New tools and platforms can help pharmacists to support patients.

A recent New York Times lifestyle article featuring technology solutions for the mundane tasks of our lives highlighted a digital talking pill bottle with a light-up cap. Its purpose is to remind you when it’s time to take medicine and to order a refill when you run out.

No longer relegated to the inside pages of AARP The Magazine, medication adherence has gone mainstream, front and center, as we pursue the value equation of cost over quality, post health care reform. Medication nonadherence is a big health and cost problem. Half the 3.2 billion annual prescriptions filled in the United States are not taken as prescribed. Fewer patients with chronic health conditions take their medications as prescribed. The price is high—$105.4 billion in avoidable US health care costs as a result of nonadherence.1

Adherence is generally defined as taking medicine the way the doctor prescribed it—the right amount, at the right time, and for the length of time prescribed. As awareness of patient nonadherence and its ramifications increase, most of the consumer technology solutions that have emerged have focused on forgetfulness and seek to resolve the problem through behavioral aids via reminders to pick up filled prescriptions, take medicines, and order refills. The reminders come in the form of text messages, e-mails, smartphone apps, interactive voice reminders, and prizes for self-reporting adherence success.

Reminders make sense if we assume that the patient is completely on board with the course of treatment and, from time to time, simply forgets. But reminders alone fail to address (1) the larger issue of why people don’t take their medicines as prescribed and, perhaps more importantly, (2) the goal of having a common understanding of why they were prescribed and, ultimately, what the prescriber is trying to accomplish in partnership with the patient.

One of our pharmacy customers recently shared an example of a patient routinely returning to the emergency department for treatment of anxiety. The pharmacist identified a pattern: the hospital visits consistently fell a few days shy of the refill date on the patient’s Xanax prescription. Our customer, whose pharmacy includes an aggressive adherence and medication management program, reached out to the patient, engaging her in order to understand the problem. The patient couldn’t afford transportation to the pharmacy, so she was trading a handful of Xanax for a ride. The solution was home delivery. The patient hasn’t returned to the hospital since. These patient-centered types of solutions are not resolved through a one-size-fits-all technology.

Why People Don’t Take Their Medications

Reasons for not taking medications are as complex and individual as each patient. Cost clearly influences adherence, with more people taking medicines when insurers eliminate or reduce prescription co-payments. But eliminating out-of-pocket costs alone is not enough, according to a recent study showing nonadherence rates of up to 40% among patients covered by health plans with no prescription co-payments.2 Other factors influencing a patient’s decision to take medicines as prescribed include religious and cultural beliefs; family dynamics such as a negative outcome for a relative who took a similar medication; health literacy; financial constraints; transportation; geography (where they live); and lack of coordination of care across the patient’s health team.

We know that if patients take their medications, it leads to better health, which ultimately requires less care. Achieving medication adherence means engaging with patients along their journey and aligning pharmacy services and support with their lifestyles. As part of our technology development, we conducted a series of focus groups among individuals aged 30 to 60 years and 60 years and older who either take multiple medicines daily or are caregivers for someone who does. When participants talked about “forgetting” to take their medicines, it was often the result of changing their routines for travel, eating out, or needing to take a pill with food at a time when eating wasn’t convenient.

As important as understanding why people don’t take their medications is the need to understand what motivates some to stick with a treatment plan. When we asked participants why they adhere to their treatment plan, we heard the following reasons: to be independent, to be able to work and continue enjoyable activities, and to be there for others who are important to them. These are among the reasons why pharmacists are seeing considerable success when they incorporate pouch packaging into their adherence programs for patients taking multiple medications. Packaging the medicines by time of day gives patients independence—it’s easier to tuck a pouch into a pocket or purse than to lug a bag filled with pill vials. And patients say it helps reduce the stigma of being viewed as a person with an illness; in fact, it helps them feel less sick and empowers them to get on with their lives. Since patients typically frequent pharmacies more often than any other type of health care facility, the “high-touch” environment of the pharmacy is becoming a popular place for reinforcement and review of medication action plans. What better place to close the touch gap?

Understanding patients and their health care goals, beliefs, and challenges expands how we define and view nonadherence. “Adherence implies mutual engagement on the part of the provider, the patient, and their caregiver that results in consensus regarding the patient’s treatment regimen.”3 Shifting our thinking to center on the patient and how community pharmacists can enable and support self-management of health and illness calls for technology that positions pharmacists to discuss the goals and fears of patients and how pharmacists can best align their services and support to achieve maximum wellness. Programs that have made adherence a priority, including Geisinger Health System and Group Health Cooperative, leverage information technology and patient-level data to understand patients’ attributes and then tailor interventions to those attributes.4

Health Information Exchanges: Sharing Information

For decades, community pharmacists have been patients’ trusted advisors and easily accessible without an appointment. Now, technology must elevate the pharmacist’s role among health care providers by connecting pharmacists to health information exchanges for fast, secure communication of vital medical information. Key information tracked at the pharmacy, such as a patient’s refill record, medication possession ratio, or patient interaction notes, should be shared with the rest of the care team. Technology must leverage that accessibility and become an extension of the pharmacist’s clinical thinking, enabling medication synchronization, prompting intervention for at-risk patients, and plugging into other providers’ patient scheduling capabilities.

Today, we have dispensing automation technology that aims at driving efficiencies behind the counter to allow pharmacists to be out in front, counseling patients to promote positive health outcomes. Emerging medication therapy management workflows and telepharmacy solutions will extend the pharmacist’s reach to patients—including those who never set foot in the pharmacy—to provide remote counseling and medication therapy management. Pharmacy dispensing processes are beginning to evolve from a drug-oriented process (each bottle filled on its own—independent, for all intents and purposes, of the others) to a more patient-oriented process with batched monthly fills, often scheduled in accordance with the patient’s desires and touch points, with a concurrent review to ensure that the whole regimen makes sense for the patient. Now available are adherence solutions that incorporate pouch packaging and dispensing to support patients in maintaining active, independent lives while managing their wellness and illness. And we have technology platforms that can identify and prioritize patients, schedule fill times and patient meetings, and even assist with tracking patient care.

In addition to changing the way medications are distributed, the associated medication management services and the manner in which those adjunctive services are delivered are being driven by more sophisticated analytics. By leveraging technology and predictive modeling to identify patients at the greatest risk for nonadherence and downstream medical events, pharmacists can target those patients for counseling and follow up for a strong value proposed to payers.5 Engaging with those patients to understand their health goals and obstacles to adherence offers the greatest return on patient outcomes, population health, and overall health care costs.

As nearly 10,000 US adults turn 65 years of age daily, aging with independence at home will increasingly be a lifestyle of choice—and of financial necessity. In-home monitoring solutions are seeing explosive increased demand. Imagine in-home medication management technology that serves as the 2-way connection between the patient and the pharmacist as the touch point for the larger health care team. What if that technology lets the pharmacist know in real time that a critical medication was taken in the morning, but skipped at noon?

That information could trigger real-time engagement with the patient—was it nausea? Maybe he was feeling better and decided to skip a dose. There’s the opportunity for the pharmacist to talk with the doctor, perhaps suggesting another option. Or it might create the opportunity for the pharmacist to help the patient understand what he is taking and why, what might be making him feel too sick to eat lunch, and what he can expect to have happen if he continues to skip doses. These types of solutions are not too far off from becoming mainstream, scalable, and affordable modalities of in-home monitoring.

We’re not there yet, but community pharmacists are on the right path in leveraging technology to support patient engagement. Every patient is on a journey, and the challenge is for pharmacists and all members of the health care team to collaboratively understand and engage them in the self-management of their medications and health. 


Tom Rhoads is chief executive officer of Parata Systems, a leading provider of technology solutions to support coordinated care, better health outcomes, and lower medical costs, empowering pharmacists to grow their businesses. Over the last year, Rhoads has convened a number of regional Innovation Summits, facilitating an industry dialogue among pharmacists and other health care providers focusing on the role of pharmacists and technology solutions in a value-based health care system.
Rhoads’ previous experience in the health care industry includes Baxter Healthcare and Cardinal Health Corporation. He is a graduate of Duke University, and holds an MBA from The Citadel. He serves on the Pharmacy Times advisory board, is a member of the North Carolina Technology Association, and the Chief Marketing Officer Council, and is an Iron Duke alumnus of Duke University. He also represents Parata with numerous pharmacy industry organizations, including the National Association of Chain Drug Stores and the National Community Pharmacists Association. Parata and Pharmacy Times are partners in the Next-Generation PharmacistTM Awards, the national program recognizing pharmacy innovation and leadership, which entered its fifth year in 2014.



References
  1. Avoidable costs in US healthcare: the $200 billion opportunity from using medications more responsibly. IMS Institute for Healthcare Informatics. July 2013.
  2. Cutler DM, Everett W. Thinking outside the pillbox—medication adherence as a priority for health care reform. N Engl J Med. 2010;362:1553-1555.
  3. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119(23):3028-3035.
  4. Cutler DM, Everett W. Thinking outside the pillbox—medication adherence as a priority for health care reform. N Engl J Med. 2010;362:1553-1555.
  5. Williams AB. Issue brief: medication adherence and health IT. The Office for the National Coordinator for Health Information Technology. January 9, 2014.