Ix for Rx Management: Seeking Your Input
By Josh Seidman | Popularity: 13%I posted on February 19 about the launch of our Ix for Rx Management work. We are embarking on research to examine how information therapy (Ix) strategies can address the huge problems associated with inadequate medication adherence, safety, and selection.
This work will lead to a series of public webinars and one or more white papers in September and October of this year and probably additional events, learning collaboratives or other activities in 2010. As we launch this work, I’d love to have input from as many people as possible as to where the most important issues are and what are the best leverage points for addressing them.
I welcome comments on the following questions:
- What are the greatest barriers to medication adherence (from list below or others)?
- Knowledge
- Motivation
- Health literacy
- Cost
- Provider support
- Social support
- What are the best Ix levers for improving medication adherence (e.g.,email/cell phone reminders targeted to moment in care)?
- How can Ix strategies be deployed to reduce medication errors?
- What Ix tools are most useful in ensuring appropriate selection of medications for an individual?
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March 4th, 2009 at 9:28 pm
It’s encouraging that Ix is tackling the issue of Rx management. However, I’d like to suggest reframing the list of Rx management priorities somewhat. As an industry, we still don’t ask the most important question related to Rx management. We ask about compliance and prescribing errors which are important, of course, but the critical questions about medication safety have not yet warranted the level of visibility that they deserve. Medication safety has to do both with initial drug selection, and then monitoring what happens afterwards.
Current Rx safety initiatives primarily focus on prescribing errors with e-prescribing and drug interaction alerts. However, this is not enough since a high percentage of drug-related problems are not due to error but occur in people taking the right drugs, in the right combinations, at the right dose. Most unintended drug effects are not predictable and cannot be avoided; the best we can do to manage the majority of side effects and interactions is to detect them early, before they become serious or even life-threatening. ADRs, however, often go undiagnosed. When ADRs are mistaken for other conditions, patients undergo unnecessary and uncomfortable diagnostic evaluations, inappropriate treatments, and prolonged disabilities.
Several reasons may account for the lack of ADR detection. First, clinicians often don’t consider an ADR, even when classic signs are present (Physician Response to Patient Reports of Adverse Drug Effects, Golomb, McGraw, et al). In addition, there are important barriers to investigating a possible ADR, especially for patients taking multiple drugs. The greatest barrier is the amount of time and effort required with conventional drug information resources, including drug interaction checkers, to manually look up the relevant information. Thoroughly researching ADR information for a patient on 7 drugs, for example, can take between one and two hours. Using conventional information tools requires that the clinician read at least 7 drug monographs (or side effect lists) and then read a monograph for each potential drug interaction. Because it takes so long to do the research, a thorough analysis is often not performed.
Electronic software tools can reduce delayed recognition of medication problems. Recent data has shown that computerized tools identify a greater number of adverse events compared to conventional reporting by health care providers. My company, Enhanced Medical Decisions, Inc. has developed a robust tool that uses informatics and natural language software to rapidly search professional drug databases and pinpoint information that is necessary to assess possible ADRs. The tool enables a clinician to identify possible ADRs within minutes by inputting patient symptoms and medication lists, either real-time or in batch mode. Research that would have taken hours is compressed to a few minutes using informatics technology. The tool has been designed for use by patients as well as professionals since ADR discovery is a team effort at its best.
Information therapy has an important role to play in drug safety. Early ADR detection can be improved by implementing software-based surveillance systems and natural language-based informatics tools. A “messaging system” that electronically compares treatments “just in time” against evidence-based information can assure that medication selection is appropriate. Educational programs can encourage patients to report questionable symptoms to their physicians, and caregivers to address the ADR under-diagnosis problem. Rx management programs could play a central role in enabling all of the above.
March 5th, 2009 at 11:15 am
The typical reason for non-adherence is forgetfulness. This can be attributed to lots of reasons - feeling better, not knowing that they have refills. There are lots of other reasons - side effects, financial.
Non-adherence is a complicated issue to address. In all the CMS related DM pilots where adherence was studied, not one of the 20 had an impact (that I know of).
There are lots of things being tried - e-mails, text messaging, automated calls, letters, DM programs, POS programs by the pharmacies. Not much has had an impact. Some of these programs include barrier surveys. Some of them use motivational interviewing techniques.
The key is personalized communications that are frequent enough to keep the member engaged and provide them with relevant and motivating information to encourage them to act and stay compliant. This has to be multi-modal, adaptive, and engage the multiple constituents.
March 5th, 2009 at 6:14 pm
Marlene,
Thanks for the thoughtful comments. Medication safety (including ADRs) is definitely a part of “Ix for Rx Management.” Although we began our research focusing on medication adherence, but the entire IxCenter Board of Directors agreed that it was important that the topic be broadened to include the full range of medication issues for which Ix interventions can be successful.
Josh
March 6th, 2009 at 3:49 pm
George,
These are really important lessons to keep in mind as we evaluate potential solutions. How do we create communications that are tailored enough to be personalized to the individual? How do we make them adaptive (to both the moment in care and to the varying individual needs)?
Josh
March 10th, 2009 at 7:46 am
If you think of the DIKW model (Data, Information, Knowledge, Wisdom), it is important to take into account available information for solutions. That could be claims data, lab values, diagnosis codes, demographic information, member preferences, intervention history, and many other attributes. The key is understanding which are relevant and how to use them.
You have to develop an intervention model that allows you to create sub-segments of the population. Those sub-segments can then be treated differently based on channel (letter, voice, e-mail) and messaging (clinical, savings).
The challenge becomes managing all of these data elements and sub-segments while delivering an adaptive technology (at a reasonable price point) that interacts with the consumer and changes based on their different responses.
We have had a lot of success in this area at Silverlink Communications using voice based solutions. As we have expanded into other less dynamic media like print, it is harder to do this.