Part VI – PDMP Visualization
BY JIM HUIZENGA, M.D. AND CHIEF CLINICAL OFFICER OF APPRISS HEALTH
Series Introduction – Appriss Health has long held that chronic pain and addiction (substance use disorder) are separate medical conditions and that each deserve a unique clinical approach. We have spent years developing clinical decision support tools and in doing so have obtained the feedback from countless medical professionals, including many pain providers. Through those providers we have also heard (directly and indirectly) from many chronic pain patients as well.
To continue this conversation, over a long series of blog posts, we will explore our approach to benefit/risk assessment, data presentation, and clinical support…and how they relate to our goal of creating a usable and balanced, clinical viewpoint that protects access to care while highlighting areas of risk that clinicians and patients should be aware of.
A picture is worth a thousand words. Maybe even more?
My previous posts have been a bit wordy at times (I am a physician after all…) but stick with me because we’re going to transition to posts full of pictures. We closed out the last blog post with an image (don’t look back just yet) that corresponds to the following prescription history:
This prescription history is fairly representative of a typical PDMP report. I know the print is small but go ahead look it over and try to build a mental picture of what’s going on. You can probably see that the patient has recurrent prescriptions for opioids (hydrocodone and tramadol) and benzodiazepines (clonazepam).
Now, please try to answer the following questions as well:
- Has usage of both types of medications been consistent or has it varied over time?
- How many providers have written prescriptions for opioids?
- Has the patient had more than five providers writing prescriptions for opioids in the last year?
- Have any prescriptions overlapped with other prescriptions from different providers?
- How many providers have written prescriptions for sedatives (benzodiazepines)?
- Are any of the providers in the same practice or coordinating their care for this patient?
The answers to the above questions are at the bottom of this post but try to answer them yourself before scrolling down.
My guess is that you were probably able to answer some or all of the questions but I bet it took some serious time (remember that Massachusetts study).
Is there a better way to represent this PDMP data and ensure that the provider doesn’t inaccurately interpret this information in the limited time he/she has? Perhaps allowing a provider to get answers to the above questions in just a few seconds?
But it involves graphing out the data in an intuitive manner.
Let’s get graphing.
We are going to start with a reverse timeline that goes back two years for the horizontal axis:
Then, add a vertical axis containing prescriber names with the most recent on the bottom.
Now, let’s start adding prescriptions. We have more than one type of prescription (opioids and benzodiazepines) to graph, so let’s use colors to distinguish the two. Let’s make opioids (or narcotics) red and benzodiazepines (or sedatives) blue.
When we draw them let’s always make 1 pixel width = 1 day and let’s draw them with 50% opacity (I’ll explain later). If we magnify to the pixel level we can see how a 3 day, 7 day, and a 14 day opioid prescription should appear:
Okay, let’s now take the oldest prescription and put it in the graph. This prescription was for hydrocodone, 150 pills to be used over 25 days and was written about two years ago by Dr. Garcia.
Let’s add the next prescription the patient received to make sure we understand the time direction. Remember we’re going in reverse time order so as we move left on the graph the prescriptions are more recent.
Now, let’s add in all of the prescriptions from Dr. Garcia.
I said earlier that we will draw in prescriptions so that 1 pixel width equals 1 day and also using 50% opacity. The 50% opacity allows us to see when prescriptions in the same line overlap, as happens around the one year mark, seen above. This overlap is representative of filling a prescription before the previous one ran out. This could happen for any number of reasons, such as the patient was traveling and would be out of the area when her prescription needed refilling or perhaps because the patient took extra pills and ran out early. Regardless, it should be apparent looking at the graph above that Dr. Garcia has been regularly prescribing an opioid for the patient for the last two years.
Let’s go ahead and add in the rest of the prescription data:
Now, let’s add in an “All Prescribers” line which collapses/condenses all the prescriptions into a single line to help identify gaps when no prescriptions were active (if they exist).
And finally, because opioids can have different relative strengths let’s add in an MME graph below the Rx Graph to complete the picture.
With all of the graph drawing now done (realize that a computer program creates this graph in about 1/100th of a second!), let’s go back to our original questions and see if it is easier to get to the answers.
- Has usage of both types of medications been consistent or has it varied over time? It is fairly easy to see that the patient has received steady opioid and sedative prescriptions for the last two years, but, then a few months ago began receiving additional opioid prescriptions.
- How many providers have written prescriptions for opioids? Count each line with a red prescription and you get to five pretty quickly.
- Has the patient had more than five providers writing prescriptions for opioids in the last year? Easy to see that the five providers writing opioids have been in the last few months.
- Have any prescriptions overlapped with other prescriptions from different providers? The recent opioid prescriptions from Drs. Garret, Webb, Fields, and Kelly all overlap with Dr. Garcia’s prescriptions (Overlapping Rx, red, to the right). The sedative prescriptions from Drs. Reid, Fox, and Taylor DO NOT overlap with each other (Non-overlapping Rx, blue, to the right).
- How many providers have written prescriptions for sedatives (benzodiazepines)? There are three lines with blue prescriptions (Non-overlapping Rx, blue, to the right).
- Are any of the providers in the same practice or coordinating their care for this patient? Given that Drs. Reid, Fox, and Taylor are all writing for consecutive prescriptions they may very well be in the same practice. Or, at least they appear aware of the other prescriptions and may be coordinating their care.
With just a bit of practice and familiarity with the graphs, a provider can see important patterns of prescription use in SECONDS that, at a minimum, would have taken significant time to recognize, or, worse, would have been misinterpreted. These important patterns often reassure providers that a patient’s care (and actions) have been appropriate, such as is the case with the patient above receiving sedative prescriptions from three different doctors who are probably coordinating their care.
But this patient’s opioid use, which has been stable for almost two years, requires some further evaluation, I believe. I can see a significant problem and it isn’t just because of the fact that the patient has recently seen five different providers for opioids.
We’ll look more closely at that in the next blog post.
- Consistent benzodiazepine usage and consistent opioid usage until a few months ago
- Trick question because you can’t really know for sure…but it appears the clonazepam prescriptions all start and stop in a coordinated manner so likely the three sedative providers are working together
How well did you do? And, how long did it take?
To read more on this series:
- Part I – Benefit and Risk
- Part II – Risk Defined
- Part III – Dependence and Addiction
- Part IV – PDMPs
- Part V – Multiple Provider Episodes
- Part VI – PDMP Visualization
- Part VII – Interpreting PDMP Visualizations
- Part VIII – Scoring PDMP Data
- Part IX – Understanding How PDMP Data is Scored
- Part X – Machine Learning
- Part XI – Epilogue