Pharmacy
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
Unraveling the US Healthcare Puzzle
It has been a couple of weeks since the last time I updated the blog – lots of going on here, traveling around the US, and uncovering new problems/opportunities in the US healthcare system, meeting new people and attending a few other conferences besides Health 2.0 in San Francisco.
A few days ago I attended some sessions at the AdvaMed Convention in Washington DC. Really enjoyed a session at the NZ Embassy with AdvaMed participants as well as attending the International Delegates Forum where 30 odd companies got a chance to introduce themselves and facilitate networking and possibilities of new partnerships. Even though most attendees were from the medical device industry, AdvaMed was an excellent place to learn about new emerging technologies, problems those devices are trying to solve and find possible synergies for LHD with some of them. Was impressed by how NZTE (New Zealand Trade and Enterprise) are doing an excellent job of helping NZ innovative companies attain entry into the US market, get them up to speed with current legislation and obstacles, and expand their networks.
After that was the NCPA Convention (National Community Pharmacists Association) in Philadelphia. It was an excellent expo and invaluable day spent walking around, talking with people, learning more about Medicare Part D and MTM (Medication Therapy Management), discovering that it is such a new and therefore quite flexible market with so many opportunities and ways to go particularly in MTM services and retail chains. Everyone I was talking to are seeing retail chains being a new “one stop shop” for all kinds of healthcare services including receiving healthcare and medication review/optimization services. Lots of going on in this area, though it still seems to be quite vague in terms of best practices (probably a good thing in terms of opportunities). The main problem though is still reimbursement, i.e. who pays the pharmacist or any other qualified care provider for MTM services? And how much ? (especially taking into account all the complex cases where chronic or elderly patients are on multiple medications, and the review/reconciliation/risk management, optimization for complex cases can take over 2 hours while providers are reimbursed maximum for 1 hour, etc). I was able to meet with a few market leaders in the industry, and got very good insights.
Last stop before I head back to NZ is San Diego. Seems like my company is moving in the right direction and I have some interesting developments to announce soon in terms of our US operations and business. On November 3 I arrive in Wellington, NZ to attend the annual HINZ conference - the major NZ exhibition for Health IT. I am very much looking forward to that. As some of you may know NZ is a very innovative country yet with a small market NZ companies need pipelines to enter the vast US market. These past 4 weeks in the USA have gone a long way to creating our own pipeline for LHD into the US market.
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
Tools to assemble all the pieces of primary care data together
This coming Thursday I give a talk to the General Practice Research Group at Otago University.
Otago University is one of the two main medical schools in New Zealand, and is highly regarded internationally for its innovative research and education of top class clinicians.
Some of the General Practitioners in the Department have expressed interest in Lifetime Health Diary™, especially as we are now beginning to be used on the ground by registered nurses in community health settings. Anything that can alleviate pressure points in healthcare delivery, particularly around early interventions and patient engagement, is something of interest to General Practice and I look forward to the opportunity to demonstrate what our product can do.
Topics I will be covering will include…
- How to improve communication between patient, community care provider & General Practitioner.
- Smoother handoffs between different care settings and providers (including better follow up and communication tool after discharge.
- Provide better and quicker understanding of poly-medication regimes.
- Medication Optimisation and measuring patient progress by regimes.
- Health Reconciliation Tool between rest homes, GPs and pharmacists.
- Distance medicine / Rural health.
- Green prescriptions (i.e. exercise and lifestyle recommendations), patient health management & patient safety.
- Preparing for the upcoming 40-year bulge of aging Baby Boomers
I look forward to writing up some notes about GP reaction, comments, and generally what happened at the talk next week.
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
Tools to help pharmacies manage medications
It seems obvious doesn’t it? Pharmacists are the acknowledged experts at handling medicines. They spend years training for it, and all day long mixing medications and checking for contraindications, mistakes, oversights, etc.. So it is often with shock that a newbie to the medical industry reacts when finding out that because pharmacies have traditionally only been reimbursed for dispensing medicine, they have taken a backseat to your GP or specialist in terms of managing patient medications.
However, things are beginning to change. There are some really interesting things afoot with pharmacies…
Some pharmacies in New Zealand are now managing Warfarin. “15 pharmacies nationwide now carry out “standing orders” to decide what doses of the blood thinning drug warfarin patients should receive.”
And in the United States, pharmacists are partnering with health groups to assist in patient outcomes “Some health plans are even paying pharmacists to monitor patients taking regular medications for chronic illnesses like diabetes or heart disease”. “We are not just going to dispense your drugs,” said David Pope, a pharmacist at Barney’s. “We are going to partner with you to improve your health as well.”
In both New Zealand and the United States, Adherence rates stand at only 50% (the number of people who take their medications as prescribed), which the NY Times article above says costs nearly $300 billion a year in emergency room visits, hospital stays, and medical expenditures.
But as the pharmacists take on the increased role of managing medicines, they are going to face a challenge: accessing a complete and continuous drug record for the individuals in their care. This is due not just to incomplete and disparate data silos, but in a country such as New Zealand it is common for people to fulfill their prescription at any pharmacy, which means that pharmacies cannot know what other prescriptions a patient may have received from another GP (or more).
In fact, as pharmacists move into the front line in helping people manage their medicines better, they are going to need more than just better tools for access, they are going to need better tools for capturing and displaying that data in a comprehensive and easily understandable manner. This has been an overlooked area of need, but one that we think will move increasingly into the limelight as health groups, insurers, employers, and indeed pharma themselves demand a more intuitive at-a-glance understanding of a person’s medication regime than the hodge-podge of data sets that are currently used.
In fact, I would wager that a few years from now, intuitive data displays will seem obvious, and we will all wonder how we managed to cope in the old days when data looked like….just data!
Yours in Health,
Hamish
