This is the second blog in a series of patient scenarios that describe common challenges associated with medication management. Each scenario provides the background and reasons for these and discusses the shortcomings of the technology used by many healthcare organizations today. We’ll then explain how Meds 360° helps solve these problems, and how it can improve quality of care, reduce risk, and improve clinician and patient satisfaction in the process.
The post is a continuation of our last piece in the series, focusing on the potential downstream clinical impact on patients who are admitted to the emergency department (ED) or hospital without being able to provide an accurate list of medications they are taking. This very common occurrence often results in poor outcomes and unnecessary costs. And often, these adverse events don't end after the patient has been discharged.
In Part 2, we lay out a likely post-acute care scenario for Joe - a 70-year-old, white male with congestive heart failure, non-insulin dependent diabetes, hypertension, hyperlipidemia, and chronic lower back pain.
As described in Part 1, after becoming lightheaded and short of breath one afternoon, Joe was transported by a neighbor to Our Lady of Lourdes emergency department (ED). Upon admission, he was unable to accurately recall all of his medications to the ED admissions nurse. The electronic health record (EHR) at Our Lady of Lourdes did not provide the information either, because the physicians who prescribed those medications for Joe are outside of the hospital's enterprise.
Due to the admitting physician prescribing several medications that Joe was already (but unknowingly) taking, Joe had a mild ischemic stroke while he was in the hospital. He was successfully treated with Tissue Plasminogen Activator (tPA), but his length of stay increased by six days. When finally discharged, Joe was taking ten medications: Lasix, digoxin, lisinopril, metformin, pravastatin, Eliquis, carvedilol, Plavix, Soma, and Dilaudid which was prescribed for severe lower back pain that reemerged the day before discharge.
Problems Continue During Joe’s Post-Acute Care
When physicians in a post-acute care setting see patients without full knowledge of or access to the medications being taken, things often go wrong too. Let’s consider what could happen to Joe after being discharged from the hospital if he visits a physician who does not use Meds 360°.
Three days after being discharged from his nine-day stay, Joe is seen in follow-up by a neurologist at the Mercy Health System Outpatient Neurology Clinic. His condition has generally improved, but he complains of continued severe lower back pain. The neurologist sends Joe for a consultation with a neurosurgical colleague, who orders MRIs that show osteoarthritis and a bulging disc at L-4 and L-5. The neurosurgeon orders a fentanyl patch for Joe and tells him he may want to consider surgery if things don't improve in the next couple of weeks.
Because Mercy Health System’s EHR doesn’t integrate with Our Lady of Lourdes’ and Joe doesn't mention it, the neurosurgeon is unaware that Dr. Xi, the admitting physician at Our Lady of Lourdes had prescribed Joe Dilaudid just a week ago. Joe fills the prescription for the fentanyl patch at the Mercy Outpatient Pharmacy, which is just across the state line from where he lives, so his opioid prescription does not show up in the Prescription Drug Monitoring Program (PDMP) database.
Joe heads home and applies the fentanyl patch. He also takes Dilaudid and Xanax, unaware that the combination is problematic. A week later, he becomes dizzy, falls, and hits his head. A neighbor finds him on the floor in his home. The neighbor calls 911, and Joe is readmitted to Our Lady of Lourdes 15 days after his initial discharge.
Unfortunately, Joe doesn’t have family nearby to help him with his medicines. He’s trying his best to care for himself, but being on ten medications, and still not fully recovered from nine days in the hospital, it’s obvious that Joe isn't the best historian of the medications he's taking.
How Joe’s Follow Up Care Could Have Been Better
Let’s imagine that Joe’s neurologist and neurosurgeon have access to Meds 360° software. After a look at Joe’s medication profile with data visualization, they would have changed their plan of treatment.
In the timeline view, Meds 360° groups Joe's medications into GPI-6 based therapeutic categories. Notice that all the antihypertensives are grouped together. All the antidiabetics are grouped together too, and so are the other therapeutic categories. The reason this is so useful is that a clinician can quickly spot issues such as refill gaps - which show as a dotted line between refills (a proxy for potential non-adherence), therapeutic interchanges, and multiple stops and starts in a given therapeutic class.
Therapeutic duplications are also immediately apparent because they are displayed as orange hashtags. For example, even though Joe remembers taking oxymorphone for his chronic back pain, he forgot about the new prescription for Dilaudid that was just written by Dr. Xi at discharge. But a neurosurgeon whose institution has provided him with Meds 360° not only sees the therapeutic duplication of Dilaudid and oxymorphone on the timeline view, he also receives a therapeutic duplication alert on the left hand side of the screen, which, when opened, highlights two concomitant opioids.
Using Meds 360°, Joe’s neurosurgeon concludes that opioids are ineffective for his chronic back pain. He doesn't prescribe fentanyl and instead advises Joe to stop taking the oxymorphone because it hasn't been helping for over a year. Instead, he develops a new care plan focused on nerve blocks, explaining that if it’s unsuccessful, the next course of treatment would be surgical intervention. The neurosurgeon also cautions Joe about using opioids in combination with muscle relaxants and antianxiety agents.
This data review and subsequent counseling and care plan change result in no fentanyl patch being prescribed. And because he isn't placed on duplicate opioids, Joe does not get dizzy and fall and avoids the hospital readmission completely.
Healthcare organizations must capture a timely and accurate view of a patient's current medication regimen. The current process of relying on patient memories and siloed EHRs is error-prone and results in poor outcomes and unnecessary costs such as the ones Joe experienced during his inpatient stay. The Meds 360° technology solution supports care teams in avoiding both of these by delivering a patient's complete and accurate medication history in a streamlined view of actual prescription pick up and change data from pharmacies and PBMs.
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