Pharmacy Information Systems Technologies for Enhancing Medication Safety

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Pharmacy Information Systems Technologies for
Enhancing Medication Safety

• Elizabeth Chrischilles, Professor of
  Epidemiology, The University of Iowa

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Outline

• Evidence base
• Types
• Clinical functionalities
• Integration options
• Pharmacy practice issues

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Evidence Base for Clinical Benefits of Pharmacy
Information Systems

• There are no published epidemiologic studies
  relating pharmacy records or pharmacy claims data
  to actual adverse events for large populations.
• There has been one negative randomized controlled
  trial of computer-generated DUR alerts to
  pharmacists. Intervention and control pharmacies
  continued to receive alerts from their in-store
  systems but intervention pharmacies received
  on-line alerts from the Medicaid fiscal
  intermediary.
• The evidence for is too limited to judge the
  value of pharmacy information systems.

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Types of Pharmacy Information Systems

• Stand-alone systems contain
• Practice management software, perhaps linked with
  automated dispensing, bar-coding.
• Clinical decision support software
• Prospective drug utilization review (PDUR) alerts
• In-depth electronic clinical reference
  information
• Special programs (e.g. problem-oriented pharmacy
  records for disease state management, MTMS
  programs).
• Integrated systems
• interface with clinical information systems
• Including CPOE/e-Prescribing, laboratory, EMR
• interface with automated dispensing and
  bar-coding

Theoretically limited by less access to
electronic patient clinical data
Theoretically higher quality of care and greater
efficiency
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Clinical Functionalities of Pharmacy Information
Systems

• Real-time clinical decision support
• e.g. screening for drug-drug, drug-allergy, and
  drug-disease interactions, dosage range screening
  Prospective Drug Utilization Review (PDUR)
• e.g. reference information for med reviews,
  disease state management protocols.
• Real-time ADE surveillance
• e.g. screen medication orders and laboratory test
  results and deliver rules-based alerts.
• Retrospective ADE surveillance

Focused on prevention, applies tools to check
medication orders, suggest monitoring tests
Focused on detecting problems as they are
occurring, intervention
Focused on detection, system adjustment for
quality improvement.
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Problems with PDUR

• Screening criteria that provide the logic for the
  alerts
• Compendia do not agree on amount of risk inherent
  in drug-drug interactions.
• Vendor systems do not agree on what drug-drug
  interactions are included.
• Evidence review for deciding what to put in these
  systems is not standardized.
• Clinical data are often not incorporated in the
  rules.
• Typically restricted to medication, gender, and
  age.
• The clinical patient database is often limited.
• Diagnosis and allergy data may often be missing
  anyway.
• Prescriptions may be incompletely ascertained
• PDUR operated by health plans theoretically has
  the advantages of including all outpatient
  prescriptions regardless of where dispensed.
• Carve-outs and plan dis-enrollment can cause
  incomplete data.
• Pharmacists over-ride 80 of alerts.
• Messages are not useful or actionable

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Integration Options

• Notation
• CPOE computerized physician order entry
• CDS clinical decision support (includes
  software for generating alerts)
• CIS clinical information system.
• an inpatient information system that provides
  healthcare professionals with CPOE, CDS,
  medication administration documentation, and
  clinical views of data provided by ancillary
  information systems such as pharmacy and
  laboratory.
• CDR clinical data repository.
• Data may appear in the clinical information
  system via a direct interface with an ancillary
  system or from a database source such as an
  institutional clinical data repository.

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Pharmacy Stand-Alone vs. Pharmacy-Lab Integration
for ADE Surveillance
Components of an electronic ADE surveillance
program pharmacy data. (from Classen and
Metzger Int J Qual Health Care 200315(S)i41-i47)
Components of an electronic ADE surveillance
program pharmacy and laboratory information.
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CPOE-Pharmacy Information System Integration
Figure from Chaffee and Bonasso Am J Health-Syst
Pharm 200461506-13.

• Higher quality of care is the theoretical benefit
  of integrating pharmacy information systems (PIS)
  with clinical information systems (CIS).
• Institutions implementing CPOE also face the
  challenge of pharmacy system integration.

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CPOE-Pharmacy Information System (PIS)
Integration Options
CPOE, PIS use the same architecture, database
structure, and CDR. Potential for integration of
CDS and interdisciplinary communication.

• Integrated all-in-one system
• Bi-directional orders interface
• Unidirectional orders interface
• No interface

Orders from CPOE transmit to existing PIS Orders
generated or corrected in the existing PIS are
populated in orders and med admin sections of the
CIS
Pharmacy has to reenter orders in the CPOE system
that are incorrect.
Medication orders entered in CPOE system and
printed in the pharmacy.
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CPOE-Pharmacy Scope-of-integration considerations

• Settings served (inpatient vs. inpatient and
  outpatient)
• Different settings may require different
  interfaces.
• Types of medication orders
• Processing needs vary for each order type
• Content of medication orders
• How much information will be transmitted to the
  PIS via the pharmacy interface? May require
  customization be purchased separately.
• Non-medication-order messages.
• Most PISs and many CISs have not been designed to
  incorporate interdisciplinary communication
  tools.
• Allergies and Diagnoses
• There are a host of integration questions
  associated with allergy and diagnosis data
  stemming from the different sources for the
  information, accessibility of stored data, need
  for ongoing synchronization, and format and
  coding of allergy information.
• Medication administration documentation and
  billing
• Electronic medication administration records,
  automated dispensing machines, and
  bar-code-scanning devices all require interface
  work.

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Technical Aspects of Interfaces

• There is no defined methodology for addressing
  the many facets of interface specification
  creation, norhow the interface will behave in
  conjunction with the CPOE system and the PIS.Not
  only are the data in this scenario complex, but
  the implications of an error in medication order
  transmission can directly impact patient care.

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Pharmacy Practice Issues

• Pharmacist interventions to resolve medication
  problems result in medication change in about 50
  (community) to 80 (hospital) of cases.
• The evidence base for effectiveness of clinical
  pharmacy services is solid.
• The evidence base for effectiveness of expanded
  community pharmacy services (e.g. medication
  reviews, pharmaceutical case management, and
  disease state management) is rapidly growing.
• But pharmacists over-ride 80 of
  computer-generated PDUR alerts

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Pharmacy Practice Issues

• Computer systems for clinical decision support in
  hospital pharmacy practice
• Opportunities for integrated information systems
  are best for pharmacy practice within hospitals
  or health systems. However, CDS in many (most?)
  hospital pharmacy information systems operates
  independently of other hospital databases.
• Rules-based pharmacy information system DUR
  alerts are commonplace.
• In-depth electronic clinical reference databases
  via drug information departments.
• Pharmacy-lab side databases are increasing.
• Alerting of prescribers and pharmacists via
  common CDS software run on a common CDR is
  (almost?) nonexistent.
• Integrated CPOE/pharmacy systems are increasing
  but emphasize legibility errors and CPOE
  rules-based alerts using clinical reference
  databases that are often different than those in
  pharmacy systems.
• Few CPOE/pharmacy integrated systems have
  interdisciplinary messaging capabilities.
• Some CPOE/pharmacy integrated systems have only
  unidirectional or no interface.

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Pharmacy Practice Issues

• Computer systems for clinical decision support in
  community pharmacy practice
• Rules-based pharmacy information system DUR
  alerts are commonplace.
• Access to in-depth electronic clinical reference
  databases via internet.
• Diagnosis, allergy, and laboratory information
  must be collected from patient or provider by the
  pharmacist, but the patient is accessible to the
  dispensing community pharmacist.
• MMA is expected to increase delivery of expanded
  pharmacy services especially for more complex
  patients.

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Service Categories
Specialty Services
Specialty Codes
Medication Therapy Management Services (MTMS)
CPT EM / MTMS
Dispensing Related Services
Dispensing Fees
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Value of Pharmacy Information Systems
?

• Stand-alone systems contain
• Practice management software, perhaps linked with
  automated dispensing, bar-coding.
• Clinical decision support software
• DUR alerts
• In-depth electronic clinical reference
  information
• Special programs (e.g. problem-oriented pharmacy
  records for disease state management, MTMS
  programs).
• Integrated systems
• interface with clinical information systems
• Including CPOE/e-Prescribing, laboratory, EMR
• interface with automated dispensing and
  bar-coding

Theoretically limited by less access to
electronic patient clinical data
But community pharmacists have greater patient
access.
?
Theoretically higher quality of care and greater
efficiency.
But CDS for hospital pharmacists mainly runs on
only pharmacy data.
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Summary Opinion

• Pharmacists are a rich reservoir of clinical
  knowledge and perspective that is complementary
  to physician services. Automation of dispensing,
  reimbursement for medication therapy management
  services and other specialized clinical services,
  and enhanced clinical patient information access
  are three potent current forces likely to expand
  pharmacy capacity to improve medication safety.