D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2018 . No. 2 ASSOCIATION BETWEEN ELECTRONIC MEDICAL RECORD IMPLEMENTATION OF DEFAULT OPIOID PRESCRIPTION QUANTITIES AND PRESCRIBING BEHAVIOR IN TWO EMERGENCY DEPARTMENTS M. Kit Delgado, Frances S. Shofer, Mitesh S. Patel, Scott Halpern, Christopher Edwards, Zachary F. Meisel, Jeanmarie Perrone Journal of General Internal Medicine – first online January 16, 2018 KEYFINDINGS Setting a low quantity of opioid tablets as the default option in electronic medical record prescribing orders may “nudge” clinicians to prescribe fewer opioids. When two emergency departments implemented a 10-tablet default instead of a manual entry, the proportion of 10-tablet prescriptions written more than doubled, from 20.6% to 43.3%. Conversely, 20-tablet prescriptions decreased from 22.8% to 16.1%, and prescriptions for 11-19 tablets decreased from 33.5% to 20.1%. THE QUESTION authors compared weekly prescribing patterns proportion of prescriptions written for 20 tablets before and after the 10-tablet default by (displayed second in the EMR) decreased The epidemic of opioid overdose deaths in the tracking the quantity of tablets supplied at from 22.8% to 16.1%, and prescriptions for 11-19 US has its roots in prescription opioids. Patients discharge for the most commonly prescribed tablets decreased from 33.5% to 20.1%. who receive a prescription for a large quantity opioid, oxycodone with acetaminophen (Oxy/ of opioids, especially those new to opioids, are An unintended consequence of the default APAP). at risk for long-term use or for having leftover option was that the proportion of prescriptions tablets that are later misused or abused. written for fewer than 10 tablets decreased from Patients often receive 30 or more opioid 20.4% to 15.4%. Additionally, the proportion of tablets for acute pain, despite current opioid THE FINDINGS prescriptions written for more than 20 tablets prescribing guidelines recommending only a During a 41-week period, patients received increased slightly, from 2.8% to 5.1%, half of fraction of that quantity (10-12 tablets). Default 3,264 prescriptions for Oxy/APAP across which were for 28 tablets (the health system- options, or pre-set selections, in electronic the two EDs. The average number of tablets wide default if the clinician clicked on “Database medical records (EMRs) can influence behavior prescribed remained the same after the default Lookup” in the new EMR). in other contexts, and may be a way to guide option was implemented, but the median clinicians toward prescribing smaller quantities number per prescription decreased slightly from of opioid tablets. a low baseline of 11.3 to 10 in one ED and from THE IMPLICATIONS 12.6 to 10.9 in the other. In 2015, two Penn Medicine emergency This study suggests that default options in the departments (EDs) implemented a new EMR However, the proportion of prescriptions EMR are a powerful, low-cost tool to nudge that featured a default setting of 10 opioid written for the default option of 10 tablets clinicians to prescribe fewer opioids. Because tablets, replacing one that required the clinician more than doubled from 20.6% pre-default to baseline prescription quantities were already to enter the number of tablets manually. The 43.3% post-default (Figure 1). Conversely, the low in the two EDs, the overall number of COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI THE STUDY FIGURE 1. QUANTITY OF OXY/APAP TABLETS DISPENSED BEFORE AND AFTER IMPLEMENTATION OF ED EMR DISCHARGE ORDER DEFAULT OF 10 TABLETS The authors used EMR data from the emergency departments of the Hospital of the 50 University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PMC) between PERCENT OF PRESCRIPTIONS 43.3% 40 October 1, 2014 and June 29, 2015. 33.5% This 41-week period included data from the 30 old EMR system that required physicians to 22.8% 20.4% 20.6% 20.1% manually enter opioid pill quantity (weeks 1-22 20 15.4% 16.1% for HUP and 1-26 for PMC) and the new EMR system that included a preference list with the 10 5.1% default quantity of 10 tablets displayed first 2.8% (weeks 23-41 for HUP and 27-41 for PMC). In 0 the new EMR, the clinician could “opt out” of <10 10 1-19 20 >20 QUANTITY OF TABLETS the default by selecting a quantity of 20 tablets, which is displayed second, by modifying either ■ No default ■ 10-tablet default of these orders, or by choosing “Database Lookup,” where a health system default of 28 opioid tablets prescribed did not change. But departments and indications, health system level tablets is displayed, as well as manual entry the significant shift to the default quantity, defaults should also be set low. This study found options. consistent with ED prescribing guidelines, that opting out of the 10-tablet default led some suggests that this is a simple and scalable to select the health system default of 28 tablets, approach to change prescribing behavior while which led to a small, unintended increase of Delgado, M.K, F.S. Shofer, M.S. Patel, S. preserving clinician autonomy. This approach prescriptions for more than 20 tablets. Halpern S., E. Christopher, Z.M. Meisel, J. could have a significant impact in “right-sizing” Changing defaults in EMRs have been useful Perrone. Association between Electronic post-operative opioid prescriptions for acute pain, for which quantities prescribed are in changing clinician behavior in other contexts, Medical Record Implementation of Default significantly higher and 50-70% of tablets are such as increasing the rates of prescribing Opioid Prescription Quantities and never taken. generic rather than brand-name drugs in Prescribing Behavior in Two Emergency primary care. Departments. Journal of General Internal This study also suggests that default options Medicine. 2018. doi: 10.1007/s11606-017-4286-5 must be implemented cautiously to avoid Further research is needed to evaluate the unintended consequences. A default option effects of implementing an opioid default should be set at the lowest baseline quantity option in EMRs on a larger scale, in systems being prescribed to avoid inadvertently with higher baseline prescription quantities, and over a longer timeframe. This research LDI Research Briefs are produced by encouraging some clinicians to prescribe more is ongoing in a newly-funded trial called LDI’s policy team. For more information than before the default was set. Second, REDUCE. please contact Janet Weiner at beyond setting default quantities for specific weinerja@pennmedicine.upenn.edu. LEAD AUTHOR DR. M. KIT DELGADO M. Kit Delgado, MD, MS, is an Assistant Professor of Emergency Medicine and Epidemiology at Penn and a practicing trauma center emergency physician. He leads the Behavioral Science & Analytics For Injury Reduction (BeSAFIR) lab, which applies data science and behavioral economics for preventing injuries and improving trauma and emergency care. He has developed a novel line of research leveraging smartphone technology and behavioral economic interventions for injury prevention with a focus on reducing motor vehicle crashes due to distracted and alcohol-impaired driving. He is also testing behavioral economic interventions to promote opioid stewardship for acute and post-operative pain management. Finally, he conducts health services research to optimize trauma and emergency care systems. His work is funded by the National Institutes of Health, the U.S. Department of Transportation, and the Agency for Health Care Research and Quality. In addition to being an LDI Senior Fellow, he is a faculty member in the Center for Emergency Care Policy and Research, the Center for Health Incentives and Behavioral Economics, the Penn Injury Science Center, and the Children’s Hospital of Philadelphia Center for Injury Research and Prevention. He is also a member of the National Academies of Sciences, Engineering, and Medicine Committee on Accelerating Progress to Reduce Alcohol-Impaired Driving Fatalities.