Outcomes reporting: Pharmacist’s role is often ill-defined but unavoidable
Proactive approach saves grief, protects turf, improves results
Ask a half dozen industry experts what a pharmacist’s role in outcomes reporting should be, or for that matter, what outcomes are, and you’ll get a half dozen different answers. This lack of consensus is the main stumbling block for pharmacists who have key, if ill-defined, roles in helping their facilities meet managed care performance measures.
Murky as the issues are, pharmacists don’t have the luxury of waiting until the debate stills. Their active participation in guiding, tracking, and measuring outcomes is necessary to win and retain managed care contracts and their system’s accreditation.
Suggestions and guidelines on just how you will go about all this guiding, tracking, and measuring are being hammered out in pharmacological institutions and think tanks across the country. The American College of Clinical Pharmacists, the Association for Pharmacoeconomics and Outcomes Research, and the Center for Pharmaceutical Outcomes Research, to name a few, are working on reports offering a variety of methodologies, models, and theories behind outcomes reporting.
Should your outcomes approach be humanistic, economic, patient-specific, systemwide or intermediate? Are you using clinical markers, questionnaires, or drug therapy? Is your outcomes tracking approach serving a payer, an employer, accreditation, or the patient? Can it serve all four? Right now there are more questions than answers.
If there is consensus, it’s largely on two points: First, a multidisciplinary, interdisciplinary, or multivariable approach all three terms are being used is the gold standard. In other words, no one is interested in outcomes found only within the pharmacy, even while o one is sure, at least right now, how pharmacists will contribute outside their home turfs. And second, outcomes reporting is the latest runaway train coming to a pharmacy very ear you.
A light at the end of the tunnel
"Standards and guidelines for outcomes in pharmacoeconomics are being done, but no organization has yet been able to get through the political hurdles of making broad recommendations. There’s a great deal of work going on trying to establish guidelines, but it’s still in its infancy," says Gordon Vanscoy, PharmD, MBA, vice chairman of the department of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy.
It’s bound to be a rocky childhood. Many pharmacists are afraid of sharing internal proprietary issues or trade secrets, adds Vanscoy, which can limit some of the methodology being offered by researchers or health systems. This will make it harder for some of the current thinking on outcomes to go beyond pure theory and into a clinical setting. Nonetheless, he says, "Outcomes research and its quality are extremely variable and extremely hot. People are looking for outcomes research."
Not only looking, but competing, says Colleen O’Malley, MS, director of the American Society of Health-System Pharmacists’ Center on Managed Care Pharmacy. "Systems are going to live and die by their outcomes. And outcomes are becoming a real marketing tool as systems get more aggressive, saying, Our asthmatics do better than XYZ’s down the street.’ And they’re also going to use them to be more aggressive to employers: Our migraine patients have only lost two days of work on average,’ for example, or Our MI patients are back to work in X amount of time.’ The data are really going to drive that, and employers are looking for that more and more," she says.
Why are provider systems so consumed with outcomes data? Because the payroll depends on it, says David Holdford, PhD, assistant professor of pharmacy administration at Virginia Commonwealth University’s Medical College of Virginia in Richmond. "All payers are requiring are demanding this information. If you can’t show the value, then you’re out of a job. I think the only way out of it for an individual pharmacist is retirement."
Taking a holistic approach
With pharmacists already pursuing a more clinical role in health care to advance or, some say, save their profession, industry experts believe that same strategy applies to outcomes reporting.
"From the pharmacy side, it’s not just looking at drug costs, the perspective is clearly to look at drug therapy and how they can affect outcomes," Vanscoy says.
Agrees O’Malley, "If you start by taking out or tinkering with drug costs, then what are you doing to the other costs of the equation? That’s why there needs to be a systemwide approach."
Others believe that even before specific outcomes measures are undertaken, a clear view of organizational goals must come first. "If I were a manager or pharmacy director, I would look at the needs of my organization and the levels of success I’m trying to achieve for my patients, doctors, and the system. Do what’s best for the people I’m working for, then try to fit it in with accreditation and outside reporting agencies," Holdford says. "When you choose outcomes, they must be easy, cheap, and practical to your practice site and must be sensitive to changes in services provided. That’s critically important. Is quality of life a good sensitive measure of what pharmacists do? Do we have measurable effects on quality of life in the population we have?"
How you marry quality of life issues and economics presents one of the thorniest problems. Vanscoy takes a three-part approach: humanistic or patient quality of life measures, economic factors including the cost per life saved or the cost of extending life, and clinical markers such as simple hospitalization or the number of clinical events. However, he cautions that whatever criteria you adopt, "It must be tangible, significant, and measurable, and if you can’t influence it, you need to look at something different."
The rocky track ahead
A pharmacist’s ability to influence an outcome may be severely limited in many cases, especially those that cross provider systems.
"It’s difficult to look at outcomes when we get a referral from a managed care organization," says Burt Finkelstein, PharmD, director of pharmacy and management services at Johns Hopkins Bayview Medical Center in Baltimore. "Without control of patients when they leave the hospital,what we’ve done here for care and planning is changed. So unless there’s complete control of a patient, a lot of outcomes are not applicable to the hospital setting. Patients can come in on a different formulary from ours and then switch back to them when they leave."
Obviously, coordinating care among providers in a system will have to improve. Pharmacists probably will play a key role in this coordination, at least as far as the pharmaceutical care is concerned. But that means you’ll have to be able to track your patients across your system and perhaps outside of it. This type of record keeping will be onerous for a practitioner, Holdford says, and probably beyond what most are capable of at the moment.
O’Malley explains, "Many organizations and health systems know about pharmacy costs or DUR or labs or ER visits, but don’t have the system [information technology] to piece it all together. Right now, many can’t say the cost to treat a condition."
Versatile, integrated information technology will be essential in the near future, Holdford says, but unfortunately systems automation has not emphasized integration until recently. "If you have a stand-alone system with medical records and a lab with a different system, that’s a problem," he says.
Ivory tower vs. reality
Vanscoy stresses that outcomes measurement is being developed on two planes, that of academic modeling and that of practical applications in the hospital. "The academic research is being constructed like standard clinical trials, while practical outcomes have limited data and real-world constraints," he says. "We’re trying to create a scientific construct like with clinical trials but one that’s not as onerous, and I think we’re also in our infancy with this."
O’Malley also sees inconsistencies between the academic models and what ultimately can be done clinically. "The best outcomes, whether financial, quality of life, or medical, in the real world don’t have the luxury of starting with a clean slate," he notes. "You already have patients being treated a certain way. You need to look at how doctors X and Y treat a patient, determine which is better, then go back for a systemwide approach."
[For more information, contact:
Gordon Vanscoy, PharmD, MBA, Vice Chairman, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 1104 Salk Hall, Pittsburgh, PA 15261. Telephone: (412) 825-8331.
Colleen O’Malley, MS, Director, ASHP Center on Managed Care Pharmacy, 7272 Wisconsin Ave., Bethesda, MD 20814. Telephone: (301) 657-3000.
David Holdford, PhD, Assistant Professor of Pharmacy Administration, Virginia Commonwealth University, Medical College of Virginia, 410 North 12th St., Richmond, VA 23298. Telephone: (804) 828-6103.
Burt Finkelstein, PharmD, Director of Pharmacy and Management Services, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224. Telephone: (410) 550-0100.]
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