In the journey to determine, define, and track metrics when starting a service or measuring an already existing service, there are going to be barriers along the way. Being able to anticipate these barriers ahead of time can lead to less frustration and more success.

IDENTIFYING WHICH METRICS ARE MOST MEANINGFUL TO YOUR ORGANIZATION

As we discussed in previous chapters, being able to align metrics with organizational priorities is critical. Selecting metrics that matter to your organization will make it more likely that positive outcomes will hold weight with leadership within your organization, but this selection may be challenging. If you are in a larger health system, look to leadership to identify what may be important. It could be pharmacy leadership, physician's group leadership, quality leadership, or leadership in the population health or value-based care space. These individuals will have knowledge about the organization's strategies for reimbursement and for providing care. Clinic managers can also be a great starting point for gaining insight into metrics that are important to the organization. Clinic managers are often responsible for sharing quality data with providers and will likely have insight into financial data and reimbursement strategy as well. Identifying potential key stakeholders up front that you can engage to learn about what quality metrics would be important to your organization is critical.

LEVERAGING INFORMATION SYSTEM RESOURCES

In many organizations, whether a private practice office or a physician's group in a large health system, information system (IS) resources are often difficult to come by. Understanding the structure of your organization's IS team may help you leverage resources. Generally, a particular subset of the IS team supports an organization's electronic health record. Within that subset, there may be additional smaller teams that support specific areas of the electronic health record. Some organizations may have virtual health teams, pharmacy teams, and/or ambulatory teams for their electronic health record. One or more of these teams may be able to offer support for tracking of selected metrics.

When possible, it is ideal to capture data needed for metric tracking within the documentation template. This creates less work for the pharmacist(s) if double documentation can be avoided. Some electronic health record platforms offer customizable forms in which data can be selected or captured via a comment box. Other options might include the use of specific “smart” statements put into clinical documentation and later pulled into a report.

Some of the options described above reflect the ideal state in leveraging IS resources for more automated reporting. As discussed in earlier chapters, some organizations or practices may not be able to achieve this ideal early on in pharmacy services or with pilot projects. It may be necessary to employ other tools (described above in Box 13.1) to track metric data. If you are unsure as to which types of tools may be available within your organization, your IS team will be able to help with that as well. Alternative options may be available that could support data collection for metric tracking.

Financial Transparency

When discussing data collection for metric tracking, it may not always be feasible to access the data you need. Depending on your position within an organization and the organization's stance on sharing financial information, access to some financial data may be limited. This could be a large barrier if you belong to an organization that is more focused on fee-for-service, for it will limit the ability to assess the financial sustainability of the service.

If you have access to financial data, it is important to ensure that you have access to the data you need for any metrics you select. For example, if you are in an organization that is part of an Accountable Care Organization (ACO), having access to ACO patients’ cost of care would be important. Depending on what financial metrics you may be tracking, it can still be difficult—even with access to data. Identifying revenue can be straightforward, especially if your electronic health record identifies a service provider. This service provider can be the pharmacist for any pharmacist-provided service, even if it is billed incident-to. This can allow for tracking billing codes and attached revenue for any services with the pharmacist as the service provider. Some organizations elect to use tracking codes, which are specific codes created by an organization to track visits completed by a pharmacist. These codes can be added to visits with billable charges to separate those claims tied to pharmacy services. Other organizations may elect to create specific visit types for tracking pharmacy-specific visits and services.

Financial incentives tied to value-based care models may be more difficult to track. Understanding any value-based care models your organization may be engaged in is very important for both establishing and tracking these metrics to ensure you can attribute improvement in quality measures and closures in care gaps to pharmacists performing services that align with these quality measures.

When identifying and selecting metrics to track, financial metrics may be the most challenging for several reasons. Access to financial data can be a barrier. Even in circumstances where you have access to the necessary data, being able to attribute that financial benefit to the pharmacist can be a struggle. Proactively working to understand what data you might have access to and how data flows within your health system and with third-party payers is important. Developing a solid strategy can help ensure that pharmacists receive the appropriate attribution for the services they are providing.

Tool for telehealth pharmacy practice evaluation: Brainstorming for barriers or challenges to determining metrics and tracking data for telehealth pharmacy services can help with preparation to overcome these obstacles. One of the most challenging barriers for many pharmacists is transparency related to financial metrics. Before establishing financial metrics to measure, involve key stakeholders from the finance department or clinic leadership to determine what data will be available to track and measure.

PATIENT EXPERIENCE

Having a strong workflow to help patients navigate their telehealth experience is important. A 2020 systematic review and meta-analysis shared the top patient-reported barriers to leveraging telehealth in older adults (Kruse et al. 2020).1 These themes of patient-reported barriers are listed in Box 14.1. Being able to address some of these barriers may help improve the patient experience. For example, can your organization provide additional support for patients to help them navigate telehealth technologies? Does your organization offer the ability for patients to gain access to devices to support telehealth, potentially through grant-funded programs? Could your organization provide education to patients on the safety and security of telehealth platforms and telehealth encounters? Are you able to provide a demonstration of a telehealth visit for a patient while they are in the office? Are there specific platforms that may address the visual or auditory needs of patients?

Themes of Patient-Reported Barriers to Accessing Telehealth

  • Technical literacy

  • Lack of desire

  • Cost

  • Lack of technical support

  • Visual acuity

  • Social implications

  • Ownership of technology

  • Privacy and security

  • Medical literacy

  • Trust of the Internet

  • Mental acuity

  • Hand–eye coordination

  • Auditory acuity

  • Computer anxiety

Source: Adapted from Kruse C, Fohn J, Wilson N, et al. JMIR Med Inform. August 12, 2020;8(8):e20359.

If your clinic or your organization has a way to proactively address some of these themes of patient-reported barriers to accessing telehealth, it may help increase your overall engagement in telehealth services as well as patient experience. It is important to review the feedback you receive regarding the patient experience to see what barriers may exist for your specific populations.

PATIENT SAFETY

Patient safety concerns are still present with telehealth services and require some different advance preparation. The Agency for Healthcare Research and Quality (AHRQ) published an article outlining various considerations for patient safety and telehealth during the pandemic, but some of these considerations may extend beyond the pandemic as long as we continue telehealth pharmacy practice services.2

Telehealth offers the opportunity to provide a new way for patients to access care that may be more convenient for them. During a pandemic, it also may be safer for patients to engage in services via telehealth instead of traditional methods. Even outside of a pandemic, telehealth offers flexibility to engage patients who may have transportation issues or live far from the clinic, or high-risk patients who may benefit from telehealth visits to avoid potential exposures. Telehealth visits are not always appropriate for patients. Workflows designed to identify which patients may be more appropriate for in-person visits and when to advance to in-person care are critical.

Modalities for reporting patient safety events should be available. The ability to track events related to telehealth services versus traditional services may be important. It will help medication safety teams identify specific patterns with telehealth services that could be addressed from a system perspective to improve patient safety. These events can be learning opportunities for teams and for the healthcare system seeking to improve processes.

REFERENCES

Section 4: Clinical Vignette

Scenario 1

You are working on selecting key metrics to track and report on for your telehealth pharmacy services. Your clinic has been very focused on how the pharmacist can improve the clinical outcomes of patients. At the current time, your clinic is not involved in any value-based care plans, but there is talk about partnering with a local employer-sponsored health plan to improve patient outcomes specifically related to diabetes. While revenue generation has not been a focus of your position, you have heard rumblings recently about a renewed focus on clinic revenue and improving margins. What metrics might be ideal for you to track based on this information?

Response 1

Clinical outcomes of patients with diabetes would be a key metric to focus on given the information above. Capturing information related to hemoglobin A1c (HbA1c), statin use, blood pressure control, nephropathy screening, and eye exams would be important. Also consider how you will demonstrate changes in these measures. Will you compare to patient's baseline data or create a standard of care group for comparison?

In addition to the metrics above, you will also want to ensure that you are tracking revenue generated from your chronic care management (CCM) billing. Even if revenue is not something that pharmacy services have been asked to generate in the past, creating a financially sustainable service is crucial. In this case, the physician practice is not involved in value-based care, so generating and tracking revenue is an important consideration.

Scenario 2

You are creating a presentation reviewing metrics to share with your clinic leadership, including providers, to demonstrate the successes to date of telehealth pharmacy services. You feel that your data set is very compelling, but you are hoping to make it more humane to allow your audience to connect to the service and patients on an emotional level. You decide to include a brief patient success story to share with the audience but are struggling with how much detail to provide or what type of success to demonstrate.

Response 2

Including a patient success story can create an emotional response in your audience that will lay a strong foundation for receiving the data to be presented. Patient success stories do not have to be long or involved. A short vignette can be very powerful. After consideration, you decide to include the following patient story for a patient who received telehealth pharmacy services. “A patient was referred to pharmacy due to uncontrolled diabetes, which was putting him in jeopardy of losing his CDL license. His initial hemoglobin A1c (HbA1c) was 9.9%. Following medication adjustments and lifestyle education, this patient's HbA1c was reduced to 6.9% six weeks after initial pharmacy appointment. Pharmacy continued to follow the patient, and three months later his HbA1c reduction was maintained at 6.5%. During this time, the patient also had a 5% reduction in body weight. This patient was able to maintain his CDL and keep his job with the support he received via telehealth pharmacy services.”