Pharmacy Technology Report (March 2019) by McMahon Group

Best Practices in automation, informatics and patient safety

MARCH 2019 • Vol. 5. No. 1

Safer Opioids Dashboard helps drive down inappropriate use Page 16

Telemedicine spurs 100% ASP compliance Page 3

App closes the loop on drug diversion Page 4

Tech eases ‘scourge’ of drug shortages Page 10

Amazon still a giant question mark Page 14

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PHARMACY TECHNOLOGY REPORT • MARCH 2019

100% JC compliance achieved

ABx Stewardship Gets Telemedicine Boost ANAHEIM, CALIF.—Distance need not be a barrier in optimizing antibiotic stewardship, according to a poster about a novel TeleStewardship program presented at the ASHP 2018 Midyear Clinical Meeting. “We were facing the same struggle that a lot of other small, rural hospitals do as they try to implement the Joint Commission’s standards for stewardship: We lacked the expertise of an infectious disease [ID] physician on staff,” said Ashleigh Mouser, PharmD, BCPS, a pharmacy clinical coordinator at Hardin Memorial Hospital in Elizabethtown, Ky., and the author of the poster (abstract 4-096). Nearly 60% of U.S. hospitals have antibiotic stewardship programs (ASPs) that do not meet all seven of the CDC’s core elements for the programs, which equate to the Joint Commission’s standards. Hardin Memorial already had an established pharmacist-led ASP. In August 2017, around the time the hospital began to use a new rapid blood test that helps put patients on the appropriate antibiotic sooner, it contracted with MDstewardship, a telemedicine group in Omaha, Neb. Through the service, providers and pharmacists at the hospital have 24-hour access to ID physicians for consultation via phone, video or secure texting.

‘We can’t let distance get in the way of good patient care. You can get an expert where you need them [via telemedicine].’ —Ashleigh Mouser, PharmD, BCPS Compared with the months before the service launched, the team documented a 26% decrease in average days of antibiotic therapy per 1,000 patient-days, a 50% reduction in hospital readmissions for bacteremia, and an increase from 100 to 329 in average monthly pharmacist interventions. For the first time, Hardin Memorial is now meeting all of the Joint Commission’s ASP standards. “The biggest impact was being able to [discuss rapid diagnostic blood test results and other factors with an] infectious disease physician and see if we were making the right decision,” Dr. Mouser said. “As a pharmacist, it gives you that extra tool in your toolbox.” Hardin Memorial patients with positive rapid blood tests are reviewed by hospital pharmacists, who consult the remote ID physicians whenever it is necessary. The TeleStewardship physicians also will communicate directly with hospital physicians, if needed.

Hardin Memorial pays a fee for the telemedicine service based on the average daily census of its 300-bed hospital. And while Dr. Mouser said she could not share specific cost figures, “when we looked at this model vs. contracting with an ID on-call physician, the annual savings was about $30,000, Plus, we felt the MDstewardship program offered more services with a true focus on stewardship.” Regardless of the system choice, “We can’t let distance get in the way of good patient care,” Dr. Mouser stressed. “You can get an expert where you need them. I hope other small, rural hospitals struggling with stewardship will be able to implement something similar.”

Quick Access to Lab Results Juliana Chan, PharmD, an associate professor at the University of Illinois at Chicago, has helped run a telemedicine clinic for incarcerated patients with hepatitis C. Telemedicine works, she said, “because all that is needed is access to labs to make a recommendation.” Dr. Chan suggested that such a program could benefit not only rural hospitals but any site that might need additional support staff. “It’s always possible to miss something if you’re not seeing the patient yourself,” said Montgomery Green, PharmD, an associate professor at the Belmont University College of Pharmacy in Nashville, Tenn. That’s why it is so important to train staff to look beyond ID test results to determine the most appropriate treatment, she stressed. That caveat aside, “the rapid blood culture tells us a lot,” Dr. Green said. “Many of my own recommendations are made remotely, based solely on the patient’s chart and the rapid test. So it makes a lot of sense for this to be done by telemedicine.” —Lynne Peeples

Dr. Green reported a speaker consultantship for BioFire (a rapid diagnostic company). Drs. Mouser and Chan reported no relevant ﬁnancial relationships.

PHARMACY TECHNOLOGY REPO RT • MARCH 201 9

App Closes the Loop on Drug Diversion I

f time is money, the University of Virginia (UVA) Health System has just hit the jackpot with new anti-diversion machine learning technology. In a pilot rollout of the technology at the system’s 600-bed main hospital, the system, powered by the BD HealthSight anti-diversion app, slashed the time it takes to detect and audit suspect behaviors by nurses and launch internal investigations—from 40 hours per month to 30 minutes—versus prior manual processes. The technology also largely eliminated false positives, Katelyn M. Hipwell, PharmD, MPH, the pharmacy clinical operations manager at UVA, in Charlottesville, told Pharmacy Technology Report.

6 Best Practices for Hospitals 1. Establish a written process for managing diversion. 2. Identify who is responsible to drive the process, primarily pharmacy together with nursing. 3. C-suite hospital leaders should oversee, make diversion a priority, and review metrics often. 4. Let staffers know there is ongoing monitoring of the medication management system. 5. Involve IT to maximize technology interoperability and ensure a smooth rollout. 6. Involve human resources so pharmacy leaders and nurse managers are clear on what they’re empowered to do if they suspect diversion. This includes helping any addicted staffers. Sources: BD, University of Virginia Health System.

The app creates a closed loop between automated dispensing cabinets and electronic health records. The integration strategy helps the UVA diversion team track more than 50 kinds of discrepancies that may signal drug diversion. The system’s algorithm compares nurse behaviors in the same care unit and patient base to be in tune with varying patient needs for controlled substances. The algorithm is being expanded to include the OR, the central pharmacy system and infusion pumps/systems. The system also “learns” as it amasses more diversion data—a key feature, because diverters often alter their behaviors to avoid getting caught. That learning deepens as the disposition of each investigation is reported to the

BD cloud-based portal. The tool also ranks certain behaviors stronger or weaker as a diversion signal. “We’re creating a community of users that shares how diversion happens,” said Ranjeet Banerjee, the worldwide president of Medication Management Solutions for BD, San Diego. “We’ll keep adding new signals to the list as we expand monitoring across the care continuum.” Full app access at UVA goes to Dr. Hipwell, as well as an information technology pharmacist assigned to controlled substance data, her controlled substance specialist technician, their backups and pharmacy leadership. Nurse managers can see only what is necessary to investigate high-risk people within their areas pushed to them by Dr. Hipwell’s team. “We have open dialogue with nurse managers and everything is digitally documented,” Dr. Hipwell said. “Nurse managers can now do in 10 minutes what used to take them up to two hours. Our pharmacy team and nurses are freer to do their clinical patient care, and can investigate more people more accurately.” Facilities can use such documentation to comply with DEA requirements and avoid fines, which can reach up to $4 million, according to Mr. Banerjee, adding, “Diversion is an enormous challenge that is magnifying today. Patient safety is compromised if clinicians are impaired, or [if they] contaminate vials or syringes by injecting themselves, or if opioids aren’t available.”

Earlier Efforts The HealthSight pilot is only the most recent effort by UVA to optimize diversion and pain management. In March 2018, it developed algorithms in and around the OR to help limit opioid use and diversion. UVA data showed a 30% to 40% reduction in opioid usage pre-op, intra-op and post-op, while patient pain scores “stayed the same or slightly better, allowing us to conserve opioids for appropriate patients,” Dr. Hipwell said. Multimodal therapies include acetaminophen, ibuprofen, naproxen, celecoxib, ketorolac, lidocaine patches, diclofenac gel and gabapentin, plus nonpharmacologic treatments such as acupuncture, transcutaneous electrical nerve stimulation and meditation. As for the app-based UVA pilot, Fred Pane, RPh, FASHP, the vice president of pharmacy services at Coordinated Health, in Allentown, Pa., lauded that approach. “Diversion has been such a manual process to track and prevent; there is no one medication management system that is secure,” he said. “If this app truly creates a track-and-trace capability all the way until medications are administered to the patient, that’s an advancement.” —Al Heller The sources reported no relevant ﬁnancial relationships.

PHARMACY TECHNOLOGY REPO RT • MARCH 201 9

Integration yields a million-dollar boost in charge capture

EHRs & Smart Pumps: a Powerful Connection ANAHEIM, CALIF.—Smart pump–electronic health record (EHR) interoperability has long been used to protect patients by reducing the risk for medication errors. But could the technology also increase a hospital’s bottom line? New research reveals it just might. Interoperability is “known to improve safety and documentation accuracy, and lead to nursing efficiency,” said John W. Beard, MD, MBA, the medical director for medical affairs at ICU Medical, and a co-author of a poster (7-052) presented at the ASHP 2018 Midyear Clinical Meeting. “But what’s been missing is understanding the financial impact.” To fill that gap, Dr. Beard and his colleagues investiest gated the effects of this interoperability—or bidi-rectional communication between devices—with auto-documentation of infusion therapy start and stop times. More specifically, they evaluated Current Procedural Terminology (CPT)-coded infusion therapy billing claims for patients admitted to a Pennsylvania community medical centerr in 2016, and then again in 2017. Between those periods, the facility moved from auto-documen ntation of start times only to auto-documentation of both start and stop times. His team found that the number of billed therrapies—counted as the number of CPT codes submitted— tt d increased between 2016 and 2017, whereas the number of patients did not significantly change. The emergency department (ED) saw an approximately 4% increase in the number of billed therapies (P<0.001), and the non-ED units showed a rise of about 32% (P<0.001). For the overall study population, all codes associated with therapies delivered by infusion pumps increased significantly. To estimate the potential financial impact of these changes, the team converted the number of additional CPT codes submitted to dollar amounts that correspond to Medicare Addendum B rates. Overall, the annualized increase in value of the corresponding 2017 Medicare Addendum B rates was $1,147,652 (13.5%). When divided by study groups, the ED had a $478,980 increase in claims, whereas the non-ED units had an increase of $668,672. The bulk of the potential increase in billing claims, according to the investigators, was tied to infusion pump– delivered therapies of hydration and IV infusions. Dr. Beard suggested the findings extend the value of smart pump–EHR interoperability beyond patient safety to include improved hospital financial performance through charge capture and billing compliance. “Turns out, this is a safety technology with a financial impact,” he said. Further, the gains demonstrated across units and by admission status—claims increased by $610,712 for outpatients and $536,940 for inpatients (Table)—may imply

Table. Effect of Interoperability on IP and OP Billing Visit Type

No. of Billed Therapies

% Changea

Annualized Billing, $

2016

2017

14,605

16,566

13.4 (0.001) 536,940

Outpatient

22,430

25,180

12.3 (0.001)

Total

37,035

41,746

12.7 (0.001)

610,712

P value = 0.001 0 001 for all. all

IP, inpatient; OP, outpatient outpatient

that the effects are generalizable to the broad hospital population and could drive greater adoption of smart pump–EHR inte eroperability. The team m also took a deeper look at the speciffic CPT codes affected and found thatt many of the codes associated t d with ith IV injection therapies also increased significantly. “With interoperability and improved documentation of delivered therapies, attention and vigilance associated with documentation practices may have spilled over into injection therapies as well,” Dr. Beard said.

ISMP’s Take Michelle Mandrack, MSN, RN, the director of consulting services at the Institute for Safe Medication Practices, said the researchers’ efforts to document the financial benefits of integration makes sense. “It is expensive and complex to implement smart pump interoperability with the EHR,” she said. “We really believe that organizations should adopt interoperability from a safety perspective, but if you have this kind of opportunity for better documentation and resulting cost savings, it may help organizations make that commitment to move forward.” Jennifer Biltoft, PharmD, the system director of clinical pharmacy services for SCL Health, in Greater Denver, noted that her organization has used similar interoperability data to help justify implementation. “We continue to see benefits when data are validated by nursing,” Dr. Biltoft said. “And this gain comes at little to no added work for pharmacy.” —Lynne Peeples The sources reported no relevant ﬁnancial relationships other than their stated employment.

Take the guesswork out of inventory planning As demand grows for specialty pharmaceuticals, it’s more important than ever to ensure you have life-saving therapies on hand when they’re needed, without creating additional financial risk or waste. Cardinal Health offers a suite of flexible consignment solutions — including RFID — to help improve efficiency and control the costs of specialty pharmaceuticals. We help you fulfill the promise of providing critical therapies — and free you to focus on delivering the best possible care. Let Cardinal Health Specialty Pharmaceutical Distribution customize an inventory solution for you. Visit cardinalhealth.com/SPD-RFID or email specialtysolutions@cardinalhealth.com.

© 2018 Cardinal Health. All Rights Reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks of Cardinal Health and may be registered in the US and/or in other countries. All other marks are the property of their respective owners. Lit. No. 1SPD18-828755 (7/2018)

PHARMACY TECHNOLOGY REPO RT • MARCH 201 9

Avoiding High Risk in Low-Flow Infusions Large-volume syringes not always the safest option ANAHEIM, CALIF.—The use of high-vol26% of those low-flow infusions were done 3 mL ume syringes is comm mon for very with 20-mL sy yringes. 5.93% –––––––– low-flow infusions, co ontradictAmong a all infusions of 0.5 mL or 5/6 mL 1 mL ing best practice recomless, 32 2% were given in 60-mL 0.07% 11.64% mendations and possing syringes (Figure). a potential safety risk So, why haven’t providS for patients, accorderrs consistently followed 10/12mL 60 mL ing to research pre-the recommendations? sented at the ASHP Truth is, Dr. Robertson T 18.65% 31.78% 2018 Midyear Clinical noted, it can be much n Meeting. easier to simply dise “It is really impor-pense every drug in a p tant to use the righ ht 60 0-mL syringe. It is also syringe size to ensu ure posssible that awareness 20 mL the best continuity y of regarding the importance of 30/35 mL 19.34% flow for critical medicausing tthe appropriate syringe 12.59% tions,” said Andrea Ro obertson, size has n not yet fully spread. PharmD, a clinical specialist in In its review w, the team also looked pharmacy at Smiths Medical in at the d distribution of patients’ Plymouth, Minn., and a co-author th weights. i ht Infants, especially neoFigure. Infusions of 0.5 mL/hour of the poster (7-060). nates, are particularly suscepor less by syringe size (N=12,997). Low-flow infusions are comtible to issues with flow rates, and they represented the largmonly used in fluid-restricted or fluid-intolerant patients, such as those in neonatal or est group receiving infusions (37%) in their data set. Dr. Robertson emphasized the importance of ensuring pediatric ICUs. In August 2016, the FDA published a recthese patients have the best continuity of delivery for ommendation that advised clinicians to use the smallest these appropriate syringe size for patient infusions to ensure critical medications. ideal continuity and flow (bit.ly/2HCXEWX). The FDA “Clearly this is an area that the education and commuclassified low-flow infusions as less than 5 mL per hour nication from the FDA was needed,” she said, adding that and very low-flow infusions as less than 0.5 mL per yet further education also may be critical. hour. The agency warned that a lack of flow continuity Protecting the Most Sensitive Patients could “result in serious clinical consequences, including delay of therapy, over-infusion or under-infusion.” Shi-Fong George, PharmD, a critical care clinical pharProgrammable syringe infusion pump manufacturers macist at Ann and Robert H. Lurie Children’s Hospital of Chicago, also emphasized the critical need to use also have been making these same recommendations in their manuals, Dr. Robertson noted. the appropriate syringe size for pediatric patients. “Our smaller patients, particularly neonates, are most sensitive “So, the idea here was to look and see what was really to fluid volume and minute medication changes,” said Dr. happening,” she said. “What size syringe were people actually using? Did it match the recommendations?” George, who was not involved in the poster. For example, she noted, using a large syringe to deliver Dr. Robertson and her team reviewed data from proan inotropic drug such as epinephrine in neonates with grammable syringe infusion pumps between January 2010 and March 2016 at 17 inpatient hospitals, focusing cardiac issues often can cause dramatic blood pressure on nine frequently used continuous infusion drugs and fluctuations with each dose change. “It is often crititheir most common concentrations. Then they further cal in this case to use the 5-mL syringes for continuous narrowed the data to infusions that had a rate of 0.5 mL delivery,” said Dr. George, “so that the smallest titration in medication volume and dose can be consistently and per hour or less, and identified the syringe size used. accurately Overall, among the nearly 4.5 million infusions they controlled.” —Lynne Peeples reviewed, the most used syringe size was 60 mL—even for very low flow rates. Nearly 60% of the infusions of norepinephrine were in 60-mL syringes. Use of morThe sources reported no relevant ﬁnancial relationships other than their stated employment. phine most closely aligned with the recommendations:

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$200K savings projected

Tech Helps Ease ‘Scourge’ of Shortages ANAHEIM, CALIF.—A comprehensive pharmacy automation platform has helped a large health system alleviate the harmful effect of drug shortages on patient care and pharmacy finances, according to data presented at the ASHP 2018 Midyear Clinical Meeting. “Drug shortages have become a scourge,” said Rafael Saenz, PharmD, the director of pharmacy at the University of Virginia Medical Center in Charlottesville, and a session presenter. “We are constantly discovering them and trying to manage them.” The rate of drug shortages has been increasing in the United States. Pharmacists faced 186 new shortages last year compared with 146 in 2017, according to Erin R. Fox, PharmD, BCPS, FASHP, the senior director of drug information and support services at University of Utah Health in Salt Lake City. She suggested that the issue has become more critical because the large number of products in short supply affects a particularly large number of patients. While drugs in short supply may be available in different dosage forms or strengths, or from different companies, those differences can present their own challenges. Alternatives are often more expensive. Perhaps even more

‘Switching from a 2-mg vial to a 2-mg preﬁlled syringe can mean 100 hours of informatics work. We’ve got to make it easier to make [drug shortage–related] changes.’ —Erin R. Fox, PharmD, BCPS, FASHP all-in-one drug shortage management solution, to create a single platform for all the pharmacy systems at his medical center. “I had a bunch of disparate systems that didn’t naturally speak to each other,” Dr. Saenz said. “They all had to be interfaced or linked.” Now, there is one access point from which the team can control all the systems. They have gone a step further with OrbitalRX to also collate data feeds from all their disparate systems. The goal, Dr. Saenz explained, is to know at any time what the wholesale distributor has on hand as well as what the medical center’s inventory is across all distribution points—primarily in its automated dispensing cabinets. m “Whenever a medication goes on shortage, not only can we tell where the inventory is n and whether we need it to be sequestered or a moved around, but we can do that from anym where in world,” he said, noting that the softw ware program allows his team to meet virtually. Furtherm more, “we can see trends in the distributor’s inventory to predict whether or not they are going to be short on some ething.”

Being Proac Proactive May Pay Off challenging is that whenever a hospital purchases a different concentration of a product, pharmacy and information technology groups often have to invest significant hours to revise the drug library and ensure it is wirelessly updated. For example, Dr. Fox noted that “switching from a 2-mg vial to a 2-mg prefilled syringe can mean 100 hours of informatics work. We’ve got to make it easier to make [drug shortage–related] changes.” “We need to go from a reactive state to a more proactive state with drug shortage management,” added Dr. Saenz, noting that his department employs a pharmacist whose full-time job is to manage drug shortages. With that aim, his department recently worked with OrbitalRX (orbitalrx.com), a company that offers an

Based on b basic supply and demand rules, being more proactive enables the medical center to replenish inventory at a lower price point than if they only reacted to shortages. The system has only been in place a few months so far, but Dr. Saenz said he hopes to save more than $200,000 in fiscal year 2019. “People need a quick way to get a picture of what they have on hand,” Dr. Fox said. “This really highlights how complicated and time-consuming managing drug shortages can be and how folks are looking for solutions, because this level of workload is pretty unsustainable.” —Lynne Peeples Dr. Saenz reported no relevant ﬁnancial relationships. Dr. Fox reported that the University of Utah Drug Information Service receives funding from Vizient to provide drug shortage content.

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PHARMACY TECHNOLOGY REPO RT • MARCH 201 9

RFID, Other Tech for Containing Rx Costs T

echnologies like radiofrequency identification (RFID) and data analysis can have an important role in keeping a lid on specialty drug–related spending. According to data provided by Cardinal Health, analyzing spending and utilization, as well as finding cost-effective alternatives to high-priced drugs can shave as much as 7% off a hospital’s drug spend. RFID-based consignment can also cut drug spending significantly. Kathy Chase, PharmD, the director of Drug Cost Control Services at Cardinal Health, said that “hospitals tend to be data-rich and information-poor, in that they often do not assimilate all of the data they have into actionable, meaningful information.” To address this need, Cardinal Health created the Drug Cost Opportunity Analytics (DCOA) service, which draws on data from drug purchasing databases and electronic health records (EHRs). The service examines the top drivers of drug spending and analyzes utilization trends for those drugs, documents which diagnoses they are being used for, how they affect hospital lengths of stay, and which physicians are the highest prescribers, Dr. Chase said (Table). “Once you know what diseases these medications are being used for and who is prescribing them, you can determine whether prescribers are following best practices and whether there are lower cost or more effective or safer drugs to use instead,” she said, adding that the DCOA service also benchmarks these metrics against more than 300 hospitals across the country. The DCOA service can be used to track antibiotic usage,

which helps with stewardship efforts and saves staff time, Dr. Chase added. “Building spreadsheets and assembling antibiotic stewardship reports is time not spent on clinical care,” she said, noting that the DCOA service helped one unnamed health system save $3.5 million on what would have been an $83 million annual total inpatient drug spend. Another system cut $7.5 off its $212 million annual inpatient drug spend using the DCOA service, she said. David Cecere, PharmD, MBA, the assistant director of pharmacy at WVU Medicine, in Morgantown, W.Va., who has no financial interest in Cardinal Health’s services, said the DCOA service is a good idea. He added that such a system should also consider product shrinkage. “If a patient was given a partial vial, a program should account for that waste,” he said, adding that interfacing with a hospital’s EHR to obtain clinical and utilization information “could be tricky depending on the system’s interfacing capabilities.”

Specialty Drug Consignment Plus RFID Combo

A specialty drug consignment program offered by Cardinal Health also can help reduce drug spending, said John Kilgour, vice president of acute and alternate care sales for specialty pharmaceutical distribution. As part of the service, Cardinal Health delivers RFID-tagged specialty products to an institution where they are placed in RFIDenabled storage cabinets provided by the company. Built-in scanners automatically detect the tagged drugs as they are put in or removed from the storage cabinet. The service provides a real-time understanding of inventory, including expiration dates and product recalls, Mr. Kilgour said, noting that drugs are autoDCOA Dashboard matically reordered when stock falls below par levels. Table. December 2018 Savings Opportunities Pharmacists and providers can track Show 5 b entries Search: Excel their consigned inventory, locate products anywhere in their facility and move Potential LOS Variance them within their network, all by using a Savings, to Benchmark mobile device app. “This really tightens DRG DRG Description $ Mean Discharges up the inventory management process 193 Simple pneumonia 10,496.24 -0.28 9 Exclude and brings it right to the patient’s bed& pleurisy w MCC side, ensuring that potentially lifesaving 56 Degenerative ner- 7,571.59 -2.64 7 Exclude specialty products are delivered to the vous system disorpatient right away,” Mr. Kilgour said. ders w MMC The service worked well for the 167 Other respira7,562.06 -0.66 4 Exclude 300-bed Norton Children’s Hospital in tory system OR Louisville, Ky., which reported cutting procedures $150,000 off its inventory spending by 54 Nervous system 6,909.64 3.06 2 Exclude using Cardinal’s RFID-based consignneoplasms w MCC ment program in 2018 (bit.ly/2SNKAlV). 379

GI hemorrhage w/o CC/MCC

4,356.16

1.18

Exclude

CC, complication or comorbidity; DCOA, Drug Cost Opportunity Analytics; DRG, diagnosis-related group; GI, gastrointestinal; LOS, length of stay; MCC, major complication or comorbidity; OR, operating room

—David Wild The sources reported no relevant ﬁnancial relationships other than their stated employment.

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PHARMACY TECHNOLOGY REPO RT • MARCH 201 9

Still waiting for the feared pharmacy fulﬁllment revolution

Amazon’s Clinical Recruits Tread Lightly

n the wake of its acquisition of PillPack last summer and the announcement of its joint health care venture with Berkshire Hathaway and JPMorgan Chase, dubbed “ABC” and headed by physician author Atul Gawande, MD, Amazon has announced a series of new recruitments. The staff moves by ABC include Taha Kass-Hout, MD, the former FDA chief health h informatics officer; Maulik Majmudar, MD, a former associate director of the transformation lab at Massachusetts General Hospital, in Boston; and pharmacy benefits expert Jason Tzau, PharmD. What does this flurry of clinician hiring signal about the company’s plans for further ventures in pharmacy? Dr. Tzau sits on the health care benefits team to serve as a liaison between the new health venture and Amazon employees, but beyond that, no one at Amazon would comment. Experts in the field say it’s unclear what Amazon is ultimately planning to roll out—and that the company itself might not know yet—but it is making smart hires. “These are good people, with expertise in multiple areas,” said Tim Kosty, RPh, MBA, the president of Pharmacy Healthcare Solutions, in an interview with Pharmacy Technology Report. “This suggests to me that they are still evaluating a lot of different options, and they need people to help them vet those options from various industry perspectives.” Amazon’s challenge will be to strategically differentiate its service offerings, Mr. Kosty suggested. “They’re trying to hit a moving target. They don’t want to play the same game that the entrenched interests play; they want to create a different offering, and they need to figure out what that is.” Mr. Kosty pointed out that there are already established, vertically integrated companies, such as CVS/Aetna and Cigna/Express Scripts, offering a range of services in most segments of the market that Amazon might attack. “Whatever strategy they come up with,” he said, “I’ll be very surprised if they’re able to create a differentiator that’s a home run, something no one else has seen.” Pharmacy information technology expert Jerry Fahrni, PharmD, said it’s hard to predict what Amazon’s long-term strategy might be, based on just a few hires. “It’s common to gobble people up just to sit and talk to them, especially in the tech industry. They hire them to think, and that may

be what Amazon is doing here.” “Most providers at every level of the health care continuum sho ould be both excited and a little bit wary” of Amazon’s next moves, suggested Richard Ptachcinski, PharmD, the CEO of Pharmacy Consulting International. “If you’re interested in doing things differently, which people have been talking about for years, then you would be excited. If you’re one of those groups that has lived by the status quo for a long time, then you may be a bit vulnerable.” Whether as a provider, specialty, mail order or retail pharmacy, Amazon’s latest moves into health care show that “people are going to have to do business differently than they have in the past to be able to meet different competitive forces,” Dr. Ptachcinski said.

Partnership May Be Next Big Thing Dr. Fahrni predicted that Amazon may not necessarily pursue something transformative, and instead focus on what they do best: warehousing and distribution. “I could envision them partnering with one of the big boys, like Walgreens or CVS, being a partner for distribution around the warehouse and delivery side. They’re insanely efficient in that arena. I had expected them to get into pharmaceutical delivery already, either from the warehouse side to the pharmacies or to your house, and the fact that it hasn’t happened yet suggests it’s proving harder than they thought. So we may see them partnering further with someone who knows that sphere already.” Whatever ABC finally chooses to do, they’ll have plenty of competition, including 98point6, an under-the-radar startup with an on-demand primary care platform that is led by CEO Robbie Cape, formerly of Microsoft. About 50 self-insured employers have signed up for the service and it is now licensed to practice medicine in all 50 states plus Washington, D.C. And in mid-January, Microsoft announced a partnership with Walgreens Boots Alliance to become Walgreens’ new cloud provider. The two companies said they are working on solutions to cut health care costs. —Gina Shaw The sources reported no relevant ﬁnancial relationships.

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PHARMACY TECHNOLOGY REPORT • MARCH 2019

rom electronic health record (EHR)-based dashboards that track prescribing g, to mobile apps that detect opioid-related changes in breathing, the tech-ba ased armamentarium that providers can use to chip away at opioid overprescribing and overdose is growing. Here are some innovative offerings culled from the manage ed care, VA and health-system sectors.

EHR-Based Tools Help Slash Opioid Rx by 62% ANAHEIM, CALIF.—Employing dashboards, order sets and other electronic health records (EHR)-based tools has helped a VA health system tackle opioid misuse at the point of prescribing. “Our pain management order sets list acetaminophen as the first option, and only then do we suggest opioids, and we list those in order of their risk of complications and their cost,” noted Kathy Davari, PharmD, an associate chief of pharmacy, clinical services, at the Atlanta VA Health Care System. The order sets also include

recommendations for terminating opioid treatment and emphasize that patients should not abruptly stop using opioids, because of the risks for withdrawal. “We also have a related order set that allows physicians to order urine drug screening and comprehensive laboratory tests for up to one year for a given patient with just one click,” Dr. Davari said at the ASHP 2018 Midyear Clinical Meeting. EHR-based dashboards are another effective tool for the team, Dr. Davari noted. The dashboards can identify patients at high risk for overdoses as well as providers who overprescribe opioids. Using the dashboards, pharmacists can list patients according to the amount of daily morphine milligram equivalents (MMEs) they are receiving or their concomitant use of medications such as benzodiazepines, which increase the risk for respiratory

depression. “We can then discuss management of these patients with their providers and issue recommendations or, in the case of pain management pharmacists or hematologists/oncologists, they can write an order that is then approved by the physician,” Dr. Davari said. “This saves providers’ time and improves patient access.” Pharmacists also use dashboards to identify whether a provider has checked the prescription drug monitoring program database, the date of the most recent urine drug test or the next follow-up appointment, and whether naloxone is prescribed for patients receiving at least 50 daily MMEs. These metrics also can be use for benchmarking, which allows Atlanta VA pharmacists to identify physicians who could benefit from further education because of their high-dose prescribing or other outlier behaviors. “We meet with them or email them to share information on prescribing guidelines, and Source: HealthIT.gov review their prescribing later to confirm they have been complying with the guidelines,” Dr. Davari said, adding that the dashboards are accessible to physicians as well. “Sometimes seeing their own prescribing practices relative to others’ practices can be an eye-opener and help them improve their own opioid prescribing.” Since the initiative was rolled out in late 2012 and early 2013 along with other nontechnology strategies, such as the formation of an opioid use committee, several measures have improved. For example, prior to these initiatives, 16.6% of Atlanta VA prescriptions were for opioids, a number that decreased to 14.5% by 2014 and was at 6.3% in late 2018, for a 62% reduction. —Lynne Peeples The sources reported no relevant ﬁnancial relationships.

PHARMACY TECHNOLOGY REPORT • MARCH 2019

Mobile Apps Alert of Possible Opioid Overdose

hat if an app could help reduce the nearly 40,000 opioid-related deaths a year? Two separate research teams say that goal is not far-fetched. The Second Chance mobile app, developed at the University of Washington, provides rescue treatment to those experiencing overdose, according to Kimberly Lenz, PharmD, a clinical pharmacy manager at the University of Massachusetts Medical School, in Worcester. The app, which its developers are submitting for FDA approval, sends inaudible sound waves to a person’s chest up to 3 feet away to monitor them for respiratory depression and apnea. It also can detect movements associated with opioid overdose (bit. ly/2GgyX17). The developers tested the app in 209 patients at a supervised injection facility in Vancouver, British Columbia, and found it was 96% sensitive and 98% specific in detecting opioid-induced central apnea as well as 87% sensitive and 89% specific in identifying respiratory depression (Sci Transl Med 2019;11[474]). Dr. Lenz noted the utility of the app is limited by the need to have a person own a smartphone and have it on and close to them with the app open on their phone. However, she is nevertheless encouraged by it. “My hope is that these types of algorithms will continue to expand into wearable technology that can help curb the opioid overdose crisis,” she said. The developers say they will be adding a feature that sends a message to a friend or to emergency services so that they can administer naloxone. “Any

system with capabilities to alert a person’s contact or emergency services could be an effective way to deliver naloxone to people in need,” Dr. Lenz said.

A Reset on Opioid Safety Another technology that could help shave down the number of opioid-related overdoses and improve treatment outcomes is reSET-O (Sandoz/Pear; bit. ly/2UEHu0Q), an app that received prescription FDA approval in December 2018 for the management of opioid use disorder, said Kaelyn Boss, PharmD, a managed care resident at Commonwealth Medicine of the University of Massachusetts. “The app provides users with cognitive-behavioral therapy and skill-building exercises, and also allows practitioners to track a patient’s progress,” Dr. Boss explained. The data behind the FDA’s approval of reSET-O showed the app increased retention in a 12-week substance use disorder program by nearly 20%, from 68.4% among patients who received standard care to 82.4% among those who used the app (bit.ly/2Gfs3ch). “By making [OUD] treatment available through mobile devices, it may increase patient retention in treatment programs and improve outcomes,” Dr. Boss said. Indeed, “the ability to integrate mobile technology into the recovery journey is an important step, since mobile devices have become such an integral part of modern life.” —David Wild

The sources reported no relevant ﬁnancial relationships.

Health Plan Fights Opioid Overuse ORLANDO, FLA.—Some managed care organizations see the value in promoting safer opioid prescribing and use—and leveraging technology to achieve that goal. Anthem, for example, has been placing a particular focus on minimizing first-time opioid use, according to Jeff White, PharmD, MS, a staff vice president at the company, with headquarters in Indianapolis. “If

we want to get ahead of this crisis, we need to prevent new people from getting addicted and reduce the excess opioids in the community,” Dr. White said during a session at the 2018 Nexus meeting of the Academy of Managed Care Pharmacy. To help achieve these goals, Anthem implemented a pharmacy point-of-sale edit that limits shortacting opioid prescriptions to seven

days for patients who are receiving an opioid for the first time, Dr. White said. “We purposely selected newly starting patients because if you’re opioid addicted and we stop that opioid, there could be unintended consequences that are terrible,” he explained, adding that Anthem also requires prior authorizations for all long-acting opioid prescriptions. see PLANS FIGHT, page 18

PHARMACY TECHNOLOGY REPO RT • MARCH 201 9

PLANS FIGHT continued from page 17

The seven-day limit has had d “a huge impact” on reducing opioid use among Anthem members, D Dr. White said. The company’s data a showed the number of hydrocodone-acetaminophen prescriptions fell by 31% among its commercially insured members and 36% among plan members with Medicaid insurance within roughly one year of implementing the edit in May 2017. In addition, Anthem has been tar-geting high-risk opioid users, suc ch as people receiving opioids from more e than one provider or pharmacy, and individuals using opioids with benzodiazepin nes and muscle relaxants concurrently—a combination that can cause central nervouss system m or respiratory depression, as reported in Specialty Pharmacy Continuum (bit.ly/2ABoXLi)—or those using opioids during methadone or buprenorphine-based medication-assisted treatment for opioid use disorder (OUD). Clinical pharmacists at Anthem have been identifying patients meeting these risk criteria through another technology tool—claims reviews—and then notifying providers of these patients’ use patterns, at times taking measures such as limiting their opioid dispensing to one pharmacy, Dr. White explained. Collectively, these measures eliminated high-risk opioid dispensing in 9,356 high-risk members targeted through the program within one year after implementation, Anthem found. Additionally, people who were limited to opioid dispensing from a single pharmacy had 35% fewer emergency department visits and 67% fewer urgent care center visits in the year after the initiative compared with the year before.

Anthem also has been using proprietary mobile and web-based digital technologies to help patients with OUD manage their pain without o opioids, said Stephanie Yu, PharmD, an analytic cal pharmacist at Anthem. “These digital technologies incorporate evidencebase ed treatment options such as cognitive e-behavioral therapy [CBT] to target the e perception of pain, which is closely linked to substance use disorder,” Dr. Yu explained. Y Although Dr. Yu did not present data supporting CBT, the literature has shown it can be highly effective for substance abuse. Indeed, CBT approaches “have among the higha est level of empirical support for the e trreatment of drug and alcohol use disorders,” according to one review (Psychol Add dict Behav 2017;31[8]:847-861). Off n note, Dr. Yu said, these CBT tools allow user ers tto personalize their pain management. “For example, a patient can choose to engage in a relaxation technique to cope with their pain, or they can use cognitive exercises to handle anxiety or negative thoughts associated with managing their pain.” Anthem’s website-based CBT programs are a place where patients can access behavioral health tools, and they also serve as hubs where physicians, behavioral health specialists and social workers can connect with one another and the patient through video conferencing, she said. Tracking a patient’s progress through such digital tools has given providers an idea of what pain management strategies a patient is using and how effective they are prior to their appointment, Dr. Yu noted. —David Wild The sources reported no relevant ﬁnancial relationships.

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