State Update
Vital Signs: May 2012
Editor's Note: Madeleine Biondolillo, M.D., bureau director
for health care quality and safety at the Department of Public
Health (DPH), is approaching her first full year at the
Massachusetts DPH. She is an MMS member with a background in
geriatric service provision and primary care.
Vital Signs recently interviewed Dr. Biondolillo about the
Drug Control Program and the Prescription Monitoring Program (PMP),
which fall under her oversight at the DPH.
VS: Can you give us some background on the
PMP?
Dr. Biondolillo: The program was created as a
joint effort of the MMS and DPH 25 years ago to identify Schedule
II prescriptions. In 2010, the Legislature created the opportunity
for there to be an electronic version. Massachusetts is leading the
way in making the technology available to prescribers so they can
have it in their armamentarium of tools to provide care to
patients. Online access started in December 2010. About 2,000
prescribers have enrolled since then and every pharmacy is
enrolled. The database includes prescriber and patient data on all
prescriptions filled in Massachusetts for federally scheduled
medications.
We've taken a paper-based tool and automated it for better
access. Physicians we speak to all the time who use this in their
care are almost uniformly thrilled with it… particularly those who
do pain management and emergency care. There are also a lot of
primary care physicians who feel they would benefit greatly from
this tool. In general, it gives the opportunity to work with
patients when the physicians have a concern, either on the basis of
their own judgment or when they use the system and find a reason
for concern in a patient's history.
We do screens and define areas of questionable activity to be
four or more prescriptions from different prescribers filled at
three or more pharmacies. That benchmark was defined in
collaboration with the medical review group, which balances issues
of patient privacy and needs with diversion concerns.
VS: What role does the medical review group
play?
Dr. Biondolillo: These are physicians,
dentists, and a podiatrist brought together on a quarterly basis to
look at data and case report studies of prescriber utilization of
the PMP, reports of which information is accessed by law
enforcement, and they set the threshold on questionable
activity.
Right now, data show that two-thirds of one percent of patients
fall into the questionable category and they account for four
percent of prescriptions.
VS: What can the program do to identify the scope and
areas of the problem in Massachusetts?
Dr. Biondolillo: Depending on how the data is
viewed, we will be able to see where patients live, and for
providers, to determine if they are in an at-risk location. The
data will help us allocate treatment and law enforcement
resources.
The technology is about to be upgraded to allow expanded
capabilities in many areas. We have the opportunity to link data
sources together with the trauma registry and ambulance trip
records (to identify overdoses). We're planning to reduce our lag
time for the data down to about 10 days as a priority and to
improve batch lookups, which will allow a physician or their
designee, such as a nurse, to screen all patients scheduled for a
particular day.
The providers who are using the system now, such as emergency
physicians, are looking up lots of people. When you get used to
doing it, it takes seconds. When you do the risk-benefit analysis
of not doing it, if it takes about 10 or 15 seconds, it's
completely worth doing. I agree that it would be best to integrate
and automate the search process, but if batch lookups are
delegated, it has to be to a licensed health care provider, such as
a nurse, over whom the department has regulatory authority and who
has patient privacy and confidentiality responsibilities.
VS: What about efforts to make it automatic for
prescribers to be eligible to access the system?
Dr. Biondolillo: You mean when they renew their
licenses? We're very amenable to that and anything that will
increase the ability of the system to be used. There is a tension
between the rights of privacy of the patients and ease of use of
the system, but because there are such protections in license
renewals, it seems feasible to make that happen.
Integration into EHR systems when you're considering writing a
prescription is absolutely ideal, and I believe the technology is
available. We're very interested in this. We're doing a test pilot
with a local hospital integrating its EHR into the database. We're
also trying to embed screening tools in the system that will show
appropriate referral to treatment if patients trigger screens.
This is a tool that is part of a compendium of things to deal
with this issue. If we don't use it right, it will be a blunt
instrument; if we use it correctly, it will be a good start, but
you absolutely have to have a conversation with the patient and the
physician as to what is going on.
We know we have a crisis, and we have to be more sophisticated
than we've been.
- William Ryder
