Dr Calvin Knowlton on Innovative Practices in Enhanced Medication Therapy Management

Calvin Knowlton, BScPharm, MDiv, PhD, chief executive officer and founder of Tabula Rasa HealthCare, discusses innovative practices that have been introduced in Enhanced Medication Therapy Management (eMTM) and what he sees in the future for eMTM improvement and innovation.

Transcript

What innovative practices have been introduced in Enhanced Medication Therapy Management?

The program in eMTM, enhanced medication therapy management, that we offer, has to do with identifying components of medications that can cause adverse drug events, mostly in the elderly. So, the components would be, for example, if somebody’s on 10 medications and 3 or 4 of them may cause sedation, then we quantify them and say they have a sedation risk of 8. We also look at anticholinergic risk, which is drugs that make you dry, like a Benadryl dries your nose but dries your mouth, dries your lungs, dries your bowels, and dries your brain. That can cause people to be prone to fall and then go to the ER and the hospital, so we look at that.

We look at many drugs that cause dysrhythmia in the heart. They affect some of the ion channels in the heart, and if they build up, they can clog the channels a bit, and people have a dysrhythmia and have a heart problem and actually can die. We look at other actions of medications. For example, if you have somebody on 10 medications and 3 of them go through a particular pathway to get cleared from the body or excreted, think of a pathway like a car parking space, and there’s only so many parking spaces in the intestine and the liver for these drugs to get metabolized, or water solubilized. So, they go to the kidneys, and if you have 3 or 4 drugs in that pathway, the drug that has the highest affinity to those parking spaces will get in there first and clog them all, and the other drugs they are taking will just go in and not get metabolized and they’ll be full strength for hours, so you get what’s called an unintentional overdose.

That construct is called competitive inhibition, so we look at competitive inhibition also. In other words, we look at sedation burden, we look at anticholingeric burden, can they fall, will they fall. We look at the heart effect, we look at the competitive inhibition, and we also look at information on relative risk of adverse events that’s published by the FDA for different drugs. We put that into a system and do some statistics on it, and we can show the pharmacist with these 10 drugs for Ms. Jones, think about these types of adverse events or side effects she may be exhibiting.

So that’s kind of new, new information and people haven’t been doing that. The reason that it’s different is becayse pharmacists and physicians with electronic health records, for about forty years, have had the same system of 1 to 1 drug interaction, and it just says when you see these two drug interactions, you may get whatever side effect, but it doesn’t tell you what’s going on underneath, why, and if you have somebody on 10 medications there’s no way you can really keep track of that. So, our system we’ve introduced in the eMTM project we’re doing does what we call multi-drug simultaneous analysis.

What do you see in the future for eMTM improvement and innovation?

First, let me say thank you to the CMS for doing this, because they have enabled us to have a crucible or a petri dish of experiment to try and come out with something where pharmacotherapy effects Part A and B. In other words, the expense for medicine and medical and hospitalizations and heretofore pharmacotherapies been in its own silo over in Part D, and A and B have been in their silo. So, what CMS is doing with this change for value-based care is they’re bringing everything together in all counts, and that’s going to be exciting. Whether it’s in Part D or whether it’s in the Blue Cross Plan, everyone’s going for value-based care which is optimized care.