Saturday, September 10, 2011

Exchanging Health Information to improve medication adherence

Getting the right medicine into the right patient at the right time is a particularly challenging problem in outpatient care. Consider the required steps:
  1. Prescriber selects the right medication
  2. Prescriber prescribes the right medication
  3. Patient carries the paper prescription to the pharmacy
  4. Pharmacist interprets the written prescription correctly
  5. Pharmacist selects, packages and labels the medication correctly
  6. Patient returns to pharmacy
  7. Patient receives the correct package
  8. Patient takes the medication as prescribed
  9. Patient requests refill at appropriate time
  10. Return to Step 5
There are lots of variations on this scheme depending on insurance, expired prescriptions, need for clarifications, etc, etc., etc. A big one recently is that Step #3 is sometimes replaced by a network connection with quite high reliability.

There have been a number of studies on "secondary non-adherence" in which the pharmacy records identify patients who don't get refills (Step #9). There have even been some analyses of patients who drop off their paper prescription but fail to pick up the medicines (Step #6). However, until recently, the gap between prescribing and dispensing the first unit (Steps #3, "Primary Non-adherence") has been very difficult to study because of the lack of information exchange between the prescriber and the dispenser.

Marsha A. Raebel and the good folks at the Kaiser Permanente Institute for Health Research in Colorado just published an article in The Journal of General Internal Medicine about using health technology to identify those patients who need help in getting their first fill. They looked at over 12,000 new electronic prescriptions for  blood pressure, cholesterol or diabetes. Overall, about 7% failed to pick up their first medication, even though these patients had pretty good insurance coverage.

It is not clear yet why these folks don't show up to pick up their pills. Nor is it clear exactly what should be done about it. However, it is clear that this kind of health information exchange between prescribers and pharmacists should trigger an alert to someone inside the system: "This patient is not getting the intended care - call them and find out why!!"

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