PHA6123 LEC: Drug Info Ambulatory Care and Community Practice & Enabling Safe and Efficacious Medication Use

AMBULATORY CARE

It is a field that covers a variety of practices outside the area of an institution or hospital.

Ambulatory care clinicians

use multiple drug information skills to provide quality drug information to patient and healthcare providers.

AMBULATORY CARE

Examples	clinical pharmacist in community pharmacy
	outpatient facility of hospitals
	on-site service provider from employer wellness program

RESPONSIBILITIES OF A DRUG INFORMATION SPECIALIST IN AMBULATORY CARE

1.	Assist in the search for most cost-effective therapy plan
2.	Ensuring that medications are following current practice guidelines
3.	Ensuring that patient’s have proper understanding of their medications
4.	Guide the proper disposal of unused or unwanted medications Example: Recipio
5.	Deliver preventive health information for diseases
6.	Incorporate quality assurance into daily practice

 TASKS OF DRUG INFORMATION SPECIALIST IN AMBULATORY CARE

1.	research appropriate medical treatment
2.	bridge gap between available data in health information technology and utilizing these data to treat patients
3.	educate patients about their treatment

Drug Formularies

list of medications that are approved to be paid or provided at a discounted rate by individual or insurance plans

Drug Formularies

• aids in prescription decision-making

• some medication regardless of formulary status require prior approval from insurance

Drug Formularies

• aids in prescription decision-making

helps clinicians remain updated with the most current procedures in the management of a condition

Drug Formularies

aids in the logical prescription decision- making

Electronic Databases

health-related literature such as tertiary resources made into an electronic or internet-based format.

Electronic Databases

serves as readily-accessible source of drug information via apps or internet websites

Electronic Databases

clinicians can educate patients with the use of these databases for an on-the-go information source

Electronic Databases

requires careful evaluation (because not all are credible websites) of the quality of information provided

Areas filled by Ambulatory Clinicians

administration of specific medications (e.g., insulin, inhalers, inj. anticoagulants)

Areas filled by Ambulatory Clinicians

• management of ADRs (e.g., hypoglycemia, bleeding)

  • ADR: unexpected effects 

  • Side effect: expected effects

Areas filled by Ambulatory Clinicians

• proper medication disposal

• provide immunization information

  • For immunizing pharmacists

Areas filled by Ambulatory Clinicians

• dosing adjustments (e.g., during preoperative periods, specific illness)

  • Example: Cancer patients that requires

COMMUNITY PRACTICE

Pharmacy practice is moving away from its emphasis on a hands-on distribution model toward an emphasis on system management and patient care services.

COMMUNITY PRACTICE

• Pharmacists are encouraged to “embrace community pharmacy health care beyond dispensing” — this is to fill in knowledge gaps in the patient’s understanding of their healthcare management.

COMMUNITY PRACTICE

Pharmacists are viewed as medication expert and trusted professionals — can served as key medication advisor.

Accuracy and Trust

• xx of drug information and xxprovided by the pharmacist are main reasons for coming back to the community pharmacy

substitutes

Drug leaflets, websites, and pharmacy assistants or technicians serve only as _ for patient education.

PATIENT EDUCATION

delivers written or verbal drug information through a planned activity initiated by the health care provider.

PATIENT EDUCATION

specific for a individual patient and patient condition

CONSUMER HEALTH INFORMATION

• sought by patient in response to their need for more information about their health status.

• not specific to a patient

Social Media as New Forms of CH

social media sites allows patients to create content and share information about their health on the internet.

Social Media as New Forms of CH

wisdom of crowds is a belief when patient share information through social networking, their collective wisdom is more beneficial than the expert opinion of one individual.

Social Media as New Forms of CH

e.g. wikis, blogs, forums, social networks, video-sharing platforms

Mobile Health — Dawn of Smartphones

gives more power to patients to access information about their medications and diseases states using health applications.

Mobile Health — Dawn of Smartphones

mobile technology as a platform for health information is skyrocketing and pharmacist must keep up to this modern avenue for health care information.

Mobile Health — Dawn of Smartphones

e.g. MyFitnessPal, GlucoseBuddy, ZocDoc

Credibility of Application

• Are credentials of the app suitable?

• Are authors/publishers clearly listed?

• Are there advertisements?

• Is the organization that developed the app reputable?

• Are there disclaimers of content?

Accuracy of Information

• Is it peer-reviewed?

• Is the information current and/or frequently updated?

• Are there guidelines to support recommendations made?

Are references cited?

Evidence-Based Medicine

• Are recommendations evidence-based?

• Are recommendations general or specific in nature?

• Are opinion statement clearly marked?

Are users directed to professional prior to any changes made with health care routine?

Easy-of-use

• Does the app fit the screen?

• Is the set-up well designed and organized?

• Is the app easily navigated?

• Does the app have a search function?

Is there a main menu to clearly lay content out?

Health Literacy

• Is the medical jargon used easy for lay to understand?

• Is font and set-up of app easy to read?

• Does the app gear information for the consumer?

extension

Pharmacist can encourage patients to consult with them and view CHI’s only as an _ of care and a way to improve communications.

classes or programs

• Pharmacist can design _ to teach patients about the use of quality CHI especially those found on the internet — HON certified sites.

real way

The only _ to assess quality of web information is for pharmacist to personally evaluate if the sources is useful for the needs of the patient.

information therapy

Pharmacists can provide _ in order to increase the health literacy of patients —the new model of drug information in community practice.

INFORMATION THERAPY

providing patients with evidence-based patient education and/or medical information at just the right time to most effectively assist the patient in making specific health decision or change in their behavior.

HEALTH LITERACY

capability of patients to read or hear health information, understand it, and then act on the health information.

Medication Use Process (MUP)

is a system of interconnected parts that work together to achieve the common goal of safe and effective medication therapy.

MEDICATION USE PROCESS

the process is commonly cyclical and uses several forms of health information technology (HIT)

MEDICATION USE PROCESS

The parts are:	1	people
	2	system
	3	procedures
	4	policies

Prescribe

starts in selecting a medication based on the patient status and history; prescription is the order to the pharmacy

Transcribe

encoding or entering the medication order on the system to assess if there are any discrepancies

Dispense

the preparation and distribution of medication that is then given to the patient

Administration

typically yhe job of the nurse ut we can also be involved in it by reviewing the appropriateness of the medicine such as if it is the right dose or frequency

Monitoring

assessing the patient’s response to the medication; should document all outcomes

Adverse Drug Event (ADE) Monitoring

computer programs that use electronic data and predetermined set of rules or guidelines to IDENTIFY ADE when occurs or is about to occur.

Automated Dispensing Cabinets (ADCs)

automated devices with a range of function: medication storage and retrieval for administration, medication charging, and automated inventory management.

Bar Code Verification

ensures that the 5 RIGHTS OF MEDICATION ADMINISTRATION (drug, dose, route, time, patient) is followed at the point of care.

Clinical Decision Support Systems  (CDSS)

computer programs that AUGMENT clinical decision making by combining referential information with patient-specific information to prevent negative actions and update providers of patient status.

Computerized Provider Order Entry (CPOE)

allows provider instructions (e.g., prescriptions, clinical notes) to be electronically entered for the treatment of patient who are under a provider’s care

Electronic Medication Administration Record (eMAR)

electronic version of traditional medication administration records with support from CDSS and Bar Coding Verification. Enables real-time documentation and billing of medication administration.

Electronic Prescribing

a process where prescriptions are made electronically, verified and then processed resulting in a labelled medication product with supportive documentation and shareable patient medication profile.

Intelligent Infusion Pumps (Smart Pumps)

software-driven medication pumps that help eliminate pump programming errors using standardized drug database and dosing parameters.

Rules Engines

similar to ADE monitoring, built with logic rules to aid in monitoring specific aspects of patient care

THE MEANINGFUL USE PROGRAM

a program used to incentivize the use of certified electronic health record (EHR) technology containing protected health information

THE MEANINGFUL USE PROGRAM

Focus:	1	improve quality, safety, and efficiency of information transfers
	2	engage patients and families about important health information
	3	improve care coordination among healthcare providers
	4	maintain privacy and security of health information

PHARMACY INFORMATICS 

It refers to a form of clinical informatics that focuses on the following:
1	use of information,
2	use of information technology, and
3	use of automation technology to ensure safe and effective medication usage.

Patient-specific Information

• created and applied in the process of caring for individual patients

• example: medical/medication history, physical assessments, laboratories test and interpretations.

Patient-specific Information

commonly stored in health care facilities

CONSUMER HEALTH INFORMATICS

a field where patient generates and manages their health information in addition to traditional settings. This field may include internet-based systems and DTCA.

Knowledge-based Information

• forms the scientific basis of healthcare which includes referential information

• example: clinical practice guidelines,medication literature

Interoperability

in the PH, there is no coordination of EHRs for patients. It is not even recorded in the community setting. This is most likely to result in uncoordinated medication therapy or even oversight.

Interoperability

there is no hospital to community or community branch to branch interoperability, every patient is treated like a new patient every time.

Lack of Government Initiative

in the PH, the gov’t with DOH and other health offices are not keen into showing more support for Pharmacy Informatics.

Lack of Government Initiative

There are no programs like “The Meaningful Use Program” in the US that pushes for innovation and technological advancements in the general health care.

Security, Privacy, and Confidentiality of PHI

despite presence of data privacy act, it is still a concern on how effective this measures are in the protection PHI of patients.

Security, Privacy, and Confidentiality of PHI

• professional standards, policies, and regulations must be made to instruct different professionals on their specific roles towards managing PHI.

PHI– protected Health Information

Security

restricting access to PHI only to authorized people

Privacy

being free from unauthorized intrusion and protection of PHI

Confidentiality

limit of access or restriction to certain types of information

medication errors

In a report published by the Institute of Medicine (IOM), 19% of ADEs were due to_.

The ADEs were all related to order entry

1	handwritten reports due to illegible writing
2	manual order entry due to typo
3	use of non-standard abbreviations

CPOE and Electronic Prescribing eliminates:

1	illegal handwriting
2	decrease medication errors
3	delay in order completion

CPOE

must support clinical workflows that results into clear, concise, and actionable advice and warnings.

CPOE

should also be paired with other HITs (e.g., CDSS) to ensure safe and effective medication orders.

CPOE

must have secure access with permanent access logs.

CPOE

may also cause alert fatigue and may require care setting design changes to improve responsible use of CPOE and other HIT.

ALERT FATIGUE

alerts and warning forms CPOE or other HITs that appear too frequently may lead providers to ignore or override the CDSS message

CDSS/CDS

are computing systems that provides intelligently filtered information to clinicians and patients to foster better health processes.

Inference engine

is the brain of the CDSSS, it evaluates the available information with consideration to patient-specific information.

Knowledge base

composed of various clinical knowledge (e.g., clinical guidelines, diagnoses, drug interactions), it feeds information to the inference engine.

Communication mechanism

is where patient information is entered and feedback from the CDSS is communicated to the clinician.

CDSS

can help decrease ADEs, costs and length of stay of patients and improve clinical workflow and use of information at point of care.

TRANSCRIPTION

• Pharmacist are expected to interpret medication orders and assess for any drug-related problems.

• common problems for transcription are similar to the problems mentioned with order entry.

TRANSCRIPTION

• HIT-associated transcribing errors (use of CPOE) may still be encountered.

  • example: mistaken inventory display for dosage guideline, fragmented CPOE, inflexible formats resulting to wrong orders

TRANSCRIPTION

CDSS is very useful in checking drug-related problems but pharmacists must remain diligent in reviewing orders.

Acute Care Pharmacy Setting

• Carousel (rotatable) cabinets, ADCs, robotic cart filling system, and sterile compounding devices are common forms of HITs.

• most HITs in this setting depend on properly assigned bar coding system

Community Pharmacy Setting

• patient information management system (PIMS), Interactive Voice Response (IVR), e-prescribing, automated counting and dispensing systems.

• PIMS's core is interoperability 

• the goals are to fill prescriptions efficiently, keep track of prescription records, provide reminders for pick-up, and monitorinventory.

ADMINISTRATION

Medication administration is carried out by physicians, nurses, pharmacists, caregiver, or the patient themselves.

Bar Code Medication Administration (BCMA)

ensures that the 5 Rights of medication administration is followed.

E-prescribing

eliminates errors from handwritten Rx and allows real-time updates of medication.

MONITORING

The end goal of monitoring is to create CLINICAL INTERVENTIONS.

Clinical interventions

• _ are activities that intercedes to modify the medication use process.

• Purpose: promote safety, quality, efficient and cost-effective medication therapy.

Documentations should be:

1	easy to use
2	fits in the workflow
3	sufficient with details
4	flexible with modifications
5	searchable
6	shareable