Pharmacist Opportunities within Telemedicine

Transcription

1 Pharmacist Opportunities within Telemedicine Bryan Robinette, PharmD, BCPS-AQ Cardiology, Sonia Everhart, PharmD, BCPS, BCCCP Desiree Kosmisky, PharmD, BCCCP March 13 th, 2017

2 Disclosures Sonia Everhart, PharmD, BCPS, BCCCP Served as presenter at Philips Connect2Care Conference Desiree Kosmisky, PharmD, BCCCP Served as presenter at Philips Connect2Care Conference Bryan Robinette, PharmD, BCPS-AQ Cardiology Nothing to disclose

3 Objectives Describe the design and rationale for tele-health services in both critical care and heart failure clinic settings. Outline how technology is being effectively utilized in both a tele-icu setting and with virtual visits in a multidisciplinary heart failure clinic setting. Discuss the potential impact of telemedicine pharmacy services and pharmacists interventions in enhancing patient care.

4 Pharmacist Opportunities Within Telemedicine: The Heart Failure Virtual Model Bryan Robinette, Pharm.D., BCPS Clinical Pharmacy Specialist Heart Success Program Sanger Heart and Vascular Institute Carolinas HealthCare System Northeast Concord, North Carolina March 13 th, 2017

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6 The Compelling Need to Address the Epidemic of CHF: Heart Failure diagnosis is the most common: Cardiovascular discharge Medicare discharge Reason for inpatient readmission There is significant variation as to how CHF is managed across the continuum of care- from primary care through complex inpatient services Despite the existence of multiple initiatives within a healthcare system, often times there is no clear, unifying procedure or plan for heart failure It has become evident that this has been targeted by the reform efforts coming out of Washington

7 Heart Failure Management Pearls Managing Heart Failure is complex Multidisciplinary approach is beneficial Dietician Pharmacist Social worker Nurse High risk for readmission High Mortality rates Medication errors are common

8 Heart Failure Economic Challenges Heart Failure Hospitalizations drive health care costs Readmissions The current all-cause 30 Day readmission rate for Heart Failure 25% Readmission Penalty Readmission penalty: cost 2,217 hospitals roughly $280 million in over the next year Financial Impact Hospitals lose (on average) over $1500 per Heart Failure readmission Resource Utilization Heart Failure patients have long lengths of stay averaging 4.7 days

9 The Heart Success Model

10 Elements of Change- Where are we going? Element of Change Today Future Care Focus Care Management Delivery Models Care Setting Sick care Manage utilization and cost within a care setting Fragmented/silos In office/hospital Healthcare, wellness and prevention, disease management Manage ongoing health (and optimize care episodes) Care continuum and coordination (right care, right place, right time) In home, virtual (e-visits, home monitoring, etc.) Quality Measures Process-focused, individual Outcomes-focused, population-based Payment Financial Incentives Financial Performance Fee-for-service Do more, make more Margin per service, procedure (bed, physician, etc.) Value-based (outcomes, utilization, total cost) Perform better on measures, make more Margin per life

11 Heart Success Clinic Non-Capture Reasons Distance Multiple appointments Cost Transportation Don t want to come VAMC Hospice ESRD on HD 30-40% of primary heart failure admissions are not captured at Heart Success Clinic

12 Virtual Care Benefits Virtual Care helps build patient relationships and optimize their care journey. Patient Access: Faster Access, More Options Savings: Reduced Travel, Less expensive options Health: Improved health and quality of life Physician Revenue: Grow Pt volumes and modify case mix Efficiency: Improve work flow Health System Productivity: Increase revenue from existing assets Growth: Capture market share* and reduce leakage Quality: Improve outcomes and document results Savings: Reduce operating costs SG2 *Market Share is defined by covered lives, not encounters.

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14 CHS-Lincoln 30 Day All Cause Same Facility HF Readmission Readmission Observed Readmission Expected Readmission O/E 0

15 Transitional Care CHS-Lincoln Virtual Heart Success Clinic Keeping in line with the Medical Home Partnered with Home Health and SHVI-L Office to provide Virtual Appointment Access to sub-specialists and multi-disciplinary team Home Health Visit within hours for application of monitor Telemedicine Virtual Visit within 3-5 days via laptop technology in home or SHVI-L office Staff trained at CMC Heart Failure Clinic to ensure same standard of care

16 CHS Lincoln Heart Failure Virtual Visits: 2016 Data 200 Virtual Visits Total Patients SHVI-L Home Health 33 Total Visits # Patients

17 Insert Video here

18 Heart Success Virtual Clinic Value Creation Have saved over 34,500 miles and over 950 hours for patients and families Non-Capture rate <5% vs 30% at CMC No Show rate less than 2% (SHVI-L Office) vs 8-9% at CMC and CHS-NE All Patient Satisfaction surveys rated experience as top box Improved Clinical Face time to 100% in home Observed/Expected Readmission Ratio: 0.78

19 Active Learning Question Which of the following were observed with the Heart Success Virtual Clinic? A. Non-capture rate < 5% B. No show rate less than 2% C. Clinical Face time 100% D. All of the above

20 Active Learning Question Which of the following were observed with the Heart Success Virtual Clinic? A. Non-capture rate < 5% B. No show rate less than 2% C. Clinical Face time 100% D. All of the above

21 Conclusions Virtual visits have significantly impacted readmission rates at CHS-Lincoln The virtual visit concept can be applied to other practice settings Patients and family members love the virtual model

22 Tele-ICU Pharmacy: Technology, Medications and Critical Care Sonia Everhart, PharmD, BCPS, BCCCP Desiree Kosmisky, PharmD, BCCCP

23 Tele-ICU Services Remote delivery of critical care services Combines audiovisual technology, telemetry, alerting systems, and electronic medical record review 11% of nonfederal adult ICU beds Varied benefits including reduced ICU and hospital length of stay and mortality Cost-effective or cost-saving Lilly C, et al. Crit Care Med. 2014; 42(11): Becker C, et al. Am J Med. 2016; 129(12):e333-e334.

24 Virtual Critical Care at Carolinas HealthCare System (CHS) Implemented in /7 nurse monitoring and intensivist intervention from 3 p.m. to 7 a.m. Current coverage of 326 ICU beds Benefits: Additional layer of care to the bedside team Patients remain closer to home Reduced ICU length of stay and in-hospital mortality despite increased acuity Benefit optimized with prompt new patient evaluation Carolinas HealthCare System Jan 12. Virtual Critical Care. [Video file]. Retrieved from

25 Virtual Critical Care Facilities

26 Active Learning Question #1 What outcomes have been observed with implementation of tele-icu services? A. Reduced ICU and in-hospital mortality B. Increased malpractice claims C. Reduced ICU and hospital length of stay D. A and B E. A and C F. None of the above

27 Active Learning Question #1 What outcomes have been observed with implementation of tele-icu services? A. Reduced ICU and in-hospital mortality B. Increased malpractice claims C. Reduced ICU and hospital length of stay D. A and B E. A and C F. None of the above

28 Haupt MT, et al. Crit Care Med. 2003; 31(11): American College of Clinical Pharmacy. Pharmacotherapy. 2014; 34(8): Critical Care Pharmacy Services American College of Critical Care Medicine guidelines for critical care services and personnel Pharmacy services provided by qualified and competent pharmacist are essential to ICU American College of Clinical Pharmacy Standards of Clinical Practice Require residency training or equivalent post-licensure experience and board certification ICU pharmacists Reduce costs, morbidity and mortality

29 Initial Proposal for Service Utilized Premier TM peer group drug expenditures for Virtual ICU facilities Critical Care Pharmacist interventions: Cost savings through evaluation of therapy appropriateness and effectiveness Improve core measure performance Timely implementation of recommendations/orders/protocols Optimize physician workload

30 Initial Proposal Financial ROI Reviewed physician coverage and tasks Estimated that 30% of physician time/tasks could be delegated to pharmacist Potential cost savings of $102,000 via reduction of swing shift physician utilization

31 Tele-Pharmacy Services Implemented September 14, 2015 Hours: Monday through Friday 3 p.m. to 11 p.m. 1 FTE pharmacist position 2 full time pharmacists cover this position Alternate weeks

32 Tele-Pharmacy Services Pharmacy interventions performed for 315 eicu monitored beds Population served includes 10 facilities 8 to 130 ICU beds per facility Critical Care Pharmacy services Three facilities with dedicated daytime critical care trained pharmacists Limited availability of critical care trained pharmacists on 2 nd shift and none on 3rd Unique order entry and electronic medical record (EMR) documentation strategy Standard workflow developed

33 Clinical Alerts Blood Glucose < 70 mg/dl > 180 mg/dl Magnesium < 1.7 mg/dl > 3 mg/dl Phosphorus < 2.6 mg/dl > 4.6 mg/dl Potassium < 2.8 mmol/l > 6 mmol/l Sodium < 128 mmol/l > 152 mmol/l Lactate > 2 mmol/l

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35 Additional Tele-Pharmacist Activities Review ventilator bundle report Deep venous thrombosis and stress ulcer prophylaxis Chart reviews Patients flagged by clinical alerts New admissions during shift Evaluation of Code Sepsis antibiotic selection and dosing Antimicrobial escalation for rapid blood culture identification panel as extension of antimicrobial stewardship Drug information resource for Virtual Critical Care and outlying facilities

36 Tele-Pharmacist Process Pharmacist views clinical alert, new patient admission, report, etc. Pharmacist conducts chart review and formulates recommendation Recommendation reviewed and agreed to by physician Pharmacist documents intervention in third party platform Pharmacist writes progress note in EMR and cosigns to physician Pharmacist enters verbal orders

37 Data Review September 15 th, 2015 to December 31 st, ICU beds covered by tele-pharmacist 18,620 alerts reviewed 18% of alerts actionable 73% of interventions tied to alerts 4,592 interventions performed in 2,481 patients in 2,499 separate encounters 1.85 interventions per patient

38 Alerts and Interventions per Month Number Month Interventions Alerts

39 Interventions by Activity Group Activity Group VTE Prophylaxis Stress Ulcer Prophylaxis Electrolyte Management Medication Management Code Sepsis Glucose Management

40 Interventions by Facility 8% 4% 11% 14% 13% 14% 21% 15% n = 4581* Cleveland (n = 941) Union (n = 668) Grace (n = 663) Lincoln (n = 596) Mercy (n = 522) University (n = 367) Stanly (n = 201) Pineville (n = 623) *11 alerts from Carolinas HealthCare System NorthEast excluded due to lack of routine tele-pharmacy coverage

41 Top 10 Interventions Activity Type Number Code Sepsis: antimicrobial review 1003 Increase sliding scale insulin dose 674 Treatment recommendation for low electrolyte level 313 Evaluate hypoglycemia 289 Initiate sliding scale insulin therapy 254 Increase basal insulin dose 215 Initiate basal insulin 194 Adverse drug event avoided 152 Initiate stress ulcer prophylaxis therapy 151 Discontinue Medication 138 Total 3383

42 Top 10 Glycemic Interventions Intervention Number Increase sliding scale insulin dose 674 Evaluate hypoglycemia 289 Initiate sliding scale insulin therapy 254 Increase basal insulin dose 215 Initiate basal insulin 194 Decrease/discontinue basal dose 83 Initiate EndoTool 80 Evaluate hypoglycemia 31 Transition from EndoTool 19 Discontinue oral hypoglycemic agent(s) 16 Total 1855

43 Impact on Glycemic Control

44 Hypoglycemia Rates Number of Significant Hypoglycemic Events (Blood Glucose < 50 mg/dl) per Patient Days with at Least 1 Reportable Glucose Value September 1, August 31, 2015 September 1, June 30, 2016 p-value (chi square test of proportions) Facility A 93/3468 (2.7%) 61/3176 (1.9%) Facility B 82/2986 (2.7%) 66/2281 (2.9%) Facility C 184/4004 (4.6%) 92/3317 (2.8%) < Facility D 223/6997 (3.2%) 259/5681 (4.6%) < Facility E 154/3009 (5.1%) 138/2787 (5.0%) Facility F 141/2353 (6.0%) 97/1906 (5.1%) Facility G 163/5172 (3.2%) 185/4154 (4.5%) Facility H 79/2174 (3.6%) 25/752 (3.3%) Overall 1119/30163 (3.7%) 923/24054 (3.8%)

45 All CHS: Glycemic Control 100% 90% 19% 20% 23% 19% 16.8% 20.0% 19.6% 16.7% 16.2% 15.2% 14.6% 13.1% 13.6% 155 % Days with Average Glucose in Specified Range 80% 70% 60% 50% 40% 30% 20% 10% 0% Q Q Q Q Q Q Q Q Q Q Patients days with average daily glucose > 180 mg/dl (%) Q Patients days with average daily glucose > mg/dl (%) Patients days with average daily glucose > mg/dl (%) Q Q mg/dl Patient days with average daily glucose <= 110 mg/dl (%) Avg Daily glucose Data collected through Philips esearch database

46 Code Sepsis Total of 1060 regimens reviewed Fifty-seven cases where medication added or regimen changed Renal dose adjustments Elevated lactate alert Integrated into Infection Screening Tool Assist nursing and physicians in identification of Code Sepsis patients Ensure correct order sets are utilized

47 Hyponatremia Interventions Risk of osmotic demyelination syndrome with overcorrection of serum sodium 60 interventions in 49 patients across 9 ICUs Interventions included: Notification of actual or potential overcorrection Increased frequency of laboratory monitoring Fluid management alterations DDAVP administration Discontinuation of potentially exacerbating home medications System-level changes to order sets planned

48 Adverse Drug Events Avoided Examples Dual anticoagulant therapy Sedation changes Antibiotic changes Medication management in renal failure Clozapine restart after therapy interruption Mitigation strategy for hypertonic saline bolus 152 adverse drug event avoided interventions Estimated cost savings of $165,000 to $620,000 in 2016 dollars Hug BL et al. Jt Comm J Qual Patient Saf. 2012; 38 (3) p 120. Bureau of Labor Statistics Inflation Calculator at

49 Active Learning Question #2 Which of the following are areas where CHS tele-pharmacists have made interventions targeted at improving patient care? A. Hyponatremia B. Avoidance of adverse drug events C. Hyperglycemia D. All of the above E. None of the above

50 Active Learning Question #2 Which of the following are areas where CHS tele-pharmacists have made interventions targeted at improving patient care? A. Hyponatremia B. Avoidance of adverse drug events C. Hyperglycemia D. All of the above E. None of the above

51 Physician Workload Optimization 1640 interventions triaged to physician in 171 telepharmacist work days 9.6 interventions per 8 hour shift Estimated 10 minutes per intervention (5 to 15 minutes) Tele-pharmacists identified clinical concerns beyond bedside requests and Best Practice Alerts Represents 96 minutes of physician time reallocated during peak admission hours Contributed to efficiency of physician workflow Minimized or eliminated need for physician EMR review

52 Future Tele-Pharmacy Directions Planned expansion to 354 beds by end of 2017 Additional proposed tele-pharmacist coverage One pharmacist during dayshift (TBD) M-F One pharmacist M-F from 3 p.m. to 11 p.m. Metrics Global data review Utilization rates for each facility Goal to review all new admissions and Code Sepsis cases as well as majority of census throughout the day

53 Future Tele-Pharmacy Directions Interdisciplinary rounds at facilities without critical care pharmacist Acute kidney injury Renal dosage adjustments and nephrotoxin review Fluid management Focus on patients with positive fluid balance Pain, agitation, and delirium management

54 Translation to Your Facility Review current physician processes. How much time do they spend on tasks that could be completed by a pharmacist? Review your pharmaceutical expenditures Any high dollar medications that would benefit from additional pharmacy oversight? Are you meeting your Core Measures? Which ones can pharmacy impact? Sepsis? VTE? Others? Is Antimicrobial Stewardship available? If not, would this be a good place start?

55 Contact Information Sonia Everhart, PharmD, BCPS, BCCCP Desiree Kosmisky, PharmD, BCCCP Bryan Robinette, PharmD, BCPS AQ-Cardiology