Themes and Example Quotes from Clinicians and Leaders
| Theme | Quotes |
|---|---|
| Theme 1: Although they accept responsibility for managing OUD, most PCCs perceive OUD risk conversations as difficult and prefer to minimize (1) the number of patients on their panels with OUD risk and (2) conversations with them, especially in the absence of a trusted relationship. | The initial feeling before they saw the [Opioid CDS] material was that it didn't feel like something that they were totally clamoring for, but they understood the utility of it… People said, “This is not something I want to take on. Even if I was able to do it, I wouldn't seek it out because I don't feel comfortable with that as part of my practice. I don't feel like I want that to be part of my practice.” (Clinic Leader #591) |
| I think it's to start with, not wanting the conversation [about opioids]. We have our own patients now that we cannot-- well, some, of course, were able to taper their medications, but I think for the most part, the doctors here do a lot of screening not to add chronic pain patients to their panel. (Clinic Leader #449) | |
| I hate to say it, that while I don't minimize the importance or the gravity of opioids and why we need to be thinking about this, but I'm fighting the fights that I need to fight, and that is not my fight, with regard to that patient. (PCC #793) | |
| If it starts out as, “I'm treating my pain,” because usually it's been a prescription. It started out as a prescription and then this was okay, but just use escalated or they were misusing it or needing early refills or whatever. Yeah. It seems like that's when people get angry because that's when they can feel like they're being labeled as something that maybe they're not. (PCC #501) | |
| But if I've got a long time patient who's known me, who trusts me, and I tell them this is what I really believe, and I've been telling them what I believe for 15 years, and they believe what I believe, it's easier than somebody who shows up on my schedule that I've never met before, who just says, “I just want my pain medication.” And I say, “Well, you're taking way too much, and this seems like a problem,” and this and that and the other thing. And we always get off on the wrong foot. So those are not fulfilling conversations no matter what. (Clinic Leader #591) | |
| Theme 2: PCCs are enthusiastic about a CDS tool that addresses a topic that they are interested in treating (cardiovascular risk), but they lack interest and enthusiasm in treating OUD and have fewer patients who might benefit. | The docs find [the CV-CDS] incredibly useful. Yeah, we really like that one. … that has been a wonderful tool and a really strong convincer for patients to get behind some treatments that are good for them. So, yeah, that one we actually use pretty aggressively, I think. (Clinic Leader #591) |
| For the [CV-CDS], I think we've been pushing doctors to do it. There's a central push to have everyone get measured. Everyone gets measured. And we do that on a monthly basis at the most, and maybe at least quarterly, to look at individually how their printing rates have been. …It gives a better idea on how our management is, how we could improve it, and of course, as I mentioned, the volume of patients that we see-- diabetes, cardiovascular, hypertension. Very interesting. Versus narcotics, pain meds, pain patients. There's not an interest to take care of those patients. (Clinic Leader #449) | |
| I guess I don't interact with it a ton because I maybe have one or two patients that I'm filling [opioids] for at this stage. (Clinic Leader #327) | |
| I have not heard-- usually, typically, any concerns with a tool like that will rise up to either the clinic medical director or to myself. I've not heard anything. And typically, our clinic medical director would share with me. So, I don't think there are any concerns. I haven't heard from anyone that it's inaccurate. I haven't heard from anyone that links didn't work or anything like that.(Clinic Leader #642) | |
| I think there are some clinicians that I just don't think really want to use any type of resources. They just want it to be like, ‘This is how I prescribe, and I'm done.’ And that's kind of consistently what we've seen in his practice. (Clinic Leader #528). | |
| Theme 3: Several contextual problems related to primary care settings impact the PCC’s ability to manage OUD, including time constraints, burnout, and few waivered colleagues. | One of the problems that we've run into over the last two, three years with COVID, the pandemic, with the massive amounts of staff shortages that we've had, I would say that every clinic we have gone into kind of a crisis mode. …What it means is that we have a workforce that is extraordinarily stretched thin, both because we lack the numbers of people we need, and then in addition to that, we lack the staff. …As this has happened, we're now having increasing amounts of burnout and lack of staff resiliency. Then the idea of coming in and training, like, “Here's something new,” that is a problem as well. (Clinic Leader #950) |
| I mean, with any initiative we're faced with, the understanding is, ‘yeah, this sounds like a great idea, and this is good for our patients’ and that sort of thing. There isn't an argument that it isn't something that should be medically useful. The problem is that there is a limited amount of us, and it is difficult to have those conversations at any time about narcotic use and so on. … I think the perception I got was, ‘this feels like another thing we have to do’ versus ‘this is a support that is good for us and our patients.’ It felt like more of an imposition than a support. And that is rough to combat because nobody is looking for more things to do than they've got to do right now. (Clinic Leader #591) | |
| If the [CDS] will save clinicians time, eventually we can get buy-in. If it will improve health and not save time, eventually we'll get buy-in. It's going to be a little bit of time. If it's going to be just a little bit of extra time, but it's going to significantly improve patient health, that-- in a better world, it would get done. But in this world, it's not happening. So the, “Hey, it's going to help patients--” Because we are getting bombarded with, “It's just one more thing. It's just five clicks.” But this is years ago when I wasn't a leader. My leader at that time came to me and said, “Hey, [NAME], it's just one more thing. It should take less than 30 seconds.” And I said, “I counted how many things take 30 seconds that we've added in the past 10 years. I counted them, and it comes to 16 minutes, and I have a 20-minute visit. So, these ‘just one more things’ have now taken 16 minutes of my 20-minute visit. (Clinic Leader #950) | |
| I think the timing may be a factor for some, but not the main reason. I think we can make time if we think it's important. But it's something that we'd like to not spend a lot of time whatever for. We just feel like we have to do other things instead. (Clinic Leader #449) | |
| I have a Suboxone waiver. It's just that I don't use it as often. And it's just not practical because our clinic does not have any other-- well, at least as of the last few months we didn't have any provider who could back me up. So, if, in my absence, somebody needed Suboxone, that would just create a whole lot of chaos in the clinic. I had to back away from prescribing Suboxone altogether. (PCC #324) | |
| Theme 4: For clinicians to use a CDS (for any problem), it needs to be highly visible, be simple to use, save time, and add value to care. | I didn't feel like [the CDS] was too many clicks. [For me], it was just kind of like, “Okay. Where do I find that again?” And so, I think it's maybe that functionality. Whereas when it's printed, it's right there in front of you. (Clinic Leader #528) |
| I feel like the [CDS] tool is almost hidden. I really have to go searching for it in the [EHR], in general. It could be just even about A1C or CV risk or whatever, so not just Opioid [CDS]. But it's harder for me to get at. It feels like it's kind of buried in there for some reason. And so that, to me, seems like it's maybe the biggest hindrance, or it was for me. (PCC #501) | |
| The rule of thumb for anything [EHR]-based is the fewer clicks, the better. And so obviously keep it simple. We don't want to have endless popping-up windows and hard stops and things like that. And so, if you want this to be a tool of great utility and more frequent use, keeping it as streamlined as possible. Obviously, you have to cover certain things, but the more questions you have to address, the more of a detour it seems to be from, perhaps, the main or even secondary agenda of a very time-based encounter. I think the less you're going to see people want to stay engaged with it. (PCC #793) | |
| I think part of it is I would say forgetfulness, right, that we have a really useful tool. So, I think that kind of bringing it to the forefront of our mind, that reminder of utilizing it, it would be helpful. (Clinic Leader #591) | |
| I feel that it's not being used appropriately or properly because of lack of awareness in the first place. (PCC #324) | |
| Theme 5: The values of an opioid CDS for non-waivered PCCs are in identifying and screening those at risk, facilitating referrals, and having access to patient and clinician resources on opioid use best practices. | We want things that are going to help our patients, and we want things that are going to make our lives more efficient. (PCC #324) |
| One thing with the [CDS] is you can tell as a feedback [sic] if you're doing a good job treating your patients. So, there's a lot of reinforcements there… But, for the most part, our doctors feel that they're doing something good for the patient and for themselves. (PCC #449) | |
| I think the [CDS] will be helpful in that regard to, maybe, have more of a metric, if you will, that a person can look at with me—a patient can look at with me to say, “Here's why I'm wanting to have more of a conversation about this.” …There's a scale there that you have to respect and honor, and it's all about appropriateness. (PCC #793) | |
| That was really a good tool, especially for those who would be prescribing Suboxone. So right now, I am not, and I don't think I would in the near future, at least” (Clinic Leader #396) | |
| If you're Suboxone waivered or not—and we have two of our providers who are Suboxone waivered, so I do know they utilize it a lot more. I connected with one of our [physician assistants] who is Suboxone waivered, and she said it's a tool that she uses multiple times a day. Some of the clinicians here that really don't do a lot of, I would say, any opiate management-- not necessarily than that. More so, they're just not necessarily maybe screening for a risk in these patients. They don't use it as much. (Clinic Leader #528) | |
| I mean, I think that that's where the clinician has to kind of utilize both their clinical judgment and the tool. And if they have suspicions that that may be an issue, that tool may help them kind of have that hard conversation with the patient. People can kind of get stuck in their ways of, well, this is what I've always prescribed, and maybe I've overlooked some of these red flags. And so I think it could be a good way for them to have those difficult conversations with patients. (Clinic Leader #327) | |
| Having access to a list of resources, if we can kind of get sort of a menu of options, as to who are the people who are there to help us out in this journey. …Then, having access to resources for people who test positive is key, because many of these people find it difficult to get access to either a pain specialist or a buprenorphine provider or somewhere they can get the right kind of treatment. (PCC #324) |
Abbreviations: CV-CDS, cardiovascular risk reduction; CDS, clinical decision support; PCCs, primary care clinicians; OUD, opioid use disorder.