Quality Initiatives: Pharmacists in the Forefront

Pharmacists can lead quality transformation within their organizations.

Health systems face unprecedented pressure to improve care quality despite an increasingly complex patient population. In this era of health care reform, the US Department of Health and Human Services (HHS) has been funding numerous initiatives to improve patient care and lower costs. Among these initiatives are practice-driven projects aimed at improving care in kidney dialysis centers, home health agencies, and hospitals. These quality initiatives provide pharmacists with an opportunity to take the lead in achieving the goals defined by their organization while enhancing their role on the health care team.

EHR Documentation

As a part of the Medicare Improvement for Providers and Patients Act of 2008, the Centers for Medicare & Medicaid Services (CMS) permanently established the Physician Quality Reporting System, whose purpose is to promote the reporting of quality metrics from eligible providers. The quality measures reporting applies to physician fee schedule (PFS) services provided to Medicare Part B beneficiaries. Providers who meet the reporting requirements are eligible for an incentive payment equal to 0.5% of their total estimated Medicare Part B PFS payments. Beginning at the start of 2015, however, those providers not in compliance will be subjected to a 1.5% payment adjustment to these claims. In 2016, this percentage will rise to 2%. One of the options for completing this reporting is the use of electronic health records (EHRs).

Due to a historical lack of provider status, pharmacists have long been in the position of having to demonstrate their value to the health care system. This has often resulted in double documentation in EHRs by pharmacists to show the impact of outcomes, safety, patient satisfaction, and quality initiatives. This information can be invaluable to organizations in the current environment where meaningful use of certified EHRs is a driver for reimbursement (ie, CMS incentive programs). Starting in 2011, meaningful use objectives were defined by CMS and used to determine incentive payments. Each year, the measures increase in scope and complexity, challenging organizations and eligible providers to adapt in an effort to improve quality and receive incentive payments.

Meaningful Use Definition and Objectives

Meaningful use is defined as the utilization of certified EHR technology to:

• Improve quality, safety, and efficiency, and reduce health disparities
• Engage patients and family
• Improve care coordination and population, and public health
• Maintain privacy and security of patient health information.

Ultimately, it is hoped that meaningful use compliance will result in:

• Better clinical outcomes • Improved population health outcomes
• Increased transparency and efficiency
• Empowered individuals
• More robust research data on health systems.

Stages of Meaningful Use

Meaningful use sets specific objectives that eligible professionals and hospitals must achieve to qualify for CMS incentive programs. These objectives have been set forth in stages. The stage 1 goal for 2011-2012 was improvement of data capture and sharing, and the stage 2 goal for 2014 was the advancement of clinical process. In 2016, stage 3 will focus on improving health outcomes.

Creating a Road Map: What Are the Quality Priorities of the Organization?

By demonstrating their usefulness in achieving top organizational priorities, pharmacists can prove their value to the organization beyond individual patient care visits. These priorities will vary from organization to organization, but by identifying them early, pharmacists can position themselves to contribute and lead the initiatives that will help their organization achieve the accreditations that they are pursuing.

Several years ago, our federally qualified health center, the El Rio Community Health Center in Tucson, Arizona, became a National Committee for Quality Assurance Level 3 medical home. This designation was achieved at all of our sites through teamwork and excellent EHR documentation by clinical pharmacists. The pharmacists were instrumental in meeting the medication reconciliation and patient safety goals for high-alert medications. Our organization was also recently accredited by the Joint Commission. Our department had representation on the survey preparation committee, and our input allowed for approval of point-of-care testing. This was critical to the provision of care to underserved populations, as multiple clinic visits are often prohibited by transportation issues. These designations have led to our participation in a new accountable care organization.

Pharmacists Can Lead Quality Improvement Efforts

Given the rising burden of chronic disease in the United States, it is critical to increase the number of primary care providers available to see patients. Clinical pharmacists can play a vital role through the development of standing orders/collaborative practice agreements. This allows an organization to increase provider contact with patients while also freeing up physicians to treat acute illness.

The first example of this type of chronic disease management is our diabetes management service started 14 years ago with our most difficult to control diabetes patients. Providing intensive, frequent management appointments, pharmacists were able to demonstrate the importance of their role in the management of diabetes in the clinic setting. Several years later, a dietitian was added to the service, and at the time of this writing, there are 8 clinical pharmacists providing diabetes management services. By pursuing American Diabetes Association and American Association of Diabetes Educators accreditation, El Rio Community Health Center received reimbursement for intensive diabetes management and care provided by the clinical pharmacists. This care continues to result in improved glycated hemoglobin (A1C) levels and patient adherence to treatment guidelines.

The second example is our anticoagulation service. A pharmacist is uniquely positioned to run an anticoagulation services program given the proliferation of potential drug interactions. At each visit with the pharmacist, medication reconciliation is performed, allowing for the identification of adverse drug events so that poor outcomes can be avoided.

The treatment of chronic pain is often cited as one of the most time-consuming aspects of primary care by new physicians. El Rio Community Health Center’s newest service is a pain consult collaborative practice that covers nonnarcotic options for pain. Physicians can refer patients with persistent pain to the service for medication review and assessment. Medications that fall under the standing orders are addressed and pain guidelines followed. This initiative has significantly improved appropriate prescribing and adherence to best practices in pain management. By improving the way pain is addressed in the primary care setting, both patient and provider satisfaction increase.

Keep Current with Changing Quality and Reimbursement Requirements

As previously discussed, CMS adjustments in payments for Medicare Part B patients will be an important management tool for organizations. Pharmacists can work in collaboration with information technology departments to ensure that their organization will meet the documentation requirements to avoid penalties and promote quality.

Since January 1, 2015, CMS has been using a new service code for care management needs not provided in a face-to-face visit for Medicare Part B beneficiaries. This will allow reimbursement for critical care components such as lab review and telephone call encounters. In turn, these drive patient satisfaction and accessibility. Pharmacists can collaborate with physicians to ensure continuity of care between visits, which results in improved patient care outcomes.

Collaboration: The Linchpin in Addressing Care Gaps

One of the most frequent forms of feedback we receive from patients is regarding the timeliness of health care provider responses. Accessibility is critical to patient satisfaction and can often be best achieved through teamwork among the providers on the health care team.

As an example, many of our physicians take call at local hospitals. While performing these duties, they continue to receive messages at clinic, and lab results are returned for their review. This can create a considerable burden of work when the physicians return from their hospitalist duties. A pilot project was implemented in which pharmacists were responsible for responding to and assessing lab results. Depending on results, pharmacists instructed the physician’s team to call or send a lab letter to patients. If a critical value was returned that could not be addressed by the pharmacist, that pharmacist would inform the physician on call to respond to the situation. This collaboration has since become a permanent service provided by the clinical pharmacy team and has had an immense impact on patient satisfaction and provider retention.

The US health care system continues to evolve with an emphasis on preventive care. Two initiatives utilized by El Rio Community Health Center that attempt to address gaps in care are care guidelines and i2i Systems management. Clinical pharmacists are responsible for updating care guidelines at each patient encounter and when they manage lab results for out-of-office providers. This results in fewer missed opportunities for preventive care services, such as screening mammograms and colonoscopies.

The clinical pharmacists fill an important role in addressing these gaps as the documentation of the care guidelines can add extra time to a provider’s patient visit. Additionally, our i2i Systems software allows for population view data to be pulled from the medical record to enhance care, most recently to identify patients whose A1C remains above 9%. By identifying these patients, we can perform targeted interventions and reduce the burden of diabetes in the population that uses our clinic.

Pharmacists play a vital role in quality initiatives, both by taking the lead and working as part of the team. Provider status can only enhance these partnerships and create additional revenue for pharmacists’ visits for individual patients. Currently, the Pharmacy and Medically Underserved Area Enhancement Act (HR 592, S 314) is being debated in both chambers of Congress and, if passed, could increase the role of the pharmacist on the health care team.

As pharmacists continue to work toward full integration among care teams, they must endeavor to understand their organization’s quality priorities, step up improvement efforts, keep abreast of changing requirements, and foster collaboration.

Amy K. Kennedy, PharmD, BCACP, is an assistant professor in pharmacy practice and science at the University of Arizona College of Pharmacy. She also serves as the residency program director for the PGY-1 pharmacy residency at El Rio Community Health Center. Dr. Kennedy earned her PharmD from the University of Wisconsin-Madison and completed a community practice residency and community-based participatory research fellowship at Virginia Commonwealth University School of Pharmacy. She is board certified in ambulatory care. As a clinical pharmacist, Dr. Kennedy provides care to her patients in a patient-centered medical home model. Dr. Kennedy’s current teaching and research interests include preventive health, the impact of mental health on medical outcomes, outpatient pain treatment, pharmacy professionalism, and the pharmacist’s role in caring for the underserved.Sandra Leal, PharmD, MPH, is the vice president for Innovation at SinfoníaRx, a provider of medication therapy management (MTM) services nationally. Her role is to develop, implement, and sustain new clinical MTM programs. She previously served as medical director for El Rio Health Center, a large federally qualified health center. In that capacity, she established a pharmacy collaborative practice agreement to integrate pharmacists in patient care teams embedded in an accountable care organization and patient-centered medical home. Dr. Leal has been active in advocating for recognition of pharmacists as health care providers to ensure that every patient experiences the benefit of comprehensive medication management to improve their health outcomes and safety.