Assessing the Effect of a Telepharmacist’s Recommendations During an Integrated, Interprofessional Telehealth Appointment and Their Alignment with Quality Measures

Abstract

BACKGROUND:

A growing provider shortage contributes to the widening gap in significant disparities that rural communities face. To expand access to care for rural-dwelling patients with epilepsy, a national nonprofit organization initiated an integrated, interprofessional telehealth program.

OBJECTIVE:

To identify gaps in care based on a telepharmacist’s recommendations and determine whether these recommendations aligned with Health Effectiveness Data Information Set (HEDIS) performance measures.

METHODS:

A retrospective chart review was conducted for patients who had an appointment with an integrated interprofessional care team composed of an epileptologist, a social worker, registered nurses, and a pharmacist. This novel approach integrated provision of care by team members at geographically distinct remote locations. The pharmacist conducted comprehensive medical reviews via video conferencing and made recommendations to the epileptologist, primary care provider, and/or patient, as appropriate. The consultation was documented in the electronic health record (EHR). The pharmacist’s recommendations were categorized as 1 of the 24 preselected HEDIS performance measures or as a non-HEDIS measure. The analysis used descriptive statistics to report patient demographics and pharmacist recommendations.

RESULTS:

This study included 86 participants. 86 initial and 36 follow-up appointments were conducted between April 2016 and October 2017. The majority of patients were female (52%), with a mean age of 26.2 years (SD = 14.6, range 4-76) and were taking an average of 6.1 medications (SD = 3.6). 159 comorbidities or conditions were identified in the EHR along with 306 recommendations, for an average of 3.6 recommendations per patient (SD = 3.2). 41 (13.4%) recommendations aligned with preselected HEDIS measures, including medication management for depression (31.7%), hypertension (24.4%), asthma (9.8%), and comprehensive adult diabetes care (14.6%). The remaining 265 recommendations lacked sufficient documentation for categorization or failed to align with any targeted measure.

CONCLUSIONS:

This retrospective analysis showed that only 13% of pharmacist recommendations aligned with HEDIS quality measures. While it demonstrates the added value of clinical pharmacists in novel telehealth approaches, future work is needed to develop strategies to increase the number of recommendations aligning with HEDIS measures that adhere to national consensus treatment guidelines via telepharmacist training and improved documentation.

What is already known about this subject

• In 2015, 3 million adults and 470,000 children had a diagnosis of epilepsy in the United States.

• Typically, patients in rural areas experience health care disparities, while individuals with epilepsy may experience greater access-to-care issues, given that there are only 170 epilepsy centers across the nation.

• The health care system is transitioning to value-based payments that incentivizes optimal patient outcomes through achievement of performance measures, such as the Health Effectiveness Data Information Set (HEDIS) performance measures.

What this study adds

• This study offers an innovative solution to health care disparities of rural-dwelling individuals through an interprofessional telehealth program for those with epilepsy.

• The importance of a telepharmacist’s role on a health care team was reflected in the number of chronic condition and medication-related recommendations made to epileptologists, primary care providers, and patients.

• Only 13% of recommendations made by a telepharmacist aligned with the HEDIS performance measures, suggesting the need for further research to identify effective strategies for better alignment to improve patient outcomes.

Epilepsy constitutes the fourth most common neurological disease in the United States, affecting 3 million adults and 470,000 children in 2015 alone.^1,2 In 2004, the annual estimated indirect and direct costs totaled $4,500 per patient, resulting in total costs of $15.5 billion each year.³

Despite disease prevalence, only 50% of patients with active epilepsy received care within the previous year from a primary care provider, along with either a neurologist or epileptologist.⁴ Furthermore, less than one fourth of patients with uncontrolled disease followed up with an epilepsy specialist.⁵ Patients living in areas closer to epilepsy centers, defined by the National Association of Epilepsy Centers as “programs that provide comprehensive diagnostic and treatment services to individuals with uncontrolled seizures,” were more likely to receive specialist care.⁶ With only 170 epilepsy centers throughout the nation, rural patients in particular experienced significant disparities in specialized care.⁵

In conjunction with the need for innovative health care programs, new approaches are also warranted that reflect changes in health care funding models. The shift from fee-for-service to value-based models emphasizes the importance of reaching optimal health outcomes and incentivizes reimbursement for health care providers.^7,8 Performance measures, such as the widely used National Committee for Quality Assurance’s (NCQA) Health Effectiveness Data Information Set (HEDIS), can track progression toward improved patient outcomes.^7,9 These measures are used by providers to improve patient care and reduce health care costs.⁸

The health care system faces multiple challenges with the increasing shortage of primary care providers and the unmet health care needs of medically underserved populations.^6,10,11 To help bridge this dearth in providers who treat chronic primary care diseases, pharmacists are expanding their roles via innovative technologies, such as telehealth, to reach patients residing in rural areas.^12,13 These telehealth solutions provide more opportunities for pharmacists to collaborate with integrated interprofessional teams, despite geographic separation from other team members.¹³ Furthermore, pharmacists can reach patients who may not have otherwise had access to similar pharmacy services.¹³

To address this unmet need, an academic-based medication therapy management provider partnered with a national nonprofit patient organization to develop an innovative, interprofessional telehealth service. The academic-based provider employed a team of pharmacists to provide comprehensive medication reviews (CMRs) for the improvement of patient outcomes through adherence.^13,14 The nonprofit patient organization serves the epilepsy community by improving access to care, education, and funding of research initiatives.

This novel, jointly created telehealth service brought together an interprofessional team to extend the provision of care to patients residing in rural areas of Illinois. The purpose of this study was to (a) demonstrate a scalable model for telepharmacist integration into a value-based payment system; (b) describe the telepharmacist’s recommendations, identifying opportunities to improve patient care and expand pharmacy services; and (c) determine if the telepharmacist’s recommendations aligned with the HEDIS performance measures.

Methods

Study Design and Setting

This retrospective program evaluation assessed the role of pharmacist-performed CMR during interprofessional, patient telehealth appointments. This project was deemed exempt by the University of Arizona Institutional Review Board.

The interprofessional telehealth team consisted of an epileptologist, a social worker, registered nurses, and a pharmacist. Team members in geographically dispersed locations used multiway video conferencing to participate in synchronous patient appointments.

Patients traveled to a rural office near their communities and participated in appointments via video conferencing. An in-office registered nurse took patients’ vitals and assisted with technology, if necessary. The epileptologist assessed for seizure control and medication selection according to national epilepsy guidelines. The social worker provided assistance with facilitating individualized education programs and housing and transportation arrangements, when appropriate. During the appointment, the telepharmacist performed a CMR with the patient that included a review of all medications (e.g., prescriptions and over-the-counter and herbal products). The telepharmacist assessed the appropriateness, effectiveness, and tolerability of therapies used to manage the patient’s diagnosed medical conditions, with emphasis on monitoring for pharmacokinetic and pharmacogenomic considerations. The telepharmacist’s recommendations were communicated to the epileptologist responsible for evaluation and treatment and to the patient during the appointment. Recommendations to the primary care physician were provided via telephone following the telehealth encounter. The telepharmacist’s recommendations were recorded live in the pharmacy note section of the electronic health record (EHR) in a standardized format.

Study Population

Patients were included if they participated in an interprofessional telehealth appointment and received a telepharmacist-delivered CMR between April 2016 and October 2017. Patients were excluded if they had a diagnosis of cancer or end-stage renal disease or were receiving hospice care. Patient consent was not required to receive health care for epilepsy or a seizure disorder; however, patient consent was needed for the consult with the telepharmacist and the video appointment.

HEDIS Measures

Of the 81 HEDIS standardized performance measures developed by the NCQA to improve quality of health care, 24 were preselected based on the pharmacist’s scope of practice. Selected measures included the following: chronic conditions (e.g., asthma, depression, diabetes, and cardiovascular disease); disease prevention (e.g., immunizations); and safety (e.g., laboratory monitoring, drug-disease interaction, and high-risk medications in the elderly). Some of the selected HEDIS measures included adult body mass index assessment, medication management for people with asthma, comprehensive adult diabetes care, and statin therapy for patients with diabetes (Appendix, available in online article).

Data Collection

Study investigators retrospectively reviewed the telepharmacist’s notes in the EHR in February 2018. Patient characteristics extracted and recorded in the electronic spreadsheet included age, gender, insurance provider, number of medications taken, comorbidities, and the telepharmacist’s recommendations.

Data Analysis

Descriptive statistics were used to analyze patient characteristics, and the telepharmacist’s recommendations were mapped to the preselected HEDIS measures to identify whether they aligned. Alignment was determined by assessing how well the pharmacist recommendations adhered to the HEDIS measures. The number of recommendations that did not align with the preselected HEDIS measures (termed non-HEDIS measures) were also calculated. All analyses were conducted using Microsoft Excel, version 15.38 (Microsoft, Redmond, WA).

Results

All patients (N = 86) who received an initial telepharmacist consultation during the 19-month study period were included in this retrospective review. The majority of patients were female (52.3%) with a mean age of 26.2 (SD = 14.8; range = 4-76 years). Patients were enrolled in various insurance plans or combinations thereof. The most common plan was Blue Cross Blue Shield (17.4%), while the remaining participants were insured through a mixture of private and government (Medicare and Medicaid) plans. Interestingly, the health insurance provider was unknown to almost half of the participants (46.5%). In addition, patients were taking an average of 6.1 (SD = 3.6; range = 0-20) medications. A total of 159 comorbidities were recorded in the pharmacist’s notes, with an average of 1.85 per patient. The most commonly recorded diagnoses were mental health (39.5%) and gastrointestinal conditions (16.3%; Table 1).

TABLE 1.

Demographic Characteristics of Study Participants (N = 86)

Characteristic	Total, n (%)
Age, years, mean (SD)	26.2 (14.8)
Female gender	45 (52.3)
Health insurance plan
Commercial	24 (27.9)
Medicaid	12 (14.0)
Medicare	1 (1.2)
Medicaid and commercial	3 (3.5)
Medicaid and Medicare	2 (2.3)
None	4 (4.7)
Unknown	40 (46.5)
Number of medications taken, mean (SD)	6.1 (3.6)
Comorbid conditions
Seasonal allergies	13 (15.1)
Hyperlipidemia	2 (2.3)
Diabetes mellitus	3 (3.5)
Gastrointestinal	14 (16.3)
Gynecologic	8 (9.3)
Headache	9 (10.5)
Hypertension	7 (8.1)
Hypothyroidism	6 (7.0)
Mental health	34 (39.5)
Muscle spasm	4 (4.7)
Nausea	2 (2.3)
Pain	9 (10.5)
Pregnancy	2 (2.3)
Respiratory condition	9 (10.5)
Insomnia	11 (12.8)
Other	15 (17.4)

SD = standard deviation.

Of the 86 patients, 25 (29.1%) had follow-up appointments with the telepharmacist. Thirty-six follow-up appointments were conducted, ranging from 1-4 per patient (mean = 2.8, SD = 0.8). Thus, some patients had multiple follow-up appointments, while others had none.

During the initial and follow-up appointments, the telepharmacist made 306 recommendations, averaging 3.6 (SD = 3.2) recommendations per patient. A total of 13.4% of recommendations aligned with preselected HEDIS measures; however, the remaining 86.6% could not be categorized as such, so they were designated non-HEDIS recommendations. The most commonly identified HEDIS measures that mapped to the pharmacist’s recommendations were medication management for depression (31.7%), hypertension (24.4%), asthma (9.8%), and diabetes (17.1%). Examples of non-HEDIS measure recommendations included medication and adherence counseling, identification of and recommendations to resolve drug-drug interactions, referrals for vaccination in pregnant patients; and fall risk prevention education (Table 2).

TABLE 2.

Categorization of a Telepharmacist’s Recommendations to Patients into HEDIS and non-HEDIS Measures

Recommendation	Patients Receiving Recommendation n (%)	Recommendations Made n (%)	Recommendations per Patient Mean (SD)
Total recommendations made	82 (95.3)	306 (100.0)	3.6 (3.2)
HEDIS measure	21 (24.4)	41 (13.4)	2.0 (1.2)
Medication management for people with asthma	2 (9.5)	4 (9.8)	2.0 (1.4)
Controlling high blood pressure	7 (33.3)	10 (24.4)	1.4 (0.8)
Comprehensive adult diabetes care	4 (19.0)	7 (17.1)	1.8 (1.0)
Antidepressant medication management	8 (38.1)	13 (31.7)	1.6 (1.1)
Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications	1 (4.8)	1 (2.4)	1.0 (0.0)
Annual monitoring for patients on persistent medications	6 (28.6)	6 (14.6)	1.0 (0.0)
Non-HEDIS measurea	79 (91.9)	265 (86.6)	3.4 (3.2)

Note: Percentages for each of the HEDIS measures sum to 100% using 41 as the denominator. The total HEDIS measures and the non-HEDIS measure recommendations sum to 100%.

^aExamples of non-HEDIS measures: medication and adherence counseling; identification of and recommendations to resolve drug-drug interactions; tetanus, diphtheria, and pertussis vaccination in pregnant patients; and fall risk prevention education.

HEDIS = Healthcare Effectiveness Data and Information Set; SD = standard deviation.

Discussion

This study’s key findings showed that the telepharmacist made over 300 recommendations for the 86 participants, for an average of 3.6 intervention recommendations per patient. These recommendations focused on HEDIS-related measures for asthma medication management, controlling hypertension, comprehensive adult diabetes care, and managing antidepressant medications that adhered to national consensus guidelines, including the American Diabetes Association, the American Heart Association, Centers for Disease Control and Prevention, and the Global Initiative for Asthma. To that end, patients living in rural areas typically have higher rates of diabetes and hypertension compared with urban dwellers.^15,16 Despite the importance of lifestyle changes in clinical disease management, pharmaceutical intervention is often still required.¹⁷ Thus, this review underscores the pharmacist’s role in provision of comprehensive disease management regardless of chronic conditions.

The large number of recommendations made in this study demonstrates the potential benefit of integrating a telepharmacist into an interprofessional virtual care team. However, these recommendations aligned with HEDIS measures targeting other chronic diseases beyond epilepsy; currently, there are no epilepsy-specific HEDIS measures. While not related to epilepsy per se, the telepharmacist’s recommendations were important in patients’ overall chronic disease management. Furthermore, polypharmacy (taking multiple medications for multiple conditions) can create challenges regarding proper administration and subsequent patient adherence-related issues,¹⁸ yet the telepharmacist helped bridge this gap to ensure appropriate and safe overall medication-taking behavior.

Interestingly, the per patient recommendations far surpassed those reported by others.^14,19 Buhl et al. (2017) reported 0.809 and 0.818 recommendations per patient per year for those participating in pharmacist-delivered CMRs over a 2-year period, respectively. Also, Buhl et al. only noted medication additions or deletions rather than total recommendations per patient, so it is possible that the interventions were underreported.¹⁹ Finally, Johnson et al. (2018) included recommendations for medication-related problems and health promotion education in their total (n = 1,339); however, it still resulted in only 2.58 interventions per patient.¹⁴

Integration of a telepharmacist was important for multiple reasons. First, the pharmacist played a critical role in helping address health care disparities for these Illinois residents with epilepsy and other chronic conditions. This is especially notable given that this state has the fifth largest population of patients with epilepsy.² Second, the telepharmacist enabled completion of a CMR in the presence of an epileptologist, providing an opportunity to discuss the patient’s medication profile to resolve any issues at the point of prescribing and allowing for patient input and engagement. Previous research has shown that greater access to pharmacists and shared decision making improved communication between health care professionals.²⁰ As such, telepharmacists can offer a range of clinical interventions related to adherence, safety, gaps in care, vaccines, and cost savings, further illustrating their value to telehealth teams in caring for patients with multiple conditions, including epilepsy.¹³

Despite the considerable number of recommendations made by the telepharmacist, the majority failed to align with any HEDIS measures. Previous studies have evaluated the effect of pharmacist recommendations on specific quality measures. Two studies evaluated high-risk medication use in the elderly, including 58 inappropriately prescribed medications (n = 234), 33 drug-disease interactions, and inappropriate medication use (n = 143)^21,22; 24.8% and 23.1% of the patients in these 2 studies received HEDIS measure recommendations, respectively.^21,22

While the current study found 13.4% of patients with a HEDIS recommendation, a higher result was anticipated given the larger number of measures evaluated. Possible reasons for the lower than anticipated recommendation alignment may include the following: HEDIS measures only target specific conditions; younger patients often exhibit relatively few comorbidities; and ambiguous documentation of comorbidities within the EHR prevented categorization and alignment with a HEDIS measure. It is also worth noting that no HEDIS measures exist for epilepsy, the primary reason for these patients receiving care.

Finally, current HEDIS measures were unable to capture the scope and quantity of recommendations provided by the telepharmacist. For example, there are no measures to account for certain vaccinations or for nonacute management of chronic obstructive pulmonary disease.²³

Many patients only had a few comorbidities; however, the HEDIS measures focus predominantly on chronic diseases, which typically increase with age.²⁴ Thus, it was not surprising that few recommendations aligned with these measures. Furthermore, the actual number of comorbid mental health conditions observed in this study parallels what others have reported. In particular, 1 study reported the prevalence of depression and anxiety in 31.3% and 29.1% of patients with epilepsy, respectively.²⁵ Another study reported similar prevalence rates of 32.5% and 22.4% for depression and anxiety, respectively.²⁶ However, they also reported the rates for bipolar disorder and attention deficit hyperactivity disorder in 14.1% and 13.2% of patients with epilepsy, respectively.²⁷ Given the prevalence of mental health disorders in these populations, pharmacist involvement in the interprofessional team is critical to ensure that these patients receive treatment for these conditions in conjunction with their epilepsy medications.

There was ambiguity or lack of specificity among documented comorbidities, making it difficult to align the telepharmacist’s recommendations with HEDIS measures. For example, a patient had a documented general breathing condition; however, due to lack of detailed information in the EHR, it was impossible to determine if any recommendations would meet the specific measure for medication management of asthma. Furthermore, inadequate documentation in the patient notes potentially resulted in artificially underestimating recommendations aligning with HEDIS measures. A previous study also reported that lack of sufficient documentation resulted in difficulty assessing quality metrics.²⁸ Therefore, it may be beneficial to provide additional pharmacist training on appropriate documentation to ensure that their recommendations align with HEDIS measures to improve the quality of information collected in order to ultimately improve patient outcomes.

This telehealth program was innovative in many regards. It involved the partnering of a telepharmacist, an epileptologist, and registered nurses into an integrated team of care providers. While this study demonstrates the value of a pharmacist as part of a comprehensive care team, further investigation is needed to compare patient outcomes of similar telehealth programs lacking an integrated pharmacist and in-person consultations by interprofessional coordinated care teams of similar composition. Moreover, there are opportunities for growth within this program to expand telehealth services to more diverse populations and in different settings (e.g., rural locations in other areas of the country), including patients with other disease states.

Limitations

There were several limitations to this retrospective study. First, this pilot service was conducted at a single clinic with a small sample of patients with epilepsy to improve access to pharmacist counseling services. Thus, this limits the generalizability to other populations or settings. Second, comparative data were not available due to the lack of a control group. Third, comorbidities, along with recommendations made and accepted, was often poorly documented or lacked adequate detail to categorize the telepharmacist’s recommendations. Finally, the HEDIS measures were limited in their expansiveness, and only 24 measures were selected to be used that reflected the telepharmacist’s scope of practice in this study. The inclusion of additional (new or existing) measures may increase the number of recommendations that align with HEDIS measures.

Conclusions

This retrospective review demonstrated the added value of a telepharmacist as part of an interprofessional epilepsy care team and the role of pharmacists in general as integral partners in novel telehealth approaches. Furthermore, it highlights the importance of the telepharmacist’s role, demonstrated by the large volume of chronic disease management medication-related recommendations made to the epileptologist, primary care providers, and patients. While this interprofessional program was designed for patients with epilepsy, the innovative strategies and technologies employed may be applicable when designing programs for other chronic conditions and their management. Future work is needed to develop strategies to increase the number of recommendations aligning with HEDIS measures that adhere to national consensus guidelines for comorbid conditions via telepharmacist training and more thorough documentation.

APPENDIX. Preselected NCQA HEDIS Measures Used for Retrospective Review

1. Adult body mass index assessment

2. Childhood immunization status

3. Immunizations for adolescents

4. Medication management for people with asthma

5. Asthma medication ratio

6. Controlling high blood pressure

7. Persistence of beta-blocker treatment after a heart attack

8. Statin therapy for patients with cardiovascular conditions

9. Comprehensive adult diabetes care

10. Statin therapy for patients with diabetes

11. Antidepressant medication management

12. Follow-up care for children prescribed attention deficit hyperactivity disorder medication

13. Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications

14. Diabetes monitoring for people with diabetes and schizophrenia

15. Cardiovascular monitoring for people with cardiovascular disease and schizophrenia

16. Adherence to antipsychotic medications for individuals with schizophrenia

17. Metabolic monitoring for children and adolescents on antipsychotics

18. Annual monitoring for patients on persistent medications

19. Medication reconciliation after discharge

20. Appropriate treatment for children with upper respiratory infection

21. Avoidance of antibiotic treatment in adults with acute bronchitis

22. Use of multiple antipsychotics in children and adults

23. Potentially harmful drug-disease interaction

24. Use of high-risk medications in the elderly

HEDIS = Health Effectiveness Data Information Set; NCQA = National Committee for Quality Assurance.