Face it, we have a drug problem

Situations like the following occur countless times every day across Canada.Confused senior is brought to the ER. In her purse is a tattered paper medication list from 2016.New patient at a walk-in clinic is asking for a prescription for Tylenol 3 “to tide me over until my family doc returns from vacation.” He denies seeing other physicians for opioids.Patient presents at a pharmacy and can’t find his paper prescription.Pharmacist in Ontario notices a missing limited use (LU) code on a prescription, faxes a clarification to the physician inconveniencing her and the patient who must return to the pharmacy the next day.What do these vignettes have in common? Medication info is not available when needed, resulting in inconvenience, inefficiency, and risk of medication errors, the most common iatrogenic cause of morbidity and mortality.The problem is patient medication data is located on multiple disconnected data islands: paper (charts, prescriptions, faxes), EMRs, pharmacy information systems (PIS), hospital systems as well as provincial drug information systems (DIS). Prescriptions are uploaded to the DIS by pharmacies when they are dispensed. Comprehensiveness varies as some provinces don’t upload all drugs. Only a few provinces provide access to the DIS, which would be helpful to the narcotic-requesting and ER patients above. Access is view-only, so updating the electronic record must be done manually. Consequently it’s not easy to compile and synchronize medication records as patients move across healthcare settings. A model of Canada's current medication management system (click for expanded view)E-prescribingE-prescribing is proposed to tackle some of these problems. E-prescriptions replace paper and fax and are sent electronically to a pharmacy by integrated EMR/PIS tools. They are more efficient, encrypted for security and can’t be lost or counterfeited. Without need to manually transcribe between systems, errors are reduced.In countries such as Denmark, Estonia, and Albania, e-prescribing is well established and 70% of US physicians e-prescribe. In Canada two major platforms have emerged, Canada Health Infoway’s prescribeIT and QHR’s FreedomRx, but little e-prescribing is happening as yet.The platforms send e-prescriptions from an EMR to patient-selected pharmacies. Physicians and pharmacists can e-communicate so getting a missing LU code is easy. But neither service enables patient e-communication. Neither maintains its own database, so if a province doesn’t have a comprehensive DIS it’s not possible for physicians and pharmacists to look up medication from other prescribers or pharmacies.PrescribeIT and FreedomRx are not compatible with each other so prescriber and dispensing pharmacist have to be using the same system. This means regions must choose a single platform, leaving Infoway and FreedomRx vying for acceptance by prescribers, pharmacies, regional authorities, and governments, all of whom have varying degrees of control over adoption. Hence the rollout of e-prescribing will be complicated and slow with no endgame in sight.E-prescribing is not enoughQHR and Infoway deserve kudos for attempting here-and-now solutions in an antiquated system. But ideally e-prescribing and comprehensive patient medication data should be seamlessly available without users having to go outside their electronic record systems. With so many moving parts it’s hard to imagine this coming together anytime soon. And even if it did we wouldn’t be able to prevent or deal with the following common scenarios.Patient without a drug plan arrives at a pharmacy to pick up a prescription for a brand name combination steroid/antihistamine nasal spray. At pickup he is given an invoice for $150. Expressing shock he is told the same drug combination, a generic steroid plus OTC antihistamine spray, purchased separately would only cost $40.Patient goes to a pharmacy to pick up a prescription and finds it’s not in stock. She goes to another pharmacy and waits to pick it up.Patient goes to a pharmacy only to find out his prescription is not covered by his health insurance. A model for medication management in the Omniverse (click for expanded view)Medication management 2.0 (and 3.0) in the OmniverseIn my proposed system, the Omniverse, a single common database would replace DISs, EMRs and PISs, containing the patient's entire medication history as well as formularies, drug inventories, prices, drug and other health science information, user demographic info, e-communications—all updated in real-time. The database would be accessed by customized apps tailored to user-type.The Omniverse’s structure would provide unrestricted access to medication information, a far cry from the limits of our current system. Apps would have a simpler structure than today’s EMRs/PISs because they would manage only user experience—workflow and interface. Data, user authentication, privacy, security, compliance, and certification would be managed centrally. Developers could easily build and iterate intuitive apps with new features and functionality to improve efficiency, convenience, and safety.10 ways the Omniverse would revolutionize medication management1) Up-to-date medication listsFinally being able to trust that patient medication lists are current would help healthcare workers practice more safely and efficiently. An ER physician would be aware of what meds a frail patient with chest pain was taking and what were prescribed but not filled, as would other members of the patient's healthcare team. Patients, notably the elderly, would be relieved of the responsibility of carrying around up-to-date medication lists. And medication errors would be greatly decreased.2) Modern database managementThe Omniverse would have a relational database where data could be instantly accessed and reassembled. Search and sort within and across subsegments of the Omniverse could be done in seconds with Google-like ease, unimaginable with today’s systems.A patient’s medication history could be sorted by prescriber, drug class, subclass, date of prescription, dose, duration, reason for discontinuation, etc. If one wanted to focus on a patient's history of antidepressant use for example, with a click one could filter out other medication. Such sorting could be done for groups of patients such as one’s entire medical practice or any subset. Timelines of treatment could be plotted such as BP control over time with meds and dose, which would make comprehensive review quick and easy.Wider searches could be done on the fly by any user looking at trends, such as what percentage of patients in Toronto diagnosed with influenza got Tamiflu, then subsegmeted into practice setting, say ER or primary care. In wider searches user profile info on individual patients and providers would be anonymized. Searches could be catalogued to let users know what other similar users are interested in, a novel use of social learning with real-time statistics.Any search, any time, access authorized with a modern patient-controllable privacy system. An audit trail easily viewable by users (including patients) could discourage inappropriate viewing of records even among those authorized.3) Modern prescription workflowsPrescriptions would be logged onto the database unlike current generation e-prescribing where the script is sent to a specific pharmacy. Patients would have a PHR (patient health record) app on their mobile phones, which among many functions would manage medication. From the PHR app a patient could direct the prescription to a preferred pharmacy and if desired set up an automatic workflow to send there.Patients could be automatically notified when prescriptions are ready for pickup or opt for delivery, also set automatically if desired. Other items could be purchased online concurrently through the PHR app such as toiletries or cleaning products. With all data central it would be easy to have Uber-like delivery services integrated. Prices could be low because algorithms would maximize workflow to batch route deliveries from multiple pharmacies in the most efficient manner.4) Integrated online pharmaciesSuch workflows could make brick-and-mortar pharmacies less common as putting pills in a bottle could easily be decentralized at lower cost. Just as Amazon has become the largest retailer, mainstream pharmacies could move online. This doesn’t mean that we won’t have oversight and contact with pharmacists. But why should patients have to wait twice, once to drop off and then to pick up prescriptions, while their assistants rush between orders to put pills from big bottles into little ones? It wouldn’t be difficult to e-communicate or speak with a pharmacist virtually as needed. None of this would prevent patients from lining up at the pharmacy if they choose.5) Monitoring and the internet-of-thingsWe could monitor drug adherence easier. Patients could record in the PHR app when medication is taken. This could be done automatically by pill bottles that can measure when a pill is removed and send a bluetooth signal to an internet-connected device like a cellphone, an example of the internet-of-things integrated in healthcare. With the PHR app this info could be automatically uploaded to the Omniverse. With the permission of the patient (through tools in the PHR app) health personnel or family members could digitally 'check in' on the patient’s drug adherence. If the checking were automated, the checker could be notified by an alarm if adherence dropped below a minimum threshold.6) Transparent drug pricingThe $150 nasal spray example above could be avoided at the time of prescribing as the Omniverse would contain current pricing for all medications, prescription and OTC. As a physician is prescribing a text box could pop up with the price and comparative prices of similar drugs. Proton pump inhibitors (PPI) vary in price by a factor of five. A physician could get into the habit of prescribing the higher price (but no more effective) PPI, unaware of the price difference. Integrated prices could keep us mindful without being intrusive.Pharmaceutical companies go out of their way to convince us of the benefits of ‘new’ drugs, in the nasal spray example a combination of two old drugs. But they aren’t transparent about price. Even if a patient has a drug plan, prescribing less expensive but equivalent drugs makes sense because the cost of the medications is passed onto the workforce or society in the form of higher taxes.It’d be interesting to see if physicians as a group would prescribe cheaper medication. Prescribing data could be sub-segmented into physician types and regions. Would knowing prices have a greater effect on gastroenterologist or family physician prescribing? How would rural doctors be affected compared to those in cities? In Ontario, the nascent Ontario Health Teams could compete to be the most responsible prescribers. Total savings could be posted on an online constantly updated counter graphic. To protect physicians’ privacy, prescribing data for individual physicians could be anonymized. Perhaps if doctors stopped prescribing the more expensive PPIs, drug companies would lower prices. The Omniverse could create a team sport out of using consumer pressure to lower prices.In another example, say a patient was taking 10 medications. What if the best prices for individual drugs were in different locations? With decentralized pharmacies it would be possible to obtain medications from more than one source to secure the lowest overall price. With integrated decision support this could be arranged by patients on their PHR apps in a few clicks and medications delivered together. As in the PPI example this would put downward pressure on prices.7) Transparent drug inventoryHow often do we write prescriptions only to find out the pharmacy has run out or the medication is not available regionally? In the situation above the patient only finds this out at the pharmacy and the physician is contacted to change the prescription or the patient is directed to another pharmacy. In the Omniverse when the patient directs the prescription to a pharmacy, they would get a warning the drug is out of stock. If the workflow was in place at the time the prescription was being written the prescriber and patient would be notified at that time. Either you change the script or the patient directs to another pharmacy, no time wasted.When there are shortages of medication a mass e-communication could notify prescribers who could also be notified when shortages are over. With supply always known, users could see when inventories for a particular drug were getting low and mass concern could apply pressure on manufacturers to prevent shortages.8) Narcotics managementWhen patients present asking for narcotics physicians currently have no way of verifying what, where, when or for whom previous scripts were obtained. In provinces that have DISs this can be accessed but is often cumbersome. In the Omniverse with easy drug sorting (see 1) you could do a one click search for a 'super-category' representing opioids, benzodiazepines, and stimulants. It would be easy to select by drug class, name, prescriber and date prescribed, check the patient’s claim that the family doctor is on holiday, and view the patient’s narcotics contract. It would be interesting to see how transparency would affect the behaviour of patients habitually seeking controlled substances. It certainly would make prescribing safer.9) Insurance integrationIt’s cumbersome for patients to manage health plan reimbursements because they are in external systems. There is some integration at the pharmacy but not complete. If health plans were integrated into a patient’s Omniverse profile, they could be included in the prescription writing workflow. If a physician started entering a drug not covered by the plan, a pop up could notify her of similar insured options. Payment and reimbursement for medication could also take place synchronously during prescribing if the patient authorized it with the PHR app on their phone, this if their bank or credit card were included on their profile in the Omniverse.Some readers may be shocked by this but consider that we’re already doing banking online. In Estonia the income tax system is online and integrated with health records. If Canada did the same thing your prescription receipt info could be automatically submitted to Revenue Canada while you sit on the exam table.10) Decision supportEMRs shorten the work of prescribing by predictive characters, allowing us to save ‘favourite’ prescriptions, and easy re-prescribing. But there are more sophisticated shortcuts possible in the Omniverse. Once a diagnosis is made, evidence-based prescribing could be enabled, for example with community acquired infections, to suggest certain antibiotics. Or consider helicobacter pylori which has several multi-drug protocols that frequently change. You could prescribe with one click. In another example the system could learn your usual choices for treating eczema and offer them first.Widely used medical databases could hyperlink and populate a SOAP note in a patient’s electronic record. Imagine one-click prescribing directly from an integrated Up-to-Date app! The Omniverse could keep track of your CME credits and link to the patient encounter where you did the learning. Upon reviewing your CME you could sort by the topic, date, drug, diagnosis or even patient! Credits could be automatically logged with your accreditation body, CFPC or the Royal College, a far cry from the multi-step process of learning, documenting and reviewing today.A new prescriptionMomentum is building to move forward with e-prescribing in Canada, but we’ll need greater systemic changes to fix glaring problems and modernize into the future. An Omniverse-like system could provide a new prescription for medication management—one that we need more now than ever.Dr. Jonathan Marcus is a family doctor in Toronto. His writing on practice management and healthcare technology has appeared in the Medical Post, and he has spoken at the Ontario Medical Association and the CFPC’s Family Medicine Forum on electronic communications in healthcare. You can reach him at jonathan_marcus@mac.com.

Face it, we have a drug problem

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