G. Cameron “Cam” Deemer is president of DrFirst of Rockville, MD.
Tell me about yourself and the company.
I’ve been president of DrFirst for about 14 years. DrFirst is primarily a technology platform company working in the medication management space. To de-jargonize that, we provide core technologies such as electronic prescribing, controlled substance prescribing, and a lot of things around medication history and interoperability. Those are often included in EHR platforms, hospital systems, HIEs, and pharmacies. We have a pretty broad footprint across the industry.
What is the best source for an accurate medication list other than asking the patient or their family members directly?
I would say DrFirst, of course. [laughs] Seriously, the medication history lists have come a long way. There has been a core medication history list provided by Surescripts for many years. We take that list and add medications to it from sources that aren’t providing their med history to Surescripts.
Getting a complete list is one issue. The other is making sure that the list is in a format that a hospital can intake into their own system. We do considerably massaging of the feed to make sure it has the right data elements. We clear up any discrepancies, such as around drug descriptions versus the NDC numbers and things like that. Then we help hospitals be ready to intake information from outside.
The best source is really a hospital or a physician that is using a very strong industry feed. It’s continuing to get better all the time.
It has always seemed hard to get old medications off the list, which could be done either by asking the patient if they’re still taking it or checking their refill records. Is that still a problem?
One of the things that’s exciting right now is being able to involve the patient more in that discussion. Medications they are no longer taking are one thing, but probably the more relevant issue these days is that patients are deciding how to medicate themselves. For example, it’s difficult to get a good, complete list of nutritional supplements that a patient might be taking.
But the other issue is that if I prescribe you a drug and you have some kind of reaction to it, maybe you decide that you’ll only take half a pill instead of a whole pill. Or maybe you discontinue it for a few days, you feel better, then you take it again and you feel bad again, so you discontinue it. Knowing how you’re dosing yourself versus how the therapy was prescribed to you needs to be addressed. We’ve been working on that primarily through more mobile interaction with patients, helping them understand how the doctor views their medication records and giving them a chance to update those appropriately for the physician.
I’m interested in your Link app, in which the patient receives a message under their doctor’s name listing the medication that was ordered, where their prescription was sent, and how much money they will owe as their co-pay. It even allows them to schedule a pick-up time with the pharmacy. Does offering a patient-facing application give DrFirst a way to grow in a new way?
It does. You and I talked about two years ago when we were starting beta testing of Link. We went into full-blown production with it within the last several months and have sent it to millions and millions of patients.
The way it works is that we know you’ve been to your physician, so we will reach out to you and try to make sure that you don’t abandon your prescription. We try to deal with what’s on your mind at that time. How much is it going to cost? What am I taking this for again?
A survey we did recently found that nearly half of all consumers aren’t sure they can take the medicine the way they were directed to take it because they can’t remember. The physicians usually are in kind of a hurry and the patient’s not thinking because they’ve just been diagnosed with some issue. Imagine that you were just diagnosed with diabetes or with high blood pressure and you’re not sure what that means. You’re not sure how you’re going to tell your spouse about it. You’re worried about how it will affect you physically. You may not be listening that carefully while the doctor is running through how you’re supposed to take your medicine.
We try to fill those gaps by reminding the patient. These are the meds that were prescribed. Here’s the pharmacy that has your prescription. Here’s some information about that therapy to remind you of the things your doctor told you. If you’re worried about how much it’s going to cost, here is the co-pay amount. Here is a financial assistance program, or maybe a consumer discount card if you don’t have insurance, which a lot of people don’t these days, or maybe they’re in a high-deductible plan. We take that cognitive load off the patient of not being able to remember what to do, being afraid of what they might have to do, and worrying about it. We ease them into starting their therapy.
I’ve always felt less empowered with e-prescribing. Before, I had a piece of paper that I could carry around to shop prices, I could get the prescription filled whenever I wanted, and I could research the drug before going to the pharmacy. Now I’m barely out of the doctor’s office when Walgreens starts the robocalls telling me to come pick up my prescription. Does Link re-empower the patient?
That’s an excellent observation. I actually feel the same way when I get a text message from the pharmacy telling me to come pick up a prescription. I may not have even been thinking about that at all. It’s just all happening in the background somewhere.
Another element of that is the rise of patient portals. On the one hand, it’s positive that we’ve been getting federal pressure for patient portals to be available in every EHR system, every hospital system. But it’s another way of taking some control away from the patient. Their data gets scattered between many electronic systems. It’s hard for them to bring it all together in one place. It’s hard to even just remember how to get to your portal a lot of times.
By going after the patient with this mobile solution only when they need it, we are trying to empower the patient to have all of their information in one place so they don’t have to remember what to do in order to get their questions answered. That’s probably the key here. As things become more electronic, there’s no reason that the patient should have a miserable experience of trying to navigate those electronic pathways.
Is the prescriber notified if the patient uses Link and decides for whatever reason to not pick up their prescription?
Not today, but we will have that shortly. We are incorporating a secure messaging channel from the patient back to the physician.
This is a new concept. Historically, physicians haven’t communicated with patients through text messaging, secure text, for a number of reasons. But that recent survey I mentioned found that an enormous number of patients, like 90 percent, said they would rather receive a text message from their doctor than a phone call, being steered to a portal, or being contacted via any the other methods they would normally get. We’re trying to meet patients where they are and give them the tools to be able to communicate something back to their physician in a manner that’s efficient for both the patient and the doctor.
This is a brave new world of trying to address what we call the care triangle. Think of a triangle with the physician on the top, a pharmacy at one corner, a hospital at the other corner, and the patient in the middle. Everybody needs to interact with and talk to the patient. But also, everybody at the corners needs to communicate back and forth with each other. We’re using secure collaboration tools to let all of those entities talk to each other in a real grassroots way so that we don’t have enterprise boundaries any more, or divisions between the medical professionals and the patients they serve. Letting everyone have the tools to be able to talk back and forth.
We hope that will be an important next step in making sure that all of the people who are working on behalf of a patient can synchronize and coordinate their care and to allow the patient to understand what’s happening and to be a part of it.
It would be interesting to put the patient instead of the provider at the center, with each patient having their own Facebook-like page in which all those messages and the patient’s replies are collected in one place that the patient themselves controls. Is that possible?
That’s actually what it is today. From a provider’s point of view, when they’re in our secure collaboration tool, they’re seeing one thread for a patient. It’s like text messages, with topics bouncing all over in the thread. In the collaboration tool, it’s centered around this patient that the care team is working on. From the patient’s point of view, everything comes into one queue where they can see a consistent record of the communications they have had.
What is the impact of an app that targets the patient specifically?
Link is quite powerful. We’re seeing close to 25 percent improvement in prescription abandonment just through Link. But we know that some patients, and particularly those who care for patients, need a more persistent experience.
But we also know at the same time that patients don’t care as much about their health as we would like them to. They don’t consistently focus on it in a productive way, which is why we forget where our portals are. We’re not in them all the time checking on things and sending messages back and forth. It might be because people don’t want to be defined by their illness. It might be that it’s just too psychologically heavy to continually think about your illness. But we tend to be concerned in spurts when we’re ready to pay attention.
A key focus for DrFirst is reaching the patient only at those times that they really care. During the times when they have less concern, we are just being available if they need us. We aren’t trying to get their attention during those times. We think that most patient applications fail because they assume the patient will be interested enough to continually interact with the application. We’re trying to put ours together in a way that addresses actual patient needs when they are occurring without requiring a lot of other activity otherwise.
What’s being done with opioid prescribing?
With all the pressure for physicians to use EPCS, it’s now about efficiency. Physicians not only are required to order the prescriptions electronically, but they also have to check the PDMPs, the state controlled substance registries. That is such a burden.
I saw my family physician recently and his office gave me three pieces of paper when I walked in. The first one said, you need to acknowledge that we don’t write controlled substance prescriptions out of this office. They made me sign that. The second one said, if I do write you a controlled substance prescription, I’m only going to write a three-day supply, and then you have to come back and see me again and pay for another office visit. I signed that. Then the third one said, the state of Arizona requires me to check the PDMP and they won’t pay me to do that and neither will your insurance company, so you have to pay me $15 for every controlled substance prescription I write for you. I had to sign that.
That’s happening all over the country. Doctors are pulling back from prescribing opioids because they don’t want to check the PDMPs. It’s too onerous. We’re starting to create a crisis of pain as opposed to a crisis of overdose.
To alleviate that, we’ve been putting a lot of effort into making electronic connections to every available state PDMP and then bringing the information into the physician’s workflow. Instead of leaving your EHR, authenticating into another system, entering patient demographics, and then going back to your system and typing the information in — because typically you’re not allowed to download it, you have to retype it — we make it so that right in the process of writing the script the opioid history is just right there, with no effort required. This addresses what unintentionally has became the next issue of patients — their doctors being unwilling to care for their pain at all as a rebound to the epidemic in the form of “let’s just not write them.”
It has been gratifying to see how enthusiastic physicians have been about making it this intuitive. It ought to be this simple and we’re we’re making it work that way for them.
Do you have any final thoughts?
We’re entering a time when there is so much pressure on the EMR community to continue to build features into their EMRs. We’re starting to lose the connection to the patient. The next big opportunity is getting all this information that impacts patient care in front of the patient at a time when they are ready to accept it and in a format that they can put to practical use as part of their therapy.
Patients for too long have been treated like miniature doctors who are laser-focused on their care. People don’t really work like that. I’m excited about digging in at the grassroots level to provide solutions to the real problems patients have trying to initiate and maintain their therapies over time.