Orsula Knowlton, Pharm.D., M.B.A.

Orsula Knowlton, Pharm.D., M.B.A., is co-founder, president, and chief marketing/business development officer at Tabula Rasa HealthCare. She shares how the company’s Medication Risk Score addresses interactions in complex medication regimens, how pharmacogenomics can identify opportunities to improve outcomes, and why it’s critical for these tools to be in pharmacists’ everyday software workflows.

ComputerTalk: Orsula, tell us about Tabula Rasa HealthCare’s concept of a medication safety program.

Orsula Knowlton: It’s a concept that we developed around our Medication Risk Score in order to address the very serious issue of adverse drug events, which are the fourth leading cause of death in the United States. We’re trying to help patients understand and take ownership of their medication safety, while at the same time positioning the pharmacist as the medication safety coach.

CT: So even with the sophisticated pharmacy systems out there today and the ease of access to drug interaction review, there’s still room for improvement?

Knowlton: What we find is that the existing one-to-one drug interaction reviews aren’t able to address the cumulative, multi-drug effect of a complex medication regimen. For example, when your vials all have a sleepy eye on them, how do you address that cumulative risk of sedation? When medications are metabolized by the same drug pathway, how can these competitive interactions be managed? To date there
really hasn’t been a way to identify the cumulative risk at the point of care. So we developed the Medication Risk Score, and a good analogy is to the FICO score. The score takes many factors into consideration to assess the risk of a medication regimen as a whole.

CT: How does the Medication Risk Score fit into a pharmacy system’s outcomes-focused dashboards, such as adherence metrics?

Knowlton: For the pharmacist, the Medication Risk Score provides the capability not just to assess quickly a patient’s cumulative risk, but to manage that risk as well. If the risk score is flashing danger, then the pharmacist can run scenarios to assess which medication recommendations will bring the risk score down into the safe zone. Our technology is able to pinpoint the specific medications that are causing the elevated risk, and because of this the pharmacist has actionable information that he or she can use to make recommendations for changes.

CT: That’s a powerful tool for the pharmacist.

Knowlton: It’s a very powerful tool, and it really helps build the pharmacist-patient connection. We’re also empowering patients directly, with an app that lets them identify modifications to their risk score based on changes such as when selecting OTCs. So, say you find yourself trying to pick out an OTC medication, or consider a case in which a caregiver is picking out an OTC. For a headache, do you want acetaminophen or ibuprofen, based on your whole medication regimen? When  should you take this medication based on your other medications and how they are metabolized? That’s the kind of question a patient or caregiver can answer with the app, and see the impact of a choice on the risk score and access a pharmacist by requesting a Medication Safety review™.

CT: Pharmacogenomics is another area of expertise for Tabula Rasa HealthCare. How does that come into play?

Knowlton: Pharmacogenomics allows us to build on the Medication Risk Score to develop a precision-based personalized medication regimen. Today, the pharmacogenomics test can be done at a minimal cost. It’s a one-time test that we can then incorporate into the risk score calculation on an ongoing basis. Just to give you a sense about what a powerful multiplier pharmacogenomic data is, let me tell you about a recent study we did in an elderly population of about 300 patients. We found that 78% percent of individuals were taking at least one medication that they couldn’t fully metabolize. That’s a huge opportunity for the pharmacist to improve outcomes by recommending medications for these patients that can be fully metabolized, enhancing their medication safety. This is another time when you really need to be able to address multidrug interactions. For example, someone might have two functional genes to fully metabolize a medication, but if you add another medication that is a substrate and also goes through the same pathway, it may be that the person is phenotypically a partial metabolizer and not a real full metabolizer of the medication regimen as a result of the drug interaction.

CT: So it gets complex.

Knowlton: It does sound complex, however, pharmacists are trained in the science of pharmacokinetics, pharmacodynamics, and pharmacogenomics.. But what we provide is a visualization for pharmacists to be able to easily identify the areas for risk and to be able to take action to reduce it.

CT: There’s great opportunity here for the pharmacist to do what’s been an ongoing goal: practice at the top of her license.

Knowlton: That’s exactly right. And we’re providing online accredited education, so that pharmacists can be sure they have the skills to use these tools, even if they haven’t used them in a long time.

CT: Can pharmacy management system vendors bring the Medication Risk Score and the ability to address pharmacogenomics into their software’s workflow?

Knowlton: They can. We are working with a number of EHR [electronic health record] and pharmacy system vendors, and our goal is to be able to integrate seamlessly into their workflow. We have modern APIs that enable the integration to be very streamlined. We’ve applied resources to this because we understand how important it is to bring the Medication Risk Score and pharmacogenomics tool into the pharmacy system or EHR workflow and to have it work quickly from the point of view of the pharmacist.

CT: This presents a real opportunity for forward-thinking pharmacy management system and EHR vendors out there to say, hey, let’s pull this tool in and make it available to our pharmacy users because this is the kind of service that’s going to help them differentiate themselves and raise the level of service and improve  outcomes dramatically.

Knowlton: Exactly. Fundamentally, it’s the right thing to do to offer a medication safety program that’s incorporating pharmacokinetic and pharmacodynamic science at the point of care. The pharmacogenomic testing is another opportunity for the patient to understand what medications they can or cannot take and to include that in an ongoing way in the medication review process with the pharmacy. We are not aware of any system that does this today.  And then we see the mobile app really tying this all together and helping solidify the connection between the patient and the pharmacy. The combination of all these tools at the point of care is a real game changer in medication safety. CT