{"id":18982,"date":"2018-10-17T15:52:21","date_gmt":"2018-10-17T21:52:21","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=18982"},"modified":"2023-09-28T16:36:09","modified_gmt":"2023-09-28T22:36:09","slug":"using-electronic-medical-records-to-help-manage-chronic-pain","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/using-electronic-medical-records-to-help-manage-chronic-pain\/","title":{"rendered":"Opioid offensive: UCHealth teams turn to electronic health record for help managing patients with chronic pain"},"content":{"rendered":"
<\/div>

The public health crisis spawned by the explosion in opioid prescriptions over the past decade has been well chronicled. The avalanche of addictive medications has cost tens of thousands of lives, hollowed out whole communities, depleted the workforce, spurred commitments for emergency federal funds, and pitted some states hard hit by the scourge against drug manufacturers.<\/p>\n

Now a survey of the damage leads to other thorny questions: How to help the millions of patients who still rely on opioids to manage their pain while reducing their risk of dependence? And as restrictions on opioid prescribing tighten, what can providers to do to steer patients suffering persistent pain toward safer alternatives?<\/p>\n

A strategy is emerging at UCHealth, where providers serving University of Colorado Hospital<\/a> on the Anschutz Medical Campus are developing tools to help clinicians make better-informed decisions about treating their patients\u2019 pain. Their ally is the Epic electronic health record (EHR) and the vast repository of data that lies within it. It\u2019s a joint effort that brings together physicians, pharmacists, information specialists and others committed to protecting patients while ensuring they receive appropriate treatment. The work complements a major effort to reduce the number of opioids prescribed in UCHealth\u2019s emergency departments and direct patients to alternative treatments<\/a>.<\/p>\n

Finding middle ground<\/strong><\/h3>\n

It\u2019s a delicate balance, said Katy Trinkley<\/a>,\u00a0<\/a> associate professor in the Department of Clinical Pharmacy at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. Trinkley worked until recently with clinicians in UCH\u2019s Internal Medicine Clinic on the Anschutz campus, helping to ensure the safety of patients\u2019 medications, including opioids. In the Internal Medicine Clinic, she saw firsthand providers face the challenge of treating patients\u2019 chronic pain safely and helped develop a pharmacist-managed chronic pain clinic. Trinkley co-authored an August 2017 article that details the work<\/a>.<\/p>\n

\u201cPeople need pain relief and support without jumping straight to opioids,\u201d Trinkley said. \u201cAs pharmacists, we are well-positioned to know when it is appropriate to prescribe them and how to reduce their use.\u201d<\/p>\n

One problem for busy providers under pressure to reduce opioid use is a lack of time and administrative resources, Trinkley added. To address that, she\u2019s moved into clinical informatics, finding ways to use data from the EHR to aid providers treating complex cases that often involve not only pain but also medical comorbidities and mental and behavioral health issues.<\/p>\n

\u201cWe\u2019re trying to identify new tools in the electronic health record to close care gaps or optimize care,\u201d Trinkley said.<\/p>\n

Electronic helpers<\/strong><\/h3>\n

One example now in place: a \u201cmorphine dose calculator\u201d that is programmed into the EHR. The tool allows providers to quickly convert the amount of an opioid, like oxycontin, that a patient takes to its morphine equivalent. That produces a number the provider can use to judge risk of addiction, overdose and side effects like constipation and dizziness that can complicate care.<\/p>\n

Also in the works is a \u201cpain summary button\u201d that will pull and assemble information from the EHR about a patient\u2019s pain medication history and display it discreetly. It\u2019s a way to standardize and gain a more objective picture of an individual\u2019s pain history, Trinkley said. Another project close to completion is a registry of the thousands of patients treated with opioids at UCH and the patterns of those prescribing the medications \u2013 a key to finding ways not only to reduce opioid use but also to improve the quality of care, Trinkley said.<\/p>\n

\u201cThe registry is important to help providers understand the patient population and begin to understand their prescribing practices,\u201d said Dr. Peter Smith<\/a> a family medicine specialist with UCHealth who has helped to develop a variety of tools for primary care physicians managing chronic pain patients. Smith said the registry will also help to assess how well providers and practices meet guidelines set by the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain.<\/p>\n

Smith pointed out that screening patients and assessing their risk of harm from opioids is difficult because of the number of potential factors involved. The opioids themselves are potentially addictive, of course, but conditions as diverse as anxiety disorders, depression, obesity, liver and kidney problems and regular use of alcohol, sedatives and other drugs are additional risk factors.<\/p>\n

It\u2019s difficult to imagine a clinician in any practice making that assessment in a relatively short visit, but there is now electronic help available, said Smith, who began work on a project to ease the burden with Dr. Richard Altman, an internist at UCHealth\u2019s Lone Tree Medical Center<\/a>. Altman, who is also a trained computer programmer, created an application that quickly scours far-flung corners of a patient\u2019s medical chart for the opioid medication risk factors Smith describes. The final product is neatly packaged in 10 to 15 lines of easy-to-scan summary text.<\/p>\n

\u201cIt\u2019s an opioid risk assessment tool,\u201d Altman said. \u201cProviders use their clinical judgment to decide on the next step for treating their patients.\u201d<\/p>\n

Throwing a flag<\/strong><\/h3>\n

Altman said the program is available to \u201canyone seeing patients with pain, which is just about anyone.\u201d An individual provider can use it simply by typing the dot phrase \u201c.OPIATERISK\u201d in the EHR, or it can be embedded in an Epic note or SmartPhrase so that it pops up automatically. Its first major adopter, he said, is the Medication Access and Renewal Center (MARC), which works with providers and patients on medication-related tasks. The MARC\u2019s protocols include using the tool for every patient who has a refill request for an opioid medication, Altman said. If the risk assessment is high, the MARC notifies the prescribing provider, who is better positioned to make an informed decision about the safest course of treatment.<\/p>\n

\"A
Katy Trinkley, a professor of clinical pharmacy at CU, worked with providers in the Anschutz Internal Medicine Clinic at UCHealth University of Colorado Hospital to manage patients with chronic pain. She now works to develop electronic tools to assist providers in meeting that challenge.(Photo by Patrick Campbell\/University of Colorado)<\/figcaption><\/figure>\n

\u201cIt helps to give feedback as you go,\u201d Altman said, noting that aside from the MARC he\u2019s gotten anecdotally positive feedback about the tool\u2019s usefulness in addressing the pervasive problem of treating chronic pain safely. Simply severely restricting or eliminating access to opioids won\u2019t meaningfully address it, he said.<\/p>\n

\u201cThe challenge is that pain is real and pervasive in everyday life,\u201d Altman said. \u201cOpioids are seen by physicians and patients as a very useful tool in combating pain. Unfortunately, they are addictive, dangerous and not known to be effective in the long term for chronic pain.\u201d<\/p>\n

Getting a provider \u201cthe right information at the right time in a format that is readable,\u201d Altman said, can help them clarify with patients their goals of care, like regaining the ability to walk without debilitating pain. With that, providers might guide patients to non-narcotic treatments like physical therapy, acupuncture, and analgesic creams that can \u201chelp them regain their lives,\u201d he said.<\/p>\n

Tracking take-home meds<\/strong><\/h3>\n

Meanwhile, a five-year National Institute on Drug Abuse-funded clinical trial <\/a>now underway at UCH led by anesthesiologist Dr. Karsten Bartels, is looking at fine-tuning opioid-prescribing after surgeries. Bartels published a small study <\/a>in 2016 of patients sent home with opioids after surgery. One question: how many did they take? It turned out many of them took only a small number: five of a 30-day supply, for example.<\/p>\n

The initial study also raised the question of what happens to all those unused pills. How are they stored or disposed of?<\/p>\n

\u201cIt\u2019s good not to be wasteful,\u201d Bartels said. \u201cAnd if these medications are being stored in medicine cabinets, they are potentially available for non-medical use.\u201d<\/p>\n

The current study surveys three groups: women after cesarean sections; general gastrointestinal surgery patients; and thoracic surgery patients. They are surveyed once a week for four weeks about how much of their medications they used and how they stored them.<\/p>\n

\u201cWe want to decide who needs what rather than a one-size-fits-all solution,\u201d Bartels said. \u201cWe\u2019re trying to find out how much opioid medication a patient actually needs and take that information and put it into practice.\u201d The idea is not simply to reduce the number of opioids prescribed, he emphasized, despite that impulse being \u201cwhere the pendulum is swinging\u201d in health care.<\/p>\n

\u201cWe have to be careful not just to limit the number of medications, but rather to give patients what is appropriate,\u201d Bartels said. \u201cWe have to identify patients with different pain requirements. That goes in both directions. There are patients who will need no opioids, but there are patients who do need them in higher doses than is commonly prescribed. We have responsibility to all of those patients.\u201d<\/p>\n

Bartels said he\u2019d like to see the study results translate to clinical decision support for surgical providers deciding on appropriate pain management for their patients as well as educational tools for patients. He notes that patients get plenty of attention to their pain levels while they are hospitalized. That includes offering them non-opioid medications. The guidance shouldn\u2019t end when they go out the door, he said.<\/p>\n

\u201cMy goal is to extend this kind of comprehensive approach when patients are discharged home,\u201d he said.<\/p>\n

Good tools take time<\/strong><\/h3>\n

The promise of clinical decision support in managing opioid use \u2013 or addressing any health problem \u2013 should not obscure the resources required to build tools that will help providers improve patient care, said Miranda Kroehl, PhD, assistant director of the Center for Innovative Design and Analysis <\/a>(CIDA) at the Colorado School of Public Health. Kroehl has worked with Trinkley since 2014 and was a co-author of the 2017 paper detailing the pharmacist-managed chronic pain clinic.<\/p>\n

Kroehl and her fellow biostatisticians at CIDA help researchers like Trinkley design studies that are most likely to produce data that answer specific questions. \u201cWe have to define the expectations and the realities of the study upfront,\u201d Kroehl said.<\/p>\n

For example, if the goal of a pilot is to reduce opioid use, the researcher must define a reasonable period of time to gather enough data to assess and measure the results. Even with that information in hand, the researcher would have to define what he or she considers a significant reduction. And of course every study must be designed with the available resources in mind.<\/p>\n

\"A
UCHealth Family Medicine specialist Peter Smith has been a leader in developing resources for primary care physicians managing patients with chronic pain.<\/figcaption><\/figure>\n

If the work yields new decision-support tools, they should be designed to complement, not complicate, providers\u2019 patient care, Kroehl added. For example, \u201cbest practice advisories\u201d that pop up to alert a provider to a clinical consideration are common in the Epic EHR \u2013 and sometimes a source of frustration.<\/p>\n

\u201cClinical decision support is a great and challenging way to interface with providers at the point of care,\u201d Kroehl said. \u201cBut they are still an intervention. We have to make sure not only that the tools work but also that providers are using them.\u201d<\/p>\n

The prickly problem of pain<\/strong><\/h3>\n

Smith also sees major challenges that remain despite the progress made in helping primary care physicians work with their chronic pain patients. Many patients also struggle with mental and behavioral health issues, substance use disorders, and trauma, with scant societal resources to address them.<\/p>\n

\u201cWe often are dealing with patients caught in the middle of these problems,\u201d Smith said.<\/p>\n

In addition, the patients Smith and his colleagues see frequently present with less than clear-cut symptoms or a straightforward problem like a sprained ankle.<\/p>\n

\u201cWe\u2019ve gotten better at using alternatives to opioids to address acute pain,\u201d he said. \u201cBut we get many patients with vague concerns that are not attributable to specific ongoing biologic damage.\u201d He explained that in some cases chronic pain is attributable to a single cause, like degenerative disease. Very often, however, patients may continue to suffer long after one would expect the pain to end.<\/p>\n

\u201cIn these cases, the brain may have lost its ability to know the body has healed,\u201d Smith said, comparing the problem to a smoke alarm ringing constantly.<\/p>\n

\u201cIt\u2019s a disconnect between the actual tissue damage and the pain experience,\u201d he said. \u201cAs a physician, it\u2019s a challenge to help patients develop insight into that problem without making them feel that their pain is being discounted.\u201d<\/p>\n

Decision-support tools and programs aside, Smith stressed the importance of removing the stigma often attached to people struggling with chronic pain and opioid use. He noted that a number of UCHealth primary care practices now schedule a minimum of four focused visits per year for patients who use opioids regularly for pain.<\/p>\n

\u201cWe\u2019re trying to socialize the idea of a dedicated visit for chronic pain,\u201d Smith said. \u201cWe don\u2019t say to patients with diabetes, \u2018Oh, by the way, let\u2019s manage your diabetes as an afterthought at the end of your visit for three other problems.\u2019 We have dedicated visits for patients with diabetes.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

The public health crisis spawned by the explosion in opioid prescriptions over the past decade has been well chronicled. The avalanche of addictive medications has cost tens of thousands of lives, hollowed out whole communities, depleted the workforce, spurred commitments for emergency federal funds, and pitted some states hard hit by the scourge against drug […]<\/p>\n","protected":false},"author":2143,"featured_media":19812,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[6],"tags":[3714,3717,3716,1163,9187,3715],"class_list":["post-18982","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-healthy-living","tag-clinical-decision-support","tag-marc","tag-medication-and-renewal-center","tag-opioids","tag-readysetco","tag-university-of-colorado-skaggs-school-of-pharmacy-and-pharmaceutical-sciences"],"acf":[],"yoast_head":"\nUCHealth teams use electronic health records to manage patients with chronic pain<\/title>\n<meta name=\"description\" content=\"Using a variety of tools, including electronic medical records to assist providers in identifying the risks of addiction in patients with chronic pain.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.uchealth.org\/today\/using-electronic-medical-records-to-help-manage-chronic-pain\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Opioid offensive: UCHealth teams turn to electronic health record for help managing patients with chronic pain\" \/>\n<meta property=\"og:description\" content=\"Using a variety of tools, including electronic medical records to assist providers in identifying the risks of addiction in patients with chronic pain.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.uchealth.org\/today\/using-electronic-medical-records-to-help-manage-chronic-pain\/\" \/>\n<meta property=\"og:site_name\" content=\"UCHealth Today\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/uchealthorg\/\" \/>\n<meta property=\"article:published_time\" content=\"2018-10-17T21:52:21+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2023-09-28T22:36:09+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/uchealth-wp-uploads.s3.amazonaws.com\/wp-content\/uploads\/sites\/6\/2018\/12\/05091626\/UCHealth_University_of_Colorado_Hospital_Aerials_2018_04.jpgeee.jpg\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Tyler Smith\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@uchealth\" \/>\n<meta name=\"twitter:site\" content=\"@uchealth\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Tyler Smith\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"11 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/www.uchealth.org\\\/today\\\/using-electronic-medical-records-to-help-manage-chronic-pain\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.uchealth.org\\\/today\\\/using-electronic-medical-records-to-help-manage-chronic-pain\\\/\"},\"author\":{\"name\":\"Tyler Smith\",\"@id\":\"https:\\\/\\\/www.uchealth.org\\\/today\\\/#\\\/schema\\\/person\\\/98c85c0e40c4933eedcec2cd054f349d\"},\"headline\":\"Opioid offensive: UCHealth teams turn to electronic health record for help managing patients with chronic pain\",\"datePublished\":\"2018-10-17T21:52:21+00:00\",\"dateModified\":\"2023-09-28T22:36:09+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/www.uchealth.org\\\/today\\\/using-electronic-medical-records-to-help-manage-chronic-pain\\\/\"},\"wordCount\":2189,\"publisher\":{\"@id\":\"https:\\\/\\\/www.uchealth.org\\\/today\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/www.uchealth.org\\\/today\\\/using-electronic-medical-records-to-help-manage-chronic-pain\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/uchealth-wp-uploads.s3.amazonaws.com\\\/wp-content\\\/uploads\\\/sites\\\/6\\\/2018\\\/12\\\/05091626\\\/UCHealth_University_of_Colorado_Hospital_Aerials_2018_04.jpgeee.webp\",\"keywords\":[\"clinical decision support\",\"MARC\",\"Medication and Renewal Center\",\"Opioids\",\"Ready. 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