Health Outcomes- The Role of the Patient

In a recent editorial published in the May/June edition of the Journal of the Advanced Practitioner in Oncology (JADPRO), Drs. Ramirez and Campen exposed systemic failures in detecting drug-drug interactions (DDIs) in the oncology setting. Their article was an extrapolation of a Chicago Tribune exposé that addressed the same issue albeit in the community pharmacy setting. Ramirez and Campen basing their editorial on the "Swiss cheese model" identified 4 gaps: (1) prescriber knowledge, (2) computer screening, (3) pharmacist knowledge, (4) patient education. The authors concluded that "The system is failing, and the problem only seems to be growing".

Where do we go from here? how do we fix such a problem? in previous posts, I mentioned the shift toward a new healthcare paradigm of patient outcomes data collections. Perhaps one of the most important contributor to the gaps exposed by Ramirez and Campen is the use of multiple pharmacy as a provider of pharmaceuticals. For instance, a patients may receive his chronic illness therapies from a mail order supplier, his acute medications from his local drug-store and his oncology or immunological therapy from speciality pharmacy. Not to mention that all these medications maybe prescribed by various specialists and general practitioners. In addition, the availability of apps and websites that provide cost comparison and coupons promoting patients to shop for medications from various sources compound the multi-pharmacy use problem. There is enough evidence in the literature that indicates that this issue reduces adherence to medication, and increase the risk of unchecked DDIs.
Historically, pharmacists enjoyed the highest level of trust to provide drug information to patients, improved adherence by reminding patients of due refill, promoting medication therapy management (MTM), avoid dispensing medication causing potential DDIs without discussion with prescribers.
However today, in the multi-pharmacy use model that centralized one pharmacist is removed and the patient's safety is therefore compromised.

As we move into this new paradigm change in healthcare where costs trumps all, there seem to be two options to keeping a centralized data on the patient's medication therapy.
1) Health insurance agency (governmental or non-governmental): data is maintained and reviewed in real-time, screened for the potential drug-drug interaction, duplication of therapy, dosage appropriateness...etc (not to mention these services are currently sporadically available). In addition, there must be some routine review conducted by health insurance agency in the like of case management. However, inherent in such a model, are ethical concerns and conflicts of interests that need to be addressed. For instance, how would cost influence choice of therapy? or how would the agency use patient's data?
2) Patient portal data gathered from various healthcare providers is stored to a secured patient portal with ease of use. Patient is then educated on the its use and it is ultimately the patient that grant access to the healthcare providers. Furthermore, built in application to enhance health literacy and engaging the patients in a meaningful way to take charge of their health. This seems to be the best model, relying on a universal electronic health record (EHR) as opposed to a multiple provider-dependent variations of electronic medical record (EMR). However, this model is not without shortcomings, mainly patient literacy. Yet this can be overcome with patient education and user-friendly customization according to the patient's health literacy level. Ultimately, the onus is therefore on the patient to take charge of his/her records and disseminate this information to his/her clinicians.

Improving patient's health outcomes is not simply the burden of the "system" as if the "system" is some extrinsic entity. Improving patient's health outcomes relies significantly on education the patient and improving their health literacy so that the patients take charge of their health.

Measuring Patient Outcomes- An Elusive Proposition?

Improving patient health has been the question that plagued the medical society for years if not decades. In fact, I dare to say, that improving patient health is the impetus of the medical community.
In our modern era, improving patient health is rapidly becoming synonym with patient outcomes. With economic concerns over cost of diagnoses, therapies and subsequent monitoring, the third-parties (governmental or private) cost reimbursements leave us scrambling to find what works and what doesn't. While articles after articles in peer-review journals and in common news outlet speaks of novel therapy or newly discovered diagnostics, the burden of new information is crippling health care professionals and/or is pigeon-holing them into a super-specialties. Furthermore, continuing education, an ethical obligation for healthcare professionals, should be designed to meet certain objectives that address performance (Moore's level 5) and patient health (Moore's level 6).
However, our poor attempt to categorize patients according to their age/gender/race and disease or attempt at bucketing diagnostics/therapies into a one group, have led to unsatisfactory results in measuring patient outcomes. At best, some were subjectives on part of the clinicians, or retrospective and anecdotal evaluation. In addition, the lack of guidance on patient outcomes measurement compound the problem even further.
What now? The question remains; how do we measure patient outcomes? This elusive endeavor can prove challenging in the modern paradigm of healthcare. Are objective biomarkers for a particular disease state a determinant of positive or negative patient outcomes? In other words, if for example we manage a patient with diabetes to attain a hemoglobin A1C below 7%, does that mean we have a positive outcome? How about that patient weight? complications? yes, I submit that the diabetic guidelines account for all of these, and perhaps on a singular patient level a clinician may have evaluated all known factors. But chasing these factors and numbers reduces the practice of medicine into a fruitless play of cat and mouse.  Healthcare practitioner after all "do not treat numbers but treat people".

Ultimately the outcomes measurement is only achievable in a holistic, multi-disciplinary approach that relies on the three main pillars of medicine: the physician, the pharmacist and the nurse. This endeavor is attainable when all three pillars are interconnected and not standing alone; physician feels safe being challenged on certain therapy choice, pharmacist welcomes the nurse's input on the patient's concern or shortcoming, and the nurse provides accurate and complete patient information and relays patient's concern to the physician. This leads me to my first proposition: there must be a genuine and complete open communication across the healthcare medium. 

However, for this communication to be successful it should be patient driven. All conversations of patient outcomes should be put aside until the patients themselves take charge. Although patient apathy is a different issue for a different discussion, recognizing the submissive, inherent attitude of patients as subordinate to their healthcare providers should be noted. Because this patient behavior is well documented in lower socioeconomic environment, special effort should not be spared in providing compatible education. Which leads me to the my second proposition: patient education material should be engaging with less text and more infographics providing the appropriate contexts.

In summary, measuring patient outcomes will continue to be elusive, but it is not illusive. It is attainable provided we approach the subject in a systematic, comprehensive way and are willing to challenge and be challenged by a new healthcare paradigm.