For more than a decade, numerous health institutions have researched whether computerized physician order entry (CPOE) and clinical decision support (CDS) tools have reduced rates of adverse drug events. A 2012 Drug Topics article explained that, while electronic order entry is helpful for reducing transcription errors, the CDS is a key factor in successful patient outcomes. Many of the studies on CDS effectiveness are hospital-based. In PACE, however, the clinician’s role can extend well beyond that of the hospital clinician. PACE clinicians are intimately involved in many aspects of their participants’ daily lives. Often they are also involved in growing their PACE organizations, advocating for healthcare change, performing community service, teaching, conducting research, and more. With such busy schedules, it can be difficult for physicians, nurse practitioners, and pharmacists to have a medication safety conversation at or before the point of e-prescribing. That’s why CareKinesis expert pharmacists have developed a clinical rules engine that provides medication decision-support in real time, via alerts on the e-prescribing screen of EireneRx. We call these Medication Risk Mitigation (MRM) Vectors. And, because other PACE clinicians often perform prescription order entry in our pharmacy software (e.g., when redacting a verbal order), we have provided MRM Vector functionality for these users as well. MRM Vectors include drug-drug interaction and drug-allergy warnings; duplicate therapy warnings; renal dosing guides for participants with lab values; aggregate anticholinergic burden and sedative load; and more. CareKinesis continues to refine our solutions, working with our client medical directors to perfect and customize our CDS tools for
PACE clinicians.
For more information on PACE clinical decision support tools, contact CareKinesis or attend our free clinical webinar on February 27, hosted by Bob Alesiani, PharmD, CGP, Chief
Pharmacotherapy Officer at CareKinesis. Email [email protected] for more information.
Part D Information ……..2 FWA PI Efforts .…………..2 Acetaminophen Alert .....3 Treatment Guidelines …..3 OMS …………………………..4 ERx Aide Tool ……………..4 Satisfaction Survey ……...5 CAP Update ………………..5 Clarithromycin …………….5 Calendar of Events ……...6
Who are we? CareKinesis is a comprehensive pharmacy solution for PACE providers. We offer dedicated PACE pharmacy services, including 24/7 personalized medica-tion management and customized adherence packaging for PACE participants. The CareKinesis model improves medication-related outcomes and increases PACE clinic operational efficiency.
“Everyone did a great job transitioning our 400+
participants to CareKinesis in one month. The responsiveness from CareKinesis was above and
For the first two webinars in our 2014 series, CareKinesis was delighted to partner with Capstone Performance Systems. In case you missed them, both webinars in the “Demystifying the Part D Audit” series are available on the CareKinesis website under the Education & Events tab. These free educational sessions featured Capstone’s Matthew Zimmerman and Dr. Richard Schamp, and CareKinesis’s own Dr. Michael Ristagno.
For 2014, CMS has requested that Part D sponsors pay particular attention to automatic shipments or home delivery of prescriptions in an effort to prevent Fraud Waste and Abuse (FWA). In December, CareKinesis worked directly with the CMS’s Division of Part D Policy to assure that our PACE pharmacy prac-tices are compliant. Reconciliation: To avoid medication dispenses for par-ticipants who are in the hospital, or had been transferred or moved to a facility, CareKinesis enables clients to adjust participant ‘status’ in EireneRx. PACE clients are asked to notify CareKinesis of all care transitions to prevent FWA. We take this one step further and assist clients in conducting formal medication reconciliation and providing targeted medication reviews upon care transi-tions to prevent any potential medica-tion errors, reduce re-admission, and also assure that patients will have their medications on the date needed. Adherence: CareKinesis also views medication non-compliance, non-adherence, and non-concordance as potential areas for waste. Clients are encouraged to per-form adherence assessments upon enrollment and upon suspicion that any participants may be non-adherent. Then, 90- or 180-day follow-ups may be completed to measure trends and to identify improved medication adher-ence possible medication changes. Clinical Pharma-cists are available to meet with participants who are suspected of non-compliance. Once iden-tified, CareKinesis Clinical
Pharmacists make medication recom-mendations to ameliorate the situations. The one-on-one meetings can occur in the Center or via conferencing service. Med Changes: Both targeted and comprehensive medication reviews focus on medication changes. Common medication changes include additions, restarts, discontinua-tions, disruptions, dose changes and intraclass substitutions. While the number of medications per participant has been traditionally uti-lized to identify risk, complications seem to occur when medications are initiated, discontinued and changed over time. Adverse drug events (ADEs) often occur soon after medication initialization. A Nov 2013 JAGS study by Kanaan et al. identified that more than half of ADEs occurred within 14 days post-hospital discharge. More than a third of ADEs were preventable, and more severe events were more likely to be deemed preventable. We continue to review the literature and are beginning an in-depth focus on participant medication changes. Overutilization: For information on how CareKinesis assists PACE clients with the Medicare Part D Overutilization Monitoring Sys-
tem (OMS), see CK Responds to OMS article in this newsletter.
Compliance is a priority
at CareKinesis, and we are committed to helping you prevent Fraud, Waste and Abuse. For information on CareKinesis
JNC-8 Guideline on the Management of High Blood Pressure & 2014 AHA/ACC Guideline on Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease by Jennifer Santamala, PharmD(c) In 2013, two new guidelines were published which re-evaluate the way patients are treated for both high blood pressure and blood cholesterol. The ‘American College of Cardiology (ACC) and the American Heart Association (AHA) Guideline on the Treatment of Blood Cholesterol to Reduce Atheroscle-rotic Cardiovascular Disease (ASCVD)’ diverges from the previous LDL-C target goals for patients to a per-centage reduction of LDL-C. In the previous ATP III blood cholester-ol guidelines, treatment was recom-mended based upon how many risk factors a person had and therapy was guided by calculating a person’s 10-year ASCVD risk using the Framingham Risk Score (FRS). If a patient’s 10-year ASCVD risk score was >10%, therapy was usually warranted. However, in the 2013 AHA/ACC cholesterol guideline, patients are treated based upon whether or not they fall into one of the patient groups that has been proven to benefit from statin therapy. Included are patients with clinical ASCVD, LDL-C > 190mg/dL, diabetics with LDL-C 70-189mg/dL and those with a 10-year ASCVD risk score > 7.5%. A modified
cardiovascular risk calculator is also being used to assess patients’ 10-year risk. In the new 2014 guidelines, patients who have a risk >7.5% are candidates for statin therapy. The ‘2014 Evidence-Based Guideline for the Management of High Blood Pres-sure in Adults (JNC-8)’, published in the Journal of the American Medical Asso-ciation recommends a more lenient approach to treating high blood pressure, stating that stricter guidelines provide no additional benefit to patients.
The JNC-8 guidelines for high blood pressure redefine the blood pressure goals that patients should achieve. For instance, the goal for patients > 60 years old without diabetes or chronic kidney disease is now <150/90mmHg and the goal for patients with diabetes or chron-ic kidney disease is now <140/90mmHg. Conclusion: The AHA/ACC guidelines will most likely require more patients, especially the elderly to be considered for statin therapy due to the new risk calculator. Due to the reduction in blood pressure target goals, as stated in the JNC-8 guidelines, more patients may be able to discontinue or reduce the dose of their blood pressure medication.
NEW TREATMENT GUIDELINES: BLOOD PRESSURE AND
CHOLESTEROL
FDA ALERT: Acetaminophen
Combination Products
In January 2014, the FDA requested clinicians to “stop prescribing and dispensing prescription combination drug products that contain more than 325 milligrams of acetaminophen per tablet, capsule, or other dosage unit.” This request is intended to reduce the inadvertent aceta-minophen overdoses for which our PACE population is particu-larly at risk. Advancing age, comorbidities, and multiple medications can alter the body’s ability to metabolize and elimi-nate drugs. In an effort to reduce the use of opiates for pain, there has been an increase in the use of aceta-minophen given at higher, more frequent and routine doses to manage osteo and rheumatoid arthritis. CareKinesis is already working with our PACE clinicians to assure that participants are on the accurate and safe total daily dose of all medications, including acetaminophen. Our recommen-dation has been a total maximum daily dose of 3 grams acetaminophen, which is lower than the FDA’s total recommended dose. Clients, please EireneRx-message your clinical pharmacists or call 888-9-PharmD for further infor-mation or recommendations.
EIRENERX: AIDE ASSIGNMENTS TOOL
With this EireneRx tool, homecare supervisors can document assignments for aides to conduct in participant homes. The supervisor creates the care plan by indicating the times and durations of the visits and then determining what tasks should be completed. Categories include: Bath, Hair, Dressing, Toileting, Directives, Ambulation, Meals, and more. Saved assignments are stored in the participant’s profile and supervisors can generate a weekly form for aides to use in the homes. Nurse users can view this feature by opening a participant’s profile, then clicking “Aide Assignments” from the quick-links menu in EireneRx.
CMS has developed a new Medicare Part D Overutilization Monitoring System (OMS) to ensure sponsors have implemented effective and appropriate controls to assist in the prevention of overutilization. CMS now makes reports available via the Acumen Patient Safety Analysis Website.
CMS requires PACE Organizations to review and complete Overutilization Issue Response Forms for participants identified with a potential overutilization issue and assigned a beneficiary ticket. Quarterly reports will be provided to the sponsor identifying potential overutilization issues through PDE analysis. The specific metrics are:
1. Opioid Outliers: non-hospice beneficiaries with daily morphine equivalent dose (“MED”) greater than
120mg for 90 consecutive days, and who used more than 3 prescribers and more than 3 pharmacies.
2. APAP Outliers: Beneficiaries who may be taking more than 4g of APAP per day for more than 30 days. 3. CPI Referral Outliers: Beneficiaries referred by the Medicare Center for Program Integrity for review of
possible utilization issues.
CareKinesis is currently developing automated systems for the Opioid and APAP overutilization metrics that will be accessible in EireneRx™. Until these are deployed, CareKinesis provides PACE partners with review and detailed analysis of their specific OMS reports (downloaded from the Acumen site) and related recommendations, as well as:
1. Participant-specific dispense reports with calculated MED. (Drug therapy reports based on prescription data are available in EireneRx™ for narcotics and narcotic analgesic-combinations.)
2. an Opioid Conversion Tool to be used at the point of prescribing, to raise awareness of daily MED.
3. Participant-specific dispense reports with calculated total APAP daily dose. [CareKinesis Clinical Pharmacists have been using the more recent stricter guidelines for APAP, which is a maximum recommended dosing of 3 g/day due to risk of hepatotoxicity.]
4. Participant-specific opioid and APAP utilization reports and related recommendations.
Please contact your Client Liaison or email [email protected] for more information.
CK RESPONSE TO OMS
CLINICAL NEWS: CLARITHROMYCIN
Recently, the Journal of the American Medical Association published a research study that concluded that among older adults taking a calcium-channel blocker, concurrent use of clarithromycin was associated with a greater risk of 30-day hospitalization with acute injury, compared with azithromycin, due to inhibition of CYP3A4 activity.
The good news is that we see very little use of clarithromycin and a significantly greater use of azithromycin in our PACE population (and the overall population as well). The bad news is increased azithromycin resistance to Strep, Staph, Haemophilus, etc., (not to mention Chlamydia & N gonorrhoeae) since the “Z-Pak” is so commonly prescribed for stuffy/runny noses, cough and throat irritations.
JAMA. 2013;310(23):2544-2553. doi:10.1001/jama.2013.282426. Published online November 9, 2013.
SATISFACTION SURVEY RESULTS In January, CareKinesis emailed clients a brief satisfaction survey. On a 1 to 5 scale, clients rated their satisfaction and their likelihood to re-fer and partner again with CK. Respondents this year reported that the greatest benefits of our pharmacy services included:
“Pharmacist availability, knowledge”
“Amazing real-time system”
“Ease of access and more safety in prescriptions”
“Promptness, efficiency and knowledge of PACE needs”
When asked what improvements they’d like CareKinesis to make this year, many respondents made suggestions about EireneRx reports and additional functionality.
We also received requests for additional reports and for CE-approved educational programs.
We look forward to delivering in 2014!
CAP MEETING UPDATE
January 2014: Clinical Advisory
Panel User Group Meeting
CareKinesis (CK) hosted its fourth semi-annual Clinical Advisory Panel (CAP) User Group meeting on January 30th-31st, 2014. The meeting was an opportunity for CareKinesis PACE client Medical Directors to provide feedback to CareKinesis on an array of topics and to meet some of the top thought-leaders on personalized medi-cine, including Scott Megill, CEO of Coriell Life Sciences (CLS), to obtain CME credits, and to network with other PACE Medical Directors. Scott Megill and CLS are winners of the North American Entrepreneur prize and the Global Entrepreneur prize in the IBM SmartCamp competition.
Due to the popularity of his presentation, Dr. Jacque Turgeon from the University of Montreal will be providing an all-day seminar in March on the topic of pharmacogenomic metabolic enzyme inhibition, the root cause of most drug-drug-drug-drug (etc.) interactions which yield pre-ventable Adverse Drug Events. CareKinesis PharmDs will participate in this accredited training including four hours of review of CYP-450 superfamily and other enzymatic systems followed by four hours of case studies. CAP User Group members and other client-practitioners interested in gaining a knowledge and experience with this science are welcome to attend – please contact your Client Liaison for more information.
If you are a Client Medical Director who was unable to attend the CAP User Group meeting but are interested in the handouts, kindly contact your Client Liaison.
Disclosure: Dr. Calvin Knowlton is a member of the Coriell Institute Pharmacogenomics Advisory Group and serves on the board of Coriell Life Sciences.
And, check out Altitude Edge Consulting’s free webinar on Tuesday, March 4 @ 1pm ET On-boarding: Taking New Hires from Chaos to Understanding For more information or to register, email [email protected].
CAREKINESIS CALENDAR OF EVENTS
Feb 27 Webinar: Decision Support Tools in PACE Pre-scribing
Mar 13 Webinar: EireneRx 101
Apr 7 Reception: Cupcakes & Cordials at the NPA Policy Meeting, Washington DC
