Using Electronic Health Record-Based Clinical Decision Support to Affect Prescribing Behavior

To address the opioid epidemic, integrated clinical decision support within the electronic health record (EHR) to impact prescribing behavior was developed and tested. A multidisciplinary expert panel identified risk factors for misuse, abuse, or diversion of opioids through literature reviews and consensus building for inclusion in a rule within the EHR. This rule logic powered an alert presented to prescribers; however, we ran the rule “silently” to test it, collect baseline data, and refine the rule. Based on one month of “silent” data, thresholds for triggers were modified to minimize prescriber burden while capturing a significant number of at-risk patients. The following five objective criteria available in the EHR were programmed to “trigger” the alert: 3 or more prescriptions for an opioid in past 30 days; 2 or more onsite administration of opioids in past 30 days; current prescription with 50% or more remaining (“early refills”); previous presentation for opioid overdose; and positive blood alcohol content or toxicology screen for cocaine or marijuana.

Once triggers were tested and finalized, the alert was launched. Analysis of prescriber response to the alert for opioids in the outpatient setting found that among encounters with an alert, the prescriber typically acknowledged the alert and continued the prescription (84.9%). In 15.1% of cases, the prescriber cancelled the prescription. In 38.0% of these cancellations, the patient left the encounter without receiving an opiate (n=2,032).

We successfully built an EHR alert to address opioid prescribing by providing critical information at the point of care. The “silent” phase data were useful to appropriately tune the alert and obtain support for widespread implementation. Future healthcare initiatives can utilize the EHR to collect data prospectively to inform interventions to address a variety of public health problems. It is important to note that the goal of this project is to integrate the provision of information to support clinical decision-making into the workflow in order to increase patient safety and to decrease subjectivity or bias when assessing risk for prescription opioid misuse or abuse. There are legitimate medical uses for opioids; therefore, the desired outcome is not always a cancellation. We believe risk information is useful to the prescriber regardless of their response, and this platform lays the groundwork for healthcare organizations to meet the emerging requirements to assess existing prescriptions and/or risk factors prior to prescribing opioids.