- Complex diseases, both chronic and acute, often require significant investments in time and money from the four P’s of healthcare – patients, providers, payers, and pharmacists – to manage in a cost-effective and coordinated manner.
Reducing spending and improving outcomes for high-needs patients, especially those who may struggle with medication adherence, should ideally involve frequent communication and collaboration to keep individuals on track with treatments.
But in the fragmented, pressure cooker environment of modern care, it is all too easy for patients to slip through the cracks between primary care providers, specialists, and the inpatient setting.
Adding another “P” to the equation may be the solution for engaging patients at the higher end of the cost and complexity spectrum.
The phone – or, more accurately, the smartphone – is an extremely valuable tool for fostering digital engagement with specialty pharmacy patients at CVS Health, says Dr. Surya Singh, VP and Chief Medical Officer of Specialty Pharmacy.
Tailored digital communications with patients, and a link back to providers through CVS’s Epic System EHR, have drastically improved medication adherence and active participation among patients receiving specialty pharmacy services in a pilot program.
The encouraging results have prompted CVS to expand its innovative digital engagement program to even more conditions served by its specialty pharmacy division.
“Traditionally, the patient engagement component of specialty pharmacy has consisted of monthly or bi-monthly calls to remind consumers about refills and the like,” Singh explained to HealthITAnalytics.com.
“But now that everyone is carrying around these supercomputers in their pockets, we should be able to take advantage of that. We need take another step towards making digital interactions as rich and specific as they can be.”
Specialty pharmacy is a high-value proving ground for new population health management techniques.
Specialty drugs account for close to half of the nation’s pharmacy spending, according to a recent report by IQVIA, and many of these courses of treatment can exceed $100,000 per individual. The expenses involved create a strong incentive for payers, pharmacists, and providers to ensure patients are maximizing the impact of their prescriptions.
However, it is often difficult for a patient to maintain adherence from beginning to end, says Singh.
“The problems are persistence – how many people take the medication all the way through the time it was prescribed – and adherence, or if they’re taking the medication the way it was prescribed,” he said.
For a condition like chronic myelogenous leukemia (CML), a typically slow-moving blood cancer, “the drugs involved in treatment are fairly toxic, so persistence and adherence tend to be low,” he added. “Adherence can be under 60 percent in some categories of specialty care, including for some types of cancers.”
In 2016 and early 2017, CVS Specialty’s CML patients became the first to participate in a digital engagement pilot program aimed at generating more tailored communications delivered at personalized intervals.
“We have basically gone through each medication that we offer, segmented the population into sub-groups, and figured out when certain side effects or impacts are likely to occur for each type of patient receiving a certain medication for a specific condition,” said Singh.
CVS used clinical trial data and patient-reported outcomes data to pinpoint when a person is most likely to experience a common side effect for a particular medication, such as nausea, he explained.
“Instead of simply sending a boilerplate message at 15 days and 60 days, we can now send messages at the point when that side effect is likely to pop up. The participant can press one if they’re currently experiencing nausea, or press two if they are not.”
“If they are having that side effect, we can offer them the opportunity in real-time to interact through a secure application with someone on their care team, or talk live to someone if that better meets their needs. It’s very encouraging when you get a message soon after a side effect starts, because it feels like someone knows what your struggle is and that someone is there to offer help right when it’s needed.”
Users can receive the messages asynchronously on their smartphones or other devices, allowing them to read and respond to the secure communication when they have time to do so.
Messaging that corresponds to more directly to anticipated changes in an individual’s experience can also help to prevent “information overload” at the time of a diagnosis or when a person starts his or her treatment plan.
“If you tell a patient once or twice that they might experience a long list of possible side effects, that tends to go in one ear and out the other,” observed Singh.
“That is especially true when they are starting treatment for something like cancer – they are still dealing with the emotional trauma of the diagnosis and what it means. It’s often not possible for them to take in more information at that point and really internalize it.”
“However, if you give them the information in intervals when they are thinking about it again – they start feeling terrible and wondering if it’s the medication or if they need to go see their doctor – that tends to be a more productive strategy.”
The CML pilot showed exactly how impactful data-driven digital engagement can be. CVS Specialty Pharmacy saw optimal medication adherence that was around 30 percent higher than a control group.
Optimal adherence is measured as having a medication possession ratio of more than 85 percent.
“That is a bigger improvement than we have seen for almost any other type of adherence support program. It’s pretty dramatic, and it convinced us that we should roll out this program to other disease types,” said Singh.
Around 80 percent of patients eligible for the program have agreed to engage through the secure messaging platform, which was developed in-house to meet the specific needs of CVS patients.
“We’re very happy with that number,” said Singh. “We would love to increase it to 100 percent, but there will always be some people who don’t want to participate for one reason or another. I believe that the saturation point will be between 85 and 90 percent, which is a very good result as far as we’re concerned.”
Now that the pilot has expanded to include other conditions, Singh and his team are also seeing high engagement from other types of participants, including parents caring for the complex medical needs of their children.
“For example, cystic fibrosis patients tend to be a pediatric and young adult population, and they are heavily dependent on their caregivers,” he said. “The caregiver is trying to manage clinical tasks alongside the emotional wellbeing of the patient, and these very serious conditions can often leave caregivers feeling like they are lacking in control.”
“The most difficult part of taking care of a loved one, especially a child, is feeling out of control when all of these procedures and other things are happening to them. This gives them another modality to receive information when they need it and when it’s most appropriate. You get very high engagement rates because it helps them know that someone is available.”
Patients or caregivers who express concerns or wish to ask questions about their medications can connect directly with their care teams through the secure messaging app, said Singh.
“Depending on the type of request, a different member of the care team may respond to the communication,” he explained.
“If it’s a specific medication issue, the pharmacist that has been engaged with that patient will be the one notified of an incoming question and he or she will have the conversation. If it’s something like nausea, which could be a medication issue or could be something else, a nurse might be more appropriate to triage that concern.”
The care team acts as an important bridge between the pharmacy and clinical components of a patient’s care, Singh added.
Communication back to the primary care provider or specialist is a critical part of the program, and that conversation also relies heavily on health IT tools.
“Non-engagement is an important data point for us,” he said. “If a patient doesn’t respond to the first message about a lab reminder or symptom checker, we will reach out to them by phone to figure out what is going on.”
“If they don’t respond by the third attempt at communication, we will contact their provider and let them know that the patient is not engaging with us. This is simply so that the provider is aware of the situation – the last thing we want is for an individual to be lost to treatment. Oftentimes the provider is better positioned to make sure that dialogue with the patient is still continuing.”
Members of the specialty pharmacy care team can also use their clinical judgement to decide when reach out to a provider if they are concerned about a symptom that may require more intensive management or may indicate a change in the patient’s health status.
Much of this communication across service boundaries is conducted through CVS Health’s electronic health record.
“A lot of our EHR work putting in Epic Systems for specialty pharmacy over the past year has allowed us to improve our communication with providers by enabling bidirectional data exchange,” said Singh.
CVS Health has made a significant investment in Epic across its various patient-facing branches, including in its retail clinics. The ongoing partnership allows CVS to be an active player in a mature, data-driven ecosystem that connects the entire continuum of care.
“We are at the tail end of rolling out Epic in our specialty space,” said Singh. “We’ll be able to add these digital interactions to a record within Epic so that the clinical providers will also be able to view the data if they’re on Epic, too. They can just click over to the CareEverywhere portion of Epic and see what’s been going on with the patient’s interactions with CVS Specialty, and vice-versa.”
Ensuring clear and comprehensive digital communication between CVS and partnering providers is an important part of collaborating to manage an individual across organizational lines.
“We don’t want to duplicate efforts, and we also don’t want to inundate the physician with every little thing that we’re doing,” he said. “Speaking as a doctor myself, I know that when I get too much information from partners and it isn’t filtered and selected carefully, it just becomes noise.”
“So we have worked very hard to tailor our communications to ensure that we’re being meaningful in what we share, both to our patients and their providers. Technical integration is a significant component of that, and we are actively looking for ways to leverage our health IT systems and make sure that everyone is able to make a maximum contribution to the wellbeing of the patient.”