For many healthcare executives, patient experience and satisfaction is one of their top priorities, and this should come as no surprise, as the move from a fee-for-service to pay-for-performance model ties reimbursements directly to quality of care. In the hospital setting, the Centers for Medicare and Medicaid Services (CMS) measures “quality” using two metrics—patient satisfaction and patient outcomes.
The patient experience is the responsibility of the entire care team. From admission to discharge, everyone has the ability to impact quality of care and patient satisfaction, which includes prevention of errors. It probably goes without saying, but there is no faster way to create an unsatisfactory experience than through error. According to a study conducted by researchers at Johns Hopkins, medical errors are the third leading cause of death in America. Research from the Institute of Medicine of the National Academies shows specifically that medication errors impact at least 1.5 million people in this country each year. While death is a worse-case scenario, these figures prove that medical error can be costly on many levels.
Appropriate medication management is central to meeting CMS quality measures, which is used to determine reimbursement rates. This is particularly true with regard to the emphasis on avoiding unnecessary readmissions. Medication management also is central to managing healthcare costs. Data from the Network for Excellence in Health Innovation (NEHI) and Massachusetts Technology Collaborative suggests that inpatient, preventable medication errors cost the U.S. healthcare system more than $16.4 billion annually.
Medication learning tools may augment prescribers’ effectiveness, and are never more necessary with the explosion of new pharmaceutical options available. Tools that are concise, evidence-based and delivered at the point of care may be most effective to meet a provider’s educational needs. This could potentially result in improved patient outcomes that translate into higher CMS quality scores and higher reimbursement rates.
Staying Current with Medication Learning
Staying current with the latest changes in medicine is a daunting challenge. Many prescribers receive the newest drug information from pharmaceutical representatives who are incentivized to promote their products. This isn’t to say that the information is incorrect or harmful, but rather to illustrate that pharmaceutical company-generated information may be written and presented in a way that is biased towards the benefits of their specific medication and may not help prescribers choose among all options.
Because medication prescribing is not one-size-fits all, having an independent and unbiased source for medication information is important. Physicians and other prescribers need to be aware of the many different drug therapy options for different conditions, and how to best compare and contrast these medications in terms of efficacy. Pharmacists need to be current on important drug interactions, medication side effects, and dosing recommendations. Medication learning resources that are provided by independent, unbiased sources may also help facilitate appropriate medication use during transitions of care.
Given how often errors occur at transitions, an effective resource has the potential to improve efficiency, lower costs, and reduce errors, which could enhance overall patient care quality. Effective resources might be those edited together by pharmacists and prescribers, and delivered in a concise and easy to digest format. These relevant resources, written and edited together by a team of pharmacists, researchers and prescribers, might more effectively meet the needs of learners than those from non-clinical or non-practice environments.
Dr. Donato’s Medication Learning in Practice
In my clinical role as an inpatient academic hospitalist with Reading Health System, I am fortunate to regularly do my rounds with a pharmacist and a pharmacy student along with my ward team. We consistently rely on medication learning materials to help with patient care, which in many cases has had a significant impact on outcomes.
A recent example involves one of my patients who had developed wound sepsis nearly three weeks after a urological surgery. This patient was placed on a new SGLT-2 inhibitor preoperatively for diabetes control. Recalling information I had learned in my role as a volunteer editor with an independent medication learning provider, I was aware of the higher risk of urogenital infections due to the medication he had taken prior to surgery, despite the fact he had stopped taking the medication two days before this admission. After discussing his prior medication with him, I was able to determine that there may indeed have been a connection between his oral diabetes medication and this infection, which was then subsequently reported to the FDA and his urologist.
Dr. Hood’s Medication Learning in Practice
As the medical director at Quality Independent Physicians, a large Kentucky-based Accountable Care Organization (ACO), I led the research on the impact of medication learning across the entire enterprise. The study found that seven months of deployment of an unbiased educational medication resource, Prescriber’s Letter, across the continuum, helped our practices align medication learning procedures organization wide. These resources, coupled with a commitment to creating and communicating standardized clinical practice guidelines, and an inclusive atmosphere that encourages clinician buy-in organization-wide were shown to create the most positive results.
The intervention was associated with reduced 30-day hospital readmissions by 7 percent and decreased hospitalization across all disease states by 26 percent. My organization’s medication management learning program proved effective in boosting these and other important CMS quality scores, while helping successfully manage key, at-risk patient populations.
Optimizing Patient Outcomes with Medication Learning
Historically, the impact of purely educational-based quality improvement interventions has been small. This is partly because they are often removed from clinical care environments and presented in online formats that do not engender memory retention. In addition they are not delivered to the groups considered to be the “key decision makers.” Delivery of point-of care information, especially if embedded into health information prescribing systems, may help influence prescriber behavior and decrease variance, but only if effectively and accurately delivered. If inaccurate or non-timely, they will be ignored by prescribers. For example, data from a study published in Applied Clinical Informatics in 2014 suggests that up to 90 percent of drug interaction alerts in electronic health records are simply overridden.
Medication errors tend to happen in one of five stages: ordering, transcribing, dispensing, administering, and monitoring/reporting. “Just-in–time” medication learning could potentially address the dispensing, administering, and monitoring processes, with the greatest impact on the ordering/selecting of correct medications. Medication learning systems present key data to prescribers, augmenting their patient interactions, resulting in the potential to decrease medical error.
Effective medication learning can also be critical to facilitate transitions of care. When a patient leaves the hospital without proper education or monitoring it has the potential to create catastrophic results. We should never assume a patient would do what they are supposed to do. A common example is called the “walk away,” which is a patient who walks away from the pharmacy window because their total bill is too high. This is simply problematic if we’re treating reflux, but could be fatal if we are treating a new blood clot. Medication learning tools have the potential to give patients and prescribers fingertip access to costs, drug interactions and alternatives that may also improve adherence.
Health systems are extremely complex organizations. Preventing errors is often a process that requires understanding and controlling for a large number of variables. It is easy to assume if a patient has a medication on their list that someone else has thought about why that medication needs to be continued, and for how long. However, that is often not the case. These errors of commission, which is when we are reluctant to stop the train because we assume someone else is driving, are all too common, and seem to occur more often when multiple prescribers are involved.
With today’s emphasis on healthcare quality, efficiency, and cost-effectiveness, we’re always looking for ways to improve. A consistent process, coupled with concise resources for medication learning delivered at the point of care delivery may reduce variability and errors in prescribing, which we believe should improve the overall patient experience.
