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When a Primary Care Physician Misses Medication Non-Adherence

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This is the third in a series of blog posts that describe common challenges associated with medication management. Each provides the background and reasons for these and discusses the shortcomings of the workflow and technologies used by many healthcare organizations today. We then explain how Meds 360° helps solve these problems, and how it can improve the quality of care, reduce risk, and improve clinician and patient satisfaction in the process.

This blog post completes a clinical scenario that features Joe, a 70-year-old, white male with congestive heart failure, non-insulin dependent diabetes, hypertension, hyperlipidemia, and chronic lower back pain. You'll find the previous two posts about Joe's hospital admission, discharge, specialist visit, and readmission in the scenarios: Serious Medication Errors and Hospital Admissions Part 1 and Part 2, as well as the post, Handling Missed Therapeutic Duplication at Outpatient Clinics.

This is the final phase of Joe's journey through the "business as usual" workflow of his local healthcare system. Where busy emergency departments (EDs), overloaded schedules, disparate electronic health records (EHRs), and lack of visibility into medication data create a tangled web that can cause patients unintended yet significant harm, as well as poor outcomes.

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Joe's Medication Reconciliation with His PCP

Eight days ago, Joe was discharged from Our Lady of Lourdes hospital after he'd fallen in his home due to an unintended drug-drug interaction that included opioid medications. This admission was technically a readmission because several weeks before this fall that left him unconscious at home, Joe had been in the hospital for ten days, recovering from a cardiac event. During the initial hospitalization, and unbeknownst to his PCP Dr. Holt, Joe hadn't picked up his last two fills of the antihypertensive, lisinopril.

Now eight days post-discharge, Joe visits with Dr. Holt, who does a "brown bag" medication reconciliation. Joe has brought all ten of his pill bottles, but Dr. Holt is rushed because the clinic schedule is running 30 minutes behind and doesn't have time to examine the labels on every bottle carefully. And, because she has no visibility into Joe's past medication pick-up history, his two-month gap in hypertension therapy goes unnoticed.

Joe's blood pressure is 160 over 97, so Dr. Holt tells him to double up on the lisinopril over the next seven days and call her if his blood pressure monitor doesn't indicate that it's normalizing in about three to four days.

A few days later, Joe finds himself again short of breath and dizzy. He's transported back to Our Lourdes ED with a blood pressure of 200 over 100. He's in heart failure and is readmitted. When Joe's care manager learns of this, she's frustrated. She had no way to know that he had abandoned his antihypertensive medication. And without that information, she had no way to help Joe stay well and out of the hospital.

How the "Brown Bag" Reconciliation Could Have Gone Better

Had Dr. Holt's organization been using Meds 360°, her "brown bag" reconciliation with Joe would have been a whole different conversation.

Using the timeline view, Dr. Holt would have immediately seen the dotted lines between the solid bars, indicating Joe hadn't picked up these pills over the last few months. (See Figure 1.) She would have quickly concluded that his antihypertensive nonadherence could play a significant role in CHF exacerbation - which is exactly what landed him in the hospital in the first place.

cureatr-lisinopril gaps on timeline-1

Figure 1

Having visibility into this critical piece of information - the lack of medication pick-up - could have led Dr. Holt to conduct a motivational interview with Joe. Such a conversation would allow the two to discuss Joe's personal and health goals as well as the importance of taking the lisinopril to achieve those goals.

Although it's impossible for Joe to turn back the calendar days at this point and pick up those two months of missed medications, he does tell Dr. Holt he' learned the hard way what can happen if he stops taking his antihypertensive. Joe agrees to be more diligent about picking up his refills and taking the medication as prescribed - and in doing so, he avoids a possible fourth CHF readmission three days later.

How the Meds 360°PDMP Module Could Have Also Helped Joe Avoid His Fall

In our previous blog post about Joe's clinical scenario - Handling Missed Therapeutic Duplication at Outpatient Clinics - Joe's neurosurgeon prescribed a fentanyl patch. Given that the neurosurgeon's EHR doesn't integrate with Our Lady of Lourdes,' and Joe didn't mention it, the neurosurgeon was unaware that the admitting physician at Our Lady of Lourdes had prescribed Joe Dilaudid just a week ago.

Joe filled the fentanyl patch prescription across the state line from where he lives - making the neurosurgeon's check of his state's Prescription Drug Monitoring Program (PDMP) ineffective for catching the therapeutic duplication. Meanwhile, Joe applied the fentanyl patch for his back pain while also taking the Dilaudid and Xanax, and the combination caused his dizziness - leading to a fall and readmission.

Prescription Drug Monitoring Programs (PDMPs) are state sponsored databases that enable providers to identify potential opioid abuse. At least 40 states now mandate the providers to check the PDMP before prescribing controlled substances.

The number one reason that physicians often skip a PDMP check is that it takes too much time and requires them to leave their workflow to log into a separate PDMP website. Cureatr has made that a lot easier. Our goal is to simplify the process dramatically, as well as improve the efficiency of how the provider views the information. We've leveraged the data visualization in our Meds 360°timeline view for this purpose. And, we're able to provide PDMP data for 41 states; state databases don't have that level of visibility, which is why the neurosurgeon didn't see Joe's across-the-line refill.

In Cureatr's PDMP Module, a single click from the Meds 360° timeline checks the PDMP data from all states that have made theirs available and presents it using data visualization. (See Figure 2.) There are no data entry requirements to retrieve the PDMP report using this one click lookup. And for scheduled patients, the data is pre-fetched for the provider's review.

PDMP Module

Figure 2

Like the core Meds 360°screens, the PDMP Module provides a timeline-based view of controlled substance prescriptions within the past 12 months. It also sends providers alerts for 4 or more prescribers, 4 or more dispensing-pharmacies or Milligram Morphine Equivalents (MMEs) in excess of 50 or 90 in accordance with State guidelines. And, clinicians who access the PDMP using the Meds 360° PDMP Module receive the same credit for the lookup as they would have if they'd accessed their state PDMP directly.

Medication Adherence


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