Health Systems Final

Electronic Medical Record (EMR)

Computerized documentation of a patient's healthcare at a single institution

Electronic Health Record (EHR)

Computerized documentation of a patient's healthcare over a period of time

Can include multiple institutions

Personal Health Record (PHR)

Computerized application for patient use

Contains information about patient visits and insurance coverage

What is in an Electronic Health Record (EHR)?

A comprehensive computer-based application

Helps store and manage healthcare records

Contains both clinical and administrative information

EHR Components

Clinical data repository

-- Database containing clinical information (allergies, medications, demographics, etc).

Interface

-- Digital device the provider uses to access patient centered information

EHR Capabilities

-- Enter orders, write notes, schedule appointments, etc. with support from CDS and CPOE.

Benefits of EHRs

Increased functionality as compared to paper-based medical records

24-hour accessibility for providers

Comprehensive format allows for multi-disciplinary approach.

Integrated applications (CDS, CPOE, etc.) help guide users

Contains computer based documentation systems to document clinical decisions in real time.

Limitations of EHR

Difficulties in data input

-- Most EHR systems have multiple ways of entering the same data

Lack of interoperability/sharing

-- Different systems (or even components of a single system) often encode similar information using different words, codes, etc.

-- EHR products from different vendors lack the ability to information share

The consequences of the limitations of EHR

Certain data not populating every relevant component of the patient chart

Can result in conflicting information within a single chart

Increases in difficulty in timely information sharing for a single patient seen by multiple health systems

Increases difficulty in collecting accurate data for research

Common US EHR vendors

EPIC

Oracle Cerner

MEDITECH

(Big three)

Others:

-- Nextgen

-- Valant

-- Praxis EMR

EHR systems are not

Interoperable across venders

Lacks the ability to exchange patient information and other data across different systems

When locating a patient in EHR

Find a patient by looking at an institution's patient list

Locate a patient by searching by Medical Record Number (MRN)

EHR Background patient information

The sidebar will contain information such as:

-- Patient name

-- Age

-- MRN

-- Allergies

-- Renal funciton

-- Height

-- Weight

Clinical documentation in EHR

There is a physician and pharmacist tab

Medications tab

Medication administration record Tab

Notes in EHR

Progress notes contain:

-- History of present illness

-- Past medical history

-- Medications prior to admission

-- Summary and plan for patient case

This tab also contains notes from other providers (nursing, care management, physical and occupational therapy, etc.)

Pharmacist notes in EHR

Example of pharmacist notes in an EHR:

-- Vancomycin dosing

-- Warfarin dosing

-- Bivalirudin infusion rate adjustments

-- Medication reconciliation notes

-- Anticoagulation and methotrexate counseling

Please note: dosage adjustments and pharmacist to dose medication initiatives are institution specific and require a set protocol to be in place.

EHR medication tab

Active medication list with drug, dose, route, and frequency, and start times

Medication Administration Records (MAR) in EHR

Displays all currently ordered or administered medications

Imaging in EHR

Allows easy access to results of computed tomography (CT), magnetic resonance imaging (MRI), chest X-rays, and more.

Click on circle in charts for full results of the test

Laboratory results in EHR

Contains results from several encounters

Value in red if outside of normal limits

Trend labs over time

Trending labs over a period of time may alert the pharmacist of acute changes while admitted.

Labs can be trended over days, months, or even years.

What is Computerized Provider Order Entry (CPOE)?

The way in which providers electronically enter orders into an EHR

This includes any order (medications, labs, imaging, etc.)

May order one medication or multiple linked orders in the form of an order set.

CPOE and Error Reduction

Medication related errors most prevalent cause of medical errors

-- About 90% of medication errors occur at the ordering and transcribing stage

CPOE allows for:

-- Legible orders

-- Standard dosing regimens

-- Standardized administration instructions

-- Order sets for ease and efficiency of order entry

Benefits of CPOE

Medication error reduction

Timely

Care coordination

Research capabilities

CDS integration

Cost reduction

The CPOE Process

Provider sign in

-- Identity verification

-- Specific prescription authority and ordering privileges reviewed

Drug choice

-- Patient chart review

-- Choices of dose, route, and frequency are offered to provider

Dispense drug

-- Order transmitted to pharmacy for verification

-- Pharmacist reviews and verifies or rejects the order

Utilizing CPOE in Practice

Allows for selection of a single medication or multiple in the form of an order set

Provides suggestions for drug, dose, administration directions, duration, and frequency

Pharmacist use of CPOE

Pharmacist may order medication if:

1. There is a set protocol in place

2. A provider with prescription authority directly communicates the order to pharmacy

Clinical Decision Support (CDS)

Integrated within CPOE to alert providers of guideline or knowledge based information

Example of CDS alerts include:

-- Allergies

-- Duplicate therapies

-- Drug interactions

-- Dose too high/too low

-- Exceeding total daily dose

Benefits of CDS

Notifies provider of potentially serious adverse events

Requires documentation to bypass, requiring providers to slow down and think through alerts

Limitations of CDS

Potentially alerting providers of clinically insignificant problems

Alert fatigue

Disruption to workflow

Types of CDS alerts

Passive decision support

Active alerts

Passive decision support

Directs users to appropriate practices without workflow interruption

Examples: order sets, drop-down lists

Active alerts

Passive patient specific information and may be interruptive or non-interruptive

Examples: formulary substitutions, allergy warnings

Examples of CDS alerts

Duplicate therapy

-- Provides reasons to bypass alerts

Dose too high

-- Weight suggestions

What to consider when verifying

Is the medication indicated?

Correct dose?

Correct route?

Correct frequency?

Is the duration of the order appropriate?

What is the appropriate timing of this medication?

Are there any drug interactions?

Are there other possible or definite contraindications?

Patient specific considerations

Drug indication

Labs

Duplicate therapies

Allergies

Timing

You are the verifying pharmacist one evening, and an order for metoprolol comes into your queue. What parts of the EHR will you utilize to ensure the order is appropriate and safe for the patient?

Patient specific considerations

-- Labs

-- Side bar: Allergies

Medications tabs:

-- Check for duplicates, interactions, etc

Verification screen

-- Dose

-- Route

-- Drug

-- Timing

-- Administration instructions

Rejecting an order CPOE

Computer based documentation systems require the user to select a reason for discontinuation/order rejection

Appropriate documentation for clinical decision making

Approving and Order COPE

Once drug is deemed appropriate, the pharmacist can select verify to being the drug distribution process

CDS

May notify providers of important safety concerns, but never replaces the need for clinical judgement

Drug formulary

A continually updated list of approved medications and related information, representing the clinical judgment of pharmacist, physicians, and other experts in the diagnosis and/or treatment of disease and promotion of health

Aims to guide safe and effective medication use

Ongoing review process to ensure best practices

Formulary system

1. A structured method to assess medications for inclusion or exclusion

2. Establishes prescribing, dispensing, and administration guidelines

3. Balances clinical efficacy, safety, and cost

Formulary system pros

Promotes evidence based care

Reduce cost

Streamlines inventory control

Formulary system cons

Limits access to medications

Requires continuous evaluation

Contributes to dissatisfaction

Pharmacy and Therapeutics (P&T) Committee

Who

-- Multi-disciplinary: Pharmacist, nurses, physicians, administrators

What

-- Establish and maintain the formulary system

When

-- Ongoing process

-- Meetings multiple times a year at a regular cadence

Why

-- Provide patients access to safe, effective, and affordable medications/healthcare

How

-- Voting -> quorum requirements

-- Representation from all stakeholders

P&T Committee Responsibilities

1. Establish and maintain the formulary system

2. Select medications for formulary inclusion

3. Evaluate medication use and outcomes

4. Prevent and monitor adverse events and medication errors

5. Evaluate and develop drug therapy guidelines

6. Develop policies and procedures for handling medications

7. Educate on the optimal use of medications

P&T Subcommittee Examples

Antimicrobial Stewardship

Critical Care

Hematology/Oncology

Medication Safety

Preioperative Care

Ambulatory

Antithrombotic Stewardship

Hopsital Medicine

Open Formulary

Minimal restrictions

Broad medication availability

Closed Formulary

Limited access, with defined prescribing criteria

-- Expertise

-- Patient care location

-- Disease state

Formulary restrictions

Limits use of specific medication based on area of expertise, disease, location.

Examples:

-- Expertise: Only Cardiology/Pulmonology can order Tadalafil (Adcirca)

-- Disease: Tenectoplase for STEMI

-- Location: Vasopressin can only be administered in critical care units

Reason:

-- Safety

-- Monitoring

-- Cost

Therapeutic equivalents

Drug products with different chemical structure but of the same pharmacologic or therapeutic class and usually have similar therapeutic and adverse profiles

Therapeutic interchange

Authorized exchange of therapeutic alternatives in accordance with previously established and approved written guidelines/protocols.

Formulary changes

Formal process should be in place to continuously update the formulary

-- Involves a submission of request from medical staff

Request should include:

-- Agent to be considered if addition or deletion

-- Rationale for request

-- Expected annual use (number of patients)

-- Alternative agents currently on formulary

Drug Monograph

A written, unbiased evaluation of specific medications.

Includes:

-- Generic/Trade Name

-- Therapeutic/Pharmacologic Class

-- Pharmacology

-- Pharmacokinetics

-- Indications

-- Clinical studies

-- Adverse Effects/Interactions

-- Dosing Ranges

-- Dosage Form and Cost

-- Recommendation

Therapeutic Class Review

An evaluation of a group of medications with an established therapeutic class

Evaluates:

-- Indications

-- Pharmacokinetics/dynamics

-- Adverse effects

-- Drug interactions

-- Dosage regimens

-- Cost

Example: Evaluating the class of tetracyclines to determine which specific agents maintain, add, or remove from formulary

Drug-Use Evaluation (DUE)

Also known as: Medication Use Evaluation (MUE)

Systemic process used to assess the appropriateness of drug therapy by evaluating data on drug use in each healthcare environment against predetermined criteria and standards

Results and action plan can be presented to P&T committee to improve/implement systems.

Types of DUE's

Diagnosis related DUE

-- Patients with a specific disease or diagnosis

-- Example: Selected antibiotics fro community acquired pneumonia (CAP)

Prescriber related DUE

-- Patients managed by a service or provider

-- Example: Selected cardiovascular drugs may be limited to cardiology specialist

Drug specific DUE

-- Specific drug dose/frequency

-- Example: Dosage regimen of low molecular weight heparin

FOCUS-PDCA

Find a process to improve

Organize a team that knows the process

Clarify current knowledge of the process

Understand causes of process variation

Select process improvement

Medication Use Policies

Ensure safe and standardized medication use

Standardize medication prescribing, dispensing, and administrating process

DOES NOT REPLACE CLINICAL JUDGEMENT

Examples:

-- Verbal order acceptance polices

-- Controlled substance handling procedures

-- Adverse drug reaction reporting

-- Medication error documentation

Policies

Rules and guidelines to help direct the action of healthcare workers

Examples;

-- Verbal orders can only be accepted from a prescribing provider

-- If a patient experiences an ADR, then the supervising healthcare worker should fill out a safety report

Protocols

Written document that explicitly defines how to act based on specific inclusion and exclusion criteria

Examples:

-- Vancomycin pharmacist to dose

-- Warfarin pharmacist to dose

-- Renally dose-adjusted antibiotics

Purpose of Competencies

Ensure pharmacist maintain up to date clinical knowledge

-- Must be dedicated to life-long learning

Support standardization and quality of practice

-- Demonstrate proficiency in evolving therapeutic areas

Examples:

-- Licensure exams (NAPLEX, MPJE)

-- Specialty certifications (BCPS, BCCP)

-- Continuing eduction requirements

Pharmacist Competencies Once

Pharmacokinetics

Direct thrombin inhibitor therapy

REMS Drugs

CAR-T cell therapy

Pharmacist Competencies recurring

Media fill and gloved fingertip testing

Antimicrobial stewardship

CE credits for license renewal

Transition of Care simplified

Home --> Hospital --> Home

Defining transitions of care (TOC)

The coordination and continuity of care with the patient moves within or among healthcare settings, providers, or health states

Phases of care for TOC

Home --> ED --> ICU --> Floor --> Inpatient Rehab --> Home

NTOCC Seven Essential Interventions

Medication Management

Transition Planning

Patient and Caregiver Education

Information transfer

Follow up care

Healthcare provider engagement

Social Determinants of Health

Why does TOC matter?

20% of patients had adverse event within 3 weeks of discharge

30% patients had at least one medication discrepancy

20% medicare beneficiaries readmitted within 30 days

Consequences of Fragmented care

Medication error

Readmissions

Complications

Decreased functional status

Increased dependency

Activities during TOC

Comprehensive medication management (CMM)

Medication reconciliation

Medication and self-management education

Medication acquisition assistance

Follow up call or visit

Comprehensive medication management

1. Assessing the patient

2. Evaluating medication therapy

3. Developing and initiating plan of care

4. Provide ongoing follow up

Medication Reconciliation

Process of creating the best list possible of all prescription and non prescription medication, herbal, and vitamins the patient is taking

1. Medication history

2. Compare inpatients and outpatients medication lists

3. Address any discrepancies

Medication History

Pharmacy led

List should include:

-- Drug name

-- Dose

-- Frequency

-- Special instructions

-- Last refill

Allergy review

Discharge medication reconciliation

Medications started in the hospital

Medications ordered at discharge

Medication education

Ensure the patient understand

-- Indication of medication

-- Administration instructions

-- Changes to medication regimen

Develop self-care skills

-- Teach back process to optimize patient education

-- Assess health literacy

Medication Acquisition

Formulary and cost review

Co-pay cards

Prior Authorization

Meds to beds

Follow up

Provide a bridge from one care setting to the next

Assess adherence to care plan

Triage difficulties during transition

Clearly communicate with patient

Risk Stratification

LACE INDEX

8Ps Screening Tool

LACE INDEX

Length of stay

Acuity of admission

Comorbidities

ED Visits

8Ps Screening Tool

Polypharmacy

Psychological

Principle diagnosis

Physical Limitations

Poor health literacy

Patient support

Prior hospitalization

Palliative care

Barriers to effective transitions

Inadequate communication

-- Between providers

-- Between care settings

-- With the patient

Poor care coordination

-- Follow up

-- Labs and monitoring

Lack of role clarity

-- Who is responsible for care plans, medications or lab orders, follow up

What is clinical pharmacy? (Overarching definition of clinical pharmacy per ACCP)

Area of pharmacy concerned with the science and practice of rational medication use

What is clinical pharmacy? (Big picture)

Discipline of Clinical Pharmacy

-- Emphasis on caring values, specialized knowledge, experience, and judgement

Clinical Pharmacist

-- Manage therapy in direct patient care settings both independently and in collaboration with other health care professionals

Role of the clinical Pharmacist in Health Care

-- Medication resource for both traditional and non-traditional therapies

Attributes of clinical pharmacists

Desire to stay up to date with literature

Ability to critically evaluate literature

Maintain strong communication skills

Willingness to collaborate with other healthcare professionals

Desire to advocate for patients and for the profession

Development of strong leadership skills

History of Clinical Pharmacy

1960s = Initial pharmacist involvement in decision making and development of drug information centers occurred at University of Kentucky

1975 = John Mills and the Mills Commission release Pharmacist of the future, recommending pharmacy be considered a clinic profession

1979 = ACCP and the European Society of Clinical Pharmacy (ESCP) were formed to promote clinical pharmacy

1980 = New residency accreditation standards were released by the American Society of Health System Pharmacists (ASHP)

1980s = Hundreds of studies were published describing the value of clinical pharmacy services

1988 = Establishment of the first board certified pharmacy specialty: BPSC

1992 = The American Associations of Colleges of Pharmacy (AACP) House of Delegates Voted the PharmD as the only recognized professional degree in pharmacy

Advancements in clinical pharmacy led to acceptance of the following concept

A clinical pharmacist's primary responsibility is to identify, prevent, and resolve drug related problems in order to optimize drug therapy for each patient

Education of training of a clinical pharmacist

Tradition:

Pre-pharmacy --> pharmacy school --> PGY1--> PGY2 --> BCPE

Non Tradition:

Pre-pharmacy --> Pharmacy school --> Community, etc.

Board certification

Board of Pharmacy Specialities (BPS) is the post licensure certification agency that promotes recognition of Board Certified Pharmacists within the health care system

BPS certification = Voluntary process by which a pharmacist's education, experience, knowledge, and skills in a particular practice area are confirmed well beyond what is required for licensure.

Who is on the team in a clinical setting?

Attending physician

Nurse

Occupational Therapist

Dietician

Advanced Practice Provider

Clinical pharmacist

Speech-language pathologist

Social worker

Learners

Physical Therapist

Behavioral Therapist

Respiratory therapist

etc

A day in the life of an Ambulatory Clinical Pharmacist

Work up patients

Conduct Clinic + telemedicine visits

Discuss interventions with provider

Education and complete administrative task

A day in the life of an Inpatient Clinical Pharmacist

Work up patients (pre-round)

Care team rounds

Order verification, plan follow up (post round)

Education and complete administrative task

Pharmacist 's patient care process (PPCP)

Collect

Assess

Plan

Implement

Follow up: Monitor and Evaluate

Medication Reconciliation (PPCP)

Where does it land on the PPCP: Collect

Process of comparing the medications a patient is taking (and should be taking) with newly ordered medications

Obtain an accurate list of each patient's medications

-- Inpatient: Use to identify medications taken at home prior to hospitalization

-- Outpatient: Used to verify current medications at home and learn about any changes

Pre-rounds or Clinic Visit (PPCP)

Where does it land on the PPCP: Collect and Assess

Collect information from the patient and electronic health record (EHR)

-- Notes (past medical history, details from patient interview)

-- Results (labs, imaging, pathology, etc)

-- Medication dispense history

Use a problem oriented framework to determine treatment approach

Prioritize the patient's specific medication needs

Care team collaboration (PPCP)

Where does it land on the PPCP: Assess

Discuss overnight events or new information from last visit to determine clinical utility of each medication

Evaluate effectiveness, safety, accessibility, and affordability of each medication

Assess adherence and the patient's medication routine

Identify specific medication-related concerns requiring intervention

Where does it land on the PPCP: Plan and Implement

Collaborate with other care team members to optimize the medications necessary for the patient's active medical concerns

Review the care plan with the team toward the end of the visit or following rounds to ensure it is appropriately implemented

Inform the patient and/or caregivers about the plan

Implement Interventions (PPCP)

Where does it land on the PPCP: Implement

Review patient's chart to ensure labs and medication orders are placed correctly

Verify orders (inpatient only)

Document the care plan as indicated (i.e., note, acuity, etc.)

Drug Utilization Review (DUR)

Therapeutic duplication

Drug-disease contraindications

Drug-drug interaction

Drug-allergy interaction

Medication, dose, frequency, duration

Clinical misuse

After Visit or Post Rounds (PPCP)

Where does it land on the PPCP: Follow up: Monitor and Evaluate

Monitor necessary blood cultures, lab values, or imaging that may affect the medication plan

Collaborate and make changes to the plan as needed

Give appropriate hand off for any outstanding medication-specific concerns to covering pharmacist and other team members

Therapeutic Drug Monitoring

Renal dose adjustment

Vancomycin + aminoglycosides

Warfarin dosing + continuous anticoagulation

Therapeutic interchange (non-formulary items)

Code Blue response

Pharmacist role in a medical emergency

-- Drug manipulation, dosing, and timing

Advanced Cardiovascular life support (ACLS)

Rapid Sequence Intubation (RSI)

Intensive care unit (ICU) and Floor codes