Complementary and integrative health approaches can be effective treatments for pain. But while these approaches – like chiropractic care, meditation, massage, relaxation, tai chi, and yoga – have been shown to alleviate some types of pain, doctors don’t always know how to provide them to their patients. This is particularly true after major surgery.
Time constraints typical of routine healthcare visits make it harder still. “Why don’t you try a low-impact yoga class?” may be a tougher sell than a prescription for a pain pill, explains Andrea Cheville, M.D., a rehabilitation and pain medicine specialist at the Mayo Clinic in Rochester, Minnesota.
Cheville and her colleagues are studying the use of decision-making tools embedded into electronic health record (EHR) systems. Offering various treatment options can help patients manage their own pain by selecting non-drug pain care after surgery, as well as help clinicians support that choice. Through the Mayo Clinic’s EHR system, Cheville’s team will offer surgery patients the chance to express interest in various complementary health approaches. The researchers hope to show that patient preferences can be smoothly incorporated into medical care – both to reduce pain after surgery and minimize the needs for opioids.
The research is part of the Helping to End Addiction Long-term InitiativeSM, or NIH HEAL InitiativeSM and its effort to evaluate innovative therapies for pain management and how to implement them. The study is one of several testing practical and scalable solutions to most effectively implement evidence-based interventions and pain management guidelines.
Modifying Electronic Health Record Systems
The researchers will follow more than 70,000 patients who are scheduled to have various types of surgery. Over a period of 3 years, each of 24 surgical practices in Mayo Clinic’s locations across the country will have their EHR system modified, enabling them to be “switched on or off” to accept information about patient preferences for pain treatment.
The researchers will compare patients who use the typical EHR system after surgery to patients who use the enhanced (switched on) EHR system, with options to express interest in complementary health treatments for pain. The study team will determine if patients who are offered non-medicine options experience less pain and recover more quickly from surgery. They will also look at patients’ anxiety after surgery and how much follow-up care they need.
The research team has spoken with and shadowed many Mayo providers to understand use of the current Mayo Clinic EHR system to figure out how to build the enhanced version that records patient preferences.
Offering Patients a Menu of Options
Clinical guidelines state that ideal pain care is integrative – emphasizing a holistic, patient-focused approach to healthcare and wellness that treats a whole person rather than, for example, one organ system. Yet complementary and integrative health approaches are seldom presented to patients, Cheville notes.
When the Mayo Clinic enhanced EHR system is switched on and a patient who is scheduled to have surgery logs onto the site, he or she encounters a “conversation guide” about pain. The guide explains the likelihood of pain after surgery and the reasons for limiting opioids, and it offers several non-medicine options a patient can choose to add to his or her pain management plan.
The system offers options in three categories: movement (yoga, tai chi, and walking); physical (acupuncture, acupressure, massage, transcutaneous electrical nerve stimulation, and hot and cold therapy); and relaxation (progressive muscle relaxation, paced breathing, meditation, guided imagery, music listening, and aromatherapy). All these approaches do not involve medicine but have been shown by multiple research studies to reduce pain.
“We’re trying to help patients, at a glance, understand what these treatments are and encourage them to pick two or three that we can support during and after their hospital stay,” Cheville explains.
The selections are saved in a patient’s EHR record as computer-coded tags know as data elements, alongside blood pressure, diagnoses, prescriptions, and other medical information. Patients can change their preferences anytime.
A Seamless Integration
Because any change to an EHR system can be a headache for healthcare workers, who use the computer system all the time, the research team has closely tracked Mayo Clinic healthcare providers who work with the system.
“We want to influence them so that the right thing becomes the easy thing,” says Cheville’s colleague Jon Tilburt, M.D., an internist co-leading the study.
All healthcare providers who access a patient’s EHR can also access a patient’s choices about non-medical pain treatment options, giving them opportunities to incorporate those options into a treatment plan directly or at least to validate the patient’s choices.
For example, a surgeon might see a prompt about a patient’s complementary treatment preferences during an appointment. This heads-up offers the surgeon an opportunity to gear a treatment plan toward those choices, which can help a patient feel more at ease.
“These messages can be very powerful when they come from a surgeon or a member of the surgical care team,” Cheville says.
After surgery, if a patient recovering in the hospital says they are in pain, the computer might prompt the bedside nurse to consider offering resources related to the individual’s pain management preferences. That could mean reminding the patient that they were interested in listening to music to relax or scheduling the patient for an acupressure appointment.
Later, if the patient goes to a physical therapist, the therapist might consider integrating massage into the care plan or suggesting that the patient use a cold pack at home, if the patient expressed interest in those options.
A Promising Approach for Patients and Providers
These researchers have already tested the enhanced EHR system with several patients who were scheduled to have back surgery.
Many were glad to see suggestions for a variety of pain management options other than medications. “One of the things we’ve heard from patients is ‘I was validated and given permission to talk about these approaches with my provider,’” Cheville says.
Healthcare providers also liked the new system. For example, when a patient calls to ask for an opioid refill, the enhanced EHR system suggests screening the person for opioid misuse or overuse, counseling them on alternative ways of dealing with pain, or consulting with a psychologist or social worker.
One Mayo Clinic physician assistant explained that even though she knew patients were at risk of opioid use disorder, she didn’t know how to help. Through the enhanced EHR system, that provider can now suggest other options, Cheville recalls. “She was so excited by that.”
Read About This Project on NIH RePORT
Learn more about Cheville and Tilburt’s project, “Non-pharmacological options in postoperative hospital-based and rehabilitation pain management (NOHARM) pragmatic clinical trial," funded by the NIH National Institute on Aging, grant 1UG3AG067593-01.
National Institute on Aging (NIA)
Learn more about NIA.