PDMP: Lessons Learned From Mandating Prescriber Compliance - Dr. John Dreyzehner, David Hopkins and Terence O'Leary

1. 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

2. 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.

3. 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.

4. 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

5. Agenda
• Background
• Kentucky’s Mandatory KASPER
Registration and Usage Legislation
– 2012 House Bill 1
– 2013 House Bill 217
• Implementation Challenges
• Results

6. Background

7. 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

8. 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.

9. 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%

10. Kentucky’s Mandatory KASPER
Registration and Usage Legislation
2012 House Bill 1
2013 House Bill 217

11. 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

12. 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.

13. 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

14. 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

15. 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

16. Implementation Challenges

17. 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

18. 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

19. 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

20. Cabinet
for
Health
and
Family
Services
KASPER Reports

21. 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

22. Results

23. 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

24. Cabinet
for
Health
and
Family
Services

25. Cabinet
for
Health
and
Family
Services

26. Cabinet
for
Health
and
Family
Services

27. Cabinet
for
Health
and
Family
Services

28. Cabinet
for
Health
and
Family
Services

29. Cabinet
for
Health
and
Family
Services

30. Cabinet
for
Health
and
Family
Services

31. 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

32. David R. Hopkins
Kentucky Cabinet for Health and Family Services
502-564-2815 ext. 3333
Dave.Hopkins@ky.gov

33. John
J.
Dreyzehner
MD,
MPH,
FACOEM
MANDATED
PDMP
USE
A
Collaborative
Journey
in
Tennessee
John
J.
Dreyzehner,
MD,
MPH
Commissioner
Tennessee
Department
of
Health

34. 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

35. 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

36. Lesson learned: Lives get saved.
Fewer addictions.
As
PDMP
queries
go
up,
doctor
shopping
goes
down
36

37. 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
HighUtilizationPatients
PatientRequests(inMillions)
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

38. Results
from
Prescriber
Survey
Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses
Q6: Answered: 769 Skipped: 3738

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses
Q3: Answered: 766 Skipped: 4047
Results
from
Prescriber
Survey

48. Results
from
Prescriber
Survey
Source: June 2013 Voluntary End-User Survey Regarding CSMD, 805 Total Responses
Q4: Answered: 768 Skipped: 3848

49. Results
from
Prescriber
Survey
Source: June 2013 End-User Survey Regarding CSMD, 805 Total Responses
Q5: Answered: 765 Skipped: 4149

50. 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

51. 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
MMEinBillions
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

52. 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

53. 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

54. Supply
and
Demand:
The
Substance
Abuse/Misuse
Market
Triangle
54

55. Substance
Abuse/Misuse:
Constraining
the
Market
PDMP
Addresses
All Three
55

56. 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

57. Thank
You

58. 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

59. 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

60. 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

71. 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

72. 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

73. 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

74. 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