Nebraska finds success with expanded PDMP

Prescription drug monitoring programs (PDMPs) are considered an important tool in helping to address the country’s opioid addiction epidemic. When President Donald Trump’s opioid task force released its recommendations earlier this year, creating a national, interoperable PDMP network was high on the list.

But while PDMPs can help reduce over-prescribing of opioids, they also have the potential to help providers and patients do a better job of coordinating prescriptions, provided they have enough data. In January, Nebraska became the first state that required pharmacists and pharmacies to report all dispensed prescriptions to the state’s PDMP in an effort to provide that data to physicians.

According to officials there, the transition is going well so far.

“This has gone more smoothly than we imagined,” says Kevin Borcher, PDMP program director at the Nebraska Health Information Initiative (NeHII), the not-for-profit that serves as the state’s health information exchange (HIE). “We were expecting to have about 10 times the data available, and that’s exactly what we are seeing. We were concerned about potentially increasing the number of errors in the system, but we’ve actually decreased the error rate compared to 2017.”

“We were able to connect all of the pharmacies quickly,” adds Nick Barger, principal pharmacist at DrFirst, the IT company that manages pharmacy data in the state. “Providers today in Nebraska have more information available to them in a cleaner fashion, along with decision support capabilities.”

Last year, the state tapped DrFirst to deploy a solution to capture state prescription information and pass it on to the PDMP. DrFirst’s platform is designed to make it easer for pharmacists and prescribers to identify potentially adverse drug combinations and duplicate therapies.

DrFirst collects prescription details and makes them available through NeHII to all of the state’s providers, as well as 552 pharmacies and approximately 400 mail-order companies.

“It’s important to understand the context of what the state was trying to accomplish,” says Barger. “The state wants to improve healthcare outcomes, and is working with different constituents in the state to help make providers more well informed so they can have the best conversations with patients about their therapy.”

By providing physicians with greater visibility into medications, Barger says doctors can make better decisions about what medications to prescribe – in addition to spotting any potential overprescribing of controlled substances or possible addiction issues.

“The whole premise behind how we operate our PDMP is focused on patient safety,” Borcher says. “Some PDMPs focus on law enforcement or abuse, but Nebraska looks at it as a patient safety issue. If we have all of the prescriptions, not only can we prevent misuse or abuse of controlled substances, we can also provide better patient care by knowing all prescriptions that a patient has had dispensed.”

Better data

Borcher credits communication and collaboration with pharmacies, software vendors and providers to ensure the success of the new, expanded system.

According to Borcher, since no other state had attempted this, there were a lot of unknowns involved in the initiative. “With the unknown comes some fear, and there was a lot of concern that because this had never been done, whether or not it could be successful.”

The state worked with pharmacists and pharmacy chains, as well as DrFirst and other software vendors, to make sure they were prepared for any potential obstacle. “And that was successful,” Borcher says. “Right off the bat we had more data and better quality data.”

NeHII also made an effort to ensure that providers wouldn’t have to drastically alter their processes to support this expanded use of the PDMP. Providers, while supporting the goals of PDMPs around the country, have often complained about the administrative burden of using them. That’s one reason compliance is sometimes in low in states that don’t have a legislative mandate in place requiring doctors to check the PDMP.

To make compliance easier, NeHII has emphasized integrating the process into the normal workflow for physicians, and Barger says that DrFirst has been focused on integration with electronic health records in Nebraska and in other markets.

“We are working on addressing those concerns,” NeHII’s Borcher says. “We have integrated the PDMP into the HIE, but we have also eased the workflow through single sign-on within the electronic health records (EHRs). Providers can access the HIE and with one click access the PDMP. We continue to look for opportunities to enhance that.”

Every state but Missouri now operates a PDMP, and provider use has increased. (Missouri Gov. Eric Greitens attempted to launch one last year, but the effort has largely been blocked by the state legislature. St. Louis County launched its own PDMP in 2017.)

Earlier this year, California passed a new law that requires prescribers to query the PDMP before prescribing controlled substances. There are now 28 states that require PDMP queries before prescribing opioids.

States and providers have struggled with PDMP interoperability, both between different PDMPs in different sates, and between PDMPs and electronic medical record systems. In Michigan, for example, less than half of the state’s physicians can access the PDMP via their EHR, despite the state spending $2.8 million to upgrade the PDMP specifically for that purpose.

Several states have partnered with neighboring states to create data interchange agreements, and 46 states are part of the National Association of Boards of Pharmacy (NABP) PMP InterConnect platform for sharing prescription drug data. The Opioid Crisis Response Act, recently passed by the U.S. Senate, includes provisions that will allow PDMPs to share data with state public health agencies and licensing boards, and authorizes a Department of Health & Human Services grant program for improving interoperability, as well as a proposal for giving state Medicaid agencies access to PDMP data.

Next steps in Nebraska

With the expanded PDMP up and running, Barger says that Nebraska is moving into an optimization phase so that providers can use decision support tools in the DrFirst platform that can help them make better sense of the pharmacy data they are receiving. That includes automatically calculating opioid milligram equivalents for each patient, for example.

Borcher says that the state is also interested in some potential improvements that would require legislative changes. “We’re exploring interstate data sharing, and looking at expanding our capabilities for integration and trying to promote and support interoperability, which is being encouraged at the federal level,” Borcher says, noting that providers will be required to query PDMPs when prescribing controlled substances for Medicaid and Medicare patients starting in 2020.

As for the new model in Nebraska, Barger at DrFirst says his company has seen interest in other states for expanding PDMP use beyond controlled substances. “We’re starting to see a wave around PDMP use for prescribers and a national initiative to make that easier to check,” Barger says. “It’s a natural continuation that this flows into the more holistic interoperability framework that Nebraska is using.”

Brian Albright is a freelance writer based in Ohio.