Reducing Unwarranted Opioid Prescribing

Program Goals

• Raise individual providers’ awareness of their opioid prescribing patterns
• Decrease the amount of unnecessary opioid prescriptions

Organizational Outcomes

• 95th percentile for provider agreement that EHR enables prevention of opioid misuse

Collaborative-Verified Best Practices

Service-oriented support

Keys to Success

• Don’t tell doctors what to do—tell them what they’ve done, and then provide the means and culture for peer-to-peer comparative conversations.
• Be relentless with your data integrity. If bad data goes in, then provider trust is eroded, and needed peer-to-peer conversations don’t occur.

What WellStar Medical Group Did

WellStar Medical Group (WMG) analyzed their EHR data to determine differences in opioid prescribing patterns among providers. WMG was unsure whether the stark differences in prescribing patterns were due to disease burden, socioeconomics, social determinants of health, or payor mix among their 900+ physicians and 500+ advanced practice professionals (APPs). Through their analysis, they uncovered that there was no single, patient-centered reason for the variation, which meant that some physicians and APPs within the same specialty who cared for patients with similar pain burdens were simply prescribing opioids more or less frequently than their peers out of preference.

This revelation is not new, nor is it unique to WellStar Medical Group, but their approach to the problem is. The typical approach in the industry has been a finger-pointing approach where doctors are labeled good or bad because of their prescribing patterns. In reality, prescribing opioids is not a bad practice when they are actually needed based on solid clinical grounds.

WellStar Medical Group acted on the advice of their Chief of Surgery, Dr. Bill Mayfield, who said, “Don’t tell doctors what to do. Tell them what they’ve done.” Initially, none of the providers at WMG knew their comparative data regarding their prescribing habits. The first step was to provide them with this data, which would lead to peer-to-peer conversations about the differences in prescribing habits and whether more or less opioid use was medically warranted or not.

This was easier said than done. To enact such a plan, WMG needed executive approval and a plan. They got such approval and developed a plan to meet the following points:

1. Decide what is defined as an opioid. WMG chose to follow the American Hospital Formulary Service (AHFS) classification for opioids.
2. Choose the metric. This could be morphine equivalents prescribed per script, per physician, or per time interval or some other metric. WMG chose to measure the number of opioid-containing prescriptions per 100 prescriptions.
3. Create the right amount of transparency. Peers should be able to see comparisons but also have enough confidentiality to minimize defensiveness and ensure psychological safety.
4. Define attribution methods. Is the surgeon who performed the operation responsible for the opioid prescription? Or is it the internist who provides the ongoing care? WMG chose the internist.
5. Set up proper data visualization. Providers need to be able to quickly see how their prescribing habits compare to those of their peers within the same specialty, providers of the same specialty practicing at a different location, and providers of other specialties who are more or less apt to prescribe opioids.
6. Ensure data integrity. This is paramount to the project. If one medication is inappropriately included or provider attribution is incorrect, the entire program and its analysis are at risk.
7. Deliver reports to individual providers confidentially. At WMG, these reports were hand delivered with a cover letter that reiterated the intent of the data.

During the implementation of this program, WMG also implemented other initiatives, such as opioid-sparing perioperative analgesia (as part of an ERAS program), and a direct, EHR-embedded link to the Georgia Prescription Drug Monitoring Program (PDMP). As a result, they saw an 11% decline in opioid prescribing in the first six months of the program. It is difficult to accredit a certain percentage of this decline to each program, but WMG believes that having a multi-pronged approach is best. It will lead to less initiating, less quantity per prescription, fewer repeat prescriptions, and more impactful patient/provider education. When clinicians are engaged and collaborate by sharing their data and their thoughts, awareness increases.