Managing Morphine Equivalent Dose and Red-Flagging Red Flags

1. Linking and Mapping
PDMP Data
Presenters:
• Jason Hoppe, DO, Emergency Physician and Medical Toxiocologist,
University of Colorado and Rocky Mountain Poison and Drug Center
• Benjamin Sun, MD, MS, Emergency Medicine Physician, Oregon Health
and Science University
• Christopher Baumgartner, Drug Systems Director, Washington State
Department of Health
• Gillian Leichtling, Senior Research Associate, Acumentra Health
PDMP Track
Moderator: Christopher M. Jones, PharmD, MPH, Director, Division of Science Policy,
Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health
and Human Services, and Member, Rx and Heroin Summit National Advisory Board

2. Disclosures
Christopher Baumgartner; Jason Hoppe, DO; Gillian
Leichtling; Benjamin Sun, MD, MS; and Christopher M.
Jones, PharmD, MPH, have disclosed no relevant, real,
or apparent personal or professional financial
relationships with proprietary entities that produce
healthcare goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Explain the benefits, challenges and
opportunities of linking PDMP data to clinical
data.
2. Identify the benefits of mapping data to target
treatment expansion and overdose prevention
efforts.
3. Describe a state GIS mapping tool that
integrates PDMP data with existing databases
and displays community-level results.
4. Provide accurate and appropriate counsel as
part of the treatment team.

5. Linking PDMP Data
Jason Hoppe, DO
Department of Emergency Medicine
University of Colorado SOM

6. Disclosures
• Dr. Hoppe has no relevant, real, or apparent
personal or professional financial relationships
with proprietary entities that produce health
care goods and services
• Dr. Hoppe is supported by a Harold Rogers BJA
grant for PDMP research partnership via the
Colorado Division of Regulatory Agencies but
this presentation does not reflect the opinions
of either entity

7. Benefits of linking data
• Maximize possible benefit to public health by
translating research findings to clinical practice
– Enhance patient safety and individual
healthcare experiences
– Expand knowledge about diseases and
treatments
– Strengthen healthcare system efficiency and
effectiveness
– Help businesses meet customer needs

8. Benefits continued
• Evaluate the true value of PDMPs and the
impact of PDMP interventions
• Help evaluate causation/cause-effect
relationship identify modifiable causes
• Evaluate prescribing decisions across multiple
providers, settings and care organizations
• Improve interpretation of PDMP data, risk
factors improve decision-making

9. Investigator data needs
• No identifiable data!
• Clinical data
– Diagnosis, visits/discharges, meds, risk factors,
imaging, past med/social history, drug screens
• PDMP data
– Patient: Past/future medication use, overlaps, co-
prescribing, MME, # of providers/pharm/Rx/$$$
– Prescriber: # Rx, doses/trends in dosing, co-
prescribing, comparison to peer group
• Time periods (not dates)
• Outcomes (clinical and/or PDMP)

10. Barriers for PDMP studies
• Informed consent not realistic or efficient
• Impractical/impossible to re-contact research
subjects
• Even if possible, final group may not represent
intended group
• Need to have reliable, de-identified data sets
– Data sets in separate places, correct matching
– Waiver of informed consent

11. Barriers continued
• Statutory authority of governing body
– Interpretation of law
• Hospital and state are legally separate entities
– PDMP vendor may be third entity
• Multiple data use agreements (DUA)
• Payment mechanism
• Resources
– Little incentive to invest in infrastructure to support
research, not the mission of state or PDMP vendor

12. Current mechanisms to link data
• PDMP pulls data
• Vendor pulls data
• Researcher pulls data
• Department of public health
• Considerations: DUAs, resources, cost, time,
PHI protection, data transfer, data accuracy

13. Ideal mechanism for linkage
• Collaborative relationships
• Within confines of state laws
– Legal and regulatory safeguards in place
• Timely
• Cost effective
• Reproducible
• Reasonably assures de-identification
• Automated data transfer

14. Ideal mechanism “A”
• Approved investigator requests clinical data
for IRB approved study
• Verified suitability
• Identifies pts and obtains pt info
• Accuracy assessed
• De-identifies data set
• De-identified data set back to investigator
Choi et al. (2015), Establishing the role of honest broker: bridging the gap
between protecting personal health data and clinical research efficiency.
PeerJ 3:e1506; DOI 10.7717/peerj.1506

15. Ideal mechanism “B”
• Request clinical or public health data for IRB
approved study
• Verified suitability
• Identifies pts and obtains pt info
• Public health data linked to appropriate pt
• Accuracy assessed
• De-identifies data set
• Merged, de-identified data set back to
investigator
Choi et al. (2015), Establishing the role of honest broker: bridging the gap
between protecting personal health data and clinical research efficiency.
PeerJ 3:e1506; DOI 10.7717/peerj.1506

16. Honest broker
• Layer of protection; HIPAA safe harbor
• Individual, organization or system acting as a
neutral intermediary to collect/supply data to
approved requestors in a way in which it is not
reasonably possible to identify participants
• Firewall between investigator and identifiable
information
• Independent of the research team

17. Linking PDMP Data
Benjamin Sun, MD, MPP
Oregon Health & Science University

18. Disclosures
• Dr. Sun is supported by NIH grant R01DA03652
• Dr. Sun has disclosed no relevant, real, or
apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.

19. Learning Objective
• Explain the benefits, challenges and
opportunities of linking PDMP data to clinical
data.

20. The Plan
• NIH supported study to assess the impact of
PDMP use of emergency physicians on opioid
prescribing and patient outcomes
• Collaboration with WA State Department of
Health (PDMP) and Health Care Authority
(Medicaid)
• Beneficiary and physician level linkage of
PDMP and beneficiary level data

21. The Plan

22. Challenges
• Getting Permission
• Getting the Data

23. Getting Permission- State IRB
• State IRB
– Concerns about patient and provider identifiable
information
– Proposed complex linkage strategy
• PDMP vendor will create encrypted patient and
provider identifiers
• All files released to research team will have encrypted
identifiers, no direct patient identifiers

24. Getting Permission- State IRB
• Ambiguity in legislative language
– RCW 70.225.040 (4): “The department may
provide data to public or private entities for …
research…
– IRB questioned whether data release by PDMP
vendor violates legislation
– Department of Health issued memo clarifying
PDMP vendor is agent of DOH

25. Getting Permission- State IRB
• Limited Resources
– Very lengthy turnaround times
– Initial review and approval: 9 months
– Minimum risk amendment to add additional
variables: 6 months

26. Getting Permission- Data Use
Agreements
• Separate DUA required with Department of
Health
• Requires contracts and legal review on both
sides
• Very slow: 6 months

27. Getting Permission- Lessons Learned
• START EARLY
– We initiated IRB application 9 months prior to
study start; still had ~6 month delays
• ACTIVE MANAGEMENT
– Get on phone immediately to understand
potential barriers
– Conference calls when multiple parties involved
• USE (AND THANK) YOUR ALLIES

28. Getting the Data

29. Getting the Data- PDMP
• Vendor manages PDMP on behalf of state
• PDMP vendor saturated with PDMP core
tasks, non-core requests are delayed (2 years)
• Other possible solutions
– Contract directly with state
• Pay existing staff
• Hire new staff
– Varying ability of state partners to do this

30. Getting the Data- PDMP
• We are obtaining de-identified, non-linkable
PDMP files so that research team can
understand data structure
• We hope to obtain linkable PDMP files by late
summer 2016

31. Overall Project Management
• Research staff fully occupied preparing
Medicaid files for analysis (~500 million lines
of data)
• Plan to complete 4 analyses that only require
data we already have (detour from core
questions about PDMP use)
• Close contact with sponsor

32. Summary
• Getting permission
– Begin IRB/ DUA process as soon as possible
– Actively manage the process
• Getting data
– Explore all options, including having state
personnel prepare data
• Treat your collaborators well!

33. PDMP Track: Linking and
Mapping PDMP Data
Gillian Leichtling – Acumentra Health
Chris Baumgartner, WA State Dept. of Health

34. Disclosure Statement
• Gillian Leichtling and Chris Baumgartner have
disclosed no relevant, real or apparent
personal or professional financial relationships
with proprietary entities that produce health
care goods and services.

35. Learning Objectives
1. Explain the benefits, challenges and
opportunities of linking PDMP data to clinical
data.
2. Identify the benefits of mapping data to target
treatment expansion and overdose prevention
efforts.
3. Describe a state GIS mapping tool that
integrates PDMP data with existing databases
and displays community-level results.
4. Provide accurate and appropriate counsel as
part of the treatment team.

36. MAPPING OPIOID AND OTHER
DRUG ISSUES (MOODI) TOOL
Washington State

37. WA State Unintentional Poisonings
Workgroup (UPWG)
• Began quarterly meetings in June 2008
• Representatives from public & private organizations:
• State/local health agencies, tribal authorities, insurers, law enforcement,
substance abuse prevention/treatment, poison control, health professional
associations, academic institutions, etc…
• Developed short-term actions
• Increase provider and public education
• Identify methods to reduce diversion through emergency departments
• Increase surveillance
• Support evaluation of practice guidelines for providers treating chronic,
non-cancer pain
• Support prescription monitoring program

38. 2016 Washington State Interagency
Opioid Working Plan
38
Goal 1: Prevent opioid misuse and abuse
• Improve prescribing practices
Goal 2: Treat opioid dependence
• Expand access to treatment
Goal 3: Prevent deaths from overdose
• Distribute naloxone to people who use heroin
Goal 4: Use data to monitor and evaluate
• Optimize and expand data sources

39. Opioid Plan - Goal 4 Strategies
1. Improve PDMP functionality to document and
summarize patient and prescriber patterns to
inform clinical decision making
2. Utilize the PDMP for public health surveillance
and evaluation
3. Continue and enhance efforts to monitor opioid
use and opioid-related morbidity and mortality
4. Monitor progress towards goals and strategies
and evaluate the effectiveness of our
interventions

40. Bureau of Justice Assistance (BJA)
Previous
• Category 1:
Implementation
• FY 2010
• FY 2011
• Both closed
Recent
• Category 2:
Enhancement
• FY 2012
• Ends March
2016
Current
• Category 3:
Data-Driven
Approaches
• FY 2014
• Jan 2015 – June
2016
40
Harold Rogers Prescription Drug Monitoring Grants to
the Washington State Department of Health

41. Category 3 Harold Rogers Grant
• Data-Driven Multidisciplinary Approaches to
Reducing Rx Abuse
Program goals:
• Pilot innovative approach
• Form multidisciplinary action group
• Examine multiple data sources
• Identify target areas and create data-driven
response strategies
41

42. Project Implementation Partners
42
Washington Dept. of Health - PDMP
• Oversight, dataset prep
Acumentra Health
• Project management
University of Washington
• Analytic guidance
Looking Glass Analytics
• Mapping tool development

43. MOODI Purpose: Local Visualization
• E.g., risky Rx patterns, Rx opioid or heroin overdose
hospitalizations and deaths
Identify Needs
• E.g., buprenorphine access, methadone/OTP, naloxone,
PDMP registration, prescription drug disposal sites
Identify Resources
• E.g., medication-assisted treatment (MAT) “service
deserts” with high treatment need and low availability
Identify Gaps
43

44. Datasets Currently Included
• Dispensing records
• Prescriber registrationsPDMP
• Opioid OD hospitalizations
• Opioid OD deathsOverdose
• Buprenorphine-waivered physicians
• Opioid Treatment Program list
• State treatment admissions data
MAT
• Naloxone sites
• Safe Rx drug disposal sitesOther
44

45. Supporting Documents
 Guidance manual to aid
stakeholders in interpretation
and prioritizing interventions
 Technical document with
analytic detail
45

46. SAMPLE SCREENSHOTS
Opioid Mapping Tool

47. MOODI Functionality
Users can:
 Click to see technical details and definitions
 Zoom in or out
 Display up to 4 maps simultaneously
 View results using various denominators (e.g.,
counts, rates per 1,000 prescriptions, rates per
1,000 population)
47

48. Multiple Prescriber Episodes
48

49. High Dosage
49

50. Side-by-Side: Prescribing Risks
50

51. Overdose Hospitalizations
51

52. Travel Time to Buprenorphine Prescriber
52

53. Availability of Opioid Treatment Programs
53

54. Additional Maps
• Other maps look at bup maintenance/long-term
treatment, patients in OTP services, PDMP
registration, and dot maps for naloxone and Rx drug
disposal sites
• Maps in progress:
– Buprenorphine service availability: considers
active/inactive prescribers and caseload
– MAT service deserts: shows index score across needs
and resources related to MAT

55. USING, SUSTAINING, AND
EXPANDING MOODI
Stakeholder Examples and Next Steps

56. State Stakeholder Examples
56
Medicaid
Official
Identifies areas with
high opioid issues,
few bup prescribers
Targets outreach
efforts to providers to
seek bup waivers
Health
Officer
IDs areas with high rates
of high dosage and
overlapping benzos
Targets prescriber
education efforts
Behavioral
Health
Official
IDs areas where bup
prescribers are
providing short-term
prescriptions
Works to ID barriers
to maintenance bup
treatment

57. Local Stakeholder Examples
57
County
Health
Officer
IDs areas with high
rates of overdose and
no naloxone
Targets pharmacies for
naloxone distribution
Prevention
Coalition
Low rates of PDMP
registration, high rates of
multiple prescriber episodes
Implements PDMP
registration
campaign
Police
Chief
High rates of opioid
overdose
Seeks funding for first
responder naloxone
trainings
Medical
Provider
High rates of
overdose and Rx
risk
Convenes local prescriber
workgroup with county health
officer

58. Sustaining/Expanding MOODI
 Working on funding to sustain and expand,
for example:
 Show trends over time
 Add additional opioid-related data
 Administrative: crime lab, arrests, ER, EMS
 Survey: BRFSS, statewide student survey
58

59. Expanding Stakeholder Groups
 MOODI infrastructure now in place and may
be useful for others, for example:
 Add marijuana-related data for state groups
working on this issue
 Make platform available to other states
59

60. Contact
Chris Baumgartner, PMP Director
chris.baumgartner@doh.wa.gov
Gillian Leichtling, Mapping Project Manager
gleichtling@acumentra.org
Project Partners
WA Department of Health
Acumentra Health
University of Washington (Caleb Banta-Green, Ryan Hansen)
Looking Glass Analytics
60

61. Thanks!
• Questions?

62. Linking and Mapping
PDMP Data
Presenters:
• Jason Hoppe, DO, Emergency Physician and Medical Toxicologist,
University of Colorado and Rocky Mountain Poison and Drug Center
• Benjamin Sun, MD, MS, Emergency Medicine Physician, Oregon Health
and Science University
• Christopher Baumgartner, Drug Systems Director, Washington State
Department of Health
• Gillian Leichtling, Senior Research Associate, Acumentra Health
PDMP Track
Moderator: Christopher M. Jones, PharmD, MPH, Director, Division of Science Policy,
Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health
and Human Services, and Member, Rx and Heroin Summit National Advisory Board