Facing scrutiny

Friday, September 01, 2017 12:45 PM

Peer review and regulators

by Elizabeth S. Grace, MD, FAAFP, CPEP Medical Director

“I got a letter in the mail from the board – I was totally shocked. A patient’s mother filed a complaint saying that I got her son addicted to opioids, and the board requested several charts.”

These are the words of a physician, recently referred to the Center for Personalized Education for Physicians (CPEP) after being sanctioned by their licensure board for prescribing inappropriately. (Details altered to protect identity.) CPEP is a Colorado-based not-for-profit that has been helping physicians since 1990 through educational needs assessments, targeted remedial education, reentry programs and continuing medical education seminars.

While the majority of our programs are open to all physicians, most assessment-program participants are referred by licensure boards and, currently, approximately one-third of our assessment-program referrals are for physicians who have had concerns raised about controlled substance prescribing.

Most of the referred physicians are aware of the current concerns about opioid prescribing and the opioid epidemic, but they do not believe that their prescribing habits are any different from their colleagues, and are surprised by the board’s inquiry. Others admit that they may have been uncomfortable with some of their prescribing but felt that they were doing the best they could for their patients with the resources available.

Legislation in Colorado prohibits the medical board from reviewing the Prescription Drug Monitoring Program (PDMP) to identify the state’s highest prescribers; board inquiries are prompted by specific triggers – such as NPDB reports or complaints filed with the board, as in this physician’s case. Once an investigation has been initiated, if adequate cause exists, the board can subpoena a clinician’s PDMP record and identify the patients of highest concern.

“It seems that they were interested in patients who were on higher morphine equivalent doses and those on combinations of benzodiazepines and opioids.”

Prescribing guidelines published in the recent past do not agree on what thresholds of dosing should prompt higher levels of screening and caution, but they all acknowledge the increased mortality risk for patients on higher overall doses of opioids; therefore it is not surprising that these patients get a lot of attention.

For example, in Colorado the Policy for Prescribing and Dispensing Opioids from 2014 states that morphine milligram equivalents (MMEs) over 120 are “more likely dangerous” and warrant additional precautions including consideration of referral. More recently the CDC guidelines recommend careful reassessment at doses over 50 MME and avoidance of doses over 90 MME.

In addition, since the FDA’s “black box” warning about and the CDC recommendation against co-prescribing of opioids and benzodiazepines, licensing boards and other overseeing entities will raise concerns about clinicians who have a significant number of patients on both agents, especially if the rationale for doing so (and why an alternative approach is not being used) is not evident from the record. Other things that might attract the attention of someone reviewing a medical record would include: prescribing opioids for vague or ill-defined purposes and prescribing for conditions for which opioids are not generally recommended, such as migraine or fibromyalgia.

“When they looked at my records, they were concerned about my electronic medical record documentation. They couldn’t understand why I was increasing doses of certain patients and they couldn’t tell how I was responding to abnormal results. More precisely, to them it looked like I wasn’t doing anything when patients had ‘unexpected’ urine drug test results.”

While this is not a problem unique to electronic medical records, our observation at CPEP is that the EMR format may make it more difficult for clinicians to document their clinical rationale – which is so important when anyone else is reviewing a record, be it the licensing board or a physician consulting on a patient’s case. Furthermore, it is more variable in how, where and whether a clinician documents things that occur outside of an office visit in an EMR – for example, documentation of a phone call with a patient to discuss a urine drug test result delivered to the physician in paper format one or two days after the patient has been seen.

In a paper record, there are few options; in an EMR there may be several options and they may not be easy to find (or print out in response to a records request).

“I was working at the Quick-Fix Clinic back then. It is an absolutely toxic work environment. I can’t take good care of patients in a 10-minute visit. On top of all that, the clinic’s top opioid prescriber retired and I inherited all of his pain patients. I should have left months before I did.”

There are “environmental” influences that impact our ability to do a good job as clinicians. These range from practice environments that might pressure us to see many patients, patient satisfaction scores that subliminally influence physicians to want to make their patients leave the office happy, isolated practices in which clinicians lose sight of the evolution of good practice, or personal and financial stressors that distract us from our work.

Clinicians will benefit from developing an awareness of personal vulnerabilities and when they may be impacting practice. Physicians generally have good instincts and if your gut feeling is that a practice is not a good fit for you, the best way to keep out of the sights of the licensing board and to protect your license (and your patients) may be to pay attention to that little voice inside your head.