Medication Optimisation
Why Drugs Don’t Work. Adherence, Compliance and MTM
“These Drugs don’t work”. We hear that all the time. Yes, some of them unfortunately don’t. However, most of the time drugs do not work simply because they do not interact in a beneficial way with each other. Secondly, the majority of patients do not adhere (only 25% of patients take their medications exactly and for as long as prescribed (American Hearth Association: Statistics you need to know.). The other 75% cost the healthcare system up to $290 billion in avoidable costs (The New England Journal of Medicine ).
For these 2 reasons, drugs don’t work. The question is really why do these two reasons exist in the first place? When the drug is prescribed relatively few health professionals discuss with their patients possible interactions with other medications or herbal supplements (for example, a survey of 100 patients taking the anticoagulant warfarin found that 69% of patients take of some kind of herbal or dietary supplement, but only 35% report that their healthcare provider asked them about supplements).
And why do patients not adhere? Although I am not an expert in the field, my homework in this area indicates a lack of medication reconciliation on the clinician side and lack of incentives on the patient side, further fueled by a lack of education and guidance from the experts (including pharmacists and providers).
The first problem, medication reconciliation, is well summed up by a recent post by John Halamka about Smart Medication Reconciliation and Problem Lists: patients (his parents) received unnecessary medications as well as did not receive necessary ones because of the challenges of retrieving their history of active as well as non-active medications. Disparate data silos across our healthcare systems DO NOT talk with each other: Neither physicians nor pharmacists are able to grasp the whole picture of a medication history; herbal supplements taken by many are not discussed with the healthcare provider; discharged inpatients do not discuss the medications s/he is still on with their local physician/pharmacist who prescribes and dispense new drugs, etc. etc. – there are many examples of how different databases do not exchange patent’s related and holistic health information.
The problem of non-adherence comes down to a lack of communication, guidance, education, and support, as well as lack of time, human resources, an inappropriate reimbursement system and lack of “smart” technical tools to assist and help the providers. Communication, guidance, education etc. can easily be performed by a community pharmacist – a certified provider who often already has a personal relationship with his/her patients.
“Smart” decision-support tools available to the pharmacist, ongoing personal/phone communication and follow ups, medication review/reconciliation/optimization/suggestion, educational materials, support 24/7/365 through alerts going directly to the provider, a shift from time- and cost-inefficiency, labour-intensity and limitations of current MTM (Medication Therapy Management) services to a comprehensive, outcomes-based, personalized therapy which considers lifestyle and wellness factors while determining the most appropriate therapy. A wise and timely combination of all these activities will deliver results: improve adherence (reducing overall healthcare costs) and better health outcomes while putting the pharmacist – a trained medication professional – at the forefront and letting him/her effectively utilize valuable skills for the benefit of all the parties involved.
Yours in health,
Hamish
Solving the Unsolvable? Putting Pharmacy data in front of everyone at once
You would think Pharmacy data would be easy – after all, how difficult can it be to capture a person’s medicine regime and display it to the health professionals who need to see it?
Well, if the physicians, pharmacists and specialists are all on different software and systems, and the patient has no access at all, it is close to being unsolvable.
Thanks to sterling support from the pharmacists and pharmacologists in New Zealand we have been working with, we have managed to convert pharmacy data into not only a more easily comprehendible display, but allow that display to be viewed in real-time by any health professional the patient chooses to authorize. Yes, that’s right; the patient owns the record, and is able to authorize the relevant health professionals to view it. With clinicians in New Zealand, we are collecting initial consent from the patient at community pharmacies, which are motivated through the writing of regular prescriptions to have repeat customers collect medications at their store.
The more we work on this, the more we find out the problems people are having with the current system that keeps patients effectively in the dark. We are creating a small brochure to describe LHD MedView™, and the printer who we are using for the job spent a few minutes telling me about his wife who is on a real cocktail of medicines, hardly any of which he could remember as she was whisked to hospital suddenly a couple of weeks back. It also turned out that when her regime was analyzed, it was not optimal to begin with and the hospital instigated a number of changes. Changes which her next GP visit will probably not have easy or even any access to!
It is staggering to think how much inefficiency, wastage and suboptimal outcomes occur simply because patient’s medicine regimes are not well stored nor tracked, nor optimized over time.
We are very happy to be able to release the beta of our new product, LHD MedView™, which we hope will go some way to help solving these issues. I will write about LHD MedView™ next week – I should also be able to include a live link to the product by then as well.
There are quite a few acquaintances in the USA waiting to see this product, so next week I will jet off to the USA to visit them. If you are in or near San Francisco, Los Angeles, San Diego, Washington DC or Boston area (possibly NY too), then let me know. I would be happy to meet up to chat a bit more about it and find out if it can be of benefit for you.
Yours in health,
Hamish
Tools to assemble all the pieces of primary care data together – Part 2
Last Thursday (see my post from last week) I gave a talk to the General Practice Research Group at Otago University. one of the two main medical schools in New Zealand. It was a really interesting discussion, with much the interest being centered around providing General Practitioners with the ability to view medication regimes in a more easily and quickly comprehensible format.
There was also interest in using Lifetime Health Diary™ in extreme patient cases, where it can be difficult to draw up a complete patient background and keep track of it – particularly when a patient is seeing multiple practitioners and specialists. Some of the GPs present said they would like to try using it with some of their “problem patients”.
Perhaps unsurprisingly, there was also interest in Lifetime Health Diary™ assisting with smoother handoffs between different care settings and providers (including a better follow up and communication tool after discharge). One concrete example mentioned of interest was helping community pharmacies reconcile health and medication regimes of patients and providing a strong link between nursing homes, GPs and pharmacists. In other words, a genuine Health Reconciliation Tool.
This ties in strongly with another theme of interest – Distance Medicine and Rural Health. Rural pharmacies, as the only dispensary for many miles around, have the potential to serve as a pure source of community pharmacy usage – unlike in cities, where consumer choice in using any pharmacy creates data silos between patient and the various pharmacies and GPs they frequent.
I look forward to being able to release the view of our new medication optimisation tool in the next few days, I will post that on next week’s blog, and discuss why clinicians we have spoken to are looking forward to using it.
Yours in health,
Hamish
Better hospital hand-offs for patients with multi-med regimes
Last week I wrote about Hospital hand-offs and medical errors, and how they are a systemic problem in hospitals and that it is an area that needs to be improved.
It is a complex problem, a number of organizations are embarking on projects in attempts to solve the issue. There are various innovative strategies such as Project BOOST and Project RED (Re-Engineered Discharge), which respectively provide a comprehensive toolkit for handoffs and patient-centered interactions to learn about after-care plans following discharge.
Paul Levy, CEO of Beth Israel Deaconess Medical Center in Boston writes about a Senior Resident, Kelly Graham, who helped initiate three simple interventions that dramatically improved patient handoff outcomes.
Recently I met with the CEO from Mercy Hospital in Dunedin, who said that
a better tool for medication hand-offs would help during admissions as well as patient discharges. All too often now the “Hospital Reconciliation Tool” consists simply of patients bringing a bag with all the meds they are on
- we checked with Beth Israel Medical Center in New York, where it is also the same procedure. Conversations we have had with various clinicians indicates that to hope that all medications are all neatly noted down correctly and then made available for clinicians in the hospital to view whenever required is just that, a hope.
We hope we can provide a solution to at least the medicine reconciliation part of the equation soon with our new Med Optimization tool. It should work for hospital handoffs as well as community-based healthcare at pharmacies. If anyone working at a hospital would like to try out a better handoff tool for medication regimes, by all means drop us a line.
Yours in health,
Hamish
The Benefits of Medication Management & Optimisation
My post last week on Tools to help pharmacies manage medications has received comment in various places, so I thought I would extend it out a little more.
Last week I observed that both here in New Zealand and in the USA, pharmacies are increasingly moving into the field of medicine optimisation through medicine management. Why not? After all pharmacists are acknowledged experts at handling medications.
Dave Nazaruk in a white paper he produced for StayWell Custom Communications lists some revealing statistics on P.15 that show the cost of not managing medicines properly:
- The (US) healthcare system incurs more than US$177 billion annually in mostly avoidable health care costs to treat adverse events from inappropriate medication use.
- MRPs (medication-related problems) rival the costs of cardiovascular disease…for every dollar spent on prescription medications, we spent approximately the same amount treating MRPs associated with those medications.
These are pretty sobering statistics. Medication management and optimisation is currently a very ad-hoc system, full of loopholes and inefficiencies. GPs do not necessarily know where your prescriptions will be filled, and pharmacies do not know if you are on medications from other GPs in addition to the GP clinic that their pharmacy prescribing systems is directly connected to.
Apart from the inefficiencies, it is downright dangerous for people to be on multiple medications without having a systematic method of management. From my own anecdotal evidence, earlier this year a GP here in Dunedin told me that the worst case he had heard of in New Zealand concerning a lack of medication management resulted in an elderly lady being on 73 medications prescribed from 42 GPs! I asked him what safeguards were in place to prevent that kind of situation, and he replied, “Nothing!”.
So what might better risk assessment tools look like? Ultimately, such a tool needs to be wrapped around the patient, so the record can travel with them. In the short term however, a lot of efficiencies would be gained from community pharmacists and GPs and other providers being able to better comprehend a multi-medication patient’s medication regime. Currently, the data sources are not only disparate, but understanding them is non-intuitive, difficult and time-consuming.
This is easier said than done, gathering medication sources is not just difficult technologically, but involves an exercise of covering up data gaps and assumptions behind members of the care providing team that are often not captured systematically. And then reconciliation of all the data take the challenge to a new level altogether! However, the rewards in terms of better health outcomes for individuals, as well as system savings as a result greater efficiencies make this space an imperative for innovation.
Yours in health,
Hamish
