ORIGINAL ARTICLE
Electronic Opioid Risk Assessment Program for Chronic Pain Patients: Barriers and Benefits of Implementation Stephen F. Butler, PhD*; Kevin Zacharoff, MD*; Sadaf Charity, MBA*; Kristen Lawler, BA*; Robert N. Jamison, PhD† *Inflexxion Inc., Newton, Massachusetts ; †Pain Management Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
& Abstract Objectives: A preliminary electronic pain assessment program known as Pain Assessment Interview Network, Clinical Advisory System (painCAS), was implemented in 2 pain centers over the course of 10 months to understand the tool’s impact on opioid risk assessment documentation and clinical workflow. The program contains validated electronic versions of screeners for opioid misuse risk (SOAPP-R and Current Opioid Misuse Measure). Methods: Charts of patients with an initial and 2 follow-up visits were randomly selected for review of presence of opioid risk assessments before and after implementation of the electronic assessment program. Clinical and administrative staff members were interviewed to gain their perceptions of the impact of the program. Results: Significant increases were observed in the documentation of opioid risk assessments between the baseline patient chart reviews before implementation of the program (n = 66) and the postintervention patient chart reviews after the implementation of the program (n = 39), for both initial and follow-up clinic visits (P < 0.001). Specific benefits of the program identified by 7 clinicians and 8 administrators included ease of use, reduced paperwork, completion of
Address correspondence and reprint request to: Stephen F. Butler, Ph.D, Inflexxion Inc.,320 Needham Street, Suite 100, Newton, MA 024641594, U.S.A. E-mail: [email protected]. Submitted: June 04, 2013; Revision accepted: September 15, 2013 DOI. 10.1111/papr.12141
© 2013 World Institute of Pain, 1530-7085/14/$15.00 Pain Practice, Volume 14, Issue 3, 2014 E98–E105
the assessment before the clinic visit, and incorporation of information directly into an electronic medical record (EMR). Perceived barriers to implementation included poor patient compliance, changes in administration workflow, and difficulties associated with patients with no email addresses, and limited computer skills. Conclusions: Implementation of an opioid risk electronic pain assessment program significantly increased the likelihood that a risk assessment would be included in the medical record, which has implications for improvement of quality of care. & Key Words: analgesics, opioid, analogue pain scale, assessment, pain, Informed consent, lower back pain, multidisciplinary pain centers, opioid analgesics
INTRODUCTION There has been a steady increase in the number of opioid prescriptions written in the past 2 decades in response to greater awareness of undertreated pain.1 This has led to a parallel increase in opioid misuse and abuse.2 Potential solutions to the continuing rise in opioid abuse, misuse, and diversion have become an ongoing focus in regulatory, legal, and governmental action, and there has been a recent call for risk assessment monitoring of those chronic pain patients who are being considered for prescription opioids for chronic pain.3 The Food and Drug Administration (FDA) has specifically targeted the extended-release and long-acting opioid formulas by
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issuing a call for risk evaluation and mitigation strategies (REMS) designed to reduce opioid abuse and misuse.4 In light of REMS, implementation of a standardization process for risk assessment for those who are potential candidates for opioids or who are prescribed opioids for chronic pain has been recommended.3 Clinically, a universal precautions approach has been recommended. This approach assumes a degree of risk for each patient and includes risk assessment strategies as well as close patient monitoring to initiate and modify therapy in a safe and controlled manner.5 Recent attention has been given to the implementation of electronic pain assessment programs within pain medicine in order for clinics to be “paperless” and to take advantage of the benefits of computer and Internet technology designed specifically for persons with chronic pain and the providers who treat them.6,7 Previous studies have focused on the benefits of using electronic assessment programs to collect composite data, reduce personnel time, and document patient change. It has been predicted that secure electronic assessment using the Internet would outweigh the benefits of paper questionnaires. However, barriers and challenges exist in implementing any electronic pain assessment program within a busy clinic, particularly related to the changing of workflow and behavior among administrative and clinical staff and the patients invited to use the program.8–10 The painCAS program is a systematic computeradministered assessment for chronic pain patients.11,12 It is a beta version of an electronic assessment and tracking program designed to provide a comprehensive evaluation of pain patients including (1) demographic information (eg, age, gender, medical history), (2) pain assessment and quality-of-life evaluation (eg, pain intensity, activity interference, mood, medication use, side effects), and (3) an electronic version of the Screener and Opioid Assessment for Patients with Pain (SOAPPR), which is a 24-item self-reported assessment tool to help identify risk of opioid misuse among chronic pain patients.13–16 For follow-up clinic appointments, a beta version of the painCAS assessment with the Current Opioid Misuse Measure (COMM), which is a validated 17-item assessment of current opioid misuse, is used.17– 19 The painCAS program offers a summary of patient information with a pain diagram and risk assessment scores that can be easily integrated into an electronic medical record (EMR) system (Figure 1). A focus of the program is to summarize and document the results of the assessment and to continually evaluate and track the risk
of aberrant drug-related behavior for those considered for opioid therapy. It was especially designed to offer clinicians a way to rapidly identify, track, and appropriately treat chronic pain patients at risk of aberrant drug-related behavior. The purpose of this study was to implement a pilot version of the web-based painCAS electronic assessment software program for chronic pain patients in two clinical settings and to study the impact of the program on assessment documentation and clinical workflow. A primary objective of this study was to determine the impact of this program on documentation of risk assessments in the EMR. Currently, in many clinical settings, the clinic staff must manually calculate the scores for the questionnaires and then scan or transcribe paper versions into the EMR to document the risk assessment scores. We hypothesized that use of an electronic risk assessment program would significantly increase the documentation of risk assessments in the EMR. A secondary objective was to understand the challenges related to implementing an electronic risk assessment program in the clinical setting. We recognized that one of the biggest barriers to the adoption of a risk assessment program would be the change of workflow required among administrative staff. We hypothesized that the proportion of medical records that included a recent (past 3 months) opioid risk assessment would increase 3 to 6 months after patients had been administered the risk assessment program (in place of paper-and-pencil versions of the assessments) and that the clinic workflow around administering, scoring, and documenting opioid risk assessments would improve following implementation of the electronic risk assessment tool.
METHODS The study was conducted at two independent sites, which represented a private pain clinic (Center 1) and a pain center at a large research hospital (Center 2), both within urban environments, between January and September 2012. Both sites were using paper versions of risk assessment measures (SOAPP-R and COMM) for pain patients being considered for opioid therapy. The study was approved by their respective IRBs. Clinicians and administrative staff from both centers were recruited and consented. After signing the consent form, training sessions with the administrative staff were conducted at both centers on use of the software program. Next, randomly selected medical records associated with pain
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Figure 1. Screen shot of the pain assessment report.
patients who had an initial and two follow-up clinic visits from the consenting provider’s caseload were identified for baseline chart review to compare a “practice-as-usual” period with a postintervention period after implementing the software program into the clinics. This allowed for an evaluation of the incidence and change in risk assessment documentation in the EMR after introduction of the painCAS software program. Pre- and postintervention interviews were conducted with the clinicians and administrative staff using structured interviews. The goal was to track the electronic software assessment completion rates and to assess the impact on clinic processing. Chart Reviews Chart reviews were conducted by existing staff at each clinical site who were not directly involved in the study.
These research assistants were instructed to review the medical charts for the presence or absence of opioid risk assessment documentation, including the painCAS Beta reports at the postintervention time points. This chart review was performed for randomly selected patients at baseline who had an initial and at least 2 follow-up visits and then again for new patients at postintervention who had at least an initial and two follow-up visits and who had the opportunity to have been exposed to painCAS. Specifically, chronic pain patients were included for the baseline chart review if they were (1) English speaking, (2) assigned to one of the consented clinicians, and (3) had an initial clinic visit and at least 2 follow-up visits within the past 12 months. Similarly, postintervention charts were included for new patients who were (1) English speaking, (2) assigned to one of the consented clinicians, (3) sent painCAS assessment requests, and (4) had an initial and at least 2 follow-up clinic visits in the
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past 5 months after the baseline were included into the random chart review. Patients were included in the chart reviews whether or not they have been prescribed opioids. A secure online form was created for conducting the chart reviews. The goal was to identify 10 charts for each consented clinician for review during the baseline chart review procedure [10 9 7 = 70]. During the postintervention chart review, research assistants reviewed charts of patients who received painCAS assessments and attended an initial clinical visit, and at least 2 follow-up visits. Staff Interviews Semi-structured interviews were conducted over the telephone to gather information on perceptions of the workflow with respect to administration, scoring, and documentation of paper-and-pencil opioid risk assessments. These interviews of the clinicians and administrative staff included questions regarding demographic information, current workflow related to risk assessment, level of satisfaction with current assessment processes, and the barriers and benefits of the assessment processes. Interview questions included Likert-type scales (ie, not at all helpful to very helpful), multiple choice items, and open responses to questions created for this study. Following the intervention period, participating clinicians and administrative staff were interviewed again to determine the impact of the electronic pain assessment program on their perceptions of efficiency in clinical workflow. The postintervention clinician interviews included questions regarding experience with using the electronic pain assessment program, perceived helpfulness and value of the program, benefits and barriers of its implementation, and feedback received from patients about its use. Each clinician was paid $200. Postintervention interviews for administrative staff included questions of experience with integrating the electronic pain assessment program, satisfaction with integrating it into clinical workflow, the barriers and benefits of using the program, and feedback received from patients about the program. Each administrative staff was paid $100. Postintervention questions were similar to the baseline interview questions and included open responses to questions. Intervention Upon completion of the baseline interviews and chart reviews, both study sites launched the intervention.
Consented administrative staff sent links to the electronic risk assessment program to all new patients as well as existing patients new to opioid treatment of those receiving treatment from the consented clinicians. Patients were sent the initial assessment when the patient or the patient’s referring clinician contacted the study site to schedule an initial clinic visit. Patients were also sent links for follow-up assessments prior to their follow-up clinic visits. If a patient did not complete the assessment prior to arriving at the clinic for their appointment, the administrative staff was encouraged to administer the electronic assessment program to the patient in the clinic using a laptop computer with Internet access. A clinician report was generated in the web-based system for each assessment completed by a patient. The participating administrative staff would login to the website created for this study and download the clinical report for every completed assessment and save it in the appropriate electronic medical record for the consented clinician to access and review prior to or during the patient’s clinical visit. We were interested in testing whether the proportion of medical records that included opioid risk assessment (SOAPP-R or COMM) would substantially increase 6 months after patients of participating clinicians had been administered the electronic pain assessment program in place of the paper–pencil versions of the assessments. Comparisons were made using chi-square analyses (SPSS version 20). Bonferroni correction for multiple tests set the alpha level for significance at P < 0.017. All data collected through the semi-structured interviews were summarized using standard descriptive statistical techniques, including calculating averages and percentages of participant responses.
RESULTS Seven clinicians (2 from Center 1 and 5 from Center 2), including physicians and nurse practitioners, and 8 administrative staff members (2 from Center 1 and 6 from Center 2) were recruited from both study sites. Participants included 5 physicians, 2 nurse practitioners, and 8 administrative staff (including administrative assistants, practice assistants, and patient/clinic coordinators). The clinicians had an average 6.5 years of experience in the chronic pain treatment specialty field. Over half the participants were female (53%) and most participants were Caucasian (66%). Others were Asian (13%), African American (13%), and other (8%).
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In total, 105 patient charts were included in the baseline and postintervention reviews. Of these, 66 charts were reviewed for the baseline or “practice-asusual” time period. Thirty-nine patient charts were identified that met the inclusion criteria for the intervention condition (ie, patient was assigned to one of the participating clinicians, had 1 initial and 2 follow-up clinic visits, and was identified for the painCAS assessment). The number of patient charts included in the postreview for each clinician averaged 5.6 (Center 1 = 7.5; Center 2 = 4.8). The patients represented in the baseline and postintervention charts were 47% female in Center 1 and 41% female in Center 2. Most of the patients represented in the chart reviews were Caucasian (89% at baseline and 97% at post), while a minority were African American (5% at baseline, 2.6% at post), Hispanic (5% at baseline and none at post), and Asian (1% at baseline and none at post; Table 1). Significant increases were observed in the documentation of opioid risk assessments between the baseline chart review when the electronic pain assessment program was not in use and the postintervention chart review when the program was in use (Table 2). At postintervention, the patient charts included documentation of opioid risk assessment 79.5% of the time, whereas at the baseline time point, the charts included documentation of any risk assessment only 40.9% of the time (Χ2 = 14.8, df = 1, P < 0.001). For the follow-up clinic visits, documentation of the COMM was present Table 1. Combined Demographics of Reviewed Charts Variable Age (mean, SD) Gender (% female) Race (%) Caucasian African American Hispanic Asian
Baseline Charts (n = 66)
Completed PainCAS (n = 39)
51.0 (13.0) 47.0
48.8 (10.1)* 41.0
89.0 5.0 5.0 1.0
97.4 2.6 0.0 0.0
*No significant differences were found between groups.
Table 3. Completion Rates for PainCAS Assessment by Center and Total (n = 155)*
Table 2. Presence of Risk Assessment in Medical Records (% present) Before and After PainCAS Implementation
Variable Initial risk assessment (SOAPP-R) Follow-up risk assessment (COMM) Any risk assessment COMM, Current Opioid Misuse Measure.
in the charts 43.6% of the time when the program was in use, whereas it was only present 4.5% of the time when the program was not in use (Χ2 = 24.24, df = 1, P < 0.001). The baseline clinician (n = 7) and administrative staff (n = 8) interviews focused on clinical processes for administering and documenting opioid risk assessments before implementation of the program, while the postintervention interviews focused on the implementation of the electronic pain assessment program at the study sites to provide a comparison of clinical processes and workflows with and without the program. Overall, 58.7% of all patients sent a request to complete the electronic pain assessment program completed at least one assessment, (69.0% for Center 1 and 52.6% for Center 2; Table 3). Over half of the consented clinicians (57%) indicated that they reviewed the pain assessment reports as part of their clinical process, while 43% did not receive or review any reports. Following implementation, all participants were asked how the program impacted their workflow. Most of the clinicians (4 of 7) said it made no difference in their work flow or said it made their job easier, while 3 of the 7 of administrative staff said that the pain assessment program made their workflow more difficult (one administrative staff member declined to answer, citing lack of exposure to using the program.) Additional feedback from the administrative staff suggested that having the patient complete the electronic pain assessment in the clinic was time-consuming and interrupted the clinical workflow because it took 20 minutes or more to complete whereas administration of the paper opioid risk assessments typically took 5 to 10 minutes to administer to a patient. Half of the clinicians (4 of 8) said they had more confidence in the automatically calculated scores than the manually calculated scores, while the other half said
Before PainCAS (n = 66)
After PainCAS (n = 39)
30.3% 4.5% 40.9%
76.9% 43.6% 79.5%
X2
P
21.4 24.2 14.8
< 0.001 < 0.001 < 0.001
Variable
Center 1
Center 2
Total
N of patients who received a painCAS request No assessment completed Any assessment completed Initial assessment completed Follow-up assessment completed
58
97
155
18 (31.0%) 40 (69.0%) 22 (37.9%)
46 (47.4%) 51 (52.6%) 41 (42.3%)
64 (41.3%) 91 (58.7%) 63 (40.7%)
18 (31.0%)
10 (10.3%)
28 (18.1%)
*No significant differences were found between groups.
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they had the same level of confidence in both types of calculation. Before the introduction of the electronic risk assessment program, participants reported scanning paper assessments, or manually transcribing assessment responses and scores into the EMR, all carried out by various clinical staff including psychologists, social workers, and administrative staff. The interviews indicated that the process for documenting paper risk assessment results could be improved with the aid of an automated process where scores and responses would be automatically uploaded to the EMR. Five of 8 members of the administrative staff indicated that integrating the electronic pain assessment program into the clinic was easy, compared with half (3 of 7) of the clinicians. One clinician declined to answer, citing lack of exposure to the painCAS report. Most of the administrative and clinical staff (5 admins and 6 clinicians) indicated they would like to continue to use this program in their practice (Table 4). Challenging aspects of using the paper risk assessments included the following: (1) getting patients to complete the assessments in time for the results to be available for treatment planning; (2) not having the ability to use the assessment results to their full advantage due to a lack of tracking capabilities; (3) time it took to score and concerns over accuracy of the scoring; (4) communicating with the other clinicians providing care for the patient or the referring clinician; (5) not having a standardized process; and (6) adding the results to the EMR and having access to the results at the time when they are needed. Table 4. Combined Pre- and Postinterview Responses of the Administrative (n = 8) and Clinical Staff (n = 7) 1. What aspects of the program could be improved? Administration staff Clinicians Better tracking of the assessment Improve process for in-clinic assessment Have patients register themselves Make summary reports easier to without prompting locate on the EMR Add date and time of next Need for immediate upload of report appointment to EMR Improve process for in-clinic Make improvements in the program assessment Add pertinent information for patients 2. What aspects of administering the program to patients worked well? Administration staff Clinicians Easy to send Report has good accessibility Immediate access to results Program can be completed online and in the waiting room Easy to upload Report can be retrieved electronically Reduced paperwork Risk assessment scores are automatically calculated Useful report completion email notification
Suggested improvements to the electronic pain assessment program included the following: (1) improve the process for starting and completing the painCAS assessment in the clinic, as the current process took too long; (2) have a way to automatically send the assessment report to the patient’s medical record; (3) improve ease of access to the assessment report in the EMR; (4) improve the assessment tracking system so it is more efficient and streamlined; and (5) have a status indication of whether the report has been downloaded to the EMR.
DISCUSSION The results of this study confirm that the proportion of medical records that included a formal opioid risk assessment (in this case, SOAPP-R or COMM) among chronic pain patients increased for the electronic pain assessment program condition over the practice-as-usual or no-painCAS condition. Specifically, highly significant differences in favor of the electronic pain assessment condition were observed for the presence of documentation of risk assessment for the SOAPP-R for baseline visits, and for the COMM assessment for follow-up visits. Introduction of the electronic risk assessment program increased this documentation level to nearly 80%. Only 5% of charts contained reference to COMM in follow-up visits in the practice-as-usual condition, while the electronic assessment program increased this documentation to 44%. Although less than half of charts documented this follow-up risk assessment, the increase in the COMM documentation suggests a significant impact on the likelihood of follow-up risk assessment. Results observed in this study suggest that, despite continuing issues associated with integrating an electronic tool like the painCAS into the workflow, the value of doing so can be clinically significant. A barrier to the use of an electronic risk assessment program compared with the pencil-and-paper version was the longer time needed for implementation of the program. The time calculated for the electronic pain program included the entire process of setting up and registering patients, activities that were not yet part of the clinic flow, as well as additional questions asked by the painCAS assessment. This was compared to the pencil-and-paper assessment that consisted of simply handing a clipboard to a patient and having the patient complete the paper questionnaires. Furthermore, comparison of the pencil-and-paper time did not include the time spent by administrative or clinical staff scanning or
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otherwise inputting the assessment data into the EMR. This study helps to document that any change in an organizational process is likely to be met with resistance because of the slow process of adapting to change. Prior research has demonstrated the difficulties with successful integration of any new innovation into the clinical process.8,10 While it is important to continue to evaluate and modify the software, it is equally important to consider how the introduction of an electronic pain assessment program would impact the work load of personnel within a busy clinic practice. Specific perceived benefits were primarily related to ease of use, automation, and incorporation of information in an electronic format into an EMR. Alternatively, challenges and barriers to implementation included changes in workflow and difficulties encountered in administering the assessment via email. Some patients chose not to comply with prompts to complete the assessment program before their clinic visit and more attention is needed in determining reasons for this noncompliance. There is also the possibility that completed files were omitted from being placed in the EMR by administrative staff, and greater attention to understanding the process of attaching assessment files to each patient’s EMR would be valuable. Some clinical staff reported not seeing the summary reports on the EMR. Labeling difficulties and the need to examine past notes could account for this omission. Some providers suggested that this would be improved if there was an easyto-access place in the EMR where the reports could be reliably saved. In an ongoing primary care study using the painCAS program, summary reports are attached to email messages to each of the providers as well as being attached as separate notes on each patient’s medical record. We believe that this will have the added benefit of alerting the providers to each of the summary reports. There are a number of limitations of this study that need to be highlighted. First, because the electronic pain assessment program was used by a select number of patients and their clinicians in the centers, it was difficult for the providers to know which patients were included in the study and which ones were not. Some of the missing follow-up data may have been due to the administrative staff being unaware of which patients had been enrolled in this study. Also, some clinicians had fewer initial patients than others. This was because they were not in the clinic every day, they had already had a full practice and were not taking new patients, or they were away for some of the time during this pilot study. Thus, there were fewer charts to review postin-
tervention than before the electronic program was implemented. The program may be of greater utility if the centers incorporate this program with all the patients at the same time so that all providers would become familiar with this assessment tool. A longer period of follow-up is also needed. Second, this trial was conducted in two interdisciplinary pain centers where they had been using opioid risk assessment measures. Thus, we do not know how the painCAS would be incorporated in a primary care setting or how it would be used in centers where opioid risk assessment is not routinely conducted. Finally, because the painCAS Beta included only a limited version of the comprehensive pain assessment, there was an unwillingness to eliminate the paper versions of the comprehensive pain assessment. Thus, patients new to the clinics were completing 2 assessments, which might have made the completion of initial and follow-up assessments to be perceived as a burden. A revised version of the painCAS currently in development could prove to be as useful to the providers as the paper-and-pencil assessments, and there could be a greater willingness to replace the paper versions of the initial assessment with an electronic assessment software program. Despite these limitations, this pilot study confirms that implementation of an electronic risk assessment program can increase the likelihood that a risk assessment will be performed and included in the medical record. While it seems that many of the professional participants were able to conceptualize the benefits of implementing such a program, the details of doing so were also fraught with some difficulties. Future investigations will hopefully reveal effective strategies for implementation of an electronic pain evaluation program to improve quality of care.
ACKNOWLEDGEMENTS Special thanks are extended to Diane Palombi and Rachel Porter for their active participation in the study and to the staff and patients from Brigham and Women’s Hospital and Boston Pain Care Center. This study was funded by an educational grant from Endo Pharmaceuticals.
REFERENCES 1. Strassels S. Economic burden of prescription opioid misuse and abuse. J Manag Care Pharm. 2009;15:556–562.
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2. Stanos SP, Bruckenthal P, Barkin RL. Strategies to reduce the tampering and subsequent abuse of long-acting opioids: potential risks and benefits of formulations with physical or pharmacologic deterrents to tampering. Mayo Clin Proc. 2012;87:683–694. 3. Jamison RN, Serraillier J, Michna E. Assessment and treatment of abuse risk in opioid prescribing for chronic pain. Pain Res Treat. 2011 Article ID 941808, 12 pages http://www. hindawi.com/journals/prt/2011/941808/ (Accessed August 10, 2012) 4. Food and Drug Administration. Extended-release (ER) and long-acting (LA) opioid analgesics risk evaluation and mitigation strategy (REMS). Reference ID: 3154773. Approved 7/2012. (accessed on August 6, 2012) 5. Webster L, St. Marie B, McCarberg B, et al. Current status and evolving role of abuse-deterrent opioids in managing patients with chronic pain. J Opioid Manag. 2011;7:235– 245. 6. Provenzano DA, Fanciullo GJ, Jamison RN, McHugo GJ, Baird JC. Computer assessment and diagnostic classification of chronic pain patients. Pain Med. 2007;S3:167–175. 7. Marceau LD, Smith LD, Jamison RN. Electronic pain assessment in clinical practice. Pain Manag. 2011;1:325–336. 8. Jamison RN, Gintner L, Rogers JF, Fairchild DG. Disease management for chronic pain: barriers of program implementation with primary care physicians. Pain Med. 2002;3:92–101. 9. Marceau L, Carolan S, Schuth B, Jamison RN. Pain diaries as a tool to improve pain management: is there any evidence? Pain Med. 2007;S3:101–109. 10. Marceau LD, Link CL, Smith LD, Carolan SJ, Jamison RN. In-clinic use of electronic pain diaries: barriers of implementation among pain physicians. J Pain Symptom Manage. 2010;40:391–404.
11. Zacharoff KL. Impact of an Electronic Pain and Risk Assessment on Documentation and Clinical Workflow. Poster presented at the Annual Scientific Meeting of the American Academy of Pain Medicine, Ft. Lauderdale, FL, April 11, 2013. 12. Charity SS. Impact of an Electronic Pain and Risk Assessment on Documentation and Clinical Workflow. New Orleans, LA: Poster presented at the Annual Scientific Meeting of the American Pain Society; 2013. 13. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004;112:65–75. 14. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9:360–372. 15. Butler SF, Budman SH, Fernandez KC, Fanciullo GJ, Jamison RN. Cross-Validation of a Screener to Predict Opioid Misuse in Chronic Pain Patients (SOAPP-R). J Addict Med. 2009;3:66–73. 16. Akbik H, Butler SF, Budman S, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). J Pain Symptom Manage. 2006;32:287–293. 17. Butler SF, Budman SH, Fernandez KC, et al. Development and validation of the current opioid misuse measure. Pain. 2007;130:144–156. 18. Butler SF, Budman SH, Fanciullo GJ, Jamison RN. Cross validation of the current opioid misuse measure to monitor chronic pain patients on opioid therapy. Clin J Pain. 2010;26:770–776. 19. Meltzer EM, Rybin D, Saitz R, et al. Identifying prescription opioid use disorder in primary care: diagnostic characteristics of the Current Opioid Misuse Measure (COMM). Pain. 2011;152:397–402.
Electronic Opioid Risk Assessment Program for Chronic Pain Patients: Barriers and Benefits of Implementation Stephen F. Butler, PhD*; Kevin Zacharoff, MD*; Sadaf Charity, MBA*; Kristen Lawler, BA*; Robert N. Jamison, PhD† *Inflexxion Inc., Newton, Massachusetts ; †Pain Management Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
& Abstract Objectives: A preliminary electronic pain assessment program known as Pain Assessment Interview Network, Clinical Advisory System (painCAS), was implemented in 2 pain centers over the course of 10 months to understand the tool’s impact on opioid risk assessment documentation and clinical workflow. The program contains validated electronic versions of screeners for opioid misuse risk (SOAPP-R and Current Opioid Misuse Measure). Methods: Charts of patients with an initial and 2 follow-up visits were randomly selected for review of presence of opioid risk assessments before and after implementation of the electronic assessment program. Clinical and administrative staff members were interviewed to gain their perceptions of the impact of the program. Results: Significant increases were observed in the documentation of opioid risk assessments between the baseline patient chart reviews before implementation of the program (n = 66) and the postintervention patient chart reviews after the implementation of the program (n = 39), for both initial and follow-up clinic visits (P < 0.001). Specific benefits of the program identified by 7 clinicians and 8 administrators included ease of use, reduced paperwork, completion of
Address correspondence and reprint request to: Stephen F. Butler, Ph.D, Inflexxion Inc.,320 Needham Street, Suite 100, Newton, MA 024641594, U.S.A. E-mail: [email protected]. Submitted: June 04, 2013; Revision accepted: September 15, 2013 DOI. 10.1111/papr.12141
© 2013 World Institute of Pain, 1530-7085/14/$15.00 Pain Practice, Volume 14, Issue 3, 2014 E98–E105
the assessment before the clinic visit, and incorporation of information directly into an electronic medical record (EMR). Perceived barriers to implementation included poor patient compliance, changes in administration workflow, and difficulties associated with patients with no email addresses, and limited computer skills. Conclusions: Implementation of an opioid risk electronic pain assessment program significantly increased the likelihood that a risk assessment would be included in the medical record, which has implications for improvement of quality of care. & Key Words: analgesics, opioid, analogue pain scale, assessment, pain, Informed consent, lower back pain, multidisciplinary pain centers, opioid analgesics
INTRODUCTION There has been a steady increase in the number of opioid prescriptions written in the past 2 decades in response to greater awareness of undertreated pain.1 This has led to a parallel increase in opioid misuse and abuse.2 Potential solutions to the continuing rise in opioid abuse, misuse, and diversion have become an ongoing focus in regulatory, legal, and governmental action, and there has been a recent call for risk assessment monitoring of those chronic pain patients who are being considered for prescription opioids for chronic pain.3 The Food and Drug Administration (FDA) has specifically targeted the extended-release and long-acting opioid formulas by
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issuing a call for risk evaluation and mitigation strategies (REMS) designed to reduce opioid abuse and misuse.4 In light of REMS, implementation of a standardization process for risk assessment for those who are potential candidates for opioids or who are prescribed opioids for chronic pain has been recommended.3 Clinically, a universal precautions approach has been recommended. This approach assumes a degree of risk for each patient and includes risk assessment strategies as well as close patient monitoring to initiate and modify therapy in a safe and controlled manner.5 Recent attention has been given to the implementation of electronic pain assessment programs within pain medicine in order for clinics to be “paperless” and to take advantage of the benefits of computer and Internet technology designed specifically for persons with chronic pain and the providers who treat them.6,7 Previous studies have focused on the benefits of using electronic assessment programs to collect composite data, reduce personnel time, and document patient change. It has been predicted that secure electronic assessment using the Internet would outweigh the benefits of paper questionnaires. However, barriers and challenges exist in implementing any electronic pain assessment program within a busy clinic, particularly related to the changing of workflow and behavior among administrative and clinical staff and the patients invited to use the program.8–10 The painCAS program is a systematic computeradministered assessment for chronic pain patients.11,12 It is a beta version of an electronic assessment and tracking program designed to provide a comprehensive evaluation of pain patients including (1) demographic information (eg, age, gender, medical history), (2) pain assessment and quality-of-life evaluation (eg, pain intensity, activity interference, mood, medication use, side effects), and (3) an electronic version of the Screener and Opioid Assessment for Patients with Pain (SOAPPR), which is a 24-item self-reported assessment tool to help identify risk of opioid misuse among chronic pain patients.13–16 For follow-up clinic appointments, a beta version of the painCAS assessment with the Current Opioid Misuse Measure (COMM), which is a validated 17-item assessment of current opioid misuse, is used.17– 19 The painCAS program offers a summary of patient information with a pain diagram and risk assessment scores that can be easily integrated into an electronic medical record (EMR) system (Figure 1). A focus of the program is to summarize and document the results of the assessment and to continually evaluate and track the risk
of aberrant drug-related behavior for those considered for opioid therapy. It was especially designed to offer clinicians a way to rapidly identify, track, and appropriately treat chronic pain patients at risk of aberrant drug-related behavior. The purpose of this study was to implement a pilot version of the web-based painCAS electronic assessment software program for chronic pain patients in two clinical settings and to study the impact of the program on assessment documentation and clinical workflow. A primary objective of this study was to determine the impact of this program on documentation of risk assessments in the EMR. Currently, in many clinical settings, the clinic staff must manually calculate the scores for the questionnaires and then scan or transcribe paper versions into the EMR to document the risk assessment scores. We hypothesized that use of an electronic risk assessment program would significantly increase the documentation of risk assessments in the EMR. A secondary objective was to understand the challenges related to implementing an electronic risk assessment program in the clinical setting. We recognized that one of the biggest barriers to the adoption of a risk assessment program would be the change of workflow required among administrative staff. We hypothesized that the proportion of medical records that included a recent (past 3 months) opioid risk assessment would increase 3 to 6 months after patients had been administered the risk assessment program (in place of paper-and-pencil versions of the assessments) and that the clinic workflow around administering, scoring, and documenting opioid risk assessments would improve following implementation of the electronic risk assessment tool.
METHODS The study was conducted at two independent sites, which represented a private pain clinic (Center 1) and a pain center at a large research hospital (Center 2), both within urban environments, between January and September 2012. Both sites were using paper versions of risk assessment measures (SOAPP-R and COMM) for pain patients being considered for opioid therapy. The study was approved by their respective IRBs. Clinicians and administrative staff from both centers were recruited and consented. After signing the consent form, training sessions with the administrative staff were conducted at both centers on use of the software program. Next, randomly selected medical records associated with pain
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Figure 1. Screen shot of the pain assessment report.
patients who had an initial and two follow-up clinic visits from the consenting provider’s caseload were identified for baseline chart review to compare a “practice-as-usual” period with a postintervention period after implementing the software program into the clinics. This allowed for an evaluation of the incidence and change in risk assessment documentation in the EMR after introduction of the painCAS software program. Pre- and postintervention interviews were conducted with the clinicians and administrative staff using structured interviews. The goal was to track the electronic software assessment completion rates and to assess the impact on clinic processing. Chart Reviews Chart reviews were conducted by existing staff at each clinical site who were not directly involved in the study.
These research assistants were instructed to review the medical charts for the presence or absence of opioid risk assessment documentation, including the painCAS Beta reports at the postintervention time points. This chart review was performed for randomly selected patients at baseline who had an initial and at least 2 follow-up visits and then again for new patients at postintervention who had at least an initial and two follow-up visits and who had the opportunity to have been exposed to painCAS. Specifically, chronic pain patients were included for the baseline chart review if they were (1) English speaking, (2) assigned to one of the consented clinicians, and (3) had an initial clinic visit and at least 2 follow-up visits within the past 12 months. Similarly, postintervention charts were included for new patients who were (1) English speaking, (2) assigned to one of the consented clinicians, (3) sent painCAS assessment requests, and (4) had an initial and at least 2 follow-up clinic visits in the
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past 5 months after the baseline were included into the random chart review. Patients were included in the chart reviews whether or not they have been prescribed opioids. A secure online form was created for conducting the chart reviews. The goal was to identify 10 charts for each consented clinician for review during the baseline chart review procedure [10 9 7 = 70]. During the postintervention chart review, research assistants reviewed charts of patients who received painCAS assessments and attended an initial clinical visit, and at least 2 follow-up visits. Staff Interviews Semi-structured interviews were conducted over the telephone to gather information on perceptions of the workflow with respect to administration, scoring, and documentation of paper-and-pencil opioid risk assessments. These interviews of the clinicians and administrative staff included questions regarding demographic information, current workflow related to risk assessment, level of satisfaction with current assessment processes, and the barriers and benefits of the assessment processes. Interview questions included Likert-type scales (ie, not at all helpful to very helpful), multiple choice items, and open responses to questions created for this study. Following the intervention period, participating clinicians and administrative staff were interviewed again to determine the impact of the electronic pain assessment program on their perceptions of efficiency in clinical workflow. The postintervention clinician interviews included questions regarding experience with using the electronic pain assessment program, perceived helpfulness and value of the program, benefits and barriers of its implementation, and feedback received from patients about its use. Each clinician was paid $200. Postintervention interviews for administrative staff included questions of experience with integrating the electronic pain assessment program, satisfaction with integrating it into clinical workflow, the barriers and benefits of using the program, and feedback received from patients about the program. Each administrative staff was paid $100. Postintervention questions were similar to the baseline interview questions and included open responses to questions. Intervention Upon completion of the baseline interviews and chart reviews, both study sites launched the intervention.
Consented administrative staff sent links to the electronic risk assessment program to all new patients as well as existing patients new to opioid treatment of those receiving treatment from the consented clinicians. Patients were sent the initial assessment when the patient or the patient’s referring clinician contacted the study site to schedule an initial clinic visit. Patients were also sent links for follow-up assessments prior to their follow-up clinic visits. If a patient did not complete the assessment prior to arriving at the clinic for their appointment, the administrative staff was encouraged to administer the electronic assessment program to the patient in the clinic using a laptop computer with Internet access. A clinician report was generated in the web-based system for each assessment completed by a patient. The participating administrative staff would login to the website created for this study and download the clinical report for every completed assessment and save it in the appropriate electronic medical record for the consented clinician to access and review prior to or during the patient’s clinical visit. We were interested in testing whether the proportion of medical records that included opioid risk assessment (SOAPP-R or COMM) would substantially increase 6 months after patients of participating clinicians had been administered the electronic pain assessment program in place of the paper–pencil versions of the assessments. Comparisons were made using chi-square analyses (SPSS version 20). Bonferroni correction for multiple tests set the alpha level for significance at P < 0.017. All data collected through the semi-structured interviews were summarized using standard descriptive statistical techniques, including calculating averages and percentages of participant responses.
RESULTS Seven clinicians (2 from Center 1 and 5 from Center 2), including physicians and nurse practitioners, and 8 administrative staff members (2 from Center 1 and 6 from Center 2) were recruited from both study sites. Participants included 5 physicians, 2 nurse practitioners, and 8 administrative staff (including administrative assistants, practice assistants, and patient/clinic coordinators). The clinicians had an average 6.5 years of experience in the chronic pain treatment specialty field. Over half the participants were female (53%) and most participants were Caucasian (66%). Others were Asian (13%), African American (13%), and other (8%).
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In total, 105 patient charts were included in the baseline and postintervention reviews. Of these, 66 charts were reviewed for the baseline or “practice-asusual” time period. Thirty-nine patient charts were identified that met the inclusion criteria for the intervention condition (ie, patient was assigned to one of the participating clinicians, had 1 initial and 2 follow-up clinic visits, and was identified for the painCAS assessment). The number of patient charts included in the postreview for each clinician averaged 5.6 (Center 1 = 7.5; Center 2 = 4.8). The patients represented in the baseline and postintervention charts were 47% female in Center 1 and 41% female in Center 2. Most of the patients represented in the chart reviews were Caucasian (89% at baseline and 97% at post), while a minority were African American (5% at baseline, 2.6% at post), Hispanic (5% at baseline and none at post), and Asian (1% at baseline and none at post; Table 1). Significant increases were observed in the documentation of opioid risk assessments between the baseline chart review when the electronic pain assessment program was not in use and the postintervention chart review when the program was in use (Table 2). At postintervention, the patient charts included documentation of opioid risk assessment 79.5% of the time, whereas at the baseline time point, the charts included documentation of any risk assessment only 40.9% of the time (Χ2 = 14.8, df = 1, P < 0.001). For the follow-up clinic visits, documentation of the COMM was present Table 1. Combined Demographics of Reviewed Charts Variable Age (mean, SD) Gender (% female) Race (%) Caucasian African American Hispanic Asian
Baseline Charts (n = 66)
Completed PainCAS (n = 39)
51.0 (13.0) 47.0
48.8 (10.1)* 41.0
89.0 5.0 5.0 1.0
97.4 2.6 0.0 0.0
*No significant differences were found between groups.
Table 3. Completion Rates for PainCAS Assessment by Center and Total (n = 155)*
Table 2. Presence of Risk Assessment in Medical Records (% present) Before and After PainCAS Implementation
Variable Initial risk assessment (SOAPP-R) Follow-up risk assessment (COMM) Any risk assessment COMM, Current Opioid Misuse Measure.
in the charts 43.6% of the time when the program was in use, whereas it was only present 4.5% of the time when the program was not in use (Χ2 = 24.24, df = 1, P < 0.001). The baseline clinician (n = 7) and administrative staff (n = 8) interviews focused on clinical processes for administering and documenting opioid risk assessments before implementation of the program, while the postintervention interviews focused on the implementation of the electronic pain assessment program at the study sites to provide a comparison of clinical processes and workflows with and without the program. Overall, 58.7% of all patients sent a request to complete the electronic pain assessment program completed at least one assessment, (69.0% for Center 1 and 52.6% for Center 2; Table 3). Over half of the consented clinicians (57%) indicated that they reviewed the pain assessment reports as part of their clinical process, while 43% did not receive or review any reports. Following implementation, all participants were asked how the program impacted their workflow. Most of the clinicians (4 of 7) said it made no difference in their work flow or said it made their job easier, while 3 of the 7 of administrative staff said that the pain assessment program made their workflow more difficult (one administrative staff member declined to answer, citing lack of exposure to using the program.) Additional feedback from the administrative staff suggested that having the patient complete the electronic pain assessment in the clinic was time-consuming and interrupted the clinical workflow because it took 20 minutes or more to complete whereas administration of the paper opioid risk assessments typically took 5 to 10 minutes to administer to a patient. Half of the clinicians (4 of 8) said they had more confidence in the automatically calculated scores than the manually calculated scores, while the other half said
Before PainCAS (n = 66)
After PainCAS (n = 39)
30.3% 4.5% 40.9%
76.9% 43.6% 79.5%
X2
P
21.4 24.2 14.8
< 0.001 < 0.001 < 0.001
Variable
Center 1
Center 2
Total
N of patients who received a painCAS request No assessment completed Any assessment completed Initial assessment completed Follow-up assessment completed
58
97
155
18 (31.0%) 40 (69.0%) 22 (37.9%)
46 (47.4%) 51 (52.6%) 41 (42.3%)
64 (41.3%) 91 (58.7%) 63 (40.7%)
18 (31.0%)
10 (10.3%)
28 (18.1%)
*No significant differences were found between groups.
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they had the same level of confidence in both types of calculation. Before the introduction of the electronic risk assessment program, participants reported scanning paper assessments, or manually transcribing assessment responses and scores into the EMR, all carried out by various clinical staff including psychologists, social workers, and administrative staff. The interviews indicated that the process for documenting paper risk assessment results could be improved with the aid of an automated process where scores and responses would be automatically uploaded to the EMR. Five of 8 members of the administrative staff indicated that integrating the electronic pain assessment program into the clinic was easy, compared with half (3 of 7) of the clinicians. One clinician declined to answer, citing lack of exposure to the painCAS report. Most of the administrative and clinical staff (5 admins and 6 clinicians) indicated they would like to continue to use this program in their practice (Table 4). Challenging aspects of using the paper risk assessments included the following: (1) getting patients to complete the assessments in time for the results to be available for treatment planning; (2) not having the ability to use the assessment results to their full advantage due to a lack of tracking capabilities; (3) time it took to score and concerns over accuracy of the scoring; (4) communicating with the other clinicians providing care for the patient or the referring clinician; (5) not having a standardized process; and (6) adding the results to the EMR and having access to the results at the time when they are needed. Table 4. Combined Pre- and Postinterview Responses of the Administrative (n = 8) and Clinical Staff (n = 7) 1. What aspects of the program could be improved? Administration staff Clinicians Better tracking of the assessment Improve process for in-clinic assessment Have patients register themselves Make summary reports easier to without prompting locate on the EMR Add date and time of next Need for immediate upload of report appointment to EMR Improve process for in-clinic Make improvements in the program assessment Add pertinent information for patients 2. What aspects of administering the program to patients worked well? Administration staff Clinicians Easy to send Report has good accessibility Immediate access to results Program can be completed online and in the waiting room Easy to upload Report can be retrieved electronically Reduced paperwork Risk assessment scores are automatically calculated Useful report completion email notification
Suggested improvements to the electronic pain assessment program included the following: (1) improve the process for starting and completing the painCAS assessment in the clinic, as the current process took too long; (2) have a way to automatically send the assessment report to the patient’s medical record; (3) improve ease of access to the assessment report in the EMR; (4) improve the assessment tracking system so it is more efficient and streamlined; and (5) have a status indication of whether the report has been downloaded to the EMR.
DISCUSSION The results of this study confirm that the proportion of medical records that included a formal opioid risk assessment (in this case, SOAPP-R or COMM) among chronic pain patients increased for the electronic pain assessment program condition over the practice-as-usual or no-painCAS condition. Specifically, highly significant differences in favor of the electronic pain assessment condition were observed for the presence of documentation of risk assessment for the SOAPP-R for baseline visits, and for the COMM assessment for follow-up visits. Introduction of the electronic risk assessment program increased this documentation level to nearly 80%. Only 5% of charts contained reference to COMM in follow-up visits in the practice-as-usual condition, while the electronic assessment program increased this documentation to 44%. Although less than half of charts documented this follow-up risk assessment, the increase in the COMM documentation suggests a significant impact on the likelihood of follow-up risk assessment. Results observed in this study suggest that, despite continuing issues associated with integrating an electronic tool like the painCAS into the workflow, the value of doing so can be clinically significant. A barrier to the use of an electronic risk assessment program compared with the pencil-and-paper version was the longer time needed for implementation of the program. The time calculated for the electronic pain program included the entire process of setting up and registering patients, activities that were not yet part of the clinic flow, as well as additional questions asked by the painCAS assessment. This was compared to the pencil-and-paper assessment that consisted of simply handing a clipboard to a patient and having the patient complete the paper questionnaires. Furthermore, comparison of the pencil-and-paper time did not include the time spent by administrative or clinical staff scanning or
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otherwise inputting the assessment data into the EMR. This study helps to document that any change in an organizational process is likely to be met with resistance because of the slow process of adapting to change. Prior research has demonstrated the difficulties with successful integration of any new innovation into the clinical process.8,10 While it is important to continue to evaluate and modify the software, it is equally important to consider how the introduction of an electronic pain assessment program would impact the work load of personnel within a busy clinic practice. Specific perceived benefits were primarily related to ease of use, automation, and incorporation of information in an electronic format into an EMR. Alternatively, challenges and barriers to implementation included changes in workflow and difficulties encountered in administering the assessment via email. Some patients chose not to comply with prompts to complete the assessment program before their clinic visit and more attention is needed in determining reasons for this noncompliance. There is also the possibility that completed files were omitted from being placed in the EMR by administrative staff, and greater attention to understanding the process of attaching assessment files to each patient’s EMR would be valuable. Some clinical staff reported not seeing the summary reports on the EMR. Labeling difficulties and the need to examine past notes could account for this omission. Some providers suggested that this would be improved if there was an easyto-access place in the EMR where the reports could be reliably saved. In an ongoing primary care study using the painCAS program, summary reports are attached to email messages to each of the providers as well as being attached as separate notes on each patient’s medical record. We believe that this will have the added benefit of alerting the providers to each of the summary reports. There are a number of limitations of this study that need to be highlighted. First, because the electronic pain assessment program was used by a select number of patients and their clinicians in the centers, it was difficult for the providers to know which patients were included in the study and which ones were not. Some of the missing follow-up data may have been due to the administrative staff being unaware of which patients had been enrolled in this study. Also, some clinicians had fewer initial patients than others. This was because they were not in the clinic every day, they had already had a full practice and were not taking new patients, or they were away for some of the time during this pilot study. Thus, there were fewer charts to review postin-
tervention than before the electronic program was implemented. The program may be of greater utility if the centers incorporate this program with all the patients at the same time so that all providers would become familiar with this assessment tool. A longer period of follow-up is also needed. Second, this trial was conducted in two interdisciplinary pain centers where they had been using opioid risk assessment measures. Thus, we do not know how the painCAS would be incorporated in a primary care setting or how it would be used in centers where opioid risk assessment is not routinely conducted. Finally, because the painCAS Beta included only a limited version of the comprehensive pain assessment, there was an unwillingness to eliminate the paper versions of the comprehensive pain assessment. Thus, patients new to the clinics were completing 2 assessments, which might have made the completion of initial and follow-up assessments to be perceived as a burden. A revised version of the painCAS currently in development could prove to be as useful to the providers as the paper-and-pencil assessments, and there could be a greater willingness to replace the paper versions of the initial assessment with an electronic assessment software program. Despite these limitations, this pilot study confirms that implementation of an electronic risk assessment program can increase the likelihood that a risk assessment will be performed and included in the medical record. While it seems that many of the professional participants were able to conceptualize the benefits of implementing such a program, the details of doing so were also fraught with some difficulties. Future investigations will hopefully reveal effective strategies for implementation of an electronic pain evaluation program to improve quality of care.
ACKNOWLEDGEMENTS Special thanks are extended to Diane Palombi and Rachel Porter for their active participation in the study and to the staff and patients from Brigham and Women’s Hospital and Boston Pain Care Center. This study was funded by an educational grant from Endo Pharmaceuticals.
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2. Stanos SP, Bruckenthal P, Barkin RL. Strategies to reduce the tampering and subsequent abuse of long-acting opioids: potential risks and benefits of formulations with physical or pharmacologic deterrents to tampering. Mayo Clin Proc. 2012;87:683–694. 3. Jamison RN, Serraillier J, Michna E. Assessment and treatment of abuse risk in opioid prescribing for chronic pain. Pain Res Treat. 2011 Article ID 941808, 12 pages http://www. hindawi.com/journals/prt/2011/941808/ (Accessed August 10, 2012) 4. Food and Drug Administration. Extended-release (ER) and long-acting (LA) opioid analgesics risk evaluation and mitigation strategy (REMS). Reference ID: 3154773. Approved 7/2012. (accessed on August 6, 2012) 5. Webster L, St. Marie B, McCarberg B, et al. Current status and evolving role of abuse-deterrent opioids in managing patients with chronic pain. J Opioid Manag. 2011;7:235– 245. 6. Provenzano DA, Fanciullo GJ, Jamison RN, McHugo GJ, Baird JC. Computer assessment and diagnostic classification of chronic pain patients. Pain Med. 2007;S3:167–175. 7. Marceau LD, Smith LD, Jamison RN. Electronic pain assessment in clinical practice. Pain Manag. 2011;1:325–336. 8. Jamison RN, Gintner L, Rogers JF, Fairchild DG. Disease management for chronic pain: barriers of program implementation with primary care physicians. Pain Med. 2002;3:92–101. 9. Marceau L, Carolan S, Schuth B, Jamison RN. Pain diaries as a tool to improve pain management: is there any evidence? Pain Med. 2007;S3:101–109. 10. Marceau LD, Link CL, Smith LD, Carolan SJ, Jamison RN. In-clinic use of electronic pain diaries: barriers of implementation among pain physicians. J Pain Symptom Manage. 2010;40:391–404.
11. Zacharoff KL. Impact of an Electronic Pain and Risk Assessment on Documentation and Clinical Workflow. Poster presented at the Annual Scientific Meeting of the American Academy of Pain Medicine, Ft. Lauderdale, FL, April 11, 2013. 12. Charity SS. Impact of an Electronic Pain and Risk Assessment on Documentation and Clinical Workflow. New Orleans, LA: Poster presented at the Annual Scientific Meeting of the American Pain Society; 2013. 13. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004;112:65–75. 14. Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9:360–372. 15. Butler SF, Budman SH, Fernandez KC, Fanciullo GJ, Jamison RN. Cross-Validation of a Screener to Predict Opioid Misuse in Chronic Pain Patients (SOAPP-R). J Addict Med. 2009;3:66–73. 16. Akbik H, Butler SF, Budman S, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). J Pain Symptom Manage. 2006;32:287–293. 17. Butler SF, Budman SH, Fernandez KC, et al. Development and validation of the current opioid misuse measure. Pain. 2007;130:144–156. 18. Butler SF, Budman SH, Fanciullo GJ, Jamison RN. Cross validation of the current opioid misuse measure to monitor chronic pain patients on opioid therapy. Clin J Pain. 2010;26:770–776. 19. Meltzer EM, Rybin D, Saitz R, et al. Identifying prescription opioid use disorder in primary care: diagnostic characteristics of the Current Opioid Misuse Measure (COMM). Pain. 2011;152:397–402.
