When I came to Jefferson, we were essentially a 1.5 hospital system. Along with 1 community hospital just south of us, we prided ourselves as being a flagship academic medical center and a destination tertiary care institution. In fact, this was so long ago, that in 1990, of course, there was no such thing as a website for our hospital.
I am happy to report that in the past 5 years we have grown to a 16-hospital system, making us one of the largest delivery systems in the Northeast, with revenue exceeding $6 billion. Along with our growth, which is not unique in the healthcare marketplace, have come many challenges. Readers may be familiar with some of these challenges, including that certain hospitals in our network are on one electronic medical record (EMR) system and other hospitals are on a different EMR system.
We have multiple cultures, which may also be familiar to readers, including those of full-time academic medicine and of community-based private practice fee for service, which we hope will exist in tranquility side by side. This editorial is focused exclusively on some of the challenges that integration poses in terms of the delivery of safe and effective pharmaceutical care.
Each of the disparate institutions that make up Jefferson Health has its own legacy formulary. We have created an enterprise formulary committee, on which I also sit, under the leadership of our chief physician executive. It should come as no surprise that this is a huge challenge for our system, because there is vast variation related to the content of these formularies across the entire system.
This variation alone should be vexing enough, because it offers an insight into the continued presence of unexplained clinical variation in what clinicians do every day. On deeper questioning of pharmacy directors and individual physician leaders at each institution in Jefferson Health, the typical refrain is, “This is what our doctors are accustomed to!” It is as if we have institutionalized clinical variation—variation that is not evidence-based and that results in many downstream safety issues.
Tackling unexplained variations in the formularies will require hard work on the part of the enterprise formulary committee. Members of this committee have already begun to catalog the differences in the formularies and have worked together using evidence-based guidelines from sources such as the Academy of Managed Care Pharmacy to bolster support for streamlining the process. It is going to be a multiyear process, with the need for a good deal of input from each of the institutions. In a recent study, researchers have looked at nonformulary medication approvals to determine if nonformulary medications promote formulary cost-savings and improve quality of care and patient safety.2 One can imagine that at the central medical school–based hospital, the type of cases seen may be different from those seen in the outlying community. Surely, solid organ transplantation, bone marrow transplantation, and advanced cancer care call for a formulary different from the one found at a 200-bed community hospital in which these services are not delivered.
I searched the literature to see if other integrated delivery systems have described their own journey. I did find that in a study of outpatient care facilities in the Veterans Administration (VA), Thorpe and colleagues described what they call “dual health care system use” and its impact on high-risk prescribing for patients with dementia.3 In their study, veterans who used the VA system as well as the private system had more far-reaching complications related to their medication use than VA-only users.3 This is particularly important because, the VA system has a robust integrated pharmacy and medical record system available in all the VA healthcare settings. This system is clearly built to achieve good outcomes. Yet, when using indicators of unsafe medications among veterans with dementia, the researchers found that approximately 4 of every 10 (39%) VA-only users still received potentially harmful medications.3,4
In other words, even within the VA system itself, without dual-system use, veterans were at great risk for unsafe medication practice, despite a robust integrated EMR system. Now, looking at Jefferson Health, my level of concern has increased as we begin the journey toward what I will call “the delivery of a more integrated product.” How will the enterprise formulary committee, with multiple different inpatient and outpatient EMR systems, cope with the potential of unsafe medication practice? This is an important additional challenge that we will face in the near term.
Truly integrated delivery systems, with only 1 owner of the hospital, the ambulatory center, and even the pharmacy itself (such as Kaiser Permanente), have a long history of creating a centralized formulary with a robust safety process. From its national pharmacy office in Oakland, CA, Kaiser Permanente leaders are able to quickly review drug interactions, safety issues, current US Food and Drug Administration approvals, and similar things with a clear eye toward a systemwide agreement.5 It may take Jefferson Health years to achieve a comparable level of systemwide agreement with regard to its formulary.
Additional challenges for the enterprise formulary committee will clearly revolve around governance. That is, will there be a central medication safety committee across all 16 hospitals? How will clear conflicts of interest, as they relate to clinical trials, pharmacy relationships, and speaker bureau membership, be dealt with as an enterprise? How will exceedingly expensive cancer chemotherapies be allocated across all our hospitals?
Clearly, we are not the only evolving integrated delivery system facing these issues. It is surprising how little peer-reviewed research is extant to help answer some of these pressing organizational and governance-related questions.
- Nash DB. The price of PEACE. Am Health Drug Benefits. 2016;9(9):473-474.
- Her QL, Amato MG, Seger DL, et al. Review of nonformulary medication approvals in an academic medical center. Jt Comm J Qual Patient Saf. 2017;43:89-96.
- Thorpe JM, Thorpe CT, Gellad WF, et al. Dual health care system use and high-risk prescribing in patients with dementia: a national cohort study. Ann Intern Med. 2017;166:157-163.
- Gifford DR. The Veterans Affairs pharmacy system: perfectly designed to achieve the outcomes it gets. Ann Intern Med. 2017;166:221-222.
- Bridges F, Elliott W, Millares M. The life of a new drug: conception to formulary decision. Drug Bulletin. July-August 2015.