KEEYS: The need for electronic records

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By Christopher A. Keeys

In any given month, about 40 percent of the approximately 1,900 clients actively enrolled in the D.C. AIDS Drug Assistance Program (ADAP) are not utilizing antiretroviral medications.

However, almost all of these “nonutilizers” have active prescriptions for antiretroviral drugs written by their physicians, nurse practitioners or physician's assistants. The experience in the District of Columbia may not be unique. ADAP programs across the country report similar rates of “nonutilizers” (about 40 percent).

The D.C. Medicaid program's top two drug categories, in descending order, are antiretrovirals (for HIV) and antipsychotics (for mental health disorders). Optimal treatment adherence with antiretrovirals is more difficult for persons with debilitating mental health disorders. The primary methodologies and resources available to review the appropriateness of, and the patient's adherence to, an outpatient medication-treatment regimen are limited to retrospective reviews - i.e., three months after the fact. The retrospective review, referred to as RetroDur, is also common to other Medicaid programs in the United States.

Coordination of pharmacy services and drug benefits for patients between their health care providers (e.g. physicians, nurses, pharmacists) and health care organizations (e.g. ADAP, Medicaid, D.C. Pharmacy Alliance, Department of Mental Health, commercial insurers, hospitals and nursing homes) is complex and fragmented.

Preventable risks associated with fragmented pharmacy services, from a quality perspective, include untimely and incomplete identification of prescription-utilization patterns leading to temporary or permanent patient nonadherence.

Also, fragmented and delayed review places patients at greater risk of dangerous drug interactions, medication errors and serious adverse drug events. Consequently, the patient experiences poorer health outcomes, and the health system realizes a lower quality of care and higher overall health care cost.

Drug utilization and epidemiology data on antiretroviral drug treatment are available to the Drug Utilization Review (DUR) Board from several sources, e.g. D.C. Medicaid, D.C. HIV/AIDS Administration - ADAP, published studies, the Kaiser Foundation and others. The public health concerns regarding HIV/AIDS care and treatment adherence need to be highlighted for the benefit of all stakeholders in the health care system.

The DUR Board is a key stakeholder and clinical board composed of physicians and pharmacists from the academic, practice and governmental communities. It is mandated by Congress under regulations approved in the Omnibus Budget Reconciliation Act of 1990 to promote safe, appropriate and cost-effective use of prescriptions and other medications for the more than 100,000 D.C. Medicaid recipients, including those diagnosed with HIV/AIDS.

Utilizing data from evidence-based medical studies and accepted medical practice, the board reviews medical and pharmacy claims records and forwards thousands of potential medication-related concerns regarding patients' treatments to physicians and other health professionals on an ongoing basis.

At our meeting last month, the DUR Board began an exploration of the challenges impeding effective treatment of the diverse population of D.C. residents living with HIV/AIDS. As with many other health professionals who practice in the District, we were disheartened by the recently released statistics from the District's HIV/AIDS Administration on the status of the HIV/AIDS epidemic in the District. The DUR Board also recognizes that important health care delivery issues undermine efforts for effective treatment of patients infected with the human immunodeficiency virus.

Although much has changed in health care since the epidemic began almost three decades ago, HIV/AIDS is still a complex challenge. As a contemporary clinical group, we seek to find solutions and advocate on behalf of HIV/AIDS care for our community.

We are focused on innovation emerging from an ongoing pilot quality-improvement project initiated by a clinical pharmacy group in cooperation with the D.C. HIV/AIDS Administration.

The DUR Board supported expanding the innovation to include some Medicaid recipients. The project combines concurrent (real-time) drug utilization reviews from a physicians' electronic outpatient prescriptions (e-prescribing) and patients' electronic medical records with clinical pharmacy services to identify “nonutilizing” HIV-infected patients. It establishes measures for adherence interventions from the providers, including physicians and treatment specialists. The ultimate goal for patients is to improve health outcomes through improved treatment adherence.

Recent policy and/or regulatory actions announced by President Obama's administration, the Centers for Medicare and Medicaid Services (CMS) and the D.C. government all establish tangible evidence for advancing e-prescribing and electronic medical records in health care organizations and clinical practice.

Innovations in information technology in health care, combined with advanced pharmacy services and concurrent drug-utilization review have joined the fight to improve coordination of care and reduce the community burden of HIV/AIDS. I can envision a day soon when e-prescribing and concurrent DUR will be strongly encouraged or mandated for prescribing and dispensing antiretrovirals to our patients in the District and other modern communities battling this epidemic.

Christopher A. Keeys is president of the D.C. Drug Utilization Review Board and Clinical Pharmacy Associates Inc. He is an adjunct professor at the Howard University College of Pharmacy, Nursing and Allied Health Sciences.