The PRO-PM Provider-Reported Narcotics Question | What You Should To Know

The Struggles with Narcotic Reporting

During our most recent webinar, “Knee-Deep in CMS THA/TKA PRO-PM,” there were many questions and comments, regarding the Use of Chronic Narcotics data element. This question is not a patient-reported risk variable but a physician-reported risk variable required as part of THA/TKA PRO-PM reporting.  It highlights a persistent issue for many in the field who are unclear on how to handle this question in their workflows and care transitions. The goal of this blog is to share what spurred these questions and to discuss reporting on this question for IQR, ASCQR, and OQR preoperative data collection. 

What is the Provider-Reported Narcotics Question and how does it relate to the IQR, OQR, ASCQR TKA/THA PRO-PM?

The Narcotic use for ≥ 90 days pre-operative is a required data element for all variations of THA/TKA PRO-PM reporting programs. The source of the information is the medical record/EHR, and is ‘provider-reported’. This data element requires an evaluation by a healthcare provider that the patient either meets or does not meet (yes or no) the definition for the “use of chronic (≥90 day) narcotics. It is defined as having any daily or regular intermittent dose of morphine (or a hydromorphone equivalent) for at least 90 days. This definition intends to capture patients with severe pain requiring chronic narcotics prior to THA/TKA procedures.   

CMS leaves it to individual surgeons or healthcare providers (that is, clinicians interacting with the patient/the patient’s medical record) to determine whether the medication the patient is on is a narcotic and whether very short replacement narcotic use warrants coding as chronic narcotic use for the purposes of collecting this variable.  Lastly, providers should collect data that reflects overall narcotic use (or any narcotic use), not just narcotic use specific to joint pain.

• Data Element: Use of Chronic Narcotics Question PRO Surveys
• Definition: Use of narcotics for 90 days or more (Pre-op). “This definition intends to capture patients with severe pain requiring chronic narcotics prior to THA/TKA procedures and is somewhat subject to interpretation.”
• When Is Information Collected:  The element is collected preoperatively less than 90 days prior to surgery. 
• Collection Method: Provider-reported – Stored in EHR
• Data Response Options: 0 = No | 1= Yes (Narcotic use for ≥ 90 days pre-operative)

The complexity of narcotic reporting arises from the lack of standardized processes to document this information.  Until now, documentation of provider-reported narcotic usage has not been part of the workflow, and this new measure is requiring organizations to design new systems and processes that capture the data.  Although the Centers for Medicare & Medicaid Services (CMS) guidelines aim to streamline reporting, practical application often reveals gaps that need addressing.   Therein lies the root source associated with the abounding questions, and frustrations, related to this Narcotic element.

EHR Extraction | Where does/should this data live? 

All EHRs have an active medication ‘list’.  You would think that it would be easy to pull this information from the active medication list, but there are challenges associated with that methodology.   First, the EHR must be able to identify/classify that the medication is a narcotic, which is not a native feature for most EHRs.  Secondly, just because a patient has been prescribed narcotics, doesn’t mean they are using them in a chronic fashion.  Another option is the physician documentation- almost all H&P’s address medication consumption.  While this is often accurate information, the challenge arises in extraction—physician notes are not discrete data elements, so a mechanism of pulling this text into a discrete field is a must. There is technology that can do the work, and naturally, humans can as well. Both methods, however, require time and resources to build.   Another option is to build out the field within the EHR, and embed it into the preop workflow.  This is the route many of our clients have chosen. In summary, documenting this data in the EHR often requires EHR updates/modifications, and development of processes to ensure ‘providers’ get the information into the EHR. 

Common Practices We See Emerging 

PAT’s (pre-admission testing) Clinic Workflow:  Many organizations have a pre-admission testing program that is managed by a healthcare provider.  They communicate with patients prior to the surgery, making collection of the narcotic data a fairly natural addition to the current workflow.  As far as documentation is concerned, most PAT programs have a checklist created in the EHR.  This checklist is being modified to include the narcotic question in a simple yes or no format. 

Anesthesia Flowchart:   The anesthesiologist  has to lay eyes on the patient before surgery.  They are filling out flowcharts as part of their normal workflow, so we are seeing clients add the narcotic use question to the anesthesia pre-op documentation requirements. 

Surgery Check-In:  Another emerging process is having the registration staff capture the data from the patient and enter it in the EHR as part of the check-in process. 

Patient-Reported then Provider Verified: CMS has made it clear that this information is provider, not patient, reported. However, as you can see, creating the systems and workflows around getting the data into the EHR requires thought and processes development. For organizations impacted by IPPS, the timeline to create this necessary infrastructure was short.  We have clients who, while in the process of developing a sustainable long-term solution, are adding the question to the patient-reported outcome survey.  Then, a provider goes through the survey answers and verifies the information is accurate and then will store it in the EHR. While this can work, it is an extra step and time consuming, and meant to serve as a temporary solution while the infrastructure and processes are being built.

What are the Patient-Reported Data Elements? 

As a quick refresher, the THA/TKA PRO-PM does require collection of several patient-reported data elements on both the pre-op and post-op report. The PRO-PM requires a wide range of information: 15 non-PROM elements must be recorded, alongside a combination of 6 PROMs depending on procedure and organization preference:

• PROMIS-10 Global or VR-12: These tools assess the patient’s overall health and well-being, including physical, mental, and social aspects.
• HOOS Jr. (Hip Disability and Osteoarthritis Outcome Score): Hip Osteoarthritis PROM. Measures hip function. 6 Questions. Raw score 0-100, with 100 reflecting optimal hip function (Pre & Post Op).
• KOOS Jr. (Knee Injury and Osteoarthritis Outcome Score): Knee Osteoarthritis PROM. Assesses knee function. 7 Questions. Raw score 0-100, with 100 reflecting optimal knee function (Pre & Post Op).
• Total Painful Joint Count (THA/TKA): A single question PROM that asks the amount of pain experienced last week in the other hip/knee (Pre-Op)
• SILS-2 Health (THA/TKA): Health Literacy PROM. 1 Question. Helps identify a patient’s level of health literacy (Pre-Op).
• Oswestry Index Question (THA/TKA): Assesses back pain and disability. 10 Questions. Scored on a scale from 0% to 100%, reflecting disability level. The PRO-PM mandates 1 question of the ODI (Pre-Op).

Final Thoughts

The first wave of freak out with THA/TKA PRO-PM is the patient-reported outcome requirement. Obtaining a 50% capture rate pre-op and one-year is no easy task.  The great news for our clients is that CODE absolutely helps with this! The second wave of freak out with THA/TKA PRO-PM has been the Provider-Reported Narcotic data element.  While there is nothing CODE can do directly to help with this particular aspect, we will continue to advocate that CMS supports a patient-reported yet provider verified process. The patient is providing firsthand information on their chronic pain and narcotic use whether being interviewed by a clinician or completing the PRO-PM survey themselves.  It should therefore be reasonable to allow patients to be asked and to answer the chronic narcotics question along with the other PRO-PM questions.