Overview 

While the overall national opioid prescribing rate declined from 2012 to 2017 (from 81.3 to 58.7 prescriptions per 100 persons), prescribing rates of opioid medications continues to remain very high in certain areas across the country. Use of prescription opioids for pain presents serious risks, including overdose and opioid use disorder. In 2017, 70,237 persons died of a drug overdose in the United States; 67.77% (47,600) of those overdose fatalities involved an opioid. Overdose deaths from opioids, including prescription opioids and heroin, have increased almost six times since 1999.

In March 2016, the Centers for Disease Control and Prevention (CDC) published the CDC Guideline for Prescribing Opioids for Chronic Pain (CDC Prescribing Guideline) to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings, and to ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs. To help support uptake and use of the CDC Prescribing Guideline, CDC and the Office of the National Coordinator for Health Information Technology (ONC) have been working collaboratively to convert the recommendations into standardized and shareable electronic clinical decision support (CDS) tools to be used in electronic health records (EHRs). Integrating the content of the CDC Prescribing Guideline into electronic CDS will equip providers with the tools and resources they need to quickly assess when it is appropriate to initiate opioid use for the treatment of chronic pain and how to safely maintain or discontinue use in patients who are currently on long-term opioid therapy.

Currently, this collaboration has successfully created CDS content and developed an electronic CDS implementation guide for all 12 CDC Prescribing Guideline recommendation statements. University of Utah Health has piloted six CDS interventions and implemented recommendation #5 into its clinical workflow.

Moving forward, CDC and ONC, in conjunction with several clinical partner sites, are piloting CDS tools in clinical settings using EHRs. These pilots are helping ONC and CDC better understand and address the successes and challenges related to implementing standardized electronic CDS tools. The expectation is that these pilots will also serve as a bridge between the development of standardized CDS tools and the implementation of these CDS within production environments. 

Announcements  


Project Pilot Announcements

Medical University of South Carolina Initiates Pilot

The Office of the National Coordinator for Health IT (ONC) and the Centers for Disease Control and Prevention (CDC) are pleased to announce that the Medical University of South Carolina (MUSC) Biomedical Informatics Center (BMIC) is conducting a pilot of clinical decision support (CDS) interventions for the CDC Guideline for Prescribing Opioids for Chronic Pain (CDC Prescribing Guideline). The pilot will involve testing standardized CDS artifacts implementing CDC Prescribing Guideline recommendations. The pilot CDS services interact with commercial electronic health record (EHR) systems by utilizing the Health Level Seven (HL7) CDS Hooks and Fast Healthcare Interoperability Resources (FHIR) standards. In addition, this pilot will leverage MUSC’s BMIC FHIR Gateway to facilitate interactions between CDS services hosted on an independent server and the MUSC EHR. MUSC will perform this pilot as a subcontractor to Security Risk Solutions, Inc.

Yale New Haven Health Completes Successful Pilot

The Office of the National Coordinator for Health IT (ONC) and the Centers for Disease Control and Prevention (CDC) are pleased to announce that Yale New Haven Health (Yale) successfully completed a third year of piloting standardized clinical decision support (CDS) artifacts. Yale tested standardized CDS artifacts that implemented recommendation statements from the CDC Guideline for Prescribing Opioids for Chronic Pain (CDC Prescribing Guideline). The electronic CDS services were hosted on an independent server and accessed remotely from Yale’s development instance of their commercial electronic health record (EHR) system. These services interacted with the EHR system by utilizing the Health Level Seven International (HL7) CDS Hooks and Fast Healthcare Interoperability Resources (FHIR) standards.

The pilot’s goal was to assess the feasibility of implementing shareable electronic CDS modules that provide point of care clinical guidance from the CDC Prescribing Guideline. In 2021, testing focused on implementing emerging CDS Hooks functionalities such as the order-sign hook and suggestion cards. The order-sign hook provides CDS interventions when a clinician is ready to sign one or more orders for a patient. CDS Hooks suggestion cards add actionable functionality to alerts.

Yale piloted a CDS service that implemented recommendation statement 10 of the CDC Opioid Prescribing Guideline. Recommendation 10 counsels clinicians to conduct urine toxicology testing (to assess for prescribed medications as well as other controlled prescription and nonprescription drugs) before starting a patient on opioid therapy and to consider administering urine tests for that patient at least annually. Using the order-sign hook, Yale implemented a CDS evaluation and subsequent recommendation to conduct a urine toxicology test before a clinician signed a prescription in the EHR. With the addition of suggestion card functionality, when a clinician accepted a CDS alert, a draft urine toxicology screen order was added to the existing draft prescription order. Yale’s groundbreaking CDS pilots demonstrated the advancement of technology to help improve opioid prescribing practices providing safe and effective pain management for patients.

Duke Health Completes Successful Pilot

The Office of the National Coordinator for Health IT (ONC) and the Centers for Disease Control and Prevention (CDC) are pleased to announce that Duke Health (Duke) successfully completed a second year of piloting standardized clinical decision support (CDS) artifacts. Duke tested standardized CDS artifacts that implemented recommendation statements from the CDC Guideline for Prescribing  Opioids for Chronic Pain (CDC Prescribing Guideline). The electronic CDS services were hosted on an independent server and accessed remotely from Duke’s development instance of their commercial electronic health record (EHR) system. These services interacted with the EHR system by utilizing the Health Level Seven (HL7) CDS Hooks and Fast Healthcare Interoperability Resources (FHIR) standards.

The pilot’s goal was to assess the feasibility of implementing shareable electronic CDS modules that provide point of care clinical guidance from the CDC Prescribing Guideline. In 2021, testing focused on implementing the emerging CDS Hooks functionality of the order-select hook and additional CDS enhancements. The order-select hook triggers a CDS invocation when a clinician selects an order within an EHR. In addition, CDS enhancements tested by Duke included EHR alerts when a patient’s urine toxicology test included unexpected results.

Duke piloted a CDS service that implemented recommendation statement 10 of the CDC Prescribing Guideline. Recommendation 10 suggests that clinicians conduct urine toxicology testing (to assess for prescribed medications as well as other controlled prescription and nonprescription drugs) before starting a patient on opioid therapy and to consider administering urine tests for that patient at least annually. The CDS services piloted by Duke also reviewed existing urine toxicology screen results for positive findings of nonprescription controlled substances such as cocaine and phencyclidine (phenylcyclohexyl piperidine, abbreviated as PCP). When a CDS review found unexpected positive results, the CDS captured any subsequent negative results for those substances. The resulting alert reported both the positive findings and any subsequent negative results. Duke’s implementation of this recommendation leveraged the order-select hook, allowing the evaluation and alert to run when a clinician initially selected a medication order in the EHR.  Duke’s innovative pilot demonstrated advances in standardized CDS technology to help improve opioid prescribing practices providing safe and effective pain management for patients.

Project Presentations

Multi Project CQL Webinar February 24, 2021

Utilizing Clinical Quality Language (CQL) for CDS

  • Bryn Rhodes, Dynamic Content Group dba Alphora
  • William Lober, University of Washington School of Medicine
  • Chris Moesel, MITRE
  • Dave Dorr, Ohio State University School of Medicine
  • Max Sibilla, University of Pittsburgh School of Medicine
  • Emilia Flores, University of Pennsylvania Health System
  • C. Holder, ThoughtWorks
  • Dave Carlson, Clinical Cloud Solutions

More information about this webinar and a webinar recording is available here https://alphora.atlassian.net/wiki/spaces/PUB/blog/2021/03/03/1367605264/CQL+for+CDS+Seminar+-+2+24+2021

Virtual Panel Presentation AMIA 2020 Virtual Annual Symposium November 18, 2020

Building on Success: Standards-based Decision Support in Commercial EHRs

  • Kawamoto, University of Utah
  • Rhodes, Dynamic Content Group
  • McPeek Hinz, Duke University Health System
  • Malinowski, Cerner

Subscribers to the AMIA 2020 Virtual Annual Symposium: Digital Collection can access a recording of this panel presentation

Virtual Panel Presentation ONC Clinical Decision Support Workshop September 15, 2020

Federal Updates on Clinical Decision Support: Pain Management and Prescribing

  • Roland Gamache, PhD, Agency for Healthcare Research and Quality
  • Joshua Richardson, PhD, RTI International
  • Kristen Miller, DrPH, National Center for Human Factors in Healthcare
  • MedStar Health
  • Wes Sargent, Centers for Disease Control and Prevention
  • Greg White, Security Risk Solutions
  • Kensaku Kawamoto, MD, PhD, University of Utah

A recording of the ONC CDS Workshop, including this panel presentation is available at  https://www.healthit.gov/news/events/clinical-decision-support-cds-workshop

Virtual Panel Presentation ONC Tech Forum August 10, 2020

Advances in Opioid Prescribing through Health IT

  • JaWanna Henry, ONC, Moderator
  • Verlyn Hawks, Utah Navajo Health System
  • Ronald Larsen, State of Utah, Department of Commerce
  • Emily Mitchell, Accenture Federal Services
  • Bryn Rhodes, Database Consulting Group
  • Jaime Smith, Surescripts
  • Eugenia McPeek Hinz MD MS, Associate Chief Medical Information Officer for Duke University Health System

A recording of this panel presentation is available to registered participants at https://kauffman.6connex.com/event/onctechforum/en-us#!/WorkingSessions/n566743 


CDC Recommendation Statements Summarized

1. Selection of non-pharmacologic therapy, nonopioid pharmacologic therapy, opioid therapy

7. Considerations for follow-up and discontinuation of opioid therapy

2. Establishment of treatment goals

8. Evaluation of risk factors for opioid-related harms and ways to mitigate patient risk

3. Discussion of risks and benefits of therapy with patients

9. Review of prescription drug monitoring program (PDMP) data

4. Selection of immediate-release or extended-release and long-acting opioids

10. Use of urine drug testing

5. Dosage considerations

11. Considerations for co-prescribing benzodiazepines.

6. Duration of treatment

12. Arrangement of treatment for opioid use disorder

Project Artifacts

Opioid Prescribing Support Implementation Guide FHIR R4 (includes artifacts for implementing all 12 CDC recommendations)http://build.fhir.org/ig/cqframework/opioid-cds-r4/
Opioid Prescribing Support Quick Start Guide (for recommendations #10 and #11)http://build.fhir.org/ig/cqframework/opioid-cds-r4/quick-start.html 
CDC Opioid Prescribing Guideline  FHIR R4 - Process Documentationhttp://build.fhir.org/ig/cqframework/opioid-cds-r4/process-documentation.html
CDC Opioid Prescribing Guideline FHIR R4 - Integration Documentationhttp://build.fhir.org/ig/cqframework/opioid-cds-r4/integration-documentation.html
CDC Opioid Prescribing Guideline FHIR R4 - Implementation Documentationhttp://build.fhir.org/ig/cqframework/opioid-cds-r4/implementation-documentation.html
CDC Opioid Prescribing Guideline FHIR R4 - Service Documentationhttp://build.fhir.org/ig/cqframework/opioid-cds-r4/service-documentation.html

Opioid Prescribing Support Implementation Guide STU3 and DSTU2 (recommendations #4, #5, #7, #8, #10 and #11)

http://build.fhir.org/ig/cqframework/opioid-cds/index.html

CDC Opioid Prescribing Guideline - Process Documentation

http://build.fhir.org/ig/cqframework/opioid-cds/process-documentation.html

CDC Opioid Prescribing Guideline - Integration Documentation

http://build.fhir.org/ig/cqframework/opioid-cds/integration-documentation.html

CDC Opioid Prescribing Guideline - Implementation Documentation

http://build.fhir.org/ig/cqframework/opioid-cds/implementation-documentation.html

CDC Opioid Prescribing Guideline - Service Documentation

http://build.fhir.org/ig/cqframework/opioid-cds/service-documentation.html

Opioid MME FHIR R4 Implementation Guidehttp://build.fhir.org/ig/cqframework/opioid-mme-r4/index.html

Project Team Contacts

Name

Role

Email

Jawanna Henry, MPH (ONC)

PoC ONC

Jawanna.Henry@hhs.gov

Lolita Kachay, MPH (ONC)

PoC ONC

Lolita.Kachay@hhs.gov

Mera Choi, JD, MPP, MPM (ONC)

Secondary PoC ONC

mera.choi@hhs.gov

Johnathan Coleman, CISSP

HIT Program Manager/ HL7 Support

jc@securityrs.com

Amber Patel, LLM

HIT Project Manager

ayp@securityrs.com

Greg White, MS, MA

Computer Scientist/Analyst

gw@securityrs.com



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