Now that patients have been selected for the program and risk stratiﬁed, creation and maintenance of a master list is critical to ensure that UDT is happening at a rate corresponding to that risk…
Creation and maintenance of a master list for patients in the HARMS Program is important because it will dictate who is getting selected for UDT and how frequently. The master list keeps track of all the patients in the program, including each patient’s assigned risk category. The list will be used to randomly select patients for UDT. At our clinic, we keep track of patients in an Excel spreadsheet on a password-protected computer. This spreadsheet is also able to randomly select patients at the appropriate frequency and organize names into a user-friendly manner for the booking staff to book UDT appointments.
The master list is a living document with patient names being added and removed as they enter and exit the program, and risk categories being updated. Patients that have failed to provide UDT despite being selected are kept on a “recall” list in this document to ensure they don’t fall through the cracks. Keeping this one document updated ensures that appropriate patients are getting booked for UDT, and inappropriate patients (like those who have left the program and are no longer on opioids) are not.
By the time of master list creation, the patient lists initially generated by the EMR query have been evaluated and trimmed by the physicians, with risk estimates assigned to each patient. Initial master list creation is most easily done by taking these completed lists of names and risk categories from each physician and simply entering them into a common spreadsheet such as this one. The risk category can be selected from the drop-down menu. Note that Level 1 and 2 are both considered low risk and for the purposes of randomization make no difference (the only difference is in the opioid dispensing interval). The Recall List is organized on its own tab at the bottom. The Recall List keeps track of patients that despite being randomized are not providing a UDT for whatever reason (see Chapter 5). For details on how to use the spreadsheet to randomize patients for UDT, see Chapter 4. When first opening the Excel spreadsheet, you may get a “SECURITY WARNING: Macros have been disabled” message. Simply click “Enable Content” which allows the formulae we have designed into it to be functional.
Once the initial list is created, several situations will arise:
Adding a patient: for new patients, add the patient name at the bottom of the list and select the appropriate risk category from the drop-down menu.
Removing a patient: when a patient is removed from the program simply delete his/her row. The message to remove the patient from HARMS should only be conveyed to you by the prescribing physician. If a patient claims they are no longer on opioids when being phoned for a UDT, verify with the prescriber before removing the name. In our experience, it is not uncommon that patients come off of opioids and the physician is either unaware, or forgets to notify the administrator to remove.
General maintenance: once per year, consider routing a list of patients in the program to their MRP. This gives physicians a chance to remove names that shouldn’t be there. You also may consider using an EMR query on a yearly basis to detect patients that should be in the program who are not (similar to the strategy used in Chapter 1). At our clinic, we felt this yearly EMR query was low-yield since it has been engrained in all of the physicians to reflexively add any new patients on opioids to the program.
Depending on the clinic preference, you may consider having an agreed-upon place in the chart where a patient’s enrollment status and risk level can be found. This makes it easy for anyone looking at the chart, to know if the patient is already enrolled in HARMS, and to refill an opioid prescription. In our OSCAR EMR, we write a single line under the “Reminders” section that says HARMS Program and a risk level. To make this process as streamlined as possible, the physician messages the administrator a risk level “HARMS, Level 3” when adding a new patient to the program and the administrator then adds the patient to the master list, and writes the line under the Reminders section. Likewise, when removing a patient, the physician messages the administrator who then takes the patient off the master list and removes the note in the Reminders section. We have heard of other clinics adopting HARMS and creating their own toolbars to organize all of this information (and more) automatically. You may contact Joyce Stansell, Quality Improvement Decision Support Specialist for numerous Northern Ontario Family Health Teams, at . Joyce would be happy to share the HARMS Program tools they have created in Nipigon for PS Suite. For a handout on the tools they have developed to simplify the HARMS Program for Telus PSS, see www.harmsprogram.ca/TelusPSS.
- The master list is where all of the HARMS Program patient information is organized that will dictate who is randomized for UDT and how often. It can also be seen as the interface between clinicians and administration, so it’s important that clinicians update administrators when changes need to be made, and administrators notify clinicians when concerns arise (ie. patient says they are no longer on opioids, or not providing UDT - see Appendix II).
- Consider using our spreadsheet to keep track of patients and to randomize them in a user-friendly manner at a rate concordant with their risk category.
- If using TelusPSS EMR, then consider utilizing the HARMS Program toolbars developed by our colleagues in Nipigon.
Now that we have a patient master list, the next step will be selecting patients for UDT…