COMPUTERTALK’S SEPTEMBER/OCTOBER 2018 cover story, “Opportunity at the Point of Care,” described the current state of point-of-care (POC) testing opportunities and the incredible work being done with rapid strep and flu testing, immunizations, pharmacogenomics, and more.
The question becomes, how does pharmacy take those POC processes and weave them into the larger healthcare narrative? How does one marshal the potential of POC testing at the community pharmacy to drive not just efficiency and cost savings, but also to profoundly move the needle on improving chronic disease care delivery?
It is our belief that pharmacies will increasingly use POC testing to create their own opportunities for enhanced services. That is the work that will generate true value for the healthcare system at large by improving overall care quality. As such, POC must be part of a larger goal, a piece of the story we tell prescribers and payers across the country.
THE VARIABILITY PROBLEM
Variability in healthcare is an expensive problem, but one that community pharmacy is uniquely suited to help solve. Care guidelines should be the solution to this problem, but a recent National Institutes of Health (NIH) grant, “Strategies to Increase Delivery of Guideline-Based Care to Populations with Health Disparities,” described how dismal guideline uptake can be in primary care:
“Despite the research supporting the use of evidence-based practice recommendations, clinical practice guidelines are rarely universally implemented in routine clinical care, resulting in gaps between recommendations and actual clinical practice. For example, despite the potential deaths prevented with implementation of cardiovascular disease guidelines, only 50–60% of patients with cardiovascular disease risk factors receive recommended treatment. Only 50% of primary care physicians are aware that there are chronic obstructive pulmonary disease (COPD) guidelines; even among those who are aware of the clinical practice guidelines, only 25% actually use them. The reasons for the failure to implement guidelines are clearly multi-faceted.” (NIH PAR 18-133 Background)
THE GUIDELINES AS A STRATEGY
For the pharmacist, measuring care against guidelines demystifies a patient’s chronic care plan. Discussing any discrepancies in current care with a patient within the context of guidelines may elicit detailed discussion about history or purposes behind a given course of therapy. For example, a patient with seemingly improper statin intensity may recall an intentional dose decrease due to side effects that may not have been top of mind without the review from the pharmacist.
No medical professional is capable of completely keeping up to date with all practice changes and standards. This presents pharmacists with a great opportunity to integrate into chronic care delivery. Understanding the guidelines is a good start, but POC testing has given pharmacists a unique avenue to make the right kind of care actually happen.
POC allows a pharmacist to identify gaps and problems, monitor what is being done to fix them, enrich the patient medical data, and take greater responsibility for patient care plans. POC testing is particularly valuable for pharmacies and their patients when it’s focused on assessing adherence to evidence-based treatment guidelines.
There are patients who do not enjoy access to high-quality primary care. Pharmacists not only help manage chronic care through traditional dispensing processes, but can also fill gaps in the lab-monitoring plan for patients through POC testing, collaborative practice agreements (CPAs), and the right technology.
With that data in hand, pharmacists have the most current information needed to help their patients navigate their chronic care plan with their primary care provider. If a patient does not have high-quality primary care, the impact of the pharmacist is multiplied.
Regardless of where a pharmacy is located, POC testing is an excellent opportunity to use CPAs to grant pharmacists authority to take action on therapy problems immediately. The impact pharmacy has on improving vaccination rates, another area of opportunity at the point of care, is well documented. While more pharmacies are using various solutions and procedures to screen for potential vaccination needs, the opportunity to screen for guideline care gaps remains largely untapped. Many pharmacies have had great success in using influenza vaccination or Medicare Part D visits to identify needs for additional vaccinations. Those same visits are also great opportunities to identify and engage with patients who may benefit from guidelines interventions, which may result in a need for POC cholesterol or A1c testing, for example.
Regardless of pharmacy POC strategy, having a proper documentation system is critical — CPAs must be housed, patient information must be documented, and the tools used to enhance guideline care quality must be accessible to pharmacist users.
In North Dakota, the MTM Express platform, which is a product of my employer, About The Patient, has been heavily utilized due to it being the documentation platform for several clinical services for payers in the state. With design roots as a medical record for community pharmacies, it is flexible enough to meet many different needs for various practices, from POC testing documentation to a guideline support engine for pharmacists.
“As with anything in pharmacy, the proper tools are essential,” says Mike Schwab, executive vice president of the North Dakota Pharmacists Association. “We’ve learned that using the guideline suite and patient education modules within the platform increases pharmacist confidence regardless of location or pharmacy and offers great ways to integrate students and technicians into delivering advanced care in the community pharmacy.”
The proper tools and ability to document their own POC data in a medical record format has given pharmacists confidence in their own skills and grown their credibility with patients and prescribers.
Schwab maintains that one cannot be a true drug therapy expert without moving into the arena of additional responsibility for the quality of care provided, and POC is a foundational building block. “Just as there was some reluctance to adjust workflows to start immunizations, once pharmacists make use of POC and guideline care delivery, they regret waiting so long to start,” he says. “They really see the value they have in creating a true healthcare delivery environment for their patients.”
THE BRIDGE FROM REGULAR TO IDEAL CARE
Pharmacies are the intersection of patient, prescriber, and community. It’s no longer enough to be a single provider on an island — the future belongs to those who collaborate to bring the best in quality to patients at every step of their journey.
When presented with the proper information, tools, and authority, pharmacists are answering the call to improve care quality across the country in some novel ways. Truly, the accessibility of the community pharmacy is just beginning to be leveraged — the next few years offer some exciting opportunities for advancing clinical community pharmacy. POC has incredible potential but is far from the answer itself. It needs to be coupled with a level of clinical rigor that fixes the guideline care gap that exists currently.
It may be that POC testing is the bridge that starts to connect guideline care decisions, MTM (medication therapy management) interventions, and enhanced services at the pharmacy. It’s undeniable that patients respond to physical services, which is why POC is such a powerful relationship building tool. It’s immediate and tangible, it elevates pharmacy as a healthcare provider in the eyes of the patients, and the movement toward quality elevates community pharmacy in the eyes of prescribers, health systems, and payers.
When community pharmacy reaches that point, POC testing ceases to be another service line to be offered and becomes transformative for community pharmacy practice. CT
Jesse Rue, Pharm.D., B.C.P.S., is clinical coordinator for the About the Patient program, part of the North Dakota Pharmacy Service Corporation in Bismarck, N.D. The program was created to enable pharmacists to provide disease state management for patients to enable them to live their best, healthiest life. You can contact him at jrue@ aboutthepatient.net.