Tram Thai, BCACP, AE-C, is a clinical pharmacist with Cureatr. In this position, she is responsible for implementing and expanding Cureatr's clinical pharmacy services. She works directly with patients, the Cureatr team of pharmacists and pharmacy technicians, and monitors the performance and delivery of Cureatr's telepharmacy service. Tram joined the Cureatr team in April 2021.
In this interview, Tram discusses what attracted her to Cureatr, what she loves and finds challenging about being a pharmacist, successes of a major Cureatr initiative, and the role of technology for improving medication reconciliation. She concludes the interview by sharing the stories of three patients who were recently helped by Cureatr's clinical pharmacy services.
Q: In your journey as a pharmacist, what led you to Cureatr?
Tram Thai: I've had my fair share of experience in pharmacy practice, from retail and hospital to ambulatory care and academia. Based on those experiences, I feel I was able to get a grasp on the challenges that patients face in healthcare, especially when it comes to their medications. I've worked on a lot of projects at different organizations to help improve systems but felt I was only slightly improving the suboptimal medication management problem facing the healthcare system.
When I learned about the opportunity to join Cureatr and looked into what they were doing and were all about, I saw this as a chance to be a part of something great. I not only get to work with patients and other clinicians but also engineers, product experts, and marketing talent that care about the medication mismanagement problem as much as I do. Instead of me wishing healthcare would improve, I saw an opportunity to work with great people to find innovative ways to make that dream a reality.
Q: What do you love about being a pharmacist?
TT: In healthcare today, it's often difficult for patients to figure out the root cause of an issue, whether it be the reason they can't get a medication, why they're experiencing a certain side effect, or why they're struggling to connect with someone who can help them. Being able to problem solve and help people in ways they do not expect are probably some of the biggest reasons why I love being a pharmacist.
I also love to empower my patients with information to help them better understand their medications and how the medications benefit them or work with their disease states. There's nothing better than hearing patients, say, "Wow, no one ever told me that before. Now it makes sense why I need to take this medication."
Q: What are some of the biggest challenges you face as a clinical pharmacist?
TT: Instead of starting with my biggest challenges, let me start with my biggest issue: the lack of understanding around the term "clinical pharmacist." People don't really know what a clinical pharmacist is. Oftentimes, patients question what I do as a clinical pharmacist and what value I bring that their regular neighborhood, retail pharmacist cannot. It is important to explain to patients that in no way, shape, or form are clinical pharmacists intended to replace their neighborhood pharmacist. Neighborhood pharmacists have a wealth of information to offer patients that cannot be replaced, but clinical pharmacists often have access to more information about patients, including their imaging and lab work that neighborhood pharmacists simply don’t have access to. Clinical pharmacists and neighborhood pharmacists can work together to help manage a patient's disease states, answer patient questions, and work alongside with physicians to help improve a patient's overall health, keep them out of hospital, and ultimately get them feeling better.
I think the term clinical pharmacist is often new for many providers as well. Sometimes they may receive our recommendations and not really understand where those recommendations are coming from because they may not know how much information we have about our patients. We'll make recommendations and sometimes no action will be taken. It may require our making a phone call to a provider and having a conversation for them so they act on our recomendations.
So, my issue and challenge are one in the same. I feel that before the benefits of our work as clinical pharmacists can be fully realized, there needs to be more widespread understanding and awareness of our role in the patient’s care team and their overall health.
Q: Cureatr has been working hard at improving medication reconciliation post-discharge (MRP) for its clients and their patients. What have you seen as some of the major successes of this initiative?
TT: First and foremost, we've been able to decrease readmission rates for patients. That's a benefit all around for hospitals and patients. No one wants to go back into the hospital for something that was preventable.
We're also improving access to medications post-discharge. I think one of the most important roles that a clinical pharmacist plays in overall patient health is using the medication reconciliation post-discharge process to identify whether patients were able to pick up their medications. And if they weren't, finding out why not? Then working to help resolve that issue.
When people hear about medication non-adherence, they often think the cause is patients simply not feeling like taking their medications. This is usually not the case. There are several reasons of why a patient does not pick up or take their medications. Perhaps a medication requires prior authorization, or the patient feels like they can't afford the prescription, or the pharmacy doesn't have it in stock so the patient must wait. At Cureatr, we've been instrumental in helping patients improve their access to medications post-discharge in a timely manner.
We are also identifying and resolving medication errors and then, aside from medications, helping to improve patient awareness of their disease state and non-medication related ways to better manage it, such as lifestyle and diet changes. Everybody has a different lifestyle. Instead of giving patients a blanket statement like "follow a low salt diet and make sure you eat a lot of vegetables," we dive into a patient's lifestyle to tailor a plan that will work best for them.
We're also identifying non-medication-related issues post-discharge to help patients connect with someone who can help address those issues.
Sometimes when you hear the term MRP, you think the process only involves reviewing medications and making sure patients are taking them, which oftentimes is all that is done. At Cureatr, we are striving to do more than that. There are always more issues that the patient needs help with that either we can help resolve or at least find someone who can help. The MRP is really just a baseline of the service. All the other issues that come to the surface when we're talking to the patient allow us to set the patient up for success in managing not only their medication but their overall health.
Q: It is well-documented that most medication errors occur during transitions of care. What role do you think technology and the clinical pharmacist can play in improving medication reconciliation at these crucial encounter points?
TT: I think one of the most challenging aspects of reducing medication errors and improving safety involves ensuring that accurate information about a patient's medications travels with that patient throughout the whole healthcare system and that any changes to the patient's medication list is shared with other providers.
Medication reconciliation is designed to avoid common medication errors, but it's not always as easy as it sounds. As I mentioned before, this is where I think the clinical pharmacist can play a huge role. If you think about med rec, it's a step-by-step approach that includes verification, so we collect accurate medication history; clarification, where we ensure that the medication and doses are appropriate; and then reconciliation, where we document every change and make sure that it all checks out with the other medications and patient information.
These steps are a lot more difficult than they might appear due in large part to the fragmented nature of the healthcare system. Sources of information on medications are scattered in several different places. Physicians' offices have records, but they're hard to keep current, especially if there are prescriptions coming from other specialists. Pharmacies have records, but usually only for prescriptions filled at that specific pharmacy or chain. For some of the same reasons, hospital medical records may be incomplete.
I think technology plays an important role in the medication reconciliation process by pulling all that fragmented information into one platform so that the three steps — verification, clarification, and reconciliation — can be streamlined.
Q: Can you share a few experiences of how your work with patients has resulted in improved health outcomes?
TT: I'll share three recent experiences.
1. Drug-to-Disease State Interaction
The first concerns a drug-to-disease state interaction with a patient I had a visit with today. He has a history of heart failure and diabetes. He's on a medication for diabetes that has been shown to exacerbate his heart failure — more specifically, to cause fluid overload. Since heart failure patients have a weak heart, they must monitor how much fluid they're intaking. This diabetes medication even has a box warning about how it's been shown to exacerbate in heart failure patients and the use of it should be avoided.
After looking at this patient's history, I noticed his diabetes was well controlled to the point where it doesn't even warrant any type of treatment for diabetes anymore. I reached out to the doctor to discontinue that medication. I couldn't reach the doctor, so I spoke with one of his colleagues. This doctor agreed that the medication should be discontinued; they just wanted to confirm with the patient's physician. I have no doubt in my mind that they'll call me back in a few hours and agree with the recommendation.
This is a great development. It will possibly prevent a drug-related hospitalization, and that's all because I understood that the patient has a specific disease state and shouldn't be on this medication for two reasons: one, because their diabetes is already controlled, and two, because they have heart failure.
2. Medication Access Problem
The second experience involves more of a medication access problem. Yesterday, I had a patient who was recently discharged with a blood clot. The hospital prescribed a blood thinner, which he had a reaction to, so he had a follow up with his physician and they prescribed another blood thinner. I called this patient yesterday, which was his third day out of the hospital. When I spoke with him to ask how he was doing on the new blood thinner and if he was having any adverse reactions, he told me he was unable to pick up the medication because the pharmacy didn't have it in stock. This immediately had me concerned.
While this is day three of hospital post-discharge for the patient, it's now day two without any sort of blood thinner. Keep in mind he just got discharged for a clot, so you can understand my concern and the patient's concern. I told him I was going to call the pharmacy to see if they could do a quick search to see if any other pharmacy in the vicinity had that medication in stock. This pharmacy is one of the big retail chains so I was shocked to hear that they nor any of the other same retail pharmacies in the area did not have this common blood thinner. That means the patient would have gone at least 2.5 days without this blood thinner.
I kept calling around. I figured I had two avenues to pursue. The doctor's office could prescribe an injection in the stomach to help protect the patient until they could get their medication, so I called the nurse and she said she was going to talk to the doctor about it. In the meantime, my other option was to continue doing my due diligence and calling other pharmacies outside of that network to see if they had the medication.
I finally found a pharmacy that had the blood thinner so I immediately called the physician's office to have them prescribe to the new pharmacy. The patient was able to get the medications and start it last night. Now he feels better knowing he has what he needs and does not need to worry about possibly being re-hospitalized for something he had no control over.
3. Providing Clarity and Peace-of-Mind
The third experience concerns a patient I visited with that had a ton of questions for me regarding his supplements, which I answered. He had also started on a blood thinner and was concerned about that because he has a history of a blood disorder, so I explained to him some signs and symptoms of bleeding to watch for. He was very happy with our visit. Our phone calls with patients typically occur immediately after discharge and then one month after. I gave this patient my number and told him he was more than welcome to call any time with additional questions.
I get a phone call from this patient on the Monday of the following week and he's frantic. He tells me he was experiencing signs of blood in his urine. He knew that I wasn't a physician, and he wasn't expecting an answer from me on what to do, but he was panicking because he had been trying to get a hold of three different specialists over the weekend and none responded to him. He was able to reach one of his physicians, which was his primary care physician (PCP). The physician told the patient to continue taking the blood thinner, and if his symptoms worsened, to give the PCP a call the following week.
This wasn't comforting. He still hadn't heard from his cardiologist, hematologist, or urologist, so I could understand his concern. He called me because he said I was such a huge help to him the previous week that he thought maybe I could help him get in contact with these physicians.
After hearing his concerns, I immediately hung up the phone and did what I could. I contacted one of his emergency department (ED) physicians to see if they could call him and assess his symptoms. It was a good call because the ED physician called the patient immediately. The physician was able to bring the patient in to assess why exactly he was experiencing blood in his urine. It prevented a hospitalization, and the patient felt like somebody actually cared for him and helped him through his journey.