In many ways, emergency physicians across the country are at the front lines of the battle against opioid abuse and addiction, as patients who are abusing or addicted to opioids are frequent users of emergency care.
The ED is often a hospital “entry point” for addicted patients, who present in the ED asking for prescription opioids to manage pain, or patients who are overdosing may arrive for treatment or are experiencing related crises. A significant challenge facing the healthcare industry in trying to combat opioid addiction is the lack of real-time information available at the point of care to alert emergency physicians about a patient’s medication use and history of ED visits.
Armed with real-time information about patients’ and their opioid use, physicians can provide referrals for substance abuse treatment or case management, rather than duplicating medical tests performed at another hospital. Tied in with the issue of opioid addiction, but also separate from it, excessive use of ED care is an ongoing problem facing hospitals and health systems as high users of ED care often have underlying social, mental or substance abuse problems that require care coordination and healthcare services provided outside of a hospital.
Healthcare leaders in Texas recently took steps to address many of these challenges facing hospital ED care teams by working with Salt Lake City-based company Collective Medical to give care teams throughout the state access to the Collective network and care coordination platform. The Texas Hospital Association (THA), which represents more than 85 percent of the state’s acute care hospitals and healthcare systems, or about 486 organizations, announced a partnership with Collective Medical back in May that will enable ED care teams in member hospitals to have access to an information exchange for more actionable information at the point of care.
While Texas is not the hardest-hit state in the opioid epidemic, the number of people in Texas dying from an overdose of opioids continues to grow. In 2016, there were 1,375 opioid-related overdose deaths in Texas, a rate of 4.9 deaths per 100,000 persons compared to the national rate of 13.3 deaths per 100,000 persons, according to the National Institute on Drug Abuse.
According to Collective Medical, the Emergency Department Information Exchange (EDie) platform will enable care teams in Texas hospitals to more rapidly identify complex patients in real-time with notifications and actionable care plan information. Through the platform, which integrates with electronic health record (EHR) systems, providers also gain insights into their patients, such as prior ED utilization, social determinants, prescription histories and advanced directives, which enables provide to make informed decisions regarding medically unnecessary admissions and readmissions.
“Collective is proven to improve patient outcomes in states across the country, and it is an invaluable tool for hospitals combating the opioid epidemic,” Ted Shaw, THA president and CEO, says. Shaw adds that deploying the Collective platform is just the first step to connecting all the caregivers at various point in the continuum of care. “We want to make sure that whether it be in the ER, or in the outpatient setting, within the hospital or between two hospitals, that there is a connectivity that results in actionable information, that sends alerts, and puts information in front of caregivers that allows them to make informed decisions.”
The partnership also supports THA’s recent voluntary guidelines for hospital ED prescribers of opioids, Shaw says. “One challenge with the opioid crisis in Texas is the need to capture information and look at the prescribing patterns out there, and then share that information appropriately in a HIPAA compliant fashion. This system is one that would do that,” he says.
Heather Marshall, M.D., a Texas-based ED physician and president of the Southwest Region for Alteon Health, a physician-led company that provides management and ED staffing services for hospitals, says the technology platform has been a “gamechanger” for ED clinicians in organizations where it’s been deployed.
When ER clinicians have access to real-time information about their patients, including medical histories, ER visits and prescriptions, it enables clinicians to provide better patient care and creates more operational efficiency, Marshall notes. “Instead of taking me two hours to figure out what’s going on with the patient, I have the information in 15 minutes. We can then provide the appropriate care to the patients, and by turning patients more quickly, we create operational efficiency as we can care for more patients.”
She continues, “We have people who have opioid problems and are simply accessing ER departments in good faith because they are not feeling well, but the solution to their problems isn’t necessarily that they need another CT scan, the solution to their problem is that they need treatment and they need to deal with the underlying disorder,” she says, noting that the ED network is a “win for everybody.” We get better operational efficiency when we’re not having to repeat workups and we’re able to get patients follow-up care.”
Marshall recently moved to Houston, but also currently continues to practice emergency medicine in New Mexico, where she previously lived. Marshall is familiar with Collective Medical’s ED network and care coordination platform as a result of her previous emergency medicine work both in New Mexico and in Washington State, where the technology has been deployed. The benefits of the Collective network also havespread by word-of-mouth among ED physicians.
About 10 years ago, many practicing clinicians in Seattle hospitals were recognizing the growing problem of opioid abuse and overdoses, according to Marshall. “Many of the practicing clinicians had identified issues with care coordination and lack of interoperability between EHRs. We felt it day-to-day, but we didn’t have data to move things. In 2007, the levers shifted, and we were able to identify that we had a health emergency on our hands and we needed a different set of tools,” Marshall says.
Several hospital ER departments in Seattle initially piloted Collective Medical’s EDie platform, and the platform was then rolled out across most of the state as part of a statewide collaborative effort to address overutilization of ED services. That effort was spearheaded by the Washington State American College of Emergency Physicians, the Washington State Medical Association and the Washington State Hospital Association. The initiative, called “ER is for Emergencies,” deployed seven best practices, one of which centered on interoperable health information exchange. As part of that effort, the collaboration engaged with Collective Medical to deploy its EDie technology. Other best practices focused on development of patient care plans, participating in prescription monitoring programs and patient education on appropriate ED use, Marshall notes.
According to a Brookings Institute study of the Washington State “ER is for Emergencies” program, the state saved $ 34 million in emergency department costs and Medicaid ED visits declined 10 percent in its first year of use in 2013. Likewise, care teams across the state have reduced opioid prescriptions coming out of the ED by 24 percent since the program’s inception.
A similar effort was rolled out in in the state of New Mexico in 2016 through a collaboration between the New Mexico Hospital Association, UnitedHealth Group, Molina Healthcare, Blue Cross Blue Shield and Presbyterian Healthcare Services. Collective Medical is currently partnered with more than a dozen state hospital associations and more than 550 hospitals in 13 states, from Alaska to Massachusetts, have deployed the company’s software and have joined the ED network. The technology platform is endorsed as a best practice for emergency medicine by the American College of Emergency Physicians.
According to Collective Medical, use of the network has improved care collaboration in healthcare organizations across the country. CHI St. Anthony’s Hospital, a critical access hospital located in Pendleton, Oregon, was able to reduce unnecessary ED visits from identified frequent ED users from 17 percent of overall visits to nine percent within six months of implementing the Collective platform. Within one year, the hospital reduced narcotic prepack prescriptions coming out of the ED by 60 percent and realized hospital cost savings of $ 200,000, the company says.
Even with widespread use of EHRs and health information exchanges (HIEs), Marshall says there are often gaps in real-time information about a patient’s medical history and a technology solution, such as the Collective Medical platform, can help to fill those gaps
“It’s a difference between push and pull,” she says, noting that an ER physician typically needs to have a concern about a patient or a suspicion that a patient has recently been to another ER in order to query the EHR or HIE. “You’re really dependent on making a judgment about a patient or them disclosing information. That’s a pull; I have to go and ask for information,” she says. “What Collective Medical Technologies is doing is their system is a push system. Every state or organization sets the trigger threshold for what they are looking for. The ER doctors can set the trigger threshold so that if a patient has been to a local ER, let’s say five or six times in the last 12 months, the system pushes that notification to the physician.”
A Collective Effort to Combat the Opioid Crisis
There are efforts at the hospital, community, state and federal level to address the growing problem of opioid misuse, abuse and addiction. Last week, the U.S. Senate passed The Opioid Crisis Response Act of 2018, which includes numerous important health IT provisions. The House passed its version of the legislation in June, and a committee to reconcile the differences between the two is nearing a resolution.
While the opioid crisis has gained attention in the past few years, Marshall says the problem of opioid abuse and addiction has been building for two decades. “When I was in medical school from 1996 to 2000, all the teaching to nurses and physicians was that we don’t treat pain enough. The entirety of the subject matter on this was more pain treatment, and for some reason, we locked ourselves into thinking that only meant opioids,” she says. “It’s become pretty clear to me that what I was taught in medical school has created a new set of problems, and we didn’t have a good handle on how to treat that problem.”
She continued, “We’ve learned that even giving three or four days of scheduled narcotics can change the patient’s body chemistry such that they develop some tolerance. If I’m a treating clinician, and I suddenly have information that tells me that the injury that this patient has is an old injury, not a new injury, that might change the medicine that I prescribe that day.”
Marshall also notes that there is growing support in the medical community for the application of universal precautions to patients being considered for or treated with opioid therapy for chronic pain. The concept of universal precautions has its origins in infectious diseases, such as wearing gloves when handling blood products. “The idea is that we should be using universal precautions every time we prescribe opioids. Every person that I prescribe an opioid to has a risk for addiction. As an ER physician, I don’t have time to do the level of analysis to determine that person’s risk. So, you can give a patient two pills, and then have them follow up with a primary care doctor a pain management specialist who can determine the co-morbidities for addiction dependence or medication misuse,” she says.
And, Marshall notes that the work to address today’s opioid epidemic will be a long-term effort. “It’s going to takes us 15 to 20 years to catch up to the addiction that has developed over the last 20 years. But, if we start doing the right things now, we’re going to see the benefit in 10 to 15 years,” she says.