Overview

This pilot program at a community health center utilized pharmacist eConsults to improve quality of care for medication-related problems in primary care practices.

Organization Name

University of Connecticut School of Pharmacy - PRISM Initiative (https://pharmacypractice.uconn.edu/prism/ ), Weizmann Institute - Community Health Center, Inc.

Organization Type

• FQHC

National/Policy Context

• Clinical pharmacist eConsult services are a promising method to decrease primary care workload for complex medication-related issues.

Local/Organizational Context

• Demonstrates the feasibility of adding a clinical pharmacist to an eConsult network as a pharmacotherapy specialist.
• The pharmacist eConsult program sought to demonstrate an innovative method to incorporate clinical pharmacist services in the context of a practice that does not have the ability to employ a full-time clinical pharmacist.
• The pharmacist eConsult program improves medication-related care quality and safety, and has the potential to reduce PCP workload burden.

Patient Population Served and Payor Information

• 24 Primary Care Providers (MDs, DOs, APRNs) sent an eConsult to the clinical pharmacist with 123 questions about drug therapy regimen optimization or adverse drug events for 57 patients over an 8 month period.
• For the eConsult questions, 40.4% of patients were male and 59.6% of patients were female.

Leadership

• The project was developed by Marie Smith, PharmD and Daren Anderson, MD; Dr. Anderson provides leadership for the ongoing service.

Funding

• This project was sponsored by the UConn Office for the Vice President of Research.

Research + Planning

• The team developed guidelines for medication-related issues and questions that would be suitable for pharmacist eConsults based on  published studies (see Sources section for references), as well as predetermined criteria according to disease registries and population health databases.
• The eConsult pharmacist/population health team educated primary care providers (PCPs) and office staff on the availability of this new service through a series of 30-minute lunchtime seminars and video-conferences.
• The team set up a template for the patient information elements that needed to be sent to the pharmacist with the eConsult question (e.g. EHR medication list, recent PCP notes, medical problems, recent labs, recent hospital or discharge summaries).

Tools or Products Developed

• Clinical Pharmacist eConsult Workflow
• Clinical Pharmacist eConsult template
• Clinical Pharmacist service contract

Training

• Pharmacists and PCPs were trained in how to use eConsults to communicate medication-related questions and clinical recommendations with each other.

Tech Involved

• eConsult/eReferral
• Website

Team Members Involved

• Administrator
• Pharmacist
• Physicians
• RNs

Workflow Steps

• Pharmacist eConsults are asynchronous communications between PCPs and clinical pharmacists within a secure web-based platform.
  • PCPs can send patient-specific questions to a clinical pharmacist to address questions related to:
    • Medication optimization
    • Preventable adverse drug events
    • Difficulty treating chronic conditions and reaching therapeutic goals
    • Medication dosage adjustments
    • Polypharmacy assessments
• Clinical pharmacist reviews the patient’s medical and medication information.
• Clinical pharmacist sends the PCP any recommendations for drug therapy changes, monitoring needs, patient education tips within 24-48 hours.

Budget Details

The following sources of costs were estimated by the CareZooming team:

• Labor costs associated with clinical pharmacist time to complete the eConsults
• Operational costs for eConsult platform

Where We Are

• Date (Month/Year) Project Described Started: August 2018 – April 2019 for pilot project, service is ongoing
• Date (Month/Year) Paper Published: June 2019 (Poster Presentation), manuscript in development

Outcomes

The pilot project data was compared across individual PCPs and practices:

• Use of eConsults: The largest utilizer of pharmacist eConsults were APRNS, who sent about three times the number of eConsults and four times the number of separate questions in each eConsult as MD/DOs.
• Number of Medications: 35% of eConsults involved patients taking up to 6 medications, 37% of eConsults involved patients taking 7 to 12 medications, 28% involved patients taking more than 13 medications.
• Types of Medication-related Problems (MRPs): 66% of medication-related problems involved medication safety and efficacy (majority were potential ADEs/drug interactions) with the remaining MRPs focused on drug indication and adherence.
• Implementation: 72% of pharmacist eConsult recommendations were implemented, 17.5% were not implemented, 3.5% were pending, and 7% were unknown.
• PCP Satisfaction: Overall, PCPs reported a high level of overall satisfaction and clinical value with the pharmacist eConsult service; 34% of PCPs reported that the clinical pharmacist’s eConsult recommendations decreased their workload
• Types of eConsults: The figure below displays the most common eConsult concerns (Fig. 1) and types of medications involved (Fig. 3).

 

• eConsult Utilization: During the pilot program, 22% of all PCPs used the clinical pharmacist eConsult service.  For PCPs who used the eConsult service,  54% of PCPs sent only 1 eConsult, 21% of PCPs sent more than 2-3 eConsults, and 25% sent more than 4 eConsults. The majority of  eConsults are sent by APRNs (25%) and MDs (23%), followed by DOs (14%). There was no utilization by PAs.
• Completion Time: The average amount of time necessary to complete each eConsult was 56 The time was lower for MDs (49.8 minutes) than DOs (105 minutes) or APRNs (56 minutes).

Benefits

• Practices can consider using eConsults to incorporate clinical pharmacist services on-demand, especially when they are unable to employ a clinical pharmacist.
• Clinical pharmacist eConsult services decrease PCPs’ workload when treating complex medication-related issues that require time to research adverse drug events, clinical decisions on evaluating evidence-based treatment options, changing medications within different therapeutic classes, tapering dosage regimens, etc.
• This pilot project demonstrated the feasibility of adding a clinical pharmacist to an eConsult network as a pharmacotherapy specialist.

Unique Challenges

• Since this was a new service, PCPs needed to be reminded on a regular basis that they have the ability to ask a clinical pharmacist for a pharmacotherapy eConsult.
• Unlike PCP eConsults to medical specialists, the process to initiate a clinical pharmacist eConsult was not embedded in the EHR.
• Some PCPs were not familiar with the clinical training and expertise of a clinical pharmacist, or had not worked with a clinical pharmacist, so they did not know what type of questions were most suitable for a clinical pharmacist eConsult.

Sources

• This primer was developed by the CareZooming team based on our interpretation and analysis of a poster presentation and with consent and permission of the author and/or their representatives. Dr. Marie Smith and/or her representatives reviewed the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
• Vuernick, E., Smith, M., Anderson, D., Thurston, J. (2019, June). On-Demand Pharmacist eConsults to Diversify and Enhance the Primary Care Workforce. Poster session at the Academy Health Annual Research Meeting, Washington, D.C., United States.
• (For Research & Planning) Smith M, Giuliano MR, Starkowski MP. In Connecticut: Improving Patient Medication Management In Primary Care. Health Affairs, 30, no.4 (2011):646-654.
• (For Research & Planning) Sorenson TD, Pestka DL, Brummel AR, Rehrauer DJ, Ekstrand MJ. Seeing the Forest Through the Trees: Improving Adherence Alone Will Not Optimize Medication Use. J Manag Care Spec Pharm. 2016;22(5):598-604.