Doctor-pharmacist teamwork can apply to many settings

A message to all physicians from Ardis Dee Hoven, MD, chair of the AMA Board of Trustees.

By Ardis Dee Hoven, MD, an internal medicine and infectious disease specialist in Lexington, Ky., is president of the AMA. She served as chair of the AMA Board of Trustees during 2010-11 Posted Aug. 16, 2010.

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The near-term future of health care in the United States is going to be -- to say the least -- interesting.

Within the next five years, we will see millions more people covered by health insurance, a rapidly aging population as the baby boomers cross the 65-year-old threshold at a rate of about 8,000 per day, and a long-predicted shortage of physicians.

Volumes already have been written on each of these subjects, and the basic message is that the medical community must find ways to work smarter as we care for more patients and more older patients, many with chronic health conditions.

One place where we have a good opportunity to increase efficiency and enhance patient health is in drug therapy management. It's no secret that patients have a notorious disinclination to take their medications. As many as 50% of patients may not take their medications as prescribed, and as many as 25% never fill their prescriptions. This, of course, ricochets back onto physicians and hospitals, with costs estimated at more than $100 billion in caring for people who get sicker because they did not obtain their medications or did not follow their prescribed treatments.

AMA President Cecil B. Wilson, MD, and I recently met with leaders of a number of pharmacist organizations to discuss ways our two professions can work together not only to improve patient health but also find ways to assure that neither our efforts nor theirs are short-circuited by unresponsive or unknowing patients. The AMA recognizes the important contributions that pharmacists provide to patients in institutional and community settings, and at this meeting, it was evident that our pharmacist colleagues saw value in developing further collaborative partnerships with us in drug and disease management.

Collaborative drug therapy management is not new. Every day in the hospital and other controlled settings, such as my own outpatient HIV clinic, physicians and pharmacists work together, and we value those relationships. In the community, some of us also participate in both formal and informal collaborative practice agreements, and have for years. These agreements can, but do not necessarily, include management and monitoring of medications, patient counseling and adherence counseling.

CDTM arrangements can be a powerful and positive way to enhance patient care and reduce costs. But they are neither easy nor simple -- and our challenge is to expand something that works in the relatively closed systems of a medical practice or hospital into the community setting where a patient may use several pharmacies and often may see many prescribing physicians. In the closed setting, we work together so well because we communicate effectively, and everyone plays his or her unique role.

Happily, we are not following an unmarked trail. Several successful community-based initiatives already exist -- all on a small scale, and all depending heavily on frequent communication among the collaborators. The most well-known of these is probably the Asheville Project, a 14-year-old program in Asheville, N.C.

The first participants in the Asheville Project were volunteer city employees with chronic conditions such as diabetes, asthma, high cholesterol and hypertension -- plus a partnership collaboration of physicians, a local hospital system, the North Carolina Center for Pharmaceutical Care and the city. From the beginning, a key part of the Asheville Project involved educating patients in depth on their conditions.

In the Asheville Project and others like it, community pharmacists receive extensive training from physicians and others, and then they are paired with patients and follow a prescribed protocol. There is ongoing communication among all the partners and data from every visit is shared with the patient's physician. If warranted, the physician is contacted during the patient-pharmacist visit.

The project began with 47 patients in Asheville in the mid-1990s. In the years since, the city has saved thousands of dollars and seen improvements in employee health. Today there are thousands of patients in similar programs in dozens of U.S. communities. The Asheville Project and others based on it help teach patients how to manage their own care -- along with the help of a team of health care professionals. Everyone, including the patient, benefits from this project, where everyone works collaboratively and functions at the height of his or her training.

Recognizing the importance of this kind of collaboration, the federal government is supporting multidisciplinary care, especially for patients with chronic conditions. Since 2003, the federal Medicare Prescription Drug, Improvement and Modernization Act allowed for qualified providers to be reimbursed for CDTM services.

In the coming months and years, as the Patient Protection and Affordable Care Act is implemented in the states, arrangements like CDTMs may be one way to help our patients.

We know these systems can work because we've seen them work in the hospital setting. The challenge is to find ways to make them work more broadly, in the "real world" where ongoing communication is more difficult and patient adherence is harder to chart. Clearly the advent of electronic medical record keeping will be beneficial, but it will not be a panacea.

Even if this approach to drug therapy management is widely embraced, CDTM will never be "one size fits all." Each community, each patient and each physician-pharmacist relationship will be different from the others.

But it's a good idea, and as we continue to work with our pharmacy colleagues, we will be sure to emphasize appropriate guidelines and scope of practice. In fact, pharmacy's leadership agrees that we can only move forward when everyone plays his or her unique role. We call that a positive step forward for patients.

Ardis Dee Hoven, MD , an internal medicine and infectious disease specialist in Lexington, Ky., is president of the AMA. She served as chair of the AMA Board of Trustees during 2010-11

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