Establishment and outcomes of a model primary care pharmacy service system.

PURPOSE: The establishment and outcomes of a model primary care pharmacy service system are described. SUMMARY: A primary care pharmacy practice model was established at a government health care facility in March 1996. The original objective was to establish a primary pharmacy practice model that would demonstrate improved patient outcomes and maximize the pharmacist's contributions to drug therapy. Since its inception, many improvements have been realized and supported by advanced computer and automated systems, expanded disease state management practices, and unique practitioner and administrative support. Many outcomes studies have been performed on the pharmacist-initiated and -managed clinics, leading to improved patient care and conveying the quality-conscious and cost-effective role pharmacists can play as independent practitioners in this environment. These activities demonstrate cutting-edge leadership in health-system pharmacy. Redesign has been used to improve consistent access to a medication expert and has significantly improved the quality of patient care while easing physicians' workload without increasing health care costs. CONCLUSION: A system using pharmacists as independent practitioners to promote primary care has achieved high-quality and cost-effective patient care.     

Opportunities for improving the quality of hypertension care in a managed care setting.

Hypertension management practices and patient health outcomes in a managed care setting were evaluated. Health-system pharmacists analyzed plan medical and pharmacy claims data for September 1, 1998, to August 31, 1999, to identify hypertensive enrollees (n = 23,316). Reviews of pharmacy claims and medical charts of a sample of hypertensive patients (n = 374) determined blood pressure control status, prevalence of cardiovascular risk factors, and comorbidities. The majority of patients treated for hypertension (66%) did not achieve blood pressure control. Analysis revealed a high prevalence of cardiovascular risk factors among hypertensive patients, with 92.2% of study patients having two or more risk factors. Reviews of 132,512 pharmacy claims revealed that one half of all prescribed therapies were for monotherapy, and 21% of hypertensive patients were prescribed combination therapy with two different agents. Data from a large managed care organization revealed that more than half of all hypertensive patients had inadequate blood pressure control. A quality improvement program for hypertension care that can improve patient health outcomes must educate patients and health care providers about the implications of the disease, identify patients with compelling comorbidities, evaluate pharmacologic regimens, and recommend therapeutic changes when necessary.     

Quality of life assessments in clinical practice

The main objective of a publicly funded health care is to improve the health of the population as much as possible, and to reduce inequalities in health within that population. The traditional medical approach is essential, however there are increasingly demanding explanations as to how the medical care provides health, these explanations must encompass more than laboratory results and clinical opinions. Quality of life represents the functional effect of an illness and consequent therapy upon a patients predicted by the patient, provides information about the physical and social functioning and mental well-being. Chronic diseases are the perfect objectives of quality of life evaluation, since in chronically ill patients the long term health outcomes are the most important as opposed to the short term improvements. The quality of life of these patients in impaired at several points, such as the disease has an impact on psychological functioning, impact on work (school) and every-day life, impact on family life, impact on social functioning and impact on the economical status of the patients. In practice we have a wide variety of potentially efficient heath care activities, drugs that provide an improved clinical status. The core problem is whether the physician and the patient have the same rating for one particular health state. The results of quality of life assessments suggest that, however we have objective and reliable tests to assess the patients health state we can not predict how patients are feeling as a result of an intervention. As assessment of a patients quality of life provides important complementary information and should be measured together with the conventional clinical indices in the everyday clinical practice.     

Cultural Competency in Health Care and Its Implications for Pharmacy

As the United States becomes more diverse, a patient's cultural influences on health outcomes and health care decision-making and delivery need to be considered. Cultural influences affect a patient's decision to take drug therapy and concomitant alternative therapies. Seven components have been identified to improve culturally competent care in a variety of practice sites. The first component to developing culturally competent practices involves the analysis of self and system attitudes and practices toward various cultures. In the second component, health care providers should increase their knowledge about the cultures they serve through different patient assessment techniques, readings, and community activities. The third component involves improving cross-cultural communication by being aware of differences in social norms, assessing health literacy, using interpreters, knowing another language, and using bilingual patient education materials. In the fourth component, pharmaceutical care plans should accommodate cultural preferences such as the use of herbs, spiritual healers, and additional family decision-makers. Therapeutic plans should be negotiated between patient and provider to optimize outcomes. The fifth component discusses health care provider and system involvement in the community through health fairs, ethnic festival participation, and communication with cultural decision-makers to help provide culturally competent care by fostering communication ties. In the sixth component, knowing and following regulations such as the federal Culturally and Linguistically Appropriate Services and the Joint Commission standards for organizational cultural competency can help enhance care for patients from various cultures. In the last component, quality assurance assessments of procedures to improve care for various diverse cultures should be conducted, with findings (in terms of strengths and areas of improvements) shared with other providers and systems. Pharmacists and pharmacy technicians in a variety of systems and practices can improve care to patients with differing cultures by using these seven components to enhance culturally competent care.     

Key factors for sustainable integration of pharmacists in team-based primary care physician practices

ObjectivesTo (1) identify strategies for financial justification of pharmacists integrated into team-based primary care, (2) describe the payment models currently used for integration of pharmacists into team-based primary care, and (3) elicit key factors facilitating sustainable pharmacist-provided patient care services in the primary care setting.DesignQualitative analysis using semistructured interviews.SettingNonacademic outpatient primary care physician practices throughout the United States from January to April 2014.ParticipantsPharmacists responsible for leadership of clinical pharmacists in primary care practices whose positions are supported through nondispensing patient care services.Main outcome measuresCurrent payment model, infrastructure, documentation strategies, and methods of quality assessment.ResultsTwelve interviews were conducted. Practices included a combination of single- and mixed-payer models in integrated and nonintegrated health systems. Various billing strategies were used, particularly in nonintegrated models, to sustain pharmacists in primary care practices utilizing both fee-for-service (FFS) and value-based incentives payments. Five main themes were elicited: (1) Pharmacists are integrated and valuable members of health care teams; (2) pharmacists are documenting in an accessible electronic health record; (3) data tracking is a facilitator for justifying and adapting practice; (4) systematized processes for pharmacist integration exist in each practice; and (5) pharmacists’ responsibilities on the team have grown and evolved over time.ConclusionPharmacists’ contributions to improving patients’ medication-related care are the same regardless of payment model. Financially sustainable integration of pharmacists on the team involves using a combination of FFS and value-based incentive payments, consistent documentation, meaningful collection of pharmacists’ contributions to improve the quality of care, and a firm understanding of the practice’s needs and financial structure. These themes can be used as a guide for pharmacists as they establish themselves in an FFS environment and adapt to a future in value-based care.     

A learning pharmacy practice enabled by the pharmacists’ patient care process

To address the Quintuple Aim of health care improvement, the profession of pharmacy is on the verge of a practice transformation that incorporates continuous learning from medication-related data into existing clinical and dispensing roles. The pharmacists’ patient care process (PPCP) enables a learning pharmacy practice through the systematic and standardized collection of real-world medication-related data from pharmacists’ patient care activities. A learning pharmacy practice continually generates data-powered discoveries as a byproduct of PPCP interactions. In turn, these discoveries improve our medication knowledge while upgrading our predictive powers, thus helping all people achieve optimal health outcomes. Establishing a practice management system connected to the PPCP means that data are generated from every PPCP interaction, combined with existing data, and analyzed by teams of pharmacists and data scientists. The resulting new knowledge is then incorporated into all future PPCP interactions in the form of predictions coupled to actionable advice. The primary purpose of a learning pharmacy practice is to combine the power of predictive modeling with evidence-based best practices to achieve and sustain population-level health improvements. This purpose is achieved by systematically optimizing individual medication use in an equitable manner on a global scale.     

How Population Health Management and Big Data Can Rock Your World

Hospitals and health systems like yours have been aggressively pursuing a range of information systems over the last several decades. Cited goals are often efficiency, lower costs, better decisions, and better patient outcomes. But how do these systems purportedly lead to population-level improvements in care? In this column, we address the connections that are anticipated as well as challenges to be expected along the way.Let’s start with some definitions. Population health management, according to a leading outcomes management provider, is the “aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.”¹ While we like this definition because systems are used in a way that patient care is provided to individual patients, we think that the intelligence gained from each patient encounter can concurrently be applied throughout the continuum of care for any population being served. Big data is a buzzword in health care, even though other industries have been using the analysis of huge quantities of digitized data for many years. In health care, the rapid adoption of the electronic health record (EHR) provides an opportunity to finally having a real chance for improving health outcomes and controlling costs.The definition of big data varies, but we will define it as the “ability to access and analyze information that holds the key to more efficient, higherquality health care while significantly shortening the time between research and translation into practice.”² Big data is made possible because health care is now moving toward being a real digital enterprise to leverage the collective power of information. In our examination of health system technology devices that have been deployed for the last 10 years, we discovered that some had the ability to be networked but many were not. The EHR can now be the data hub for providers while supporting care provision by consolidating and analyzing these digital warehouses of real-time data to discover trends and make predictions.In a previous column, we described these processes as enterprise performance management. At a strategic level, a health system would generate critical success factors and key performance indicators that would lead to outcomes improvement. At an operational level, data would be gathered as a byproduct of rendering patient care to determine how well these indicators of success were being met. The system would generate e-mails to managers to give them feedback on any success factors assigned to them. Exception reports could include deficiencies, meeting of goals, and exceeding expectations. When best practices were identified within the enterprise, the methods being utilized to exceed expectations could then be used to address the problems experienced in units where expectations were not being met.In our experience, niche industries are being generated by the inability of EHR vendors to address both the developmental needs to improve their core product for its primary purpose of patient care and to add all of the population health and data analysis capabilities required. Add to this the fact that the individuals who are needed at the health system level to work with data analysis are the same people that Google and Microsoft are recruiting as quickly as possible. Thus, entrepreneurs look at the needs of health care and bring the skills and expertise necessary to the task. The expectation is that the EHR vendors who are going to cooperate by providing the needed data will eventually wrap the capabilities of these consultants into the everyday functions found in their systems.The complexity inherent in population health management is quite high. The data sources and their divergent information standards bring about the first challenge. Again, starting with a specific EHR, integration or interfaces must be established with any ambulatory electronic medical record being utilized by employed or affiliated providers. Each of these medical records could utilize one of 10 standards to include HL7, CCR, CCD, and so on that will need to be translated and normalized to be of any use for analysis. Next, we have separate computerized prescriber order entry systems, labs, imaging, health information exchanges, payers, and claims data. Each of these data sources must be integrated and normalized before they provide any real utility.Now we need to talk about clinical decision support systems. As a provider, you are probably already aware of the problem we call flag fatigue where alerts and warnings interrupt your provision of care for your patients. The challenge for an enterprise decision support system will be to ensure that the right provider is involved in the appropriate intervention at the appropriate point in the care process in the appropriate facility for the appropriate patient at the appropriate time. Get your mind around this complexity. Now think about multidisciplinary care team coordination and communication. How are we going to know who did what, when, and how?Alerts that are needed in population health management can also start when care gaps are identified. They can start when a patient steps on a digital scale that transmits a 10-lb weight gain due to heart failure–related edema. The alert may take place because patient outreach is indicated and an assignment for this task must be made. Action may be needed due to a patient’s entry in a notes section of a patient portal. Alerts may occur because quality reporting is either missing or the values entered have triggered the need for a response.Right now, we’re spending most of our time putting these data in and straddling the current reimbursement system that is so heavily based on fee-forservice care provision while preparing for anticipated, future ways of providing care. To understand how life will be different as these changes take place, look at those health systems that have already gone through significant population health management transitions and who use big data routinely to improve their operations.We have been attending presentations by health systems that have started with the care provision of their own employees as a way to get some small population experience in the area and then moved on to larger populations they were able to attract. Just Google “population health management” and explore testimonials on how care provision has changed among these frontrunners. Some will definitely rock your world or at least give you a few “ah-ha” moments. We would enjoy hearing your comments and questions on this topic. You can reach Bill at felkebg@auburn.edu or Brent at foxbren@auburn.edu.     

Does organisational culture influence prescribing in care homes for older people? A new direction for research

Prescribing in care homes for older people has been the focus of much research and debate because of inappropriate drug choice and poor monitoring practices. In the US, this has led to the implementation of punitive and adversarial regulation that has sought to improve the quality of prescribing in this healthcare setting. This approach is unique to the US and has not been replicated elsewhere. The literature has revealed that there are limitations as to how much can be achieved with regulation that is externally imposed (an 'external factor'). Other influences, which may be categorised as 'internal factors' operating within the care home (e.g. patient, physician and care-home characteristics), also affect prescribing. However, these internal and external factors do not appear to affect prescribing uniformly, and poor prescribing practices in care homes continue to be observed. One intangible factor that has received little attention in this area of healthcare is that of organisational culture. This factor has been linked to quality and performance within other health organisations. Consideration of organisational culture within care-home settings may help to understand what drives prescribing decisions in this particularly vulnerable patient group and thus provide new directions for future strategies to promote quality care.     

Implementation Science to Advance Care Delivery: A Primer for Pharmacists and Other Health Professionals

Health care is experiencing increasing pressure to implement evidence‐based interventions that improve quality, control costs, and maximize value. Unfortunately, many clinical services and interventions to optimize medication use do not consistently produce the intended humanistic, clinical, and economic outcomes. The lack of conclusive results is believed to stem from the widely recognized research‐to‐practice gap. The field of implementation science seeks to discover and apply strategies designed to accelerate successful integration of interventions into routine practice. This primer provides an overview of implementation science principles for pharmacists and other health care providers interested in accelerating practice transformation to improve health care delivery and, ultimately, patient care.     

病例注册登记的行动计划

摘 要注册登记研究越来越多的应用于评估某一特定疾病、状况或暴露人群的特定结局。疾病注册登记和产品注册登记为常见的注册登记研究类型,两者的研究人群常常存在重叠,容易造成混淆。因此,欧洲药品管理局提出了“病例注册登记”的概念,并发布了开展病例注册登记的行动计划。该计划从患者人群入手,促进使用已有的病例注册登记,促进建立和使用新的注册登记,旨在获取可靠的数据信息并引导监管决策。了解设计和策划病例注册登记以及如何开展预试验,对开展类似的病例注册登记研究有一定的指导意义。本文概述了病例注册登记的行动计划,包括其背景、概念,以及可用的方法。     

Unlicensed pharmaceutical preparations for clinical patient care: Ensuring safety

Most medicinal products dispensed to patients have marketing authorization (MA) to ensure high quality of the product, safety, and efficacy. However, in daily practice, to treat patients adequately, there is a medical need for drugs that do not hold MA. To meet this medical need, medicinal products are used in clinical care without MA (unlicensed), such as products prepared by (local) pharmacies: the pharmaceutical preparations. Three types of pharmaceutical preparations are distinguished: (i) reconstitution in excess of summary of product characteristics; (ii) adaptation of a licensed medicinal product (outside its official labeling); (iii) medicinal products from an active pharmaceutical ingredient. Although unlicensed, patients may expect the same quality for these unlicensed pharmaceutical preparations as for the licensed medicinal products. To assure this quality, a proper risk‐benefit assessment and proper documentation in (centralized) patient registries and linking to a national pharmacovigilance database should be in place. Based on a risk assessment matrix, requirements for quality assurance can be determined, which has impact on the level of documentation of a pharmaceutical preparation. In this paper, the approach for good documentation including quality assurance and benefit‐risk assessment will be discussed and possibilities for patient registries are described to make these crucial preparations available for regular patient care. KEY POINTS

• Ensuring pharmaceutical quality and performing a proper benefit‐risk assessment will guarantee safe use of pharmaceutical preparations.
• Good documentation of (ultra‐)orphan treatments can be collected in centralized patient registries and should be combined with existing information in (inter)national databases and self‐reflection of patients.
• Linking patient registries to a centralized database for adverse drug events is highly recommended as it increases safety control of the (ultra) orphan pharmaceutical preparations.

     

Pharmaceutical care programmes for the elderly: economic issues

Pharmaceutical care is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. It describes the process through which a pharmacist collaborates with a patient and with healthcare professionals in designing, implementing and monitoring a therapeutic plan that will produce specific, desirable therapeutic outcomes for the patient. The elderly are a patient population who could particularly benefit from pharmaceutical care provision as they are at greater risk of experiencing significant drug-related problems such as inappropriate prescribing, noncompliance with prescribed medication and adverse drug reactions/interactions leading to a decrease in health-related quality of life. The extent of economic benefit of pharmaceutical care reported in the literature is variable and its generalisability is suspect due to the lack of trials which have utilised a robust research design. The few studies which have undertaken a rigourous economic evaluation have used a range of data collection methods that is reflective of the difficulty of capturing essential data. Furthermore, even in well-designed studies, the generalisability of economic evaluations to other countries is questionable because of unique national data collection systems and an inability to pool international data because of disparities between different healthcare systems. The use of a suitable measure for health-related quality of life is also problematic in a very diverse and heterogeneous population such as the elderly and, therefore, adds to the difficulties of inclusion of such measures in economic analyses of pharmaceutical care programmes. A more standardised approach to data collection is required to facilitate economic analyses as an essential element in the evaluation of any pharmaceutical care programme for the elderly. Suggestions on such approaches, together with a critical appraisal of studies performed to date, are the focus of this review.     

Designing solutions for securing patient privacy--meeting the demands of health care in the 21st century.

OBJECTIVES: To define the issues surrounding patient privacy, examine the political context in which debate is taking place, and present a novel technology model for addressing privacy, confidentiality, and security in 21st century health care. SUMMARY: The discussion of privacy addresses one of the basic issues in health care today--the tension between the needs of the individual patient for privacy and confidentiality and the needs of society to effectively manage health care practices and control health care costs. Patient concerns for privacy, confidentiality, and security are legitimate, and can usually be reduced to issues that potentially affect an individual's employment, ability to get and maintain health coverage, and have control over his or her records and care. These concerns, combined with several precipitating events, are forcing the issue of privacy into the political arena, where new health policy decisions will be made. The debate must be framed within a principle-centered approach that focuses on boundaries, security, consumer control, accountability, and public responsibility. A global, distributed electronic health record management model that provides location-independent, secured, authenticated access to relevant patient care records by qualified health care professionals on a need-to-know basis provides solutions. Information asset considerations should be designed to equitably represent the ownership needs of corporate entities, society, and the individual. CONCLUSION: A secure electronic health record structure that systematically ensures a high level of accountability combined with thoughtful dialogue among key stakeholders in the public policy development process can offer the privacy outcomes we seek.     

The overall safety profile of currently available vaccines directed against infectious diseases

The vaccines currently used worldwide for the prevention of infectious diseases are quite safe in comparison to most pharmaceutical and biological agents. Vaccine components may contribute to inflammatory, allergic or anaphylactic reactions. Most adverse events are transient and well-tolerated. Transient severe adverse reactions occur at rates of one in one thousand vaccinations; permanent severe adverse reactions occur on the order of one in one million. The most common of the severe adverse reactions are syncope and allergic reactions. Providers can take steps to prevent or ameliorate these reactions by pursuing both prelicensure testing (albeit limited) and postlicensure testing and monitoring. Systems that enhance the detection of safety concerns include national passive and active surveillance as well as regional vaccine registries and provider-based patient education. Since vaccines are used in universal programmes, their safety is paramount to their continued acceptance. Healthcare managers, including administrators of hospitals, clinics, practice groups, health maintenance organisations (HMOs) and managed care plans, can and should support providers in minimising adverse events associated with vaccines by supporting postvaccination observation policies, postlicensure testing and surveillance, vaccine registries and patient education systems.     

The overall safety profile of currently available vaccines directed against infectious diseases

The vaccines currently used worldwide for the prevention of infectious diseases are quite safe in comparison to most pharmaceutical and biological agents. Vaccine components may contribute to inflammatory, allergic or anaphylactic reactions. Most adverse events are transient and well-tolerated. Transient severe adverse reactions occur at rates of one in one thousand vaccinations; permanent severe adverse reactions occur on the order of one in one million. The most common of the severe adverse reactions are syncope and allergic reactions. Providers can take steps to prevent or ameliorate these reactions by pursuing both prelicensure testing (albeit limited) and postlicensure testing and monitoring. Systems that enhance the detection of safety concerns include national passive and active surveillance as well as regional vaccine registries and provider-based patient education. Since vaccines are used in universal programmes, their safety is paramount to their continued acceptance. Healthcare managers, including administrators of hospitals, clinics, practice groups, health maintenance organisations (HMOs) and managed care plans, can and should support providers in minimising adverse events associated with vaccines by supporting postvaccination observation policies, postlicensure testing and surveillance, vaccine registries and patient education systems.     

Lessons learned in managed care

Competition, reduction in health care premiums, rising health care costs, aging of the population, and technologic advances are several factors that create both challenges and opportunities for managed care organizations (MCOs). The demands to constantly improve quality of care and efficiency of operation while holding down costs are drivers meant to stimulate organizations to constantly strive to rethink their process of care provision. The most cost-effective program is one that maintains its health plan members who are active in the community and away from the institutional setting. This is optimally achieved through an accessible and comprehensive ambulatory practice. Innovation and paradigms of practice change in the acute, subacute, and long-term care arenas have allowed us to dramatically impact quality and utilization in these expensive areas, while at the same time freeing up additional time for MCO primary care practitioners to focus on their community-based patients. MCO primary care providers have not only supported but welcomed these changes in their organization, recognizing that these innovations represent a component of the continuum of health care needed to effectively serve their patients.     

尘肺并发肺心病的健康教育

通过对尘肺病人进行健康教育,为病人创造良好的心理氛围,安静舒适的环境,科学的饮食结构,安全有效的氧疗,加强体育锻炼,提高病人健康自护能力,提高生活质量。使临床护理与健康教育相结合,有效提高治疗和护理效果,改善病人的生存质量。     

Managing Care for Patients With Substance Abuse Disorders at Community Health Centers

Coordinating medical and substance use disorder (SUD) services is associated with good health and treatment outcomes but it is not widely practiced. This may be due to a lack of real-world models for coordinating care. This study examined the operational practices associated with a sample of community health centers (CHCs) identified as effectively coordinating SUD services relative to other CHCs. Case studies were used to describe the process of identifying patient need and linking patients with SA treatment services, and to generate propositions about operational approaches for effectively coordinating care. Integrating behavioral health staff within the primary care team was identified as especially critical for facilitating key care transitions. Additional operational approaches that aim to improve care transitions within and across care settings were identified. Future study will be needed to understand the significance of these approaches in terms of health and treatment outcomes. On-going coordination activities among primary care and SUD provided for shared patients remained a challenge for all sites.