Participants
Overall, 42 VA primary care physicians (12 from MA, 15 from IL, and 15 from PA) participated in the study (Table 1). Just over half of participants (n = 22; 52%) were male and 26 (62%) were non-Hispanic white. Overall, participants practiced medicine following residency for a median of 18 years (IQR 10–24), with a median of 8 years (IQR 3–14) practicing within VA.
Table 1 Characteristics of Department of Veterans Affairs (VA) Primary Care Physician Respondents Physicians’ General Experiences
Broad Acceptance but Varied Approaches to Use
Physicians from Illinois and Massachusetts were broadly supportive of PDMPs, and physicians from Pennsylvania generally desired access to one. In fact, only one physician with access to a PDMP indicated that he did not use it (Table 2). One physician from Pennsylvania said, “I would absolutely use it…it would help me cut down on the risk of a patient obtaining opiates from another source, and probably decrease the overall rate of overdose in Pennsylvania.”
Table 2 Supplemental Quotes Characterizing VA Physicians’ General Experiences, Barriers to Use, and Facilitators in Using Prescription Drug Monitoring Programs While physicians endorsed PDMP use in general, they exhibited varying approaches to use. In examining the coded statements from participants, we grouped responses into two categories regarding participants’ overarching approach to PDMP use: (1) systematic and (2) subjective. These approaches, which physicians often applied concurrently, were influenced by a combination of state and institutional policies, as well as physicians’ concerns for misuse, work flow, and clinic routine. For example, physicians could be classified as applying both approaches if they used the PDMP in accordance with state mandates and when they had clinical suspicion for opioid misuse.
The systematic approach was characterized by algorithmic use of the PDMP, driven largely by state- and facility-level mandates. Physicians who applied this approach routinely checked the PDMP when writing new prescriptions and/or at set intervals thereafter. In Massachusetts, 10/12 (83%) physicians applied a systematic approach, whereas in Illinois, 11/15 (73%) physicians applied such an approach. In Pennsylvania, 4 /15 (27%) physicians envisioned applying a systematic approach. One physician from Massachusetts said, “We’re required to access the database before we start a patient on chronic opioids, and then periodically we review it for renewals, but that’s sort of maybe once or twice a year.”
The subjective approach was largely characterized by use of the PDMP when there was clinical suspicion for opioid misuse. Additionally, some respondents indicated that their use was dictated by time and competing demands. Physicians from Illinois (12/15, 80%) were slightly more likely than physicians from Massachusetts (9/12, 75%) to engage in subjective use, while the majority of Pennsylvania physicians (9/15, 60%) envisioned applying a subjective approach. One physician from Illinois said, “So if there are any (red) flags or concerns for me, like if I have a patient who is requesting early refills, or who has lost medications, or I have any other reason to be worried about their risk for… regarding opioids….I use it more for indications rather than just routine review of patients.”
Challenge to Underlying Biases
PDMP use also challenged physicians’ underlying biases regarding opioid misuse. Overall, five physicians were surprised by certain patients who they discovered were receiving opioids from non-VA prescribers, causing them to re-evaluate their own biases regarding who they suspected could be misusing opioids. One physician said, “I used to kind of make a value judgement of my patients about whether or not I felt they were reliable and make prescribing choices based upon that. And in doing this [using the PDMP] I’ve realized that all of those things have to go out the window.”
Barriers to PDMP Use
Administrative Burdens
Many physicians felt “nickel-and-dimed” regarding the extra time it took to log on to the PDMP, execute a search, and document the findings. One physician commented, “I think it’s just the extra step. You have to sign in, you know, and it takes those extra minutes that’s hard to find when you’re with a busy practice and have only so much time with the patient that you’re seeing at that moment.”
Physicians also reported an overall increase in workload related to PDMP use, including required documentation and the additive effect of state-based mandates. According to one physician, “One of the things in Massachusetts that I’m a little bit concerned about is (that) I think we’re supposed to check the PDMP every time we prescribe a narcotic to one of our patients, even if it’s chronic. And that’s just adding a little bit more work to everything.”
Incomplete or Inaccessible Data
This theme manifested in three key ways. First, physicians were extremely sensitive to the absence of up-to-date VA data within their states’ PDMPs. While VA had started to broadly provide pharmacy data with state PDMPs by 2016, many physicians reported that VA data was still unavailable at the time of these interviews. “There has been an embarrassing, egregious delay in VA getting access of their data—pharmacy data—to the state’s PDMP,” said one physician. Physicians felt that this placed extra burden on them to monitor their patients’ comprehensive opioid use, as only they had access to their patients’ complete record of VA and non-VA prescriptions.
Second, VA physicians consistently commented on differences in the accessibility of neighboring state data within their PDMP. VA physicians in Illinois had access to data from several neighboring states, which they felt enhanced the reach and effectiveness of their PDMP. Despite their close geographic proximity to neighboring states, physicians in Massachusetts did not have access to other states’ PDMP data. “It (the PDMP) only gives me information about Massachusetts. So, for our patients who might be accessing medications in bordering states—I have no idea if that’s happening or not, and I wish I did.”
Third, physicians commented on the difficulty of using the PDMP for homeless Veterans, as one state’s PDMP required residential information that was unavailable for homeless Veterans. “I just had one new… patient who … came to us as homeless. It was difficult for me to check on the prescription monitoring program because they’re homeless and we need to use zip code for this (accessing the PDMP).”
Facilitators of PDMP Use
Suggestions for Future Improvement
In addition to barriers, physicians cited multiple facilitators of PDMP use, including several practices that they recommended states or VA consider to improve use, and those that are currently in place at their VA facilities.
Physicians indicated two key ways that VA could further improve PDMP use. First, physicians frequently commented on the importance of integrating data contained within the PDMP with the data and medical records already present within CPRS. One physician commented, “I just think it would be so wonderful if it (PDMP data) could be integrated into our data—our normal accessing of the chart in a way that—If I could just somehow click in the chart and it would fill out a bunch of fields for me—that would be amazing.”
Second, physicians indicated that a pre-designed note template within VA’s Computerized Patient Record System (CPRS) would expedite documentation and serve as a valuable reference for future clinical encounters. One physician indicated that his facility is currently implementing such a note, while others desired the use of such a note. “When you check the state PDMP, you put the information into (a) templated note that’s identifiable in CPRS…The note will automatically populate with the data that the state PDMP was last checked… I wouldn’t have to search to find out whether the database has been checked recently or not because it tells me that.”
Current Features or Practices that Enhance Use
Physicians felt that the quality of the PDMP website, including the registration process, log on time, and website design, were major factors that enhanced use. One physician said, “The website itself is great. It gives me the pertinent information—just the stuff I’m looking for.”
Physicians also valued the ability to delegate responsibility to check the PDMP to nurses and clinical pharmacists in their patient-aligned care teams to decrease their overall work load and facilitate patient care. “The big innovation is that I can delegate authority to query the database to my nurse… I—it’s not like it requires all that many keystrokes to get in, but I just wouldn’t do it with any regularity if she didn’t help.”