"How do we improve opioid control, not just in our own office, but also among referring physicians?" he says. "Patient treatment agreements, assessments, urine screening, a prescription monitoring program — how can we share that information with our primary care colleagues?"
For Dr. Sayeed and his colleagues at DuPage Medical Group, the answer lies in the sharing of electronic medical records, which allows all physicians to stay up-to-date on the latest changes in prescriptions, tests and health needs of patients treated with opioids. The clinical pathway is intended to help make prescriptions more consistent and has served to lessen uncertainty among physicians who sought greater collaboration with pain specialists. "We've had a very positive response from our primary care doctors, and we have continued to refine the pathway based on their input," he says.
Dr. Sayeed discusses the steps taken to facilitate and implement a collaborative electronic medical record-based clinical pathway between primary care physicians and pain management specialists.
1. Identify sources of miscommunication between primary care physicians and pain management physicians. The need for a collaborative system stemmed primarily from the types of patients referred to Dr. Sayeed and his colleagues. "We were getting a lot of patients referred from primary care physicians because they felt uncomfortable writing the prescriptions for medication," he says. "They may have inherited a patient that was on chronic opioids and felt uncomfortable with that scenario, or they were concerned with a patient that was misusing."
The biggest challenge, however, was in the communication of the reasons as to why the patients were referred from primary care to pain management. Specifically, it seemed as though primary care physicians were wary about under prescribing or overprescribing pain medications. "As we looked into this, we found that the prescribing habits of our primary care physicians did exhibit some variability, even within their own practices," says Dr. Sayeed. One physician would prescribe Oxycontin, for example, and another physician within the practice would not refill the medication. While such variability is certainly not unique to DMG, it presented an ideal opportunity to partner with physicians throughout the group to improve the quality of patient care.
To facilitate greater collaboration among prescribing physicians and to ensure that patients were given consistent care, Dr. Sayeed and his colleagues collaborated with their primary care colleagues to create a clinical pathway that allows both primary care and pain management physicians to access a patients' electronic medical record and keep track of all prescriptions, check-ins and tests.
2. Facilitate the sharing of electronic medical records among a network of physicians. The sharing of electronic medical records was particularly convenient for Dr. Sayeed and his colleagues, all of whom are part of the multispecialty medical system DuPage Medical Group, which is comprised of more than 400 providers who use the same electronic medical records system. DMG has also recently developed a partnership with nearby Edward Health System in Naperville, IL, which will enable Edward’s physicians to utilize the same electronic health record system. “In total, we will have more than 500 providers who utilize the same EMR," says Dr. Sayeed.
Shared access to patient medical records enables pain management physicians to stay up-to-date with the patient's progress with his or her primary care physician, and vice versa. However, collaboration does not necessarily require electronic medical records, Dr. Sayeed says. "Collaboration can be done by fax or phone, as long as the communication channel is there," he says. "It's about reaching out to primary care physicians, understanding what their concerns are and addressing them. It's about evidence-driven prescribing that enables the best care for patients."
3. Create a clinical pathway in electronic medical records. When a primary care physician logs in to the electronic medical records system to access a patient's record, a yellow prompt will appear indicating that the patient is currently being treated with opioids, Dr. Sayeed says. The prompt also allows the physician to initiate a clinical pathway developed specifically for such patients, which provides tools that can be utilized to effectively manage the care of such patients and allows for discrete documentation that can later be accessed by a pain management physician who is consulting the same patient's record.
This system results in improved communication when a primary care physician refers a patient to a pain management specialist. "When we see that patient, all of the information is there [in their record], and we don't have to read the mind of the primary care doctor to know why the patient was sent here," says Dr. Sayeed. "When we send the patient back, the primary care physician can see [on the medical record] what our specific concerns were with the patient."
4. Share crucial components for the care of patients being treated with opioids. These components include: patient and physician treatment agreements, urine and blood lab screens and LFT tests, prescription monitoring database checks, functional and psycho-social assessment scores, regular three-month follow-up appointments and referrals of patients to pain medicine specialists when appropriate. DMG has included each of these components into its clinical pathway in an effort to improve patient care and facilitate the sharing of information between the providers in its network. "Based on the sharing of that information, we have the ability to collaborate on the development of safer, more appropriate care plans for each of our patients," says Dr. Sayeed.
Succinct psycho-social (DIRE Score) and functional assessment tools are utilized to determine the patient’s appropriateness for treatment with opioids and the progression of their condition in response to treatment. With the results of these tests in hand, primary care physicians can more readily and confidently prescribe opioid medications and determine when to refer the patient to a specialist, says Dr. Sayeed. "With access to the pathway’s tools, a primary care physician can also assess if the patient has been abusing or diverting medications," he says. "They can address all of that before they engage in chronic opioid prescriptions — they don't need to wait until it gets out of control, and until the liability is out there, before they send patients to us."
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