individual or group’s 2017 final score and precise payment adjustment, log in to the QPP portal and follow the “QPP Performance” prompt. Your final score will likely be what you expected based on your attestation and/or other submission(s). If there is a difference, it could be due to new information reflected in the Quality component of your score, for example:

  • If, based on sufficient volume, you were subject to the All Cause Hospital Readmission measure, that data would be included in both the numerator and denominator of your Quality score.
  • If one of your CQMs was CAHPS for MIPS, that score will now be reflected.
  • If you reported a CQM for which no historical benchmark had been available at the time of submission, a benchmark may have been created subsequently, based on 2017 performance data.

If you believe that there is an error in CMS’ calculation of your final score—and therefore your payment adjustment—you can request a “Targeted Review” by September 30, 2018.

Better Patient Reported Outcomes Lead to Better Outcomes

Barbara Mullarky

Barbara Mullarky

Director, Product Management at SRS Health
Barbara has had a successful career in the healthcare industry, working for both vendors and healthcare provider organizations. She has held roles in sales, marketing, product management and professional services, working with EMR and department-focused solutions for the laboratory and imaging.

Prior to becoming the Director of Product Management at SRS, Barbara was with GE Healthcare (now GE Digital), where she held the positions of Senior Product Marketing Manager for Centricity imaging products, Product Marketing Manager and Customer Collaboration Leader for what is now Caradigm, and Upstream Marketing Manager for Centricity Laboratory. Barbara also worked at the University of Arizona Medical Center, where she managed a team that was responsible for implementing and maintaining 27 departmental IT solutions, the ambulatory EMR and the patient safety initiatives.

Originally from New Jersey, Barbara now lives with her husband in Tucson, AZ. She is a graduate of the West Virginia University College of Medicine and is a registered Medical Technologist. When not at work, she loves traveling, taking photographs, watching football and spending time with her two Brittanys.
Barbara Mullarky

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Outcomes is a hot topic in the healthcare industry. It is one of the criteria being used to define value-based reimbursement strategies and, more importantly, to drive better care for patients.

For some time now, payers and government agencies have been using traditional measures to evaluate outcomes, assessing the number of patients who were readmitted within 30 days, or how many post-surgical infections occurred. For the most part, this data was retrospectively analyzed; it was used to put process improvements into place, but it seldom took into account patients’ own opinions on how they were doing. Ultimately, how can we claim a successful outcome if the patient doesn’t subjectively experience an improvement in health and well-being?

outcomes-blog-v2Many EHRs provide some level of clinical decision support—reminding doctors of how long it has been since an osteoporosis patient’s last bone scan, or when it’s time to review an arthritis patient’s therapy and order blood tests for his or her medications. Some might put this in the category of outcomes, but to me, they are really alerts. Can they affect outcomes—of course! But do they really tell us how the patient is doing?

To change this paradigm, practices are moving toward collecting and measuring patient reported outcomes (PROs). The National Quality Forum defines PROs as, “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.” PROs provide data on what patients are able to do and how they feel by asking questions. They not only cover the clinical aspects of pain, swelling, and range of motion, they assess the patient’s reported status for physical, mental, and social well-being.

In orthopaedics, standardized surveys such as PROMIS, HOOS, and KOOS have been designed to collect patient-reported information before and after surgical procedures. This allows physicians to prospectively and retrospectively evaluate data provided by their patients.

Prospectively, the surveys can be used to determine the factors that will drive a better outcome for the patient. Using best practices standards, physicians can make a determination prior to taking action as to how successful the outcome will be. By discussing potential outcomes, lifestyle factors, and behavioral changes with the patient before surgery is scheduled, doctors can better predict the outcome and recommend the best path—all while controlling costs. For example, if a patient does not have reliable transportation to get to follow-up appointments and physical therapy, physicians might provide information on local transportation services or decide on inpatient versus outpatient rehab.

Retrospectively, if a patient reports unsatisfactory results, doctors can gauge the patient’s feedback against the original expectations of the treatment plan. It might be that the patient is meeting, or even surpassing, the predicted outcome. That little piece of information might change the patient’s outlook and get him or her back on the path to success. Alternately, doctors can determine what could have been done to either reach a better outcome, or develop a more accurate prediction. These learnings can be implemented as best practice to drive better outcomes for future patients.

PROs can also be used as a benchmarking tool, as a way to gauge success against others in the same practice or the same market.

Today, only 35% of orthopaedic practices are collecting outcomes data. Part of this is due to the complexity of managing the process—of collecting, analyzing, and making the data relevant. The most critical step is of course getting the patient to respond to surveys, but equally important is presenting that data in a way that orthopaedists can review it and share it with the patient at the point of care, during the appointment. This allows them to intervene quickly when a negative outcome is reported. Imagine a future when a patient reporting a pain level of 9, a knee that is red and swollen, and an inability to stand without assistance automatically triggers a message to your office to call and intervene. Not only can this save the patient an unnecessary trip to the emergency room, but it can potentially save the practice money if it is doing bundled payments.

At SRS, we believe that the process of collecting and acting on patient reported outcomes should be as automated as possible, and should all take place in the same system you work in, day in and day out—your EHR. That is why we have made this vision a reality with our integrated Outcomes solution.

Are You PDMP Ready?

According to the United States Centers for Disease Control and Prevention, opioid addiction claims 115 lives and sends more than 1,000 people to emergency rooms every day, and has killed 64,000 people in 2016. It is the leading cause of death for Americans under 50 years old.

Prescription opioids are a main factor in the crisis. Although there has not been an overall change in the amount of pain reported by Americans, opioid prescriptions have quadrupled since 1999.

What’s being done to help?  Prescription Drug Monitoring Programs (PDMPs) are state-run drug-monitoring programs that collect and track controlled-substance prescriptions in a searchable database. They provide physicians with intelligence about prescribing and patient behavior that can help them make appropriate prescribing decisions. Learn how you can get PDMP ready:infographic-srs-pdmp

Why an EHR Solution Is a Must-Have for 2018

Diane Beatini

Diane Beatini

Vice President, Sales at SRS Health
Diane Beatini is the Vice President of Sales. She oversees the Sales, Account Management, and Sales Operations teams. She works to promote the complete SRS product suite of HCIT solutions to medical practices of varied sizes and specialties. Diane’s background includes an MBA in marketing and finance with 15 years of executive sales and customer service management experience in the radiology, medical device, and pharmaceutical industries.
Diane Beatini

Looking back at 2017 as we head into 2018, the resounding theme in healthcare has been the push to bring down costs and drive up quality by increasing efficiency and improving care coordination. As the healthcare landscape shifts and evolves with groundbreaking alliances such as the proposed CVS Health/Aetna partnership, it is interesting to note that the percentage of office-based physicians using an EMR/EHR solution is a significant 86.9%, with only a small percentage of medical practices still using traditional paper charts. (Health IT Dashboard)

Reasons cited by physicians for remaining on paper include failed implementations, fear of a loss in productivity, and security concerns. While these are valid concerns, practicing medicine using traditional paper charts is becoming increasingly difficult as the industry moves to a value-based payment model, with more emphasis placed on patient engagement, interoperability, and shared patient data.

Typically, physicians spend 30–40 hours per week interacting with their patients. In a paper-based office, each patient visit results in approximately 10–13 pieces of paperwork, detracting from the time spent on patient care. (Benefits of Modern EMR vs. Paper Medical Records) Even if the physicians themselves do not handle the paper, their staff must, and a paper-driven staff results in an unproductive office. Since paper charts can only be in one location, clinical and administrative staff spend valuable time locating and providing charts. When there are multiple office locations, the additional chart transport compounds the problem and the practice becomes even more unproductive. Most practice administrators estimate the cost of a chart pull at $5.00 in lost productivity. Multiplied across hundreds and thousands of active charts, the numbers become staggering.

To remain competitive in the ever-changing healthcare environment and to attract patients and physician recruits, an EHR solution is a must-have for 2018 and beyond. As the penalties increase and reimbursements decline year by year, EHRs play a critical role in helping to preserve and drive revenue and reduce costs. Significant benefits of adopting an EHR include:

  • Reduced Administrative Burden An EHR can eliminate redundancies in documentation, provide fast and accurate record transmission, and drive efficiencies throughout the clinic, inclusive of patient intake. This can be accomplished while mimicking the traditional paper chart, which allows for an easy transition from paper to an electronic system.
  • Heightened Cost Efficiencies – An EHR can drive productivity, saving physicians and clinical staff valuable time and reducing the need and/or cost of transcription services, chart rooms, and record clerks. Regulatory resources through a reputable HCIT partner can assist the practice in penalty avoidance and meeting the requirements for MACRA/MIPS.
  • Patient Referrals/Community Presence – A 2006 Harris Interactive Poll reported 55% of adults believed that the use of EHRs would reduce the number of medical errors, and 60% believed the use of EHRs would lower their healthcare costs. (Benefits of Modern EMR vs. Paper Medical Records). Since that time, patients have come to expect electronic access and communication with their providers through the use of a patient portal. In addition to medical records access, secured messaging, and appointment and refill requests, an integrated patient portal embedded in the EHR allows patient-entered information and demographics to automatically populate the chart and the note, saving critical time and expense.
  • Patient Safety – EHRs improve patient safety by providing an organized, all-inclusive electronic chart that houses reminders, messages, and alerts in addition to exam notes, diagnostic images, and medical, medication, and allergy history. Each chart is readily accessible from any office location as well as remotely so providers have the complete information when responding to messages from inside or outside the office.

So why do some practices continue to hold out? The most common reason cited for not making the transition is the inability to obtain a physician consensus—there are differing opinions as to the best EHR, and even as to the best approach, including how much or little interaction they want with the solution, and the degree of elimination of paper from the practice.

Successful adoption of a solution, therefore, can be ensured by working with a vendor who can tailor the implementation to the needs of the practice and its providers, addressing individual physician workflow preferences and providing flexibility and ease of use. Further, practices can ensure that the solution will support their preferred clinical workflows by choosing an established and recognized EHR partner with proven experience in their medical specialty. The right partner will also be able to provide testimonials and client references documenting its ability to implement, train, and transition practices from paper charts without any impact on either patient volume or productivity. Is your practice still on paper and if so, what’s holding you back?

The Top 5 Challenges for Orthopaedists

In a recent article featured on Becker’s Healthcare, 19,200 physicians representing over 27 unique specialties were surveyed on what the most challenging parts of their careers were.

Here are the top 5 challenges for orthopaedists:

The Top 6 Challenges for Orthopaedists

It is also interesting to note that “Despite challenges, 79 percent of orthopedists would choose a medical career again, and 95 percent would choose orthopedics again.”

Would you?

2018 MACRA (MIPS) Proposed Rule: The Abridged Version

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

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lynns-notesThe proposed rule is here, and it’s another long one! So for those who don’t have the patience (or the time) to read through the 1,000+ pages, here are some highlights from what CMS is suggesting for the second year of MIPS. Bear in mind that these are proposals; they must be confirmed in the Final Rule, which will be released by November. (What had already been set in stone within the MACRA legislation itself is the maximum penalty and related incentive: 5% in 2020 based on performance in 2018, up from 4% in 2019 based on performance in 2017.)

  • CMS would allow clinicians to use either 2014- or 2015-Certified EHR technology to report for 2018. Acknowledging the slower-than-anticipated pace at which EHRs are achieving the next required certification, this accommodation will facilitate more successful, non-rushed upgrades and provide sufficient time for training on the new capabilities and associated requirements. To encourage the move to 2015 CEHRT, 10 ACI bonus points would be awarded for its exclusive use. (Finalized as proposed)
  • The Quality reporting period returns to full year, but ACI (Advancing Care Information) and Improvement Activities remain at a minimum of 90 days. Cost is still unscored, but performance in this category will be evaluated by CMS and feedback will be provided to clinicians to prepare them for 2019 when, by law, the cost category must account for 30% of the MIPS score. (Finalized as proposed)
  • The proposed performance threshold separating “the winners” from “the losers”, (i.e., recipients of positive vs. negative payment adjustments), would increase from 3 points out of 100 in 2017 to 15 MIPS points in 2018—still an eminently achievable bar. (Finalized as proposed)
  • CMS would implement increased protection for small groups (≤15 eligible clinicians)—these are the practices that had been predicted to be the most vulnerable to penalties. (Finalized as proposed)
  • Many more clinicians would be exempt from MIPS altogether because the eligibility threshold would increase from $30,000 to $90,000 in annual Medicare revenue and from at least 100 to at least 200 Medicare patients.
  • Small groups that do participate in MIPS would receive 5 bonus points toward their score, in an attempt to level the playing field.
  • And my favorite proposal (Unfortunately, not finalized as proposed) is one that specialists, in particular, will appreciate: the elimination of the restriction that all 6 quality measures had to be reported by the same submission method. In 2018, clinicians would be able to mix and match submission methods within a category. Specialists, who have typically been faced with an insufficient number of relevant eCQMs, would be able to continue reporting those measures which are available by EHR submission, but could supplement them with registry or claims measures that are also specialty specific. The result would be more meaningful reporting and more equitable scoring. This is a request that SRS has included in its comments to each of the previous proposed and final MACRA rules, so we were very happy to see this change.

MIPS is only one of the two MACRA participation options, and CMS has also proposed some changes designed to accelerate the shift from MIPS to Alternate Payment Models. More on that topic in a future post.