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Joseph Hsu, MD, FAOA Researchers at Atrium Health Musculoskeletal Institute’s Department of Orthopaedic Surgery and Atrium Health Carolinas Medical Center have developed electronic health record-integrated digital tools that run silently in the background, monitoring evidence-based risk factors for opioid or benzodiazepine abuse and alerting clinicians if a patient appears at risk. The development of the two platforms, Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM) and Implementing a Multimodal Path to Recovery (IMPROVE), was funded by grants from the CDC, as part of its call for novel strategies to address the opioid epidemic.

“We really wanted to create useable tools, not just for orthopaedic surgeons but for clinicians in many other areas who help their patients manage pain,” says co-developer Joseph Hsu, MD, vice chair of Quality at Musculoskeletal Institute. “PRIMUM runs logic in the background when a prescriber starts an opioid or benzodiazepine prescription. Opioids have gotten all the headlines, but my colleagues and I could tell from the numbers back in 2013-2014 that benzodiazepines were going to be a problem as well, and that’s proven true.”

The PRIMUM logic monitors for five objective and evidence-based risk factors that may indicate misuse, abuse, or diversion of prescription opioids and benzodiazepines. Those risk factors are: early refill of a current prescription (i.e., with >50% remaining); two or more emergency or urgent care visits with onsite opioid treatment within the past 30 days; three or more opioid/benzodiazepine prescriptions within the past 30 days; past opioid or benzodiazepine overdose; and a positive toxicology screen for blood alcohol, cocaine or marijuana.

“The platform needed to be evidence-based and objective,” says co-developer Rachel Seymour, PhD, vice chair of Research at Musculoskeletal Institute. “Physicians use their judgment and what they know of the patient, but that can be subject to bias or information can be missing.” Additionally, risk factors can be buried too deep in patient records to be useful – and while patient screenings are important, not all are forthcoming about their own risk. For all these reasons, identifying and flagging objective risk was key.

The platform is fully integrated into a normal workflow, so there’s nothing extra the physician has to do. If a patient does not have any of the risk factors, the doctor won’t even know it’s running. If there are risk factors, an alert pops up when a prescription is started, and in response, prescribers have the option to continue, modify or cancel the prescription.

According to Atrium Health data, PRIMUM generates alerts in nearly 25% of patient encounters where an opioid or benzodiazepine is prescribed – and physician decision-making is affected in about 20% of those alerts. In the first six months of its rollout, Atrium Health researchers calculated that the system prevented 43,000 high-risk prescriptions.

“We really wanted to get out in front of this crisis and bring a multidisciplinary team to build the system,” says Dr. Seymour. “And any doctor in any location can benefit from it – outpatient, emergency departments, rehabilitation, inpatient care, and hybrid facilities in urban, suburban and rural settings.” Although the system was built using the Cerner system, Atrium Health is in talks with another major provider to expand its reach.

The team has made rolling updates to the platform – a critical one was to integrate the CDC’s opioid guidelines. “In our second iteration of PRIMUM, we received funding and partnered with the CDC to operationalize their guidelines on prescribing,” says Dr. Hsu. “So we built in information about high-dose vs. long-acting prescriptions, the option to co-prescribe naloxone, and an opportunity to put patients on a pain agreement after 90 days.”

Since PRIMUM is always silently scouring for information, it gets “smarter” over time – and the larger the healthcare system it’s embedded in, the more it can learn. Importantly, the platform has shown sustained impact, without any evidence of alert fatigue from healthcare providers, which highlights its utility as a long-term tool.

“I am very proud of this important, nation leading effort by our clinical experts, to keep our patients safe,” says Claude T. Moorman III, MD, president at Musculoskeletal Institute. “Dr. Hsu and Dr. Seymour’s continued commitment to addressing the opioid crisis at large is a great credit to Atrium Health and our Musculoskeletal Institute.”

Last year, Atrium Health received additional grant funding from the CDC to develop IMPROVE, for use in the acute care setting. The aim here is to identify risk factors for opioid dependence, including alcohol use and mental health issues, and provide doctors with actionable information regarding alternatives for pain management.

“Patients who are taking prescription opioids two weeks after they’re prescribed are at the greatest risk for still taking them five years later,” says Dr. Seymour. “This entry into pain management is a critical time. IMPROVE is about a multimodal approach to pain management.”

The platform offers guidance on a number of alternative strategies, from non-opioid medications to cryotherapy to cognitive therapy. The goal is not only to reduce the reliance on opioid monotherapy but also to measure whether such an intervention will reduce the number, dose and duration of opioid prescriptions on a larger scale.

“These are three pillars of pain control – pharmacological, physical and cognitive therapies,” says Dr. Hsu. “The challenge is that people don’t realize that there are other options because we’re a pill-centered country. My colleagues and I have dug deep into the strategies that are safe and effective. With IMPROVE, we didn’t just want to call out a patient’s risk and not do anything about it – we wanted to offer alternatives that are effective.”

As the platforms continue to accrue data and expand capabilities, the team hopes more facilities will take advantage of them. “This is a platform that’s evolving – we never accept that we’ve solved it,” says Dr. Hsu. “There are constant iterations and refinements. And one of the great things is that since it’s publicly funded, our goal has always been to give it away for free. This is not an Atrium Health thing, it’s a public health thing.”

For more information, please contact:

Joseph Hsu, MD, FAOA
Vice Chair of Quality, Atrium Health Musculoskeletal Institute
Professor, Orthopaedic Trauma, Atrium Health Carolinas Medical Center Department of Orthopaedic Surgery
Joseph.Hsu@AtriumHealth.org

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