As highlighted in Chapter 11, when developing metrics to track for a service, it is important to understand your organization's priorities and focus. Are there specific initiatives going on within your organization that your pharmacy service could demonstrate impact? Are there upcoming strategic priorities that could leverage pharmacy telehealth practice? How is your organization aligned with reimbursement and future strategy for reimbursement? And the most important question: where do we find the information?
Breaking down metrics into different categories may be helpful when determining where to find the information you will need to measure outcomes. Clinical data will likely always be obtained through the electronic health record. Financial data may come from a variety of sources, depending on which metrics you are tracking. If you are tracking measures that are more closely related to value-based care, you may need to engage your population health partners or other teams that are involved in value-based care. Look for quality committees, clinically integrated network teams, or even a clinic manager to help determine where they may obtain data. For revenue-based measures, your electronic health record may offer some reporting capabilities. Your clinic manager may also be a resource to help you obtain these data. If you are in a larger health system, you may have a finance manager who can help gather these data.
Patient and provider experience outcomes may come from sources external to the electronic health record. The method for finding patient experience outcomes will largely depend on how you elect to track patient experience. Utilization of tools that are used throughout your clinic or health system will likely require partnership with the clinic manager or physician group/health-system leadership. If you are using a self-developed tool, data access and tracking are easier. Provider experiences with pharmacy services will likely need to be a tool that is developed and tracked internally. While there is not a wealth of literature published on provider satisfaction with telehealth pharmacy services, some papers outline provider perception and/or satisfaction with pharmacy services in general. Albanese and colleagues described creating a survey to measure provider perception of pharmacy services within a patient-centered medical home (PCMH).1 They developed a 63-item survey to determine which pharmacy services were worthwhile when considering clinical, cost and medication access, and educational services. The survey was administered using an online platform and included physicians, nurse practitioners, and physician assistants at the primary care PCMH. Through use of this survey, Albanese et al. were able to identify specific pharmacy services that the providers considered to be of the most value, including medication counseling, polypharmacy assessment, medication adherence assessment, and medication reconciliation.1 In addition, in the primary care setting, pharmacists have been found to reduce burnout among primary care providers and benefit patient care in multiple areas, including satisfaction that patients were receiving better care, increased provider access, and achievement of quality measures.2
Tool for telehealth pharmacy practice evaluation: Data mining and analysis is a fluid and dynamic process that usually involves key stakeholders across an organization. It may be challenging to engage all the necessary parties initially, so have patience! Also, be aware of how upgrades to electronic health record platforms may impact metric reporting.
HOW TO TRACK METRICS
When determining how to track metrics, it is important to understand what organizational resources you may have available to you. If you are a pharmacist within an independent physician practice, it may be harder to leverage reports and data retrieval from the electronic health record in an automated fashion. If you are part of a larger health system with a robust physician group network, however, you may be able to leverage data analysts or Information Systems (IS) resources to help with metric tracking via reports and dashboards.
Many organizations start tracking service metrics with homegrown tools, such as databases or spreadsheets. If your organization takes this approach, it is important to standardize components of the tracking when possible. For example, if the same service is provided at multiple physician clinics, it would be important to have a spreadsheet template that is used to track the same data points everywhere the service is provided. This allows for the data to be uniform and easier to analyze for the service overall.
Examples for Tracking Different Types of Metrics for Pharmacy Telehealth Practice
Chapter 11 highlighted multiple metrics across five different domains used for pharmacy telehealth practice. This chapter provides some meaningful examples demonstrating the application of some of those metrics.
Access to Care
In many areas of the country, access to a primary care provider is delayed due to a shortage of primary care providers. Over 7,200 primary care healthcare professional shortage areas (HPSAs) have been designated across the United States by the Health Resources and Services Administration (HRSA) in the U.S. Department of Health and Human Services.3 This can contribute to patients delaying or not receiving needed care.
Ambulatory care pharmacists delivering care through telehealth technologies can help bridge the care gap in HPSAs and increase available primary care access through collaboration with providers. Tracking and evaluating key access metrics can describe that value. Demonstrating a decrease in median lag time or third next available appointment can serve as valuable metrics in support for ambulatory care pharmacy services. If a provider is able to increase their panel size through partnership with a pharmacist, more patients receive needed care.
A 2017 study by Brunisholz and colleagues4 evaluated the quality of team-based care in patients with diabetes or high blood pressure with or without an ambulatory care pharmacist on the care team. Care delivered by the pharmacist was provided both face-to-face and over the telephone, with about 70% of encounters delivered remotely. Study results demonstrated increased touches with the clinical care team in the cohort with the pharmacist on the team (8.4 vs. 5.1 visits per patient-year, p <0.001). The authors hypothesized that more frequent follow-up was a contributing factor to the positive clinical outcomes that were achieved. Leveraging telehealth to deliver care allowed the pharmacists to increase patient touches and ultimately improve care.4
Metrics demonstrating increased revenue or expense savings can prove valuable to building and sustaining any ambulatory care model, including telehealth pharmacy practice services. Understanding the priorities and focus of an organization will be key to determining which financial metrics might be most impactful. For example, in an integrated health system highly focused in value-based care, demonstrating a decrease in per member per month (PMPM) expenses might be a key metric. A private practice in a fee-for-service model may prioritize the profit generated per encounter.
Financial impact on patients, payers, and the health system are all important considerations. Reducing patient out-of-pocket expense for medications, for example, can result in positive patient experiences, improve medication adherence, and reduce provider frustrations. Payers are interested in any demonstration of decreased expenses (medical or pharmaceutical). Tracking and reporting improvements in generic prescribing, formulary adherence, or PMPM will be valuable metrics to gain support for one's telehealth service. Return on investment (ROI) may be a difficult metric to obtain, depending on data accessibility, but it will speak loudly to decision makers within most organizations. An example of a simple spreadsheet used to track financial metrics is provided in Figure 12.1.
Hawes and colleagues studied the financial outcomes of pharmacist-led telehealth visits for both diabetes management and warfarin management. Services were billed using incident-to billing with a supervising physician. For anticoagulation management, G0248 was billed once for training, and future e-visits were billed once monthly using CPT code 99444. In the diabetes group, e-visits were billed using CPT code 99444. The margin per patient for the anticoagulation program was estimated to be $25 per month for the first year and $16 per month for the second year. The margin per patient for the diabetes program was estimated to be $25 per month, based on an average of 2.4 e-visits and 1.4 in-person visits over four months. This study helped demonstrate that there are opportunities to generate reimbursement from telehealth pharmacy practice visits with a positive net margin.5
There is a lot of emphasis on patient experience within hospitals and health systems. Consider the following example from a clinical ambulatory pharmacist in a transplant clinic. Two surgeons worked with the solid organ transplant service. One had the best results following surgery, but a terrible bedside manner. A second surgeon had a higher complication and failure rate than the first but was very personable at the bedside. Which surgeon do you think patients perceived delivered the higher quality of care? That's right, surgeon number two. Providing a quality patient experience is vital to the perceived quality of care and loyalty to the health system and care team.
When considering how to evaluate patient experience or patient satisfaction with a service, it is a good idea to see what methods for gauging patient experience your organization already leverages. You may be able to utilize a platform that is already in place and will require little manual work. Another benefit to using a preexisting patient experience platform is that organizational leadership will already be familiar with the tool, so it will require little explaining or teaching. A downside to using a preexisting tool is that the questions may not all be relevant to pharmacy services, or it may not capture specific questions that you wish to address. For example, pharmacists at one health system on the East Coast adapted the survey used for medical practices, creating a pharmacist clinical survey. This provided valuable insight into patient experience with the care being delivered by clinical pharmacists. As an adapted survey, it also included some questions that were not directly related to the patient's experience seeing the pharmacist (e.g., nurse/medical assistant support). Further adaptation of a survey tool to address the uniqueness of a telehealth service may also be needed.
Hatton and colleagues published a study in 2018 evaluating the patient experience with pharmacist-provided care using clinical video telehealth (CVT). For the purpose of this study, telehealth was defined as video-teleconferencing. The researchers hypothesized that patient satisfaction would not differ between face-to-face delivery and care provided using CVT. Patients were asked to answer 10 questions assessing the pharmacist's patient-centered communication and clinical competence and skills. The survey was self-administered. Survey questions utilized a typical 5-point Likert Scale for responses, with a score of 1 indicating a high level of disagreement with the statement and a level of 5 indicating a high level of agreement. Baseline demographics were similar between face-to-face and CVT populations. A response rate for the survey was not tracked. Based on the survey results, greater than 80% of patients in both the face-to-face and CVT populations responded with high agreement or satisfaction (a Likert score of 5) with the pharmacist use of patient-centered communication as well as clinical competence and skills. There were no statistically significant differences between the two groups. This led the authors to conclude that patient satisfaction did not differ based on the care delivery method.6
A 2016 article by Maxwell and associates assessed patient satisfaction with a pharmacist-led CVT program for chronic disease management. A clinical pharmacy specialist (CPS) provided clinical services via CVT to patients at a clinic where there were no onsite clinical pharmacy services. Patient satisfaction with the care provided by the pharmacist and CVT as a care delivery method was assessed as a secondary outcome. Twenty-six patients received services during the six-month evaluation period. A modified version of the Satisfaction with Pharmacists (SWiP) Scale was used, with three questions added to assess patient satisfaction with services delivered via CVT. The survey used a 5-point Likert Scale to measure responses, with a zero indicating that a patient was not at all satisfied with services and a 4 indicating patients were very satisfied with services. All 26 patients completing six months of pharmacy services delivered via CVT completed the survey. The median score was 39.5 (interquartile range 36–40) with a maximum score of 40. When looking specifically at the questions related to CVT as a method of care delivery, the median CVT satisfaction score was 12 (interquartile range 12–12) with a maximum score of 12. These results led the authors to conclude that patient satisfaction with CVT as a care delivery method was very high.7
If leveraging a preexisting patient satisfaction tool within your health system isn’t possible, there is always the option to develop your own tool. Options may include a brief comment-card-style survey where patients may answer a few questions and then have a place for open comments or feedback. Comment cards can be mailed with a self-addressed stamped envelope provided for return. Another option would be to develop a brief phone survey that can be administered within several days of an appointment. With this option, it is important that the survey be short, with a rating scale that is easy for patients to follow over the phone. With all of these options, maintaining the patient's sense of anonymity is important. Patients may be more likely to provide open and honest feedback if they have a sense of anonymity. For example, with a phone survey, it is likely best if the pharmacist who performed the service is not the individual to reach out to the patient to collect data. This might be a role for another pharmacist on the team or a great way to leverage students within a layered learning model.
As outlined in Chapter 11, measures of effectiveness relate specifically to patient outcomes and often may be clinical markers of disease improvement or assessment of healthcare utilization. Following is an outline of several published studies demonstrating the effectiveness of telehealth services. A more in-depth review of published telehealth literature and positive outcomes can be found in Chapter 1 of the present volume.
The aforementioned study conducted by Brunisholz et al.4 demonstrated positive clinical outcomes, utilizing recognized disease markers as the metrics. In this study, an estimated 70% of patient encounters were conducted virtually. Patients in the pharmacist cohort were more likely to achieve their HbA1c and/or blood pressure goals when a pharmacist was part of the care team. Additionally, these targets were met more rapidly than with the usual care cohort. Kaplan-Meier survival analysis showed improved achievement of goals at 180 days postintervention (48% vs. 27%, p <0.001 meeting blood pressure targets; 39% vs. 30%, p <0.05 meeting diabetes targets).4
A systematic review and meta-analysis reviewed the effectiveness of pharmacy telehealth services. The review found that most services were for chronic disease management, with the telephone being the most common mode of communication. This review found an overall positive impact on outcomes related to chronic disease management.8
A study by Litke et al. looked at both telephone and video encounters in which chronic disease management was provided for rural veterans. In this study, comprehensive medication management was provided by clinical pharmacy specialists via both telephonic and telehealth pharmacy practice models. Statistically significant improvements in diabetes and hypertension, as well as clinical improvements in lipid management and tobacco cessation, were seen.9
There is not a considerable breadth of literature describing the success of clinical pharmacy services provided via telehealth compared with traditional methods. In addition, emerging telehealth technologies, including remote patient monitoring devices, create ample opportunities for pharmacists to engage in practice-based research to add to the literature.
When evaluating utilization of a service, several options can be considered. One could look at the potential number of patients eligible for a service and how many of those engage in the service. That could be further broken down to look at those that may only engage in an initial visit versus those who engage in follow-up visits. If your engagement in a service is low, it may be worthwhile to reach out to patients who did not engage at all to determine barriers to engagement. You could also follow up with patients who only had one visit and no follow-up visits to help determine why the individual did not find value in the service. Chapter 14. will discuss more in-depth barriers to patient utilization of telehealth pharmacy services.
Tool for telehealth pharmacy practice evaluation: Establish metrics and methods for data collection prior to the start of a service! The metrics and tracking methods should be reevaluated on a periodic basis to ensure that the metrics being measured are still relevant and that the data collection methods are as efficient as possible.
FunkKA, PestkaDL, Roth McClurgMT, et al.Primary care providers believe that comprehensive medication management improves their work-life. J Am Board Fam Med. 2019; 32(4):462-473. doi: 10.3122/jabfm.2019.04.180376.
Designated Health Professional Shortage Areas Statistics: Designated HPSA Quarterly Summary. Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services. https://data.hrsa.gov/topics/health-workforce/shortage-areas. Accessed May 18, 2021.
BrunisholzKD, OlsonJL, AndersonJW, et al.“Pharming out” support: A promising approach to integrating clinical pharmacists into established primary care medical home practices. J Int Med Res. 2018 Jan;46(1):234-248. doi: 10.3399/bjgp19X705461.
BrunisholzKD, OlsonJL, AndersonJW, et al.“Pharming out” support: A promising approach to integrating clinical pharmacists into established primary care medical home practices. J Int Med Res. 2018 Jan;46(1):234-248. doi: 10.3399/bjgp19X705461.10.1177/0300060517710885)| false
HawesEM, LamberE, ReidA, et al.Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home. Am J Health Syst Pharm. 2018 Jun 15;75(12):901-910. doi: 10.2146/ajhp170174.
HawesEM, LamberE, ReidA, et al.Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home. Am J Health Syst Pharm. 2018 Jun 15;75(12):901-910. doi: 10.2146/ajhp170174.10.2146/ajhp170174)| false
HattonJ, ChandraR, LuciusD, et al.Patient satisfaction of pharmacist-provided care via clinical video teleconferencing. J Pharm Pract. October 2018;31(5):429-433. doi: 10.1177/0897190017715561.10.1177/0897190017715561)| false
MaxwellLG, McFarlandMS, BakerJW, et al.Evaluation of the impact of a pharmacist-led telehealth clinic on diabetes-related goals of therapy in a veteran population. Pharmacotherapy. March 2016;36(3):348-356. doi: 10.1002/phar.1719.
MaxwellLG, McFarlandMS, BakerJW, et al.Evaluation of the impact of a pharmacist-led telehealth clinic on diabetes-related goals of therapy in a veteran population. Pharmacotherapy. March 2016;36(3):348-356. doi: 10.1002/phar.1719.10.1002/phar.1719)| false
NiznikJD, HeH, Kane-GillSL. Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review. Res Social Adm Pharm. 2018 Aug;14(8):707-717. doi: 10.1016/j.sapharm.2017.10.011.
NiznikJD, HeH, Kane-GillSL. Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review. Res Social Adm Pharm. 2018 Aug;14(8):707-717. doi: 10.1016/j.sapharm.2017.10.011.10.1016/j.sapharm.2017.10.011)| false
LitkeJ, SpoutzL, AhlstormD, et al.Impact of the clinical pharmacy specialist in telehealth primary care. Am J Health Syst Pharm. July 1, 2018;75(13):982-986. doi: 10.2146/ajhp170633.10.2146/ajhp170633)| false