Category: Software

Musings on software and pharmacy information technologies.

Not Documented? Not Done!

The other morning, before my staff arrived to work for the day, I took a phone call from one of the group homes we service. They wanted to know if we had received an order for a dose change on a patient’s sertraline. I looked in our systems and concluded that we had not yet received an order. It turns out that I was mistaken. Deconstructing my mistake illustrates a time honored saying: If you didn’t document it, you didn’t do it!

Where’s Waldo?

Like any busy work environment, knowing where to look for information is the key to success. There are limited ways the  order in question, a prescription, can arrive:

  • A faxed in prescription
  • A mailed in prescription.
  • An electronic prescription
  • A phoned in prescription
  • A hand-written prescription brought in by the patient

Once an order has been processed, documentation should be found on the pharmacy management system (PMS). At our pharmacies, the old prescription would be discontinued, and a new prescription would be entered with the new directions. This is what I expected to find if we had processed the order.

Our pharmacy also uses a clinical documentation system, PharmClin, to document all activities as they relate to drug therapy. Any notes or pending issues related to a dose change should be documented in this system. This additional documentation is very valuable to us as it allows us to document many of the important details that complete the clinical story as they relate to the patient’s drug therapy.  PharmClin makes this information easily accessible and retrievable.

I went searching. I found no unprocessed orders. The original order on our PMS still active, and no new prescriptions for sertraline were present. There were also no notes in PharmClin related to a dose change of sertraline. In other words, I did not find Waldo. Based on a lack of evidence, we did not appear to have the order yet.

When my staff pharmacist arrived, I mentioned the call and was informed that she was aware of the order and that it had already been addressed and picked up. I was flummoxed! How could this be? As it turned out, the situation was a lot more complicated than the phone call suggested.

The Details

The patient was taking 200 mg of sertraline daily. The previous day, prescriber decided to switch the patient to escitalopram. My pharmacist correctly identified that the patient should not simply stop taking the sertraline without some attempt to taper the dosage over time and contacted the prescriber’s office. She was told that the prescriber did indeed tell the house staff to taper the dose of the sertraline and provided a flow sheet of the taper. In other words, there was no prescription written to decrease or taper the sertraline. As Homer Simpson says, DOH!

Continuous Quality Improvement

Multiple mistakes were made here. My first mistake was not asking additional questions of the house staff that called. I made the assumption that we were looking for a dose change for sertraline and failed to see the new Rx for the escitalopram. The other omissions were made before I received the call: the sertraline order was not discontinued in the PMS, and the communication with the prescriber was not documented in PharmClin.

The scenario above an epidemic in today’s healthcare environment. The patient is told something by a primary provider, and other providers do not receive notice. The communication from the prescriber to the pharmacy, a form of documentation, was missing. Despite this, my staff pharmacist who dealt with the problem discovered all of the details after they spent time on the problem the previous day. But like the first omission, her documentation was incomplete and largely missing.

Having an tool like PharmClin to document clinical interventions is a great asset to a pharmacy. But if the tool is not used, the benefits are lost. Pharmacists across the country make outstanding interventions every day. The fact is, however, that they largely fail to document their work. In a small pharmacy with few employees, mentally keeping track of issues like this might be manageable, but eventually the system will fail. In a larger pharmacy with many more employees and patients, a systematic documentation system is a must. Remember…Do It. Document it. Done! This is how you can make every encounter count!

 

 

Compliance: Working the Numbers of PDC

Every month I await the e-mail from PQA telling me that my latest EQuIPP scores are ready. If I want to impact my scores, I need to understand the numbers behind them. Today I thought I would remind everyone how the EQuIPP compliance score, the PDC or Percentage of Days Covered, is calculated for a pharmacy.

While compliance might seem like an easy topic, it is far more complicated: compliance for patients is aggregated into a score representing the overall compliance of all patients in the pharmacy. Several assumptions are being made in order to do this.

Defining Patient Compliance

If I miss a dose once a month, most would consider me compliant. But what about missing one a week? A line needs to be drawn somewhere, and EQuIPP has arbitrarily drawn this line at 80% of days covered. This means that someone missing 5 or fewer days worth of medication in an average month is considered compliant. According to PQA, compliance is a binary (YES / NO) attribute. Either the patient is compliant, or they are not compliant, in any given month.

But EQuIPP cannot tell if a patient takes a drug 80% of the time. They are relegated to using claims data. Percentage of Days Covered (PDC) is calculated based on dispensing data from the pharmacy. PDC accounts for early or late refills by looking at the total number of days worth of drug the patient has in their possession during a period of time. For example, if a patient fills a 30 day supply of medication, and then refills the prescription 25 days later (5 days early) the second month, and 40 days later (10 days late) the third month, the PDC would be calculated based on the previous two fills as:

60 days of medication / 65 days elapsed * 100 = 92% — Based on the EQuIPP definition, the patient is compliant.

Note that the assumption is that the patient is out of medication when the refill is processed. This assumption can create erroneous calculations when used over short periods of time. In the example above, this assumption may actually overstate compliance as the patient has only taken 50 days worth of medication in 65 days and was just picking up a refill before going on vacation. It can take several months for the PDC to stabilize and more accurately reflect patient compliance. This creates additional questions for which I don’t have good answers.  For example: what is the start date for the calculation? For a new patient to the plan, it will be their first fill date after they enter the plan. But for a patient that did not change plans, how far back is the first fill date? I am assuming that the PDC is using calculating compliance over some defined period of time, probably 6 to 12 months.

Defining Compliance for the Pharmacy

Every patient included in the EQuIPP measures will be labeled as either Compliant or Non-Compliant for a given month. From this pool of patients, the pharmacy’s compliance rate is calculated. This is simply the number of compliant patients over the total number of patients. A rolling 6 month average of this calculation is the number seen in the EQuiPP dashboard.

Improving Your Measure

As many have observed, the easiest way to impact a pharmacy’s PDC for a given drug category is to target patients just falling short of the 80% threshold for compliance. Consider a pharmacy with a Diabetes PDC score of 80% with 100 patients enrolled. The CMS threshold for this measure is currently 82% and the Top 20% threshold is 92.5%. In order to move the pharmacy above the CMS threshold, two patients that are currently non-compliant need to become compliant. Likewise, moving 13 patients into compliance will move the pharmacy into the top 20%. Targeting patients with compliance between 75-79% will have the best chance for quick and easy success for the pharmacy.

To do this, a pharmacy has to identify the low hanging fruits: the patients falling just short of 80% compliance. The EQuIPP platform has the capability to show you outliers, but in practice, we have not found this very useful. Other products (Mevesi, PrescribeWellness,  McKesson and others), have platforms to help you identify the outliers. These tools are retrospective in nature because they generally use data that is pulled from your dispensing system at regular intervals. All of these tools are designed to be used outside the dispensing workflow to create a list of potential patients to target.  Once you have the list, you need an implementation plan to put the data to work. Other tools, like PharmClin, flag patients during the dispensing workflow, allowing you to target the patient in real time, avoiding the need for additional implementation. I prefer real-time identification of patients for two reasons: it takes less time and effort to identify the patients needing targeting and the data is always current. 

Taking Action

If you are starting with a list of targets, you will need a battle plan. One possible tactic is to place a note or flag on the patient record to alert the pharmacist or technician that the patient is a target when they initiate a new prescription or refill. This allows the pharmacy staff to approach the patient at the time they pick-up the medications. Another method is to contact patients outside the prescription workflow by appointment or by phone. Ultimately, the goal is to initiate a conversation with the patient.

At this point, with the patient in front of me or on the phone, I tend to be careful with how I proceed. Remember, claims data gives us very little real information. The patient may not actually be non-compliant: they may have a very valid reason for their compliance history. For this reason, I always try to be neutral when starting a compliance conversation. I might ask, for example:

I see that your refills for metformin are less frequent that I would expect. Has the dose the doctor wants you to take changed?

We often find perfectly reasonable reasons for PDC based compliance problems. Physician samples, dose changes not communicated to the pharmacy, and alternative drug supplies are commonly seen explanations found in our practice. If the dose has changed, we can fix the compliance problem by getting a new prescription from the prescriber. For other explanations, I simply document the intervention with the patient and revisit compliance in 3 months. Our use of the clinical documentation system PharmClin makes the this easy and automatically allows us to schedule a follow-up for the problem.

Sometimes, I find that the patient doesn’t tolerate the drug well, and has backed off of the dose as a result. The physician may have instructed the patient to do this temporarily, with instructions to gradually increase the dose. Metformin is a common example. Finding this, I work with the patient and prescriber to ensure that the patient achieves the desired outcome without unnecessary effects. This might mean helping the patient with their gradual dose increase, or recommending a different drug entirely. Either way, the “compliance” problem can be both documented and successfully addressed.

Addressing Non-Compliance

Most pharmacies use a medication synchronization program to address compliance problems. While this is a valid plan, it is most appropriate in the case that a patient forgets to order refills or stop in to pick up refills. I am careful and investigate a host of other possible reasons that the patient doesn’t refill their prescription on time before asking them if they are interested in synchronization.  Again, I proceed with caution. Is the reason financial? Might the reason be related to the time of administration or restrictions on what can or cannot be taken with the medication? I work hard to understand the reasons before creating a patient specific plan. If the issue is financial, finding a less expensive alternative might be needed. If the patient simply struggles with getting to the pharmacy, offering our delivery service is a reasonable intervention. Finally, if the patient forgets to order refills or has difficulty remembering to pick up medications at the pharmacy, the benefits of synchronization are a great way to help the patient become more compliant.

MedSync

One final note about medication synchronization. While this tool can be very successful in addressing compliance issues, the reasons for its success in our pharmacy are not what you might think. Filling a prescription on a regular frequency will, of course, correct the claims based PDC score. But in our pharmacy, med synchronization’s success comes from the increased level of engagement our staff have with the patient. By calling the patient each month, we can ascertain if any changes have been made and gather important informant about any problems the patient is experiencing. Additionally, we are able to approach the patient about other topics including what their therapeutic outcomes are and if they are meeting them. In short, we work hard to make every encounter count!

Re-Blog: Apple, FBI, and the Burden of Forensic Methodology

What does the current court order requiring Apple Computer to assist the FBI by “hacking” into a criminal’s phone have to do with pharmacy? One word: privacy. More and more, our patients are using their “smart phones” to keep and store their health records. Apple even includes Health Kit in their core operating system on their phones, which allows the user to store and display many different types of protected health information (PHI) in what is essentially a mini electronic health record (EHR).

It appears that many are siding with the FBI in this case without fully understanding the legal ramifications of the case. If you are interested in why the FBI’s request is far more intrusive to your patients’ privacy, skip over to Zdziarski’s Blog of Things and read Apple, FBI, and the Burden of Forensic Methodology, an excellent summary description of the implications of this case. After reading it, consider how save any PHI stored on a phone would be if Apple loses this case.

Baby Maximus Arrives

Several weeks ago, this blog discussed our use of a Parata Pass robot and our implementation of SuperSync. At that time, we announced (somewhat like proud parents) that our Parata Pass (named Phyllis) was going to be a big sister. Well Maximus (a Parata Max) entered our pharmacy almost 2 weeks ago and this blog post will address the details of preparing for and implementing automation in our retail pharmacy space. We will discuss the results of the implementation as they relate to improvements in workflow and our MedSync program in a later post.

The Purchase Details

Before finalizing the purchase, several decisions were made with respect to features that would be shipped on the machine. A couple of these decisions were made without a complete understanding of implications. And while a better understanding might not have changed the decisions made, I believe that these questions deserve a bit of discussion as it might benefit someone else down the road.

Vial Sizes. The Parata Max has the ability to label, fill, and cap, and sort prescriptions (start to finish). It is truly a marvelous example of modern automation. The machine can be equipped to use two different vial sizes. Our machine shipped with the standard 13 dram / 30 dram vial size combination. This is well suited for most retail implementations. The other option is the 20 dram / 40 dram vial size combination. This combination may be better suited for pharmacies that deal in a significant 90 day fill business. Be sure your choice of vial sizes matches your needs as changing the vial configuration is not something  that is easily accomplished after the machine ships.

Standard vs. Locking Cells. The second item that was discussed prior to placing the order was the option of locking cells. The sales person emphasized the use of locking cells as being important for scheduled (e.g. narcotic) medications. While locking cells are useful for this, they also offer an additional safety feature. With locking cells in the machine, the user (often a technician) can only have ONE cell open at any given time, minimizing the chance that a mistake is made during the filling process. Proper training, of course, also minimizes this risk, and ultimately the added cost was not worth this for us.

The Delivery Game Plan

Like any major addition to a pharmacy workflow, a lot of work was required after the purchase of the equipment but before the delivery and installation. This is very similar to parents preparing a nursery for a new arrival. A lot of attention is paid to details beforehand knowing that after the delivery there will be a lot going on. Parata, of course, has a detailed handbook of requirements that needs to be followed. These included:

  • Adding a dedicated power outlet on its own breaker for the robot
  • Network access near the installation point
  • proper space around the installed robot (three feet of open space around three of four sides and one foot on the end)
  • consideration of workflow

In our case, a small remodel was necessary to make space for the machine. The delivery crew visited about 1 week before installation to be sure the equipment could be brought into the space and all installation requirements would be done by the time they arrived for installation. I’m not sure they were confident that everything would be done in time, as the “nursery” looked far from complete at that point. Like most remodeling projects, this one finished the night before the installation was to occur.

The Arrival

After much anticipation and preparation, the big day finally came. As this was our second delivery, we were likely a bit more prepared and relaxed. Unlike the delivery of Phyllis 2 years earlier, which involved the equivalent of a c-section, Max breezed into the pharmacy without any problems. It was not until after delivery that a few problems surfaced. The “doctor” in the delivery room (the Parata technician) quickly discovered that Max had a birth defect. He was wired incorrectly at the factory for our installation (the power and network access points were on  the top of the machine instead of the bottom). Dr. Zach, however quickly created a temporary fix and scheduled a minor surgery the next day to fix the problem. Outside of this, installation and training occurred without any significant difficulties, and within a few days we were up and running. Like any new parents, we spent the next several days getting to know our new arrival.

 

IMG_4465 (1)
Preparing for delivery

The installation technician taught us how to change the labels, add vials and lids, and (of course) how to “feed it” (load) medications. Boy, can this boy eat! By the time the installation technician left us (three days later), we had only filled about 100 of the 186 different cells. At one week, we were filling about 50% of our total prescription volume on the Parata Max.

IMG_4473 (1)
Max in the “nursery”

Coming soon, we will share our experiences with now automation has improved (hopefully!) our workflow and our Medication Synchronization program.

Dispensing Software vs Clinical Pharmacy

keBack when I was a pharmacy student, there were still some pharmacies that kept prescription histories for their patients on paper and typed prescription labels on an electric typewriter. The Bates Number Machine was still a staple of many practices. Today, with the advances in computers and electronics, modern pharmacies in the United States use computerized Pharmacy Management Systems (PMSs otherwise known as dispensing systems) almost exclusively.

Today’s modern pharmacy software has helped improve workflow, and ensures accuracy in the dispensing pharmacy. New features are being added to these systems regularly. Today, the point of sale (register) is usually integrated, as is the telephone system (by use of an Interactive Voice Response or IVR system). Some vendors have created iPad based delivery apps and even added limited integration with clinical services like Outcomes and Mirixa. Overall efficiency in pharmacies today is very high, in large part due to these software packages.

But today’s pharmacy systems are really still one-trick ponies. Despite all of the “new” features, these systems still are centered around the dispensing function. Most pharmacists and pharmacy owners becoming aware that dispensing revenue is significantly down (despite increased prescription volume and sales) in pharmacies today.

Right now, the profession of pharmacy is in a transition period; moving from product based reimbursement to service based reimbursement. Traditionally, the services provided by pharmacists and pharmacies have been (unfortunately) given away along side the paid drug product. The payment received for the drug product historically provided enough profit to cover the professional time the pharmacist spent with the patient. Current payment for product, however, is drying up at an alarming rate, and the transition from product based reimbursement to service based reimbursement is still only in its infancy.

The discussion of pharmacy management systems, and the transition of pharmacy as a profession, are intrinsically related. In order to move the transition of pharmacy forward (and ultimately achieve “provider” status with both the State and federally, with Medicare), pharmacists need to prove that what they do outside traditional dispensing is intrinsically valuable.

Almost every newly minted pharmacist since the early 2000’s received a clinically oriented degree, a doctorate in pharmacy (Pharm.D). Many older pharmacists have even gone back and added this degree. The application of the clinical skills vested in these pharmacists, however, is not encourage by many employers. Many pharmacies continue to emphasize dispensing and prescription volume. And why wouldn’t they, because that is (still) what gets them paid.

Despite the lack of clinical emphasis in their workplace, many pharmacists continue to employ their clinical skills. The next obstacle for clinically motivated pharmacists, is their dispensing oriented pharmacy management system, because it is not designed to document the care these pharmacists are implementing. This is a significant problem facing the profession. If we cannot readily document the value we provide, how can we move forward, and transition toward an actual professional fee, or obtain provider status?

This is a real problem for today’s proactive pharmacists, and the problem is going to grow exponentially as the expectation that pharmacists demonstrate their value to the health care system grows. Pharmacies need a way to seamlessly document their actions, recommendations, and overall value to patients and the system, and dispensing focused software is woefully inadequate.

In our practice, the answer was to create our own documentation system to accumulate the interventions our pharmacists effect every day. Over the course of almost a decade, we massaged and integrated the software to the point where every one of our pharmacists record important information and face to face encounters with patients, documenting what was done, what needs to be done, and any communication with other health care providers. Thru tight integration with our dispensing system, the software has become an extension of our business model. Today the product is known as PharmClin. The core concepts of PharmClin are fundamentally simple, but put taken as a whole, and in the context of a clinically oriented practice, the package is so powerful and innovative that it is patented.

Many pharmacists have seen PharmClin in use (by visiting our pharmacies) or have seen images of the product in slides at national meetings. When pharmacists see what we are doing and how we are using PharmClin, most immediately “get it” and want to be able to do the same things themselves. What needs to happen next, is to bring this concept to the rest of the profession. This type of activity and documentation will be a game-changer for our profession. It emphasizes how every pharmacist can make encounters with their patients count.

The Sandbox

One of the most challenging issues facing today’s health care providers is sharing information. Technologically, one might assume that it would be easy to create a system of data exchange between providers. The reality, though, is that providers may be selective with what they will share, who they may share it with, and how they share it. The primary obstacles to sharing of information are security and access, and these barriers are as much a political issue as they are technical obstacles.

 Obstacles

Security and privacy of health information is a significant obstacle. Just like breaches in major retail stores that make the nightly news (see Forbes for a list of significant breaches in 2014), health information is also under attack (e.g. Anthem, see CNN). The same technologies that enables modern transactions are also able to be exploited by criminals.  Despite recent headlines, however, current technology (when implemented properly) is capable of reliably protecting our personal data, including a digital medical record.

Another significant obstacle is the actual exchange of medical records. All health care providers ( e.g. the physician, pharmacy, hospital and laboratory etc.) maintain some type of patient record. Every procedure, prescription, or visit results in changes in that record. Each change made by one provider (say at the hospital) would, in an ideal system, be updated automatically with the patient’s other providers (e.g. the specialist, the pharmacy and the primary physician). Assuming that security of the data can be maintained without any issue, the remaining problem is a lack of a standardized format for the record. Each repository of patient information is necessarily different because every provider focuses on different aspects of patient care. The format of the records can be very different. At one extreme,  paper record (charts) are still in use, while others may leverage electronic medical records (EMRs). In essence, each provider’s records speak a slightly different language.

The Language of Health Care

Among the first organizations to recognize the importance of intercommunication between health care records were hospitals. The laboratory’s electronic records need to communicate with the electronic chart, hospital billing systems, the computerized census system and the pharmacy’s dispensing system. An entire industry was born to help facilitate this data exchange in hospitals, and with this came the creation of several standard languages, one of which is HL7 (Health Level 7).

Using computers as gateways, hospitals use tools like HL7 to link many different systems to provide a relatively seamless transmission of information between systems. But as good as this would appear on the surface, these gateways have significant obstacles of their own. Gateways are labor intensive to maintain and regularly require maintenance to keep them running. Small changes in one system can break down communication between multiple systems. To Make matters worse, there are many different dialects of the HL7 “language” so even if two systems both speak HL7, information can be lost in translation.

Politics

If one accepts that security of the data can be handled by current technologies, and that gateways like HL7 can facilitate the translation of data, one final obstacle exists. The laws that exist to protect the privacy of health information (like the Health Insurance Portability and Accountability Act of 1996 also called HIPAA) also govern the exchange of information between providers. This exchange may or may not require a written release (depending the the relationship between both providers and the patient). The provider’s access to records needs to be limited to only their patients plus any patients. It is also possible that a given provider may still want to control what data is shared, and when it is shared.

The Implications

Because of the obstacles above, providers and patients struggle to seamlessly communicate. The fax, which became widely available in the 1980’s, is still one of the primary means of communication between providers despite the proliferation of communication options available today. The ramifications are significant, and examples of the problems created by the lack of real-time communication are easy to find. From a pharmacy perspective, four common issues are:

  • A patient admitted to the hospital. The admit process requires the hospital staff to document an accurate medication history. Hospitals do not have access to the current the prescription history for the patient maintained by the patient’s pharmacy, creating a chance possibility for errors, adverse drug events and improper therapy.
  • Therapy changes made in the hospital. These changes need to be communicated to other providers (e.g. the primary care physician and the pharmacy).  The lack of standard communication between hospitals, the primary care physician’s EMR, and the pharmacy’s records can lead to discrepancies.
  • Routine changes made at a physician office. Patients are often instructed by their physical to increase or decrease doses of drugs they take without a new prescription being issued.
  • Medical information related to drug therapy. A pharmacist managing a patient’s drug therapy requires a significant amount of medical and laboratory data to ensure optimal outcomes. Without seamless access to a patient’s relevant laboratory results, relevant diagnosis and pertinent history and physical, pharmacists are limited in their ability to perform Continuous Medication Management (CMM)

Jumping Thru Hoops

Many electronic medical records and other health care provider systems have made their way to the internet. Using secure web portals, providers can access their patient’s records from a variety of locations (office, hospital, home etc). The internet has become an enabling technology for providers trying to share information. If two different systems do not communicate (e.g. the physician’s EMR and the Hospital EMR), at a bare minimum, the provider can access both systems from a single computer to update and check records. Many providers find that they maintain accounts with multiple internet enabled medical records.

A pharmacy with good relationships with several providers might be able to gain access to a variety of records to enable productive collaboration. Besides having access to their own clinical record system, a pharmacy might have access to a hospice’s EMR, multiple nursing home EMRs, and access to records from one or more laboratories. This creates a chaotic environment where information must be gleaned from multiple sources and documentation made across many different records to ensure proper communication between all providers.

Even with great relationships between providers, gaining access similar to that described above is difficult. A pharmacy might serve 10% of a medical practices patients, and access has to be limited properly to prevent improper access. Likewise, a pharmacy would only want grant records access to a provider’s patients.

Today in healthcare, communications between providers is more important than ever before. And today, the fax still dominates communication between providers. It will likely be take a long time before all providers can come to and play in the same sandbox.

Managing Diagnosis Collection on the Fly

A key factor in performing continuous medication monitoring (CMM) is knowing the indication of  each medication a patient is taking. Sometimes this is easy to decide, and other times it can be challenging. The important step, however, is documenting the information once it is known. This article will discuss strategies and workflows that we use to collect and document diagnosis information.

Certainly of Diagnosis

When documenting a diagnosis in a patient record, it is important to state the level of certainty associated with the diagnosis. For example, the indication for some drugs is often easy to guess. Statin medications (HMG-CoA reductase inhibitors) are rarely used for anything except hyperlipidemia. We refer to the pharmacists best guess for the indication as a inferred diagnosis. Sometimes a pharmacist may consider a likely indication but recognize that the possibility exists that the medication is being used for something else entirely. An example of this might be the drug metformin. While this medication is used primarily for diabetes mellitus type 2 (formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes), it can also be used “off label” for Polycystic ovary syndrome (PCOS). In the case of a female patient without other evidence of diabetes in their profile, assigning a diagnosis of PCOS would be recorded as a suspected diagnosis. When the indication is specified explicitly, either by the prescriber or on a prescription, the diagnosis would be considered confirmed. 

Diagnosis Source

Similar to the documentation of the certainty of a diagnosis, it is important to note the source of the information in the patient record. We use three categories to refer to the source of a diagnosis.

  • Pharmacist — This is used to indicate that the pharmacist, using clinical judgment, has assigned a diagnosis based on their knowledge of therapeutics.
  • Patient — indicated that the patient has identified the diagnosis
  • Prescriber — is used when the prescriber has stated the diagnosis

A Diagnosis Workflow

At our pharmacies, CMM is performed at the final verification stage of the prescription workflow. After the pharmacist verified that the new prescription or refill has been filled with the right drug and is labeled correctly, they evaluate the profile a look for potential or real drug therapy problems. The clinical workflow screen displays the diagnosis associated with the drug being checked. If no diagnosis is specified, the system may suggest possible indications for the drug (see Figure 1 below). The pharmacist can assign an inferred indication to the patient quickly at this point. Here, the source of the diagnosis would be the pharmacist and the certainty would be marked as inferred. If a new prescription includes diagnosis information, this too can be added to the profile with the appropriate source and certainly indicators.

suggestion
Figure 1. A clinical documentation system making a suggestion for a possible diagnosis for the drug.

If a diagnosis is uncertain, the pharmacist has the opportunity to engage the patient when the mediation is picked up. At this point, the pharmacist could create an intervention (Figure 2) and flag the prescription for counseling, including a note (Figure 3) to clarify the diagnosis with the patient. When the patient arrives, the pharmacist has the opportunity to consult with the patient and determine if the inferred or suspected diagnosis is correct. Information received from the patient can then be used to further update the pharmacy record.

 

Intervention2
Figure 2 Documentation of an Intervention by the pharmacist to clarify a diagnosis

 

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Figure 3 Example of a will call tag to be placed with the prescription order to aid the pharmacist in collecting information at the point of sale.

 

 

 

 

 

Often, a patient confirmed diagnosis is sufficient for the needs of the pharmacy. Sometimes, however, the patient may not be a reliable source. In these cases, the workflow should include a method to send a short SOAP note to the prescriber requesting clarification of the diagnosis (Figure 4). Once this information is returned, the diagnosis information for the patient can be completed.

SOAP2
Figure 4 Example of a short SOAP note requesting confirmation of the diagnosis.

 

Collecting accurate, relevant patient drug-diagnosis combinations is an important step in the CMM process. Leveraging the patient at the point of sale is yet another example of making every encounter count.

Continuous Medication Management (CMM) and the Profile

[dropcap color=”white” background=”black” style=”rectangle” size=”big”]A[/dropcap]t Our pharmacies, we put a great deal of emphasis on performing clinical services while working on the dispensing counter and we call this process continuous medication monitoring (CMM). By this, I mean that the pharmacist, while verifying that the prescription was filled correctly, is also responsible for an in-depth look at the patient’s medication profile each and every time the patient has a prescription filled. To accomplish this, we have developed a software platform for our clinical pharmacists to work with while on the counter called PharmClin.

While the PharmClin package contains a comprehensive array of features including documentation for the clinical pharmacist, one of its core features is the patient profile. The single most important piece of information that a pharmacist has to make clinical assessments is the patient’s medication profile. The remainder of this post will look at the importance of the profile and how a logically formatted profile can aid the pharmacist in CMM on the fly.

A dispensing profile

Before looking at a clinically oriented profile, consider that a PMS (Pharmacy Management System) also maintains a patient profile. The user experience when trying to use most PMS profiles to perform CMM, however, quickly deteriorates. A Pharmacy Management System (PMS) is designed to facilitate dispensing. The PMS profiles are, therefore,  optimized for dispensing activities, and not CMM. Consider a PMS like McKesson’s Pharmaserv below (click to enlarge).

PMS Profile
Example Profile from Pharmacy Management System

This screen grab is fairly typical of most any commercial PMS in that it shows the history most current at the top. The level of detail visible, though is limited, and one has to select a prescription to see the previous dates (in the split window below). In all, the information visible is related primarily to dispensing.

This begs two questions:  1) what information displayed by the PMS do we not require when making clinical determinations and  2) what is missing that we would want to see? Taking these questions in order, our clinical pharmacists were less interested in:

  • Original Date (because it does not related to the first date the patient started taking the drug)
  • Refill number
  • Strength and form (because it is duplicate information)
  • Price
  • Facility
  • NDC
  • Coverage / Insurance
  • RPh and Tech

Keep in mind that almost all of these have significant value when considering the dispensing aspects of pharmacy, they just are not relevant to the most common clinical issues.

Our clinical pharmacists were interesting in seeing a few other details without having to drill down into the record. These included:

  • Days Supply
  • SIG or directions
  • Recent Refill Summary
  • A selective profile representing only the most recent therapies

Our clinical pharmacists were also interested in being to quickly spot

  • Specific therapeutic drug categories (e.g. those in the EQuIPP measures)
  • Drug interactions
  • Compliance Issues

A Clinical Profile

With this in mind, we pared our clinical profile view down to the following (for sake of comparison, this is the same profile as listed above): (again, click to view the image)

PharmClin Profile
Example profile from a clinically based system

Besides some small differences in sorting and the scale size of the screen capture, the profiles represent the same exact data. One of the first things you might notice is that the profile is narrower (taking up much less space across the screen). The changes represent most of the important items on our clinical staff’s wish list for the profile.

Some things in this profile may not be initially obvious, but are exceptionally helpful to a clinical pharmacist performing rapid CMM on the counter. To simplify the profile , only the last three dispensing incidences for each given drug are displayed, and these are all displayed together, without respect to Rx number, NDC or other drug product changes. This saves the clinical pharmacist time as they do not need to hunt thru the profile. One advantage to this method is that the pharmacist can review compliance over the last three dispense occurrences quickly.

Other simplification were made to the profile. To reduce the amount of data to be interpreted, only the last 180 day are displayed, significantly reducing clutter in the profile. If a clinical situation requires a complete history, that option is available.

Another key difference is the addition of color. While the color-key is not visible in this screen capture, the drugs are color coded as follows:

  • Statins in GREEN
  • ACE / ARBs in RED
  • Diabetic medications in BLUE
  • Drugs listed as high risk (Beer’s List) in PURPLE
  • Drugs that precipitate drug interactions in ORANGE

All of the above color-coding relates directly to the current CMS 5-STAR rating guidelines, and allow our pharmacist to quickly make 5-star related determinations on compliance, high risk drugs, and drugs that are known to precipitate interactions.

Besides color-coding drugs that are known to precipitate drug interactions, the profile has drug interaction column that highlights any interactions flagged by the PMS. This column is kept minimal and does not show the details of the interaction by design. We decided that if we did not know what was going on, we could click to look, but for the most part, knowing that an interaction was flagged was enough for our clinical pharmacist to make their assessment. Interaction pairs are easy to spot this way. Drug – Alcohol and Drug – Food interactions sometimes create an ODD number of interactions, but after a bit of practice, spotting problems becomes very easy.

The profile above is not perfect, and has changed with time as we work thru our CQI process. One of the things that would be most helpful to us would be an accurate listing of medical conditions. Unfortunately, while PharmClin and our PMS do have the capability of entering this information, we often do not have documentation of actual diagnoses. For the purposes of “on the fly” clinical work, therefore, we use implied diagnoses, and the color coding is helpful in this.

I should point out that our clinical system does a lot more than just show the pharmacist a patient profile. The patient profile is important to start the process, but once the pharmacist has identified a problem, they have to document it efficiently. Once the pharmacist notes something worth documenting, they can document an intervention system for the next pharmacist or even write a quick SOAP note to send to the prescriber. Interventions and SOAP Notes can be flagged for follow-up.

Notes on PharmClin

PharmClin (patent pending) was developed as an in-house documentation tool for a clinically oriented retail pharmacy. The product currently integrates with McKesson’s Pharmaserv, but integration with other PMS vendors is being pursued. More details about PharmClin are available on the Innovative Pharmacy Solutions website. Web demonstrations can be arranged from that website.

Software as a Service: the changing face of pharmacy software

[dropcap color=”white” background=”black” style=”rectangle” size=”big”]O[/dropcap]ver the last several years, we have watched many software companies struggle with paid upgrade cycles. As feature sets for applications have matured over the years, it has become harder and harder for companies to convince its users that they need the new features only available with the newest version.

For example, I am an amateur photographer. I occasionally need the power of Adobe Photoshop. I decided a long time ago, however, that I did not need to always have the most current version. To Adobe, I am a bad customer, as I am not supplying them with the necessary sales and revenue a for-profit company needs. If it were just me, the software companies would have nothing to worry about, but my choices with respect to upgrades have become very common, even among professionals.

Enter “Software as a Service.” This new model is slowly becoming mainstream, despite initial and continued resistance to the implied concept that we don’t own the software, but simply rent it. Microsoft Office and Adobe Photoshop are two major software platforms that are now available as subscription services with monthly or yearly agreements.

The sales pitch for “rental” or subscription software is that you will automatically receive updates as they are released, theoretically saving  you money in the long run (based on the assumption that you would always upgrade to the newest version). Because this concept has not been a huge success, some companies have even stopped selling traditional software licenses to push customers to the new model.

Eventually, I need to bring the discussion back to a pharmacy focus. You see, Pharmacy Management System (PMS) software has traditionally leveraged a subscription model: You purchase the hardware / software and then pay a monthly maintenance fee for support and upgrades. This maintenance fee is usually non-trivial and can cost thousands of dollars a year for even a small volume store.

The other day, I was speaking with my PMS vendor about a feature that I would like to see. The support person indicated that they already offer that feature. I was ecstatic. In the next breath, however, the support person indicated that this was a separate service with a monthly cost. Wait just one second, don’t I pay a steep monthly maintenance fee for upgrades and support? Why is this feature not included?

Taking a step back and looking at the pharmacy software landscape, this model has gradually crept into the marketplace. Companies like Mevesi and Prescribe Wellness along with platforms like EQuIPP offer cloud based services that integrate and extend your traditional PMS. Each of these is adding to the pharmacy overhead when the service is added. Often these services can cost thousands of dollars per year.

Many of these service packages can add a great deal functionality to your pharmacy and may be well worth their cost(s). The concern for the pharmacy owner, however, is the rapid increase in software costs in an era where reimbursement for their service and product is at an all time low. Any new feature or service must be able to create more new revenue than the service costs the pharmacy. Today’s pharmacy owner has a fine line to walk.