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February 27, 2024: Today on TownHall we are taking a look back at a previously released episode. In this episode, Jake Lancaster, Chief Medical Information Officer at Baptist Memorial Health Care interviews Colin Banas, Chief Medical Officer at DrFirst, Inc. about medication list interoperability and medication adherence. How does DrFirst use data and AI to fill the gaps in medication lists? How do they fit into the medication adherence equation? What are some current challenges in medication data that Colin recognizes?

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Today on Town Hall

As an internist, you and I have both seen like the ZPAC that was from four years ago, pop up on that list. And if someone's not paying attention, they're gonna add that back to the med list.

And you know what, someone's gonna add that to the admission orders, and so this is that sort of pharmacy cascade that can happen if you don't get the lists correct upfront.

My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health.

Where we are dedicated to transforming healthcare, one connection at a time. Our town hall show is designed to bring insights from practitioners and leaders. on the front lines of healthcare. Today's episode is sponsored by ARMIS, First Health Advisory, Meditech, Optimum Health IT, and uPerform. Alright, let's jump right into today's episode.  

Hey everybody. I'm Jake Lancaster, an internal lesson physician, and the chief medical information officer for Baptist Memorial healthcare based outta Memphis, Tennessee. And today I'm here with Colin. Bannis from Dr. First Colin. Welcome to the program.

Absolutely. I am also an internist, so, birds of a feather.

It's great to have you.

And I know you've done the podcast circuit for those that don't know you, can you please just give a little bit of your background, talk about your, maybe a little bit of your career trajectory and how you got to Dr. First.

Yeah, absolutely. So, as I mentioned, I'm in the internist by background.

I joined Dr. First a little bit over three years ago as their chief medical officer. But prior to that, I was the CMIO for Virginia Commonwealth university health system. I was there for almost 17 years. Helping to run a Cerner instance in a large academic health system before joining Dr.

First to help with innovation and strategy.

Well, it is great to talk with you today. We've talked in the past but we really wanna focus on population health and how Dr. First and medication adherence and data kind of factor into those initiatives. So, First, why don't you just tell us a little bit about what Dr.

First does how they get data, how they use data and what do your clients do with it?

Yeah, absolutely. So, to really understand Dr. First is you need to go back to the Genesis of the company. So actually founded in January 1st of the year, 2000 as an e-prescribing company. So think back to the early two thousands e-prescribing was not really widely adopted.

It. Wasn't really a thing. In fact it wasn't until meaningful use maybe oh nine 2010, that e-prescribing really started to get widespread adoption. So our founder and CEO, Jim Chen was really ahead of the curve on that and from an e-prescribing company. And of course we still do that. We are the e-prescribing engine for over 275 different EMRs, including some of the big ones.

But from there you can imagine you make a lot of relationships. With pharmacies, pharmacy, software systems, payers, and providers. And from there, we've really blossomed into a medication management as our sweet spot, really. And so we have solutions in medication reconciliation, patient adherence, population health and even price transparency.

And so the portfolio is quite large over the course of two decades. It's a pretty exciting company to work for.

Yeah. That does sound exciting. And managing medications is probably one of the toughest things we do especially as an intern, as something that comes up daily, whether you're in the clinic or in the hospital.

Which medication list is the right list, is the patient even know what medications they're on. You get all this external information from outside sources. You see a patient you're admit 'em to the hospital. They haven't been there in a couple of years, but there's this list that lives in your EHR.

Can you trust it? What do you do with it? So it's been a very thorny issue for us and. Throughout the last several years, I've had numerous projects related to trying to get the med list and med reconciliation correct. Or as correct as possible. Potentially knowing that I. It's almost impossible to know what is the correct list that the patient is actually physically has at their house that they're taking on a regular basis.

That may never all exist in one place. But talk to us a little bit about how you all use data to try to fill those gaps and make that list that the physicians see in the clinics as good as it can.


Yeah. And, and we use additional data and we use AI to fill in those gaps. So it's a really good way for you to phrase it.

But you're, probably a lot like me. You remember being on paper and I certainly recall the day that we transitioned into a modern EHR and I was actually very happy to have that button. There was a button in our EHR that would let me access what they called external medication history.

And really that was. a Lot of claims data. So, think about data that the patients when they fill a prescription using insurance for et cetera, so PBM data. And so that was a godsend because, on paper we had nothing except the interview and maybe, big bags of pill bottles, if we were extra lucky and now we finally had access to something.

But we, you and I probably quickly realized that that data. was Sometimes incomplete. It was incomplete in two ways. One, there could be medications that were just flat out missing from that list. And that has to do with whether or not the pharmacy was participating in the data feed, et cetera, or how the patient did or did not use insurance.

And then the second is the data or the medications. They could be missing pieces of the information specifically the instructions, because really, if you're looking at insurance claims data, All you're really gonna get most of the time is the name of the drug and maybe the number of pills that went out the door.

And so you still had to do a multifaceted approach to getting the med history and the med rec. Correct. And that's still true to this day, but what DrFirst is able to do is take some of those traditional data sources, but also augment them with more data. And that data comes in the form of those two decades in the industry.

So we have connections to independent pharmacies or independent pharmacy software systems, as well as things like HIEs, as well as our own e-prescribing data. And so you can take traditional feeds and then augment it with all of this additional data. And then really, I think the new challenge now that we're, post 2020 is making sure that data is a interoperable, meaning that your system can consume it.

It's not just a bunch. Blob free text and two making sure that we're removing sort of duplicative data or data that's old. I think as an internist, you and I have both seen like the ZPAC that was from four years ago, pop up on that list. And if someone's not paying attention, they're gonna add that back to the med list.

And you know what, someone's gonna add that to the admission orders, and then it's gonna. get Sort of, transposed all the way down to discharge. And so this is that sort of pharmacy cascade that can happen if you don't get the lists correct upfront. So really DrFirst is doing two things. One it's, getting more data.

So we're hopeful that you don't have to make all of those phone calls to pharmacies, et cetera, to get additional data that you didn't have before. But we're also using AI to fill in the gaps specifically for the instructions. In that data. And then when you bring it into the system, it's a simple button click rather than having to re-input it using the keyboard, the mouse, et cetera.

And we can actually prove it. That's one of my other roles in the company is leading up applied clinical research. We actually have partners that have shown improvements in not only efficiency, but also safety.

Yeah, that's great. And I really liked your point about. Potentially removing duplicative meds or those expired meds.

We see that all too frequently and sometimes we'll have physicians, particularly our procedure list, not necessarily our internists that are seeing the patient for a very specific reason, but they're admitted under them. And they don't necessarily feel comfortable removing medications as a.

An internist might if they saw that expired. ZPAC whereas if you had the logic from Dr. First coming in saying, this is we're really confident, this is an old, outdated expired med. You need to remove it that may give him a little bit more confidence. So I'd definitely be interested in that going forward.

Let's just pause for a second and just say, why is any of this important? Why is it right? Why is it matter that we have an accurate medication list?

Yeah, I mean, my sense is that, we've been talking as an industry and as informations for over 15 years about med rec it became a joint commission imperative.

We really rallied the troops. We said we gotta get MedRec. Correct. And, within a couple years you started to see momentum not only from the process, but also from the EHR vendors, in terms of giving us an ability to get these medications, reconcile them, make sure that it's appropriately safe, but I also feel like we hit a wall maybe in the last five, six years.

Where medication reconciliation started to become a check, the box phenomenon. We sort of, I think we, as an industry felt that we maxed out and if you really wanted to go above and beyond where you were currently, you started to have to throw FTEs at it. And those FTEs are usually pharmacy farm techs, et cetera.

And why I think it's important is because the literature shows. That medication errors are still the predominant cause of not only readmissions, but also increases in mortality or adverse events that occur during a hospitalization or even during a prolonged episode of care post outpatient.

And so it's too important to, to be complacent. We need to still remember that med req is probably one of the most important things. That we can be doing. And also and this is a bit selfish on my part, but there are actually additional solutions that have come to bear in those last 15 years to help make med re safer and more efficient.

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No, it's really great. No, you know, certainly as an internist who really recognize the importance of getting that medication list. Correct. But I do agree. It's right now, a lot of it is being driven, not by the safety, which should be the main driver of it, but by the need to check the box for meaningful use something else like that

will give a nod to leapfrog for those organizations that still participate in leapfrog.

They've started to transition away from a check the box, sort of measurement to a. Qualitative measurement, okay. You're doing med re how well are you doing it? Show us your deep dive on a, before and after. But I agree completely. It's too important to not get, right.

So let's shift gears a little bit and talk about medication adherence.

This is, something that insurance companies are. Kind of grading us on how well our patients adhere to the medications, particularly on the ambulatory side. How does DrFirst fit into this? Why is this important and what can health systems and providers do to improve those rates?

Yeah, and I think DrFirst is uniquely positioned because we sort of have the front end and the back end of the adherence challenge. And so. Why it's important is very similar to what we just talked about in med rec, which is it's great to get the med list, correct. Or it's great to give them the right prescriptions out the door, but if they never fill them they're gonna end right back up in the ER, they're gonna end up with a really poor outcome.

And in fact, literature obviously supports that I would say on the front end, the way Dr.First fits in and the way the industry is moving is what I would call mobile patient engagement. So. I think with COVID we saw a real uptick in patients engaging in things like portals or telehealth, and we, as an industry, felt the need to meet the patient where they are as opposed to saying, you need to come to us and we'll do it all in brick and mortar.

I think there's a lot more digital forefront or, space that we're having to operate. in And one of the things that we're able to do at least with Dr.First on the front end is post prescription. We're able to engage the patient through SMS messaging. So, the literature shows that patients look at SMS over 90% of the time.

It's not something that gets ignored. And in fact, our literature, our own numbers will show that patients engage. But what we do with adherence post prescription event is. We will provide them an SMS that gives them a unique, almost an app, like experience. We don't want you to have to go to the app store.

We don't want to want you to have to have a new username and login. And that experience shows you things like education, copay. Where did the prescription get sent? Because if you think back to the paper days, there was something tangible. The patient had. And now that's sort of gone and we're sort of giving that back digitally, but the most important thing that we do with the solution and it's called RX inform is that when it's possible, we will match patients up with copay assistance options, whether that's pharma, whether that's coupons, et cetera.

So we can give the patients an ability to go to that pharmacy and say, look at my phone, here's a QR code or a a bar. Please apply that discount and we've shown up to a 10 to 15% uptick in making sure that patients get their first fill as appropriate on the backside.

We can do this with data so we can show you as a, provider or as a case manager aggregate levels of whether patients are picking up their medications or not. We calculate things. Proportion of days covered are PDC scores. And then we can put that on really nice views or dashboards to say, okay, you're managing a C O P D population.

Well, here's the first 10 patients that you need to go touch because their PDC scores are below 80%. And so it's really a, multi-pronged sort of, effort if you will, to be able to make sure that patients get on therapy and stay on therapy.

No. Yeah. And certainly with the rise of e-prescribing I think has really made it difficult.

And, a lot of patients have different pharmacies depending on the medication. Based on how much it would cost to each pharmacy. And so we see this a good bit where we'll send it one place and especially in the emergency department where they think they have the right pharmacy information, maybe their intake of the patient's correct.

Pharmacy is not as. They don't do that quite as regularly as they do maybe on the ambulatory side. And so we send the medicine to a certain pharmacy thinking that's where the patient will pick it up. And then we call later that it's not where they thought it was gonna be so useful, certainly to have that nudge to the patient where it was actually sent.

So medication that you have a medication adherence score that you're able to show the providers, we get a score out of our EHR, a similar medication adherence score. We also get, graded by each insurance company about our medication adherence rates. Do all those overlap, which one is the source of truth?

I would imagine since y'all are kind of. Tied in more to the pharmacy. If the patient's not using insurance, you would pick that up. I'm not exactly sure how it all overlaps, how it all fits together. We get a lot of confusion sometimes from physicians about, well, which one do I use?

Yeah, you just nailed it because despite this interoperability push, we're still largely very fragmented.

And I think the use case that you gave where a. And this is happening increasingly with high deductible plans. Patients are choosing to use cash or use a coupon through one of those coupon vendors. And that data will not show up in a lot of those feeds, especially payer feeds. And so the unique position for our company for Dr.

First is that our connection to multiple sources is really giving you a source of truth because it doesn't matter. Whether or not, it went through a PBM, whether or not they used a coupon, et cetera. Like we have that data. And so I would argue that our adherence score is probably the most accurate in the industry based on the fact that we have more data.

And the cool thing is for those organizations like yourself, who have different tools who want to consume that data, we have a front end, but we can also give you the raw. You can plug it into your EMR directly. You can plug it into an enterprise data warehouse if you need to manipulate it.

It doesn't matter. The fact is that we have the data and that we have a lot of decision support and visualizations that we've layered on top of it to benefit the population.

That's great. So we mentioned some of the data challenges that exist already with. Medications coming in and being able to delete old expired medicines or redundant medicines.

What other challenges are there currently for specifically, I guess, medication, data that y'all are facing and you are working to overcome?

Yeah, I think duplicative medications is still a huge challenge. We do a really good job with that, especially when it comes from multiple data sources like pharmacies.

But there is also the challenge of CCD data, right? So, depending on your EMR, there is CCD data being displayed right next to pharmacy dispense data. And a lot of times those are duplicates and a lot of times they are not being for lack of a better word squished together or amalgamated, and those represent opportunities for double ads or errors of commission.

And so one of the things that we're working on. what can we lend to the CCD space or the HIE space in terms of looking at dispense data and comparing it to CCD data, to remove multiple duplicates, to give you really that true view that you're looking at. The second problem is still what I affectionately call semantic interoperability, which is you're getting that data from one source.

And a lot of times the SIG data is still free text. This is the dirty secret of medication data flow is that even though you put it in perfectly structured and sent it E-prescribed somewhere along the transit, it lost its structure. Now it came back to your EMR as free text. We're able to use our AI to make sure that that free text turns back into structure and that it lands in your organization system and whatever nomenclature you're expecting.

So those are the two biggies I'm really hopeful for the duplicate CCD initiative that I just talked about. We affectionately call that smart processor the way that we process the data and then the way that we can make sure that it's semantically interoperable.

Yeah, no, those certainly big challenges that we see every day in the clinic and the hospitals is those medications that come across.

And I still see the, pretext I have to enter back in sometimes, but now I know. Working to get that improved. I know we're running close on time. Is there anything else that you'd wanna share related to a population health initiatives specifically regarding medications?

Well, I think if you, , as an organization have not defined a leader or a strategy related to pop health, you're probably a little bit behind the curve ball. I think the writing's on the wall in terms of. Paper performance or quality based care. And so, please be cognizant of what's out there related to things like adherence because we, there really is an opportunity to move the needle, not only from a data perspective, but also from a patient engagement perspective to get patients on therapy and then keep them on therapy.

Well, thanks again for talking with me today. I know I learned a lot and thanks everybody for listen.

Hey, thanks, Jake. It's always fun.

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