1. MedicationQualityMatters
38 The American Journal of Pharmacy Benefits •January/February 2015 www.ajmc.com
ABSTRACT
Current medication-related measures may lead to improved
prescribing and adherence, yet they do not address medication
optimization for effectiveness and safety, medication coordina-
tion across multiple prescribers and pharmacies, and medication
follow-up required between care transitions or office visits. There
is ample room for a more deliberate prioritization of measure
development to close gaps in care that involve medication therapy
decision making and management processes. As new care delivery
models evolve to focus on value, accountability, and team-based
care, new measure development opportunities are being used
to address care gaps and to support team-based care delivery
systems and care transitions.
Am J Pharm Benefits. 2015;7(1):38-42
S
ince the publication of the report “Crossing the Quality
Chasm” by the Institute of Medicine,1
hundreds of new
healthcare quality measures have been developed at
the national, state, health plan, system, and practitioner levels
to improve healthcare and promote accountability for better
healthcare processes and outcomes.
In the United States, medication-related quality measures
are included in various measure sets, including Healthcare
Effectiveness Data and Information Set, Electronic Health Re-
cord Meaningful Use, accountable care organizations (ACOs),
and the Pharmacy Quality Alliance (PQA). Most, however, re-
late to prescribing processes, adherence rates, or electronic
health record capabilities (Table 1). While these measures
may lead to improved prescribing and adherence, they do
not address medication optimization for effectiveness and
safety, medication coordination across multiple prescribers
and pharmacies, and medication follow-up required between
care transitions or office visits.
Beyond the administrative burden, the sheer volume of
current measures makes it difficult to identify the right mea-
sures for assessing improvement in medication management
that encompass appropriate prescribing, effective dosing,
avoiding medication interactions and adverse events, and
improving adherence. While there has been keen interest
in focusing on patient outcome measures (eg, blood pres-
sure or diabetes control), there is still a need for meaningful
process measures for medication management and monitor-
ing2
—especially in new team-based care delivery models.
Measuring What Matters
Although hundreds of new quality measures exist today,
many “care gaps” still do not have measures. One approach
to measure development has been to identify measure con-
cepts for “measures that matter.” Some examples are the need
for measures that help to:
• Differentiate provider performance: clinical proces­
ses, effectiveness, and diagnostic/treatment accuracy
• Identify patient safety improvements and all-cause
harm causes
At a Glance
Practical Implications p39
Author Information p42
Full text and PDF www.ajmc.com
Medication Management: Measuring What Matters
Marie Smith, PharmD; Lynn Pezzullo, RPh; Julie Kuhle, RPh; and Woody Eisenberg, MD

2. www.ajmc.com Vol. 7, No. 1 • The American Journal of Pharmacy Benefits 39
Medication Management: Measuring What Matters
• Close identified gaps in care
• Track care coordination and transitions
• Monitor practice transformation progress
• Define high-performing teams
• Document trusted patient-provider
relationships.
There is ample room for a more deliberate prioritiza-
tion of measure development to close gaps in care that
involve medication therapy decision making and man-
agement processes. As new care delivery models evolve
to focus on value, accountability, and team-based care,
many care gaps mentioned above remain unaddressed.
These important care gap measures can be more chal-
lenging to develop; once developed, consistent measur-
ing that also adjusts for differences in patient populations
or practice settings can remain challenging.
US Quality Priorities and Gaps
In 2011, the National Priorities Partnership and more
than 50 public- and private-sector organizations worked
with the HHS to release the first report from the National
Quality Forum (NQF): “2012 NQF Measure Gap Analy-
sis.”3
This NQF report includes 6 priority areas, each with
aspirational goals and specific targets around which to fo-
cus public- and private-sector performance measurement
and improvement: health and well-being, prevention and
treatment of leading causes of mortality, person and fam-
ily-centered care, patient safety, effective communication
and care coordination, and affordable care. More work is
needed to advance the nation’s measurement capabilities
across all priority areas—especially in the gaps identi-
fied by the NQF report. Table 2 outlines some medication
management solutions that address these gaps.
Measure development that identifies the extent to which
comprehensive medication reviews are implemented at
primary care visits and care transitions can address many
of the gaps that were identified. When a practitioner con-
ducts a comprehensive medication management review,
the patient’s narrative is valued and incorporated into their
care planning—including such information as which medi-
cations they are actually taking, the impact of medication
experiences on healthcare beliefs, the challenges they face
with medication access or adverse events, and the outcomes
they have experienced.
In addition, we need to measure the extent to which:
1) patients who are at high risk for medication problems
are being identified in population health data or referred
by healthcare personnel for comprehensive medication
reviews; 2) medication optimization recommendations
based on evidence-based guidelines are sent to and ac-
cepted by prescribers; and 3) culturally and linguistically
appropriate patient medication action plans are being de-
veloped to address patient self-management goals for ef-
fective medication use and safety.
Types of Measures
There are several ways to categorize quality measure-
ment. One way is to look, in combination, at the purpose
of measurement, how measures will be used, and who will
use them. Measures can be used to: 1) provide informa-
tion to consumers in public reporting; 2) information for
payment (as in pay-for-performance or shared savings pro-
grams); 3) compel quality improvement through require-
ments from an external source; and 4) improve internal
quality improvement programs.
Another way to categorize quality measurement is by what
is being measured. Donabedian suggests using 3 categories
to evaluate medical care, each referring to a component in the
provision of patient care: structure, process, and outcomes.4
• Structural measures examine the setting in which
care is provided and whether specific desired com-
ponents are present. Examples include whether
certain qualifications are met (licensing or certifi-
cation), whether certain technology is available,
or whether policies and procedures are defined
and used. Such measures utilize specific structural
components that have demonstrated improvement
in health outcomes in scientific research.
• Process measures are useful when a specific
service or action provided to the patient is
strongly associated with improving patient
outcomes. Measurement of care processes is the
most common type of measurement.5
Examples
include whether a guideline is met or if identified
patients receive recommended medication for a
specific condition.
P R A C T I C A L I M P L I C A T I O N S
n As new care delivery models evolve to focus on value, accountability, and
team-based care, many care gaps remain unaddressed.
n There is ample room for a more deliberate prioritization of measure devel-
opment to close gaps in care that involve medication therapy decision making
and management processes.
n Measures can be developed for various uses including: 1) provision of
information to consumers in public reporting; 2) information for payment (as
in pay-for-performance or shared savings programs); 3) quality improvement
through requirements from an external source; and 4) internal quality im-
provement programs.

3. 40 The American Journal of Pharmacy Benefits • January/February 2015 www.ajmc.com
n Smith • Pezzullo • Kuhle • Eisenberg
• Outcome measures are often the best indicator
of the quality of medical care. Outcomes can be
as clearly defined as death or survival. Others in-
clude clinical end points such as blood pressure
measures, patient-related assessment of pain,
and patient care experiences. Outcome mea-
sures are often more difficult and complicated
to measure, and can be influenced by factors
not controlled by the healthcare provider. An
example of an outcome measure is the 30-day
readmission rate following hospital discharge.
Measure Value Sets
We need to ensure that medication-use measures improve
Table 1. Sample of Current Medication-Related Measures
Measure Source Medication-Related Measure Data Source
HEDIS Use of high-risk medications in the elderly Prescribing/dispensing
Persistence of beta-blocker treatment after a heart attack Prescribing/dispensing
Medication management for persons with asthma Prescribing/dispensing
Antidepressant medication management Prescribing/dispensing
Adherence to antipsychotic medications for persons with schizophrenia Dispensing/adherence
Medication reconciliation post discharge Medical records
Annual monitoring for patients on persistent medications Lab tests/drug levels
MU Drug-drug interaction checks and drug—allergy checks Electronic health record
E-prescribing capability Electronic health record
Active medication list and medication allergy list Electronic health record
ACO Current active medication list Electronic health record
Beta-blocker for left ventricular systolic dysfunction Prescribing/dispensing
Ischemic vascular disease use of aspirin or other antithrombotic Prescribing/dispensing
PQA Proportion of days covered for ACE inhibitors/ARBs, statins, diabetes meds Dispensing/adherence
Suboptimal control of asthma Dispensing/medical records
High-risk medications in the elderly Prescribing/dispensing
Adherence to oral nonwarfarin anticoagulants Dispensing/adherence
MTM-eligible members who received a comprehensive medication review Medical records
ACO indicates accountable care organization; ACE inhibitors/ARBs, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers; HEDIS, Healthcare Effectiveness Data and
Information Set; MU, meaningful use; MTM, medication therapy management; PQA, Pharmacy Quality Alliance.
Table 2. Medication Management Solutions to Address National Quality Foundation (NQF) Gaps
National Quality Strategy Domains NQF Gaps Medication Management Solutions
Health and well-being Clinical preventive services, healthy
lifestyle behaviors, community
interventions, patient-reported outcomes
Comprehensive medication reviews, culturally and linguistically appropriate
Patient Medication Action Plans (PMAPs), medication optimization
recommendations based on evidence-based guidelines
Prevention and treatment of leading
causes of mortality
Clinical preventive services, healthy
lifestyle behaviors, community
interventions, patient-reported outcomes
Comprehensive medication reviews, culturally and linguistically
appropriate PMAPs, smoking cessation plans, medication optimization
recommendations based on evidence-based guidelines
Person- and family-centered care Shared decision making, person-centered
communications, patient-reported
outcomes
Comprehensive medication reviews, active medication lists, culturally and
linguistically appropriate PMAPs
Patient safety Preventable hospital admissions and
readmissions, healthcare-associated
conditions
Comprehensive medication reviews to prevent adverse drug events and
to promote effective medication management, accuracy of medication
lists, drug education regarding high-risk medications, polypharmacy, use
of pharmacists and e-prescribing, implementation of drug-drug and drug-
allergy interaction checks, implementation of checks to prevent the use
of inappropriate medications or protocols, and prevention of medication-
related injury, emergency care, or mortality related to inappropriate drug
management or side effects
Effective communication and care
coordination
Patient-reported outcomes, care planning
and communication, care transitions,
shared accountability, disparities
Patient self-management goals incorporated into PMAPs; care transition
plans with reconciled, active medication lists; culturally and linguistically
appropriate PMAPs; medication optimization recommendations based on
evidence-based guidelines
Affordable care Patient-reported outcomes; disparities;
cost and burden; overuse, waste, and
inappropriate care
Comprehensive medication reviews to identify inappropriate, ineffective,
duplicative, and unnecessary medications; medication optimization
recommendations to prevent medication-related problems that lead to
emergency department visits and hospital admissions

4. www.ajmc.com Vol. 7, No. 1 • The American Journal of Pharmacy Benefits 41
Medication Management: Measuring What Matters
care and lead to better outcomes by addressing medication
optimization for effectiveness and safety, and coordination
across multiple prescribers, sites, and pharmacies. A mea-
sure value set is a grouping of measures that together can
better assess the value (quality and cost) of care than any
single measure can.6
Some new approaches to measure set
development and usefulness are discussed below.
Families of Measures
One new approach, introduced by the NQF Measure
Applications Partnership (MAP),7
is “measure families,”
groups of measures related to the same condition, patient
outcome, or healthcare scenario. The MAP has defined 10
families of measures assessing all parts of the NQF: cancer
care, cardiovascular disease, care coordination, diabetes,
dual-eligible beneficiaries, hospice care, patient safety,
population health, patient- and family-centered care, and
affordability. The great majority of existing measures fit
into these families and are being used in public or private
programs. Table 3 depicts a family of measures for medi-
cation safety (a subset of patient safety).
Families of measures are intended to promote align-
ment. Increased alignment of performance measures for
healthcare delivery may provide substantial benefits, in-
cluding: 1) increased clarity on the highest priority areas;
2) reduced confusion in interpreting the results of similar,
yet slightly different measures; and 3) decreased burden
associated with data collection and reporting for various
measures addressing similar topics.
Cross-Cutting Measures
Measure families are useful tools for alignment because
they can be cross-cutting in nature, with each family in-
cluding measures that span other families and settings of
care. Cross-cutting measures can be used to measure the
outcomes of several different conditions, patient-reported
therapy outcomes, or patient experiences with the health-
care system. Table 4 includes cross-cutting measures for
care coordination and care effectiveness.
The measures of medication use are applied across
conditions and sites of care. For example, a medication se-
lection for care transitions from hospital to home impacts
effectiveness and affordability, and improves population
health. Medication adherence also impacts effectiveness
and affordability, and offers opportunities for person- and
family-centered care shared decisions.
Layered Measurement Approach
A layered measurement approach recognizes that different
measures are needed for providers, organizations, and exter-
nal payment and reporting purposes. One set of measures is
applied for providers’ internal quality improvement, another
related set for internal organization management, and a third
related set for public reporting and payment (Table 5).
Healthcare organizations will eventually be required to
report common population-based performance measures,
and can choose whichever metrics serve their purposes
for internal improvement. For example, hypoglycemia-
related events may be required for care of patients with
diabetes, whereas measures of hospitalizations and emer-
gency department visits may be mandated for external ac-
countability and performance requirements.
Developing and Implementing Measures That Matter
The PQA8
is a multi-stakeholder, consensus-based
measure development organization that collaboratively
promotes appropriate medication use and develops strate-
gies for measuring and reporting performance information
related to medications. PQA has been developing mea-
sures since its inception in 2006, with the most well-known
measures being those included in the Medicare Star Rat-
ings program. Data from the Star Ratings program have
been used to compare the quality of different health plans.
Health plans have begun to collaborate with pharmacies,
since pharmacists and pharmacy teams have the ability to
influence improvement on the measures.
Since the use of PQA-endorsed measures in the Star Rat-
ing program, gradual improvement has occurred in appropri-
ate prescribing and adherence rates.9
However, a need still
remains to develop medication use measures to address gaps
in patient care. As part of the measure development process,
PQA continually looks to the future and assesses measure-
ment needs. As the healthcare system and new care delivery
models evolve, so do the types of measures that are needed to
supportteam-basedcaredeliverysystemsandcaretransitions.
Recently, PQA members approved the first Quality Im-
provement Indicators (QIIs) for pharmacist-provided med-
ication therapy management (MTM) services to patients
Table 3. Example of the National Quality Foundation (NQF) Medication Safety Family of Measures
Topic Area Clinician Hospital Post Acute Long-Term Care
Medication safety NQF #0022a
Drugs to be avoided in
the elderly/high-risk
medications
NQF #0646a
Reconciled medication
lists received by patients
at discharge
NQF #0419a
Documentation of current
medication in the medical
record
NQF #0176a
Improvement in management
of oral medications
a
NQF endorsement designation.

5. 42 The American Journal of Pharmacy Benefits • January/February 2015 www.ajmc.com
n Smith • Pezzullo • Kuhle • Eisenberg
recently hospitalized, to address readmissions.10
The de-
scriptions for these QIIs are: 1) the percentage of high-risk
patients who have been discharged from the hospital and
who receive MTM from a pharmacist within 7 days; and
2) the percentage of high-risk patients who received MTM
from a pharmacist within 7 days post discharge who are
readmitted within 30 days of their discharge.
These QIIs are not intended to be performance mea-
sures for payment or public reporting. Rather, they are in-
tended to be used by healthcare organizations for internal
quality improvement as part of a layered, cross-cutting ap-
proach to improve effectiveness of care, affordability (ie,
avoid costly readmissions), population health (ie, prevent
harm to patients), and patient- and family-centered care
(ie, medication reconciliation).
Additionally, one of the PQA work groups11
is currently
developing a set of QIIs focused on a team-based approach
to identifying patients with hypertension, and then refer-
ring for and providing comprehensive medication manage-
ment (CMM) to achieve blood pressure control. This set of
metrics is intended for use by integrated care teams in pa-
tient-centered medical homes, ACOs, or community-based
health teams that will address structure (referral for CMM),
process (provision of CMM), and outcomes (improvement
in blood pressure and blood pressure control).
SUMMARY
Most current pharmacy-related measures are medica-
tion-related performance and adherence measures. These
measures have been adopted by Medicare Part D, quality or-
ganizations, health plans, and pharmacies as part of pay-for-
performance programs, fulfillment of contractual obligations,
plan comparisons, research, and public reporting. However,
with the evolution of new healthcare delivery models, there
is a need to develop additional quality improvement mea-
sures that focus on medication management processes and
patient outcomes that can be used by pharmacists, healthcare
providers, and quality improvement specialists to implement
strategies to better understand the efficiency and outcomes
of internal medication management processes.
Author Affiliations: Pharmacy Practice, University of Connecticut
School of Pharmacy (MS), Storrs, CT; Pharmacy Quality Alliance (LP, JK,
WE), Springfield, VA.
Funding Source: None.
Author Disclosures: Dr Eisenberg and Mses Kuhle and Pezzullo are
employees of Pharmacy Quality Alliance (PQA), which develops quality
measures for medication use. Dr Eisenberg also serves on the advisory board
of VUCA Health, has received lecture fees/honoraria for lecturing for Glaxo-
SmithKline, and is a National Pharmaceutical Council meeting attendee. As
PQA employees, Mses Kuhle and Pezzullo attend PQA board meetings, con-
sult and attend meetings on behalf of PQA, and have received honoraria,
lecture fees, and grants (as well as have pending grants). PQA is a member-
based measure development organization whose membership represents
diverse organizations, some of which may have financial incentives linked to
performance on certain PQA measures.
Authorship Information: Concept and design (MS, WE, JK, LP); ac-
quisition of data (MS); analysis and interpretation of data (MS); drafting of the
manuscript (MS, WE, JK, LP); critical revision of the manuscript for important
intellectual content (MS, WE); administrative, technical, or logistic support
(JK, LP); supervision (MS).
Address correspondence to: Marie Smith, PharmD, UConn School of
Pharmacy—Pharmacy Practice, 69 N Eagleville Rd, Storrs, CT 06269-3092.
E-mail: marie.smith@uconn.edu.
REFERENCES
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Table 4. Cross-Cutting Measures
Care Coordination Effectiveness of Care
All-cause readmissions
Referrals to nonphysician services (behavioral, occupational,
physical therapy, pharmaceutical)
Transitions of care
Confirmation of diagnoses
Medication selection
Appropriate selection of patients for surgery
Medication adherence
Table 5. Layers of Measures for Diabetes Care
Measure Layer Purpose Clinical Goal 1 Clinical Goal 2
Population External accountability Fewer hypoglycemic events Depression remission
System Internal management Comprehensive diabetes care Depression response
Provider Internal quality improvement A1C test Depression screening
A1C indicates glycated hemoglobin.