Inpatient Opioid-Safety Decision Support

The Logic Layer for
Inpatient Stewardship

Precision Analgesia resolves the tension between pain management and safety. Replaces manual calculation with EMR-integrated, advisory decision support — every recommendation cited, every override documented — to mitigate liability and cost.

For Health Systems View Integration Guide
For Clinicians Demo the iOS Beta
Or try the taper engine live in your browser — no download required
Validated against CDC 2022 Clinical Practice Guidelines
Physician-Founded · Addiction Medicine Fellow, Yale
Precision Analgesia iOS app showing the Opioid Calculator

The $78.5 Billion Blind Spot

Opioid complications are no longer just clinical errors; they are existential legal and financial threats.

$78.5B

Annual Economic Burden

Prescription-opioid misuse costs the U.S. an estimated $78.5B every year (Florence et al., Medical Care 2016) — while the conventional safety alerts meant to prevent harm are overridden 70–90% of the time (van der Sijs 2006; Phansalkar 2013, JAMIA).

46%

Undetected Risk

The PRODIGY Trial (Khanna et al., 2020) found 46% of general-care-floor patients receiving opioids had respiratory depression episodes on continuous monitoring — events that intermittent manual nursing checks routinely miss.

Litigation Risk

Corporate Negligence

Shift from malpractice to systemic liability. "Failure to monitor" claims increasingly name the institution, not just the clinician — an active, growing category of hospital liability exposure.

The Integration Engine

A proprietary Clinical Validation Engine designed to sit between the clinician and the prescription via CDS Hooks. It counters alert fatigue by surfacing a specific, guideline-cited recommendation the clinician can accept or override — with the override documented.

ValidationEngine.swift
FHIR / CDS Hooks

⚠ CRITICAL GATE: Renal Gating (Documented Override)

Passive alerts are overridden 70–90% of the time (van der Sijs 2006; Phansalkar 2013, JAMIA). Our engine defaults to AVOID for active metabolites (e.g., Morphine) when GFR < 30 — proceeding requires an explicit, documented acknowledgment of the evidence.

⚠ CAUTION: Hepatic Shunt Logic

Identifies Child-Pugh Class C. Automatically adjusts bioavailability calculations for Hydromorphone (4x increase in liver failure) to prevent accidental overdose.

Methadone Guardrails

Replaces dangerous single-ratio conversion charts with dose-dependent tiered conversion (7 tiers, VA/DoD 2022 + NCCN 2025) — automatic cross-tolerance reductions, dose caps, a conservative geriatric override, and a hard refusal above 1200 MME to prevent accumulation toxicity and death.

Available Now on iOS

The Algorithm in Your Pocket

The same clinical validation engine that powers our EMR integration is available as a standalone iOS app. Use it at the bedside, in the pharmacy, or during rounds.

MME Conversion Engine

24-drug database with route-aware, organ-adjusted dosing and CDC 2022-validated cross-tolerance reductions.

Automated Risk Scoring

PRODIGY-aligned OIRD scoring with auto-generated monitoring plans and organ-specific safety gating.

OUD Consult Workflows

Integrated screeners (DAST-10, ASSIST-Lite), COWS-based induction protocols, and multimodal sparing options.

Join TestFlight Beta View EMR Integration →

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SMART on FHIR + CDS Hooks

How Integration Works

Three steps from clinician action to evidence-based recommendation — no additional training, no workflow disruption.

Step 1

Launch

Physician clicks a button in Epic or Cerner. The EMR opens a secure SMART on FHIR session — either embedded in the chart or in a new window.

Step 2

Handshake

OAuth 2.0 token exchange authenticates the session. The app queries patient demographics, lab values (eGFR, LFTs, QTc), and current medications via FHIR R4.

Step 3

Result

App loads instantly with patient context pre-filled. Safety gates auto-execute, OIRD risk is scored, and the clinician receives gated, evidence-based recommendations.

CDS Hooks
BPA Integration

Real-Time Intervention at Point of Prescribing

When a clinician selects or signs an opioid order, Epic fires a CDS Hook to our service endpoint. The Precision Analgesia engine evaluates all 10 safety rules in real-time and returns actionable cards — warnings, dose adjustments, and alternative recommendations.

For critical safety gates (renal contraindications, pediatric black box warnings), hospital Epic teams configure Best Practice Advisories (BPAs) powered by our logic — requiring documented clinical justification to override — configured and owned by the hospital's own Epic team.

// CDS Hook Trigger Points
● order-select Pre-sign
● order-sign Final gate
● patient-view Risk display
● encounter-discharge OUD follow-up

FHIR R4 Resources Consumed

Patient

Age, sex, demographics

Condition

Renal, hepatic, pregnancy, COPD, OSA, CHF (ICD-10)

Observation

Creatinine/eGFR, LFTs, QTc interval (LOINC)

MedicationRequest

Active opioids, benzodiazepines, naltrexone (RxNorm)

Implementation Timeline

From sandbox validation to live clinical deployment — a structured, low-risk rollout designed for enterprise health systems.

Phase 1 — Months 1–2

Sandbox Validation

Register on Epic's developer portal. Build SMART on FHIR launch flow, implement FHIR R4 queries, validate CDS Hooks service endpoint against synthetic patient data.

Phase 2 — Months 2–3

Hospital Partner Onboarding

Security risk assessment and HIPAA BAA execution with partner hospital. Epic staging environment configuration, clinical workflow review with pharmacy and nurse informaticists. Private SMART app registration — no Epic Connection Hub / Integration Certification listing required for pilot.

Phase 3 — Months 3–4

Clinical Pilot

Limited deployment on select medical-surgical floors. Real-world clinical validation with identified physician champions. Data collection and outcome tracking against baseline metrics.

Phase 4 — Months 5–10

Enterprise Deployment

Pilot expansion, Epic Connection Hub / Integration Certification listing application, and broader system-wide availability. Continuous outcome tracking for ROI documentation and settlement fund reporting.

Settlement-Ready Data

Table 1: Key Metrics for Abatement

Evidence-based targets to substantiate claims for Opioid Abatement Settlement funds.

Metric Category Specific Measure Target / Benchmark Source
Equity Racial Disparities (Black Pts) Close the Gap (Current OR 0.83 vs White Pts) 2024 Meta-Analysis
Clinical Safety OIRD Rate <0.5% of opioid-receiving inpatients PRODIGY 13
Prescribing MME/Day at Discharge <90 MME for opioid-naive patients CMS 7
Opioid Safety High-Risk Prescribing Reduction via active safety gates + required acknowledgment (vs. passive alerts) Study 42
Alert Quality Safety Alert Override Rate Improve on the 70–90% override rate of conventional interruptive alerts van der Sijs 2006; Phansalkar 2013 (JAMIA)

How Precision Analgesia Delivers

Automated capabilities that embed clinical recommendations directly into EHR workflows — advisory at the point of care, with every override documented — no additional training required.

Continuous Monitoring

Identifies high-risk patients via PRODIGY-derived scoring and flags them for continuous capnography — turning positive ROI into automated workflow.

Workflow-Integrated Stewardship

Standardizes EHR defaults, safety acknowledgments, and order set constraints — reducing reliance on provider memory or education alone.

Communication Metrics

Built-in patient communication templates aligned with new HCAHPS scoring — maintain satisfaction while reducing MMEs.

Litigation Defense

Generates auditable logs of every recommendation and override, building a defensible record against "failure to monitor" and "corporate negligence" claims.

A New Quality Imperative

The era of unchecked opioid prescribing in hospitals is over, replaced by a data-driven, risk-aware approach. The most successful health systems are those that view opioid safety not as a compliance burden but as a quality and financial imperative. By balancing the moral imperative to treat pain with the ethical duty to do no harm, hospitals can navigate this complex landscape.

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