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New alerts warn prescribers to rethink opioid prescriptions for patients at risk of addiction

by Atrium Health

Published on 10/1/2018

Everyday across America, an average 115 people die from an opioid overdose.1 Practitioners at Atrium Health, with locations across North Carolina and South Carolina, found a way to try and slow down the epidemic by creating an alert within the organization's electronic health record (EHR) warning prescribers to reconsider writing a prescription opioid medication to patients with a high addiction risk. Alerts also fire on benzodiazepines, a class of psychoactive drugs that can also be addictive. In more than 10 percent of cases, after an alert fired, prescribers decided against issuing an benzodiazepine prescription.2

"The alert created an environment in which we can divorce ourselves from our own biases," said Joseph Hsu, M.D., vice chair of quality, Atrium Health Musculoskeletal Institute. "The opioid epidemic crosses every demographic. It really crosses what our implicit biases are for what opioid use disorder looks like."

Criteria for those at risk include patients who are already taking opioids or had an addiction problem previously.

"Our EHR warning appears early in the prescription writing process," said Rachel Seymour, Ph.D., research group director for the Atrium Health Musculoskeletal Institute. "Our goal was to provide actionable information at the moment it is needed – in this case, that means when the prescription is initiated, before the prescriber has gone through the whole process of filling in prescription information."

Prescribers can override the alert if they feel the prescription is still the best option.

Between January and June 2016, when the alert fired, in 13 percent of all cases, prescribers across all specialties decided against ordering potential benzodiazepine prescriptions and 5 percent of all opioid prescriptions. In 22 percent of behavioral health cases, a prescriber decided against an opioid prescription after receiving an alert.

Associate Chief Medical Informatics Officer Matt Sullivan, M.D., says the alert helped prevent him from writing an opioid prescription for a woman who suffered an acute injury and should not have received one.

"I did not realize the patient had a prior issue with narcotics," Sullivan said. "The system picked up on a drug screen from many years back. I went back and opened a conversation with the woman, letting her know the system indicated she'd had a positive opioid screen in the past. She was very quick to say, 'Please, I don't want any opioid medications.' Then she told me about her history, and we were able to work through that together."

After Atrium Health received CDC funding to develop the alert, the team began their research by discretely running the alert in the background of the EHR without displaying the alert to providers. Testing the alert in the background without interrupting clinicians' workflow allowed staff to make tweaks to the alert and create the right type of workflow before introducing it to prescribers.

"We were able over a couple of months to actually collect data and fine-tune the alert and figure out the impact on workflow," said Seymour.

Testing the alert in the background also helped prevent alert fatigue — when providers become annoyed by alerts and begin ignoring them.

"What we did as a group was address their concerns one by one," said Hsu.

"It certainly pushed us to think about how we would treat pain differently," said Steve Jarrett, Pharm.D., Atrium Health medication safety officer. "I think initially when we started out, we were looking at the way to review those patients who had abuse potential. But that led us very quickly into much broader conversations about how we treat pain. How do we look for alternatives to opioids? How do we then take that information and provide tools needed to our prescribers?"

Atrium Health leaders are sharing their lessons with interested health systems and see a potential for others to set up a similar technique and work together.

"We envision at some point having a national database which we can tie into, bringing the information directly to the providers who are using the tools," said Sullivan.

"I think we have an obligation to actually help lead this," said Hsu. "We're well-positioned to do that and really get in front of the way out. The reality is that this epidemic is so widespread, and it involves millions of people."


2 January to June 2016

For more information on how Cerner is addressing the opioid epidemic, please visit our Opioid Crisis Response Center (uCern) group.

Client outcomes were achieved in respective settings and are not representative of benefits realized by all clients due to many variables, including solution scope, client capabilities and business and implementation models.