Although experts agree that the future of health is coordinated care, it is sorely lacking in the US health care system now. This article focuses on the single, relatively simple issue of medication management. Patients are prescribed barrels of pills, but there is little coordination other than looking for contra-indications and drug interactions–and these often suffer from the caretaker’s not knowing the patient’s full complement of drugs.
Sandra Raup, president of Datuit, points out that all kinds of subtleties get lost when patients are simply told how often to take a medication. For instance, if medications are spaced out throughout the day instead of being being taken all at once when we remember to take them (as so many people do), they may be absorbed more effectively and tolerated by the body. Patients–especially those with lower incomes and less education, who are more likely to be on multiple medications in the first place–need all sorts of support.
Here we come to an interesting twist: coordinated care does not have to be initiated by doctors. Given the doctor shortage and the forces keeping clinicians from adopting new models of treatment, other professionals can take on the long-term goals of improving patient health.
In a pilot ramping up in a residence for low-income seniors and the disabled in Maryland, Connected Health Resources is working with Alfa Specialty pharmacy using its Community Health Gateway to help patients straighten out their medications and keep to their schedules. This works because the pharmacy is in a somewhat unusual position: they have supported this community for some time and have built relationships with patients informally. The Gateway pilot has created a service, using Datuit’s SafeIX public API, that can potentially fulfill these needs with less work on the pharmacist’s part. The service is designed for easy navigation by the patients and their family caregivers, making it attractive to the patients and the pharmacists.
The SafeIX Platform is designed using modern programming technologies to integrate data from multiple sources (including EHRs and HIEs) into a patient record for both patients and healthcare providers to use, based on their rights to access and share it. In the Gateway implementation, the pharmacist uses the SafeIX Platform to receive CDA documents from the HIE and to auto-assist medical data reconciliation between the various documents.
This information, along with the pharmacist recommendations, are organized into a daily medication calendar using an application from Polyglot Systems Incorporated, a company that offers medication regimen summaries in 18 languages. Low health literacy and the estimated 50 million people who do not speak English at home result in many patients not understanding their medication instructions. The plain language and multilingual, easy-to-use daily calendar can make the difference between understanding and total confusion.
Datuit’s SafeIX Platform uses interoperability standards (including, in test mode, the next-generation FHIR standard) to create a patient record that can show patients everything seen by multiple clinicians and allow a patient’s self-selected care team to view and add to a shared care plan. Datuit is encouraging app developers to build mobile apps for SafeIX that would prompt patients to take medications and record whether they did so, but that’s outside the scope of the pilot. There are plenty of challenges just fulfilling the tasks they have already taken on.
First, Connected Health Resources has to break down the clinical data silos that make it difficult for patients to collect their information. According to co-founder Shannah Koss, Maryland has a relatively advanced Health Information Exchange (HIE) called CRISP. However, it is defined as a provider-to-provider exchange, so it was only after a long-term relationship and negotiation that Connected Health Resources could collect medical data on behalf of the patients. This is the first time CRISP has allowed data to be retrieved for a patient-facing organization that is not a provider.
When enrolling, the patient gives the Gateway permission to get data through CRISP. Family and friends can be invited by patients to be part of their health community and enroll in the Gateway. The invitation includes a unique code that allows the Gateway to securely share records and help with health and social services navigation. If the patient wants help or is incapable of managing the medication list, a caregiver can do so.
CRISP transmits data primarily from hospitals. To round out a more comprehensive listing of medications from clinics and other healthcare providers, CRISP has enabled the ability to query Surescripts, which provides prescription fill data from chain pharmacies and pharmaceutical benefit management companies.
Pilot participants authorize the Gateway and the Alfa pharmacists to access their medication information and maintain, share, and augment the information in the secure SafeIX Platform. The CRISP data gives more complete medication records for the pilot participants. CRISP also provides an event notification system that let’s the pharmacist know whether a patient has been admitted to a hospital or visited the emergency department. These types of transition are precisely when medications get changed, but the clinicians at those crucial junctures often don’t know all of a patient’s current medications.
Finally, over-the-counter (OTC) medications can play an important role in a patient’s care. This has to be added to the daily calendar. The Alfa Pharmacist is helping round out the complete medication picture by working with the patient and family to identify OTC medications, supplements, and the medications that are actually being taken through the medication therapy management (MTM) program. The Gateway provides the means for everyone to better understand and manage the medicines for the best outcomes.
Further, the Gateway Community Resource Finder has enabled information about important resources such as transportation, meal delivery, social services, and home nursing. The MTM pharmacist knows that patients without food or transportation to their physicians cannot adequately manage their health or medications. The underlying SafeIX Platform also allows the Gateway to offer secure messaging that looks like email and lets the pharmacist, patient, friends, and family exchange messages about the patient’s care.
Traditional EHRs don’t accommodate treatment plans of the specificity designed by the pharmacy for patients in the pilot. This is where Datuit is pushing the EHR to new horizons: its SafeIX Platform helps multiple clinicians (including long term care providers), patients, and family caregivers contribute data. For example, patients can enter their own healthcare problems, such as fear of falling. The patients, families, and clinicians can then add interventions to address them.
Like other new organizations I’ve spoken too in health care, Connected Health Resources has grand plans beyond the current pilot. They are taking it slow, because Koss believes personal health records (PHRs) have tried to do too much at once and have overwhelmed their users with too many possibilities. But she would like Connected Health Resources to grow in response to what patients and families say they need. The Gateway tools already include the ability to generate multi-lingual discharge instruction from Polyglot. The initial pilot purposefully focuses on the more narrow scope of medications along with the health and social services support. The next step will be to engage hospitals to provide the plain language multi-lingual discharge instructions.
Chronic care ultimately goes beyond medications to things supported by a patient-centered medical home (PCMH), community health workers, and the many community-based service providers. The Gateway in partnership with the Datuit SafeIX Platform are poised to allow all participants identified by the patient and families to contribute to and be part of their health community.