Dr. Baruch Fertel (Photo by: Cleveland Clinic)
CLEVELAND, OH — When Dr. Baruch Fertel took a job at the Cleveland Clinic in 2013 he knew he had a crisis on his hands. The nation was in the grip of an opioid epidemic and Ohio was ground zero.
And Fertel quickly realized that hospitals were, in some respects, doing more harm than good, often prescribing someone who came in with an ankle sprain or other small injury 30 Percocets because it was the default in the electronic health record (EHR).
“That’s a huge amount for something that maybe is a day or two,” said Fertel, the Director of Quality and Operations at the storied medical center.
According to the CDC, Ohio’s opioid prescribing habits have been higher, on average, than other states. As recently as 2017, Ohio providers wrote 63.5 opioid prescriptions for every 100 persons, compared to the average U.S. rate of 58.7 prescriptions.
But Fertel and his colleagues came up with a plan to use data to illustrate to doctors how their current prescribing practices were harmful. Fertel spent the next couple years redesigning the Clinic’s EHR, changing default doses and creating dashboards for each physician to monitor their own prescribing habits compared to their peers.
“No physician or healthcare provider wants to cause harm. It’s not why we went into this business. Every one of us care about our patients and really want to do the right thing and really want to take good care of people. But habits creep in, or there’s misinformation.” he said.
Cleveland Clinic President and CEO Toby Cosgrove shared the same sentiment. In 2017 Cosgrove wrote on the Clinic’s website that “over 75 percent of opioid and heroin deaths begin with a prescription painkiller,” urging the healthcare industry to take responsibility for its role in the epidemic by recognizing and adjusting prescribing habits.
With EHR enhancements in place, it took just two years for the total number of opioid prescriptions being written at the Clinic to drop by half. And they cut the number of opioid prescriptions exceeding 3-days to nearly zero. The project was so successful that Fertel published the results in The American Journal of Emergency Medicine in 2019.
Further proving the impact numbers have on individuals changing behavior, Fertel described an email exchange with a physician who had just received the data on his opioid prescribing habits compared to his peers, which prompted him to reach out and ask what was going on. He thought he was a reasonable opioid prescriber, but confronted with the numbers, he saw that there was room for improvement.
Fertel’s intuition was correct.
Even outside the emergency department, physicians at the Clinic are using EHR enhancements to achieve similar outcomes.
Nicholas Davalla, project manager for the Clinic’s Enterprise Quality Improvement team, explained the overall vision as rolling out in two phases: presenting physicians with meaningful data, and using the data to set new standards of care for using opioids for pain management.
“We have an abundance of data about prescribing,” he said, “but if you just give an individual practitioner their prescribing amount without any context, what does that mean?”
With that in mind, the pain management committee and department chairs are working directly with physicians whose prescribing patterns fall outside of the norm for a particular procedure to tighten up the Clinic’s prescribing practices as a whole.
Ideally, they’d like to get to a point where, as a healthy patient with no other risk factors, you know that if you are coming to Cleveland Clinic for a total knee replacement, you’ll get a set number of MMEs (morphine milligram equivalents, values assigned to opioids to represent their relative potency) for that procedure, regardless of the provider you are seen by or the hospital you are seen in.
Using data to adjust prescribing habits isn’t the only change underway. Across the enterprise, clinicians at the Clinic are innovating to improve patient’s outcomes while also reducing the amount of opioids given.
In March 2018, Dr. Eric Chiang piloted a program at Fairview hospital that reduced the amount of opioids given to c-section patients while improving their overall wellbeing. “The patients were doing much better,” Chiang told the Wall Street Journal. “They were more awake and not so sleepy or lethargic.”
Piggybacking on Dr. Chiang’s initiative, Jonathan Hunt, an obstetrics resident at Hillcrest, worked with the EHR IT team to design a tool that makes it easy to see how much opioid-based pain medication a c-section patient is getting while in the hospital so that providers can more easily figure out what the patient truly needs to be sent home with.
Now, said Davalla, a physician can see, “This patient hasn’t been on opioids for a couple of days, why would I send them home with an opioid prescription?’”
Opioid abuse is a public health concern beyond just the drug’s direct side effects and the risk of overdose, Fertel explained. The secondary effects are causing serious public health risks, too. Punctuating his message with an example, he explained that there’s been a surge in valve replacements in young people from endocarditis — an infection of the heart’s lining — stemming from sharing needles used for intravenous drugs.
But there’s hope still.
Once they are able to create data-driven standards for opioid use, that data can be shared with others in the healthcare industry. Cleveland Clinic is committed to not just fixing the immediate problem, but also healing the community along the way. Devalla said one of their goals is to recognize that they have a responsibility within the community as a large healthcare provider to innovate and to help patients treat their pain in as safe a way as possible.
“These are our neighbors, these are our friends.” Fertel said of the personal and moral responsibility he feels to help his community.
It all starts with prevention, he said simply.
“We can fix all the heart valves in the world, and it might sound silly, but we want to make sure that we don’t have to fix these heart valves.” he ended with.