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2013 Prescott Lecture: Embracing our roles as medication navigators
APhA2013
Prescott lecture
2013 Prescott Lecture: Embracing our roles as medication navigators Robert Schoenhaus
Thank you everyone for your attendance today. I am indeed honored to be receiving the Albert B. Prescott Award. Beyond the Prescott Award itself, I am quite honored to be in the company of previous winners— many of whom I know and respect. That being said, I would not necessarily count myself amongst them as visionary leaders. In fact, this all could have gone a very different way. I was neither a celebrated student nor a highly sought after resident. In truth, I was lucky that my first residency director, Dr. Kenneth Schell, gave me a chance to prove myself at Kaiser Permanente in San Diego. I think he saw something of himself in this young, demanding applicant who felt obligated to change the practice of pharmacy for the better (even if he wasn’t sure how he would do it yet). It is due to innovative pharmacy leaders like Dr. Schell that I made it to where I am. Thankfully, my PGY2 pharmacy director, Dr. Anthony Morreale, also found something attractive in a candidate he knew would “rock the boat.” Under his direction, I learned not just about the Veterans Affairs system, national formulary management, and pharmacoeconomics but also how to effectively steer a very large ship with grace and patience. Finally, of all my previous mentors who took chances, it was likely Dr. Chuck Daniels who took the biggest risk. Through some fortunate communication over shared passions, Chuck and I decided we would try and create a new position in applied pharmacoeconomics at UC San Diego Medical Center 362 JAPhA | 5 3:4 | JUL /AUG 2013
and I would pilot this effort. Somehow we got a pilot program approved within a few months, with the condition that I would save at least 1.5 times my own salary within 1 year or face termination. As you can imagine, that first year of employment was fairly nerve wracking. UCSD ultimately concluded that roughly seven times my salary had been saved through our first year interventions, with some substantial improvement in quality of care to boot. That was when I realized that Chuck had it right all along. The time had come for a position like this, and my training simply collided with the right place at the right time. My career thus far has been a series of these types of examples. Visionary leaders helping me find a voice and me not screwing it up too bad. After leaving UCSD to come to Sharp Healthcare, I quickly found myself in a managed care director role within an organization on the cutting edge of health care reform, about to be recognized as a Pioneer ACO by Medicare.
Since then, I have done everything in my power to build the foundation for future pharmaceutical care at Sharp. Leveraging every personal relationship and every ounce of technology, my staff and I have built a benefits administration practice, a lipid management service, a fully integrated specialty pharmacy, a refill/MTM service, and numerous nursing/physician partnerships that all have resulted in new referrals to our team for clinical support. Somehow, this all has occurred within the last 4 years, which is testament to the desire of Sharp Healthcare and Sharp ReesStealy Medical Group to promote and encourage practice innovation. It is innovation, more than anything else, that will drive pharmacy practice into the new age of health care reform. In February, California State Senator Ed Hernandez (D-West Covina) introduced a set of bills (SB 491, SB 492, SB 493) that would expand the scope of practice for nurse practitioners, optometrists, and pharmacists to address the large physician shortage we expect from expanded coverage. At the point of writing, these bills have passed the California Senate and are on their way to the California State Assembly for consideration. Although not all physicians believe that expanded midlevel provider practice is the solution, California pharmacists have significant poten-
About the Prescott Award
Albert B. Prescott was a maverick in the late 1800s because of his advocacy of an academic basis for pharmaceutical education. Founder and dean of the College of Pharmacy at the University of Michigan, Prescott nurtured his idea for nearly 40 years before the rest of the profession caught up with his vision. In 1900, Prescott was the first president of the American Association of Colleges of Pharmacy. This chemist, educator, and leader of pharmacists was also instrumental in founding Phi Delta Chi Pharmacy Fraternity at the University of Michigan in 1883, and he was the advisor to the Alpha Chapter and the first Honorary Brother of the fraternity. The Albert. B Prescott Leadership Award was established by Phi Delta Chi in 1987 to honor young pharmacists who lead their field. Now administered by the Pharmacy Leadership & Education Institute, this annual award is bestowed on a pharmacist who is no more than 10 years into his or her career and who has demonstrated exemplary leadership qualities as a student and young pharmacist. The recipient delivers a scholarly lecture on issues such as pharmacy as a profession, leadership, or future trends in pharmacy practice or education.
ja p h a .org
Journal of the American Pharmacists Association
Prescott lecture APhA2013
tial to help meet the unmet needs of patients and caregivers struggling with successful medication use. Hopefully, this is an idea whose time has finally come. Standing on the cutting edge of health care reform at Sharp Healthcare has helped me form a vision of just how we might see pharmaceutical care evolve. The pressures of higher patient capacity and lower reimbursement will likely be the tipping point toward team-based primary care, and I believe pharmacists must now actively embrace the role of “medication navigator” for their patients. This is not a new concept, but somehow the idea of pharmacists as partners in primary care has not fully materialized. This is no doubt due to the fragmented nature of pharmacy practice, where we often consult patients in isolation from their primary care network. I expect that one day it will sound ridiculous that pharmacists had to counsel their patients on new medications without the benefit of knowing their medical history or diagnoses. So what would it look like to have a pharmacist as a medication navigator for patients? Time will tell, but I know there is a huge unmet need. Patients leaving our hospitals are my best example. Patients with heart attacks, pneuRobert Schoenhaus, PharmD
monia, and/or advanced heart failure get discharged with 10 new medications and have no one to help them understand their regimen, no one to adequately explain why each and every medication is necessary, and no one to warn them how high their copays will be at the local drugstore. The unfortunate result often is poor medication adherence and consequent hospital readmission. Luckily, Medicare has begun to reduce payment for such readmissions and system change for safe medication practice is being prioritized (ideally, with pharmacists as part of the solution). Medication navigation can’t just be about updating a drug list. Navigation should include managing that drug list chronically, as if it were an independent, evolving disease for patients. I believe that pharmacists should begin acting as patient medication advocates, helping to manage complex regimens in partnership with primary care providers on an ongoing basis. Although ambitious, I think this goal is fully attainable as we build more integrated networks of care. In my organization, the pharmacists can access the medical record and now can enter progress notes as a “provider.” This wasn’t the case previously, because the electronic medical record had never included phar-
macist-specific privileges. In fact, when I first asked for this access, I was told that the best they could do was allow me to function as an “RN with protocol.” I hope pharmacists nationally will reject such designation, as it typically requires us to work below our legal scope of practice. Patients today get medication from a variety of sources besides their primary physician. A variety of prescribers from primary and specialty care that are part of a loose network of care, a local naturopath, or even the guy in the white coat at GNC could be the source of new medications. Where I practice, in San Diego, we also consider whatever the patient is using from across the Mexican border or what might have been received via the Internet. With all these possibilities, it is no wonder physicians often laugh if asked to review and reconcile everything a patient has in the medicine cabinet at home. Who has that kind of time within a 15-minute appointment? Wouldn’t that be like opening Pandora’s box? Perhaps we should help our increasingly overwhelmed primary care providers in new and different ways. Maybe they will agree that their focus should be on the complexities of medical diagnosis versus medication list reconciliation.
Robert Schoenhaus currently is the Director of Pharmacy Benefits Administration at Sharp ReesStealy Medical Group, which is an affiliate of Sharp Healthcare (the largest integrated health care delivery system in San Diego, CA). Schoenhaus also serves as an assistant clinical professor at five separate schools of pharmacy. He is the cofounder of the Applied Pharmacoeconomics Forum at University of California, San Diego (UCSD). As Director of Pharmacy Benefits Administration, Schoenhaus oversees all department clinical programs, projects, and daily activities that focus on pharmacy practice, prior authorization, and formulary management within the managed care population. Schoenhaus coordinates interdepartmental projects, including pay for performance, and provides data analysis and recommendations to relevant committees to support the most efficient use of pharmacy products. Schoenhaus represents pharmaceutical care issues, including health plan changes, regulatory matters, and continuity of patient care at the local, regional, and state level. Schoenhaus received his doctor of pharmacy degree from the University of California, San Francisco, and completed 2 years of postgraduate residency training at Kaiser Permanente and the Veteran’s Affairs Hospital (both in San Diego). He subsequently established a new pharmacoeconomics specialist position at UCSD Medical Center, which is the only position of its kind within the University of California system. Schoenhaus completed the California Healthcare Foundation Leadership Fellowship in 2012.
Journal of the American Pharmacists Association
j apha.org
Jul /AU G 2013 | 53:4 |
JAPhA 363
APhA2013
Prescott lecture
Certainly, within my own organization, that sentiment seems real. For example, the adoption of our fully electronic refill management program has been rapid, and we are able to successfully process a majority of primary care refill requests via protocol, thereby saving physicians precious time with patients. Quality also has improved, as pharmacist feedback on medication selection or potential errors in prescribing is often met with gratitude versus frustration. Programs like this are not without precedent,1–3 but implementation of pharmacist refill services across fragmented national networks of care is still a rarity. Undoubtedly, the success of our medication management programs also is a result of the proactive effort of my team to routinely meet with enrolled physicians face to face to explain goals and outcomes. Physicians, therefore, have plenty of opportunity on an ongoing basis to ask questions and suggest change if desired. This enduring collaboration represents the greatest promise of integrated health care: improve-
364 JAPhA | 5 3:4 | JUL /AUG 2013
ment in personal relationships between previously disjointed providers of care. After all, if I were a physician, I might be more skeptical of a pharmacist getting involved in my patient’s care if I never had the expectation of meeting him/her and having a conversation. The reality of health care reform and all the changes it will bring is upon all of us. I would argue that pharmacists, as a profession, have the most to gain out of all the chaos. We have the opportunity to fully embrace our roles as medication navigators for patients in whatever capacity our jobs allow us. Legislation and advocacy will help us along the way, but we also must convince ourselves of the necessity of our role. We must believe that we are vital to patient success and not allow ourselves to be dismissed as an ancillary service. That’s all for now. Hopefully, the past and future Prescott Award winners will continue to force positive change for the good of patients everywhere. I truly believe in the necessity of pharmaceutical care and hope you do to.
ja p h a .org
Acknowledgments: I’d like to acknowledge my wife Dr. Laura Marttila Schoenhaus for all of her love and support during these last few years, during which we both struggled to balance new careers and the births of our two perfect daughters, Emily and Leah. I would also like to acknowledge the excellent team at Sharp HealthCare, who have supported me through the last 5 years: Donald Balfour, Jerry Penso (now with AMGA), Vicki DeBaca, Silvia Rivas, Paul Hansen, Victor Monrreal, Manny Chapman, and Deeanne Nichols. Special thanks to Dean Katherine Knapp, Dr. Gary Dougan, and Dr. Michael Negrete for their help with the Prescott Nomination. Finally, thanks to all those colleagues, residents, and students who have pushed me to work for positive change in pharmacy practice. doi: 10.1331/JAPhA.2013.13522
References 1. Riege VJ. A patient safety program & research evaluation of U.S. Navy pharmacy refill clinics. www.ahrq.gov/downloads/ pub/advances/vol1/reige.pdf. Accessed June 15, 2013. 2. McKinnon A, Jorgenson D. Pharmacist and physician collaborative prescribing: for medication renewals within a primary health centre. Can Fam Physician. 2009;55(12):e86–91. 3. Cassidy IB, Keith MR, Coffey EL, Noyes MA. Impact of pharmacist-operated general medicine chronic care refill clinics on practitioner time and quality of care. Ann Pharmacother. 1996;30(7-8):745–51.
Journal of the American Pharmacists Association
Prescott lecture
2013 Prescott Lecture: Embracing our roles as medication navigators Robert Schoenhaus
Thank you everyone for your attendance today. I am indeed honored to be receiving the Albert B. Prescott Award. Beyond the Prescott Award itself, I am quite honored to be in the company of previous winners— many of whom I know and respect. That being said, I would not necessarily count myself amongst them as visionary leaders. In fact, this all could have gone a very different way. I was neither a celebrated student nor a highly sought after resident. In truth, I was lucky that my first residency director, Dr. Kenneth Schell, gave me a chance to prove myself at Kaiser Permanente in San Diego. I think he saw something of himself in this young, demanding applicant who felt obligated to change the practice of pharmacy for the better (even if he wasn’t sure how he would do it yet). It is due to innovative pharmacy leaders like Dr. Schell that I made it to where I am. Thankfully, my PGY2 pharmacy director, Dr. Anthony Morreale, also found something attractive in a candidate he knew would “rock the boat.” Under his direction, I learned not just about the Veterans Affairs system, national formulary management, and pharmacoeconomics but also how to effectively steer a very large ship with grace and patience. Finally, of all my previous mentors who took chances, it was likely Dr. Chuck Daniels who took the biggest risk. Through some fortunate communication over shared passions, Chuck and I decided we would try and create a new position in applied pharmacoeconomics at UC San Diego Medical Center 362 JAPhA | 5 3:4 | JUL /AUG 2013
and I would pilot this effort. Somehow we got a pilot program approved within a few months, with the condition that I would save at least 1.5 times my own salary within 1 year or face termination. As you can imagine, that first year of employment was fairly nerve wracking. UCSD ultimately concluded that roughly seven times my salary had been saved through our first year interventions, with some substantial improvement in quality of care to boot. That was when I realized that Chuck had it right all along. The time had come for a position like this, and my training simply collided with the right place at the right time. My career thus far has been a series of these types of examples. Visionary leaders helping me find a voice and me not screwing it up too bad. After leaving UCSD to come to Sharp Healthcare, I quickly found myself in a managed care director role within an organization on the cutting edge of health care reform, about to be recognized as a Pioneer ACO by Medicare.
Since then, I have done everything in my power to build the foundation for future pharmaceutical care at Sharp. Leveraging every personal relationship and every ounce of technology, my staff and I have built a benefits administration practice, a lipid management service, a fully integrated specialty pharmacy, a refill/MTM service, and numerous nursing/physician partnerships that all have resulted in new referrals to our team for clinical support. Somehow, this all has occurred within the last 4 years, which is testament to the desire of Sharp Healthcare and Sharp ReesStealy Medical Group to promote and encourage practice innovation. It is innovation, more than anything else, that will drive pharmacy practice into the new age of health care reform. In February, California State Senator Ed Hernandez (D-West Covina) introduced a set of bills (SB 491, SB 492, SB 493) that would expand the scope of practice for nurse practitioners, optometrists, and pharmacists to address the large physician shortage we expect from expanded coverage. At the point of writing, these bills have passed the California Senate and are on their way to the California State Assembly for consideration. Although not all physicians believe that expanded midlevel provider practice is the solution, California pharmacists have significant poten-
About the Prescott Award
Albert B. Prescott was a maverick in the late 1800s because of his advocacy of an academic basis for pharmaceutical education. Founder and dean of the College of Pharmacy at the University of Michigan, Prescott nurtured his idea for nearly 40 years before the rest of the profession caught up with his vision. In 1900, Prescott was the first president of the American Association of Colleges of Pharmacy. This chemist, educator, and leader of pharmacists was also instrumental in founding Phi Delta Chi Pharmacy Fraternity at the University of Michigan in 1883, and he was the advisor to the Alpha Chapter and the first Honorary Brother of the fraternity. The Albert. B Prescott Leadership Award was established by Phi Delta Chi in 1987 to honor young pharmacists who lead their field. Now administered by the Pharmacy Leadership & Education Institute, this annual award is bestowed on a pharmacist who is no more than 10 years into his or her career and who has demonstrated exemplary leadership qualities as a student and young pharmacist. The recipient delivers a scholarly lecture on issues such as pharmacy as a profession, leadership, or future trends in pharmacy practice or education.
ja p h a .org
Journal of the American Pharmacists Association
Prescott lecture APhA2013
tial to help meet the unmet needs of patients and caregivers struggling with successful medication use. Hopefully, this is an idea whose time has finally come. Standing on the cutting edge of health care reform at Sharp Healthcare has helped me form a vision of just how we might see pharmaceutical care evolve. The pressures of higher patient capacity and lower reimbursement will likely be the tipping point toward team-based primary care, and I believe pharmacists must now actively embrace the role of “medication navigator” for their patients. This is not a new concept, but somehow the idea of pharmacists as partners in primary care has not fully materialized. This is no doubt due to the fragmented nature of pharmacy practice, where we often consult patients in isolation from their primary care network. I expect that one day it will sound ridiculous that pharmacists had to counsel their patients on new medications without the benefit of knowing their medical history or diagnoses. So what would it look like to have a pharmacist as a medication navigator for patients? Time will tell, but I know there is a huge unmet need. Patients leaving our hospitals are my best example. Patients with heart attacks, pneuRobert Schoenhaus, PharmD
monia, and/or advanced heart failure get discharged with 10 new medications and have no one to help them understand their regimen, no one to adequately explain why each and every medication is necessary, and no one to warn them how high their copays will be at the local drugstore. The unfortunate result often is poor medication adherence and consequent hospital readmission. Luckily, Medicare has begun to reduce payment for such readmissions and system change for safe medication practice is being prioritized (ideally, with pharmacists as part of the solution). Medication navigation can’t just be about updating a drug list. Navigation should include managing that drug list chronically, as if it were an independent, evolving disease for patients. I believe that pharmacists should begin acting as patient medication advocates, helping to manage complex regimens in partnership with primary care providers on an ongoing basis. Although ambitious, I think this goal is fully attainable as we build more integrated networks of care. In my organization, the pharmacists can access the medical record and now can enter progress notes as a “provider.” This wasn’t the case previously, because the electronic medical record had never included phar-
macist-specific privileges. In fact, when I first asked for this access, I was told that the best they could do was allow me to function as an “RN with protocol.” I hope pharmacists nationally will reject such designation, as it typically requires us to work below our legal scope of practice. Patients today get medication from a variety of sources besides their primary physician. A variety of prescribers from primary and specialty care that are part of a loose network of care, a local naturopath, or even the guy in the white coat at GNC could be the source of new medications. Where I practice, in San Diego, we also consider whatever the patient is using from across the Mexican border or what might have been received via the Internet. With all these possibilities, it is no wonder physicians often laugh if asked to review and reconcile everything a patient has in the medicine cabinet at home. Who has that kind of time within a 15-minute appointment? Wouldn’t that be like opening Pandora’s box? Perhaps we should help our increasingly overwhelmed primary care providers in new and different ways. Maybe they will agree that their focus should be on the complexities of medical diagnosis versus medication list reconciliation.
Robert Schoenhaus currently is the Director of Pharmacy Benefits Administration at Sharp ReesStealy Medical Group, which is an affiliate of Sharp Healthcare (the largest integrated health care delivery system in San Diego, CA). Schoenhaus also serves as an assistant clinical professor at five separate schools of pharmacy. He is the cofounder of the Applied Pharmacoeconomics Forum at University of California, San Diego (UCSD). As Director of Pharmacy Benefits Administration, Schoenhaus oversees all department clinical programs, projects, and daily activities that focus on pharmacy practice, prior authorization, and formulary management within the managed care population. Schoenhaus coordinates interdepartmental projects, including pay for performance, and provides data analysis and recommendations to relevant committees to support the most efficient use of pharmacy products. Schoenhaus represents pharmaceutical care issues, including health plan changes, regulatory matters, and continuity of patient care at the local, regional, and state level. Schoenhaus received his doctor of pharmacy degree from the University of California, San Francisco, and completed 2 years of postgraduate residency training at Kaiser Permanente and the Veteran’s Affairs Hospital (both in San Diego). He subsequently established a new pharmacoeconomics specialist position at UCSD Medical Center, which is the only position of its kind within the University of California system. Schoenhaus completed the California Healthcare Foundation Leadership Fellowship in 2012.
Journal of the American Pharmacists Association
j apha.org
Jul /AU G 2013 | 53:4 |
JAPhA 363
APhA2013
Prescott lecture
Certainly, within my own organization, that sentiment seems real. For example, the adoption of our fully electronic refill management program has been rapid, and we are able to successfully process a majority of primary care refill requests via protocol, thereby saving physicians precious time with patients. Quality also has improved, as pharmacist feedback on medication selection or potential errors in prescribing is often met with gratitude versus frustration. Programs like this are not without precedent,1–3 but implementation of pharmacist refill services across fragmented national networks of care is still a rarity. Undoubtedly, the success of our medication management programs also is a result of the proactive effort of my team to routinely meet with enrolled physicians face to face to explain goals and outcomes. Physicians, therefore, have plenty of opportunity on an ongoing basis to ask questions and suggest change if desired. This enduring collaboration represents the greatest promise of integrated health care: improve-
364 JAPhA | 5 3:4 | JUL /AUG 2013
ment in personal relationships between previously disjointed providers of care. After all, if I were a physician, I might be more skeptical of a pharmacist getting involved in my patient’s care if I never had the expectation of meeting him/her and having a conversation. The reality of health care reform and all the changes it will bring is upon all of us. I would argue that pharmacists, as a profession, have the most to gain out of all the chaos. We have the opportunity to fully embrace our roles as medication navigators for patients in whatever capacity our jobs allow us. Legislation and advocacy will help us along the way, but we also must convince ourselves of the necessity of our role. We must believe that we are vital to patient success and not allow ourselves to be dismissed as an ancillary service. That’s all for now. Hopefully, the past and future Prescott Award winners will continue to force positive change for the good of patients everywhere. I truly believe in the necessity of pharmaceutical care and hope you do to.
ja p h a .org
Acknowledgments: I’d like to acknowledge my wife Dr. Laura Marttila Schoenhaus for all of her love and support during these last few years, during which we both struggled to balance new careers and the births of our two perfect daughters, Emily and Leah. I would also like to acknowledge the excellent team at Sharp HealthCare, who have supported me through the last 5 years: Donald Balfour, Jerry Penso (now with AMGA), Vicki DeBaca, Silvia Rivas, Paul Hansen, Victor Monrreal, Manny Chapman, and Deeanne Nichols. Special thanks to Dean Katherine Knapp, Dr. Gary Dougan, and Dr. Michael Negrete for their help with the Prescott Nomination. Finally, thanks to all those colleagues, residents, and students who have pushed me to work for positive change in pharmacy practice. doi: 10.1331/JAPhA.2013.13522
References 1. Riege VJ. A patient safety program & research evaluation of U.S. Navy pharmacy refill clinics. www.ahrq.gov/downloads/ pub/advances/vol1/reige.pdf. Accessed June 15, 2013. 2. McKinnon A, Jorgenson D. Pharmacist and physician collaborative prescribing: for medication renewals within a primary health centre. Can Fam Physician. 2009;55(12):e86–91. 3. Cassidy IB, Keith MR, Coffey EL, Noyes MA. Impact of pharmacist-operated general medicine chronic care refill clinics on practitioner time and quality of care. Ann Pharmacother. 1996;30(7-8):745–51.
Journal of the American Pharmacists Association