Increasing the Impact of Opioid Settlement Funds by Investing in Health IT Infrastructure
The U.S. opioid crisis remains an urgent and worsening public health problem, with nearly 110,000 deaths due to overdose in 2022. As opioid response needs evolve, our health information and technology (IT) infrastructure must adapt to ensure the availability of accurate and reliable data to inform data-driven community response efforts.
Across the nation, states are receiving more than $50 billion in opioid settlement funding to abate the crisis. But while each state is developing or has developed its own plan to distribute this funding, there has been little guidance around how to spend opioid settlement funds to support the health IT infrastructure needed for opioid use disorder (OUD) care and response. Strengthening this infrastructure is a critical and necessary step toward abating the opioid crisis and evaluating the impact of how opioid settlement dollars are allocated across communities.
The role of health IT in responding to the opioid crisis
Johns Hopkins published five principles for the use of opioid litigation funds:
- Spending money to save lives
- Using evidence to guide spending
- Investing in youth prevention
- Focusing on racial equity
- Developing a fair and transparent process for deciding where to spend funding
The Legal Action Center expands on these principles in the report, “Evidence-Based Strategies for Abatement of Harms from the Opioid Epidemic.” One recommendation highlights the need to improve data infrastructure to determine whether and how strategies are impacting communities, map resources that are available to respond to the crisis, and inform data-driven response plans through identifying gaps and strategically deploying resources.
The Legal Action Center recommends use of opioid settlement funds to improve surveillance and data monitoring systems by regularly extracting state-level data, improving assessment of existing data variables, and creating new systems to measure data elements for which there is no current assessment, such as tracking harm-reduction services, urinalysis and screenings among OUD patients who are jailed, measuring prevalence of pill drop-off sites operated by pharmacies and hospitals, and tracking drug-related prevention programming in schools and communities.
But little guidance exists regarding how to spend opioid settlement funds to support the health IT infrastructure for the opioid care continuum.
Comprehensive OUD treatment requires interconnectivity and coordination of care across multiple organizations, from OUD treatment facilities to behavioral health, medical, and social service agencies, including agencies for housing and transportation. The Office of the National Coordinator (ONC) for Health IT has touted the need for health IT solutions to facilitate care coordination and integration across siloed systems. Unfortunately, in many communities across the United States, this infrastructure reflects a fragmented, siloed system with inadequate communication, which makes it unable to support an integrated model for OUD care.
A 2015 U.S. Surgeon General’s report highlighted the importance of health IT in expanding communication and coordination across providers to support integrated care for people with comorbid substance use and mental health conditions. Today, information exchange among these providers is often slow, time-consuming and cumbersome unless the services are co-located—and start-up costs, regulatory and funding requirements, and limited building space are frequent deterrents of service co-location. Moreover, lack of integrated electronic medical record (EMR) systems, which may occur even when services are co-located, further impede integration of medical, mental health and OUD treatment.
These barriers reflect missed opportunities to optimize care for individuals suffering from OUD. Technology innovations provide a solution for improved care coordination.
In 2019, the ONC published a health IT playbook detailing a suite of strategies, recommendations and best practices for implementing health IT in ways that enhance the value and quality of the U.S. healthcare system. Included in the playbook is a section that identifies five priority areas for investment:
- Integrated EMRs and prescription drug monitoring programs (PDMPs)
- Smartphone apps
- ePrescribing for controlled substances
- Integrated support tools in EMRs to support clinical decision-making
Many of these technologies were successfully adopted to address the Covid-19 pandemic. But while the ONC’s playbook has contributed to reducing the clinical, regulatory and administrative burden of integrating health IT into standard clinical practice, major gaps remain in relation to its capacity to address the opioid epidemic.
First, the playbook primarily focuses on alleviating harmful clinical prescribing practices and the misuse of opioid prescriptions. While imperative, these strategies alone are insufficient. For example, the first recommendation of the playbook is to support EMR system integration with PDMPs to support providers’ ability to check PDMP data before prescribing opioids to a patient. PDMPs provide important data to drive clinical decision making. However, there is evidence that the PDMP system is antiquated and may stifle response to the opioid crisis by collecting only a limited amount of data elements that fail to provide a comprehensive understanding of complex patient histories. As such, PDMPs contribute to the fragmentation of healthcare data, creating siloed systems of care.
Another deficit of the playbook is that it solely focuses on the traditional healthcare sector, thus overlooking the role of other entities integral to addressing the opioid and overdose crisis, including first responders, harm reduction organizations, and social services agencies.
In April 2022, President Biden released the inaugural National Drug Control Strategy, which highlighted the importance of data and health information systems to reduce overdose deaths and respond to the opioid epidemic. This strategy calls for improved data systems to inform drug policy and community response via three related principles: (1) Strengthen existing data systems; (2) Establish new data systems and analytical methods; and (3) Enhance the utility of drug data for practitioners, researchers, and policymakers.
The Office of the National Drug Control Policy Director, Rahul Gupta, noted there is a severe lack of real-time data for fatal and nonfatal overdoses, which “undermines the ability to respond accountably and restricts the potential to understand the effects of actions and investments.” Such data systems must be “as transparent and accessible as possible for all persons with a need to use the data to make individual-level, healthcare sector, and public sector programmatic and policy decisions.” These systems will inform estimates of unmet needs for overdose-related medical and social services within a given geographical area. But existing or “traditional” syndromic surveillance data sources rely heavily on data from the healthcare system, including emergency medical services (EMS), emergency departments, and death records. The challenge: These data collection methods often marginalize vulnerable populations in analyses and fail to consider “hard-to-reach” or “hidden” populations, thus exacerbating health disparities along the OUD care continuum.
Furthermore, as naloxone is distributed more widely, there is less of a need for persons experiencing an overdose to access the traditional healthcare system such as contacting EMS or the emergency department. This will require reliance on “non-traditional” reporters and data sources to inform sufficient response to the opioid epidemic.
Three recommendations for improvement
As opioid response needs evolve, health IT systems must adapt to ensure accurate and reliable data in order to support data-driven community response. We have an opportunity to learn from the mistakes of the tobacco settlements and the successes of the health IT response to the Covid-19 pandemic to develop a more comprehensive model for supporting people with OUD and abating the opioid epidemic.
Here are three recommendations for a health IT strategy that could more effectively support opioid response, system integration, research and evaluation.
- Aggregate opioid-related data sources and create a centralized database.
Municipalities should consider leveraging existing health information exchanges (HIEs) to facilitate the development of an opioid-centralized database that coordinates OUD care cascade data elements across systems and platforms. Areas of the country that do not have HIEs should develop an opioid-specific centralized database. These databases should be separate and more robust than existing PDMPs; however, PDMP data will remain valuable and should be integrated with these systems. If possible, efforts should be made to fully integrate existing PDMPs with robust HIEs. Alternatively, states can transfer operations and governance of PDMPs to a state-designated HIE to ensure data can be more readily accessible for treatment purposes and integrated with full patient health information.
Where a robust HIE or similar public health infrastructure does not exist, there is a need to develop an opioid-specific centralized database and facilitate widespread adoption of platforms to support opioid data surveillance and public health response due to insufficiencies with existing data. The centralized platform should function similar to a HIE, but operate on a smaller scale and be specific to OUD data elements. The platform should meet all federal regulatory compliance standards in accordance with federal guidelines (i.e., HIPAA, 42 C.F.R. Part 2), directly meet the data needs of providers serving people with OUD and facilitate care coordination and data transfer across the hub-and-spoke ecosystem. Municipalities should consider pooling resources to support a single analytics team that could regularly populate dashboards specific to the needs of the population.
- Improve syndromic surveillance by coordinating public safety and public health efforts.
It is imperative that surveillance efforts related to the opioid epidemic be improved. These efforts should incorporate measures across the OUD care cascade and coordinate data from public safety and public health surveillance systems. Overdose surveillance should include both fatal and non-fatal overdose metrics and naloxone distribution and administration metrics and incorporate community-based data to capture individuals who do not interact with the traditional healthcare system.
Improving data collection infrastructure among outreach programs and harm reduction organizations may prove to be a valuable community-level data source.
Gathering data from first responders including EMS, law enforcement, and fire departments also provides important overdose surveillance data. ODMAP is a public safety tool developed by the High Intensity Drug Trafficking Agency (HIDTA) for first responders to improve overdose surveillance data across the U.S. Additionally, electronic case reporting (eCR) reduces the reporting burden for healthcare providers while improving the timeliness and accuracy of surveillance data. eCR automatically generates and transmits reports of reportable conditions from EMRs to public health agencies for review and action. eCR enables automatic, accurate, and complete real-time reporting, thus reducing provider reporting burden and improving timely public health response.
- Invest in emerging technologies to support the OUD care continuum.
Health IT-related opioid abatement strategies should leverage data from HIEs. These data can be used to review discharge summaries in the context of longitudinal care plans, conduct post-discharge needs assessment as it relates to opioids, perform medication reconciliations, enroll patients in applicable opioid education and outreach programs, and link patients to appropriate care to support long-term recovery.
Emerging evidence-based technologies that are commercially available include smartphone applications for OUD, such as reSET-O, a digital therapeutic. Other technologies include virtual reality, biosensors, and leveraging healthcare data to support AI-enabled interventions. There are several key areas where AI-enabled technologies may prove valuable for municipalities responding to the opioid crisis, including early OUD and relapse risk detection, overdose detection and linkage to appropriate levels of care. But reproducibility of AI-enabled technologies is lacking. Consequently, developers of AI-enabled technologies should describe their techniques and tools used to produce their results. Additionally, a majority of these technologies have not undergone rigorous scientific testing in clinical trial research, highlighting the need for funding to be allocated to advance evidence in this area.
A matter of public health
The existing health IT infrastructure is insufficient to adequately address the opioid crisis, hampering local and national response efforts. Upgrades to health IT systems and tools are needed to evaluate the impact of opioid abatement strategies implemented across communities, promote prevention of overdose and OUD, ensure that those suffering from OUD receive the full range of treatment and recovery support services needed, and help reduce harm. Such efforts could also facilitate more equitable distribution of resources and data-driven community response, empowering municipalities to address this crisis in a more standardized, comprehensive way.
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