Together is better: Standardizing a health system formulary

Formulary standardization across Catholic Health’s 24 hospitals has reduced costs, improved patient care

Three and a half years ago, a multidisciplinary group at Catholic Health Partners set out to achieve a lofty goal: implement a standardized formulary across a large health system. The idea was to have one common formulary that would be used by all hospitals in the system to provide physicians with evidence-based order sets that reflect current best practices. Today, the group has reviewed more than 100 classes of medications and drug entities that populate more than 350 order sets used within Catholic Health’s many hospitals. So far, the formulary standardization project has saved the health system around $25 million in formulary costs.

Timing and collaboration were invaluable when it came to standardizing the formulary at Catholic Health. The impetus to starting the entire formulary project was the health system’s transition to electronic medical records (EMR) using EPIC software. “We really wanted to hard-wire best practices into the EMR by having standardized order sets used by physicians across the entire health system,” said Susan Mashni, PharmD, Drug Development Specialist, who works from Catholic Health’s headquarters in Cincinnati.

The project required support and buy-in from leadership at the individual hospital level as well as the corporate level. “Collaboration [among] corporate pharmacy leadership, local pharmacy leadership, and the local pharmacists was critical to the success of formulary management,” said Nathan R. Ash, PharmD, BCPS, Pharmacy Clinical Coordinator, at St. Rita’s Medical Center in Lima, OH, one of Catholic Health’s 24 hospitals. “When everyone is engaged in the process, hospital pharmacy leaders and pharmacists have some ownership of formulary management. Our hospital staff pharmacists play a critical role in ensuring compliance with the formulary.”

Three-year plan

Catholic Health is one of the largest health systems in the United States. Located in Ohio and Kentucky, the health system includes more than 250 facilities, including hospitals, long-term care facilities, housing sites for the older patients, home health agencies, hospice programs, wellness centers, and other health care organizations.

Wayne Bohenek, PharmD, Vice President of Clinical Change Transformation at Catholic Health, came up with the idea to standardize the health system’s formulary. He engaged medical leadership at the individual hospital sites, brought Ash and other health professionals into the loop, and hired Mashni and Premier Consulting. Premier “helped us generate a plan so we could review all of our processes with medications over a 3-year period while we generated drug monographs, order sets, policies, and procedures,” explained Mashni.

The next step was to set up a formulary committee based on Catholic Health’s patient-centered access to team-based health care (PATH) philosophy. The CarePATH Formulary Committee comprises individuals from different hospitals. A working group made up of clinical coordinators, clinical pharmacists, pharmacy directors, nurses, and physicians supports the Formulary Committee.

“Together we build the most up-to-date evidence-based order sets with the best clinical content,” said Mashni. “The order sets we build are all consensus-driven, and we get buy-in from physicians [and other health care professionals] from the entire health system who join in the process.”

In October 2010, Mashni and the team tested out the new formulary at a group of five hospitals located in one geographic region. During a 6-month trial period, “we smoothed out the edges” and expanded the standardized formulary to other hospitals in the health system, noted Mashni.

Resolving differences

One of the biggest hurdles to implementing a systemwide standardized formulary was addressing the needs of individual hospitals since Catholic Health’s hospitals vary widely in size and areas of specialization. “We have everything from a small critical access hospital, to a children’s hospital, to a large teaching hospital with medical residents,” said Mashni. “What we tried to do was respect the different service lines and carve those things out from the formulary decisions.” Areas that are typically separated from formulary decisions include behavioral health, pediatrics, and stroke or trauma centers.

The overarching principle followed by Mashni and the group was that individual hospital sites can be more restrictive than the standardized formulary, but not less restrictive. For example, if the Formulary Committee decides that I.V. Tylenol should be nonformulary, then it is nonformulary, noted Mashni. “But if the Formulary Committee decides to allow for restricted use of the drug, then at each site the local Pharmacy & Therapeutics Committee decides if that is something they want to have or not,” she said. “Individual sites can be more restrictive and say they are not going to have I.V. Tylenol at their local site.”

There are always exceptions to the rule, and sometimes physicians order a drug that is not on the formulary. If this happens, an alert pops up on the physician’s order screen, and an alert is also sent to the pharmacy. According to Ash, a pharmacist will talk to the physician to identify why they would like to use a nonformulary agent. If the request is reasonable, “then the pharmacist will obtain the nonformulary agent,” said Ash. However, it is a delicate balance. If there are best practices in place, then pharmacists will try to steer physicians toward formulary agents, noted Ash.

Local level implementation

As far as the day-to-day operation on the individual hospital level, “there has not been a big change in pharmacy practice because to the local pharmacists, they have a formulary just like they always have had,” said Ash. “The only difference is the manner in which formulary decisions are made.”

However, one of the challenges early on, noted Ash, was the role of each hospital’s Pharmacy & Therapeutics Committee. “We had to transition the committee away from formulary management and toward medication use management,” said Ash. “Their main focus now is on drug utilization—how we use our drugs, where we use them, are there additional restrictions that we should think about at the local level, and are there any new processes that should be put in place around safe medication use at the local level.”

Transitioning the local Pharmacy & Therapeutics Committees to a drug utilization focus was a fairly smooth process. “We still have highly engaged Pharmacy & Therapeutics Committees even though the committee’s involvement in formulary management has declined,” Ash explained.

Collaborative efforts

With representatives from multiple hospitals and multiple disciplines, the formulary standardization process continues to be an extremely collaborative endeavor. Although there is often robust debate, therapeutic decisions are made in a timely fashion. For example, new guidelines were recently published for dosage strategies for antibiotics following surgery. The new guidelines were discussed and approved by the Formulary Committee, and the order sets were quickly updated to reflect the new dosing strategies.

Because there are so many disciplines involved with the Formulary Committee, “the collective knowledge is a lot more impressive than someone working locally on a monograph,” said Ash. “We make better decisions and I’ve had my mind changed during discussions because we get a lot of different points of view.”

Pharmacists play a critical role in developing drug monographs and participating in the Formulary Committee and the working group. “It gives us a great opportunity to represent our profession,” said Mashni. “Standardizing the formulary has been one of the health system’s greatest successes, and it gives pharmacists a lot of kudos because it shows that we can come together, work in collaboration, and achieve successes that would be more difficult to do individually.”

A standardized formulary also increases therapeutic opportunities for pharmacists. For example, the formulary allows pharmacists to make renal dose adjustments for about 16 medications. “Prior to implementing a standardized formulary, pharmacists at some sites could do it, but not at other sites,” said Mashni. “To have a policy that increases pharmacists’ responsibilities really increases our visibility and improves patient care.”