Health Information Exchange: Taking Pharmacy to the Next Level

(The following is a guest column written by Tony Schueth, CEO & Managing Partner, Point-of-Care Partners. AMCP News accepts submissions, but reserves the right to decline and edit all articles.)

Recent shifts in the health care landscape are making it possible now for the valuable information obtained and sometimes provided by pharmacists to be used by other members of the health care team. New payment models, mandates for health information technology (HIT), the rise of accountable care organizations (ACOs) and patient centered medical homes (PCMHs) have everyone in health care shuffling to demonstrate their value, including pharmacists.

Although involved in direct patient care, pharmacists’ federal and state status as health care providers is still formally unrecognized. But with unprecedented demand to remedy health care’s persistent challenges -- access, safety, quality and cost -- the industry is now recognizing the potential of extended care teams and the power of collaboration through health information exchange (HIE). There is nearly unanimous recognition that building and expanding capacity for HIE could be the communications vehicle necessary to improve processes and health outcomes at a global level.

Pharmacy, in general, and managed care pharmacy, specifically, is uniquely poised to mobilize HIE data and make a real and immediate impact in terms of patient safety, improved outcomes, and lower cost. Depending on the state, care setting and other circumstances, pharmacists already can:

Perform patient assessments (subjective and objective data including physical assessment);

  • Have prescriptive authority (initiate, adjust, or discontinue treatment) to manage disease
  • through medication use and deliver collaborative drug therapy or medication management;
  • Order, interpret and monitor laboratory tests;
  • Formulate clinical assessments and develop therapeutic plans;
  • Provide care coordination and other health services for wellness and prevention of disease;
  • Develop partnerships with patients for ongoing (follow‐up) care

And what’s different now is that there’s a rapidly emerging technical, payment and care delivery infrastructure creating real opportunity for pharmacy to perform in this capacity. Advancements in technology, to a certain extent, have contributed to the growth. Widespread adoption of EHRs and more familiarity with technology developments, like cloud computing, for example, in the past couple of years has begun to transform how organizations collaborate.

From a care delivery standpoint, studies over the last twenty-five years have demonstrated that pharmacists participating in team-based care models have made positive contributions to direct patient care and safe medication use. This was illustrated in AMCP’s Pharmacists as Vital Members of Accountable Care Organizations, 2011 (www.amcp.org/ACO.pdf/).

And it makes sense; pharmacists are uniquely positioned in the health care system to help optimize appropriate medication use and reduce medication-related problems. As a clinical expert working as part of an interdisciplinary team, pharmacists can help determine whether medication use is contributing to  unwanted effects or is achieving desired care outcomes. Who better to help improve adherence—a source of at least $100 billion annually—for example, than a pharmacist who sees the patient more than anyone else, including the physician? It would likely result in less duplication of services, fewer readmissions and higher quality of care.  

In the context of HIE, pharmacists could make an immediate impact by providing valuable medication history (i.e., Rx, OTC and herbal), medication allergy and vaccination information. As HIT systems, exchange capabilities and care models mature, pharmacists, with access to more complete data, could provide more advanced patient care services such as medication therapy management (MTM), and really start to drive value. Broadly speaking, the group of services known as MTM is meant to ensure the safe, effective, appropriate and economical use of medications for eligible beneficiaries. 

Integrated systems of care, such as ACOs, already view MTM – the more complex of which is performed by pharmacists—as essential to care delivery and to meet ACO quality and cost targets. Pharmacists in hospital and managed care settings are already actively involved with prescribers and patients, and their interactions are intended to improve quality and appropriateness of care, which are the very cornerstones of the ACO model. It is safe to assume that pharmacists in ACO arrangements will continue to take on a larger role in preventing readmission through such MTM activities as accounting for all of a patient’s medications for direct use, documenting the intended medical purpose for each medication and determining the objective and patient experience goal for the use of each medication. But there is also good reason to believe that retail pharmacy will also become more active in this space traditionally reserved for managed care pharmacy. Walgreens announced in January that it would be leading ACOs in New Jersey and Pennsylvania.

Taken a step further: community pharmacists with HIE access could also provide MTM. They could even participate in ACO-like arrangements where they are also incented to improve population management and care quality. Instead of simply checking a box indicating that MTM was performed, they could contract to be measured and incented based upon cost and quality metrics achieved across certain patient panels (i.e., diabetes, high cholesterol and hypertension, etc.). Adherence for diabetes or for high cholesterol patients, for example, is an appropriate pharmacy measure that also aligns with the goals of managed care. Using such measures, pharmacists could approach managed care organizations—and possibly others like Medicaid and physician groups—and offer to meet quality thresholds for more reimbursement. This would help those organizations meet their quality and costs goals, and shoulder some of the work. Contracts might also include reimbursement for resolving formulary issues or for increasing the number of electronic fill requests completed.

The rapid uptake of ACOs—whether they are Medicare, Medicaid or private—will only heighten the opportunity for pharmacists across various settings to take on a larger role in health care delivery. The evolution of these payment and health care delivery models will have a significant impact on health care, particularly if, for example, ACOs develop their own preferred drug lists, treatment protocols and formularies that will in turn need to leverage HIEs to disseminate this information. As advanced MTM becomes more widely conducted by pharmacists, the MTM activities and interventions will require information obtained through HIE. HIE will also provide the means to communicate the pharmacy interventions to other providers.

All this means that pharmacy is ready to be much more than one end of an electronic prescribing transaction or a source of medication history, dispensing and fill data for physicians. As a profession, pharmacy has been hard at work preparing for new exchange capabilities and the availability of more complete data. Pharmacists should continue to monitor the work of organized pharmacy and, wherever appropriate, get involved at the state association level to advance legislation and policy that enables pharmacists to continue improving patient and health system outcomes. The health care ecosystem appears to be at a point where pharmacy just might finally loosen the tie between pharmacy reimbursement and product distribution.