Part I: What Do We See in a Chronic Pain Population in a Typical Primary Care Practice?

We have worked with practices and looked at tens of thousands of medical records of patients with chronic pain, mostly in the primary care setting, with several pain specialists. The objective of these reviews is to help the practice assess the conformance of their documentation and also identify risk pools for some type of clinical action or follow-up. We know that patients end up being the real beneficiaries in the end because we are the pain specialty eyes that often see new opportunities to improve patient quality of life and/or reduce practice risk. The two often go hand in hand.

When we engage a prospect around the topic of risk stratification and its importance, we are often met with the same reactions: "Let's skip that step because we are already compliant. We have looked at all of the patients, have had many of our patients in the practice for decades, and are good doctors." We certainly believe all that to be true. We bring our own lens, based on decades of specialty experience. We also can apply the lens of state medical boards and other regulators who have their own perspective. While there may be a discussion of evolving standards of care, in the end, everyone is aligned around doing the best for patients and their outcomes.

So here is our current top ten list. This is what we see among the chronic pain population, and these are the areas that represent physician liability and risk and  opportunities to improve patient care:  

1. Concurrent prescribing of opioids and benzodiazepines, often over very long periods of time.
2. Mental health problems, like depression and anxiety, with no workup, no psychiatrist referrals, no psychologist referrals.  
3. Benzodiazepines prescribed as a first line treatment for #2.
4. High opioid dosages in patients with renal impairment and no kidney function monitoring ever, conditions which are very common in geriatric patients.
5. Long term use of opioids for conditions like migraines and fibromyalgia that have much better pain management tools. In fact, it is possible for opioids to actually worsen these conditions.
6. Lack of a pain related diagnosis related to the prescribed opioids.
7. Lack of a work up and documentation of a work up for pain condition. This can include EHR mischaracterizations / misrepresentations of clinical data resulting from notes carried from prior encounters that imply an exam that did not occur, or previous findings from prior encounters where a current status is implied in the note.
8. Lack of trials of treatment alternatives.
9. Consistently writing prescriptions in a way that don't accurately reflect the instructions to the patient in their use in an attempt to "mask" an insurance or compliance issue, e.g., writing a large 30 day opioid prescription that is intended to be used by the patient as needed for six months with no followup by the prescriber during that time.
10. No education whatsoever with respect to the topics suggested by most state medical boards and the CDC.

We could easily go on and add to this list to create a top 20 but we will leave that for another day. We have yet to find a single physician that does not have some of these issues lurking in their EMR. Usually not by intention, but for a variety of reasons that we will explore in upcoming articles.

We have solutions to address all of these issues. They are all very good at improving patient outcomes and all very good for the business of the practice.

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