In the late 1970s, a drug interaction feature was added to pharmacy management systems. These interactions were based on manufacturers’ package inserts and the drug literature available. However, they were and still are one-dimensional interactions. They do not capture the more complex issue of multiple drug interactions and competitive inhibition.

While the opioid crisis has rightfully received much attention in the press, a more common danger is overprescribing. Statistics from the Centers for Disease Control and Prevention show that people 65 or older who are on five or more medications have a 50% chance of an adverse drug event (ADEs). It’s now not about how one drug interacts with another, but a web of interactions. Throw into this mix personalized medicine, with the understanding that everyone metabolizes drugs differently, and the potential for adverse drug reactions increases dramatically. With all the medications out there, doctors, pharmacists, and other healthcare providers can’t be expected to know all the metabolic pathways of each drug in real time. So this is where the Medication Risk Mitigation (MRM) Matrix from Tabula Rasa HealthCare comes into play, with its multidimensional perspective. The MRM lets pharmacists analyze drug absorption, distribution, and metabolism, as well as accumulative drug interactions and drug-gene interactions. The MRM Matrix is the backbone of the clinical support tool MedWise Advisor. Both systems give a patient a risk score, with a color-coded visual alert and detailed clinical analysis. This takes medication management to the next level, as it illustrates competitive inhibition, and pharmacists can recommend not just a different drug, but the same drug at a different time of day or in a different dosage.

Calvin Knowlton

“When we looked at it back in 2011 and 2012, when we started this, we said, there’s got to be a different way that looks at the root cause — and that’s how we turned to the science of adverse drug events,” says Cal Knowlton, Tabula Rasa HealthCare chairman and CEO. “Maybe there’s a way to look at the underlying science that’s behind these drug interactions, and then maybe we can work to fix something — because with the one-to-one drug interaction all you can really do is say, I’m going to stop that one medication.”

“With older folks, they are seeing multiple physicians, and every physician has his or her own med for a specific problem. So what we’re seeing is a confluence of problems. It’s usually not one physician overprescribing. It’s usually the notion that it’s cumulative,” says Knowlton.

Over the past 18 months, MedWise Advisor was used in a pilot program for 240,000 patients in Midwestern health plans. The company risk stratified the population, coming up with 34,000 patients at risk for adverse drug events based on such factors as number of medical conditions, type of medications, and age. Pharmacists were then trained on MedWise Advisor to evaluate multidrug simultaneous interactions. This sort of approach takes medication therapy management to a new level, since it tweaks not just the actual medications, but how each metabolizes for a specific person. The key here is preventing an adverse drug event or reaction (harm by a drug at normal dose) and puts the pharmacist in the driver’s seat when it comes to seeing when this might happen, and letting prescribers know it’s a possibility.

Success Stories

Randy McDonough, Pharm.D., co-owner and director of clinical services at Towncrest Pharmacy in Iowa City, Iowa
Randy McDonough, Pharm.D.

Randy McDonough, Pharm.D., co-owner and director of clinical services at Towncrest Pharmacy in Iowa City, Iowa, had an early look at the MedWise Advisor program. He was impressed by the amount of evidence-based information available, like the sedation properties of specific drugs, competitive inhibition of different drugs, and adverse effects. “It really gives a full picture of the safety of a specific mediation to a specific patient,” he says.

The matrix is visual, so pharmacists can see where the problems are. “Pharmacists will be able to quickly assess potential risks and make a decision, quickly and accurately, in recommending a different dose or a different time of day for the medication,” says McDonough. The training requires pharmacists to go beyond what they are used to in evaluating clinical interactions. “At this point it is one of the most sophisticated platforms for evaluating medication interactions,” says McDonough.

There is a six-hour training program on pharmacokinetics and pharmacogenomics with MedWise Advisor. While pharmacists have had this in school, they might not have used it, and the refresher includes reviewing cases to show how to apply the MedWise Advisor program. The result is a medication safety review that can be attached to a patient record and shared in a documentation system. “The goal,” says Cal Knowlton, “is to have this integrated into the pharmacy system.”

Towncrest’s Director of Clinical Operations Kelly Kent agrees. “I graduated in 2003, and I knew about the many competitive inhibitions that exist between drugs,” she says, “but I didn’t have all the information in one place to effectively manage it.” The software illustrates the inhibitions, as well as details like how long a dose remains competitive. Pharmacists then have the knowledge to make a recommendation to a prescriber. ““We were very impressed by its comprehensiveness,” says Randy McDonough. “When you say, ‘What can we do for that patient?’, the MedWise Advisor gives a lot of information about medication safety.”

Kelly Kent Towncrest Pharmacy Director of Clinical Operations
Kelly Kent

Kelly Kent says that her staff can see how morning prescriptions are interacting with each other, for example, and click on each drug for a discussion on the clinical significance. Then there are recommendations on how to manage it.

MedWise Advisor is a stand-alone system right now in the beta pharmacies. Knowlton says the hope is to have it integrated into pharmacy systems later this year.

The Future of Pharmacy

The pilot did have funding, and pharmacists were paid for reviewing risk scores and discussing these with patients. Tabula Rasa HealthCare’s research shows a direct relationship between a higher risk score and more money spent on healthcare. Reviewing the risk scores, and finding ways to lower them, can mean actual savings for health plans. While grants currently fund the payments to pharmacists for the evaluations, the hope is that insurance companies will see the value in paying pharmacists for this.

At Towncrest Pharmacy the clinical decision-making is tracked on its in-house documentation platform, PharmClin. Kelly Kent shared a number of success stories: changing the time of day when medications were taken; changing from one statin to another drug to eliminate competitive inhibition; reducing full-dose aspirin; and moving a patient to compliance packaging as part of the medication review.

A New Way to Work

The matrix is a new way to look at patients, explains Randy McDonough, giving pharmacists many variables to evaluate. But this type of information is what can make pharmacists stand apart and get away from the silo system of healthcare. “Pharmacists have got to make these interventions, doctors have to see where they are coming from, and we need to be compensated,” he says. “Through the interventions, when you’ve shared this comprehensive information and offered a clinical intervention alternative based on good literature, that’s impressive. Doctors don’t get a lot of training on interactions. We are the experts, and it elevates how doctors view pharmacists.”

And McDonough is clear: Don’t wait until the payments are there to make changes. Prepare now and have a process. “We are ready for this,” he says. “This is an added tool to assess and make recommendations. There are a lot of benefits from this, including reimbursement.” CT

Maggie Lockwood is VP and senior editor at ComputerTalk. She can be reached at