What is the future of medication management?
I have a vision that a sick person would have access to their combined medical record and have that record available when they visit a new physician or specialist. Many share this same dream, from patients to providers, from healthcare workers to IT implementers, from payers to employers, from clinics to hospitals, nearly everyone acknowledges the merit of this vision.
For the purpose of this article, let’s limit these objectives to medication management: A person would have access to their combined medication list, have that list available electronically and have it easily accessible when they visit a new physician or specialist. It would be ideal to take that a step further and have a mechanism for a patient to report back on any discrepancies.
What are the impacts of a consolidated medication list?
The core impacts of medication management and reconciliation are significant
- Safety: Drug to drug interactions could have life or death repercussions, and at a minimum cause serious adverse reactions. Naturally our individual physicians, individual EMR systems and eRx prescribing systems all include drug to drug interaction checking now. But what happens when a patient visits a new physician or specialist and that provider is unaware of existing prescriptions?
- Adherence: When a provider sees a patient and prescribes a medication for a condition, it is often assumed that the patient uses the prescribed medication. Physicians do not always know if a patient is actually taking the required medication.
- Cost of healthcare: Redundant prescriptions may be issued when a provider is not aware of existing prescriptions. Further, because health insurance benefits often pays, prescriptions are filled that are not taken, wasting healthcare dollars.
- Patient response mechanism: Often patients themselves do not know which medications they are taking. By having a consolidated medication list available to patients they are better able to make this list available to a new provider. Making the patient aware of their medications is also a step towards increasing their feeling of control and self-efficacy. Further, if we provide a mechanism for patients to indicate which of their prescriptions they are actually taking, the provider will have a more accurate picture of active medications.
What is the current status of the industry on medication management?
In terms of interoperability, medication management is further along than any of the other interoperability challenges. The core impacts of medication management were recognized early and were one of the first components of the medical record to go ‘electronic’. Electronic prescribing has been in effect for about ten years, was included as a requirement of Stage 1 meaningful use, and is standard operating procedure in many medical facilities.
Still medication management is one of the most challenging components due to both the large number of brands of each medication, name synonyms, differing compendia with sometimes contradictory information, dosage variants, etc. Incorrect medication prescriptions have a high liability tag. Yet medications can be dispersed by more than one physician to a single patient, so there is a large benefit to managing the entire picture for one patient. Drug interaction issues also contribute to this issue.
I believe that one of the success factors of medical management interoperability was that one company was the primary provider for the electronic prescribing interface to EMR systems. One major eRx company provided both an interface and a certification process for eRx systems. This certification dictated key processes, safety requirements and data format. This made it more straight forward for EMR systems to connect. Further, pharmacy systems had one primary vendor with which to integrate, speeding that process along as well.
Have we made any progress?
Yes, we have made a lot of progress in medication management.
- Providers that have EMRs typically do electronic prescribing.
- Refill requests are also supported by the eRx interface and are therefore also available to providers through their EMR.
- Medications are included in the CDA format, the common format for medical record exchange.
- HIEs collect the medication records
- When an EMR is connected to a patient portal, the medication records can appear and would be available to patients.
- Pharmacies are creating medication applications where patients can view their medications
- Some pharmacies make their medication records available to other providers servicing their patients.
- There are medication applications that allow patients to manage their medications, some of which include medication reminders and similar features.
With all of these successes it would seem that we are awfully close to our goal.
Yes, so why have we not achieved our vision for medication management?
- Only 60% of all prescriptions are electronically prescribed.
- While most EMRs can create a common format for medications, they are not set up to send those records to the correct destination to meet patient needs.
- There are typically many connections for each office/EMR instance to support
- Patient approval is required
- Extra work is often required on the part of the already over-burdened provider.
- The ONC created a mandate and then funded HIEs across the US.
- Every HIE operates independently, initially creating their own standards, result sets exchanged, and order of implementation.
- While initially well-funded, many HIEs now seek sustainable funding solutions, often competing for other health care dollars.
- EMR vendors were then tasked with exchanging data with all HIEs (some 200 plus), with each one supporting 20+ interfaces. Additionally each HIE partnered with different HISPs, causing more implementation cases. The logarithmic aspect of this challenge is impressive.
- At the onset of this mandate, there were very few interface standards. Fortunately we have improved and now have several, though competing, interface standards. However money and time was wasted on the earlier versions and those that were implemented still need to be supported. The stronger standards are finally rising to the top so this challenge should diminish as we go forward.
- Further, not all patients trust the state-run HIE organization. They are not sure how it will be funded in the future and question if either Payers or Employers might have access to confidential information.
What is happening with patient portals in this area?
Patient portals offer the most successful implementation of our vision. When EMRs tie to a portal, the medication records are available for both the patient and the physician. Further, many of these portals offer features that help patients manage their medications.
- One of the bigger challenges for Patient Portals is that they are often tied to a specific EMR. This can be an advantage when a patient visits only physicians in the same organizational structure who are all using the same EMR. However, when the patient crosses EMR boundaries, there is often no easy way for the new physician to send their new medications to the same patient portal.
- Non EMR specific patient portals face the same integration challenges as HIEs since they are at the mercy of the EMRs to integrate to their platform. This is further confused by vendors choosing one of the many possible standards for integration. There is always a long waiting list for integration resources.
- Patient Portals still provide the best hope for a patient-focused solution if they can hold out long enough to get past the challenges. They embody the ‘right idea’. Unfortunately this is still not as commonplace as one would wish.
- If we look at Kaiser, who is way ahead of the rest of the country in interoperability, they have complete patient portals combined with Kaiser-level EMRs. They have solved these problems because they encompass such a large network in a large territory with significant market penetration.
How are pharmacies involved?
Patient medication records provided by pharmacies offer a new approach to meeting our vision. Pharmacies are offering consolidated medical records either on a web site or via a smart phone app. This is an exciting area and could be a viable solution. Many insurance policies insist that medications be filled at just one pharmacy, so right away we have all medications going through one organization.
- Pharmacy based organizations are now providing apps that include the patient’s medication list.
- This feature was recently offered by my local pharmacy. One downside is that it does not show existing prescriptions. Instead the user needs to wait until the next time a specific prescription is prescribed or filled before it appears. Eventually, perhaps after using a year, it is presumed the complete medication list will be available.
- Many of these apps do include reminders and it is likely they will be upgraded soon for more patient centered features.
- This version of the solution will come closest to our vision. At a minimum, a patient could show the physician the list on their smartphone app. One downside is that it lacks an easy way to integrate that record back to a physician, or more importantly the new physician the patient is visiting today. Perhaps if the record could be printed, then it could be provided in a printed form as an interim solution. Or perhaps a link to this summary could be provided to the new physician by the patient.
- The other limitation is that pharmacy medications alone stop the continuum of full medical record integration because they are limited to medications only. Nevertheless, if this one subset of the bigger picture is resolved successfully it could become a great example of benefits to the larger solution.
- Another related feature coming out of pharmacy systems is the web-based offering for providers to access patient medications. With this approach a physician can enter the name of the pharmacy and patient identification and get access to the patient’s medication list online. It still needs to be typed into the EMR, but at least it is available.
- Medication management apps are also being offered by independent application developers. These will face many of the challenges that the portals face, but may help to move the paradigm along.
Are there other impediments to meeting these goals?
There are conflicting beliefs and tendencies regarding patient engagement
- Some providers do not trust patient reported data
- Physicians do not value ‘patient feedback’ in the same way they value other diagnostic information.
- Additionally, few EMR systems support mechanisms for recording patient reported data
- Some providers are pushing patients to manage their own care.
- Some patients are not able to report accurately, which has led to the success of apps that use sensors to track and report patient information.
- Physicians are already over-burdened. They are willing to take on new initiatives only if it is simple to do, does not cost anything extra and makes life easier.
- Physicians don’t want to leave their EMR interface for any additional steps. The EMR must support functionality automatically before it becomes main stream.
- There is provider concern that putting patient data in the hands of the patient will bring on a whole slew of new issues.
- The security issues involved with exchanging data directly between patients and physicians have not been clearly identified.
Other interesting solutions
One vendor created a very interesting solution. They provide both a web interface and a mobile app that combines all of the patient’s medical record. They encountered all of the typical challenges with trying to access the electronic record and importing it into their app. They found a way to work around the technology roadblocks: The patient gives the company contact permission to get their records from their providers in whatever format is available. Part of their service is to collect the data and enter the collected information into the system. The full information is then available to the patient through either their web-based portal or their smartphone app.
Of course companies prefer to collect this information electronically, but it is interesting that when we eliminate all of the technology roadblocks the solution is simple!
Many of the technology pieces to support our vision are available today. There are many stories of cool solutions. We have yet to develop a scalable solution that pulls all the required pieces together. That said, medication management systems are way ahead of other types of health information exchange. For those 60% of prescriptions that are transferred electronically, the major eRx vendor knows what has been prescribed and what the pharmacy dispensed. The eRx vendor is focused on getting the information back to the provider through the EMR. Pharmacies have records for both electronic and non-electronic prescriptions and are willing to make those records available to patients and providers.
Technologies and processes are converging. I am hopeful that we are getting close to achieving our vision for medication management. If we can do that well for medication management perhaps there is hope for the broader goal of having the combined medical record available to patients and their providers and we could start reaping some of those advantages outlined above.
Author: Nancy Lush, Lush Group, Inc. Nancy is a member of the HIMSS Value of Provider-Patient Engagement Task Force. She has been developing sophisticated software solutions for over 35 years and has depth of experience in interoperability, healthcare systems, adapting systems for usability and data centric solutions. Her extensive operations and management experience helps her apply pragmatic solutions to the many challenges we face in HealthCare IT