EMR 'Nudging' Could Curtail Opioid Prescribing

Alexandra Wilson Pecci, January 23, 2018

Emergency Departments prescribe fewer opioid pills to their patients when the EMR default setting was set to 10 tablets.

A gentle nudge may be what it takes to reduce opioid prescribing.

Implementing a default option for a lower quantity of opioid tablets in EMR discharge orders may help combat the opioid crisis by "nudging" physicians to prescribe smaller quantities consistent with prescribing guidelines, Penn Medicine researchers show in a new study published in the Journal of General Internal Medicine.

The researchers found that physicians from two Penn Medicine EDs prescribed a fewer number of opioid pills to their patients when the EMR default setting was set to 10 tablets. Initial prescriptions for that amount shot up by 22%.

Conversely, the number of prescriptions written for 20 tablets decreased by almost 7%, and prescriptions for 11 to 19 tablets decreased by more than 13%.

Researchers analyzed prescription data from the emergency departments of the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC) between late 2014 and mid-2015, before and after the default was in place.

In 2015, both departments replaced an EMR that required clinicians to enter the number of tablets for opioid prescriptions with an EMR that includes a default quantity of 10 tablets. With this new EMR, clinicians can also "opt out" by selecting a quantity of 20 tablets, which is displayed second, or they can modify their orders.

The researchers compared weekly prescribing patterns for oxycodone 5 mg/acetaminophen (325 mg) for 41 weeks. In all, physicians wrote more than 3,200 prescriptions. After the default implementation, the median number of opioid tablets supplied per prescription decreased by a small amount from an already low baseline of 11.3 to 10 at HUP and from 12.6 to 10.9 at PPMC.

“We know that prescribing too many opioid tablets for acute pain increases a patient’s risk for long-term use or the potential to be abused if left in the medicine cabinet, so making it easier to prescribe quantities consistent with current guidelines while still keeping physician autonomy is an important part of addressing the opioid crisis we’re facing in this country,” lead author M. Kit Delgado, MD, MS, assistant professor of emergency medicine and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, said in a statement.

However, across the two EDs, there was a marked increase in the proportion of prescriptions written for 10 tablets, from 20.6% to 43.3%, whereas prescriptions for larger quantities dropped. With implementation of the default of 10 tablets, there was a small unintended decrease in prescriptions written for less than 10 tablets.

"This suggests that future efforts to set default quantities should provide a default option for the lowest baseline prescription," the authors wrote.

Similarly, Penn researchers found in 2016 that making a change to prescription default options in EHR systems immediately boosted generic prescribing rates from 75% to 98%.

Alexandra Wilson Pecci

Alexandra Wilson Pecci is an editor for HealthLeaders Media.

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