Texas has a lower rate of opioid fatalities than most states, but the toll from opioid misuse and abuse is felt in families and communities across the state.The latest data show nearly 1,200 Texans died from opioid abuse in 2015, though many researchers caution that inconsistent reporting likely means the number is higher. Nationwide, opioid-related deaths recently hit a record annual high of 42,000.
Emergency room doctors often are on the front line of the opioid epidemic, caring for patients with chronic pain as well as those struggling with addiction. Data from the Centers for Disease Control and Prevention find ER visits for opioid overdoses increased nearly 30 percent between July 2016 and September 2017. However, a study published earlier this year in the Annals of Emergency Medicine found that opioid prescriptions originating in the ER are declining and represent a relatively small percentage of opioid prescriptions compared to outpatient office visits. Still, ER physicians face a considerable challenge. Research finds pain is among the most common reason people seek help at the ER, requiring doctors to balance the very real need for pain management with the risks of diversion, addiction and overdose. And to do that as effectively as possible, they need information.
The problem is that so much of the most useful information — such as whether a patient already has a pain management plan, a tally of a patient’s recent ER visits or whether a patient unsuccessfully tried to obtain opioids at a different ER — is locked up in silos within individual hospitals and health systems. Some hospitals, however, are deciding to upend that paradigm, adopting new technology that enables the exchange of patient information among providers, with positive results for both hospitals and patients.
“It’s all about context,” said Benjamin Zaniello, M.D., chief medical officer at Collective Medical, a Utah-based health technology company. “If a patient has been to four or five hospitals in the last week, having that information goes a long way in reducing medical uncertainty.”
EDIE removes uncertainty, bias in pain treatment
Collective Medical developed EDie, a Web-based hub of emergency room data from around the country that curates actionable, real-time patient information and automatically pushes it out to ER clinicians as part of existing workflows. Nearly a decade after EDie first went live in a hospital in Washington state, the technology now is active in more than 15 states. In some states, including Washington, Oregon and West Virginia, EDie is in use at all the hospitals within that state. Zaniello said efforts are underway now to build an EDie network in Texas, with the technology already up and running in a handful of hospitals around the state.
EDie works like this: When a patient registers at an ER, EDie searches its nationwide database for a match and then curates any data it finds according to the notification criteria that each hospital sets for itself. For example, Zaniello said every hospital has chosen to receive opioid-related alerts. But the criteria also can include known care providers, care plans, history of ER visits or whether a patient has a history of violence against hospital staff. Because the technology is embedded in an ER’s workflow, it automatically pushes out alerts without being queried. Facilities that don’t have the capacity to integrate the alerts into their electronic systems receive the alerts via fax.
To date, research on EDie’s impact is promising. For example, in a study published in 2016 in the Journal of Emergency Medicine, researchers examined the impact of an EDie-driven care coordination program between three hospitals outside of Spokane, Washington, finding the effort resulted in an 80 percent decrease in the odds of a patient receiving an opioid prescription in the ER. In 2015, the Center for Health Policy at the Brookings Institution reported that the rate of visits resulting in a scheduled drug prescription decreased 24 percent after a network of hospitals adopted EDie. A 2017 CDC report on integrating and expanding the reach of state-based prescription drug monitoring programs also highlighted Washington’s EDie success. The federal agency reported that after the state’s PDMP became interoperable with EDie, the number of PDMP-provided reports pushed out to prescribers increased more than 80-fold.
A key to EDie's impact, Zaniello said, is that “by being automatic, we remove the bias from patient care, especially in regard to the opioid epidemic.” For example, he said, while ER clinicians can access a PDMP to view a patient’s prescription history, they first have to decide whether a query is needed, which requires time and additional steps. In comparison, EDie alerts are pushed out automatically and include data from a state’s PDMP, which can reduce opportunities for assumptions to which patients may or may not be struggling with addiction to factor into treatment plans.
“The point isn’t necessarily to deny a patient opioids,” Zaniello said. “But to equip providers with the information they need to help meet a patient’s pain needs without opioids.”
In other words, Zaniello said, EDie offers information that fosters and enables care coordination, whether that means finding a less risky way to treat a patient’s pain or connecting a patient with addiction, behavioral health or social services.
“EDie empowers ER clinicians to better manage their patients,” he said.
Improving care coordination, reducing ER visits
Of course, the benefits of better information go beyond the opioid problem. Back in Washington, EDie is both saving money and facilitating patient-centered care.
In 2011, the state’s Medicaid program decided to cut off reimbursements for patients who visited an ER more than three times in a year for what it deemed unnecessary care. The announcement set off alarm bells for physicians and health providers, who knew the policy could have unintended adverse consequences.
“Doctors quickly said this is a really dangerous idea,” said Alison Haddock, M.D., who at the time was an emergency department physician at Washington’s Tacoma General Hospital. “We had to do something to protect our patients and to persuade Medicaid not to take this negative action.”
With data showing that a considerable percentage of repeat ER users struggled with conditions that benefit from more coordinated care and better linkages with social services — such as mental illness and addiction services— the Washington State Medical Association, Washington Hospital Association and Washington State American College of Emergency Physicians banded together to implement ER is for Emergencies, of which EDie is a foundational component.
“So often, a patient presents at an ER not with a new problem, but an ongoing problem and each time providers end up reinventing the wheel,” Zaniello said. “But there’s probably someone in the system that already knows this patient — it’s just that the information isn’t being shared.”
The goal of ER is for Emergencies, said Haddock, who’s now an associate professor at Baylor College of Medicine and a board member at the Texas College of Emergency Physicians, was to offer patients better care by giving doctors better information, including linkages to care plans and case managers who could follow up with patients after discharge and address the issues that lead to unnecessary ER visits in the first place.
The new effort worked: In the program’s first year, the state’s Medicaid ER costs declined by nearly $34 million, and visits among frequent ER users went down by more than 10 percent. In response, Washington Medicaid officials dropped the proposal to limit ER reimbursements.
“Having access to so much more information lets us identify trends and gives us a better starting point for having meaningful conversations with patients,” Haddock said. “Being able to say ‘I know you’re in pain today, but this isn’t a brand new issue — let’s talk about it’ helps us get at the root of the problem.”
Zaniello said an ultimate goal at Collective Medical is to integrate a patient’s entire continuum of care into the exchange technology, enabling hospitals to provide more patient-centered, value-driven care to all who walk through their doors.
“Our goal is to separate the signal from the noise,” he said. “We want to tease out the most critical data and put it in a place where it can affect change.”