s Program as a Tool to Improve Patient Care and Fight the Drug Epidemic D. Todd Bess, Pharm.D. Director April 12, 2018 Disclosure Information I have no financial relationships to disclose. I will not discuss off label use and/or investigational use in my presentation. CSMD News Flash! Appriss will probably move the CSMD to a new platform in the near future. In order for you to move with it, you MUST have and keep active email address in CSMD that is unique and only you have access. If you are required by law to have access to CSMD and do not keep an active email in My Account of current platform, you will have an issue with access to the CSMD once the transition occurs. Please remember to revoke any Supervisory Relationships that are no longer active. D. Todd Bess, PharmD 1
New Feature on Patient Report Coming Soon: New Feature on Patient Report Language on patient report to remind users on how this patient was identified and has a padlock icon associated with a name on the report. The patient with the lock indicator before the name has the same first name, last name and date of birth of a person that has been reported to the CSMD by TennCare, and has been locked into a single pharmacy (TennCare will only provide coverage for this patient at their assigned pharmacy). Please assess if your patient is an active TennCare Enrollee that is locked into one pharmacy, and if so please refer this patient's pharmacy care to their assigned pharmacy. 2017 Members of the CSMD Committee Member Name Melanie Blake, M.D. Katherine N Halls, DDS Brent Earwood, APN, CRNA Brad Lindsay Shant Garabedian, DO Mike Dickerson, D.Ph. Sheila Schuler, DPM Stephen Ladd, DVM Omar Nava, PA C Robert Ellis Lisa Tittle Board Board of Medical Examiners Board of Dentistry Board of Nursing Board of Optometry Board of Osteopathy Board of Pharmacy Board of Podiatry Board of Veterinary Medical Examiners Committee on Physician Assistants Public Member Board of Medical Examiners Public Member Board or Pharmacy D. Todd Bess, PharmD 2
Do all Healthcare Providers have to Register? If you provide direct care and prescribe controlled substances to patients in Tennessee for more than 15 days per year or you are a dispenser in practice providing direct care to patients in Tennessee for more than 15 days per year, you are required to register with the CSMD. Prescription Safety Act 2016 (Public Chapter 1002) CSMD FAQ on website has been updated https://www.tn.gov/health/health program areas/healthprofessional boards/csmd board/csmd board/faq.html Requirements for Prescribers and dispensers are now similar Adds a professional duty to check the database before prescribing to someone exhibiting drug seeking behavior for any controlled substance Adds requirement for dispensers to check patients with prescriptions for opioids and benzodiazepines similar to prescribers Add CRNAs as providers that can have access Effective upon the Governor s signature on April 27, 2016 Why is it important to check the Controlled Substance? Despite the rise in opioid abuse, during the fall of 2015, a single patient was able to procure 89 prescriptions in a 90 day period by visiting a large number of dentists throughout the state of Tennessee. *Additional information* No single prescription would have hit the mandatory check requirement Patient used multiple pharmacies Doctor Shopping could have been avoided Prescribing history may show specific trends in prescriptions filled Prevention of potential overdose Pharmacist intervention as another mode of defense D. Todd Bess, PharmD 3
Outline for Data Analytics Related to TN Controlled Substance (CSMD) Patient Report Prescriber Analytics for the CSMD Reports and Survey PATIENT REPORT CSMD Data Analytics Considerations with use of the Tennessee CSMD D. Todd Bess, PharmD 4
Patient Request Page: Optional Question Added for Users to Indicate Suspected Overdose or Poisoning Training User None of these Patients Clinical Risk Indicators (high risk patients) on CSMD Reports Y = 4 Practitioners in last 90 days Y Y R R R = 4 Pharmacies in last 90 days 90 but < 120 Active Cumulative Morphine Equivalents per day 5 Practitioners in last 90 days 5 Pharmacies in last 90 days 120 Active Cumulative Morphine Equivalents per day D. Todd Bess, PharmD 5
Clinical Risk Indicators (high risk patients) on CSMD Reports Female and child bearing age (15 45 years of age) Please remember that narcotic prescriptions for women of child bearing age could result in Neonatal Abstinence Syndrome (NAS) should pregnancy occur; please discuss with your patient methods to prevent unintended pregnancy. Considerations When Reading CSMD Report Payment Type Identifying Number Private Pay 01 Medicaid 02 Medicare 03 Commercial Ins. 04 Military Inst. and VA 05 Workers Comp 06 Indian Nations 07 Other 99 D. Todd Bess, PharmD 6
PROPOSED Gateway State PMP Clinical Risk Indicators This example provided to TN CSMD by Appriss for educational purposes. PROPRIETARY AND CONFIDENTIAL Remove Linked Patients within Gateway Report Sample Gateway Report integrated into an EMR System Remove a Linked Patient from a Gateway Report You have the ability to remove linked patients in the Patient Information section. Linked Records are any patient records that were linked to make up this Patient Report. To the far right is an interactive column labeled Mark X to Remove. Each record in this list can be clicked and selected for removal from this Patient s report. (The ability to remove records within PMP Gateway will be available in Q3/Q4 of 2017.) This example provided to TN CSMD by Appriss for educational purposes. PROPRIETARY AND CONFIDENTIAL Remove Linked Patients within Gateway Report Sample Gateway Report integrated into an EMR System Remove a Linked Patient from a Gateway Report (continued) To remove one or more linked record from a patient report: 1. Mark the patient(s) to be removed from the patient report by clicking Remove. A red X will appear marking the record for removal. To unmark it, click remove again. When you mark the first patient for removal, two action buttons will automatically appear. TIP: Mark all patients you want removed from the report before you click Remove X Marked. 2. Click the Remove X Marked button to process the marked record(s) and re-run the report. This example provided to TN CSMD by Appriss for educational purposes. PROPRIETARY AND CONFIDENTIAL D. Todd Bess, PharmD 7
Remove Linked Patients within Gateway Report Sample Gateway Report integrated into an EMR System View Refreshed Gateway Patient Report The refreshed report will automatically display excluding the patients that were removed, including all associated prescription history information. This example provided to TN CSMD by Appriss for educational purposes. PROPRIETARY AND CONFIDENTIAL PRESCRIBER RELATED ACCESS TO REPORTS CSMD Data Analytics Practitioner Self Lookup D. Todd Bess, PharmD 8
Practitioner Self Lookup with Option to Include APRN / PA Prescriber Dashboard in CSMD (CSMD production date 8/6/2017) Available in the past Turned off due to alert fatigue Recently reengineered to avoid alert fatigue Order of Notifications Correlates to indicators on patient reports with slight variation as no symbols on dashboard but if you click view all notifications the symbols will appear Multiple Practitioners 5 Multiple Dispensers 5 Multiple Practitioners = 4 Multiple Dispensers = 4 MME 120 MME 90 <120 CSMD User Dashboard (Clinical Risk Notifications) a Prescribers receive emails from CSMD each week if they have new notifications D. Todd Bess, PharmD 9
Welcomes Test Test CSMD User Dashboard (Clinical Risk Notifications) Clinical Risk Notifications on Home Page in CSMD 60% of respondents received a Clinical Risk Notification 71% felt the information was useful How did the information increase awareness (could choose more than one response) 89% more aware of patients going to multiple prescriber 57% more aware of patients going to multiple dispensers 66% more aware of patients receiving highest dose of opioids Practitioner vs. Peer Report D. Todd Bess, PharmD 10
Proposed CSMD Prescriber Report Requests for You / Your Delegates Multiple provider and dispenser thresholds exceeded REPORTS AND SURVEYS CSMD Data Analytics Prescriptions in the TN CSMD In 2016, approximately 94% of overall Controlled Substances Prescriptions in TN were dispensed by licensed pharmacies and reported to the TN CSMD. Special thanks to pharmacy practice, human prescriber dispensers, and veterinarian prescriber dispensers across Tennessee for helping build a powerful tool that allows Tennessee to better fight the Prescription Drug Crisis! D. Todd Bess, PharmD 11
Number of Registrants of the CSMD, 2010 2017* 50000 45000 46,576 47,294 Number of Registrants 40000 35000 30000 25000 20000 15000 10000 13,182 15,323 22,192 34,802 38,871 42,835 5000 0 2010 2011 2012 2013 2014 2015 2016 2017 Year *VA registrants were included in 2013 2017. Ratio of Number of Prescriptions to Number of Request in the CSMD, 2010 2017* After viewing information found in the CSMD, I changed the treatment plan for a patient After viewing information found in the CSMD, I refused to fill a prescription as written Prescribers 4% 6% 30% 25% 35% Dispensers 1% 1% 19% 28% 51% ~ 65% of Prescribers have changed their treatment plan Prescribers Strongly Agree Somewhat Agree Neutral/No Opinion Somewhat Disagree Strongly Disagree ~ 79% of Dispensers are less likely to fill a prescription as written Source: 2017 CSMD Prescriber and Dispenser Survey D. Todd Bess, PharmD 12
Number of Prescriptions Reported to TN CSMD, 2010 2017* Number of Prescriptions Reported to the TN CSMD by Class of Controlled Substances, 2010 2017* Number of Stimulant Prescriptions Dispensed Among TN Patients and Reported to the CSMD, 2010 2017* D. Todd Bess, PharmD 13
Number of Benzodiazepine Prescriptions Dispensed Among TN Patients by Age Group and Reported to the CSMD, 2010 2017* MME for Long Acting Opioids Reported to the CSMD, 2010 2017* MME for Long Acting Opioids Reported to the CSMD, 2010 2017* Year Overall patients in CSMD TN patients Change among TN patients (%) 2010 3,186,575,097 3,053,655,395 2011 3,250,846,435 3,117,382,279 2.1 2012 3,281,165,787 3,144,485,150 0.9 2013 3,234,719,734 3,102,687,379 1.3 2014 2,921,833,043 2,803,168,526 9.7 2015 2,549,901,625 2,451,782,440 12.5 2016 2,122,567,448 2,043,554,990 16.7 2017 1,626,479,677 1,565,314,892 23.4 * 1) The classes of controlled substances were defined based on a CDC document; 2) Excluding prescriptions reported from VA pharmacies; 3) Excluding buprenorphine products. MME for Short Acting Opioids Reported to the CSMD, 2010 2017* Year MME for Short Acting Opioids Reported to the CSMD, 2010 2017* Overall patients in CSMD TN Patients Change among TN Patients (%) 2010 5,037,050,762 4,862,233,311 2011 5,725,823,620 5,467,276,130 12.4 2012 5,888,549,934 5,642,626,206 3.2 2013 5,673,351,755 5,456,618,080 3.3 2014 5,493,079,304 5,281,031,358 3.2 2015 5,368,706,323 5,165,968,521 2.2 2016 5,043,745,375 4,860,744,219 5.9 2017 4,582,128,792 4,425,089,600 9.0 * 1) The classes of controlled substances were defined based on a CDC document; 2) Excluding prescriptions reported from VA pharmacies; 3) Excluding buprenorphine products. D. Todd Bess, PharmD 14
Change in MME Dispensed Among TN Patients, 2011 2017* The number of potential doctor/pharmacy shoppers declined 76% between 2011 and 2017 76% 5/5/90 D. Todd Bess, PharmD 15
Conclusion s (CSMD) is a powerful tool to help protect your patients and your community Clinicians value and respond to their assessment of TN CSMD Patient Reports Major improvements of the CSMD Program are coming soon! Pharmacist and Pharmacies in your area can increase access to Life Saving Naloxone so discuss the new Collaborative Practice Agreement with THD Chief Medical Officer with your team to serve your patients and community! D. Todd Bess, PharmD 16