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Carpe Datum Carpe Diem
VIEWPOINT
Carpe Datum ... Carpe Diem Patricia J. Byrns
The Omnibus Budget Reconciliation Act of 1990 (OBRA '90)1 received widespread support from the pharmacy and medical communities during its passage through Congress. It was believed that prospective drug use review (PDUR) would blend the best of the collaborative professional practices from the inpatient experience with the efficiencies of computerized information, resulting in improved safety of drug use in the ambulatory population. The demonstration project reported in this issue of
JAPhA(pages629,640,and 650) was one of two funded by the Health Care Financing Administration (HCFA) as part of implementation. These demon tration projects provide an excellent opportunity to look at the "bigger picture" of how well the implementation has met the initial goals of the legislation. OBRA '90 PDUR simultaneously changed both the structure and process of ambulatory drug use by changing the role of the community pharmacist (a Donabedian "structure") and the process of care (required offer to counsel, use of predetermined criteria of scientific drug use, optional use of computerized knowl-
608
edge bases )-the risk management portion of the legislation. Retrospective DUR (RDUR) was a chance to assess the adequacy of PDUR (pharmacist profiling) and identify patterns of prescribing (physician profiling) that would be amenable to education~ssentially the quality control and quality improvement components of the legislation. The goal of the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project was to determine whether financial incentives, in the form of direct reimbursement, would increase the rate of provision of cognitive services (CS) by pharmacists. While this premise seems axiomatic, at the time of OBRA implementation neither the hypothesis nor the feasibility of reimbursement by multiple types of phannacies or within a public sector program had been tested. The measurement of CS in the study in many ways represents a refmement of the reports required in the state Medicaid annual reports to HCFA-What were the drug problems identified? What did the pharmacist do? Can these data allow us to estimate or evaluate the value of the PDUR process2 (i.e., conduct an RDUR of PDUR)?
Journal of the American Phannaceutical Association
Clearly the project demontrated that direct reimbursement can increase the rate of CS. The value of CS was not at issue in this study, nor should it be an issue in the overall evaluation given the study design.3 However, the CARE Project does offer additional lessons. First, the investigators believed that additional codes would be needed to capture important CS. It appears that many of these modifications reflect services that are more "patient" than "drug problem" oriented-a typology more useful perhaps in identifying patients who are not receiving, taking, or optimally using therapies necessary for primary or secondary prevention. These codes are in addition to those specified in the N ational Council for Prescription Drug Programs codes. The study notes that these coding modifications captured one-half of all documented CS.4 This suggests that the model, while still evolving, is an area of fruitful endeavor for the combined efforts of informatics and professional standards groups. What is perhaps more intriguing in the big picture analysis of DUR are the types of data constructed primarily for the study that operational programs are currently unable to capture ... the missing pharmacist. The CARE study noted that pharmacists working in medical centers or in rural settings were more likely to perform CS. This is probably not surprising to readers, because it is in such settings that prescribers and pharmacists are likely to know one another and develop relationships based on skills and competencies that enhance the ability to collaborate. 5 Systems of care with
many health professionals who do not know one another well are more likely to rely on external measurements of accountability, ~d the current methods for measuring pharmacist activities may not be optimal in this regard. For example, none of the current administrative databases of prescribing captures the identity of the pharmacist. Diffusion of collaborative practice opportunities into the community setting is likely to be enhanced by measurements that simultaneously decrease paperwork and increase accountability. Databases that routinely link pharmacist services to unique pharmacist identifiers are likely to facilitate not only community-based research, but also implementation of CS and collaborative practices on an increased scale. Carpe datum ... carpe diem ... Patricia 1. Byrns, BSN, MD, is director, Office of Research, School of Medicine, University of North Carolina, Chapel Hill. See related articles on pages 606, 629, 640, and 650.
References 1. Pub L No. 101-508. 2. § 1927(g)(3)(0) of the Social Security Act and 42 CFR 456.172. 3. For example: Gray DR, Garabedian-Ruffalo SM, Chretien SO. Cost-justification of a clinical pharmacist-managed anticoagulation clinic. Drug Intell Clin Pharm. 1985; 19:577-580. 4. Christensen DB, Holmes G, Fassett WE, et al. Influence of a financial incentive on cognitive services: CARE Project design/implementation. JAm Pharm Assoc. 1999;39:629-39. 5. Leape LL, Cullen OJ , Cla m MO, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;21 :282(3):267-70.
September/October 1999
Vol. 39, No.5
Carpe Datum ... Carpe Diem Patricia J. Byrns
The Omnibus Budget Reconciliation Act of 1990 (OBRA '90)1 received widespread support from the pharmacy and medical communities during its passage through Congress. It was believed that prospective drug use review (PDUR) would blend the best of the collaborative professional practices from the inpatient experience with the efficiencies of computerized information, resulting in improved safety of drug use in the ambulatory population. The demonstration project reported in this issue of
JAPhA(pages629,640,and 650) was one of two funded by the Health Care Financing Administration (HCFA) as part of implementation. These demon tration projects provide an excellent opportunity to look at the "bigger picture" of how well the implementation has met the initial goals of the legislation. OBRA '90 PDUR simultaneously changed both the structure and process of ambulatory drug use by changing the role of the community pharmacist (a Donabedian "structure") and the process of care (required offer to counsel, use of predetermined criteria of scientific drug use, optional use of computerized knowl-
608
edge bases )-the risk management portion of the legislation. Retrospective DUR (RDUR) was a chance to assess the adequacy of PDUR (pharmacist profiling) and identify patterns of prescribing (physician profiling) that would be amenable to education~ssentially the quality control and quality improvement components of the legislation. The goal of the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project was to determine whether financial incentives, in the form of direct reimbursement, would increase the rate of provision of cognitive services (CS) by pharmacists. While this premise seems axiomatic, at the time of OBRA implementation neither the hypothesis nor the feasibility of reimbursement by multiple types of phannacies or within a public sector program had been tested. The measurement of CS in the study in many ways represents a refmement of the reports required in the state Medicaid annual reports to HCFA-What were the drug problems identified? What did the pharmacist do? Can these data allow us to estimate or evaluate the value of the PDUR process2 (i.e., conduct an RDUR of PDUR)?
Journal of the American Phannaceutical Association
Clearly the project demontrated that direct reimbursement can increase the rate of CS. The value of CS was not at issue in this study, nor should it be an issue in the overall evaluation given the study design.3 However, the CARE Project does offer additional lessons. First, the investigators believed that additional codes would be needed to capture important CS. It appears that many of these modifications reflect services that are more "patient" than "drug problem" oriented-a typology more useful perhaps in identifying patients who are not receiving, taking, or optimally using therapies necessary for primary or secondary prevention. These codes are in addition to those specified in the N ational Council for Prescription Drug Programs codes. The study notes that these coding modifications captured one-half of all documented CS.4 This suggests that the model, while still evolving, is an area of fruitful endeavor for the combined efforts of informatics and professional standards groups. What is perhaps more intriguing in the big picture analysis of DUR are the types of data constructed primarily for the study that operational programs are currently unable to capture ... the missing pharmacist. The CARE study noted that pharmacists working in medical centers or in rural settings were more likely to perform CS. This is probably not surprising to readers, because it is in such settings that prescribers and pharmacists are likely to know one another and develop relationships based on skills and competencies that enhance the ability to collaborate. 5 Systems of care with
many health professionals who do not know one another well are more likely to rely on external measurements of accountability, ~d the current methods for measuring pharmacist activities may not be optimal in this regard. For example, none of the current administrative databases of prescribing captures the identity of the pharmacist. Diffusion of collaborative practice opportunities into the community setting is likely to be enhanced by measurements that simultaneously decrease paperwork and increase accountability. Databases that routinely link pharmacist services to unique pharmacist identifiers are likely to facilitate not only community-based research, but also implementation of CS and collaborative practices on an increased scale. Carpe datum ... carpe diem ... Patricia 1. Byrns, BSN, MD, is director, Office of Research, School of Medicine, University of North Carolina, Chapel Hill. See related articles on pages 606, 629, 640, and 650.
References 1. Pub L No. 101-508. 2. § 1927(g)(3)(0) of the Social Security Act and 42 CFR 456.172. 3. For example: Gray DR, Garabedian-Ruffalo SM, Chretien SO. Cost-justification of a clinical pharmacist-managed anticoagulation clinic. Drug Intell Clin Pharm. 1985; 19:577-580. 4. Christensen DB, Holmes G, Fassett WE, et al. Influence of a financial incentive on cognitive services: CARE Project design/implementation. JAm Pharm Assoc. 1999;39:629-39. 5. Leape LL, Cullen OJ , Cla m MO, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;21 :282(3):267-70.
September/October 1999
Vol. 39, No.5