Medication Adherence Clinical Decision Support

Clinics are randomly allocated 1:1 through a computer-generated program to either control or
intervention.

Control: All control clinics will continue to use the basic Electronic Medical Record
(EMR)-linked Clinical Decision Support (CDS) tool for cardiovascular (CV) risk factor
management. This CDS includes algorithmically derived identification of high CV risk patients
and prioritized treatment suggestions for lipids, Blood Pressure (BP), glycemic control,
weight, tobacco, and aspirin use based on distance from goal, current medications, labs,
allergies, and safety considerations. The basic CDS does not include any information on
medication adherence. Patients will receive basic CDS plus usual care.

Intervention: In intervention clinics, the basic CDS system for CV risk-factor control is
enhanced to support a team-based care model that identifies risk of non-adherence, computes
adherence information and incorporates it in the CDS, creates a registry to direct proactive
pharmacist outreach, and coordinates action plans. To do this, the CDS Web service will
combine EMR-identified medications with extracted pharmacy claims data from administrative
databases. Algorithms will identify potential primary non-adherence (no prescription fills in
the previous 105 days) and/or secondary non-adherence proportion of days covered (PDC) <80%
in patients with two or more fills to BP, statin, and non-insulin glycemic medications). When
non-adherence is identified in patients that are not meeting clinical goals based on the
above inclusion criteria, adherence information is displayed by the CDS. Patients will
receive usual care plus patient education about actions they can take to reduce their 10-year
risk of having a cardiovascular event (heart disease or stroke). Pharmacists will be trained
and assigned patients on the registry in the intervention clinics. These pharmacists will
then call the assigned patients. We plan to ensure that all the times patients are available
for a phone call are covered including evenings and weekends. Pharmacist outreach will be
conducted primarily by phone, but in-person arrangements are also an option. The registry
will include clinic patients regardless of what pharmacy or mail order service they have used
to fill their prescriptions (the patients does not have to be filling prescriptions at the
affiliated pharmacy), and pharmacists conducting outreach will identify themselves to
patients as part of the care team working with the Primary Care Provider (PCP). The
Information-Motivation-Beliefs (IMB) model will be the framework for assessing and addressing
adherence. An assessment of medication-related problems and action plan will be documented in
the EMR through order sets we develop. Examples of specific action plans that may be
recommended includes use of combination medications, lower cost alternative medications,
addressing side effects, using pill boxes, modifying pill-taking schedules and/or using
reminder systems, or referrals to medical therapeutics management (MTM) pharmacists or health
educators. Pharmacists will follow a script template for the phone outreach that walks them
through the IMB intervention and data collection. Currently, pharmacists at the three
participating chains (Goodrich, Park Nicollet and HealthPartners) have full read/write access
to the EMR in full compliance with Health Insurance Portability and Accountability Act
(HIPAA) regulations. They can make medication changes and/or communicate with the prescriber
through secure messaging or phone consultation. The date of the pharmacist outreach and
actions that result from the IMB intervention will be documented in the EMR and incorporated
into subsequent CDS tools and registries to reflect the new patient state.

Inclusion Criteria:

- One or more of the following clinical criteria:

A. In the 12 months prior to the index visit, most recent A1C >8% AND prescribed one or
more active non-insulin glycemic medications on their EMR medication list AND a potential
adherence issue for one or more of these medications based on claims data (Proportion of
Days Covered <80% in patients with >2 claims or no medication fill claim found in the
105-day period antecedent to the index visit).

B. Two consecutive encounters with blood pressure values >140/90 mm Hg AND one or more
blood pressure medications on their electronic medical record medication list AND a
potential adherence issue identified based on claims data (Proportion of Days Covered <80%
in patients with >2 claims or no claim found in the previous 105-day period).

C. Meet the following American College of Cardiology/American Heart Association criteria
for moderate or high-intensity statin use AND a statin medication on their EMR medication
list AND a potential statin adherence issue identified based on claims data (Proportion of
Days Covered <80% in patients with >2 claims or no claim found in the previous 105-day
time):

1. Age >21 with atherosclerotic CV disease identified with two or more 10th revision of
the International Statistical Classification of Diseases and Related Health Problems
(ICD-10) diagnostic codes in the last 2 years or 1 code on the problem list

2. Age >21 and LDL >190 mg/dL

3. Aged 40 to 75 AND diabetes identified by two or more ICD-10 diagnostic codes in the
last 2 years or 1 code on the problem list

4. Aged 40 to 75 with cardiovascular 10-year risk calculation >7.5%

Exclusion Criteria:

- Patients enrolled in hospice, with active cancer codes or chemotherapy, and with
pregnancy codes in the last year

- Patients without HealthPartners insurance coverage for at least 11 of the 12 months
before the index visit will be excluded from cost analysis.