Contributed by Dr. Steven Klassen, Family Physician, Thunder Bay, ON and OntarioMD Peer Leader
Recently, I accepted a 70 year old man into my family practice. He presented to our first encounter with nothing but his spouse to aid his recall. I had prior hints of his complex history but it soon became evident that neither of the pair had the memory or detail that would have been nice for this intake interview.
One of the tools I have come to cherish in such encounters is OLIS. Subtly integrated within my EMR, in a matter of a couple of clicks I am in the position to query the database for the patient in front of me. On verbal consent from this septuagenarian, I launched digital minions to fetch the last ten years of his labs. Moments later another click of a button allows me to download the retrieved treasure trove into my EMR. Less than a minute later I am pointing to a graph generated by my EMR of his hemoglobin and asking him, “ What happened to you at this dramatic dip in February 2016.?” Visibly impressed, he recalls, “Oh that is when I had my stroke and was given clot busters”. In just minutes, I was able to get a better picture of trends and perspectives that improved my ability to care for this patient without having to send him for duplicate lab tests.
Later, my questions about his diabetes were met with firm denial, yet his previous family doctor had already ordered a Hb A1c in 2015 which was reported at 6.7%. A picture of denial was emerging. The graph of his LDL cholesterol shows the classic swings of someone at one time started on a statin who later stops it only to be started again. In this case, the statin had evidently been stopped approximately a year before his stroke but promptly restarted in February 2017 fitting perfect with my lab graph. My patient and his wife look at me like I have psychic powers. I smile and thank my EMR and OLIS for the good start we were off to.
Dr. Steven Klassen, Family Physician, Thunder Bay, ON and OntarioMD Peer Leader
The 2017 Canadian Guidelines for Opioids for Chronic Non-Cancer Pain emphasized the importance of safely minimizing the dose of opioids that patients are being prescribed. The guidelines made it important for me as a primary care provider to reassess my population of patients on opioids and ensure that I was doing my best to implement the new recommendations accordingly. This presented a formidable challenge and led to the realization that it would be very useful to have an EMR tool to support this process.
In response, the East Wellington Family Health Team (FHT), the Guelph FHT, the eHealth Centre of Excellence (eCE), and TELUS Health partnered to create an Opioid EMR Toolbar (Figure 1) using content informed by the Guidelines and work done by the Centre for Effective Practice (CEP).
Figure 1. Opiod EMR Toolbar
The toolbar provided a practical and effective way to implement the new guidelines into my practice through the following capabilities:
The figure below illustrates the steps I took in using the toolbar to implement the new guidelines.
Figure 2. Steps used to systematically manage my population of patients on opioids.
During this process, I also found it very helpful to participate in Academic Detailing sessions provided by the CEP. These are one on one sessions in which an expert from the CEP met me at my office and reviewed key topics including:
Non-pharmacological and non-opioid options for the management of patients living with chronic non-cancer pain
Managing opioid therapy for patients living with chronic non-cancer pain
Managing care for patients living with opioid use disorder
The toolbar gave me the information that I needed, when I needed it, provided individualized patient decision support, and saved me a lot of time on documentation. I was able to spend more time with my patients. They felt engaged and well informed.
Within nine months of the adoption of the toolbar I was able to safely taper the dose of opioids for a significant number of my patients and there was a statistically significant reduction in the overall MEQs I prescribed over this time period (p<0.05).
I really hope that others will find similar success in helping their patients manage their pain safely and effectively. The Guidelines have paved the way for us, and the Opioid Toolbar has proven to be an effective vehicle to help get us there.
The Opioid Toolbar is now available to all users of Telus Practice Solutions EMR. The simplified version of the toolbar used for this quality improvement initiative is available through theeHealthCentre of Excellence for PS EMR (Oscar under development). eHealth coaching sessions are also available through the eCE (with Mainpro+ credits) for primary care providers across the Waterloo-Wellington Local Health Integration Network.
The Academic Detailing sessions are free-of-charge and free of commercial interest. Physicians can earn Mainpro+ credits for each AD session. More information and the process of signing up for a session is available on the Centre of Effective Practice website.
Busse, J.W. (2017). The 2017 Canadian guideline for opioids for chronic non-cancer pain. Hamilton, ON: McMaster University.
Need help supporting your patients in managing their pain? Visit the Ontario Pain Management Resources for a coordinated program of tools from partner organizations across the province.