Tracking a patient's adherence is incredibly critical in managing care overall; however, until now healthcare providers had no way of ascertaining if patients were complying with medication regimens unless the patients told them or kept their own register. Health information technology (health IT) applications such as electronic health records (EHRs) by providers and personal health records (PHRs) have increased access to varied data sources for tracking medication adherence, but accuracy and relevance of data and data sources is still under development and standardization.
Areas of Current Investigation
Fifteen projects funded by AHRQ are examining how to track medication adherence as a part of their overall project goals. Some of the AHRQ-funded projects are evaluating if presenting medication adherence information to providers and/or patients via health IT solutions impacts patient adherence to prescribed medications. Evaluating different forms of data collection to determine medication adherence include examining data collected by:
- Days covered and fill adherence
- Medication possession ratio within e-prescribing systems
- Adherence by class
- Patient self-reported adherence
Another area of investigation is determining reasons for non-adherence.
Days covered and fill adherence
Several projects link electronic prescription information to prescription fill information to present providers with information on adherence to medications during a patient encounter. Prescribing date and duration (usually via refill amounts) are available within the provider's electronic prescribing (e-prescribing), EHR, or health information exchange (HIE) system. Pharmacy information includes fill date and days supplied information.
Medication possession ration within e-prescribing systems
The medication possession ratio (MPR) is a formula used to determine compliance that is measured from the first to the last prescription. The denominator is the duration from the start period to the completion of the last prescription, and the numerator is the days supplied over that period from first to last prescription.
Adherence by class
Patients with chronic conditions create a different data set when analyzing medication adherence because of the nature of following a medication regimen. Some projects are calculating adherence to medications by therapeutic class, which involves additional analysis to group medications. A standardized industry coding system in use for medication classes does not currently exist, requiring the AHRQ projects to group medications into classes as part of their projects.
Patient Self-Reported Adherence
Capturing patient self-reported information on adherence using various health IT tools or patient interviews is being investigated, including:
- An automated telephony system for pre-visit interviews
- Tracking diagnoses by following up with patients to check their outcomes after the initial visit in the ambulatory care setting
- A Web-based platform that presents an interactive "character" to the patient to collect information about patient adherence
Determining Reasons for Non-Adherence
In general, understanding whether the non-adherence issues are intentional are critical to gaining a better understanding of adherence issues for patients. Reasons for non-adherence discovered by the grantees includes: cost, side effects, incorrect self-administration, "just-in-case" medications, system errors, and non-intentional issues such as forgetting to take the medication or not picking up the medication from the pharmacy.
Associating Prescription Data with Pharmacy/Payer Data
The primary method used to determine medication adherence using electronic data sources is via linking electronic prescription information from the e-prescribing system with pharmacy fill information. The two most common sources of fill information are pharmacy claims data provided by the insurer (or pharmacy benefit manager) and via the medication history transaction available via the Surescripts e-prescribing network.
Challenges inherent to using insurer pharmacy data include: low cost generics, access to Medicare Part D data, timeliness of data, failed matches and patient-specific instructions. Using Surescripts medication history data can also be challenging, as patients may not always pick up prescriptions that were filled which is not captured in this data. Further, different sources of electronic medication information use different codes for each different type of medication, resulting in data mapping challenges.
The challenges and opportunities associated with obtaining and using medication adherence information in real-world clinical settings includes: identifying accurate electronic gathering methods, ensuring accuracy of data and creating a standard tool to collect such data. These projects continue to provide interesting insight into how many participants in the healthcare industry may use health IT to further their knowledge of their patients' adherence and are worthy of continued study. Tracking medication adherence through health IT will be a critical advance in giving physicians and other healthcare providers the tools they need to provide better care for their patients.
Telehealth -- the use of information and telecommunications technologies to support health care delivery and administration, as well as health education -- has been applied in various capacities since the late 1950s. Different forms of telehealth (such as telepsychiatry, teledermatology, and teleradiology) have been developed and deployed across a diverse range of clinical settings.
AHRQ has funded organizations across the U.S. to implement telehealth projects in order to explore their effects on health care quality, safety, cost, and other outcomes. As of this writing (September 2007), these projects have yet to be completed. Nonetheless, grantees have begun sharing "lessons learned" from their implementation efforts. This brief highlights early findings from AHRQ-funded telehealth projects, as reported to the National Resource Center (NRC) during key informant interviews. These findings focus on:
- Technical challenges of telehealth implementation,
- Dynamics of changing workflow processes, and
- Financial implications of telehealth.
Technical Challenges Related to Implementation
Lesson 1: Pilot testing, prior to implementation, is necessary to ensure that telehealth will not introduce new sources of error into clinical processes.
Several AHRQ-funded projects reported that, during pilot testing, equipment provided by commercial vendors did not work as expected. Their experiences underscore the importance of testing to make certain that telehealth and other forms of health information technology (health IT) do what they're supposed to do, without creating new problems. Problems that might have been identified during pilot testing included equipment failures and organizational policy barriers, as described below.
- Two projects reported that the video cameras used to transmit video and still images did not provide adequate resolution to yield clear images of small pills (medications) and patient wound areas.
- One project indicated that vendor-supplied home monitoring devices were unreliable. As a result, approximately one-third of patients enrolled in the study became frustrated with the devices, and stopped using them.
- One project that used a commercial videoconference solution found the hospital's firewall sometimes blocked connections between the hospital and remote clinics. The hospital IT department could not immediately resolve the problem, because hospital IT policy did not allow external connections on some of the ports used by the videoconference software. To solve the problem, the project had to work with the hospital CIO and other executive officers to change the organization's IT policy.
Lesson 2: Ongoing, accessible technical support for telehealth systems is key to ensuring their sustainability.
AHRQ-funded grantees said technical support must be available around the clock to ensure patient safety. Large institutions reported that such support is often provided by internal IT departments. Projects at smaller organizations rely primarily on vendors for technical support during and after implementation.
- The level of support available to projects from vendors varied; many small companies were closed during weekends and evenings.
- When vendor support was not available 24 hours a day, seven days a week, projects reported greater potential for negative impact on patient safety and mission-critical patient services.
Lesson 3: Integrating telehealth systems with electronic health record (EHR) systems promotes continuity of care across clinical settings.
Several AHRQ-funded projects reported that integrating their telehealth systems with EHR systems offered many critical benefits. Integration of systems allowed these projects to capture patient data using telehealth equipment, and transmit that information to clinicians at the point of care.
- One project reported that integrating telehealth and EHR systems can help reconcile patient's medications. Specifically, integrated systems can provide pharmacists, nurses, and physicians with information about what medications a patient is using at home, as well as visual confirmation of medications dispensed by a hospital after hours.
Lesson 4: Telehealth systems involving video and images require analysis of resolution and bandwidth requirements.
Projects using telehealth for video and images should consider the level of data quality they need so that they can plan for adequate bandwidth. High-resolution video and images require significant bandwidth and are often needed for clinical interpretation. Low resolution requires less bandwidth, but also provides less quality, although in some instances it may still provide sufficient information.
- Network and bandwidth analysis and testing are necessary to ensure that sufficient capacity and speed are available to transmit or receive high-quality images. Inadequate bandwidth can delay transmission of images and disrupt or corrupt information as it is transferred.
- Adequate testing prior to the "go live" is necessary, as network upgrades and modifications can cause significant project delays.
Challenges Related to Workflow and Teamwork
Lesson 5: Technology can introduce inefficiencies to traditional care processes without workflow analysis.
To successfully implement telehealth systems without disrupting workflow (care processes), staff training is critical. Yet, even when clinical and support staff are carefully trained, pilot testing may reveal that the new systems actually increase the amount of time needed to provide care.
- Two projects had to delay their telehealth rollouts because of inefficiencies discovered during pilot testing.
- One project (which used telehealth to give rural patients access to remote specialists) learned that the system's first version was actually increasing the amount of time required to enter consults into the system.
- An intensive care unit (ICU)-based project discovered that its telehealth "cart" impeded mobility (traffic flow) for staff. As a result, staff members frequently had to move the cart during their shifts.
Lesson 6: Telehealth systems can support the provision of team-based care.
Because health care systems in the U.S. are fragmented, a team-based approach can help coordinate the activities of various care providers. Several AHRQ-funded projects reported that telehealth fostered and supported team-based care at their organizations. These grantees reported that telehealth can improve an organization's work and safety culture.
- A project using telehealth to connect nurses at 10 community hospitals with a remote, after-hours pharmacist has encouraged nursing staff to collaborate with the pharmacy staff on medication reconciliation and error issues.
- A project using telehealth to create online clinical communities of practice has fostered collaboration among specialists and other providers to address community health issues. Rural clinic staff members have also participated, partnering to improve patient education.
Challenges Related to Financial Issues
Lesson 7: Guidelines for payer reimbursement of telehealth are necessary to make telehealth efforts sustainable.
Although the Centers for Medicare & Medicaid Services (CMS) and some third party-payers have created telehealth reimbursement guidelines, acceptance of telehealth as a cost category for reimbursement is not widespread. To address this need, and ensure sustainability after its AHRQ grant funds expire, one project is identifying the component costs of health care and the potential savings when telehealth, rather than in-person visits, is used to deliver care.
Should this research prove the effectiveness of telehealth at reducing costs, the regional payers have agreed to formalize reimbursement for telehealth in several clinical areas. This would be a major step forward in telehealth reimbursement, and it may prove to be a model that other regions could use to increase acceptance of telehealth as a viable alternative to traditional, in-person health care.
- The project developed a framework for reimbursement that was generally agreed upon by regional payers.
- Specific areas being investigated by the project include: the impact of early diagnosis on treatment initiation; management of chronic illness via telehealth versus emergency care; and the effects of continuity of care offered by telehealth applications.
Measuring the Impact of Telehealth
The AHRQ -funded projects listed below are seeking to measure the impact of telehealth on the quality, safety, and efficiencyof health care:
- Accessing the Cutting Edge - Implementing Technology to Transform Quality in SE Kern (Kiki Nocella; Tehachapi, CA)
- Creating Online NICU Networks to Educate, Consult & Team (Valerie Rachal; Hattiesburg, MS)
- HIT-based Regional Medication Management Pharmacy System (Mark Schmidt; Clouquet, MN)
- Home Heart Failure Care Comparing Patient-Driven Technology Models (Lee Goldberg; Billings, MT)
- Measuring the Value of Remote ICU Monitoring (Eric J. Thomas; Houston, TX)
- Project ECHO Extension for Community Healthcare Outcomes (Sanjeev Arora; Albuquerque, NM)
- Technology Exchange for Cancer Health Network (Teresa Waters; Memphis, TN)
- Telewoundcare Network (Charles A. Bryant; Oklahoma City, OK)
- Valuation of Primary Care-Integrated Telehealth (Kenneth McConnochie; Rochester, NY)