Even as there becomes greater acceptance of the need for interoperability across domains and disciplines in order to address serious social problems such as the opioid epidemic, cultural challenges remain as major obstacles to the practical implementation of this concept.
One clear case study revealing the obstacles to interoperability can be found in the debate over access to prescription drug monitoring program data. All states but one now have an automated system in place to record the prescription of controlled substances such as the opioids that have been prescribed for pain management. The road to passing state laws enabling Prescription Drug Monitoring Programs(PDMP) and systems has been arduous, and states have reached different conclusions about who in the state should have access to these systems. The contentiousness comes from the fact that these systems contain the identity of the patient as well as that of the prescriber and there are strong feelings about the potential for an invasion of privacy in granting access to this personally identifying information.
As a result of the concerns, and with initial opposition in many states from health care providers, the laws have emerged with different calls on who controls access. The various state PDMP systems are managed and controlled in some states by law enforcement, in others by the state pharmacy board, or by substance abuse authorities. Typically, these disparate disciplines can all get to the data in the system to do their job, but in many cases the cross-disciplinary access is difficult. For example, in many states where the PDMP is managed outside of law enforcement, it is necessary for police to obtain a warrant to see individual patient records and police are prohibited from searching the PDMP database for drug diversion or doctor-shopping activities.
The consternation about access to the PDMP records has come to the fore in Michigan, where legislation has been introduced to allow the state police to have real-time access to the PDMP system under certain limitations, as reported by Carol Thompson in the Lansing State Journal. Thompson quotes mental health advocates as expressing concern that anyone (implying police) could have access to patient identification, the prescriptions they are given and other personal data and that such access could be used for purposes other than patient care. Police argue that real time full access to the data could help them spot illegal activities including fraudulent prescribing, doctors and pharmacists who are violating the controlled substance restrictions, and most importantly to disrupt the illicit drug distribution networks.
Just about every major set of informed strategies for dealing with the opioid crisis proposes that interoperability is at the heart of developing the kind of collaboration across disciplines that will be necessary to make significant progress in fighting this epidemic. Yet as the Michigan debate shows, there is a cultural predisposition in individual disciplines to distrust other disciplines in the way that they might use the data for fulfilling their own mission. Mental health providers don’t want to trust the police to refrain from using the data just for arresting drug users. Police believe that the PDMP systems should support their drug interdiction activities and detect drug diversion and doctor malfeasance.
It is not likely that a resolution of this conflict will be easily found as long as the separate cultures are singularly focused on their own mission interests and do not recognize the larger objectives that cross domain lines. Too much of the discussion over the past decade has been focused on the systems and technology for building PDMPs rather than on the policy for using the data that they may contain. Concentrating the dialog on the specific data elements that should be in the PDMP system and on the access rules in the absence of a sound public policy about using the data will never resolve this issue to the satisfaction of all stakeholders.
A balanced public policy on the use of the data would take into account the ways in which the data can be legitimately used in support of organizational objectives while limiting the secondary use for purposes that are not in the public interest. This is a fundamental policy challenge, and it will take careful study and conversations that engage all relevant stakeholders and the reasoning of thoughtful decisionmakers that understand the principles of privacy and civil liberties as well as the operational support requirements for the various domains.
In the final analysis, the only way in which this obstacle to interoperability will be overcome is for the various stakeholders to learn to trust each other, at least enough to define a useful common ground on this issue. It will only happen with extensive dialog and full respect for the needs of all potential data collectors and users. Government agencies and NGO’s can help most by convening these kinds of collaborative discussions and helping the practitioner communities find useful and helpful outcomes.
Paul Wormeli
December 27, 2018