The emerging role of chief pharmacy officer is aiding care coordination, with positive side effects that improve drug cost efficiencies, prevent readmissions, and in some cases, lighten the load from nurses' discharge work.
This article first appeared in the June 2016 issue of HealthLeaders magazine.
RWJBarnabas Health, a New Jersey–based integrated healthcare delivery network that serves more than 2 million patients annually, sent a clear message in July 2015 when it named its first chief pharmacy officer, Robert T. Adamson, PharmD, FASHP: Pharmacy professionals will be at the forefront of caring for patients.
"Pharmacy has been considered a supportive care division and involved along the line, but having pharmacy at the table from the beginning is fruitful," Adamson says. "Without a CPO, it's very difficult to marry the strategic plan of the health system with the direction of pharmacy."
Adamson, who had been RWJBarnabas Health's vice president of clinical pharmacy services, now oversees all pharmacy services across the health system, including RWJBarnabas Health's six retail pharmacies and in-hospital services for its 11 acute care hospitals and three acute care children's hospitals.
The goals of the CPO, he says, are to standardize the pharmaceutical segment of clinical pathways, such as order sets; find cost efficiencies in drug purchasing and usage; and use pharmaceutical insight to reduce length of stay and prevent readmissions.
Prescribing value
RWJBarnabas Health is not alone in promoting the visibility of pharmacy. The American Society of Health-System Pharmacists wrote in 2015 that "complex hospitals and health systems benefit from having a pharmacy executive responsible for the strategic planning, design, operation, and improvement of their organization's medication management system."
In his nearly one year in the new role, Adamson already has brought about significant change, including centralizing formerly siloed groups such as ambulatory, home infusion, mail order, and specialty pharmacy services. "Before, pharmacy was fragmented and underutilized, and now we are one voice connecting to the patient," he says.
Although ASHP recommends that CPOs report directly to the organization's principal executive like a CEO or chief operating officer, Adamson reports to the chief medical officer.
RWJBarnabas Health CMO John Bonamo, MD, MS, FACOG, FACPE, considers the CPO role a critical part of value-based purchasing. "Pharmacy is not just about lowering drug costs; it's about patients having a good experience and getting the best care," he says. Having a CPO fills the triple aim of healthcare, according to Bonamo, who points out that while, to his knowledge, fewer than 50 organizations have a CPO today, a few years from now, that number will be in the hundreds.
Bonamo considers the CPO a value-added service for physicians and key to health system goals such as antibiotic stewardship. "Our physicians rely on the CPO's advice because pharmacy is so complex. They realize they don't know what the pharmacist knows," he says.
For example, Bonamo says, if a hospital floor experiences an outbreak in urinary tract infections, Adamson would be alerted to a sudden rise in medication ordered via the health system's pharmacy application. After studying the patients' laboratory cultures, he would request tests of certain antibiotics to see which are most effective at stopping the infection. He would then rate the antibiotics by how safe they are and their cost.
"There might be a $12 antibiotic that's less toxic to the kidneys and liver," Bonamo says. Adamson would then insert the recommended treatments into the electronic medical record system so physicians would immediately see them upon diagnosis. "It's a very exacting process, as opposed to a shot in the dark," Bonamo says, acknowledging that getting to such targeted therapy has required a new lab system that is interoperable with the EMR and pharmacy applications.
The cost of value
Bonamo says Adamson also has been entrusted with the health system's more than $100 million spend on drugs. "That's a lot of money, so we have to negotiate well with pharmaceutical companies and be smart about our contracting with managed care companies who cover specialty drugs," Bonamo says.
Adamson oversees a group focused on pharmacy financials as well. "They read every contract we have with suppliers as well as insurers and then go through patient bills to find things we could have billed for that we didn't and things we should have billed differently," Adamson says, adding that through that process, they uncovered $9.5 million in revenue.
The pharmacy team also found that the unused part of single-dose vials of high-priced drugs such as those used in chemotherapy could be billed as waste, capturing another $60,000 to $70,000 in revenue per month, Adamson says.
In addition to drug costs, Adamson has focused his team on impacting length of stay and readmission rates. For the former, they identified diagnoses where an oral drug could be used instead of an IV drug to enable patients to be discharged faster, such as those with COPD. "While the pharmacy didn't save any money, the length of stay was reduced by almost a day," he says.
His team also dug into mitigating the side effects of drugs provided at discharge because "a majority of a patient's aftercare involves medication," he says. For instance, patients who are ordered a narcotic receive an accompanying stool softener because constipation is a common side effect. "These issues are much more difficult to mitigate once they happen," he says, adding that complications from medications are a common source of readmission.
The side effects of value
Roy Guharoy—vice president of clinical integration and chief pharmacy officer at Ascension, a health system in 24 states and the District of Columbia that has 137 hospitals and more than 30 senior living facilities—says he has been focused on lowering readmission rates through pharmacy since he assumed the CPO role three years ago. His primary goals have been to reduce the variances in pharmacy, improve processes, and improve patient outcomes.
Guharoy, who reports to Ascension's chief clinical officer, has worked with IT to create a medication management system within the EMR system for the pharmacy teams, and it is currently being rolled out to Ascension facilities across the country. Because Ascension has numerous EMRs, Guharoy says it will take six to eight months for the alert system to be at all facilities.
Alerts are based on algorithms that analyze patients' lab results, radiology tests, and other important data, detecting changes such as decreased kidney function. "You have to address that right away. If you wait another day or two, the patient's kidney could be gone and the length of stay goes up," he says. When the pharmacy team receives an alert, it instructs the patient's medical team in the ICU, emergency department, surgical units, or elsewhere what to do.
Pharmacists also are notified when a physician recommends a drug that varies from the organizational standard. "If our recommendation is different, we have a discussion with the physician," he says. Although pharmacy has received some pushback, "a majority of physicians have embraced" its heightened involvement, Guharoy says.
His team also studies medication-related deaths and gaps-in-care incidents within the system and across the country to ensure appropriate changes are made when necessary. For example, if a national journal publishes a report about how an IV drug compounded a certain way caused contamination and resulted in infections and hospitalization, Guharoy will direct internal pharmacists to change course.
Also, if a patient is getting multiple drugs for the same disease, the pharmacy team can help whittle it down to just one. "Some combinations of drugs can cause the heart rate to slow, which would lead to a readmission," he says.
"If not well managed, pharmacy drugs can cause a lot of harm," says Guharoy. "And despite how good a CMO is, there can be gaps," he says, pointing out that in a value-based care delivery model, gaps are unacceptable. "Pharmacists can easily fill those gaps and assist with patient care."
A binding agent
At Froedtert & the Medical College of Wisconsin, Todd Karpinski, PharmD, MS, FASHP, FACHE, became CPO of the regional health network in 2012. The system has three hospitals with 784-staffed beds, nearly 40,000 annual admissions, and more than 930,000 annual outpatient visits. Immediately, he restructured to have pharmacy teams at each facility report into him. "I think the biggest benefit of the CPO role and pharmacy realignment has been implementing best practices across the system. Instead of having to re-create best practices at each entity, we can share them," he says.
Like his peers, Karpinski has been able to standardize drug products and thereby reduce drug inventory. "We've been able to discover what drugs we are using and how we are using them."
Although he reports to a vice president, Karpinski has the support of senior executives to participate in executive-level strategy meetings that include the CEO, CMO, CNO,COO, and CFO. Having a seat at the executive table, which he says is more important than reporting structure, has enabled him to enact "innovative pharmacy practices at the bedside."
When a patient is admitted to the hospital, a pharmacist takes a detailed report of the patient's past and present medications, replacing the cursory review by nurses and physicians. "We know what drugs they are taking, what the dosage is, and how long they've been taking them," he says. "We continually reconcile that list with what they are put on at the hospital." Each hospital now has attending pharmacists who check in on patients throughout the week.
Karpinski says he is most excited about changes made at discharge. "Data shows that 31% of patients, when they leave the hospital, never take their medications, and this is a huge concern for us," he says. "We put them on medication so they don't have to come back to the hospital."
Pharmacists are dispatched to patients' bedsides at discharge to deliver medication, take payment, and review all drug instructions. They make sure that there are no duplications or unnecessary drugs. "We educate patients on their new drugs and let them know what can be stopped," he says. If patients can't afford medications, they are connected with a manufacturer assistance program or Froedtert's assistance program.
"Before this bedside program, only 9% of patients had their medications filled. Now that number is at 44%. We are aiming to get into the 60s," he says. He notes that not all patients can fill their prescriptions with Froedtert because of their insurance.
To ensure a large-enough pharmacy team to handle this new program, 12 full-time pharmacists were added. Karpinski has paid for these positions by demonstrating the value of medication management and the additional pharmacy revenue from prescriptions being filled on-site.
He says the program also has benefitted nurses and doctors who no longer have to be involved with that aspect of discharge. There was some concern, he says, that nurses would find the program an invasion of their territory, but instead they say the program helps them focus on their own expertise at discharge. "We've cut out the go-between" by allowing patients to have direct conversations with the pharmacist, he says.
Karpinski says large health systems need a CPO and that the CPO must be at the executive table. "Pharmaceuticals are becoming a huge part of the financial obligation of healthcare organizations, and these organizations are realizing the value that pharmacy brings," he says.