Peer Review Model

A Peer Review Program is a systematic intervention method developed to identify, review and intervene with high risk prescibers. The process is designed to help providers explore opioid prescribing options and best practices in a way that is clinically relevant, not punitive.

Resources
Developing a Peer Review Program within a health system requires a leadership commitment for resources and infrastructure. These include, but aren't limited to, a program manager, a dedicated data or business analyst, a utilization review nurse or other clinician, and the cooperation of a case management/social work department for patient care coordination.

Another important component is the providers (physicians, APRNs) who serve as the Peer Review Committee. This group reviews prescibing habits and determines action steps for referred prescribers. It can also be helpful to have a 'physician champion' in your system to explain the necessity and benefits of such a program to administration and to refer colleagues to the Peer Review Committee.

Peer Review Model

IDENTIFYING AT RISK PROVIDERS & PATIENTS

In order to implement a Peer Review program, the first step is to find providers in your system who are, or are at risk of, overprescribing opioids or who have patients that lack pain panels, are missing pain management contracts, patients on high doses of opioids (or have been co-prescribed benzodiazepines), are on chronic opioid treatment with a psychiatric condition, or are high risk medical patients (elderly, multiple co-morbidities, or taking other high-risk medications).
The key to finding these providers and their patients is your health system's data or business analyst. This person can pull data from the hospital's electronic medical records system and the Ohio Automated Rx Reporting System (OARRS). The procedures listed here describe the process of high prescriber and patient identification.

  • Step 1
    Request a Data or Business analyst in your hospital to find all prescriptions written in the system with DEA classes of II, III for a stipulated timeframe (like the last six months). To do this, they will use a reporting tool available in the health system's EMR (for Epic, this is called BI Launchpad) to create a report with the following headers:
    Ordering date | Patient name | Provider ID | Provider name | Medication name | Quantity | Refills | Pharmacy class | Pharmacy subclass | Discontinue reason | Order class | Order med ID | Start date | Order status | Department
  • Step 2
    The Analyst will then review the highest number and multiple prescriptions for patients in these drug classes and make a list of those providers with an unacceptably high number or mulitple prescriptions. The number deemed 'unacceptably high' is for the health system to determine and will vary by system. A pivot table is created for each provider.
  • Step 3
    The Analyst will then check the Ohio Automated Rx Reporting System (OARRS), or Presciption Drug Monitoring Program (PDMP) for each provider on the system-generated list using the provider's DEA number. The analyst will abstract a Prescriber Activity Report from the OARRS. This report provided data on prescriptions written by the provider and filled by the patient. The purpose of getting this extra data is to determine if the patient filled their Narcan prescription. If providers don’t have DEA numbers, as is sometimes the case, the Utilization Review nurse or Case Manager (subsequent steps in the peer review model) can check to see if patients have filled their Narcan prescription through Epic, or any EMR system.
  • Step 4
    The Analyst will combine the data pulled from the internal EMR and the OARRS data and analyze findings to determine list of providers to hand off to a Utilization Review nurse for review/action. Each health system would determine the threshold for what is considered unacceptable prescribing and require review/action.

UTILIZATION REVIEW

After a list of providers is generated by the data or business analyst, the list is given to a Utilization Review nurse. The nurse will follow the steps below to determine which providers will be sent on to a Peer Review Committee for further evaluation. The Peer Review Committee can be made up of your health systems' clinicians with a high level knowledge of opioid prescriptions; see below for more information about this group.

Utilization Review Steps:

Using the advocate check list, perform a chart review of the identified provider's patients who have been prescribed controlled substances. (Tip: Each question in the advocate checklist tool can become a column in an excel spreadsheet for easier analyzation).
Using the advocate checklist tool, the 10 (or other designated number) of highest prescribed patients for each provider are reviewed further. Present a summary of findings to the Peer Review committee.
Assist committee members in a developing a focused provider performance evaluation.
Assist provider by providing general resources to improve practice.
Identify at-risk patients and refer to case management or other appropriate interventions.
Initiate 6-9 month follow-up plan with provider to assess adherence to Peer Review Committee recommendations and/or further education needs.

PEER REVIEW COMMITTEE

The Utilization Review (UR) nurse presents chart review findings to the Peer Review Committee (PRC). This committee is made up of clinicians in your health system who have some specialized knowledge of opioids. These members can be physicians, APRNs or other prescribers from primary care, emergency, surgery, and/or pain & healing departments.

The PRC determines the action steps concerning providers along with the Utilization Review nurse. This committee convenes on a schedule determined by Step 1 of the Peer Review (creation of high prescibers list).

Opioid Training Courses
Examine chart reviews; sends summary letter (controlled substance peer review) detailing concerns to provider
Opioid Training Courses
Meet with highest prescribing and concerning providers
Opioid Training Courses
Depending on meeting results, additional education or training may be recommended. One-on-one education can be done through the academic detailing process outlined in this toolkit.
Opioid Training Courses
UR nurse adherence follow-up 3-6 months after PRC meeting

PATIENT INTERVENTION

After the Utilization Review nurse identifies the most at-risk patients of the high prescribers, a list of those patients will go to Case Management for care coordination. A case manager will triage patients into one of the following three categories and follow up with corresponding actions to triage level. When the patient triage is complete and the action plan in place, the case manager reports this assessment back to the Peer Review Committee. This process will include provider agreement to reach out to patients and on-going communication with the provider, patient, and peer review committee. Time frames of reaching out to patients will vary.

Opioid Training Courses
Level 1 Triage

High morphine milligram equivalent (MME) usage with no follow-up, alerts in OARRS or history, aberrant behavior.

Action

Contact patient within an acceptable timeframe (7 to 10 days); screen for follow-up appointments, referrals or services needed

Level 1 Triage
Opioid Training Courses
Level 2 Triage

Epic reflects follow-up, however still on high dose MME’s; patient misses occasional appointments or drug screens.

Action

Contact within an acceptable time frame (1 month) for screening to determine appointment and referral needs

Level 2 Triage
Opioid Training Courses
Level 3 Triage

Patient appears stable on lower MMEs and has appropriate follow-up in place.

Action

Re-evaluate patient in 4 weeks for change in record and needs assessment

Level 3 Triage
OD2A Toolkit
Additional Resources

To help you implement a peer review process in your own facility, we’ve created sample resources for each Phase of the process:

Phase 1: Provider Review Report, Sample EMR Best Practices & Narcotics Report Card for Prescribers

Phase 2: Advocate Checklist & Peer Review Summary Letter

Phase 3: MME Calculator & Patient Follow-up Template