Year: 2015

The Rewards of Performance (Updated)**

It should come as no surprise to anyone active in pharmacy that CMS has started to emphasize quality and performance as a part of the metrics being used to grade pharmacies Pharmacy Benefit Managers (PBMs). The mechanism for this evaluation are the Star Ratings, and these the pharmacy specific metrics are subdivided into several disease specific measures. Pharmacies receive scores for each measure, and the Medicare Part D Prescription Drug Plans (PDPs) are scored by CMS based on their own measures along with an aggregate of the pharmacy specific performance numbers for all of their network pharmacies. The metrics are collected and calculated by PQS (Pharmacy Quality Solutions) thru the EQuIPP platform.

Pay for Performance

Recently, 2014 performance reports have begun to emerge, and pharmacies are starting to see the fruits of their quality oriented labor. The harvest, however, appears to be a little disappointing. Below represents the report and payment made by a Medicare Part D PDP (Prescription Drug Plan) to a medium size independent pharmacy*.

Performance Report with Payment information for a medium-sized independent pharmacy (filling 250-350 Rx per day)*

Description

The pharmacy represented above is fairly successful with respect to the performance measures. The Medicare Part D plan in this report likely represents only a small fraction of the pharmacy’s Medicare Part D patient population (likely less than a few hundred patients in total). The adherence (prescription drug compliance or PDC) measures for the first two measures (ACE / ARB / DRI and Statins) are well above the 5 star goals, and represent a small subset of the pharmacy’s patient population (around 40-50 patients each). The other two EQuIPP measures represent a very small population of patients (15-16 patients), and a single patient can dramatically affect the pharmacy’s scores (consider that with so few data points, a single patient can raise or lower a score by almost 7%). There does not appear to be any weighting of performance pay based on this type of bias, which is out of the control of the pharmacy.

Another notable observation is that a high performing pharmacy can be paid a premium for very high results. The first two measures show a payment rate of 125% (a 25% premium) for exceeding the 5 star goal. The performance scale extends from 125% down to 0% based on performance. There is not a clear indication where the break in reimbursement levels are being made.

By the Numbers

Some interesting details of the “pay for performance” model being used by this plan emerge from this from this table.

  • The total amount of performance incentives available to this pharmacy for 2014 (the entire year) was $1190. (this assumes a 25% premium is available for all measures and the pharmacy exceeds all goals significantly.
  • The pharmacy serves between 51 and 109 Star Measure Medication patients that are enrolled with this plan. (it is difficult to know how many patients are represented in more than one category)
  •  15% of performance pay was assigned to non-star ratings (non-EQuIPP) measures. These include 90-day fill rate and Generic Dispensing Rate.
  • For EQuIPP Measures, performance incentives average $5.63 per patient per year
  • By patient, incentive payments work out to be below $6 to about $20 per patient per year (depending on the number of patients that fall into more than one category).
  • Payments made for Medication Therapy Management (MTM) Stars Intervention** are being counted as payment already received by the pharmacy

Discussion

The amount being paid for outstanding pharmacy performance by this plan is anemic. For each patient falling into a star-ratings category, pharmacy has the potential to increase revenue by a maximum of $20 per year. In order to maximize this incentive, a pharmacy is going to have to spend money on programs to improve outcomes. Programs like Med Sync and compliance packaging all have significant overhead, and the potential incentives do little to ensure a pharmacy will maintain a positive margin for improving quality.

The use of non-equip measures for 15% of performance incentives is a troubling trend. Remember, it is the patient, not the pharmacy or the PBM, that ultimately should have the choice of a 90-day fill. Many patient prefer regular visits to their pharmacy. While some research supports the thought that 90-day refills increase patient compliance, these studies rely on claims data, making the assumption that actual compliance is directly related the patient having possession of the medication. In truth, leveraging  90-day fills removes only one potential obstacle to adherence, a trip to the pharmacy, while numerous other possible reasons for non-compliance remain. One drawback of 90 day supplies is that compliance issues take longer to recognize. With 30 day refills, the pharmacy can address issues of compliance with the patient within the first 30 to 45 days of therapy, whereas issues with a 90 day supply will not start to become evident for close to 4 months, well after the patient has poor compliance developed habits.

Extended-day supplies have other consequences to both patients and pharmacies. Patients who receive 90 days supplies are offered  savings thru discounted co-pays. The incentive available to the pharmacy for a high 90 day fill percent (with the above example, achieving more than 25% of star-rating drugs dispensed as 90 day supplies) is $152 per year. A typical 90-day pharmacy contract offers a $0 dispensing fee to the pharmacy while the 30 day dispensing fee paid to a pharmacy is typically no less than $0.50 per Rx  If the pharmacy moves from 4% up to 25% 90-day supply fill rate, the pharmacy would be forfeiting $200 dollars in dispensing fees in exchange for only $152 in incentive payments. In this case, a pharmacy failing to make the “grade” on 90-day fill rate is actually better off, and the patient retains their choice of 30 or 90 day fills.***

Another troubling trend is the deduction the plan makes for payments received by the pharmacy for Mirixa  (Medication Therapy Management or MTM) adherence related cases. The plan is essentially creating a ceiling on the total amount a pharmacy can receive for its work. This ceiling includes both incentives and any money available for MTM adherence related case payments. The pharmacy represented in the report above completed 100% of the adherence related Mirixa cases assigned to it in 2014 and received $310 for their work. A typical MTM work-up takes 30 to 60 minutes of pharmacist time, and the effective reimbursement rate is poor, even for a highly efficient pharmacy. The deduction of the Mirixa payments flies in opposition to the quality metrics supposedly being rewarded by this system. By this method, pharmacies with a large number of MTM adherence related patients cases have the potential reach their incentive ceiling entirely by completing MTM these cases. This pharmacy would then receive little to no additional quality bonus dollars for maintaining exceptional EQuIPP scores. It is unclear if these pharmacy would actually have to pay money back to the plan if their MTM adherence related case payments exceeded their “maximum” quality payment.

The problem with using a star ratings system (like EQuIPP) it that it only indirectly measures quality. Compliance can be artificially elevated without actually modifying a patient’s adherence simply by enrolling patients in a Med Sync program or leveraging automatic refills.  Claims data will trend towards improved adherence with these programs, but is the patient actually taking the medication?  Ultimately, the quality measures will have to evolve to include metrics that better reflect the value pharmacists can contribute to the system. Right now, the quality measures are better suited to drive patients to large, robotic mail order pharmacies that can show outstanding PDC values based solely on claims data. Pharmacists offer considerably more to the patient than an indirect measure of adherence, and the measures should emphasize the strengths of pharmacists, and focus less on product. 

Conclusions

This is just a first example of how plans are trying to incentivize pharmacies to emphasize quality. Many pharmacies are taking this challenge seriously, spending significant amounts of resources to improve their scores. The current reward model, however, is in serious need of revision. Without reimbursement on par with the value pharmacist contribute to healthcare, this model will not survive. Only time will tell where we are headed. Until then, pharmacists need to step up to the plate, as it were, and show the patient and the payor that they are capable of improving outcomes. Pharmacists can make a significant contribution to lower total health care costs. We need to get out there and make every encounter with the patient count!

Footnotes

* While this chart represents real data from an actual pharmacy report, it is possible that pharmacies may see different reimbursement based on things like contracts, PSAO affiliations, geographic region etc. This graph is for illustration purposes only.

** Updates are represented by strike thru text and added italic corrections. Updated information was provided by PQS.

*** Updated: The plan here does not have a different rate for 90 day supplies.

We Have to Stop Apologizing and Just Do It!

Recently, I was at a multidisciplinary meeting to discuss how pharmacists and prescribers can work more effectively together to identify patients with certain risk factors and ensuring that they receive appropriate drug therapy.  As I discussed our continuous medication monitoring process (CMM), the prescribers in the room indicated that they were not familiar with pharmacists in their communities doing anything like what I was describing.   Sadly to say, their own experiences  going to a pharmacy as a patient did not help my argument.  The other providers described the situation, that is all to common, that they seldom talked to a pharmacist and if they did, they had to wait 25 minutes.  Now I realize that this may not be the actual case, but we have to remember that their perceptions are their realities.  After some heated discussion about the roles of pharmacists and turf issues, I finally said to one of the physicians who was sitting next to me questioning how pharmacists can do what I was describing that he should change pharmacies and go to one that does provide clinical services.

Unfortunately as we have written in previous blogs, too many community pharmacies (chains and independents) have settled for a “strip-down” model of practice where there is little to no overlap between pharmacists and just enough technician help to ensure prescriptions can be filled efficiently–but little thought to clinical services.  This “strip-down” model evolved out of profit motives and not what was best for patients and as reimbursements dwindled over the past decade, the “strip-down” model became even more prevalent and accepted.  Because of this, patients, providers, and payers get mixed messages.  They hear what I and others are talking about, but they experience something totally different when the go to a pharmacy.  It is time to change the paradigm of community pharmacy practice.

The paradigm change that I am talking about will change the perceptions of all who come to a community pharmacy.  First, we have to stop using the word “retail” when talking about community pharmacy as it gives a much different description then if you say community pharmacy.  Secondly, pharmacists need to become interventionists identifying and resolving drug therapy problems, counseling an educating patients, consulting with other providers, and documenting their activities.  Thirdly, pharmacists have to stop being passive in the dispensing functions.  We need to make sure that we engage patients to collect information that will help us better manage their medications.  Lastly, we need to make sure we have sufficient staff so that pharmacists are freed up to provide clinical services including CMM during the dispensing process.

For the past twenty something years we have been pushing community pharmacists to move from distribution functions to patient care.  One would think, after all these years, that we would have a critical mass of community pharmacists providing ongoing clinical services.  But given the response I received from the other providers at this meeting obviously they have not been exposed to it yet (and these providers were from around the country).  We have to stop apologizing and making excuses for why we are not providing patient care services and just be doing it!

What is in a Name?

Each of us has a name. For many of us, it was the name our parents gave to us. Others have nicknames they have elected to use. I know a few people who go by their middle name and still others may have legally changed their name for a variety of reasons (my favorite is a pharmacist who legally changed his first name to Rx—Rex, get it?).

We all have a name we prefer. Maybe many are not all that picky about the which is used. Me, I answer to just about anything. Really.

When I became a partner in my pharmacy, I became the third male owner, I found patients would address me about a third of the time by any of my real names (Mike, Michael, hey, you!). Frequently, patients would address me as one of my business partners names.

At one time worried about these de-personalized interactions with my patients. I would feel the need to be recognized  and correct the patient. With time, however, I became adept and recognizing when someone was talking to me because I couldn’t count of the salutation to give me context.

Today, I answer to just about any name. Specifically, though, I am comfortable answering to Bernie, Bill, and Randy. I no longer spend time correcting patients. I have come to understand what was really going on. Each patient has “adopted” one of us as their pharmacist.

The patient has made a positive association with one of my past or present business partners. The fact that they recognize me as that person in proxy is a one of the highest forms of compliment that can be given. It means that I am being recognized both for what I have done, and for what my business has accomplished.

As a side note, however, I will take action if my paycheck doesn’t have my name on it. I have to draw the line somewhere!

Why Don’t Payers Get It?

I was just on a conference call with a managed care organization (MCO) that will respond to a request for proposal (RFP) as our state shifts our medicaid administration to two or more MCOs.  Unfortunately, the MCO that we spoke with today did not have any idea about the role of pharmacists as care providers.  WHAT?!!!!  How after all these years, with pharmacy’s movement from product distribution to patient care, can a managed care organization or payer not understand the value of pharmacists as clinical providers.

Part of the reason is because payers are not seeing this type of practice across the board.  Also, not all pharmacists are practicing to the level of their degrees–identifying and resolving drug therapy problems, providing recommendations to prescribers, and documenting their activities.  Lastly, payers may be looking at the wrong metrics when reviewing pharmacies (e.g. focussing on drug costs and not clinical parameters and patient outcomes, including health care spend).

As a profession, we need to do a better job of selling ourselves to payers and, in particular, our value to the health care team.  Our value is that we have access to patients, we are able to identify and resolve drug therapy problems, we can ensure that patients are on safe and effective medications, and most importantly, we can make sure patients are achieving therapeutic outcomes–which will positively affect their total health care spend.

But all pharmacists also need to step up their efforts to develop and implement patient care services if they have  not already done so.  There is no money in product distribution because there is little value from patients and payers.  The value statement is patient care, achieving health outcomes, and the unique role and knowledge of pharmacists to monitor and manage patients drug therapy.   So, we need to make this the “norm” of pharmacy practice–not the exception.

Pharmacists, as a group, also need to be more vocal about the clinical roles to payers, legislators, and regulators.  We cannot just sit on the sideline hoping that someone can figure this out–each of us has a responsibility to advocate for our profession–to reach out to payers and let them know what you are doing and the value you bring to their clients through your patient care services.  If we do not do this, our profession will continue to experience the response that I experienced today–and that is getting old!!!

Pharmacists in the 21st Century

Pharmacy and pharmacists are navigating uncharted waters. The reason is the many the recent and significant changes in healthcare. Two very different factions emerging within the profession:

  • Medications as a commodity and
  • Pharmacists as providers of care

The competition between these factions will shape pharmacy and healthcare for years to come. Will one faction win over the other, or will the profession move in two different directions?

Medications as a Commodity

The mechanics of this faction are complicated, and there are many different parties actively involved. The net effect for pharmacy is a severe reduction in reimbursement for the drug product. Historically, pharmacies and pharmacists have earned their living providing both medication and care, but being paid only for the medication component. The downward pressure on reimbursement has resulted in what we have previously named “the stripped down model of pharmacy.”

The ramifications for the commoditization of pharmaceuticals are significant. Only by ramping up volume can a pharmacy continue to meet overhead costs. Increasing efficiency can take a pharmacy only so far down this path before the bottom line becomes negative. The largest single overhead expense in a pharmacy is wages, and one person can only fill or check a finite number of prescriptions in an hour.

Mail order pharmacy has pushed efficiency to the logical end, where one pharmacist (which is legally required in most states) is “checking” thousands of medications a day. Robotics and automation run the “pharmacy” in these operations.  These large prescription mills can deliver an almost limitless number of prescriptions every year without any human intervention. Medications show up in the mail box, and the patient has to contact an unknown pharmacists over the phone if they have any questions or concerns.

Even with a highly efficient operation, retail pharmacies across the country are struggling to maintain profitability given the ever decreasing reimbursement this model provides. Smaller pharmacies across the country are closing at an alarming rate. Many of these pharmacies service more rural areas of the country, creating in interesting dilemma for patients. This Darwinian process of survival of the biggest could have severe repercussions as healthcare evolves. In this faction, efficiency has come at the expense of patient care.

Pharmacists as Providers of Care

On the other side of the battle are the pharmacists working with patients to ensure therapeutic outcomes. In direct contrast to the high efficiency, robotic or automated systems required in the above model, a care oriented practice may have several pharmacists working at any given time. The difference is what is being provided. While the patient ultimately receives a medication (product), they are also receiving service and care. The pharmacists review the patient’s medications, look for and address real and potential problems with the patient and their doctor(s), and work with the patient to ensure that they are obtaining the optimal outcomes. Pharmacists ensure medications are used safely and effectively.

At the present time, pharmacies are still being paid primarily for product, and it is likely that no matter which direction the profession of pharmacy ultimately follows, reimbursement for the drug product will forever be limited. Future support for the pharmacist as a provider of care will have to come from a fee for service model. Medicare and other are starting now recognizing the importance of pharmacists providing care to enhance patient outcomes. Even a single pharmacy has the potential to save a payor millions of dollars yearly by providing quality care (this will be the focus of a future post here).

A fee for service or pay for performance system will eventually need to become reality. Until reimbursement for service catches up to the importance of pharmacists providing care, pharmacies that have embraced the service model are struggling to stay in business. It may not be until Medicare recognizes pharmacists as providers, allowing them to bill for clinical services to the patient’s medical benefit, that the pharmacy as a service model gains widespread traction in our healthcare system.

Winners and Losers

In case it isn’t clear, there are no clear cut winners. Pharmacies and pharmacists will continue to struggle on both sides. What is becoming forgotten is the patient, who has the most to lose.

It is likely inevitable in the current health care system,  that medications will become a commodity. Reimbursement for the product in the future will probably only be sufficient to cover basic overhead. It is with the emergence of reimbursement to pharmacists for care that the fate of pharmacy as a profession rests.

If I had to pick a faction to win, however, it would be the pharmacy as a service model. In this regard, the profession of pharmacy has a lot in common with the professional airline pilot. Consider that today’s airplanes can take-off, fly and land without a pilot, much like a prescriptions filled by an automated pharmacy. Now ask, would you want to fly in a plane without a pilot? Who will be there if something doesn’t go as planned, and the automated system cannot land the plane? Similarly, how safe would you feel if there were no one looking over your medications to ensure that there were no potential or real problems? Who will answer questions about the medications and how to best take them, and will they know you? Pharmacists providing care are an important part of the health care system. Until the time when pharmacists are recognized as providers, pharmacists will need play on both sides of the equation: making their practice as efficient as possible while at the same time going the extra mile to make every encounter with their patients count!

 

The Sandbox

One of the most challenging issues facing today’s health care providers is sharing information. Technologically, one might assume that it would be easy to create a system of data exchange between providers. The reality, though, is that providers may be selective with what they will share, who they may share it with, and how they share it. The primary obstacles to sharing of information are security and access, and these barriers are as much a political issue as they are technical obstacles.

 Obstacles

Security and privacy of health information is a significant obstacle. Just like breaches in major retail stores that make the nightly news (see Forbes for a list of significant breaches in 2014), health information is also under attack (e.g. Anthem, see CNN). The same technologies that enables modern transactions are also able to be exploited by criminals.  Despite recent headlines, however, current technology (when implemented properly) is capable of reliably protecting our personal data, including a digital medical record.

Another significant obstacle is the actual exchange of medical records. All health care providers ( e.g. the physician, pharmacy, hospital and laboratory etc.) maintain some type of patient record. Every procedure, prescription, or visit results in changes in that record. Each change made by one provider (say at the hospital) would, in an ideal system, be updated automatically with the patient’s other providers (e.g. the specialist, the pharmacy and the primary physician). Assuming that security of the data can be maintained without any issue, the remaining problem is a lack of a standardized format for the record. Each repository of patient information is necessarily different because every provider focuses on different aspects of patient care. The format of the records can be very different. At one extreme,  paper record (charts) are still in use, while others may leverage electronic medical records (EMRs). In essence, each provider’s records speak a slightly different language.

The Language of Health Care

Among the first organizations to recognize the importance of intercommunication between health care records were hospitals. The laboratory’s electronic records need to communicate with the electronic chart, hospital billing systems, the computerized census system and the pharmacy’s dispensing system. An entire industry was born to help facilitate this data exchange in hospitals, and with this came the creation of several standard languages, one of which is HL7 (Health Level 7).

Using computers as gateways, hospitals use tools like HL7 to link many different systems to provide a relatively seamless transmission of information between systems. But as good as this would appear on the surface, these gateways have significant obstacles of their own. Gateways are labor intensive to maintain and regularly require maintenance to keep them running. Small changes in one system can break down communication between multiple systems. To Make matters worse, there are many different dialects of the HL7 “language” so even if two systems both speak HL7, information can be lost in translation.

Politics

If one accepts that security of the data can be handled by current technologies, and that gateways like HL7 can facilitate the translation of data, one final obstacle exists. The laws that exist to protect the privacy of health information (like the Health Insurance Portability and Accountability Act of 1996 also called HIPAA) also govern the exchange of information between providers. This exchange may or may not require a written release (depending the the relationship between both providers and the patient). The provider’s access to records needs to be limited to only their patients plus any patients. It is also possible that a given provider may still want to control what data is shared, and when it is shared.

The Implications

Because of the obstacles above, providers and patients struggle to seamlessly communicate. The fax, which became widely available in the 1980’s, is still one of the primary means of communication between providers despite the proliferation of communication options available today. The ramifications are significant, and examples of the problems created by the lack of real-time communication are easy to find. From a pharmacy perspective, four common issues are:

  • A patient admitted to the hospital. The admit process requires the hospital staff to document an accurate medication history. Hospitals do not have access to the current the prescription history for the patient maintained by the patient’s pharmacy, creating a chance possibility for errors, adverse drug events and improper therapy.
  • Therapy changes made in the hospital. These changes need to be communicated to other providers (e.g. the primary care physician and the pharmacy).  The lack of standard communication between hospitals, the primary care physician’s EMR, and the pharmacy’s records can lead to discrepancies.
  • Routine changes made at a physician office. Patients are often instructed by their physical to increase or decrease doses of drugs they take without a new prescription being issued.
  • Medical information related to drug therapy. A pharmacist managing a patient’s drug therapy requires a significant amount of medical and laboratory data to ensure optimal outcomes. Without seamless access to a patient’s relevant laboratory results, relevant diagnosis and pertinent history and physical, pharmacists are limited in their ability to perform Continuous Medication Management (CMM)

Jumping Thru Hoops

Many electronic medical records and other health care provider systems have made their way to the internet. Using secure web portals, providers can access their patient’s records from a variety of locations (office, hospital, home etc). The internet has become an enabling technology for providers trying to share information. If two different systems do not communicate (e.g. the physician’s EMR and the Hospital EMR), at a bare minimum, the provider can access both systems from a single computer to update and check records. Many providers find that they maintain accounts with multiple internet enabled medical records.

A pharmacy with good relationships with several providers might be able to gain access to a variety of records to enable productive collaboration. Besides having access to their own clinical record system, a pharmacy might have access to a hospice’s EMR, multiple nursing home EMRs, and access to records from one or more laboratories. This creates a chaotic environment where information must be gleaned from multiple sources and documentation made across many different records to ensure proper communication between all providers.

Even with great relationships between providers, gaining access similar to that described above is difficult. A pharmacy might serve 10% of a medical practices patients, and access has to be limited properly to prevent improper access. Likewise, a pharmacy would only want grant records access to a provider’s patients.

Today in healthcare, communications between providers is more important than ever before. And today, the fax still dominates communication between providers. It will likely be take a long time before all providers can come to and play in the same sandbox.

Managing Diagnosis Collection on the Fly

A key factor in performing continuous medication monitoring (CMM) is knowing the indication of  each medication a patient is taking. Sometimes this is easy to decide, and other times it can be challenging. The important step, however, is documenting the information once it is known. This article will discuss strategies and workflows that we use to collect and document diagnosis information.

Certainly of Diagnosis

When documenting a diagnosis in a patient record, it is important to state the level of certainty associated with the diagnosis. For example, the indication for some drugs is often easy to guess. Statin medications (HMG-CoA reductase inhibitors) are rarely used for anything except hyperlipidemia. We refer to the pharmacists best guess for the indication as a inferred diagnosis. Sometimes a pharmacist may consider a likely indication but recognize that the possibility exists that the medication is being used for something else entirely. An example of this might be the drug metformin. While this medication is used primarily for diabetes mellitus type 2 (formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes), it can also be used “off label” for Polycystic ovary syndrome (PCOS). In the case of a female patient without other evidence of diabetes in their profile, assigning a diagnosis of PCOS would be recorded as a suspected diagnosis. When the indication is specified explicitly, either by the prescriber or on a prescription, the diagnosis would be considered confirmed. 

Diagnosis Source

Similar to the documentation of the certainty of a diagnosis, it is important to note the source of the information in the patient record. We use three categories to refer to the source of a diagnosis.

  • Pharmacist — This is used to indicate that the pharmacist, using clinical judgment, has assigned a diagnosis based on their knowledge of therapeutics.
  • Patient — indicated that the patient has identified the diagnosis
  • Prescriber — is used when the prescriber has stated the diagnosis

A Diagnosis Workflow

At our pharmacies, CMM is performed at the final verification stage of the prescription workflow. After the pharmacist verified that the new prescription or refill has been filled with the right drug and is labeled correctly, they evaluate the profile a look for potential or real drug therapy problems. The clinical workflow screen displays the diagnosis associated with the drug being checked. If no diagnosis is specified, the system may suggest possible indications for the drug (see Figure 1 below). The pharmacist can assign an inferred indication to the patient quickly at this point. Here, the source of the diagnosis would be the pharmacist and the certainty would be marked as inferred. If a new prescription includes diagnosis information, this too can be added to the profile with the appropriate source and certainly indicators.

suggestion
Figure 1. A clinical documentation system making a suggestion for a possible diagnosis for the drug.

If a diagnosis is uncertain, the pharmacist has the opportunity to engage the patient when the mediation is picked up. At this point, the pharmacist could create an intervention (Figure 2) and flag the prescription for counseling, including a note (Figure 3) to clarify the diagnosis with the patient. When the patient arrives, the pharmacist has the opportunity to consult with the patient and determine if the inferred or suspected diagnosis is correct. Information received from the patient can then be used to further update the pharmacy record.

 

Intervention2
Figure 2 Documentation of an Intervention by the pharmacist to clarify a diagnosis

 

tag
Figure 3 Example of a will call tag to be placed with the prescription order to aid the pharmacist in collecting information at the point of sale.

 

 

 

 

 

Often, a patient confirmed diagnosis is sufficient for the needs of the pharmacy. Sometimes, however, the patient may not be a reliable source. In these cases, the workflow should include a method to send a short SOAP note to the prescriber requesting clarification of the diagnosis (Figure 4). Once this information is returned, the diagnosis information for the patient can be completed.

SOAP2
Figure 4 Example of a short SOAP note requesting confirmation of the diagnosis.

 

Collecting accurate, relevant patient drug-diagnosis combinations is an important step in the CMM process. Leveraging the patient at the point of sale is yet another example of making every encounter count.

It’s About the Therapeutics!

As co-owners of two community pharmacies, a compounding pharmacy, and a consulting company, my business partner and I have created practices that  have developed and implemented value-added services.  The services we have implemented include immunizations (flu, pneumonia, shingles and TDaP), health screenings, disease state management, medication therapy management, medication adherence program, medication synchronization services, consultations for CPAPs, ostomies and wound care, and continuous medication monitoring.  Although I described these services as “value-added”, it is not the service in and of itself that is of value to patients, but rather the pharmacists’ knowledge and their ability to problem-solve for the patient.  As I write this blog today, I am reminded of a statement made by one of my pharmacy colleagues when asked what makes a good pharmacist and his reply was “It’s about the therapeutics, stupid!”

My colleague was absolutely dead-on.  We can offer many value-added services, but if pharmacists do not have the clinical knowledge and skills to ensure that patients are achieving their therapeutic outcomes with safe and effective drug therapy, then these services are just a shell with no real value.  As our health care system moves to a value-based system and providers are evaluated based on their performance, then it will be those pharmacists who keep up with the literature, keep their knowledge current and relevant, and are capable of identifying and resolving drug therapy problems who will thrive in this new system.

Unfortunately, there is not an easy way for pharmacists to keep their knowledge current and it requires a lot of work and energy.  It requires that pharmacist keep up with the guidelines, read and understand landmark studies, be involved in professional organizations, and apply their knowledge consistently in the practice setting.  For some it may require some remediation, whereby they may need to take a series of courses on therapeutic topics that they need to further their understanding.  But it does not end there, because to become comfortable with new knowledge, it is important that it is applied to everyday situations until it becomes entrenched in memory.  Perhaps purchasing an updated therapeutics textbook as a guide will help, along with a case study workbook to apply new knowledge and therapeutic skills.  Another approach is to connect with a faculty mentor who can provide you with reading material and cases to help you become a better clinician. Employers should invest in their employees and encourage them to attend local/state/national conferences, which would help increase their value as employees to better the practice.  Even with employer support, it still is up to the individual pharmacist to read, assimilate, and apply new knowledge.  In other words all of us need to become life-long learners.

At the end of the day, those pharmacists who keep their therapeutic knowledge current and relevant will be of great value to the health care system.  More and more payers are recognizing the value of good and effective pharmacists in reducing total health care spend and improving patient outcomes.   I am convinced that the future of our profession lies in our ability to affect patient outcomes, collaborate with other providers, and improve the bottom line of payers.  Now is the time to prepare yourself for the this future which is coming fast and furious.  It will all serve us well to remember our value to the system is all about our therapeutic knowledge and how well we can apply it to our patients!

Writing Effective Communications to Prescribers

Over the years I have been asked by many pharmacists why Towncrest Pharmacy gets such a good response from physicians and other prescribers when we send them a SOAP note and recommendations.  My response to them is that it took having many conversations with different physicians, creating easy to use physician communication forms, and learning how to write succinct, clinically relevant notes that matter to physicians.  This experience has helped me to develop a set of criteria that I use to teach pharmacists, residents, and pharmacy students on how to write an effective SOAP note.

Criteria for Physician Communication.

  1. Keep it succinct and clear.  It is important that our SOAP notes are not lengthy nor convoluted.  The information needs to read easily and be understandable.  By using the SOAP note format (S = Subjective, O = Objective, A = Assessment, and P = Plan) pharmacist create a note in a format recognizable and understood by prescribers.  Subjective information is information that the patient has told you, objective information is something that was measure (e.g. labs, vitals, etc), assessment is the pharmacists evaluation of the subjective and objective information to identify potential or actual drug therapy problems (DTPs), and the plan is the pharmacists recommendations to resolve the DTPs.  It is important to keep the SOAP note to one page, if at all possible, and include an updated medication list.
  2. Provide the prescriber with information they do not have.  What I mean here is that pharmacists need to look at their patients and their drug therapy with a critical eye.  Pharmacists need to be asking themselves how their patients are taking their medications, if they are adherent, if they are achieving their therapeutic goals, and if they are experiencing any adverse drug reactions (ADRs) including side effects and drug interactions.   By systematically reviewing each medication in this way, pharmacists can communicate information to physicians that may be otherwise unknown to them.
  3. Describe the problem.  The assessment part of the SOAP note is where pharmacists use their critical evaluation skills to identify the drug therapy problems that patients may be experiencing.  The categories of drug therapy problems that we use to describe the problem is what has been used extensively in the literature including:
    1. Untreated indication
    2. Need for additional therapy
    3. Adherence
    4. Dosing issues (dose too low and dose too high)
    5. Unnecessary drug therapy
    6. Adverse drug reaction (side effects and drug interactions)
  4. Provide concrete recommendations to prescribers.  Over the years I have learned provide recommendations that are answered with a yes or no by theprescriber.  Also, I make it clear on the form that I use thatprescribers understand that the recommendations become a prescription if approved and signed by the physician.  For example, I recently provided the following recommendation to aprescriber.
    1. Patient is taking both sertraline 25 mg QD and trazodone 150 mg QD. She has a PMH signficant for dementia with behavior disturbances, depression, and anxiety.  Her last depression evaluation indicated minimal depression.  Due to concerns about CNS ADRs with trazodone, can we attempt a trial reduction of her trazodone to 100 mg QD, #30 tablets, 11 Refills?  _____Yes  _____No
  5. Be evidence based.  It is important that pharmacists keep current with their therapeutic are are aware of the literature to support their recommendations.  This does not mean that you have to cite a particular study, but it does mean that you are able to do this if questioned and challenged.  If prescriber become confident in your knowledge and clinical skills they will more likely become more accepting to your recommendations.

Knowing and applying these criteria will help community pharmacists impact their patient’s care and help to develop collaborative working relationships with prescribers.  It is our responsibility to ensure that our patients medications are safe and effective, but we need to effectively communicate with other providers if we are to be successful in helping our patients.

Continuous Medication Management (CMM) and the Profile

[dropcap color=”white” background=”black” style=”rectangle” size=”big”]A[/dropcap]t Our pharmacies, we put a great deal of emphasis on performing clinical services while working on the dispensing counter and we call this process continuous medication monitoring (CMM). By this, I mean that the pharmacist, while verifying that the prescription was filled correctly, is also responsible for an in-depth look at the patient’s medication profile each and every time the patient has a prescription filled. To accomplish this, we have developed a software platform for our clinical pharmacists to work with while on the counter called PharmClin.

While the PharmClin package contains a comprehensive array of features including documentation for the clinical pharmacist, one of its core features is the patient profile. The single most important piece of information that a pharmacist has to make clinical assessments is the patient’s medication profile. The remainder of this post will look at the importance of the profile and how a logically formatted profile can aid the pharmacist in CMM on the fly.

A dispensing profile

Before looking at a clinically oriented profile, consider that a PMS (Pharmacy Management System) also maintains a patient profile. The user experience when trying to use most PMS profiles to perform CMM, however, quickly deteriorates. A Pharmacy Management System (PMS) is designed to facilitate dispensing. The PMS profiles are, therefore,  optimized for dispensing activities, and not CMM. Consider a PMS like McKesson’s Pharmaserv below (click to enlarge).

PMS Profile
Example Profile from Pharmacy Management System

This screen grab is fairly typical of most any commercial PMS in that it shows the history most current at the top. The level of detail visible, though is limited, and one has to select a prescription to see the previous dates (in the split window below). In all, the information visible is related primarily to dispensing.

This begs two questions:  1) what information displayed by the PMS do we not require when making clinical determinations and  2) what is missing that we would want to see? Taking these questions in order, our clinical pharmacists were less interested in:

  • Original Date (because it does not related to the first date the patient started taking the drug)
  • Refill number
  • Strength and form (because it is duplicate information)
  • Price
  • Facility
  • NDC
  • Coverage / Insurance
  • RPh and Tech

Keep in mind that almost all of these have significant value when considering the dispensing aspects of pharmacy, they just are not relevant to the most common clinical issues.

Our clinical pharmacists were interesting in seeing a few other details without having to drill down into the record. These included:

  • Days Supply
  • SIG or directions
  • Recent Refill Summary
  • A selective profile representing only the most recent therapies

Our clinical pharmacists were also interested in being to quickly spot

  • Specific therapeutic drug categories (e.g. those in the EQuIPP measures)
  • Drug interactions
  • Compliance Issues

A Clinical Profile

With this in mind, we pared our clinical profile view down to the following (for sake of comparison, this is the same profile as listed above): (again, click to view the image)

PharmClin Profile
Example profile from a clinically based system

Besides some small differences in sorting and the scale size of the screen capture, the profiles represent the same exact data. One of the first things you might notice is that the profile is narrower (taking up much less space across the screen). The changes represent most of the important items on our clinical staff’s wish list for the profile.

Some things in this profile may not be initially obvious, but are exceptionally helpful to a clinical pharmacist performing rapid CMM on the counter. To simplify the profile , only the last three dispensing incidences for each given drug are displayed, and these are all displayed together, without respect to Rx number, NDC or other drug product changes. This saves the clinical pharmacist time as they do not need to hunt thru the profile. One advantage to this method is that the pharmacist can review compliance over the last three dispense occurrences quickly.

Other simplification were made to the profile. To reduce the amount of data to be interpreted, only the last 180 day are displayed, significantly reducing clutter in the profile. If a clinical situation requires a complete history, that option is available.

Another key difference is the addition of color. While the color-key is not visible in this screen capture, the drugs are color coded as follows:

  • Statins in GREEN
  • ACE / ARBs in RED
  • Diabetic medications in BLUE
  • Drugs listed as high risk (Beer’s List) in PURPLE
  • Drugs that precipitate drug interactions in ORANGE

All of the above color-coding relates directly to the current CMS 5-STAR rating guidelines, and allow our pharmacist to quickly make 5-star related determinations on compliance, high risk drugs, and drugs that are known to precipitate interactions.

Besides color-coding drugs that are known to precipitate drug interactions, the profile has drug interaction column that highlights any interactions flagged by the PMS. This column is kept minimal and does not show the details of the interaction by design. We decided that if we did not know what was going on, we could click to look, but for the most part, knowing that an interaction was flagged was enough for our clinical pharmacist to make their assessment. Interaction pairs are easy to spot this way. Drug – Alcohol and Drug – Food interactions sometimes create an ODD number of interactions, but after a bit of practice, spotting problems becomes very easy.

The profile above is not perfect, and has changed with time as we work thru our CQI process. One of the things that would be most helpful to us would be an accurate listing of medical conditions. Unfortunately, while PharmClin and our PMS do have the capability of entering this information, we often do not have documentation of actual diagnoses. For the purposes of “on the fly” clinical work, therefore, we use implied diagnoses, and the color coding is helpful in this.

I should point out that our clinical system does a lot more than just show the pharmacist a patient profile. The patient profile is important to start the process, but once the pharmacist has identified a problem, they have to document it efficiently. Once the pharmacist notes something worth documenting, they can document an intervention system for the next pharmacist or even write a quick SOAP note to send to the prescriber. Interventions and SOAP Notes can be flagged for follow-up.

Notes on PharmClin

PharmClin (patent pending) was developed as an in-house documentation tool for a clinically oriented retail pharmacy. The product currently integrates with McKesson’s Pharmaserv, but integration with other PMS vendors is being pursued. More details about PharmClin are available on the Innovative Pharmacy Solutions website. Web demonstrations can be arranged from that website.