Health Information Technology: The Catalyst of Medication Management Services

A forward-looking strategy is essential when selecting health information technology solutions.

You’d have to have your head buried in the sand for the last decade to be unaware of the health information technology (HIT) race currently underway throughout the health care industry.

Hundreds of billions of dollars of investments are being directed to electronic medical records, mobile applications, biometric devices, analytics capabilities, and other sundries meant to transform how health care is delivered in this country. Without question, a forward-looking HIT strategy is essential for medium and long-run sustainability in a health care marketplace that is becoming increasingly prone to disruptive innovations.

In the first supplement in this four-part series, Directions in Pharmacy, we discussed the inevitability of health care reform, regardless of the Affordable Care Act, and the economics of change that are omnipresent and unyielding regardless of the success or failure of healthcare.gov or ensuing election cycles. In the second supplement, we discussed the imperative of developing care coordination capabilities and emerging population management strategies in response to a trend of shifting risk from payers to providers. The focus of this edition is on HIT and the “make or break role” it will likely play for health care organizations over the next few years.

If you currently work for a health care service provider and are charged with strategic decision making within your organization, there is a high likelihood that you are in the midst of at least one assessment of HIT solutions—and perhaps multiple, ongoing assessments—that will substantially affect the manner in which your organization provides its products or services. You know that there are a myriad of considerations at play, from the obvious (cost to implement, cost to operate) to the less obvious (vender dependency, cultural resistance). Most of your attention, efforts, and deliberation are directed at positioning your organization against others within your health care sector, and perhaps other health care sectors, as the traditional lines of separation begin to dissolve.

It’s easy to fall prey to a “keeping up with the Joneses” mentality. The allure of being the kid on the block with the brand-new shiny toy has been made stronger by the heightened sense of insecurity about the sustainability of conventional product and service delivery in pharmacy. Yet 10 to 20 years from now, after hundreds of billions of dollars are invested in HIT, and when 20/20 hindsight is available to sort out winning and losing strategies, we may find that it was wise to consider why we invested in HIT in the first place.

Some HIT solutions allow machines to fill prescription bottles in rapid succession. Others help us understand which populations of patients will benefit most from specific interventions. Still others, such as gamification apps (yes, that is a real word), are meant to better engage and activate the patient. HIT comes in all shapes and sizes with wildly varying capabilities and functionalities, but they all have one common overarching purpose—to enable our current product and service provisions to be more efficiently delivered.

In this light, HIT can be viewed as a co-enzyme, acting as a catalyst or accelerator of processes, but worthless on its own. Co-enzymes can have a dramatic effect on the precision and volume of output for biochemical processes, and are often essential—if not outright required—for the normal functioning of daily life. Kind of like your pharmacy fill system, right? But without the enzyme itself (the service you provide), what good is the co-enzyme (the accelerant)? So, before making your next HIT investment, you may want to ask yourself, “What is the core service that you are attempting to accelerate or make more efficient with the particular HIT solution under consideration?”

HIT Consideration #1: Refill Reminder Services

I had the good fortune to be invited to participate in the design and implementation of a prescription refill reminder service nearly a decade ago, before these types of fill optimization solutions became commonplace. The project was motivated by a desire on the part of retail pharmacies to increase prescription fill volume, and they utilized outbound telephone calls to the patients to remind them that their medication was overdue for refilling. The cost per call was low and the patient experience was favorable. Importantly, initial prototype deployments produced an increase in refill rates, although the upward trend was modest.

During the development of the HIT solution, there was some debate about the depth of interaction with the patient and whether it should be bi-directional in nature. Should this service simply remind the patients to fill their medications and allow them to touch-tone the refill if they wanted the medications filled? Or, should the utility ask the patient what barriers, beliefs, and motivations about his or her medication are causing them to be late with the refill? Was it co-payment burden? Was it the lack of confidence in the drug? Was it a belief that the drug wasn’t needed? Perhaps the prescriber told them to stop taking the medication and the service should be turned off in these instances? It was tempting to pursue a more complex approach with potential to be far more effective at increasing prescription fill and refill rates.

However, bi-directional communication with the patient, even if automated, is a vastly complex, more expensive HIT solution with a significantly longer time horizon to deployment. So, the HIT solution provider was left with a very difficult decision to make—go with the conventional deployment? Or invest in the more complex and expensive strategy?

It is much easier to answer this question now, roughly a decade later, with most retail pharmacies rapidly refashioning themselves as members of the “medical neighborhood,” with population-level patient engagement and health coaching solution capabilities. But this project was pre-Affordable Care Act, pre-payment reform, and perhaps most importantly, pre-HITECH (economic stimulus directed at HIT investment and deployment).

In the end analysis, it was instructive to go back to the foundational question, “What core service is this HIT solution meant to accelerate or make more efficient?”

For the more complex deployment, the utility provided a cost-effective mechanism by which to determine the patient-specific reasons for non-fulfillment of medications. But then what? Most pharmacies at the time had no service offering to pair with this HIT solution. What if the pharmacy was told by the patients that they didn’t believe medication helped them with their condition? What if they believed that their condition wasn’t of enough consequence to justify the use of medication?

Did the pharmacy have a call center to coach these patients? Did the pharmacy have ready access to the prescriber to clarify therapeutic goals? And most importantly, were their pharmacists authorized, trained, and prepared to respond within their current workflow upon receipt of this highly valuable information? If there were no medication management or patient coaching services available to those receiving a refill reminder call, what was the point of accelerating non-existent service and making its delivery more efficient?

HIT Consideration #2: PHARMACeHOME Deployment

Recently, Community Care of North Carolina (CCNC) deployed the PHARMACeHOME™ platform across its system of medical homes and associated wrap-around care management and coordination supports.

CCNC is a constellation of nearly 1700 primary care practices that contracts with multiple payers for population health management services. Back in 2007, we added medication management services to the list of supports provided to patients enrolled or otherwise linked with these medical homes. As part of this expansion, we added pharmacists from multiple settings of care to round out the service in the mold of the “medical neighborhood” model.

Rather than create a universal process with rigid protocols for the delivery of all medication management services across the state, we opted for a universal definition of activity, with flexible local deployment. This resulted in the formation of the Pharmacy Home concept wherein we followed a set of guiding principles that promoted medication optimization processes across the spectrum of care. (For a full description of the project, see www.pharmacyhomeproject.com.)

Pharmacy Home Project Principles

The mission was to bring together information flows and service offerings across multiple licensures, credentials, and settings to create:

• Well-coordinated…
• Goal-oriented…
• Continually reinforced drug use plans…for all patients as the standard of practice.

In the spirit of these guiding principles, our medication management platform sought to be universal in its documentation and definitions, but allow for flexible user types, activities, and human resource allocation of effort. What works in Charlotte, North Carolina, may not work in Boone, North Carolina, or Whiteville, North Carolina—each community having different population needs and medical cultures. But most importantly, each of these towns is diverse in the depth and type of personnel resources available to support medication management for their own medical neighborhoods.

Through the challenge grant program sponsored by the Office of the National Coordinator for Health Information Technology (ONC), we created the PHARMACeHOME™ platform, which has the ability to collect and distribute medication list data of multiple types (eg, prescription fill history, hospital discharge list, active list from the medical home’s electronic medical record), combined with information resulting from medication management services (eg, drug therapy problem finding, SOAP notes, memos and communications) and the ability to task activities to other care team members virtually across the state of North Carolina.

This type of a cloud-based system was ideal for CCNC since it supports, both directly and in partnership, so many different actor-setting combinations. An actor-setting combination example would be a pharmacist (the actor), the community pharmacy (the setting), or a nurse (the actor), and home health (the setting). CCNC currently has more than 40 actor-setting combinations involved in some manner with medication management supports for its medical homes. The PHARMACeHOME™ platform is meant to be the medium by which those activities are documented, coordinated, and directed.

Following a period of gathering wide-ranging feedback from future users, and then the development of the platform, we created extensive training materials, user guides, presentations, and educational events to prepare for the launch of the PHARMACeHOME™. It turned out that this was all very helpful for users, but was missing a key component—proper training on how to perform the services in the first place.

We mistakenly trained pharmacy technicians, licensed clinical social workers, nurses with multiple credential types, call center staff, and many other types of care team members (including pharmacists, physicians, and extenders) in the proper use of the technology without any training in the proper provision of the service. User confusion ensued and while adoption occurred, it was not without consternation.

So, we completely flipped the deployment model and revisited even the most basic elements of medication management, such as how to transcribe a medication list and how to identify the essential elements of a medication (ingredient, strength, and form). Rather than train on the technology, we now train on medication management processes first (even if it is a revisit/retrain for a well-versed pharmacist fully capable of providing the services), then we layer in training on the technology from the very purposeful perspective of how it will make the delivery of those services more efficient—and thus more effective to the betterment of their daily work flow and work satisfaction.

The result? To say there was a dramatic difference in user acceptance would be an understatement.

Troy Trygstad, PharmD, PhD, MBA, is the director of the Network Pharmacist Program and Pharmacy Projects for Community Care of North Carolina (CCNC), a parent organization of 14 regional care management networks. These networks bring together medical practices, county health departments, hospital systems, and mental health providers to integrate care delivery for Medicaid, Medicare, private plans, employers, and the uninsured. CCNC and its networks are responsible for developing and evaluating accountable care systems in North Carolina.Under his direction at CCNC, the Network Pharmacist Program has grown to include pharmacists who are involved in a number of diverse activities ranging from patient level medication reconciliation to practice level e-prescribing facilitation to network level management of pharmacy benefits. Dr. Trygstad also plays an integral role in health information technology adoption and proliferation with CCNC practices and across the state, leading e-prescribing adoption efforts as well as the development and deployment of a statewide medication management platform.He has been involved in novel adherence implementations as well as the development of adherence technologies that use administrative claims data to predict, intervene, and triage adherence interventions and coaching opportunities. Dr. Trygstad received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina.He is co-editor of the Pharmacy Times series on Directions in Pharmacy.