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

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).

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).

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 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.