Tom Lenz, PharmD, MA, PAPHS
 
Connecting the Dots: Exercise, Pharmacy and Cardiology

As policymakers continue to debate health care reform, pharmacist Tom Lenz is on pace for preventing, rather than merely treating, chronic diseases. He is doing so by innovating viable, evidence-based lifestyle protocols at Creighton University. His background and master's degrees in exercise science, a doctor of pharmacy degree, a postgraduate fellowship in cardiovascular research, and 20 years of experience working with clients and patients to modify lifestyle behavior and drug therapy are bringing new hope to patients and new possibilities to lifestyle medicine.
 
Growing up in rural Iowa in the 1980s, Tom Lenz was an avid athlete. "I played football in the fall, basketball in winter, track in spring and baseball in the summer; it's what every small town Iowa kid did back then," says Lenz, an associate professor of pharmacy practice at Creighton University's School of Pharmacy and Health Professions, and director of the Pharmacy Distance Pathway at Creighton. He excelled in track and basketball, where he made all-state honorable mention in the latter as a forward at Kuemper High School in Carroll, Iowa. In college Lenz ran marathons and continues to do so, with his wife. "I have pretty much always had an interest in maintaining an active and healthy lifestyle," says Lenz.

That love of sports and health propelled him to excel beyond the gym and field in ways even he never imagined, eventually combining exercise science, pharmacy and cardiology in far-reaching ways.
While earning a master's degree in exercise science at the University of Nebraska at Omaha, Lenz became attracted to the field of pharmacy, especially in terms of helping patients with existing illnesses."What really got me interested in pharmacy, in particular, was an internship at the Olympic Training Center in Colorado Springs while I was in graduate school," he recalls. "My work there was mostly focused on strength training and conditioning. At the time, the training center had a pharmacist who counseled athletes on what they could and could not take. That was pretty intriguing and novel to me back then," Lenz explains. "That got the wheels turning for me about the link between sports science, wellness and the world of pharmacy. I determined I wanted to go into pharmacy and do something patient-oriented and clinical. My plan was to marry the two professions in some way."
 
Marry them he has. Although many people perceive a pharmacist as a person who merely fills and refills prescriptions, the truth is that the specialty of pharmacy is about much more than that. "Pharmacy is all about helping people manage their illness, not just count their pills," says Lenz. "Pharmacists are actually over-trained for what the profession allows them to do. Ideally the pharmacist is there to help care for the disease. I tell my students that the people they will be talking with can benefit, in one way or another, from lifestyle changes. As each provider, including the pharmacist, talks to the patient about lifestyle, the more likely the patient will implement the healthy behavior."

In 2008 Lenz was the first pharmacist to earn the certification as an ACSM/NSPAPPH Physical Activity in Public Health Specialist (PAPHS) which is offered by the American College Sport Medicine and the National Society of Physical Activity Practitioners in Public Health.

After graduating in 1999, a two-year cardiology fellowship at the university's School of Medicine proved to be destiny for his future endeavors. "The opportunity to study the relationship between exercise science and pharmacy, using cardiology as a platform, was literally a 'connecting-the-dots' experience for me because it brought all three of those specialties together." Since joining the faculty of Creighton's pharmacy practice department in 2001, Lenz's marathon of education and research has been unstoppable as those three seemingly disparate but very intertwined fields of study have been his goal.

Reducing Cardiovascular Risk
Lenz found himself asking, "What can I do to get into the lifestyle medicine I want to practice?" His answer began to take shape in 2008. "I approached the Dept. Chair and the Dean about an idea for utilizing my skill sets to serve employees here at Creighton. It soon became a collaborative reality of the School of Medicine/Division of Cardiology, the School of Pharmacy and Human Resources: Creighton's Cardiovascular Risk Reduction Program. Designed by Lenz, CVRRP combines the right kinds of medications with patients' exercise regimens, dietary programs and other behaviors. The objectives of the pilot project were to (1) establish a protocol and assess the feasibility for a sustainable cardiovascular risk reduction program for Creighton University employees who meet the enrolling criteria and obtain their health care benefits through the university's benefits plan and (2) develop a new health care specialty position that coordinated the care of the program participants with special focus on lifestyle medicine. This new health care specialty position is being called an ambulatist.

Lifestyle Modifications to Specifically Meet Individual Needs

"We launched CVRRP for Creighton University employees who were between the ages of 18 and 65 years, had an existing diagnosis of hypertension and/or dyslipidemia, and obtained their health benefits through Creighton University. Those with existing cardiovascular disease (CVD) were not eligible for the pilot project. Of the 135 individuals who expressed interest in the program, 15 were randomly selected to participate. In return for meeting specific program adherence criteria, all participants receive the following benefits at no cost: blood pressure and/or cholesterol controlling medications; access to an exercise facility on the Creighton Campus; comprehensive medication therapy management by a pharmacist; health risk assessments; a lifestyle modification program designed specifically to meet individual needs; and a minimum of 12 face-to-face individual meetings with the CVRRP Clinical Director throughout the one year pilot project."
 
Lenz describes the two pillars of the program as being the one-on-one component (support group involvement, a walking club and blogging are available but optional) and the depth of commitment from all parties concerned. The employer (in this case, Creighton) and the employee are both "putting some skin in the game," as Lenz describes it. "If you commit to it, we will pay for your medications for 18 months, your gym membership, and there will not be any fees for the risk assessments or educational materials including home BP monitor and pedometer." Employees had to qualify to participate in the program, and also meet the adherence criteria to remain in it. They currently meet individually with Lenz twice a month for the first 2 months, every month for the following 4 months, every other month for the following 6 months, and every quarter of the second year. Prescriptions must be filled at the campus pharmacy and they must use their Lifestyle Journal to record goals and data such as their food diary to track daily habits and progress. Creighton published their Lifestyle Journal format last fall. "One of the reasons the program seems to be working is it's all very much tailored to participants and their needs," Lenz said.
 
Of the 15 pilot participants, eight were female and seven male with a mean age of 51.6 years. Eight participants had hypertension, 11 had dyslipidemia and four had both. After 12 months of participation, all 15 individuals remained in the program and all are meeting the established adherence criteria. Most participants, regardless of hypertension diagnosis, have shifted their blood pressure to a lower category or have maintained a normal blood pressure. All participants but one are meeting the cholesterol guidelines for their LDL-C (low density lipoprotein cholesterol). Blood glucose levels are below the diabetes range for all participants.

All participants increased their quantity of physical activity or maintained their existing acceptable quantity of physical activity after 12 months in the program with 80% meeting the recommended weekly amounts of physical activity to decrease cardiovascular risk. Additionally, all participants increased their intake of fresh fruits and vegetables during the pilot project. The average weight loss for the patients needing to lose weight was over twelve pounds, representing an average percentage of weight loss of over 5%.

At the beginning of the program, each participant was assessed for their overall risk of experiencing a CVD related event and/or a myocardial infarction (heart attack), as well as a prediction of their heart/vascular age relative to their actual age. Throughout the first 12 months, the combined group data shows that the relative risk for CVD improved by 34% and for heart disease alone improved by 47%. Additionally, the average heart/vascular age prediction at the beginning of the program for the group was greater than the actual average participant age (54.5 vs. 51.6 years, respectively). This trend was reversed prior to the twelve month point in the program resulting in a lower predicted heart/vascular age compared with the actual age of the group (51.6 vs. 52.6 years, respectively).

Quality of life data was gathered using the CDC Health Related Quality of Life questionnaire and showed that compared with baseline, the participants self reported an improvement in their general health at 12 months as compared with baseline measurements. Additionally, a summary index of unhealthy days showed that the participants reported less unhealthy days at 12 months as compared with that reported at baseline. Patients' ability to check their own blood pressure has been empowering of patients not only to more readily get help when needed but for knowing their own body more intimately and understanding their own lifestyle choices.
 
Fall of 2009 CVRRP began accepting diabetic patients who do not exhibit any cardiovascular disease. These patients have all their meds and supplies provided. Current enrollment is 35 in addition to the original 15.

eWellRx
As part of the program, Lenz has created an innovative and comprehensive electronic health monitoring, documentation and communication system, known as eWellRx, that he believes will be very successful.

After an initial screening with Lenz, eWellRx participants record vital information such as blood pressure, pulse rate, blood glucose and cholesterol levels, weight, diet, minutes of daily exercise, and medication information onto the eWellRx website. But it is much more than a documentation program, he says. "It will have a variety of other features, including a place where patients can schedule their own appointments, and a flagging system to tell me if they fail to log in blood pressure or exercise information, so I can contact them. I feel it is important that there be an electronic communication component in it where all the individual's health care providers could communicate with the patient and interact, too, providing the same information about disease prevention."

The end result, Lenz says, is reduced hospital visits, major cost reductions and in some cases, saved lives. A provisional patent on eWellRx was filed in May 2009 by Creighton University. "It will be particularly beneficial for those with chronic conditions such as diabetes, obesity or high blood pressure," he predicted. "The program could also be used by health care professionals who treat patients with chronic diseases, such as cancer, or HIV, organ transplants or bariatric surgery to coordinate patient care when several additional health care professionals are involved. Under eWellRx, a patient's medical records, including a daily diary of vital signs, dietary intake, exercise and medications - are monitored electronically by a designated health care team led by a care coordinator. The team, including the care coordinator, doctors, pharmacists, nurses and others, as well as the patient, then can communicate securely through eWellRx to address concerns such as incompatible medications or patient questions. Lenz believes eWellRx is a "giant leap forward" with the concept of wellness and chronic-condition management. Because of its electronic documentation, health care provider communication and other components, he said, the program can closely monitor patient conditions with a goal of keeping patients out of the hospital.
 
The invention could become particularly valuable as the United States moves toward uniform, electronic medical records, Lenz says. He hopes to offer an expanded program to other companies within the next year. He estimates that eWellRx, when rolled out full-scale, could save institutions like Creighton thousands of dollars annually in health costs while improving people's quality of life through positive lifestyle changes such as better nutrition and exercise habits. "Not only can eWellRx greatly reduce a patient's chance of having a stroke, heart attack or some other life-threatening event that will land him or her in the hospital, but the person can become happier in the process," Lenz said.

The Ambulatist Model of Care Coordination
There is still much to learn about providing effective health care coordination, yet a new model being developed at Creighton by Lenz is coordinating lifestyle medicine through the use of an ambulatist. "An ambulatist," explains Lenz, "is a health care provider who specializes in the prevention, management, and care coordination of ambulatory patients with chronic diseases by using lifestyle medicine and drug therapy."

An ambulatist can be any state-licensed health care provider who receives training in direct patient care. These could include physicians, nurses, pharmacists, physical therapists, occupational therapists, dieticians, chiropractors, and others. In addition to their existing health care specialty, this individual must also have training specifically in lifestyle medicine areas such as physical activity, nutrition, weight control, stress management, tobacco cessation, and others." For the CVRRP pilot project, a pharmacist (Lenz) served as the program ambulatist. In addition to developing the activities of an ambulatist during the CVRRP pilot project, a reimbursement scheme for this position is also being developed.

Reimbursement for the ambulatists services is being based on a fee-for-performance rather than a fee-for-service model. Criteria are being developed that base the reimbursement of the ambulatist on the clinical benchmarks achieved by the patient. For example, if a participant with dyslipidemia is meeting the established goals as stated in the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, the ambulatist will get reimbursed at a higher rate than if the participant is not meeting these goals. This gives incentive for the ambulatist to provide quality care with a vested interest in the outcomes of the patients.

Whether it's marathons or creating programs to get cardiovascular patients to take better care of themselves, Tom Lenz is always up for new challenges. As Lenz's work manifests, pharmacy and lifestyle medicine are teammates in providing vital and viable health care.


 
ACLM Disclaimer: Our Practice Spotlights are intended to provide examples of Lifestyle Medicine in practice. We recognize that Lifestyle Medicine practices vary widely, and inclusion in Practice Spotlight is not intended to imply official endorsement of individuals or practices.