Rashmee Patil, MD

	Every day I entered her hospital room it felt as though I was entering her actual bedroom. Any empty space I could see was covered with personal memorabilia: cards from friends and loved ones, flowers, schoolbooks and packs of her favorite candy livened an otherwise dull and unwelcoming hospital room. She had made this space her home and I didn't blame her. After a diagnosis of endocarditis that had affected one of her major heart valves, she was going to receive six weeks of antibiotics through a peripherally inserted central catheter, and she would spend those six weeks in this exact room.

	Every few days I would check in, making sure she wasn't having any fevers and that the site of the catheter was clean. Beginning my exam, I would auscultate her chest to listen for irregular heart sounds. Going through the same routine each time, she had come to anticipate my next move. "I never thought I would be in this position," she told me one day. I loosened my stethoscope from my ears instead of beginning my exam.  

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	She told me she was 22 when it started. She began drinking more heavily on weekends with friends to relieve some of the stress she was feeling in her job as a teacher. Then one weekend, one of those friends asked her if she wanted to try a line of cocaine, and she did. Surprised and euphoric from the high, she quickly dabbled in other substances and eventually advanced to intravenous drugs.

	After several weeks, she found herself injecting heroin every other day, except this time it was not just on weekends when she was drunk. She was shooting up in her office between teaching classes during the day and in her bedroom when her parents were outside watching the nightly news. Each attempt to satisfy her need for a high grew more risky. She was taking trips to surrounding cities where she had heard heroin was cheaper but not telling anyone where she was. She admitted she was ashamed, but felt she couldn't stop. 

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	I listened as she talked, partly empathizing but not fully understanding how a seemingly well-educated and highly-functioning young person with a meaningful job and a supportive family could so quickly take a turn toward a much darker path. She explained to me that because heroin was so accessible, she easily began to seek it out through different buyers on her own, despite being a novice. Her own hunger for the drug scared her.

	I thought to myself that maybe her diagnosis was the jolt she needed. Instead of falling deeper into the abyss of addiction, she was now sitting in a hospital bed, in a controlled setting, and forced to deal with her mental demons every day for the next six weeks. Of course, her story was one of many I had heard since starting to work at this rural community hospital, and with each patient encounter I was becoming less and less surprised by the details.

Next: The public health issue remains the same

	Over the past several months, I have divided my time as a hospitalist between a major metropolitan city and a small, rural town in New York State. In the hospital where I work there is an addiction unit, and I am often called for medical consultations for patients withdrawing from their substance of choice. The substances vary, but almost every patient has had an

 in one form or another. In fact, I have seen more overdoses from opioids in this small community over the past several months than I have in the five years I trained and worked in medicine in New York City. I have seen a 56-year-old woman with chronic back pain who overdosed on oxycodone, found unconscious on the kitchen floor by her husband. I have seen a 21-year-old man come in with respiratory failure after shooting up âjust one more bagâ of heroin. And more recently, I have seen tragic, accidental deaths from fentanyl, a drug that is showing up on the street in counterfeit pills being passed off as oxycodone or Xanax.

	The patient encounters may vary, but the public health issue remains the same: We have an opioid crisis in America and the numbers, like my experience in this rural town, prove it.

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	According to the most recent data from the New York State Department of Health, opioid related deaths in central New York have increased by 2,900% since 2004. Similarly, the Centers for Disease Control and Prevention (CDC) reports that an estimated 51 people die each day in the U.S. from overdoses related to prescription opioids. This number has risen five-fold since 1999.

% increase in sales of prescription opioid pain relievers in this country. Interestingly, however, there was no increase in the amount of pain Americans reported in that same period. As the White House, the CDC and other federal and state agencies scramble to find solutions to the current opioid problem, the role that doctors play is coming back to center stage. 

 for physicians prescribing opioids, recommending that doctors try less-addictive drugs, such as ibuprofen, before prescribing highly addictive pills and that they only give a few days' supply in most cases. The recommendations are meant for primary care doctors and do not apply to prescriptions for patients receiving cancer or end-of-life treatment, or to patients who have had surgery. These guidelines come after a growing backlash from some physician groups and organizations who have opposed the practice of opioid prescriptions for routine pain.

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	Many physicians have prescribed opioids to patients for conditions such as back pain and arthritic pain over the past two decades. This came as a result of pharmaceutical companies and some medical experts attesting that opioids could be used to treat common conditions without the fear of addiction. Later those claims would be found to be false even though drug companies have profited from a $2 billion industry of popularly marketed and sold drugs such as Oxycontin, Percocet and Vicodin. Though some physicians and agencies do not support the guidelines, the soaring death toll and data supporting the opioid crisis have brought together many doctors and regulators who were previously on opposite sides of the debate. 

Next:  The imminent threat must be addressed now

	Though the CDC guidelines and other new 

 from government regulators such as the Food and Drug Administration (FDA) are targeting physicians, the crisis we are facing has not occurred just as a result of physicians overprescribing. Equally complicit in the crisis have been pharmaceutical companies advertising opioids as safe and not addictive, as well as governmental agencies such as the Centers for Medicare & Medicaid Services (CMS) deciding that a patientâs satisfaction score during a hospitalization is as important in reimbursement as the patientâs survival and whether they obtained a hospital-acquired infection.

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	When part of the patient satisfaction score is linked directly to the management of pain during their hospital stay, there is undeniably a pressure for physicians to provide opioids to patients even if they feel they may not necessarily need them. Arguably these measures were initiated in legislature years after the culture of treating pain changed in the U.S. medical community as a result of a campaign by the American Pain Society (APS) to treat pain as the âfifth vital sign.â Once this new perception of treating pain as a vital sign caught on, organizations such as the Veterans Health Administration and the Joint Commission on Accreditation of Healthcare Organizations began to adopt the slogan and called on physicians to manage patientsâ pain.

	But just as any slogan or plan, there must be regulations in place after implementation. Many physicians took âmanage painâ to mean âprescribe opioidsâ and this led to a now billion-dollar industry. Ultimately, the blame can be placed on many, but the imminent threat to public health that the opioid crisis promises must be addressed now by cooperation between physicians, legislators, pharmaceutical companies and the regulatory boards who oversee them.

	Fortunately, my patient finished her six-week course of antibiotics and was discharged home. She enrolled in outpatient rehabilitation and, with the help of family and friends, regained her self-determination to live a clean and sober life. Though her outer appearance did not explain the turmoil that addiction had inflicted on her life when I first met her, hearing her story opened my eyes, yet again, to the vastness of this epidemicâs reach.

	The morning after she was discharged, I came to the hospital, printed my daily census, and looked for any new patients. There was a new patient admitted overnight who had filled the room adjacent to hers. 

Rashmee Patil is a board-certified internal medicine physician practicing in New York State

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The patient encounters may vary, but the public health issue remains the same: We have an opioid crisis in America and the numbers prove it.

Save blame for later, it’s time to work together to solve the opioid crisis

	“You have an admission,” said the ER physician on the other end of the phone. “Fifty-six-year-old male with a history of atrial fibrillation with rapid ventricular response and chest pain. Troponin is elevated. I cardioverted with 20mg IV Cardizem. Oh and he’s visiting from North Carolina and was recently admitted at a hospital there.” 

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	I hung up the phone and immediately went down to see Mr. H., a middle-aged gentleman resting somewhat uncomfortably on his stretcher. His face was flushed and he explained that he’s had a few beers since he’s on vacation with his girlfriend. “Doc, I have to leave tomorrow. I know my heart rate is all out of whack, but I have a bus to catch and I can’t afford to stay another night in New York City. I feel fine. I will follow up with my cardiologist.”

	We talk about his recent hospitalization in North Carolina, but he is unable to offer me much useful information. He tells me he was admitted to the cardiac care unit and that he underwent “some procedure,” which makes me feel even less confident in letting him leave. After some self-deliberation, I decide I can’t discharge him safely without further studies, so I reassure him that we will try our best to get the results we need in the timeliest manner possible.

	I left the exam room and headed to the computer to check over all of his results. Unfortunately for Mr. H., the odds are not in his favor. Given his diagnosis and the preliminary results I have, he requires an inpatient admission until more ancillary information can be provided. “Unless you sign out against medical advice,” I told him, “you are going to miss your bus tomorrow.”

EHRs are ruining the physician-patient relationship

	This scenario is a common one for healthcare providers. Every day we meet new patients, gather important information from the history and physical exam, and make informed medical decisions based on the data we obtain. Physicians depend largely on the reliability of the patient when taking a history, but in many cases, the patients have been admitted to our healthcare system previously, which allows us access to records from prior admissions that may help in our decision-making process.

	With the current healthcare atmosphere emphasizing both efficiency 

 quality, physicians are faced with constant pressure to do more in less time. In the case of Mr. H., obtaining data from a prior hospital stay would have been helpful in decreasing length of stay and avoiding unnecessary tests. Though he was admitted to a hospital that used electronic health records (EHRs), I could not get timely access to the details of his recent hospitalization. In order to obtain the data I needed, I would either have to ask for his consent to have medical records released and have them faxed to me, or I could attempt to call his physician in North Carolina directly and hope that he or she is on call on the Saturday night. Mr. H. was admitted. 

	Physicians experience communication gaps and data-sharing challenges such as this on a daily basis. In recent years, healthcare systems have moved from paper records and filing cabinets to EHRs, all in hopes of improving patient care and coordination. Despite the rapid increase in EHR adoption, the real issue preventing direct health data exchanges between providers is that most 

 aren’t compatible with each other and therefore can’t exchange patient information efficiently.

	In many large healthcare organizations, multiple interfaces need to be utilized internally in order to access a patient’s data in its entirety. The system used to admit a patient is not the system used to access and review imaging studies; the system that stores electrocardiograms is separate from the one that keeps discharge summaries and pathology reports; etc. The burdensome task of integrating all  these data sources distracts physicians and healthcare organizations from the goal of progress and innovation. More importantly for physicians, time spent utilizing multiple interfaces and obtaining patient data could be time better spent with the patient.

	The greatest challenge to interoperability is that there is not just one challenge. Although an increasing number of providers and developers are working to achieve interoperability, long-standing challenges have become better understood and new challenges have been identified.

	As described by the Health Information Technology Policy Committee in its December, 2015 report to Congress, the most notable barriers to interoperability include lack of universal adoption of standards-based EHR systems, complex privacy and security challenges associated with widespread health information exchange and lack of incentive to develop interoperability in the private sector.

	Exchanging health information between organizations as in the case of Mr. H. requires multiple systems and parties to cooperate simultaneously. After the widespread adoption and use of EHRs to manage health information, the next major challenge is to safely and efficiently exchange critical information across health systems in order to coordinate care among all the members of an individual’s health team and to provide higher quality care with more efficiency.

	Meeting this challenge requires the interoperability of health IT systems, including EHRs, and presents different challenges than those previously encountered when implementing a standalone system for a single organization. No single component-based recommendation by itself will be enough to achieve interoperability.

	Though there is much work to be done toward EHR interoperability, we may be headed in the right direction. In recent months, the nation's top healthcare information technology developers, including Allscripts, athenahealth, Cerner, Epic and Meditech committed to pushing interoperability. Furthermore, the Office of the National Coordinator for Health Information Technology recently laid out a 

 for achieving interoperable health IT that supports a “broad scale learning health system” by 2024.

	In an ideal world, digital health records should include a patient’s clinical story in its entirety: both primary care and hospital visits, payment information and history, patient-generated health data, pharmacy and prescription information, patient and family-health history, genomics, clinical-trial data and so on. Once this information becomes easily accessible digitally for providers as well as patients, the full potential and promise of interoperability may be realized.

	In our current system, too often care teams are spending their time calling other providers to obtain patient information, faxing paper records and trying to coordinate care efforts across a disjointed and disconnected system. We need a network connecting this data to create more effective workflows, care coordination, and prevention-based models of care. However, without broad-based coordinated efforts, it is unlikely that widespread interoperability will be achieved fast enough to deliver the health care that Americans expect and deserve.

	And as for Mr. H? He ended up signing out against medical advice and catching a bus to his next destination. 

With the current healthcare atmosphere emphasizing both efficiency and quality, physicians are faced with constant pressure to do more in less time

Author | Rashmee Patil, MD

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Save blame for later, it’s time to work together to solve the opioid crisis

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