Gary A. Christopherson

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Committee on Identifying and Preventing
Medication Errors, Institute of Medicine April
13, 2005
Effective Safe Medication Use
Gary A. Christopherson Senior Fellow, Institute
of Medicine Deputy Director, Quality Improvement
Group, CMS Senior Advisor to the Under Secretary,
Veterans Health Administration, VA
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Effective Safe Medication Use
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Bring into play VA, DoD, CMS IOM
experience Bring into play context, strategy,
person-centered health, health systems,
behavior models, performance/quality improvement
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Achieving Effective Safe Use of
Medications Context
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High Health Outcomes, Quality Status Strategic
How to bring about a self-perpetuating system
in which health status, outcomes quality are
high?
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Effective/Safe Medication Use Strategic
How to bring about a self-perpetuating system
in which medication use is effective safe?
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Achieving Person-Centered Health

• Its about people (persons, community care
  providers) their behavior
• Its about systems that support people
• Its about not harming people
• Its about achieving high health status, outcomes
  care quality

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Achieving Person-Centered Health Its about

• health
• person being at the center
• behavior (person provider)
• self care
• person/provider partnership
• health systems supporting person/provider
• care in the community
• multiple settings across those settings
• virtual health system(s)
• performance-based management
• high health status, outcomes care quality

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Achieving Person-Centered Health Context

• focus on medical more so than health
• person not at the center more provider/facility-c
  entric
• know do little on behavior (person provider)
• relatively little done to improve self care
• person/provider partnership seldom truly exists
• health systems not sufficiently effective in
  supporting person/provider (prevent errors
  support effective care
• minimal attention to care in the community
• inadequate attention to multiple settings
  cross-cutting
• at early stages of virtual health system(s)
• limited progress toward performance-base
  management
• just not there on health status, outcomes care
  quality

All this applied applies to VA, DoD, almost
all care providers/plans All this provided
provides impetus for barriers to positive
change
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Achieving Effective Safe Use of
Medications Strategy
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Health Improvement
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Effective Safe Medication Use
effective/safe use
Stop actions that harm or decrease effectiveness
Do interventions that move up to effective/ safe
use
Do interventions that prevent harm
Support actions that improve
ineffective/unsafe use
Effective/ safe medication use indicators (mStatu
s)
Do interventions that move up from
ineffective/unsafe use
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Achieving Effective Safe Use of
Medications Person-Centered
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Person-Centered Health
Person-Centered Health Coordination
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Person-Centered Health
Locations
Persons
Person(s)
Health Environ- ment
Health Care
Person-Centered Health Coordination
Virtual Health System
Time
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Achieving Effective Safe Use of
Medications Behavior
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Behavior Chain to Effective/Safe Medication Use

• person takes OTC?
• person eats drinks what?
• person takes prescription drugs prescribed
  previously?
• provider diagnoses illness well?
• provider checks allergies, food/drink, other
  meds, etc.
• provider assesses persons motivation ability
• provider chooses best treatment, w/ or w/o
  medications?
• provider chooses best medication?
• provider partners w/ person on medication use?
• in hospital or nursing home, administer right
  meds _at_ right time?
• person fills prescription correctly?
• person appropriately adheres to overall treatment
  plan?
• person takes medication correctly initially?
• person partners w/ provider on medication /-
  effects?
• provider partners w/ person ensuring best meds
  use over time?
• other providers diagnose, treat, prescribe meds
  well?
• person takes medication correctly over time?

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Person Centered Health Model for Achieving
Healthy Behavior
Re-evaluation for Future Behavior
Valance for Consequences
Motivation (or Effort)
Intrinsic Consequences
Perceived Effort to Consequences Relationship (E
(III))
E (I)
Healthy Behavior
Satisfaction
E (II)
Extrinsic Consequences
Ability
Environmental Variables (controllable
uncontrollable perceived real)
E (I) Perceived motivation (effort) to behavior
relationship E (II) Perceived behavior to
intrinsic and extrinsic consequences
relationship E (III) Perceived effort to
consequences relationship
Based on Behavioral Effectiveness Model (BEM),
Gary Christopherson, 1974 2004
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Person Centered Health Model for Achieving
Healthy Behavior Basic Concept
Motivation (or Effort)
Environmental Variables (controllable
uncontrollable perceived real)
Healthy Behavior
Consequences
Satisfaction
Ability
Based on Behavioral Effectiveness Model (BEM),
Gary Christopherson, 1974 2004
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Person Centered Health Model for Achieving
Effective/Safe Medication Use Basic Concept
Motivation (or Effort)
Environmental Variables (provider behavior
controllable uncontrollable perceived real)
Effective/ Safe Medica-tion Use
Consequences
Satisfaction
Ability
Based on Behavioral Effectiveness Model (BEM),
Gary Christopherson, 1974 2004
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Achieving Effective Safe Use of
Medications Systems Support
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Electronic Health Record Systems (EHR) Supporting
Effective/Safe Medication Use
PHR (e.g., My HealthePeople) web site,
services, virtual health record, trusted info,
self-reported info, links to other health
providers
Outside Health Organizations w/ EHRs
e Communications/ Transactions
IE
IE
Health Provider (including clinical Interface)
Data Systems
Database/ Standards
Blood System
Health Eligibility/ Enrollment System
Laboratory System
Pharmacy System
Radiology System
Scheduling System
Provider Payment System
Billing System
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Personal Health System (PHS/R) Supporting
Effective/Safe Medication Use
Health Organization A
Health Organization B
Clinic, Hospital, Rehabilitation Care Coord.,
Telehealth, Home Care, Hospice, Nursing Home
Clinic, Hospital, Rehabilitation Care Coord.,
Telehealth, Home Care, Hospice, Nursing Home
Info sharing among providers
EHR
EHR / PHS
Coordi-nation
Health Record (provider, self-entered)
eHealth support (programs, reminders, support
groups, etc)
Care in home
Trans-actions (scheduling, Rx refill,
registration, etc.)
Mess-aging (clinician person)
Health info
Person Centered Health Utilizing Personal Health
Systems (PHS)
Interaction via PHS
Direct care w/provider
Interaction via provider PHS and/or direct care
w/provider
Persons Their Family/Friends _at_
Home/Work/Travel/..
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Virtual Health System Supporting Effective/Safe
Medication Use
Community
Other health providers
EHR PHS
IE
Non health org (e.g. SSA)
Persons Primary Health Care System
Electronic Health Record (EHR)
Person
IE
IE
Personal Health Systems (PHS)
Elec-tronic Systems
Person
PHS
Person
IE
Other health org (e.g. FDA, CDC, CMS)
Other Health Info Systems
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VHS Support for Effective/Safe Medication Use

• put person at the center of med use
• incorporate person doing self care
• carry out effective person/provider partnership
• care management on patients
• link persons motivation/ability to prescribing
  and adherence behavior
• integrate diagnostics, allergies, history,
  past/current treatment, prescriptions
• trigger drug-drug drug-allergy alerts
• link medication to correct patient (e.g. bar
  code, RFID)
• link to evidence on drug efficacy
• provide guidelines on prescribing
• provide alerts when drug problems
• tie drug efficacy to persons characteristics
• identify inappropriate drugs for person
• link drugs prescribed by different providers

• provide information to person on drug
• provide info on side effects
• provide info on adverse drug events
• link to patient safety study results
• follow-up studies of on/off label drug
  prescribing
• monitor drug use and therapeutic response
• computerized patient order entry
• reduce prescription writing filling errors
• reconciliation of drugs within across setting
• alerts on drug recalls or safety issues
• support of drug trials on safety, efficacy,
  effectiveness
• support disease surveillance using drug use
  indicator
• ensure health systems support person/provider

All this support (and more) must occur
correctly for effective/safe medication use
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Achieving Effective Safe Use of
Medications Quality Improvement
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Meeting Persons Needs Achieving IOM Quality
Aims
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Meeting Persons Needs Achieving IOM Quality
Aims Medication Use
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Health Status, Outcomes Care Quality
Improvement Medication Use
Quality Improvement
Changes in Provider/Clinician Behavior
Current Health Care
Target Health Care
Changes in Health Inputs/Environment
Changes in Personal Behavior
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Health Status, Outcomes Care Quality
Improvement Medication Use
Quality Improvement
Current Health Status
Optimized Health Outcomes
High Health Status
Effective/safe Medication Use
Changes in Provider/Clinician Behavior
BEM
Current Medication Use
Changes in Health Inputs/Environment
BEM
Changes in Personal Behavior
BEM
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Achieving Effective Safe Use of
Medications Within Across Settings
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Threads Within Care Setting
Integrated or Non-integrated Health Systems
Clinic, Hospital, Nursing Home or Care in the
Community Setting
Person
Primary Provider
Behavior
Information
Medication (Prescribed OTC)
Care Coordination Management
Time
Health Status, Outcome Care Quality Improvement
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Threads Within Across Care Settings
Integrated or Non-integrated Health Systems
Clinic Care
Hospital Care
Nursing Home Care
Care in the Community
Person
Primary Provider
Behavior
Information
Medication (Prescribed OTC)
Care Coordination Management
Time
Health Status, Outcome Care Quality Improvement
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Threads Within Across Care Settings
Integrated or Non-integrated Health Systems
Clinic Care
Hospital Care
Nursing Home Care
Care in the Community
Person
Primary Provider
Behavior
Information
Medication (Prescribed OTC)
Care Coordination Management
Time
Health Status, Outcome Care Quality Improvement
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Achieving Effective Safe Use of
Medications Strategy Execution
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Achieving Person-Centered Health
High Health Status
HealthePeople Strategy
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Achieving Effective/Safe Medication Use
Higher Health Status
HealthePeople Strategy
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Recommendations To IOM

• Effective/Safe Medication Use
• focus on achieving health, not just treating
• ensure person at the center
• focus on behavior (person provider)
• strengthen self care
• strengthen person/provider partnership
• carefully balance med non-med therapies
• develop/use effective health systems
• strengthen care in the community integrate
• care manage within care settings across
  settings
• develop/use virtual health system(s)
• strengthen performance-based management
• focus on achieving high health status, outcomes
  quality, not just improvement in medication use

Higher Health Status
HealthePeople Strategy
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Effective Safe Medication Use