OAPWG Working Draft Deliverables

Submitted by lmarcial@pcorc… on Tue, 06/19/2018 - 10:00

Future Vision Scenarios, Intervention Summary Table, and Stakeholder Steps/Recommendations

Opioid Action Plan: Results - Future Vision Scenarios and Intervention Summary Table


Future State Vision Scenarios

(Numbered PCCDS interventions [x] point to the row in PCCDS Intervention Summary Table that follows the 5 scenarios below):

SCENARIO 1

PATIENT: 65 yo female, chronic knee pain from osteoarthritis 
CONTEXT: Opioid naive; PCCDS to avoid opioid initiation
  • Patient particularly bothered by knee pain she’s had for years (diagnosed as osteoarthritis). Her medical home practice enrolled her in their patient portal and ensured she was comfortable with it, so she checks the portal which directs her to helpful information, tools and guidance [1], [13]. This includes background information about osteoarthritis [1], function/pain evaluation tool (severity, alleviating/exacerbating factors, effects on daily life) [2], evidence on treatment options (effectiveness and potential harms) - and related decision guide [3]. Patient completes evaluation and decision guide tool (results recorded in portal [1], [13]), schedules PCP appointment using portal [1], [13] to discuss with PCP and take next steps. The portal guides her to fill in a pre-visit questionnaire regarding her reason and goals for the visit [4], [13].

  • During PCP huddle on the morning of patient visit, the medical assistant (MA) and provider review the pain evaluation and decision tool results and tee the tool up for further review and discussion with the patient during the provider visit [3]. They are able to view a summary of the patient’s goals, life circumstances, and attitudes regarding effects of healthcare on their life that provide a “human” snapshot to facilitate knowing the patient [4]. They also consult the Health Information Exchange to validate previous diagnostic studies and treatment plans performed at other health care organizations [8]. Patient previously had orthopedic consultation and was not considered a surgical candidate. Minimal therapeutic options were tried, leaving open the possibility of non-opioid alternatives to pain management which have not previously been attempted.

  • When rooming the patient, MA confirms/updates information in these tools [3], confirms/refines patient expectations for the visit (including questions or information needs from the patient) from the pre-visit questionnaire [4], and migrates this information into the EHR visit note, which is generated using a documentation template optimized for this purpose [5].

  • During provider encounter, patient and PCP review/use shared decision-making tool to support therapy selection [3]. After tool-supported evidence-informed discussion of risks/costs/benefits of different approaches, patients’ values/expectations [3], they agree a trial of topical diclofenac (a non-opioid medication) is the best approach, which is prescribed electronically and documented in a care plan [6].

  • After visit, patient uses mobile (smartphone or tablet) versions of tools to document progress (e.g., function/pain/activity levels) [2], support adherence to plan [6], and address questions and issues that arise [1]. These tools interact seamlessly with the practice portal and EHR so the PCP and team AND the patient each have easy methods to communicate without “extra” effort to use the system selected by the other [1], [13].


SCENARIO 2

PATIENT: 40 year old male, sudden severe flank pain (renal colic) 
CONTEXT: Opioid initiation in Emergency Department in opioid naive patient
  • Patient experiences sudden onset of severe flank pain with nausea and vomiting. His partner uses symptom evaluation tool which indicates these be related to a kidney stone and require evaluation [7], [13]. Data from evaluation tool is transferred from the evaluation tool/patient portal to the patient’s health system’s EHR and available in the ED [7], [13].

  • In the ED, the evaluation tool data is reviewed and discussed with the patient [7], [13] as other evaluation is completed. The patient is diagnosed with acute renal colic and is discharged from the ED with a care plan/instructions/e-prescriptions [6], [10] that include opioids to manage the pain and an appointment to follow-up with his primary care provider. (PDMP check as part of prescription generation [8] reveals no other documented opioid use.)

  • After ED discharge, patient reviews information in the portal about renal colic (including pain management issues) linked from the care plan and his pertinent data [13], [6], [1].

  • On visit with primary care team one week following the ED visit, the patient is still experiencing severe pain. Provider uses tools with patient for evidence-informed therapy selection (including risks/costs/benefits for options) [3], authorization [3], and safety (e.g., PDMP check that support patient communication [8]). The provider reviews the PDMP results with the patient to discuss previous, current or overlapping prescriptions for controlled substances [8] and completes an assessment for opioid use disorder [9]. In this case, there aren't any red flags, and the discussion results are recorded in the EHR using a structured documentation template [5]. These PCCDS-facilitated steps ensure synchronization of patient, clinician and payer understanding and goals and, in this case, continued short-term opioids are indicated, agreed upon and approved [3].

  • Provider/patient use template to build on the ED care plan to create a shared care plan for opioid use for acute pain management (completed during visit with links to patient tools for outside visit) [6], [13]. Includes treatment goals, pointers to patient education materials/tools patient can reference after the visit for therapeutic/side-effect monitoring and management (e.g., coping with mood/depression effects) - all documented on the after-visit summary [6], [13]. Provider uses pre-loaded e-prescription tool linked to a standardized order set for opioid continuation; the prescription/order set includes dosing per CDC guideline (lowest dose, limited duration), interaction check for drugs that can decrease opioid metabolism and increase adverse events (e.g., benzodiazepines); urine drug testing to ensure the patient isn’t already receiving opioids; scheduling follow-up visit/check-in [10].


SCENARIO 3

SUBJECT: Chronic opioid use in patients of various ages and conditions 
CONTEXT: Registry use drives outreach to enhance pain management and ‘right-size’ opioid use for individuals
  • Clinician becomes aware of evidence-based guidelines and tools (e.g., updated guidance and CDS tools related to CDC’s work on opioids since their 2016 guideline on prescribing opioids for chronic pain, updated state laws governing pain management) to support patients with chronic pain and long-term opioid use and/or high dose (i.e., high Morphine Milligram Equivalents [MME]) [11]. Uses practice registry to identify such patients [12] and begins executing the steps outlined below with each of these patients - starting immediately with those already scheduled soon, then recalling those who don’t have appointments in the next 2 months and that the care coordinator reviewing the patient list believes could benefit significantly from the new information [12]. Remaining bullets illustrate how this plays out with one particular patient.

  • Before visit, provider sends pertinent patients a message via portal [13] that there’s new guidance and evidence on how best to manage chronic pain that they’d like to discuss during the next visit [1]. Sends patients related educational information [1] and decision aids [3], along with a function/pain assessment journal (activities/function, severity, alleviating/exacerbating factors, effects on daily life) [2] the patients might find helpful in better understanding and managing their pain (for patients not using the portal, alternative outreach approaches such as phone call are provided).

  • In pre-visit planning/MA-provider huddle, results from patient’s pain assessment are reviewed [2] and opioid care plan template [6] (with screening tool for opioid misuse/addiction/overdose as well as highlighted data on last PDMP check, last urine drug screen, medications that could increase overdose risk, and other pertinent data) [9]- pre-populated with patient’s opioid use history [8], non-opioid pain treatment history and rationale, latest function/pain assessment [2]- is teed up for use during the visit.

  • During the visit, provider and patient use a shared decision-making tool that addresses chronic pain for the patient’s condition [3] and dashboard (i.e., latest function/pain info and opioid use history) [15] and PDMP check [8] to identify full scope of opioid use (and foster related provider-patient communication and support) to develop a shared care plan [6] for better managing the pain while minimizing potential adverse consequences of opioid use. . The shared decision-making tool [3] identifies evidence-informed, non-opioid interventions they agree could be beneficial add to the regimen. It also includes plans to attempt to reduce opioid use [3] if/as patient responds to the other interventions. [An order set for these interventions supports their execution and related patient education and support [10]. Includes supportive order such as a bowel function regimen of stimulant laxatives, stool softeners, and oral hydration, and evidence-informed structured tapering of opioid dosing for when that’s appropriate]

  • Patient uses their function/pain assessment journal [2] and other support resources after visits to support execution of the shared care plan [6] (e.g., ongoing assessment and optimization of function, pain, associated life and environmental events, and mental and spiritual health; appropriate use of meds and other therapies, and assessment for opioid-induced constipation and other opioid-induced side effects). [13]

  • Patient has copy of provider-signed care plan (including opioid use agreement) to share with other providers outside primary pain management setting, e.g., when receiving urgent care, to prevent under-treatment from stigma and maintain continuity of care [6], [13]. Includes contact information to primary pain management provider. Urgent and emergent care settings often see red-flags when patient knows exactly what they need to relieve a pain breakthrough crisis. Patients at this point aren’t good self-advocates. Allows receiving clinician awareness of current plan of care with contact information to confirm legitimacy.


SCENARIO 4

PATIENT: 20 year old female undergoing joint surgery 
CONTEXT: Opioid initiation after surgery in opioid naive patient
  • Prior to admission for left knee anterior cruciate ligament (ACL) repair, nurse in surgeon’s practice conducts comprehensive pain/function history using documentation template [5]. This nurse and patient use evidence-informed shared decision-making tools that present information about the typical range of pain expected after surgery and strategies (e.g., medication (such as nonsteroidal anti-inflammatory drugs and opioids) and other approaches (mind-body interventions, pain management classes analogous to birthing classes)) to manage the post-operative pain [3].

  • This discussion includes considering if the patient will need or want opioids after this surgery.  They discuss circumstances where patients don't want a prescription, e.g., because a family member in the same house is in recovery. They check the PDMP [8]—which indicates that the patient has not filled a prescription for opioids or other medications which could be dangerous in combination (such as benzodiazepines or sedative/hypnotics). They use this discussion/information to develop a post-surgical care plan that addresses pain management [6]. The care plan [6] and related resources for the patient to learn more about and prepare for post-operative pain are provided via the practice portal, which the patient can also use to provide updates about preparation for surgery and ask questions [13].

  • On admission to the hospital, the pain management care plan [6] and patient activities and questions preparing for surgery [13], are reviewed by surgical team with patient prior to procedure.

  • After procedure, in-hospital opioids ordered for patient per inpatient protocol via order set [10] informed by the patient-specific care plan, which is updated to reflect post-op orders [6].

  • Pain assessed during hospitalization [2], and orders modified accordingly [10]. Prior to discharge, provider uses shared decision-making tool with patient to optimize post-discharge pain management and minimize opioid use [3]; the resulting discussion about benefits and risks of various approaches to pain management leads to the shared decision for a prescription for a few opioid pills (with guidance on avoiding bowel complications), understanding that the patient may have more pain after the prescription runs out, but probably won’t.  Provider translates discussion results into an order set/e-prescription tool that performs safety checks and prints the prescriptions [10] and also into a post-discharge care plan [6] given to patient in paper format, and available electronically via the portal [13].

  • At home, patient used care plan to help guide recovery [6]. She tried the prescribed opioid for pain at one point but became nauseated, and found other strategies recommended in the care plan (NSAID, guided meditation, etc.) were adequate for pain control [6]. After her recovery, she disposed of the unused opioids at a local pharmacy, as recommended in the care plan [6].


SCENARIO 5

PATIENT: 33 year old male with history of multiple opioid prescriptions presents for evaluation of new symptoms
CONTEXT: Opioid Use Disorder Screening, Diagnosis, and Initiation of Medications for Opioid Use Disorder (MOUD)
  • A patient presents to a primary care clinic for evaluation of a worsening pruritic rash of 4 days duration on both forearms.

  • The primary care clinic’s EHR is linked to a Web-based clinical decision support (CDS) system that, upon entry of a blood pressure at an office visit, triggers an assessment of potentially high-priority unmet health care needs [19]. The CDS algorithm (which are not yet connected to the PDMP but could be in the future) detect that the patient may have some risk of OUD based on having had 3 prescriptions in the last year for opioid medications for various reasons (dental work, low back pain, and knee injury). The risk factor for OUD returns a flag to the EHR that creates an “OUD notification” in an ‘action items’ section of the EHR.  The provider reviews this EHR section at the beginning of the office visit and sees that the patient has potential for OUD.

    • [Other risk factors that could return a flag for OUD risk include previous diagnosis of OUD, other substance use disorders besides tobacco, or a medication for opioid use disorder (MOUD) on the active medication list.]

  • The provider starts the visit by addressing the patient’s main concern. The provider diagnoses allergic contact dermatitis and prescribes appropriate therapy.

  • After the patient’s main concern is addressed, the provider carefully shares with the patient that data in the EHR has suggested that OUD is a consideration [19] and asks permission to explore this in case it is an opportunity to improve the patient’s wellness. The patient agrees, and the provider open an OUD screening and diagnosis module [9] and ask the patient 2-6 questions for opioids and heroin use using a validated screening tool called the TAPS (Tobacco, Alcohol, and Prescription Medication and Other Substance Use Tool). The TAPS screen is positive for OUD because the patient has tried and failed to cut down on opioid pain relievers and his family is concerned. The TAPS result is saved into an EHR flow sheet at the close of the encounter for use in CDS algorithms when the patient next returns to the office. [The provider won’t be bothered with a notification to prompt for OUD screening if the TAPS has been done in the last 3 months.]

  • At the conclusion of the positive TAPS, the assessment tool opens a linked online module with a questionnaire that walks the provider and patient through an assessment of the DSM diagnostic criteria for OUD [9]. This takes 2 minutes. They also review together information in the PDMP [8]

  • The patient meets DSM OUD diagnostic criteria, so the patient and provider agree to explore patient readiness to change and identify clinically appropriate MOUD options using an OUD shared decision-making tool [17].

  • The shared decision-making tool displays treatment options based on co-morbid conditions such as pregnancy, severe liver disease, severe respiratory disease, active alcohol use disorder, use of benzodiazepines, chronic pain, and suicide risk [17].  The conditions are identified using EHR-derived data by algorithms connected to the tool and are pre-populated on radial buttons on the tool’s display screen [17].  The radial buttons can be reviewed and modified by the provider and the treatment options are automatically updated [17]. MOUD options for this patient to consider include suboxone, naltrexone (IM or PO), or methadone.  If pregnant, referral to a high-risk perinatal specialist is recommended. The tool includes shared decision-making materials that help the patient to decide which treatment option would be best [17]. [5 minutes]

  • Based on clinician recommendations and readiness to treat, the patient and clinician elect to proceed with MOUD using home initiation of suboxone. The provider has taken an online course and is waivered to prescribe suboxone. The clinician then uses an order set to generate prescriptions for: medication initiation (2 mg suboxone starting dose in a patient with suspected low opioid tolerance) plus clonidine and ondansetron for breakthrough withdrawal symptoms [16]. The order set also includes an overdose prevention kit (naloxone) suggests consideration of referrals to behavioral health and chronic pain resources as indicated, which the clinician elects to defer to the next visit [16].  

  • The clinician has run out of time and closes the visit by reviewing and printing at-home induction instructions for starting and titrating the suboxone [18]; these are also sent to the patient’s portal [13].   The results from using the shared decision-making tools, the orders, and the patient support materials populate an OUD Care Plan [6].  A return visit is scheduled with the same waivered clinician in 2-3 days.  The patient leaves with meds, instructions, and a safety kit for opioid overdose scenarios [16, 18].

  • At the return visit 2 days later, the ‘action items’ notification again appears based on the previous OUD diagnosis [19].  The clinician clicks on the notification which, based on the OUD diagnosis and suboxone medication identified, opens to an expanded section on suboxone maintenance [19]. The clinician discusses the patient’s suboxone dose and assesses for withdrawal symptoms. The patient has self-titrated to 8 mg of suboxone a day and is no longer using opioid pain relievers and experiencing no withdrawal. The clinician asks the patient to remain on this dose of suboxone.

  • The clinician then opens the algorithm tool that addresses other additional patient-specific NIDA-recommended clinical needs for this patient population [19] such as screening for certain infectious diseases (HIV, hepatitis C, chlamydia, gonorrhea, syphilis, tuberculosis), administering indicated vaccinations (Pneumococcal, hepatitis B, tetanus), urine drug screens, and depression and anxiety screening. The provider then uses the MOUD-related order set to order [16].

  • The second visit includes the following actions implemented via an order set [16]: a prescription for an additional 7-day supply of suboxone at the optimal dose, needed tests and vaccines as indicated by the algorithm tool, another visit for follow up in 7 days with the treating clinician, referral to behavioral health, (Due to time limitations, consideration of referral to chronic pain resources is deferred to the next visit.) The care plan is updated accordingly [6], and the provider discuss and provides additional OUD/MOUD support materials in print [18] and to the portal [13].


PCCDS Intervention Summary Table

PCCDS interventions that can be applied to pain management/opioid use to improve pertinent care processes and outcomes:

#

Clinical Need

PCCDS Intervention

1

 

Empower patients to begin addressing new findings/conditions outside office encounters

Topic-specific (e.g., chronic knee pain, renal colic), evidence-informed  information on treatment options and results - especially concerning pain management; related portal functionality (e.g., upload data to provider and patient <-> provider messaging)

2

Track pain severity/impacts and therapies to optimize management/results

Pain tracking journal

3

Evidence-informed shared patient-clinician decision making on pain evaluation and treatment

Shared pain management decision making tool; includes ability to have selected treatment authorized by payer

4

Patient summarizes data/goals pertinent to visit to make it more efficient/ results-focused

Pre-visit questionnaire

(Including setting priorities and realistic goals)

5

Support key pain-related data gathering/ documentation pertinent to encounter by care team

Condition-specific pain-related visit/procedure documentation template

6

Document and guide shared goals, actions, monitoring for managing condition (manage continuity of care and prevent under-treatment due to stigma when requiring treatment away from primary pain management setting)

Condition-specific pain-related care plan creation/tracking tool. Components include (as pertinent):

  • pain agreement/opioid use contract
  • follow-up visit timing (e.g., monthly)
  • urine drug screens
  • tapering plan
  • printable version for receiving clinician signed by primary treating clinician (with contact information)

7

Empower patients with guidance on addressing new symptoms

Symptom evaluation tool and related functionality (e.g., upload data to provider)

8

Review all controlled substances prescribed to patient to support safe use (more broadly, review pertinent evaluations and treatments patient has had for underlying problem)

PDMP Tool (results can be shared with the patient to discuss previous, current or overlapping prescriptions for controlled substances in developing shared care plan; ideally, seamlessly integrated with e-prescribing/order entry clinical workflow) (more broadly, leverage health information exchange for pertinent information from other providers)

9

Identify patient who have or are at risk for opioid use disorder, so these can avoided

Opioid use disorder screening/assessment tool for overdose, misuse and addiction

10

Ensure safe/effective, condition-focused ordering of primary therapeutic intervention and all key associated corollary orders and safety checks

Module (including safety checks/corollary orders and other approaches to ‘make the right action easy’) within a condition-specific pain-related order set focusing on opioid use. Includes pre-loaded, standardized e-prescriptions, e.g., for ambulatory settings or discharge from inpatient/acute care settings.

11

Current, authoritative guidance for clinicians on evidence-informed, patient-centered pain management and opioid use

Opioid/pain management guidelines (e.g., CDC’s) and related tools to implement these guidelines (e.g., other PCCDS interventions in this table and associated safety checks and ‘making the right action/decision easy’)

12

Identify which patient are receiving opioids so that as new guidance becomes available, pertinent patients can be identified and addressed accordingly

Opioid use registry, including related patient outreach tools

13

Open non-synchronous communication channels between patients/caregivers and clinicians/support staff

Portals and websites for FAQs, status reports, pre-visit questionnaires, custom questions and concerns, self management guidance/tools. Audio, video, virtual education. Office, home and telehealth appointment scheduling.

14

Ensure total opioid dose prescribed to patient are within safe limits.

Morphine Equivalent Daily Dose (MEDD) calculator for total opioid dose - ideally, seamlessly integrated with e-prescribing/order entry clinical workflow

15

Track and optimize opioid use and response (including functional status) to optimize pain management and related outcomes

Dashboard for visualizing opioid use and functional status/response over time, linked to pt-specific recommendations as appropriate (e.g., from PCCDS Intervention [3])

16

Support evidence-based implementation of medication for opioid use disorder

MOUD Order Set

17

Evidence-informed shared patient-clinician decision making on MOUD MOUD Shared Decision-making tool

18

Support patient in understanding/ implementing MOUD and related OUD management activities MOUD/OUD materials for patient education, engagement, support

19

Algorithms to detect high priority unmet health needs such as possible OUD and return notifications for action Algorithm for detecting possible OUD and notification

Critical Steps and Recommendations

People and Patients

Critical Step

  • Use the PCCDS interventions independently and in collaboration with their care teams

Other Recommendations

  • Review the future vision summary and comment if (A) this would meet my goals of providing the healthcare experience I want or (B) comment on what is needed to get there

  • Engage in actions above/below to ensure intervention/scenario value

  • Expect/demand future scenarios as routine/common

Providers and Care Delivery Organizations

Critical Step

  • Implement PCCDS interventions from Summary Table to realize Future Vision Scenarios; providers use the interventions in care delivery

Other Recommendations

  • Orgs systematically measure success resulting for their implemented strategies and tools.

  • Orgs having success share strategies/tools (e.g., on PCCDS LN’s Resource Center)

  • Orgs working on pain/opioids review/apply success models (e.g., on PCCDS LN’s Resource Center)

  • Orgs not having success try pilots of strategies/tools

  • Orgs identify their most important “problems to solve”

Healthcare IT Vendors and Providers

Critical Step

  • Provide interventions within their systems, make sure providers and patients can use these tool

Other Recommendations

  • Describe how offerings realize scenarios

  • Make opioid-specific interventions widely available, e.g., in public or vendor-specific content repositories

  • Evolve offerings to better address scenarios

  • Cultivate cross-fertilization within client base

  • Collaborate to make interventions more interoperable

Clinical Content Providers

Critical Step

  • Develop/enhance evidence-based guidance to underpin pertinent PCCDS interventions, and foster related collaborations

Other Recommendations

  • Learn the needs of CDS developers and adapt guideline development processes to facilitate CDS development

  • Make opioid-specific interventions widely available, e.g., in public (e.g., CDS connect) or vendor-specific content repositories

  • Evolve guidance to better address scenarios

  • Have guideline organizations prepare information that will help activate patients - and get it in the hands of local groups that can use it

Continuing Education Providers

Critical Step

  • Ensure clinicians/care teams appreciate future vision scenarios and role for underlying PCCDS interventions and are motivated and prepared to utilize them effectively.

Other Recommendations

  • Support standards/collaborations to make interventions more interoperable

Health IT Associations

Critical Step

  • Foster best practices and collaboration among members to realize future scenarios

Other Recommendations

  • Refine future vision with members and collaborate

  • Collaborate to make interventions more interoperable

  • Vendors can facilitate collaboration between organizations through: Sharing of best practices, Sharing of outcomes data through standardized reports across organizations

  • Create spaces (special presentations or exhibits) in national meetings to showcase these developments and learning

Patient Advocates

Critical Step

  • Use the PCCDS interventions independently and in collaboration with their care teams

Other Recommendations

  • Review the future vision summary and comment if (A) this would meet my goals of providing the healthcare experience I want or (B) comment on what is needed to get there

  • Engage in actions above/below to ensure intervention/scenario value

  • Expect/demand future scenarios as routine/common

Payers

Critical Step

  • Leverage funding available to address opioid crisis to support providers in procuring and implementing PCCDS tools and workflows that realize future vision scenarios - and infrastructure

  • Foster measurement effort to document whether/how the action plan is driving progress toward the aspiration goal

Other Recommendations

  • Medicaid agencies have CMOs, connected with other partners in this table; they could help influence implementation of this work through Medicaid network.

  • Support efforts to engage/activate patients

PCCDS Learning Network

Critical Step

  • Leverage mission, activities and resources to foster successful OAP execution.

Other Recommendations

  • Build on OAPWG to drive and provide hub for actions above

  • Add human designers to the team. Need design thinking included from the beginning just as we need patients and direct care clinicians included every step of the way.

  • Submit presentations to meetings for dissemination (e.g. HIMSS and AMIA)

Research Agencies

Critical Steps

  • Coordinate/advance current and planned research and funding to accelerate progress toward Future Vision.

  • Foster evaluation/assessment efforts to document whether/how the action plan is driving progress qualitatively toward the aspiration goal

Other Recommendations

  • Support efforts to refine and broadly execute future vision

  • Support efforts to engage/activate patients regarding future vision (payers, feds/CMS)

  • Help disseminate evidence-based PCCDS interventions (e.g., through CDS Connect)

Standards Organizations

Critical Step

  • Foster development and use of standards that support creation, interoperability and widespread deployment of PCCDS interventions underpinning future scenarios.

Other Recommendations

  • Support standards/collaborations to make interventions more interoperable

Comments

Submitted by arzt@pcorcds-ln.org on Tue, 07/03/2018 - 16:25

Permalink

I'm not a clinician, not an expert in this contect, so some of these scenarios reads a little rough for me and I do not always understand the jargon and abbreviations. You might annotate or explain some of this more fully if you want a variety of stakeholders to engage with this material. 

Scenrio 1
Sorry if I am being obtuse, but what does "PM" stand for? Also not clear to me why the CDS Tool (#3?) would necessarily, or always, be shared between the clinician and the patient. Might there be times when a tool want to show these two types of users very different things? Also not clear why the PDMP is not consulted in this scenario. Might inform the clinician about something the patient is not revealing and the HIE does not know.

Scenario 2
Just a nit: Typo in last sentence in paragraph 1 ("he" instead of "the")

Scenario 3
Since an HIE was introduced in Scenario 1, maybe the care plan resulting from this scenario should explicitly be sent to the HIE s an example of sharing with other providers (with the patient's consent).

Some overall comments:

The table below has many CDS tools in it (3, 7, 13, others). I don't understand the subtle differences between many of them so it's hard to determine whether the right one is indicated for each scenario. Some times they are referred to in the scenarios just as "tools," sometimes as "CDS Tools," sometimes as "decision making tools," and sometimes as "PCCDS Tools." Are these all meant to mean the same thing?

All the scenarios that are focused on a single patient presenting (1, 2 and 4) use a context of an opioid naive patient. Seems to me that an increasing scenario is a presenting patient who is NOT opioid naive, and sometimes even deceptive about past/current opioid use. Many of the interventions mentioned seem to be fine for a cooperative, honest patient but the situation might not unfold the same way if a different type of patient was involved in these scenarios.

Submitted by Bren on Wed, 08/15/2018 - 11:49

Permalink

Thank you for the opportunity to comment on this important body of work to address pain management in the midst of an opioid course correction that threatens access to pain relief for cancer patients, survivors and chronic pain sufferers. There are a few key interventions the work group may want to consider in its clinical decision support scenarios, if sensible from a scope perspective:

  1. Referral of patient to non-medication centric pain management resources. This would require the provider have access to a database of such resources.
  2. Discussion of patient’s goals and concerns, including financial and emotional.
  3. Financial concerns: Chronic pain is expensive to manage when most health insurance benefit plans readily cover Rx, but only sometimes cover non-medication therapies and then only after a lot of hassle for the patient and care provider. E.g. denial of physical therapy claims for chronic pain management and relief. In an ideal scenario, health insurance would cover non-medication centric pain management therapies as a matter of course, in parity with Rx coverage for same condition.
  4. Emotional concerns: Referral of patient to integrated behavioral health support to address coping skills in recognition of the chronic pain and depression relationship.