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By Brian Bamberger, Life Sciences Practice Lead
Medication adherence is among the most costly challenges facing health care today. Its a very simple concept: patients should take their medications at the times, dosages and frequencies as directed by their physician. In reality, they do not.
Nonadherence to taking medications as prescribed has major economic consequences. The direct cost of medication nonadherence on the US health care system is estimated between $100 billion and $289 billion annually in lost wages, premature deaths and unnecessary hospital and doctor visits. On top of this, a recent study estimated that pharmaceutical manufacturers lose an additional $188 billion annually in revenues.
As a result, interventions to improve medication adherence should be a top priority of the pharmaceutical industry. Efforts to date largely have focused on free drugs, reminders, or lower co-pays. We believe that changes in health information technology (health IT) to provide more accurate and complete prescribing information within electronic health records (EHRs) can go a long way toward improving patients’ compliance with their drug regimens. While this alone will not solve the problem of medication nonadherence, it is a step in the right direction – particularly with respect to improving formulary and benefit data, improving medication history information and alerting prescribers as to whether prescriptions have been filled.
Leveraging the power of EHRs to improve medication adherence Existing transactions and standards could be extended and enhanced in EHRs to provide significantly more high-quality data at the point of prescribing. However, work remains to make these transactions more accurate and useful in improving medication adherence. For example:
Formulary and benefit information. In an EHR or electronic prescribing (ePrescribing) system, formulary and benefit data are used to enable formulary validation at the point of prescribing. This information is made available through a formulary and benefit standard, which has been available for nearly a decade.
Despite the promise of formulary validation to increase formulary compliance and cut costs for prescribers and patients, this transaction is significantly underused. That is because the data underlying the transaction – including co-payments, prior authorization flags, formulary tier levels and quantity limits – are either not provided, inaccurate, or too complex to be interpreted easily by a prescriber. This creates confusion and distrust of the information among physicians. The data provided in the ePrescribing system may be insufficient to meet the needs of the prescriber and patient. Conversely, too much information may be entered, creating data overload. The result: prescribers often ignore this valuable resource when ePrescribing or rely on the pharmacist to navigate the patient’s formulary requirements after the prescription is sent to the pharmacy.
Medication history. Similarly, the medication history transaction could be leveraged for purposes of medication monitoring. Medication history shows all prescriptions for patients paid by a particular insurer. While relatively comprehensive, there are still gaps. Not all payers – such as state Medicaid programs – provide such data. In addition, information about drugs paid for in cash is not captured. Generally, EHRs are only programmed to request medication history information in advance of a scheduled visit, in most cases based upon the next day’s appointment schedule. This means the medication history information in EHRs cannot be used to proactively monitor a patient’s adherence unless the patient is scheduled to visit.
Electronic fill status. Although rarely used thus far, RxFill is a tool that can help flag patient nonadherence to medication therapies before a patient’s next scheduled visit when medication reconciliation will be performed. Using this functionality, a pharmacy system can send a real-time message to an ePrescribing or EHR system indicating the fill status (dispensed, partially dispensed, not dispensed) of new and refill prescriptions. Such feedback can help providers identify noncompliant patients. RxFill information is also sent to the prescriber in real time, eliminating the need to initiate a query to access this information outside of a scheduled appointment. However, providers are not embracing this opportunity because, in large part, they are not compensated directly for contacting patients when an adherence issue is identified between office visits. Moreover, they are reluctant to receive adherence alerts due to liability fears. Pharmacies and other industry stakeholders do not see a value proposition for investing in software development and/or ongoing transaction costs to send fill status alerts back to the prescriber because they already contact patients when prescriptions are ready and not picked up.
Closing the gap. Policies to improve medication adherence using health IT must leverage existing standards to improve the quality of prescription information available within EHRs. That said, what can be done to improve medication adherence through better information and medication management in EHRs? For example:
To improve the consistency, accuracy and completeness of formulary and benefit information at the point of prescribing, how can we establish consistent standards for formulary information provided to ambulatory EHRs that include available medications and patient cost-sharing information? What best practices can help EHR vendors create more effective displays of formulary information?
To provide EHRs with more timely and accurate medication history, how can we encourage all payers to contribute medication history information? How can we better capture data on over-the-counter purchases? Could EHRs be enabled to easily link written and filled prescriptions by carrying prescription serial numbers through on claims and pharmacy systems?
To encourage wider adoption of electronic prescription fill status, what can be done to determine the return on investment to pharmacies for the cost of sending these transactions through an intermediary or directly to the provider? What is the sweet spot for getting prescribers to use this transaction to improve patient outcomes and medication adherence without sending them into information overload and alert fatigue?
Point-of-Care Partners is exploring such opportunities with standards development organizations, payers and other stakeholders to help improve medication adherence through health IT. Let us put our ideas to work for you.