Setting a low quantity of opioid tablets as the default option in electronic medical record prescribing orders may “nudge” clinicians to prescribe fewer opioids. When two emergency departments implemented a 10-tablet default instead of a manual entry, the proportion of 10-tablet prescriptions written more than doubled, from 20.6% to 43.3%. Conversely, 20-tablet prescriptions decreased from 22.8% to 16.1%, and prescriptions for 11-19 tablets decreased from 33.5% to 20.1%

Delgado, M. Kit

Edwards, Christopher

Halpern, Scott

Meisel, Zachary F

Patel, Mitesh S

Perrone, Jeanmarie

Shofer, Frances S

English

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsResearch Briefs Leonard Davis Institute of Health Economics1-30-2018Association between Electronic Medical RecordImplementation of Default Opioid PrescriptionQuantities and Prescribing Behavior in TwoEmergency DepartmentsM. Kit DelgadoUniversity of PennsylvaniaFrances S. ShoferUniversity of PennsylvaniaMitesh S. PatelUniversity of PennsylvaniaScott HalpernUniversity of PennsylvaniaChristopher EdwardsUniversity of PennsylvaniaSee next page for additional authorsFollow this and additional works at: https://repository.upenn.edu/ldi_researchbriefsThis paper is posted at ScholarlyCommons. https://repository.upenn.edu/ldi_researchbriefs/34For more information, please contact repository@pobox.upenn.edu.Delgado, M. Kit; Shofer, Frances S.; Patel, Mitesh S.; Halpern, Scott; Edwards, Christopher; Meisel, Zachary F.; and Perrone,Jeanmarie. Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities andPrescribing Behavior in Two Emergency Departments. LDI Research Briefs. 2018; No. 34. https://ldi.upenn.edu/brief/association-between-electronic-medical-record-implementation-default-opioid-prescription" >https://ldi.upenn.edu/brief/association-between-electronic-medical-record-implementation-default-opioid-prescriptionAssociation between Electronic Medical Record Implementation ofDefault Opioid Prescription Quantities and Prescribing Behavior in TwoEmergency DepartmentsAbstractSetting a low quantity of opioid tablets as the default option in electronic medical record prescribing ordersmay “nudge” clinicians to prescribe fewer opioids. When two emergency departments implemented a10-tablet default instead of a manual entry, the proportion of 10-tablet prescriptions written more thandoubled, from 20.6% to 43.3%. Conversely, 20-tablet prescriptions decreased from 22.8% to 16.1%, andprescriptions for 11-19 tablets decreased from 33.5% to 20.1%.KeywordsOpioids, opioid epidemic, prescribing, emergency department, electronic medical record, behavioraleconomics, nudgeLicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.Author(s)M. Kit Delgado, Frances S. Shofer, Mitesh S. Patel, Scott Halpern, Christopher Edwards, Zachary F. Meisel,and Jeanmarie PerroneThis brief is available at ScholarlyCommons: https://repository.upenn.edu/ldi_researchbriefs/34THE QUESTIONThe epidemic of opioid overdose deaths in the US has its roots in prescription opioids. Patients who receive a prescription for a large quantity of opioids, especially those new to opioids, are at risk for long-term use or for having leftover tablets that are later misused or abused. Patients often receive 30 or more opioid tablets for acute pain, despite current opioid prescribing guidelines recommending only a fraction of that quantity (10-12 tablets). Default options, or pre-set selections, in electronic medical records (EMRs) can influence behavior in other contexts, and may be a way to guide clinicians toward prescribing smaller quantities of opioid tablets. In 2015, two Penn Medicine emergency departments (EDs) implemented a new EMR that featured a default setting of 10 opioid tablets, replacing one that required the clinician to enter the number of tablets manually. The authors compared weekly prescribing patterns before and after the 10-tablet default by tracking the quantity of tablets supplied at discharge for the most commonly prescribed opioid, oxycodone with acetaminophen (Oxy/APAP). THE FINDINGSDuring a 41-week period, patients received 3,264 prescriptions for Oxy/APAP across the two EDs. The average number of tablets prescribed remained the same after the default option was implemented, but the median number per prescription decreased slightly from a low baseline of 11.3 to 10 in one ED and from 12.6 to 10.9 in the other.However, the proportion of prescriptions written for the default option of 10 tablets more than doubled from 20.6% pre-default to 43.3% post-default (Figure 1). Conversely, the proportion of prescriptions written for 20 tablets (displayed second in the EMR) decreased from 22.8% to 16.1%, and prescriptions for 11-19 tablets decreased from 33.5% to 20.1%. An unintended consequence of the default option was that the proportion of prescriptions written for fewer than 10 tablets decreased from 20.4% to 15.4%. Additionally, the proportion of prescriptions written for more than 20 tablets increased slightly, from 2.8% to 5.1%, half of which were for 28 tablets (the health system-wide default if the clinician clicked on “Database Lookup” in the new EMR).THE IMPLICATIONSThis study suggests that default options in the EMR are a powerful, low-cost tool to nudge clinicians to prescribe fewer opioids. Because baseline prescription quantities were already low in the two EDs, the overall number of ASSOCIATION BETWEEN ELECTRONIC MEDICAL RECORD IMPLEMENTATION OF DEFAULT OPIOID PRESCRIPTION QUANTITIES AND PRESCRIBING BEHAVIOR IN TWO EMERGENCY DEPARTMENTS M. Kit Delgado, Frances S. Shofer, Mitesh S. Patel, Scott Halpern, Christopher Edwards, Zachary F. Meisel, Jeanmarie Perrone Journal of General Internal Medicine – first online January 16, 2018KEYFINDINGS Setting a low quantity of opioid tablets as the default option in electronic medical record prescribing orders may “nudge” clinicians to prescribe fewer opioids. When two emergency departments implemented a 10-tablet default instead of a manual entry, the proportion of 10-tablet prescriptions written more than doubled, from 20.6% to 43.3%. Conversely, 20-tablet prescriptions decreased from 22.8% to 16.1%, and prescriptions for 11-19 tablets decreased from 33.5% to 20.1%. DATA  D R I V E N . P O L I C Y  F O C U S E DBRIEFResearchLDIResearch to Improve the Nation’s Health System   2018 . No. 2COLONIAL PENN CENTER   |   3641 LOCUST WALK   |   PHILADELPHIA, PA 19104-6218   |   LDI.UPENN.EDU   |   P: 215-898-5611   |   F: 215-898-0229   |    @PENNLDILEAD AUTHORDR. M. KIT DELGADOM. Kit Delgado, MD, MS, is an Assistant Professor of Emergency Medicine and Epidemiology at Penn and a practicing trauma center emergency physician. He leads the Behavioral Science & Analytics For Injury Reduction (BeSAFIR) lab, which applies data science and behavioral economics for preventing injuries and improving trauma and emergency care. He has developed a novel line of research leveraging smartphone technology and behavioral economic interventions for injury prevention with a focus on reducing motor vehicle crashes due to distracted and alcohol-impaired driving. He is also testing behavioral economic interventions to promote opioid stewardship for acute and post-operative pain management. Finally, he conducts health services research to optimize trauma and emergency care systems. His work is funded by the National Institutes of Health, the U.S. Department of Transportation, and the Agency for Health Care Research and Quality. In addition to being an LDI Senior Fellow, he is a faculty member in the Center for Emergency Care Policy and Research, the Center for Health Incentives and Behavioral Economics, the Penn Injury Science Center, and the Children’s Hospital of Philadelphia Center for Injury Research and Prevention. He is also a member of the National Academies of Sciences, Engineering, and Medicine Committee on Accelerating Progress to Reduce Alcohol-Impaired Driving Fatalities. BRIEFResearchLDIopioid tablets prescribed did not change. But the significant shift to the default quantity, consistent with ED prescribing guidelines, suggests that this is a simple and scalable approach to change prescribing behavior while preserving clinician autonomy.  This approach could have a significant impact in “right-sizing” post-operative opioid prescriptions for acute pain, for which quantities prescribed are significantly higher and 50-70% of tablets are never taken.  This study also suggests that default options must be implemented cautiously to avoid unintended consequences. A default option should be set at the lowest baseline quantity being prescribed to avoid inadvertently encouraging some clinicians to prescribe more than before the default was set.  Second, beyond setting default quantities for specific departments and indications, health system level defaults should also be set low.  This study found that opting out of the 10-tablet default led some to select the health system default of 28 tablets, which led to a small, unintended increase of prescriptions for more than 20 tablets.  Changing defaults in EMRs have been useful in changing clinician behavior in other contexts, such as increasing the rates of prescribing generic rather than brand-name drugs in primary care.Further research is needed to evaluate the effects of implementing an opioid default option in EMRs on a larger scale, in systems with higher baseline prescription quantities, and over a longer timeframe. This research is ongoing in a newly-funded trial called REDUCE.THE STUDYThe authors used EMR data from the emergency departments of the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PMC) between October 1, 2014 and June 29, 2015.This 41-week period included data from the old EMR system that required physicians to manually enter opioid pill quantity (weeks 1-22 for HUP and 1-26 for PMC) and the new EMR system that included a preference list with the default quantity of 10 tablets displayed first (weeks 23-41 for HUP and 27-41 for PMC). In the new EMR, the clinician could “opt out” of the default by selecting a quantity of 20 tablets, which is displayed second, by modifying either of these orders, or by choosing “Database Lookup,” where a health system default of 28 tablets is displayed, as well as manual entry options.Delgado, M.K, F.S. Shofer, M.S. Patel, S. Halpern S., E. Christopher, Z.M. Meisel, J. Perrone. Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities and Prescribing Behavior in Two Emergency Departments. Journal of General Internal Medicine. 2018. doi: 10.1007/s11606-017-4286-5LDI Research Briefs are produced by LDI’s policy team. For more information please contact Janet Weiner at  weinerja@pennmedicine.upenn.edu. <10 10 1-19 20 >20QUANTITY OF TABLETS■  No default       ■  10-tablet default50403020100PERCENT OF PRESCRIPTIONS20.4%15.4%20.6%43.3%33.5%20.1%22.8%16.1%2.8%5.1%FIGURE 1.  QUANTITY OF OXY/APAP TABLETS DISPENSED BEFORE AND AFTER IMPLEMENTATION OF ED EMR DISCHARGE ORDER DEFAULT OF 10 TABLETS

Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities and Prescribing Behavior in Two Emergency Departments

Kosmopolis

University of Pennsylvania
ScholarlyCommons
Research Briefs Leonard Davis Institute of Health Economics
1-30-2018
Association between Electronic Medical Record
Implementation of Default Opioid Prescription
Quantities and Prescribing Behavior in Two
Emergency Departments
M. Kit Delgado
University of Pennsylvania
Frances S. Shofer
University of Pennsylvania
Mitesh S. Patel
University of Pennsylvania
Scott Halpern
University of Pennsylvania
Christopher Edwards
University of Pennsylvania
See next page for additional authors
Follow this and additional works at: https://repository.upenn.edu/ldi_researchbriefs
This paper is posted at ScholarlyCommons. https://repository.upenn.edu/ldi_researchbriefs/34
For more information, please contact repository@pobox.upenn.edu.
Delgado, M. Kit; Shofer, Frances S.; Patel, Mitesh S.; Halpern, Scott; Edwards, Christopher; Meisel, Zachary F.; and Perrone,
Jeanmarie. Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities and
Prescribing Behavior in Two Emergency Departments. LDI Research Briefs. 2018; No. 34. https://ldi.upenn.edu/brief/association-
between-electronic-medical-record-implementation-default-opioid-prescription
" >
https://ldi.upenn.edu/brief/association-between-electronic-medical-record-implementation-default-opioid-prescription
Association between Electronic Medical Record Implementation of
Default Opioid Prescription Quantities and Prescribing Behavior in Two
Emergency Departments
Abstract
Setting a low quantity of opioid tablets as the default option in electronic medical record prescribing orders
may “nudge” clinicians to prescribe fewer opioids. When two emergency departments implemented a
10-tablet default instead of a manual entry, the proportion of 10-tablet prescriptions written more than
doubled, from 20.6% to 43.3%. Conversely, 20-tablet prescriptions decreased from 22.8% to 16.1%, and
prescriptions for 11-19 tablets decreased from 33.5% to 20.1%.
Keywords
Opioids, opioid epidemic, prescribing, emergency department, electronic medical record, behavioral
economics, nudge
License
This work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.
Author(s)
M. Kit Delgado, Frances S. Shofer, Mitesh S. Patel, Scott Halpern, Christopher Edwards, Zachary F. Meisel,
and Jeanmarie Perrone
This brief is available at ScholarlyCommons: https://repository.upenn.edu/ldi_researchbriefs/34
THE QUESTION
The epidemic of opioid overdose deaths in the 
US has its roots in prescription opioids. Patients 
who receive a prescription for a large quantity 
of opioids, especially those new to opioids, are 
at risk for long-term use or for having leftover 
tablets that are later misused or abused. 
Patients often receive 30 or more opioid 
tablets for acute pain, despite current opioid 
prescribing guidelines recommending only a 
fraction of that quantity (10-12 tablets). Default 
options, or pre-set selections, in electronic 
medical records (EMRs) can influence behavior 
in other contexts, and may be a way to guide 
clinicians toward prescribing smaller quantities 
of opioid tablets. 
In 2015, two Penn Medicine emergency 
departments (EDs) implemented a new EMR 
that featured a default setting of 10 opioid 
tablets, replacing one that required the clinician 
to enter the number of tablets manually. The 
authors compared weekly prescribing patterns 
before and after the 10-tablet default by 
tracking the quantity of tablets supplied at 
discharge for the most commonly prescribed 
opioid, oxycodone with acetaminophen (Oxy/
APAP). 
THE FINDINGS
During a 41-week period, patients received 
3,264 prescriptions for Oxy/APAP across 
the two EDs. The average number of tablets 
prescribed remained the same after the default 
option was implemented, but the median 
number per prescription decreased slightly from 
a low baseline of 11.3 to 10 in one ED and from 
12.6 to 10.9 in the other.
However, the proportion of prescriptions 
written for the default option of 10 tablets 
more than doubled from 20.6% pre-default to 
43.3% post-default (Figure 1). Conversely, the 
proportion of prescriptions written for 20 tablets 
(displayed second in the EMR) decreased 
from 22.8% to 16.1%, and prescriptions for 11-19 
tablets decreased from 33.5% to 20.1%. 
An unintended consequence of the default 
option was that the proportion of prescriptions 
written for fewer than 10 tablets decreased from 
20.4% to 15.4%. Additionally, the proportion of 
prescriptions written for more than 20 tablets 
increased slightly, from 2.8% to 5.1%, half of 
which were for 28 tablets (the health system-
wide default if the clinician clicked on “Database 
Lookup” in the new EMR).
THE IMPLICATIONS
This study suggests that default options in the 
EMR are a powerful, low-cost tool to nudge 
clinicians to prescribe fewer opioids. Because 
baseline prescription quantities were already 
low in the two EDs, the overall number of 
ASSOCIATION BETWEEN ELECTRONIC MEDICAL 
RECORD IMPLEMENTATION OF DEFAULT OPIOID 
PRESCRIPTION QUANTITIES AND PRESCRIBING 
BEHAVIOR IN TWO EMERGENCY DEPARTMENTS 
M. Kit Delgado, Frances S. Shofer, Mitesh S. Patel, Scott Halpern, Christopher Edwards, Zachary F. Meisel, Jeanmarie Perrone 
Journal of General Internal Medicine – first online January 16, 2018
KEYFINDINGS 
Setting a low quantity of opioid tablets as the default option in electronic medical record prescribing orders may “nudge” 
clinicians to prescribe fewer opioids. When two emergency departments implemented a 10-tablet default instead of a manual 
entry, the proportion of 10-tablet prescriptions written more than doubled, from 20.6% to 43.3%. Conversely, 20-tablet 
prescriptions decreased from 22.8% to 16.1%, and prescriptions for 11-19 tablets decreased from 33.5% to 20.1%. 
DATA  D R I V E N . P O L I C Y  F O C U S E D
BRIEFResearchLDI
Research to Improve the Nation’s Health System   2018 . No. 2
COLONIAL PENN CENTER   |   3641 LOCUST WALK   |   PHILADELPHIA, PA 19104-6218   |   LDI.UPENN.EDU   |   P: 215-898-5611   |   F: 215-898-0229   |    @PENNLDI
LEAD AUTHOR
DR. M. KIT DELGADO
M. Kit Delgado, MD, MS, is an Assistant Professor of Emergency Medicine and Epidemiology at Penn and a practicing trauma center 
emergency physician. He leads the Behavioral Science & Analytics For Injury Reduction (BeSAFIR) lab, which applies data science and 
behavioral economics for preventing injuries and improving trauma and emergency care. He has developed a novel line of research 
leveraging smartphone technology and behavioral economic interventions for injury prevention with a focus on reducing motor vehicle 
crashes due to distracted and alcohol-impaired driving. He is also testing behavioral economic interventions to promote opioid stewardship 
for acute and post-operative pain management. Finally, he conducts health services research to optimize trauma and emergency care 
systems. His work is funded by the National Institutes of Health, the U.S. Department of Transportation, and the Agency for Health Care 
Research and Quality. In addition to being an LDI Senior Fellow, he is a faculty member in the Center for Emergency Care Policy and 
Research, the Center for Health Incentives and Behavioral Economics, the Penn Injury Science Center, and the Children’s Hospital of 
Philadelphia Center for Injury Research and Prevention. He is also a member of the National Academies of Sciences, Engineering, and 
Medicine Committee on Accelerating Progress to Reduce Alcohol-Impaired Driving Fatalities. 
BRIEFResearchLDI
opioid tablets prescribed did not change. But 
the significant shift to the default quantity, 
consistent with ED prescribing guidelines, 
suggests that this is a simple and scalable 
approach to change prescribing behavior while 
preserving clinician autonomy.  This approach 
could have a significant impact in “right-sizing” 
post-operative opioid prescriptions for acute 
pain, for which quantities prescribed are 
significantly higher and 50-70% of tablets are 
never taken.  
This study also suggests that default options 
must be implemented cautiously to avoid 
unintended consequences. A default option 
should be set at the lowest baseline quantity 
being prescribed to avoid inadvertently 
encouraging some clinicians to prescribe more 
than before the default was set.  Second, 
beyond setting default quantities for specific 
departments and indications, health system level 
defaults should also be set low.  This study found 
that opting out of the 10-tablet default led some 
to select the health system default of 28 tablets, 
which led to a small, unintended increase of 
prescriptions for more than 20 tablets.  
Changing defaults in EMRs have been useful 
in changing clinician behavior in other contexts, 
such as increasing the rates of prescribing 
generic rather than brand-name drugs in 
primary care.
Further research is needed to evaluate the 
effects of implementing an opioid default 
option in EMRs on a larger scale, in systems 
with higher baseline prescription quantities, 
and over a longer timeframe. This research 
is ongoing in a newly-funded trial called 
REDUCE.
THE STUDY
The authors used EMR data from the 
emergency departments of the Hospital of the 
University of Pennsylvania (HUP) and Penn 
Presbyterian Medical Center (PMC) between 
October 1, 2014 and June 29, 2015.
This 41-week period included data from the 
old EMR system that required physicians to 
manually enter opioid pill quantity (weeks 1-22 
for HUP and 1-26 for PMC) and the new EMR 
system that included a preference list with the 
default quantity of 10 tablets displayed first 
(weeks 23-41 for HUP and 27-41 for PMC). In 
the new EMR, the clinician could “opt out” of 
the default by selecting a quantity of 20 tablets, 
which is displayed second, by modifying either 
of these orders, or by choosing “Database 
Lookup,” where a health system default of 28 
tablets is displayed, as well as manual entry 
options.
Delgado, M.K, F.S. Shofer, M.S. Patel, S. 
Halpern S., E. Christopher, Z.M. Meisel, J. 
Perrone. Association between Electronic 
Medical Record Implementation of Default 
Opioid Prescription Quantities and 
Prescribing Behavior in Two Emergency 
Departments. Journal of General Internal 
Medicine. 2018. doi: 10.1007/s11606-017-4286-5
LDI Research Briefs are produced by 
LDI’s policy team. For more information 
please contact Janet Weiner at  
weinerja@pennmedicine.upenn.edu.
 <10 10 1-19 20 >20
QUANTITY OF TABLETS
■  No default       ■  10-tablet default
50
40
30
20
10
0
PE
RC
EN
T 
O
F 
PR
ES
CR
IP
TI
O
N
S
20.4%
15.4%
20.6%
43.3%
33.5%
20.1%
22.8%
16.1%
2.8%
5.1%
FIGURE 1.  QUANTITY OF OXY/APAP TABLETS DISPENSED BEFORE AND AFTER 
IMPLEMENTATION OF ED EMR DISCHARGE ORDER DEFAULT OF 10 TABLETS


https://repository.upenn.edu/cgi/viewcontent.cgi?article=1034&amp;context=ldi_researchbriefs

Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities and Prescribing Behavior in Two Emergency Departments

Abstract

Similar works

Full text

Available Versions

ScholarlyCommons@Penn

Kosmopolis