Tapering opioids for chronic non-cancer pain patients using an EMR tool and academic detailing

Submitted by Dr. Kevin Samson

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

Results

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.

Resources available

  • 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.

References:

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. 

Single EMR for Canada: A Second Opinion

A national electronic health record for primary care – – http://www.cmaj.ca/content/191/2/E28 

The above editorial describes the author’s desire and need for a single national Electronic Medical Record (EMR) in primary care.  He speculates that many of our problems in primary care could be solved by such an instance, from the sharing of records between clinics to research, to specialist access to notes.  He cites single health systems in the US and Singapore as examples of how and why this could work.  This is an interesting perspective, but one which may be overly simplistic and not shine the light on the whole picture.  There has been significant progress and development made in the digital health space in Ontario over the past ten years and this should be recognized and celebrated. This, coupled with a relentless focus on systems integration across the continuum of care, is where we should put our energy.

Although we have much in common as family doctors across the country, we all ask very different things from our EMRs.  Practice environments are not the same in inner city urban centres, suburban practices, rurally, in university health clinics or aboriginal care centres.  This delivery complexity needs to be appreciated.  Nationally over 80% of family doctors already have purchased an EMR that works for them and are using it fulsomely.  In Ontario, this is over 85%.  Physicians own their systems.  They have made significant investments in these … financially, in time spent recording information about their patients, and in blood sweat and tears producing clinically useful data.  We should appreciate this effort and use the systems to their maximum.  Much has been accomplished and advancing from where we are is a very tenable option.

Switching to one EMR solution that attempts to meet the needs of 43,500 family doctors nationally is an impossible task.  And the disruption in care created by “ripping and replacing” would take decades to recover from. Canadian provinces have collectively invested billions of dollars in EMR development, deployment and mature use. We cannot afford as a society or at any level of government to start over again. That said, fundamental health system reform, advances in integrated care models and associated compensation reform should be the driver that defines how integrated digital health platforms can and should be presented at the local, regional, provincial and national level.

Satisfaction ratings with individual EMRs is actually quite high in provincial surveys.  Even with multiple EMRs on the market, connectivity is improving year over year (witness Netcare in Alberta, Connecting Ontario and Clinical Connect in ON and Saskatchewan’s eHealth portal).  In Ontario, information from virtually every hospital is pushed directly into EMRs within minutes of it being generated via Health Report Manager.  Lab results from everywhere can be queried and downloaded through OLIS.  Integration with drug and immunization repositories is occurring now.  eReferral and eConsult systems are up and running and are becoming more and more integrated into the point of care.

As we evolve into an increasingly cloud-based environment the perceived advantages of a single EMR product or database are no longer compelling.    What is most helpful is gaining access to data for clinical, research and system planning purposes.  This is less a technical issue than a policy one.  Integration and interconnectivity are the key.  We are getting closer and closer to this daily, with the advent of single sign on, contextual launching of external digital tools from the EMR, data standards and data movement.  The most unpredictable factor is a human one: even when standards exist, having people use them consistently is a challenge.  A single EMR does not fix this.  Endless dropdown lists and tick boxes do not either.  In primary care nothing is more important than the patient narrative.  We can never lose this.

Choosing a single EMR vendor has other dangers in creating a monopolistic environment.    This makes us vulnerable as a health system and as a profession.  Currently, Ontario has certified 11 EMR vendors and 12 EMR products to a set of core requirements that improve constantly over time.  This allows progress to occur incrementally on interconnectivity, data portability and system functionality.  Having a single vendor control the entire market means that we are at the whim of one company whose business interests may not be aligned with those of clinicians or patients.  We lose our collective influence.

Open source software is not the solution to this problem either.  Although it has the advantage of being inexpensive and in some cases free, it has the disadvantage of needing as much if not more support as proprietary EMRs do.  Most physicians lack the knowledge, skill and desire to program and produce changes in their EMRs themselves. They just want to get down to the work of looking after patients. Multiple different customized instances of an open source EMR do not improve the situation overcurrent state in any way.

It may seem on the surface that having a selection of EMRs nationally is folly. But experience has shown that competition drives change and innovation.  We do not disagree that there are aggravations in navigating from an EMR to a viewer or external portals, but this is a solvable problem.  The key is to build bridges allowing access to data that is required for a clinician at the point of care.  We maintain privacy, confidentiality and security more effectively this way.  Data for secondary use can be liberated easily through these structures if we create the right policy and business drivers.  All of this comes at far less risk and with a far better user experience for the average doctor.  Banks have done it.  Retailers have done it.  We are doing it.

At OntarioMD we believe in more choice not less.  We want to encourage new software products to enter the market to speed up the pace of innovation.  Some of these are EMRs, some are apps that make an EMR fly.  We want to let doctors be doctors, not computer engineers or data scientists.  And ultimately, we think that patients should be the first and last point of approval regarding the secondary use of their personal health data.  These are our principles.   We strongly believe that the best way to accomplish them is via our current approach to EMR selection, certification and improvement.  One EMR system for all is simply not a realistic option.

OntarioMD

Darren Larsen, CMO

Sarah Hutchison, CEO