Stream: Da Vinci PDex Drug Formulary
Topic: Feedback
Mathew Bramson (Jan 07 2020 at 18:26):
Hello! Created a place to provide feedback on the Drug Formulary Resources.
Mathew Bramson (Jan 07 2020 at 18:45):
So two pieces of feedback that I have: The StepTherapy field is currently a boolean. That's a great first step, but it'd be great to have more context behind a step therapy requirement when it's true. Ideally something encoded programatically.
Just telling a provider/patient that step therapy is required doesn't give them the whole story. They don't know which drugs they need to try to satisfy that particular step therapy requirement, and they don't know what parameters around those prescriptions would satisfy the requirement.
I'd propose a linking of FormularyDrug to Medications. Each medication should ideally have some way to associate the required quantity (probably in days supply, but physical quantity could certainly be an option) to that medication that would satisfy the requirement. Typically a step therapy requirement can't be satisfied by just filling a prescription for a single day of the pre-requisite medication. By specifying this amount, you're telling the provider exactly what they need to prescribe to get the patient on the target therapy.
Additionally, there is a period within which the pre-requisite medications must have been filled for them to be eligible to satisfy the step therapy. This could be something like 90 or 120 days. If a pre-requisite for lipitor is Simvastatin but it was tried by the patient 3 years ago, that might not satisfy the step therapy requirement. It would be great if this lookback period could also be linked to an alternate medication.
Ideally you want to be able express "Drug A satisfies the step therapy requirement for Drug B if dispensed in a days supply of at least 30 days in the last 120 days."
Asking around it sounds like formularies can get even more complex than this, but at its heart, you're really just trying to get the patient to try other medications (with certain parameters) before the target drug is covered.
Mathew Bramson (Jan 07 2020 at 18:50):
Another piece of feedback that I have which is similar in nature to the first is around the QuantityLimit boolean field. It would be great to express the concept "Drug A is covered only if dispensed at a quantity below 30 capsules" or "Drug B is covered only if dispensed at a days supply of 7 days or less".
A text field gets the job done, but it'd be great to convey the limits programatically. This gives the provider or patient important information so that they don't attempt to get a prescription that will not be covered, when they can simply lower the quantity and get it covered.
Mathew Bramson (Jan 07 2020 at 18:51):
We've seen both of these concepts as text fields in the wild, but that's really not that useful in practice, as you can't guarantee the integrity of a text field and it doesn't allow you to do things like automatically adjust a prescription based a returned coverage limit or suggest an alternative prescription which satisfies the step therapy requirement of the required prescription. With this data programmatically defined you could also look back at claims and determine whether the step therapy requirement is already satisfied and thus the prescription would be covered.
Jim Cavoli (Jan 07 2020 at 19:42):
As some of us were just discussing in-person as related to the idea of the DrugAlternatives field on FormularyDrug, the concept of an "alternative" is likely not best modeled on FormularyDrug at all. This is because in the case that a user would be looking for a medication with a different DrugClass, this is really just a search on the FormularyDrug collection. Alternately, in the case someone is looking for a therapeutically equivalent drug, this is really beyond the concept of where it may or may not lie on the formulary and is more of a clinical decision support problem. While there may be separate tools that leverage the formulary data to provide more advanced recommendations in either of these spaces, it would be somewhat inappropriate for this model to try to keep enumerated list(s) of drugs some provider might be interested in for some reason or another. This is a distinct situation from the step therapy issues described above since those are really formulary conditions to grant access within a particular tier, where there are requirements/conditions specifically defined, but laying the two ideas side-by-side begins to make it clear that DrugAlternatives is perhaps too nebulous/ambitious/unreliable in light of real-world intent to be useful in the formulary model.
Last updated: Apr 12 2022 at 19:14 UTC
