By Matt Phillion
The numbers are staggering—more than 10,000 prescription medications on the market, with many patients on more than one medication at a time (PSNet, 2019). According to a recent study by the Get the Medications Right Institute (GTMRx), nearly a quarter of the patients surveyed said their medical team did not regularly review their medications, despite a third of the respondents saying they were currently taking four or more medications (GTMRx, 2021b).
The opportunity for error grows from there: One in five said they were prescribed medications by three or more physicians in the past year (GTMRx, 2021b). Healthcare leaders have identified lack of communication between prescribers and pharmacists as a major challenge in medication management (GTMRx, 2021a). But how do we improve this situation?
“We have an explosion of life-saving medications,” says Katherine H. Capps, co-founder and executive director of GTMRx. “Also 80% of how we treat and prevent illness is with medications. But multiple medications prescribed by multiple physicians to treat multiple conditions is a huge area of risk.” That’s a finding echoed in the medical literature, including a recent study in Annals of Pharmacotherapy (Watanabe et al., 2018).
What gets in the way of better oversight for patient medications? “There are professional silos that prevent us from integrated care,” says Capps. She cites an earlier GTMRx survey (2021a) among 300+ healthcare leaders who identified those silos as one of the biggest issues facing the healthcare industry. “Lack of communication between those professionals creates opportunity for error,” she says. “We know this.”
It’s seen in the numbers, too: Capps notes that roughly 275,000 lives are lost a year and $528 billion are wasted due to non-optimized medication use (Watanabe et al., 2018). “The impact of that siloed approach is lost lives and waste,” she says.
The growth of medication use feels nearly impossible to keep up with. It takes roughly 73 days for medical knowledge to double, says Capps. “This is why more strategic use of health IT to enable that interprofessional team is important,” she adds. “Getting clinical information to the point of care is essential. We’ve been working at this for years, with the growth of electronic health records for example, but those silos and lack of data sharing arrangements can prevent access to that information.”
Making change in this case means more than just a shift in communication between prescribers and pharmacists—it requires an evolution in the business of healthcare. “There is a lack of payment models that are less fee-for-service, but rather reward interdisciplinary team-based care that [moves] toward a patient- and person-centric model,” says Capps.
Without the right payment models and healthcare IT infrastructure, prescribers lack access to diagnostic findings and clinical information at the point of care.
“We know today that there are companion and complementary diagnostics that can help us target the correct therapy—but we can’t get access to the results of those diagnostics in an efficient way at the point of care,” says Capps. “When we talk about moving to a more personalized medication use process, we’re talking about enabling that through health IT, the use of companion diagnostics, a new payment model, and more.”
The pharmacist’s role
Giving the right meds to the right patient—in the right dose, and at the right time—requires a team, Capps says. Although physicians deal with diagnostic dilemmas, they can’t possibly solve for all the medication-related issues they encounter when they see a patient.
“Right now, with an abbreviated visit and a fee-for-service environment, they’re spending less than a minute talking about new meds,” says Capps. “With a payment model that rewards an interprofessional team, the outcome should be a better medication use process.”
But such a process is possible even in a fee-for-service environment, provided physicians have access to the team members who can evaluate the patient and ensure they are meeting their clinical goals. In fact, GTMRx conducted a focus group this spring and found that many physicians have been working with clinical pharmacists for years using this process of care. “Physicians are 100% open to working directly with a clinical pharmacist if they understand in what ways they can be involved,” says Capps.
This means moving the pharmacist into more of a patient care role. “When they know that the clinical pharmacist can support them in a collaborative way, they are accepting of that—many physicians have their residency training with the VA, which is a leader in this type of process of care,” says Capps.
This collaborative process can lower spending, increase patient satisfaction, and decrease physician burnout, says Capps. “We have evidence of all those things,” she says. “It helps [physicians] work with patients who have complicated medication combinations, those who are seeing other consulting physicians. They recognize the value in that.”
Rather than pushing back against physicians and treating them as resistant to change, advocating for this care model calls for education and increasing awareness, Capps says. “It’s that they may not be aware of how they can deploy this interprofessional team to benefit patients and integrate with their practice,” she says.
GTMRx sees the clinical pharmacist’s role in this situation as different from their traditional role under Medicare Part D. Instead, their role involves more comprehensive medication management. After determining if the clinical goals of therapy have been met, the pharmacist then moves through a defined process of care to ensure that the medication is safe, effective, and appropriate for the patient and able to be taken as intended.
“We’re advocating on behalf and see a real savings opportunity within—with improved clinical care and patient satisfaction, lower costs, and better outcomes,” says Capps.
As part of this practice, the clinical pharmacist works to identify patients who would most benefit from this multidisciplinary interaction. “You do a risk stratification—high-risk patients, people who are on multiple medications—and the clinical pharmacist works with the team to understand the patient’s personal medication experience,” says Capps. “Their history, preferences, observations.” The team can then identify clinical use patterns, including over-the-counter medications, bioactive supplements, and prescribed meds, and assess each medication for appropriateness, safety, and effectiveness—including interactions.
“In the past we focused on adherence. It was the only way to solve for medication therapy problems. The safety goal was ‘I got them to adhere.’ But our argument is to say ‘What if it’s the wrong meds?’ ” says Capps. “We’re talking about including that clinical pharmacist earlier [in the process].”
This approach fosters a relationship between the clinical pharmacist and the physician. “They’ll develop a care or medication plan with recommended steps, changes needed to achieve optimal outcomes in consultation with the physician,” says Capps. “The clinical pharmacist will ensure that the patient agrees with and understands that plan.”
The pharmacists communicates the plan to the provider for support, and then these activities are documented. “It’s an iterative process. Consultation and follow-up. It’s almost like physical therapy,” says Capps. “The pharmacist doesn’t do anything without your orders and knowledge—we’re a team working toward achieving these goals, and the patient is a part of that team.”
One of the most significant surprises in GTMRx’s survey findings, Capps notes, is that medications are not being routinely reviewed. “That’s disconcerting,” she says. “Medications have the biggest opportunity to help, but also to harm.”
The aforementioned combination of multiple prescriptions from three or more doctors in the past year remains a worrisome takeaway. “As consumers, we assume that the medications are being evaluated,” says Capps. “But one prescriber may not know about meds being used by other consulting physicians.”
Patients can get lost in the shuffle of when to start and stop overlapping medications, as well, and those who are taking multiple medications from multiple prescribers are most at risk. “At what point in the process do we stop and evaluate the effectiveness, the appropriateness, and the safety of these medications?” she asks. “Are we proactive in that process?”
In the event of a medication cascade, things can spiral out of control quickly. A multiprofessional team can better identify and work with patients most in danger of this—patients who have one or more chronic conditions, frequently visit the emergency department or urgent care clinic, or are taking complex medications that require specialized care.
There are many places where medication management can get off track—when patients transition from the hospital to home, or from specialty to primary care, for example. Low health literacy rates mean patients can struggle to follow their medication regimen and need more assistance.
“It boils down to knowing the patient is part of their own care team,” says Capps. “Who do they go to in order to understand? It’s clearly not the intent of any caregiver to guide them wrong.” Rather, she says, we lack the stop points to change how we practice and pay for care, how we use companion and complementary diagnostics, and how we ensure health IT best serves the goal of optimal patient care.
“We have so many scientific advancements, and the way we practice [isn’t] keeping up with those discoveries,” Capps says. “It’s essential we get medications right. It’s fundamental to how we transform care.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.
Get the Medications Right Institute. (2021a, May 19). Health care leaders say lack of communication between prescribers and pharmacists is biggest issue in medication management [Press release]. https://gtmr.org/media
Get the Medications Right Institute. (2021b, July 14). Nearly one in four people say their medications are not routinely reviewed and evaluated by their medical team [Press release]. https://gtmr.org/media
PSNet. (2019, September 7). Medication errors and adverse drug events. Agency for Healthcare Research and Quality. http://psnet.ahrq.gov/primers/primer/23/medication-errors
Watanabe, J. H., McInnis, T., & Hirsch, J. D. (2018). Cost of prescription drug–related morbidity and mortality. Annals of Pharmacotherapy, 52(9), 829–837. https://doi.org/10.1177/1060028018765159