ASHP InterSections ASHP InterSections

June 8, 2017

Informatics Helps Clinical Pharmacists Elevate Transitions of Care

PHARMACY INFORMATICS EQUIPS PHARMACISTS with the data and insight to improve transitions of care, which expands their clinical influence far beyond medication verification, reconciliation, and consultation. By providing more precise information, pharmacy informatics can improve patient safety, make transitions of care more efficient, and reduce readmissions.

Emmanuel Enwere, Pharm.D., M.S.

According to Emmanuel Enwere, Pharm.D., M.S., a Clinical Informatics Pharmacist at the University of Texas MD Anderson Cancer Center (UTMDACC) in Houston, “Integrated electronic health records (EHRs) give us a better picture of who patients are and their risk factors for readmission.” EHRs also make reviewing patient data a lot easier. “We can easily pull a report, for example, on how many patients received pharmacy transitions-of-care services or the number of readmissions in a given month with the improved data capture from an integrated EHR system,” he said.

Pharmacy Scoring System
Phuoc Anh (Anne) Nguyen, Pharm.D., M.S., BCPS, is a Clinical Pharmacy Specialist at UTMDACC who focuses on transitions of care and internal medicine. She worked with the informatics team to create a transitions-of-care pharmacy scoring system to prioritize patients on the General Internal Medicine service. The transitions-of-care pharmacy scoring system adds points to a patient’s cumulative score for various factors such as the number of medications, types of high-risk medications, age, timeliness of medication history, and allergy assessment. A higher score “helps us to determine which patients might need medication reconciliation first,” said Dr. Enwere.

Anne Nguyen, Pharm.D., M.S., BCPS

For example, due to limited pharmacy resources in the emergency center, a patient who was admitted overnight did not receive a visit by pharmacy at the time of admission. Fortunately, the patient was flagged as a priority because of age, lack of medication history, polypharmacy, high risk for readmission, and no review of allergy information, noted Dr. Nguyen. She met with the patient and discovered upon admission medication reconciliation that he was taking 10 additional medications with multiple discrepancies. “The pharmacy monitoring system — with its auto-populated, rule-based scoring, patient list, and communication handoff tools — allows pharmacy staff to better prioritize their workload based on patients’ needs,” said Dr. Nguyen.

She recalled one patient who had a score of 70. “She had 56 medications on her list — the most I’ve ever seen,” Dr. Nguyen said. The score was so high because the patient went to several doctors and pharmacies. According to Dr. Nguyen, if the cancer center hadn’t used the transitions-of-care pharmacy scoring system, pharmacists might not have been alerted and triaged the patient appropriately.

Two years ago, the UTMDACC Division of Pharmacy was awarded an ASHP Foundation Practice Advancement Initiative Demonstration Grant to evaluate the impact of a pharmacy transitions-of-care program at a National Comprehensive Cancer Center. The recent implementation of a new integrated EHR system, which included many improved transitions-of-care tools, was extremely helpful in supporting the pharmacy transitions-of-care program services. Dr. Enwere explained that getting buy-in from hospital administration was not difficult. In fact, administrators were receptive to the pharmacy’s program to improve transitions of care because it aligned well with other efforts in the health system to increase patient safety and reduce readmission rates.

Dr. Enwere and the transitions-of-care workgroup within the ASHP Clinical Information Systems section are currently looking at the use of pharmacy informatics in transitions of care from a broader perspective. They surveyed ASHP members to assess the impact of technology and pharmacists on transitions of care at health systems nationwide. The data gathered from the survey will help shine light on technology best practices related to transitions of care and potential areas where pharmacy informatics can continue to improve continuity of care.

Informatics Improves Patient Education at Johns Hopkins

Emily Pherson, Pharm.D.

Pharmacists have always played a role in patient education, particularly around medication use. Informatics is now allowing them to improve patient care. “The technology greatly expands the amount of education we’re able to do as pharmacists … and has fundamentally been a game-changer,” said Emily Pherson, Pharm.D., a Clinical Pharmacy Specialist of Adult Internal Medicine at the Johns Hopkins Hospital in Baltimore.

Again, informatics allows greater precision in prioritizing patients. According to Dr. Pherson, when a physician prescribes a new medication in one of five high-risk medication classes, the patient’s EHR at Johns Hopkins sends out an alert to the hospital’s pharmacy. After a pharmacist educates the patient about the new medication, “all pharmacists, including the decentralized or rounding pharmacists, can see that the patient education occurred and was fulfilled,” said Dr. Pherson.

The same holds true for delivery and verification of medication histories. “The pharmacy techs typically collect the medication history, and then the pharmacist checks, confirms, and reconciles the list,” she added.

Informatics Drives Innovation in Pharmacy Services
In addition to using informatics to fine-tune transitions of care, pharmacists are also using informatics to expand services. For example, direct delivery of outpatient medications prior to hospital discharge can be coordinated and optimized through data collected by pharmacy informatics tools. Although these meds-to-beds programs are not necessarily new, they are expanding in scope and precision because of technology, noted Dr. Enwere.

Samm Anderegg, Pharm.D., M.S., BCPS

As pharmacists continue to find new ways to use informatics to improve patient care, several challenges remain. According to Samm Anderegg, Pharm.D., M.S., BCPS, Health IT Consultant with the Pharmacy Health Information Technology Collaborative, one of the biggest struggles with informatics is customizing the software or developing new software to support innovative pharmacy practices.

Dr. Anderegg believes that one day, every medication a patient is taking, their family history, their social history, and other details will be logged into their EHR as discrete data points with availability to all healthcare providers regardless of practice setting. Technology will soon be able to find associations among specific medications, patient factors, and outcomes so pharmacists can understand the whole patient, he explained. In the future, the technology may be able to know what treatments are best for patients based on this data.

However, even with all the progress in informatics, said Dr. Anderegg, “It’s never going to replace the cognitive ability of clinicians, who assimilate the information to individualize treatments for our patients.”

By Damian McNamara

July 16, 2015

IT Wizardry Streamlines Hospital Discharges, TOC

Wing Liu, Pharm.D.

Wing Liu, Pharm.D.

THE TRANSITION OF CARE (TOC) after hospital discharge remains perhaps the most vexing stage in the healthcare continuum. Lapses during patient hand-offs between the hospital and a patient’s home or a post-acute care facility often include incomplete information about key aspects of care. For pharmacy care, such breakdowns typically show up as multiple, conflicting, and erroneous medication lists.

At Vanderbilt University Medical Center (VUMC) in Nashville, Tenn., patient care during TOC has improved with the use of a new software program designed by Wing Liu, Pharm.D., product manager for the inpatient computerized physician order entry (CPOE) system, and his IT team.

“We asked ourselves, ‘How can we do a better job of coordinating all aspects of the transition to ensure patient care remains uninterrupted at a high level, regardless of where patients go?’” Dr. Liu said.

The Discharge Wizard app pulls together all elements of TOC into a single application.

The Discharge Wizard app pulls together all elements of TOC into a single application.

Rolled out in 2012, the Discharge Wizard application pulls together all elements of TOC into a single application, including the often daunting process of medication reconciliation.

The solution links directly to VUMC’s electronic health record (EHR), allowing clinicians to merge and exchange key information between the two IT platforms, such as patient demographics, follow-up appointments, patient core measures (e.g., congestive heart failure), healthcare team members, current medical status, bed location, and diet and exercise regimens.

The application even compels users to conduct medication reconciliation to complete the discharge process.

“It’s designed well and is easy to use,” said Amy Myers, Pharm.D., BCPS, a clinical pharmacist at VUMC.

“During the medication reconciliation process, the system allows you to choose, medication by medication, which to stop and which to continue. The result is a single, accurate medication list, which is also accessible through the EHR. That’s a huge benefit.”

Easy-to-Read Discharge Plan Streamlines Patient Handoffs

Ultimately, the system produces a discharge plan. All patients receive an easily readable discharge letter that includes medication schedules, follow-up appointments, additional care instructions, and educational material. For patients headed to a post-acute care facility, the plan is transmitted to the new healthcare providers via fax, email attachment, or with an accompanying paper record.

Nicole Callendar, R.N.

Nicole Callendar, R.N.

“One of the best features of this solution is the option to customize the discharge report based on the patient’s destination,” said Nicole Callender, R.N., staff nurse and support liaison for the application. “The orders tell the patient exactly what is needed for his or her care.”

To encourage rapid adoption of the Discharge Wizard application into the current discharge workflow, Dr. Liu wanted the app to be a model of simplicity. By all accounts, he succeeded.

Although the application is optional, biweekly utilization reports show that clinicians use it in about 95 percent of discharges. The most useful feedback about the system’s impact on workflow and patient care, he added, comes from anecdotal reports by users vs. quantitative measures.

Any member of the care team can easily launch the application through the CPOE, but only healthcare providers and select clinical pharmacists can save information. The software guides them through a sequence of fields to gather all of the relevant information needed for a discharge report. At any point, the process can be paused and restarted by another clinician, for example, in the case that a pharmacist needs to get involved in the medication reconciliation component.

Applicability to Post-Acute Care Facility Transfers

Originally, the Discharge Wizard applied only to patients discharged home. But a Centers for Medicare & Medicaid Services grant called “IMPACT: Improved Post-Acute Care Transitions” highlighted the need for an expanded role for the system to include patients transferred to post-acute care facilities. This is a patient group that is typically burdened by complex, mutable drug regimens.

Amy Myers, Pharm.D., BCPS

Amy Myers, Pharm.D., BCPS

“This is a very vulnerable population, especially for medication errors, yet it’s often excluded from TOC studies, which typically focus on patients going home,” Dr. Myers said. “It became apparent that we needed to improve our system for sending transfer orders to the new facility.” The more robust application went live in fall 2014.

Once VUMC nurses realized that using the software application meant they didn’t have to handwrite discharge orders anymore, and that patients could actually read the reports, they were sold, said Nicole Callender.

“Now, it’s part of the culture and widely embraced,” noted Callender. “It’s at the point where, if you’re a bedside nurse who doesn’t have a printed discharge letter from the Discharge Wizard to give to the patient, that nurse is going to call the provider to ask for it.”

Allie D. Woods, Pharm.D., director of ASHP’s Section of Pharmacy Informatics and Technology, said that hospitals and health systems across the country need apps and systems like the Discharge Wizard to help reduce errors and improve medication reconciliation.

“It’s critical that TOC information is shared with all healthcare providers in a single location. This system is definitely a step in the right direction for healthcare technologies,” she added.

From the perspective of pharmacy informatics, the project has been eye opening, added Dr. Liu.

“As a pharmacist, I’ve been involved in creating an application for which my role was envisioning what it should do and how to get there,” he said. “It’s taken a team of four full-time software engineers working on it to get this far, and it’s been very gratifying to see the difference that it’s made for patients and healthcare providers alike.”

–By Steve Frandzel

Editor’s Note: The project described in this article was supported by Grant Number #1C1CMS331006 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Powered by WordPress