ATTACHMENT 24 - Opioid Non Cancer Pain Mgt_CDS Content White Paper_2018-12-18.pdf

Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-

Compliant Knowledge Artifacts (KNARTs)

Mental Health: Opioids and Chronic Noncancer Pain Clinical Content White Paper

Department of Veterans Affairs (VA)

Knowledge Based Systems (KBS)

Office of Informatics and Information Governance (OIIG)

Revision Table

Date Revision Description Author

June 2018 1.0 Document submitted by B3 B3, KBS team, VA clinical SMEs

12/20/18 2.0 Document approved by VA clinical leadership

Linda, VA clinical leadership n/a 3.0 Document published by CDS Connect

CDS Connect, KBS team, Pivotal

Clinical Decision Support (CDS) Content and Health Level 7 (HL7)-Compliant Knowledge Artifacts (KNARTs): Mental Health:

Opioids and Chronic Noncancer Pain Clinical Content White Paper by Department of Veterans Affairs (VA)

Publication date June 2018 Copyright © 2018 B3 Group, Inc.

Copyright © 2018 Cognitive Medical Systems, Inc.

B3 Group, Inc.

NOTICE OF GOVERNMENT COPYRIGHT LICENSE AND UNLIMITED RIGHTS LICENSE

Licensed under the Apache License, Version 2.0 (the "License"); you may not use this file except in compliance with the License.

You may obtain a copy of the License at http://www.apache.org/licenses/LICENSE-2.0 Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.

See the License for the specific language governing permissions and limitations under the License.

Portions of this content are derivative works from content produced by Cognitive Medical Systems, Inc. licensed under the Apache License, Version 2.0.

Additional portions of this content are derivative works from content contributed by Motive Medical Intelligence Inc., under Creative Commons Attribution-ShareAlike 4.0.

Contributions from 2013-2018 were performed either by US Government employees, or under US Veterans Health Administration contracts.

US Veterans Health Administration contributions by government employees are work of the U.S. Government and are not subject to copyright protection in the United States. Portions contributed by government employees are USGovWork (17USC §105). Not subject to copyright.

See: https://www.usa.gov/government-works Contribution by contractors to the US Veterans Health Administration during this period are contractually contributed under the Apache License, Version 2.0 and US Government sponsorship is acknowledged under Contract VA118-16-D-1008, Task Order VA11817F10080007.

Cognitive Medical Systems, Inc.

Licensed under the Apache License, Version 2.0 (the "License"); you may not use this file except in compliance with the License.

You may obtain a copy of the License at http://www.apache.org/licenses/LICENSE-2.0 Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.

See the License for the specific language governing permissions and limitations under the License.

This and related content produced by Cognitive Medical Systems, Inc. licensed under the Apache License, Version

2.0 is available at: https://bitbucket.org/cogmedsys/hl7-kas-examples Additional portions of this content are derivative works from content contributed by Motive Medical Intelligence Inc., under Creative Commons Attribution-ShareAlike 4.0. https://bitbucket.org/cogmedsys/kas-source-material Contributions from 2013-2018 were performed either by US Government employees, or under US Veterans Health Administration contracts.

US Veterans Health Administration contributions by government employees are work of the U.S. Government and are not subject to copyright protection in the United States. Portions contributed by government employees are USGovWork (17USC §105). Not subject to copyright. See: https://www.usa.gov/government-works Contribution by contractors to the US Veterans Health Administration during this period are contractually contributed under the Apache License, Version 2.0 and US Government sponsorship is acknowledged under Contract VA118-16-D-1008-0007.

Contract: VA118-16-D-1008, Task Order (TO): VA-118-16-F-1008-0007

Table 1. Relevant KNART Information: Mental Health: Opioids and Chronic Noncancer Pain KNARTs

Mental Health KNART Associated CLIN Opioids and Chronic Noncancer Pain OTRR/STORM Query – Documentation Template

CLIN0009BA

Chronic Noncancer Pain – Documentation Template CLIN0009DA Chronic Noncancer Pain – Order Set CLIN0008BA v

Table of Contents VA Subject Matter Expert (SME) Panel ........................................................................................................ viii

VA Knowledge Based Systems (KBS) Office Project Contributors .................................................................. ix

Contributing Contractors ................................................................................................................................. ix Introduction...................................................................................................................................................... x

Conventions Used ........................................................................................................................................... xi Chapter 1. Mental Health: Opioids and Noncancer Pain

1.1. Clinical Context

1.2. Knowledge Artifacts

Chapter 2. Documentation Template: Mental Health - Opioids and Chronic Noncancer Pain OTTR/STORM Query

2.1. Knowledge Narrative

2.2. Opioid Therapy Risk Report (OTTR) Query

2.3. Stratification Tool for Opioid Risk Mitigation (STORM) Query

Chapter 3. Documentation Template: Mental Health – Chronic Noncancer Pain

3.1. Knowledge Narrative

3.2. Visit Information

3.3. Physical Exam

3.4. Pain Description

3.5. Relevant Vitals

3.6. Relevant Laboratory Values

3.7. Medication Profile

3.8. Nonpharmacologic treatment

3.9. Patient Education

3.10. Activities of Daily Living

3.11. Affect/Mood

3.12. Risk Mitigation Strategies

3.13. Assessment

3.14. Plan

Chapter 4. Order Set: Mental Health – Chronic Noncancer Pain

4.1. Knowledge Narrative

4.2. Medications

4.3. Laboratory Tests

4.4. Consults and Referrals

4.5. Patient and Caregiver Education

Bibliography/Evidence

Appendix A. Existing Sample VA Artifacts Appendix B – Basic Laboratory Panel Definition

Acronyms/Abbreviations

Content and Health Level 7 (HL7)-

Compliant Knowledge Artifacts (KNARTs) vi vii

List of Tables

1. Relevant KNART Information - Mental Health: Opioids and Chronic Noncancer Pain White Paper CCWP........................................................................................................................................... iii

2. VA Subject Matter Expert (SME) Panel ...................................................................................... vi

1.1. Clinical Context Domains

viii

VA Subject Matter Expert (SME) Panel

Table 2. VA Subject Matter Expert (SME) Panel

Name Title Project Role Ilene Robeck, MD Chair of the National VA PACT Pain Champions Initiative and

Director of Virtual Pain Care Richmond VA Medical Center (VAMC) Richmond, VA

SME, Primary

Jodie Trafton, PhD Director, VA Program Evaluation and Resource Center VA Palo Alto Health Care System Menlo Park, CA

SME,

Secondary

Friedhelm Sandbrink, MD

Acting Director of Pain Management Program Office Department of VA Washington, DC

SME,

Secondary

Elizabeth Oliva, PhD VA National Opioid Overdose Education & Naloxone Distribution (OEND) Coordinator VA Palo Alto Health Care System Menlo Park, CA

SME

Eleanor Lewis, PhD Deputy Director, VA Program Evaluation and Resource Center VA Palo Alto Health Care System Menlo Park, CA

SME

Kendall Browne, MD Clinical Psychologist Seattle Puget Sound Health Care System Seattle, WA

SME

Alicia Heapy, MD Mental Health VA New England Healthcare System West Haven, CT

SME

Karen Drexler, MD National Mental Health Program Director -Substance Use Disorders VA Central Office Atlanta, GA

SME

Andrew Saxon, MD Physician Seattle Health Care System Seattle, WA

SME

Henri Roca, MD Co-Chair UAMS, Leadership and Education Program for Students in Integrative Medicine Central Arkansas Veterans Healthcare North Little Rock, AR

SME

Melissa Christopher, PharmD

National Director, Academic Detailing VACO Pharmacy Benefits Management (PBM) Mission Valley Annex VISN 22 San Diego, CA

SME

Lucille Burgo Firm Chief, Primary Care VA New England Healthcare System West Haven, CT

SME

Julianne Himstreet, PharmD

Pharmacist Eugene, OR

SME

VA Subject Matter Expert (SME) Panel ix

VA Knowledge Based Systems (KBS) Office Project Contributors

Contributing Contractors

Team Contractors Project Contract Team (Contract Number VA-118- 16-F-1008-0007)

B3 Group, Inc. (Prime) Cognitive Medical Systems (Sub) Motive Medical Intelligence Inc., (Sub)

KBS Terminology Team Contract Terminology Support

JP Systems, Inc. (Prime) Deloitte Touche, LLP (Sub)

KBS Program Management Contract Support SAMS, Inc. (Prime) Pivotal Insight, LLC (Sub)

KBS Team Team Members Clinical Decision Support Diane Montella, MD; Apurva Desai, LL.M, M.S., PMP; David Douglas, MD; Jorge Ferrer, MD, MBA, LSA; Elena Smyly, PMP; Catherine Staes, RN, MPH, PhD; Linda Wedemeyer, MD, RN, MS; Scott Wood, PhD

Informatics Architecture Keith Campbell, MD; Stephanie Klepacki Terminology Michael Lincoln, MD; Catherine Hoang, MS, RN; Cecelia Bowen, MBA, RHIA; Sarita Keni, MD; John Kilbourne, MD; Melanie Loucks, MA;

Sarah Maulden, MD, MS; Holler Miller, MS, BSN; Loren Stevenson, MD;

Brenda Washington x

Introduction

The VA is committed to improving the ability of clinicians to provide care for patients while increasing quality, safety, and efficiency. Recognizing the importance of standardizing clinical knowledge in support of this goal, VA is implementing the Health Level 7 (HL7) Knowledge Artifact Specification for a wide range of VA clinical use cases. Knowledge Artifacts, referred to as (KNARTs), enable the structuring and encoding of clinical knowledge so the knowledge can be integrated with electronic health records to enable clinical decision support.

The purpose of this Clinical Content White Paper (CCWP) is to capture the clinical context and intent of KNART use cases in sufficient detail to provide the KNART authoring team with the clinical source material to construct the corresponding knowledge artifacts using the HL7 Knowledge Artifact Specification. This paper has been developed using material from a variety of sources: VA artifacts, clinical practice guidelines, evidence in the body of medical literature, and clinical expertise. After reviewing these sources, the material has been synthesized and harmonized under the guidance of VA subject matter experts to reflect clinical intent for this use case.

Unless otherwise noted, items within this white paper (e.g., documentation template fields, orderable items, etc.)

are chosen to reflect the clinical intent at the time of creation. To provide an exhaustive list of all possible items and their variations is beyond the scope of this work.

xi

Conventions Used

Conventions used within the knowledge artifact descriptions include:

<obtain>: Indicates a prompt to obtain the information listed

• If possible, the requested information should be obtained from the underlying system(s). Otherwise, prompting the user for information may be required

• The technical and clinical notes associated with a section should be consulted for specific constraints on the information (e.g., time-frame, patient interview, etc.)

• Default Values: Unless otherwise noted, <obtain> indicates to obtain the most recent observation. It is recognized that this default time-frame value may be altered by future implementations

[...]: Square brackets enclose explanatory text that indicates some action on the part of the clinical user, or general guidance to the clinical or technical teams. Examples include, but are not limited to:

[Begin ...], [End ...]: Indicates the start and end of specific areas to clearly delineate them for technical purposes.

[Activate ...]: Initiates another knowledge artifact or knowledge artifact section.

[Section Prompt: ...]: If this section is applicable, then the following prompt should be displayed to the user.

[Section Selection Behavior: ...]: Indicates technical constraints or considerations for the selection of items within the section.

[Attach: ...]: Indicates that the specified item should be attached to the documentation template if available.

[Link: ...]: Indicates that rather than attaching an item, a link should be included in the documentation template.

[Clinical Comment: ...]: Indicates clinical rationale or guidance.

[Technical Note: ...]: Indicates technical considerations or notes.

[If ...]: Indicates the beginning of a conditional section.

[Else, ...]: Indicates the beginning of the alternative branch of a conditional section.

[End if ...]: Indicates the end of a conditional section.

☐: Indicates items that should be selected based upon the section selection behavior.

Chapter 1. Mental Health: Opioids and Noncancer Pain

1.1. Clinical Context

[Begin Clinical Context.]

Opioid use is widespread in the United States, with a prevalence that is increasingly described as epidemic.

Opioid use and misuse are particularly prevalent among veterans, many of whom suffer from chronic pain secondary to service-related injuries and mental health problems, as well as opioid-related substance use disorders, with opioid-related morbidity and mortality that have increased in tandem with growing rates of prescriptions for opioid medications [VA/Department of Defense (DoD), 2017]. In addition to the addictive potential of opioids and the risk of overdose, the problem of widespread opioid use is further compounded by the limited benefit of opioids in managing chronic pain and the adverse events associated with long-term opioid use. The development and use of the Stratification Tool for Opioid Risk Mitigation (STORM) and the Opioid Therapy Risk Report (OTRR) have provided VA with instruments for predicting and managing risk associated with the use of opioids in the veteran population (STORM: Patient Detail Dashboard: Stratification Tool for Opioid Risk Mitigation; Opioid Therapy Risk Report patient details). Ongoing work within VA Pharmacy Benefits Management (PBM) Services has the potential to further support and advance efforts in this area by defining a standardized approach for documenting findings and planning information related to veterans’ pain, function, and needs (PBM CPPO pain PhARMD template: frequently asked questions). Additional work is needed to structure this foundational documentation template for computability and to optimize it for use within primary care settings, with an emphasis on reducing rates of opioid prescription in favor of nonpharmacologic therapy and nonopioid medications, while seeking to identify and address opioid addiction in veterans in a supportive and nonjudgmental way.

Table 1.1. Clinical Context Domains

Target User Primary Care Provider (PCP), Substance Use Disorder Clinicians, Pain Clinic Clinicians

Patient Adult Priority Routine unless otherwise identified Specialty Primary Care Location Outpatient

[End Clinical Context.]

1.2. Knowledge Artifacts

[Begin Knowledge Artifacts.]

This section describes the CDS knowledge artifacts that are part of the Mental Health Opioids and Noncancer Pain group, and include:

Documentation Template: Mental Health: Opioids and Chronic Noncancer Pain OTRR/STORM Query KNART

• Documents the information required for input to a OTRR/STORM query

Documentation Template: Opioid and Noncancer Pain KNART

• Documents the information gathered in the screening, evaluation, and documentation of findings and decisions for chronic noncancer pain

• Includes logic for appropriate display of documentation sections

An Order Set: Mental Health: Chronic Noncancer Pain KNART

• Orders that support management of chronic noncancer pain

• Includes logic for appropriate display of the order set

Mental Health: Opioids and Noncancer Pain

[End Knowledge Artifacts.]

Chapter 2. Documentation Template: Mental Health - Opioids and Chronic Noncancer Pain OTTR/STORM Query

[Begin Documentation Template: Opioids and Chronic Noncancer Pain OTRR/STORM Query.]

[Technical Note: This documentation template is part of a coordinated set of KNARTs that are intended to support risk screening, evaluation and documentation of findings and decisions, and initiation of appropriate clinical orders for veterans with chronic noncancer pain. All of the KNARTs in this coordinated set are intended for use by primary care providers, as well as mental health providers who are embedded in primary care practice settings, in caring for patients with chronic noncancer pain. As part of this coordinated set of KNARTs, this documentation template is intended to enable users to query the OTRR and the STORM systems using a structured format. VA-provided documentation regarding OTRR and STORM are the preferred sources informing the structure and contents of this KNART.]

[Technical Note: Throughout this documentation template, text boxes should be converted to drop-down menus where a set list of options can be specified.]

2.1. Knowledge Narrative

[Begin Knowledge Narrative.]

[See Clinical Context in Chapter 1.]

[End Knowledge Narrative.]

2.2. Opioid Therapy Risk Report (OTTR) Query

[Begin Opioid Therapy Risk Report (OTTR) Query.]

[Technical Note: This section should be made available for all clinical providers using this documentation template.]

<obtain> District – VA Integrated Service Network (VISN)

<obtain> Parent station

[Section Prompt: Provider Group]

[Section Selection Behavior: Select one or more. Required.]

☐ Mental Health

☐ Primary Care

☐ Last opioid prescriber

☐ Last benzodiazepine prescriber

<obtain> Team(s)

<obtain> Provider(s)

<obtain> Opioid group(s)

[Section Prompt: Patients’ opioid use status]

[Section Selection Behavior: Select one or more. Required.]

☐ Long-term opioid therapy (LTOT)

☐ Active opioid prescription

Documentation Template: Mental Health - Opioids and Chronic

Noncancer Pain OTTR/STORM Query

☐ Opioid prescription in past year

[Section Prompt: Opioid use category.]

[Section Selection Behavior: Select one. Required.]

☐ All opioids

☐ Exclude buprenorphine/naloxone only patients

☐ Exclude tramadol only patients

☐ Exclude tramadol and buprenorphine/naloxone only patients

☐ Buprenorphine/naloxone only patients

☐ Tramadol only patients

[End Opioid Therapy Risk Report (OTTR) Query.]

2.3. Stratification Tool for Opioid Risk Mitigation (STORM) Query

[Begin Stratification Tool for Opioid Risk Mitigation (STORM) Query.]

<obtain> Station

<obtain> Prescriber

<obtain> Risk group

<obtain> Group type

<obtain> Measures not met

<obtain> STORM cohort

<obtain> Social Security number (optional)

[End Stratification Tool for Opioid Risk Mitigation (STORM) Query.]

[End Documentation Template: Opioids and Chronic Noncancer Pain OTRR/STORM Query.]

Chapter 3. Documentation Template: Mental Health – Chronic Noncancer Pain

[Begin Documentation Template: Chronic Noncancer Pain.]

[Technical Note: This documentation template is part of a coordinated set of KNARTs that are intended to support risk screening, evaluation and documentation of findings and decisions, and initiation of appropriate clinical orders for veterans with chronic noncancer pain. All of the KNARTs in this coordinated set are intended for use by primary care providers, as well as mental health providers who are embedded in primary care practice settings, in caring for patients with chronic noncancer pain. As part of this coordinated set of KNARTs, this documentation template is intended to support users in the screening, evaluation, and documentation of findings and decisions for chronic noncancer pain. Management of these patients is a constantly changing and complex process for health care providers Follow-up visits frequently focus on patient progress or lack thereof, or on patient concerns. For follow-up visits, a menu is included that helps providers to highlight primary areas of concern and to ask questions that move the conversation in a positive direction: 1) Questions related to level of functioning since the last visit; 2) Questions related to goals outlined by the patient; 3) Questions related to nonpharmacologic therapies tried and being contemplated; and 4) Questions related to medications, including all issues related to opioid safety. The VA-provided document "PBM PhARMD Pain Documentation Template Version 1" (PhARMD Pain Mgmt Note Template_Install Screenshots_28AUG2017.pptx) is the preferred source informing the structure and contents of this KNART, with changes to the content of this VA document as specified by the VA SME team on November 29, 2017, and December 6, 2017.]

3.1. Knowledge Narrative

[Begin Knowledge Narrative.]

[See Clinical Context in Chapter 1.]

[End Knowledge Narrative.]

3.2. Visit Information

[Begin Visit Information.]

[Section Prompt: Visit Information]

☐ Telehealth encounter; patient gave verbal consent for telehealth

[Technical Note: Autopopulate the Patient Name Object value, the Patient Age Object value, the Patient Race Object value, and the Patient Gender Object value in the form component below.]

<obtain> [Patient Name] is a [Patient Age] year-old [Patient Race] [Patient Gender] Veteran who is being evaluated for:

[Technical Note: Autopopulate the Subjective and Objective Active Medical Problems field and allow users to edit it.]

<obtain> Subjective and objective active medical problems

[Section Prompt: Initial or follow-up visit?]

[Section Selection Behavior: Select one. Required.]

☐ Initial visit

☐ Follow-up visit

<obtain> Focus of follow-up

[Technical Note: Autopopulate the Pertinent Surgical History field and allow users to edit it.]

Health – Chronic Noncancer Pain

<obtain> Pertinent surgical history

[Technical Note: Autopopulate the Medications field and allow users to edit it.]

<obtain> Medications

[End Visit Information.]

3.3. Physical Exam

[Begin Physical Exam.]

[Technical Note: Provide link (or links) to future physical exam KNART (or KNARTs). Information collected in the physical exam should be made available and editable for users completing this section.]

<obtain> Relevant findings

[End Physical Exam.]

3.4. Pain Description

[Begin Pain Description.]

[Section prompt: Impact of pain on function]

[Technical Note: Provide link to future KNART for comprehensive functional assessment]

<obtain> Functional impact of pain

<obtain> Functional impact of treatment for pain (positive or negative impact)

[Section Prompt: Type of pain.]

[Section Selection Behavior: Select one or more. Required.]

☐ Neuropathic pain

☐ Nociceptive pain

☐Mixed pain

☐ Other

<obtain> Detail

[Section Prompt: Pain location.]

[Section Selection Behavior: Select one or more. Required.]

☐ Back

[Section Selection Behavior: Select one or more. Required.]

☐ Lower

☐ Middle

☐ Upper

☐ Neck

☐ Joints

[Section Selection Behavior: Select one or more. Required.]

☐ Knee

☐ Hip

☐ Shoulder

☐ Other

<obtain> Detail

☐ Abdominal

☐ Other

<obtain> Detail

[Section Prompt: Activities or situations that worsen pain]

[Section Selection Behavior: Select one or more. Required.]

☐ Cold weather/climate change

☐Sitting, standing, walking

☐Position

☐Time of day

☐Sleep

☐ Stress

<obtain> Activity or Situations Detail

[Section Prompt: Comorbidities that impact pain]

[Section Selection Behavior: Select any or none. Optional.]

☐ Diabetes

☐ Structural imbalance (e.g. scoliosis, leg length discrepancy, hip tilt, strength imbalances)

☐ Inflammatory process

☐ Hormone imbalance

☐ Infectious disease

☐ Mental health related

☐ Anxiety

☐ Depression

☐ Posttraumatic stress disorder

☐ Other mental health-related problems

<obtain> Other mental health problems detail

[Technical Note: If "Depression" is selected, link to Documentation Template: Mental Health

- Consult Request: Consult for Depression.]

[Technical Note: If "Posttraumatic stress disorder" is selected, link to Documentation Template: Mental Health - PTSD Screening and Assessment.]

☐Substance Use Disorder (SUD) including nicotine and alcohol

☐ Alcohol

[Technical Note: If "Alcohol" is selected, provide link to AUDIT-C.]

[Section Selection Behavior: Select one. Required.]

☐ Current user

<obtain> Amount and frequency of use

☐ Former user

<obtain> Quit date (if date unknown, indicate year)

<obtain> Additional details

☐ Cannabis

[Technical Note: If "Cannabis" is selected, provide link to brief cannabis screener.]

[Section Selection Behavior: drop down box. Optional.]

☐ Type of cannabis used

☐ CBD products

☐ THC products

☐ Combined products

[Section Selection Behavior: Select one. Required.]

☐ Legal recreational

[Section Selection Behavior: Select one. Required.]

☐ Current user

<obtain> Amount and frequency of use

☐ Former user

<obtain> Quit date (if date unknown, indicate year)

<obtain> Additional details

☐ Illicit recreational

[Section Selection Behavior: Select one. Required.]

☐ Current user

<obtain> Amount and frequency of use

☐ Former user

<obtain> Quit date (if date unknown, indicate year)

<obtain> Additional details

☐ Medical

[Section Selection Behavior: Select one. Required.]

☐ Current user

<obtain> Amount and frequency of use

☐ Former user

<obtain> Quit date (if date unknown, indicate year)

<obtain> Additional details

☐ Illicit drugs

[Technical Note: Allow the user to enter any number of drugs, with a separate Drug field and its constituent form components for each drug.]

<obtain> Drug

[Section Selection Behavior: Select one. Required.]

☐ Current user

<obtain> Amount and frequency of use

☐ Former user

<obtain> Quit date (if date unknown, indicate year)

<obtain> Additional details

☐ Tobacco

[Section Selection Behavior: Select one. Required.]

[Technical Note: If "Tobacco" is selected, provide link to Documentation Template: Primary Care - Tobacco Assessment and Cessation Counseling.]

☐ Current user

☐ Every day

☐ Some days

☐ Not at all

<obtain> Amount and frequency of use

☐ Former user

<obtain> Quit date (if date unknown, indicate year)

<obtain> Additional details

☐ Toxic exposure

☐Sexual Trauma

☐Military

☐Civilian

[Technical Note: If "Military" is selected, link to Documentation Template: Mental Health - Military Sexual Trauma.]

☐Weight and Nutrition

☐ Other comorbidites

<obtain> Detail

<obtain> Comorbidities detail

[Section Prompt: Opioid related risks]

[Section Selection Behavior: Select any or none. Optional.]

☐Dose

☐Concomitant use of benzodiazepines

☐Concomitant use of nicotine

☐Comorbidities that increase opioid risk

☐Risky behaviors

☐ Concurrent use of other substances that increase risk (e.g., alcohol, cannabis)

<obtain> Detail

☐ Early refills

☐ Multiple prescribers

☐ Use of opioids for sleep

☐ Use of opioids for stress

☐ Use of opioids in a manner other than prescribed

<obtain> Detail

☐ Use of opioids not prescribed to patient

☐ Other

<obtain> Detail

[Section Prompt: Alleviating factors.]

[Section Selection Behavior: Select one or more. Optional.]

☐ Lying down

☐ Rest

☐ Heat

☐ Ice

☐ Limb elevation

☐ Movement

☐ Complementary integrative health (e.g., mindfulness)

☐ Cognitive behavioral approaches (e.g., meeting with friends, music)

☐ Other

<obtain> Detail

[End Pain Description.]

3.5. Relevant Vitals

[Begin Relevant Vitals.]

<obtain> Body mass index

<obtain> Blood pressure

<obtain> Respiratory rate

<obtain> Heart rate

☐ Other

<obtain> Detail

[End Relevant Vitals.]

3.6. Relevant Laboratory Values

[Begin Relevant Laboratory Values.]

[Technical Note: Autopopulate laboratory test results with most recent values and dates of values. Allow user to edit information.]

<obtain> Complete blood count

<obtain> Comprehensive metabolic panel

<obtain> Hemoglobin A1c

<obtain> Toxicology screen

<obtain> 25-hydroxyvitamin D

<obtain> CRP

[End Relevant Laboratory Values.]

3.7. Medication Profile

[Begin Medication Profile.]

<obtain> Allergies/adverse drug reactions

[Technical Note: Autopopulate allergies/adverse drug reactions based on available system data. Allow user to edit information.]

[Section Prompt: History of overdose and opioid-related emergency department visits and hospital admissions]

[Section Selection Behavior: Optional.]

☐ History of overdose and opioid-related emergency department visits and hospital admissions

[Technical Note: Provide a link to the national naloxone use note.]

[Technical Note: Autopopulate information for history of overdose and opioid-related emergency department visits and hospital admissions with most recent values and dates of values. Allow user to edit information.]

☐ Prior overdose(s)

<obtain> Date(s)

<obtain> Drug(s)

<obtain> Additional details

☐ Prior opioid-related emergency department visit(s)

<obtain> Date(s)

<obtain> Drug(s)

<obtain> Additional details

☐ Prior opioid-related hospital admission(s)

<obtain> Date(s)

<obtain> Drug(s)

<obtain> Additional details

[Link: Link to full report from Opioid Therapy Risk Report (OTRR) query.]

[Technical Note: Automatically link to OTRR query report.]

[Link: Link to full report from Stratification Tool for Opioid Risk Mitigation (STORM) query.]

[Technical Note: Automatically link to STORM query report.]

<obtain> Current medications

<obtain> Non-VA medications

<obtain> Previous pain-related medications

[End Medication Profile.]

3.8. Nonpharmacologic treatment

[Begin nonpharmacologic treatment]

[Section prompt: Nonpharmacologic treatment/complementary integrative health]

[Section Selection Behavior: select any or none. Optional.]

☐ Physical therapy

<obtain> Dates

<obtain> Detail

☐ Chiropractic therapy

<obtain> Dates

<obtain> Detail

☐ Massage therapy

<obtain> Dates

<obtain> Detail

☐ Whole health interventions

<obtain> Dates

<obtain> Detail

[Section Selection Behavior: Optional.]

☐ Acupuncture

☐ Tai chi

☐ Yoga

☐ Mindfulness

☐ Meditation

☐ Guided imagery

☐ Hypnotherapy

☐ Biofeedback

☐ Other nonpharmacologic treatment

<obtain> details

[End nonpharmacologic treatment]

3.9. Patient Education

[Begin patient education.]

[Section prompt: Patient education]

[Section selection behavior: select any or none. Optional.]

☐ Disease state education

<obtain> Dates

<obtain> Detail

☐ Lifestyle counseling and education

<obtain> Dates

<obtain> Detail

☐ Other

<obtain> Detail

[End patient education.]

3.10. Activities of Daily Living

[Begin Activities of Daily Living.]

[Section Prompt: Energy level.]

[Section Selection Behavior: Select one. Required.]

☐ Low

☐ Medium

☐ High

<obtain> Sleep (average continuous hours per night)

[Section Prompt: Early Awakening?]

[Section Selection Behavior: Select one. Required.]

☐ Yes

[Technical Note: If “yes” is selected, display the following question:]

[Section prompt: Cause of early awakening]

[Section Selection Behavior: Select any or none. Optional.]

☐ Pain

☐ Nightmares

☐ Restless leg syndrome

☐ Other

<obtain> Detail

☐ No

[Section Prompt: Uses continuous positive airway pressure (CPAP)?]

[Section Selection Behavior: Select one. Required.]

☐ Yes

☐ No

[Section Prompt: Changes in level of functioning since previous visit?]

[Section Selection Behavior: Select one. Required.]

☐ Yes

<obtain> Detail

☐ No

☐ Not applicable

<obtain> Other activities of daily living information

[End Activities of Daily Living.]

3.11. Affect/Mood

[Begin Affect/Mood.]

[Section prompt: Affect/Mood]

[Section Selection Behavior: Select any or none. Optional.]

☐ Anxiety

☐ Depression

☐ Thoughts of suicidality

[Technical Note: If "Thoughts of suicidality" is selected, link to Documentation Template: Mental Health - Suicide Risk Assessment KNART.]

☐ Thoughts of homicidality

[Technical Note: If "Thoughts of homicidality" is selected, link to future KNART.]

☐ Other

<obtain> Detail

[End Affect/Mood.]

3.12. Risk Mitigation Strategies

[Begin Risk Mitigation]

[Section prompt: Risk mitigation strategies]

[Section Selection Behavior: Select any or none. Optional.]

☐ Informed consent for opioid therapy

☐ Yes

☐ No

☐ Toxicology screen

[Technical Note: Autopopulate toxicology screen information from Stratification Tool for Opioid Risk Mitigation (STORM).]

☐ Toxicology results as expected

☐ Toxicology results not as expected

☐ Not done; needs to be ordered

☐ Presence of alcohol

☐ Absence of prescribed medication

☐ Further follow-up needed

☐ No further follow-up needed at this time

☐ Query of the State Prescription Drug Monitoring Program (PDMP)

<obtain> Detail

☐ Overdose education provided, and naloxone distributed

☐ Pill counts

<obtain> Detail

[End Risk Mitigation]

3.13. Assessment

[Begin Assessment.]

☐ Pain diagnoses

<obtain> Detail

[End Assessment.]

3.14. Plan

[Begin Plan.]

[Section prompt: Plan]

[Section prompt: Interventions in this section are presented in order of recommended sequence in the VA.]

[Technical Note: Users should be prompted to consider items in the Plan section in the sequence in which they are presented, based on VA preference for nonpharmacologic rather than pharmacologic interventions and nonopioid rather than opioid medication therapies.]

[Technical Note: To ensure that users understand the available options, links to standard VA definitions should be provided for all interventions if available.]

<obtain> Goals of therapy (established by patient)

[Section prompt: Self-care]

[Section Selection Behavior: Select any or none. Optional.]

☐ Movement and stretching

☐ Nutrition

<obtain> Detail

☐ Sleep and rest

<obtain> Detail

☐ Stress resilience

<obtain> Detail

☐ Social connection

<obtain> Detail

[Section prompt: Nonpharmacologic interventions]

[Section Selection Behavior: Any or None. Optional.]

☐ Physical therapy

☐ Whole health interventions

[Section Selection Behavior: Optional.]

☐ Acupuncture

☐ Tai chi

☐ Yoga

☐ Mindfulness

☐ Meditation

☐ Guided imagery

☐ Hypnotherapy

☐ Biofeedback

☐ Disease state education

☐ Lifestyle counseling and education

☐ Psychotherapy

☐ Cognitive behavioral therapy

☐ Acceptance and commitment therapy

☐ Substance use disorder interventions

☐ Tobacco cessation interventions

☐ Follow-up on toxicology screen

<obtain> Detail

☐ Medication interventions

[Section Selection Behavior: Select at least one. Required.]

☐ Nonopioid pain medication

☐ Opioid pain medication

[Section Selection Behavior: Select at least one. Required.]

☐ Query State PDMP

[Technical Note: Automatically link to the State Prescription Drug Monitoring Program if the “Query State PDMP” checkbox is selected.]

☐ Sign or Initiate consent for opioid therapy

[Technical Note: Automatically link to the consent form if the “Sign or Initiate consent for opioid therapy” checkbox is selected.]

☐ Management/prevention of opioid-induced constipation

☐ Overdose education and naloxone distribution

[Technical Note: Note that it may be desirable to add a link to the national naloxone use note in the Plan section as part of a future implementation; however, no link should be provided in the Plan section now.]

☐ Medication monitoring/diagnostic evaluation

<obtain> Detail

☐ Manage adverse drug reaction related to pain medication

<obtain> Detail

☐ Follow-up

<obtain> Date and time

<obtain> Detail

[Technical Note: Link to Order Set: Mental Health - Chronic Noncancer Pain KNART.]

[End Plan.]

[End Documentation Template: Chronic Noncancer Pain.]

Chapter 4. Order Set: Mental Health – Chronic Noncancer Pain

[Begin Order Set: Chronic Noncancer Pain.]

4.1. Knowledge Narrative

[Begin Knowledge Narrative.]

[See Clinical Context in Chapter 1.]

[Technical Note: This order set is part of a coordinated set of KNARTs that are intended to support risk screening, evaluation and documentation of findings and decisions, and initiation of appropriate clinical orders for veterans with chronic noncancer pain. All of the KNARTs in this coordinated set are intended for use by primary care providers, as well as mental health providers who are embedded in primary care practice settings, in caring for patients with chronic noncancer pain. As part of this coordinated set of KNARTs, this order set is intended to provide orders that reflect the plan items identified in the Chronic Noncancer Pain documentation template (KNART O34). The VA-provided document "PBM PhARMD Pain Documentation Template Version 1" (PhARMD Pain Mgmt Note Template_Install Screenshots_28AUG2017.pptx) is the preferred source informing the structure and contents of this KNART, with changes to the content of this VA document as specified by the VA SME team on November 29, 2017, and December 6, 2017.]

[End Knowledge Narrative.]

4.2. Medications

[Begin Medications.]

[Section prompt: Medications]

[Section Prompt: Oral Medications.]

☐ Ibuprofen 200 mg tablet oral every 4 to 6 hours as needed for pain 100 tablets 2 refills

☐ Naproxen 250 mg tablet oral 2 times daily as needed for pain 100 tablets 2 refills

☐ Acetaminophen 325 mg tablet oral 2 tablets every 6 hours as needed for pain; may increase dose frequency to 2 tablets every 4 hours; do not take more than 10 tablets per day 100 tablets 2 refills

☐ Celecoxib 100 mg capsule oral 2 times a day 60 capsules 2 refills

[Section Prompt: The following orders may be considered for patients who tolerate lower doses but whose pain control remains inadequate on lower doses.]

☐ Ibuprofen 400 mg tablet oral every 4 to 6 hours as needed for pain 100 tablets 2 refills

☐ Naproxen 375 mg tablet oral 2 times daily as needed for pain 100 tablets 2 refills

☐ Celecoxib 200 mg capsule oral 2 times a day 60 capsules 2 refills

[Section Prompt: The following orders may be considered for patients who tolerate lower doses but whose pain control remains inadequate on lower doses.]

☐ Ibuprofen 600 mg tablet oral every 6 hours as needed for pain 100 tablets 2 refills

☐ Naproxen 500 mg tablet oral 2 times daily as needed for pain 100 tablets 2 refills

[Section Prompt: Topical Medications]

[Section Prompt: Use clinical judgement regarding removing a lidocaine patch for 12 hours within a 24-hour period. That practice is controversial.]

Order Set: Mental Health – Chronic

☐ Capsaicin 0.1% cream topical 3 times a day apply to affected area 1 tube 0 refills routine

☐ Diclofenac sodium 1% 2 g gel topical 4 times a day apply to affected area 1 tube 0 refills routine

☐ Lidocaine 5% patch topical apply to intact skin to cover most painful area; apply prescribed number of patches (maximum of 3); apply only 1 time for a maximum of 12 hours within a 24-hour period 30 patches 0 refills routine

☐ Menthol 10%/methyl salicylate 15% cream topical 3 times a day apply to affected area 1 tube 0 refills routine

[Section Prompt: Other Medications that Impact Pain]

[Technical Note: Please provide link to institutional pharmacy order entry.]

[End Medications.]

4.3. Laboratory Tests

[Begin Laboratory Tests.]

☐ Complete blood count 1 time routine

☐ Comprehensive metabolic panel 1 time routine

☐ Hemoglobin A1c 1 time routine

☐ Toxicology screen 1 time routine

☐ 25-hydroxyvitamin D 1 time routine

☐ Erythrocyte sedimentation rate 1 time routine

☐ C-reactive protein 1 time routine

[End Laboratory Tests.]

4.4. Consults and Referrals

[Begin Consults and Referrals.]

[Section prompt: Consults and Referrals]

[Section selection behavior: Any or none. Optional]

[Section Prompt: In management of chronic pain it is important to address comorbidities, including medical, mental health, and substance use disorders. To the greatest extent appropriate, comorbidities should be treated in the primary care setting, using resources available to primary care, including mental health providers who are embedded in primary care.]

☐ Referral care management services evaluate needs related to chronic pain routine

☐ Referral social services evaluate for needs related to chronic pain routine

☐ Referral clinical nurse specialist evaluate for chronic pain routine

☐ Referral mental health evaluate for mental health interventions related to chronic pain routine

☐ Referral mental health evaluate for psychotherapy related to chronic pain routine

Order Set: Mental Health – Chronic

☐ Referral mental health evaluate for cognitive behavioral therapy related to chronic pain routine

☐ Referral mental health evaluate for acceptance and commitment therapy related to chronic pain routine

☐ Referral addiction evaluate for substance use disorder with chronic pain routine

☐ Referral addiction evaluate for tobacco cessation with chronic pain routine

☐ Referral pain management evaluate for chronic pain routine

☐ Referral pain management evaluate for opioid management with chronic pain routine

☐ Referral pharmacy evaluate for needs related to chronic pain routine

☐ Referral physical therapy evaluate for chronic pain routine

☐ Referral acupuncture evaluate for chronic pain routine

☐ Referral tai chi evaluate for chronic pain routine

☐ Referral yoga evaluate for chronic pain routine

☐ Referral mindfulness evaluate for chronic pain routine

☐ Referral meditation evaluate for chronic pain routine

☐ Referral guided imagery evaluate for chronic pain routine

☐ Referral hypnotherapy evaluate for chronic pain routine

☐ Referral biofeedback evaluate for chronic pain routine

[Section Prompt: Only applicable if referring to an outside facility. To inform appropriate opioid and chronic noncancer pain treatment for this patient, please provide the following information.]

Goal of Consult: <details>

Clinical Findings: <details>

Priority: Routine unless otherwise specified

<obtain> Referring Physician

<obtain> Referring Physician Contact Information

[End Consults and Referrals.]

4.5. Patient and Caregiver Education

[Begin Patient and Caregiver Education.]

☐ Chronic pain management education routine

[End Patient and Caregiver Education]

[End Order Set: Chronic Noncancer Pain.]

Bibliography/Evidence

Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. Psychol Serv. 2017;14(1):34-49.

Opioid risk stratification and mitigation tool: supporting targeted efforts to encourage and track use of recommended strategies for prevention of adverse events in patients with opioid prescriptions or opioid use disorders (AAPM 2015 panel presentation for clearance2; materials provided by Jodie Trafton, December 12, 2017).

Opioid Therapy Risk Report patient details (Office of Health Informatics - Opioid KNARTs Harmonization Project - OTRR Screenshots 20171222.docx; email communication and materials provided by William J.

Sanders, December 22, 2017).

PBM CPPO pain PhARMD template: frequently asked questions (PBM PAIN PhARMD TEMPLATE FAQ DOCUMENT2.pptx; materials provided by Ilene R. Robeck, November 27, 2017).

PBM PhARMD pain documentation template version 1: installation instructions, 28AUG2017 (PhARMD Pain Mgmt Note Template_Install Screenshots_28AUG2017.pptx; materials provided by Ilene R. Robeck, November 27, 2017).

STORM: Patient Detail Dashboard: Stratification Tool for Opioid Risk Mitigation (STORMde-idedscreenshot.png; materials provided by Jodie Trafton, December 12, 2017).

U.S. Department of Veterans Affairs; U.S. Department of Defense. VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain, Version 3.0 – 2017. U.S. Department of Veterans Affairs website. VA/DoD Clinical Practice Guidelines. https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf.

Published February 2017. Accessed February 8, 2018.

U.S. Department of Veterans Affairs; Veterans Health Administration. Querying State Prescription Drug Monitoring Programs (PDMP). VHA Directive 1306. VHA Publications website.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3283. Published October 19, 2016. Accessed February 8, 2018.

U.S. Department of Veterans Affairs; Veterans Health Administration. Informed Consent for Long-Term Opioid Therapy for Pain. VHA Directive 1005. VHA Publications website.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3005. Published May 6, 2014. Accessed February 8, 2018.

U.S. National Library of Medicine. BENGAY GREASELESS PAIN RELIEVING- menthol, unspecified form and methyl salicylate cream [Johnson & Johnson Consumer Inc.]. DailyMed website.

https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=0d75b27f-496e-495d-b788- 0dd3c0f5a32f&type=display. Revised April 2016.

U.S. National Library of Medicine. CAPSAICIN ARTHRITIS PAIN RELIEF CREAM- capsaicin cream [McCure Health Solutions Inc.]. DailyMed website.

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7c31736c-edaa-4390-a2fb-eab2fd495f7d. Revised April 2015.

U.S. National Library of Medicine. CELECOXIB - celecoxib capsule [Jubilant Cadista Pharmaceuticals Inc.].

DailyMed website. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=27d813ea-7798-09cb-734b-b970d7248f1f. Revised April 2017.

U.S. National Library of Medicine. DICLOFENAC SODIUM- diclofenac gel [Amneal Pharmaceuticals LLC].

DailyMed website. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f64b68a5-d6d2-4e92-87e7- 90af04c1f9db. Revised January 2017.

Existing Sample VA Artifacts

U.S. National Library of Medicine. IBU- ibuprofen tablet [Dr. Reddy's Laboratories Limited]. DailyMed website. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=24731405-219c-79b4-ecf0-7d5fbfda94ba.

Revised October 2016.

U.S. National Library of Medicine. LIDODERM- lidocaine patch [Endo Pharmaceuticals, Inc.]. DailyMed website. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f1c40164-4626-4290-9012-c00e33420a33.

Revised January 2015.

U.S. National Library of Medicine. NAPROSYN- naproxen tablet; EC-NAPROSYN- naproxen tablet, delayed release; NAPROSYN- naproxen suspension; ANAPROX- naproxen sodium tablet; ANAPROX DS- naproxen sodium tablet [Genentech, Inc.]. DailyMed website.

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=68848217-03c9-4377-9be6-6f567e629129. Revised January 2018.

U.S. National Library of Medicine. REDICARE IBUPROFEN- ibuprofen 200mg tablet, film coated [Redicare LLC]. DailyMed website. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=45eb33f0-71e2-11d5-e054-00144ff88e88. Revised January 2017.

U.S. National Library of Medicine. TYLENOL REGULAR STRENGTH- acetaminophen tablet [Johnson & Johnson Consumer Inc., McNeil Consumer Healthcare Division]. DailyMed Website.

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1622f694-4d63-4c56-8737-fae31f0ecfb7. Revised October 2016.

Appendix A. Existing Sample VA Artifacts

Figure A.1. V21 Chronic Opioid Therapy Ongoing Monitoring Reminder Dialog (image 1 of 3)

Figure A.2. V21 Chronic Opioid Therapy Ongoing Monitoring Reminder Dialog (image 2 of 3)

Figure A.3. V21 Chronic Opioid Therapy Ongoing Monitoring Reminder Dialog (image 3 of 3)

Figure A.4. VA Stratification Tool for Opioid Risk Mitigation (STORM) Patient Detail Dashboard

Figure A.5. PhARMD Pain Mgmt Note Template (image 1 of 18)

Figure A.6. PhARMD Pain Mgmt Note Template (image 2 of 18)

Figure A.7. PhARMD Pain Mgmt Note Template (image 3 of 18)

Figure A.8. PhARMD Pain Mgmt Note Template (image 4 of 18)

Figure A.9. PhARMD Pain Mgmt Note Template (image 5 of 18)

Figure A.10. PhARMD Pain Mgmt Note Template (image 6 of 18)

Figure A.11. PhARMD Pain Mgmt Note Template (image 7 of 18)

Figure A.12. PhARMD Pain Mgmt Note Template (image 8 of 18)

Figure A.13. PhARMD Pain Mgmt Note Template (image 9 of 18)

Figure A.14. PhARMD Pain Mgmt Note Template (image 10 of 18)

Figure A.15. PhARMD Pain Mgmt Note Template (image 11 of 18)

Figure A.16. PhARMD Pain Mgmt Note Template (image 12 of 18)

Figure A.17. PhARMD Pain Mgmt Note Template (image 13 of 18)

Figure A.18. PhARMD Pain Mgmt Note Template (image 14 of 18)

Figure A.19. PhARMD Pain Mgmt Note Template (image 15 of 18)

Figure A.20. PhARMD Pain Mgmt Note Template (image 16 of 18)

Figure A.21. PhARMD Pain Mgmt Note Template (image 17 of 18)

Figure A.22. PhARMD Pain Mgmt Note Template (image 18 of 18)

Figure A.23: PBM Pain PhARMD Template FAQ

The PBM CPPO Pain PhARMD template is a voluntary initiative of the PBM Clinical Pharmacy Practice Office (CPPO) and the CPPO Pain Subject Matter Expert (SME) Workgroup where Clinical Pharmacy Specialist (CPS) at a local facility utilize a pre-defined note template to document their clinical pharmacy encounters for patients in which they are providing comprehensive medication management services in pain. All guidance and educational documents for the PBM Pain PhARMD template can be found on the Clinical Pharmacy SharePoint site at

Pain SME Workgroup Outcomes Subgroup SharePoint:

https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/PainManagementSME/Shared Documents/Forms/AllItems.aspx?RootFolder=%2Fsites%2FClinicalPharmacy%2FPainManagementSME%2FS hared%20Documents%2FFY17%2DDocumentation%20and%20Outcomes%20Subgroup&FolderCTID=0x012 0002AD1D94329882441AB4A1134B8CA2184&View=%7B130A15D7%2D003D%2D40EA%2D9319%2DE 11F040598B9%7D&InitialTabId=Ribbon%2EDocument&VisibilityContext=WSSTabPersistence.

Links to important information:

Pain PhARMD

• Template link: Pain SME Workgroup Outcomes Subgroup SharePoint Folder:

https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/PainManagementSME/Shared Documents/Forms/AllItems.aspx?RootFolder=%2Fsites%2FClinicalPharmacy%2FPainManagementSME%2 FShared%20Documents%2FFY17%2DDocumentation%20and%20Outcomes%20Subgroup&FolderCTID=0 x0120002AD1D94329882441AB4A1134B8CA2184&View=%7B130A15D7%2D003D%2D40EA%2D9319 %2DE11F040598B9%7D&InitialTabId=Ribbon%2EDocument&VisibilityContext=WSSTabPersistence https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/PainManagementSME/Shared%20Documents/Forms/AllItems.aspx?RootFolder=%2Fsites%2FClinicalPharmacy%2FPainManagementSME%2FShared%20Documents%2FFY17%2DDocumentation%20and%20Outcomes%20Subgroup&FolderCTID=0x0120002AD1D94329882441AB4A1134B8CA2184&View=%7B130A15D7%2D003D%2D40EA%2D9319%2DE11F040598B9%7D&InitialTabId=Ribbon%2EDocument&VisibilityContext=WSSTabPersistence https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/PainManagementSME/Shared%20Documents/Forms/AllItems.aspx?RootFolder=%2Fsites%2FClinicalPharmacy%2FPainManagementSME%2FShared%20Documents%2FFY17%2DDocumentation%20and%20Outcomes%20Subgroup&FolderCTID=0x0120002AD1D94329882441AB4A1134B8CA2184&View=%7B130A15D7%2D003D%2D40EA%2D9319%2DE11F040598B9%7D&InitialTabId=Ribbon%2EDocument&VisibilityContext=WSSTabPersistence

• Template install instructions for CAC link: Pain SME Workgroup Outcomes Subgroup SharePoint Folder:

https://vaww.infoshare.va.gov/sites/ClinicalPharmacy/PainManagementSME/Shared Documents/Forms/AllItems.aspx?RootFolder=%2Fsites%2FClinicalPharmacy%2FPainManagementSME%2 FShared%20Documents%2FFY17%2DDocumentation%20and%20Outcomes%20Subgroup&FolderCTID=0 x0120002AD1D94329882441AB4A1134B8CA2184&View=%7B130A15D7%2D003D%2D40EA%2D9319…