ASAP Midyear Recap: Pharmacy Automation and Medication Safety

Tuesday, August 8, 2017
Author: 

Marsha K. Millonig, MBA, BPharm

The American Society of Automation in Pharmacy’s (ASAP) Midyear Conference brought more than 100 key technology executives together for three days of learning in Palm Beach, Florida.

Throughout the meetings, there were nearly a dozen inspiring and informing educational sessions and plenty of chances for networking with colleagues from across the country.

Personalized Prescribing

Cal Knowlton, BS Pharm, PhD, the CEO and founder of Tabula Rasa Healthcare, provided keen insights into common adverse drug events that cause more than 100,000 deaths per year and interfere with the quality of life for millions of people. Knowlton explained how typical pharmacy software systems have offered a binary view of drug-to-drug interactions which may only look at a single drug vs. a single drug. This can lead to many other factors not being considered, including multiple drug interactions and accumulative side effects.

Knowlton cited a recent JAMA study (2016; 316(20):2115-2125) that showed emergency department visits related to adverse drug events have risen 40% from 2005/06 to 2013/14. He noted the FDA’s suggestion back in 2011 that part of the answer is personalized, precision prescribing. (I’ll visit that issue in-depth in next month’s blog.) Technology solutions that assist with personalized prescribing can help address both the pharmacokinetics and pharmacodynamics issues associated with multiple drug interactions and accumulative side effects, including:

  • Pharmacogenomics (drug/gene pair, metabolic risk, competitive inhibition risk)
  • Including OTC, recreational, and herbal medications
  • Renal and liver function metrics, which affect medication metabolism
  • Accumulated side effects that foster/exacerbate preventable ADEs
  • Aggregated side effect risk (FDA, relative odds ratio)
  • Aggregated acetylcholine burden risk
  • Aggregated sedative burden risk
  • Aggregated long QT interval risk

His takeaway messages to participants were that pharmacists need medication risk mitigation (MRM) tools embedded in their workflow and that pharmacy software providers need to either license or create such tools. He also stated that payers need to move to “personalized” formularies that have sufficient drugs in each class to facilitate two or more metabolic pathways. Finally, he noted the industry needs to stop thinking that adherence metrics can be measured by “persistent” metrics. Rather, personalized/precision comprehensive medication management means medication safety being personalized, with reminder packaging and proper adherence metrics.

Future Focus

Other forward-looking presentations included:

  • The growth and status of the nationwide Community Pharmacy Enhanced Services Network in North Carolina, based on the very successful Centers for Medicaid and Medicare Services (CMS) innovation award
  • Growing use of IBM’s Watson artificial intelligence computer in healthcare and the creative partnerships being formed to use Watson’s computer power in predictive care in a variety of therapeutic areas
  • Continued movements in specialty pharmacy, including the inspiring Tim Davis, PharmD, of PANTHERx discussing how the multiple-location, independent pharmacy has evolved its specialty business as a result

I had the opportunity to describe the potential for the recently signed 21st Century Cures Act to change the healthcare landscape for all stakeholders through its new funding to spur the discovery, development, and delivery of new innovations in medical devices and drug therapies. (I will share more on that in a future blog as well.)

DUR and Alert Management

But the focus was not all about the future. Many current technology topics were tackled as well. The move toward biosimilar drugs was explored vis-à-vis its impact on pharmacy and pharmacy systems.

Highlights of 2017 legislative bills that addressed Prescription Drug Monitoring Programs (PDMPs) were reviewed. Technological advances in the world of e-prior authorization were presented, as well as the latest state requirements for ePA.

The recent Chicago Tribune editorial on December 16, 2016, titled, “Dispensing danger: How pharmacies fail to warn patients of toxic drug interactions” was addressed from the standpoint of how a variety of issues surrounding drug utilization edits and pharmacy workflow could contribute to the problem. Speaker Tim Kosty, RPh, MBA, noted many questions first visited 25 years ago, when DUR systems were being designed, are still relevant today:

  • What alerts should we display? Why?
  • What do we want the pharmacist to do with the alert?
  • To which alerts can only the pharmacist respond?
  • What impact will these alerts have on workflow?
  • What look back in time is relevant for DUR?
  • What is an active prescription?
  • Should we consider inactive prescriptions?
  • What are the clinical and legal perspectives?

Kosty reviewed a range of issues, from management decisions, clinical sources, legal issues, payer claims systems, and alert fatigue, that impact the DUR area. He ended reviewing some future strategies recently suggested by Rupp and Reynolds (Improving Clinical Decision Support in Pharmacy: Toward the Perfect DUR Alert. Rupp and Reynolds. Journal of Managed Care and Specialty Pharmacy. Jan 2017), including:

  • Sophistication of system logic used to generate pro-DUR alerts should be improved to make increased use of statistical probability models and branching algorithms to improve accuracy.
  • Pharmacy organizations should enlist clinical staff to report inappropriate or irrelevant alerts and create an expert committee within the organization to review questionable or frequently overridden alerts for the purpose of recommending system customizations and providing feedback to database providers.
  • Displayed alerts should be quickly interpretable and actionable and should include the patient safety consequences of ignoring the alert.
  • Continuous quality improvement of pro-DUR systems should be the shared goal of database and system vendors, system administrators, pharmacy organizations, and clinicians.

Kosty went on to suggest that pharmacy organizations create a continuous quality improvement function to evaluate actions taken by pharmacists on DUR edits displayed, including using both internal and external clinical experts to review results and recommend changes to improve clinical appropriateness and modify edits to reflect real-world experience. Further, he suggested that metrics be developed that measure pharmacist quality in addition to productivity. He also encouraged working with software providers to develop best practices based on real-world experience and that de-identified data being shared with software and drug compendia providers.

I believe one of the best parts of ASAP Midyear is getting a good idea of the issues that the industry is facing and the solutions being developed from great speakers with sharp insights. With this recap, I hope you have some insight as well!

Marsha K. Millonig, MBA, BPharm, is president and CEO of Catalyst Enterprises, LLC, and an Associate Fellow at the University of Minnesota College of Pharmacy’s Center for Leading Healthcare Change.

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