This week I am talking to Andrew Mellin, MD, VP, Chief Medical Information Officer at Surescripts (@surescripts). Andrew is an Internist and Hospitalist who has spent the last 20 years focused on technology innovation in healthcare and is now working to deliver trusted information into the healthcare system and close the loop on medications.
From the beginning of medicine, physicians have prescribed treatments and medicines and understood these were being taken by their patients but data shows that the adherence rates are far lower than one would expect with some 20-30% of patients not even filling the prescription and then a further cohort who don’t take the medication as prescribed.
We discuss the challenge for doctors who struggle to understand what medication their patients are taking especially as the care team expanded and multiple prescribers can contribute to a single patient’s treatments. They have managed to aggregate multiple sources of data and create a source of truth for the prescriptions that a patient is receiving. This is now real-time or near real-time offering a whole new level of insight to the clinical care team and the care coordinators
Listen in to hear the discussion on addressing the failures of the healthcare system and the biggest contributor to patients’ adherence to prescribed therapy and how real-time information and better insights can help solve these problems improve outcomes, predict and preventing adverse events and increase medication adherence by as much as 60%
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
And today I’m delighted to be joined by Dr. Andrew Mellon. He is the Vice President and Chief Medical Information Officer at Surescripts. Andrew, thanks for joining me today.
Andrew Mellin
Thanks. It’s really wonderful to be here. And it’s great to catch up with you.
Nick van Terheyden
So I’ve known you for a long time long, storied history in this space, particularly at the intersection between healthcare and technology. But our listeners done, if you would tell us a little bit about your background, how you arrived at this point, and you know, some of the steps because you’ve had some interesting points in your career that lead up to this point.
Andrew Mellin
Sure. Well, my background, I’m an internist. I worked for many years, part time as a hospitalist. But now for over 20 years, I have been in health information technology, I started at a small startup many years ago that built one of the first web based connected EHRs. Spent a number of years at McKesson and some of their EHRs and analytic solutions. I’ve also spent time implementing an EHR to large health system. And most recently, I’ve been at your scrubs. So I’ve been here a little over three years as a chief information officer. And a big part of my role is bringing that physician voice to everything we do here helping understand the workflows, the challenges, sort of the opportunities and places we can help all of our solutions to all of our concepts that are focused on at your scripts.
Nick van Terheyden
So if you would sure scripts has been around for a long time, but I don’t know that it’s always clear to everybody what they do in the industry, if you could tell us a little bit about the background before we dive into some of the areas of focus for you. Yeah, as you
Andrew Mellin
said, her skirts been around now for over 20 years, and we serve the nation was simpler, trusted, health intelligence sharing. And to give you a sense of what that means, in the scale of what we do, we connect more than 2 million healthcare professionals and organizations with trusted health care intelligence for over 99% of American patients. And our solution set is focused on to two areas. One is we focus on enhancing prescribing. We do this by simplifying the intelligence sharing for safer, more affordable prescriptions. We helped us prescribers at the point of care, make better decisions based on that patient’s benefit design, helping streamline prior authorization, and helping that communication with the pharmacy and the pharmacy benefit managers. We also informed care decisions by arming health care professionals with patient intelligence. That’s anything from bringing that medication history to the point of care. So as you’re seeing your prescribers are seeing your doctor, they know all the medications you’ve been on, no matter where you got them, to sharing clinical documents that are exchanged to the Care Quality Network across the country. So all in all, we shared over 20 billion pieces, 20 billion sets of clinical information in the past year.
Nick van Terheyden
So as you talk about this, I’m I’m reminded of my clinical practice, and you know, the number of patients that I recall coming in with the brown bag of medications, you know, that I didn’t see until I asked the question, so what medications are you taking, and they would tip the mouse onto the counter. I think if I understand correctly, sure scripts, captures that information brings it and makes it real time. And I think there’s an important distinction here because we’ve had some of that in the past, but not necessarily reliable. You’re saying there’s some surety to that?
Andrew Mellin
Yeah. So today, when you show up at your doctor, or as one of our is a hospitalist, if you showed up in the emergency room or in the hospital setting that EHR virtually every time the country will query Surescripts We will gather the data posts from pharmacies and the pharmacy benefit managers aggregate it add intelligence to that by cleaning it up and augmenting the information and bring that back into the EHR into that provider, that providers workflow for the reconciliation process. So it’s exactly right, instead of saying, you know, again, as a hospitalist I spent a lot of time doing bad breath, trying to get the patient to remember all the medications or honor transcribing those bottles that could come out of the brown bag. But what the data, what we’re providing is a clean set of data brought into the EHR that gives that doctor or maybe a pharmacist that starting point to go through that med list with the patient, reconcile the medications And you know how many I can’t think of how many times as a hospitalist patient forgot something important, right? You know, and find out later in the hospital admission or that, that they were actually on something or on a different dose, that would have really affected their care. So we’re getting all that information for you to the point of care, putting into the prescriber, the providers workflow, and helping them make those better decisions.
Nick van Terheyden
You know, I just want to say that the the bag of medications was a step up from the Tassie piece of paper that people had written down the the terms and the failure to actually capture, you know, the spelling dosage for all of those things. So you’ve captured that you’ve got it. I know, one of the biggest challenges, certainly from a clinician standpoint was something you described, which is medication reconciliation, is the some automation that you’re starting to provide, or is this just you’re providing one side of the coin and presenting it with the surety?
Andrew Mellin
Yeah, so the way we do this is we’re we’re in a partnership with our Scripps network Alliance. And in this case, it’s the electronic health records. So they’re actually the ones taking the information and bring it into the workflow of the prescriber. So we’re a bit on the back end of bringing them the information. But our goal is to get them clean, comprehensive information, so they can make those decisions. We are seeing some interesting innovations in the workflow to help the prescribers with the med reconciliation, again, it varies by EHR and how they do that. But we want to make that, you know, as crisp and as clean with the underlying data, as they start that process.
Nick van Terheyden
So, as I, as I always think about medication reconciliation, one of the big challenges is that sort of end run for patients. And I think, you know, naively as a prescribing clinician, I always assumed I’d write the prescription patient would fill it take it, that’s not the case. And in fact, the numbers are somewhat shocking, when you consider that we base our clinical decision making on the assumption that treatment was prescribed and it was taken. Tell us a little bit about where that that is and what you’ve been doing about that.
Andrew Mellin
Yeah, I’m an internist. And, you know, I think about this sort of sacred moment, when the prescriber, the physician and the patient, they’ve been talking, they come to a plan, you know, the doctor writes a medication, right, I don’t do procedures, I don’t do surgeries. So my biggest intervention is giving them a medication, potentially, that you know, prevents a future poor outcome or helps an infection or whatever it is, if that patient leaves a room and doesn’t take that medication, all that time was for naught. You know, that was all that work, we did all that discussion, all the planning, it doesn’t matter, because that key intervention of taking the medication never happens. The P, there’s so many reasons why the patient doesn’t take it, it could be medication, affordability, that’s how they see a big problem. And we’re doing some things to help bring pricing information to that prescriber and the patient at the point of care. So they can see that cost, prevent that sticker shock at the pharmacy, or even better save money by switching to a lower cost alternative and know how much that savings would be. But there’s other factors too, there’s obviously social determinants of health play a big role, there’s cultural issues, part of that. There is even transportation of going to the patient’s pharmacy, it is exciting to see a lot of the innovations in the area. I think when I was training, we never thought about sort of what happens after you wrote the medication just wrote it, like an order and you just expected it to happen. But today, we know that that’s not the case. 20 to 30% of time medications aren’t filled 50% of time medications aren’t taken as expected. And as a physician, it’s, I truly believe it’s our accountability, to to understand what those barriers to adherence are for that patient. And now that we start seeing value based care, not becoming a critical way of of reimbursing and incentivizing providers, it’s not just having that conversation, but it’s having the appropriate follow up and monitoring mechanisms to make sure things haven’t changed that moment that patients left the office.
Nick van Terheyden
So I critical in all of this is, you know, this real time level of information that allows you to provide it at the point of prescribing so you’ve, I want to say solve that. problem, you’re delivering that real time value updated information? That’s correct. It’s been validated. It sounds like you’re pulling it in from multiple entities to try and reconcile so that it’s improved in terms of overall quality and accuracy. But then there’s also this reconciliation for the actual filling of the prescription. And, you know, making sure and obviously, from the huge challenge around chronic conditions, essential, because if you’re not getting that and not getting it at the right times, how are you going about that? And what have been the experiences?
Andrew Mellin
Yeah, there’s a couple ways that we help organizations that are managing those patients, as a population, you know, outside of the office between encounters. One of the first ways and that I think, is, I love this innovation is this near real time notification of events that happen in a pharmacy, it’s also could be the absence of events that happens at pharmacies. So I’m going to share one example we’re working with Mount Sinai, they have about 10,000 patients they were managing. So these are patients with multiple chronic diseases, they are, you know, tightly managing them with care navigators. And, you know, they have a chief executive there who said, not too long ago, if our beds are filled with me, it means we failed. So they are highly motivated to help keep these patients with chronic decision diseases out of the hospital. So they built a program where they were taking claims data, putting it through spreadsheets, trying to monitor fill patterns, trying to make sure that patients are taking medications as prescribed. And that was okay. But it was a very manual process. And one of the challenges with claims data is the claims lag, it’s always, you know, two, three months late, they shared a story of, you know, they call up a patient who they thought was not adhere and the patient’s like, I’ve been in assisted living, and they’re taking care of all my medications for me now, you know, so. So that’s, that’s a tough conversation when you’re just talking to a patient, but you lose trust, because your information is out of date. So we work with them to set up this really innovative program. And the way that it works is now for these 10,000 patients, for those key medication. And so relate to those chronic diseases. They are monitoring, when the patients are picking up their refills. So if a patient has missed a refill, they get a notification says, hey, you know, Joe Smith was supposed to get their Lisinopril refilled, it’s been a few days hasn’t been refilled, then they take that information. And we’ll reach out to the patient and understand what happened was there the transportation barrier, that they forget something else change. So they’re seeing an improvement in their PVC, their, their, their, their main metric that they use to calculate medication compliance by 60%. Using this program, it’s pretty remarkable. So now they have near real time information about events in this case that aren’t occurring, that should have occurred for a patient, and then they can act on it. So instead of waiting two months for claims data, sort of waiting for that next patient encounter, they’re intervening within days of something critical happening to the patient. You’re also looking at things like when refills aren’t filled. So or when refills expire, I saw an interesting stat from village MD, where they said for some of their chronic diseases, and when they surveyed their patients, 45% of them said that they their medication adherence was simply because they ran out of refills. So that’s pretty remarkable. Almost half the time, they’ve what they are not adhering with their medication, because after 612 months, they just ran out of refills, and no one took care of that. So now again, they’re getting notifications that the refills have expired, you get the primary care physician or the to intervene to renew that prescription and nothing is missed. So with these notifications, we’re seeing some other clever ways, some other clever insights, things like monitoring when a new physician has written a medication. So you have these patients that you’re tightly managing, and an unknown physician has written a drug, maybe they are out of your network. Maybe they are a specialist student for history, and it’s time to intervene. You may it may have created a potential adverse event that they didn’t know about. You can monitor specific drug classes, looking for patients who are on opioid contracts and monitoring to see if a patient gets an unexpected opioid prescription. So this notification from across virtually all pharmacies coming to that those care managers care navigators are tightly managing those patients is really a new set of information that allows them to intervene much, much earlier, and in different ways than they’ve been able to do in the past.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist today, I’m talking to Dr. Andrew Mellon, he is the Vice President and Chief Medical Information Officer at shore Scripps, we were just talking about real time alerts. And, you know, the data that’s coming into the care coordinators, care managers, those folks are really trying to track and support individuals. You mentioned a story of an individual who had sort of fallen out of the system, because they’re gone into a different place, as one of the sort of examples of, you know, breaking trust where, you know, the healthcare system is expected to know, but doesn’t for whatever reason, it sounds like that’s one of the problems that you’ve solved was, was that the case is that one of those areas where now suddenly, it’s a proactive approach with these care managers who are reaching out to actually explore and understand at a time that’s contextual to problems occurring?
Andrew Mellin
That’s right. I mean, for medication adherence sort of outside of practice. Traditionally, it’s been a very retrospective, you know, the often if you’re just looking at claims data, it’s multiple months before you get the data. So it’s right, this provides a really proactive, near real time, new set of information to allow you to intervene on those highly managed patients, where, you know, a couple days a few days without their medications for CHF, they’re going to be in the emergency room, they’re going to be at heart failure. And it’s a chance to intervene very quickly, with a new set of data.
Nick van Terheyden
Interesting. So I, as I think about this, it occurs to me that this now starts to generate perhaps some insights that allow you to manage those populations, you know, I’m listening to you and thinking, well, what are the reasons? Are you starting to aggregate and see real drivers for and, and I know I’m using the wrong term, I’m saying non compliance. I don’t mean that pejoratively. But, you know, it’s it’s people not following the recommendations following through. We use this term non compliance, but I think it’s not the right one. But why is that happening? And what are you able to do about that?
Andrew Mellin
Yeah, there, there are ritually multiple reasons for non compliance or non adherence. You know, we, one of the biggest and often the biggest reasons is cost. So there is data studies that show for every $10, that the price of a medication goes up at out of pocket costs, the higher the likelihood that the patient’s going to come to the pharmacy and not pick it up. I know, I had a personal experience where I took my son to a pediatrician, he had really bad allergies. Being a smart doctor, I am I suggested a medication. And she’s, I think, hold her eyes a little bit and also prescribed something else I showed up to the pharmacy, and his allergy medication that I suggested was over $100. And the one she suggested was, you know, few dollars. But that kind of information, you know, I mean, analogy, medication, no big deal, right? It’s using a little bit more. But that’s your hypertension or diabetes medication, you are at the doctor’s visit. Again, you have this discussion, you shopped the pharmacy, and it’s $500, for your diabetes medication with some of these new classes, it’s all formula that’s possible. I mean, what’s going to happen? Well, you may just walk away, you know, you may have to make some really hard choices between filling that medication or paying for your food for the month, or skimping on some school supplies or other things that are really important. You may cause a lot of delays in the process and as a pharmacist, to see if there’s something alternate something different for you. None of those are good experiences. And none of those are good outcomes. And so one of the other things we’re doing is bringing back pricing information that out of pocket cost at the time of the prescribing. So the way that that works is as a patient shows up. As a doctor, you can imagine you’ve typed in your medication and the EHR, that dose what pharmacy it’s going to, within a second or two the EHR is returning what that what the patient will pay at the pharmacy, so you know the exact cost for them. You also know if it’s less expensive, maybe to do a 90 day supply versus 30. Some patients have different benefit plans associated with that, or maybe mailers cheaper for some of the chronic medications. And you’ll also get alternatives. So you know some of these diabetes medications, there’s some of these new ones that work really well. But there’s multiple drugs in the same class. And one may be a whole lot less expensive on your benefit plan. Doctors can kind of get some insights on that from the formulary information. But this gives you that exact thing. So you can have that conversation with the patient and say, you know, this is going to cost you $50. And I think it’s the right drug, is that going to be a challenge for you? Or you, the patient comes in asking for medication like I did? The doctor could say, well, that’s going to be $150. But the alternative is 10, would you rather have that? And of course, I would have said yes. So it’s really changing the discussions, changing the the the opportunity to prevent those non adherence by bringing that price information at the point of care with the provider and the patient. So they can have that discussion. And they’re no surprises at the pharmacy. That’s the biggest thing that you can do.
Nick van Terheyden
So I mean, clearly great opportunities to improve, you know, closing the loop, getting people to receive the appropriate care, the appropriate treatment, you know, some of these things feel like they’re out of your control, you know, the pricing elements. You’re obviously bringing information in and you know, you describe cost as the primary driver. I’m sure there are others. As you think about this, you’ve had some experience now with, you know, that cohort of patients, what are you excited about coming into the future?
Andrew Mellin
Yeah, I think there’s a few things I’m excited about coming in the future one, I’ll share two or three, what is we see, as we see more and more organizations taking on population out, they have now have more and more sophisticated, sophisticated tools to take a complete set of data, and help them identify who they need to intervene. So in addition to the notifications, it’s also a, you know, maybe it’s 100,000 patients, that you’re managing a little less intensely. But having a complete set of medication data, gives you a chance to run some risk analyses and other things to identify who you need to intervene on, maybe for polypharmacy, maybe for potential side effects, maybe likelihood of non adherence. So what is, you know, I’m just excited to see that value based care is continuing to grow. And organizations are doing innovative things. think the second thing is better risk algorithms. The challenge is always understanding who to intervene on and who is doing, okay, who you can like. So we’re seeing some exciting risk algorithms that help organizations point themselves in the right direction. I think the last part, something that you touched on, and we see as a big issue as a social determinants of health, where it’s exploring, you know, how to share that information, how to gather that information. And are there ways that prescribers providers care teams can be more informed universally of those determinants of health, and understand those impacts on that patient care, because often, it has nothing to do with the medication. It’s it’s transportation, cultural issues, you know, just where they live in their zip code, all those things can play such a big factor in medication, non adherence. So moving beyond just the clinical medication, to that holistic view of the patient, understanding all those factors that impact our health and wellness.
Nick van Terheyden
So, one area that occurs to me that potentially I haven’t heard you talk about that is relevant is the naturally occurring compounds that enter into the system of healthcare that, you know, physicians are often not aware of, are you thinking about those the supplements? And you know, that’s a huge business? Is that part of the strategy in the future as well?
Andrew Mellin
Yeah, we’re thinking about it. The challenge is most of those are sold over the counter. So they’re not really captured in any data system. If it’s captured in some way, we would love to interchange it. Sometimes EHRs are capturing it or doctors are prescribing it. They are an important part of the ecosystem and can play a big role and medication interactions and other things. Today, we just haven’t found a great source of that information to be able to share it widely. Hmm.
Nick van Terheyden
Interesting. Well, I unfortunately, as we do every week, I’ve run out of time, but it’s been a delight to catch up with you. Excited to see the progress and you know, the important contribution to closing that loop for the therapies that we’re prescribing for our patients. Andrew, thanks for joining me on this Show today
Andrew Mellin
thank you it’s always great to catch up with you and it’s an exciting time in healthcare right now so many wonderful innovations and it’s just great to see and hear what everyone’s doing
