US Pharm. 2011;36(8):54-56.
Welcome to the first edition of a new column, called TechRx, that will focus on the technologies that pharmacists will be encountering now and in the years ahead in this era of health care reform. In the months to come, I will review these various topics, focusing on such technology enablers as mobile health care, including the trials and tribulations of e-prescribing, medical records, and remote access to medications and medical records, to name just a few.
Additionally, our pharmacy careers will evolve over time as more and more of these technologies are introduced into the health care environment. These developments will deepen our need as health care professionals to stay informed and to optimize our own personal career paths. Our ability to understand the need to deliver quality care regardless of geography or proximity to the pharmacy is where health care is headed, and pharmacists must be in touch and engaged to help shape this evolving landscape.
Technology and Patient Safety
As we will see in this column, there is an obvious progression of health information technology (IT) and all of the various technologies that can be utilized and implemented to enhance the practice of pharmacy and health care. For example, there is a lot of work to be done in the realm of medication adherence and avoidance of adverse drug reactions (ADRs). We have seen the statistics: approximately 1% of hospital admissions in industrialized nations are due to medication noncompliance, and 5.1% (95% confidence interval [CI] 4.4-5.8) of all hospitalizations are due to ADRs.1 The mortality rate of patients admitted for ADRs is 3.7%.1 Hence, having the support of technology enablers to address these problems can only ensure a more precise way to improve patient safety. These technologies will support the various stakeholders, including the pharmacist, the clinician, other providers, and the consumer, all of whom want quality care.
Leveraging Current Technologies
To level the technologic landscape we are encountering today in our pharmacy careers, various technologies have been employed, most commonly to consolidate information and provide access to data and quality metrics. Whether it is e-prescribing or electronic health records (EHRs), the time has come to further leverage technologies to gain instant access to patient data and care information; but only by employing the technologies with a plan to enable the clinician to seamlessly integrate the data into daily workflows will we find the technology most accepted. Acceptance is the first step, and then comes the adoption of the technology into the mainstream. Technology cannot be an enabler unless it is widely integrated into clinical practice.
Once the technology is introduced and accepted, the final step is the demand for accountability of the technology’s application to ensure that the cost, quality, and safety of patient care is fulfilled using that technology. As pharmacists, we develop relationships of trust with our patients. Similarly, we need to trust the technology introduced into our clinical setting. Thus, the new technologies need to support our workflows and objectives while simultaneously building upon the mission of quality care.
Building a Bridge of Acceptance
Without being given a reason for implementing the technologies, clinicians will avoid adopting them, making it more difficult to build a uniform mechanism to share data. For example, we still see a uniform need to adopt e-prescribing nationwide as well as universal standards for EHRs. These technologies need to be adopted and implemented with the patient in mind, not just for the sake of the technologies themselves, but also as tools to support improved patient outcomes. I see pharmacists playing a vital role in building this bridge of acceptance. We can empower ourselves and those around us and answer the “why” of an acceptance of a technology.
As we move forward over the next few months together, the key points we need to think about collectively as a profession are the following: First, health care technologies need to enable and support our efforts and should enhance the quality of the patient experience and improve outcomes; this should be done using systems that support clinical workflow and improve—not hinder—operational efficiencies. At the same time, the systems must protect the privacy and security of data through the use of carefully designed technology.
Second, as pharmacists we need to support these technologies to ensure continued momentum in health care to avoid technology overload on our profession. With the Stage I Meaningful Use hurdle behind the medical community, we need to equip our profession to better understand what we have to do to support the various initiatives and how we can make them more beneficial to our patients. We need to support the various efforts to ensure success stories to keep the momentum going.
Third, having a practical understanding of the technologies and their benefits to and impact on the practice of quality care is paramount. This will enable acceptance, assimilation, and an overall appreciation of how these technology enablers can enhance our various efforts in supporting patient care.
The ultimate goal of introducing technology into health care is to make it more effective and efficient with the overarching aim of delivering value, best practices, and positive clinical outcomes for our patients. In future TechRx columns, I hope to better inform pharmacists so that they can be engaged and empowered to not only support the initiatives, but to be a part of the mix.
We will cover a variety of topics in this column. Perhaps the most relevant to pharmacists is e-prescribing. We will begin with a basic overview and will try to clear up some confusion, such as what is the actual definition of e-prescribing and how does an e-prescription differ from a facsimile, or the so-called e-fax? This is important for pharmacists to understand since they are expected to correctly report the “prescription origin code” for each prescription they fill. E-prescribing networks and the role of intermediaries will be described, and we will note that some e-prescriptions actually are converted to faxes for a variety of reasons by intermediaries. We will also review how the pharmacy software receives e-prescriptions and how older versus newer software processes the e-prescriptions in the pharmacy system.
We will review some of the requirements for e-prescribing in the Medicare Part D program, as well as in the federal HITECH meaningful-use program. Several recent studies of e-prescribing identify significant decreases in prescribing errors of all types—an important area for pharmacists to be well informed in. We will also cover some of the challenges inherent in e-prescribing of controlled substances, including authentication of the prescriber, the role of a public key infrastructure, and the need to upgrade pharmacy software and to have the software certified for controlled substances. Pharmacists should know about electronic signatures. What is the federal definition of an electronic signature, and what is acceptable in various states? In addition, there are new processes and audit trails that pharmacies are expected to adopt as they implement systems for controlled-substance e-prescribing. We will also review some of the advances with the electronic SIG, such as the introduction of RxNorm.
It is important for pharmacists to know how databases of medication history can be made available so that prescribers can check for drug–drug interactions while generating an e-prescription and before transmitting or printing the prescription. We will note the different databases that are available and the caveats associated with the various types. We will discuss issues such as when should a pharmacy claim be voided if the patient fails to pick up a prescription? This impacts the usefulness of medication history databases that rely on claims submissions.
Medication history databases can assist with the process of medication reconciliation. The systematic and complete reconciliation of medication lists for patients as they traverse the continuum of the patient-care system is a critical patient-safety issue and has been identified as such by the Joint Commission.2 However, the implementation of effective systems has been very difficult to achieve, and the role of the pharmacist in successful medication reconciliation is still viewed as critical. In addition, the domain of medication therapy management (MTM) offers great potential to enhance patient safety, and pharmacists can play a key role in educating patients about their medications, in addition to reinforcing the message to be compliant with the regimen. Such pharmacy-patient interactions can be enhanced by availability of timely clinical information via electronic means so that the MTM pharmacist has valid clinical information about the patient to use in conjunction with the reconciled medication list.
Point-of-Care Decision Support
In addition, we will discuss the availability of point-of-care decision support software for the prescriber. Such software can be very simple, such as dealing only with drug–drug interactions, to quite complex, including drug–disease interactions and drug–lab interactions. There are a variety of efforts under way to develop standardized national databases for drug–drug interactions of high clinical significance.
Many of the current databases include so many interactions of minimal or questionable clinical significance that prescribers develop “alert fatigue” and turn the software edits off. Pharmacists should be aware of the issues that are being vetted on the prescriber side of the equation. E-prescribing also affords the prescriber and pharmacist greater opportunities to communicate via electronic means. Hence, possible adverse patient effects or questions can be more readily discussed between the pharmacist and the prescriber electronically.
Other areas of great importance to the pharmacist include the use of robotics. We will discuss how robotic solutions in best-practice settings have improved patient care and reduced medication errors. Bar codes and radio-frequency identification (RFID) tags are being deployed more and more frequently in the inpatient setting to minimize medication errors. We will review some studies from facilities where computerized order entry is combined with best practices using bar coding to minimize drug administration errors in hospitals that feature best practices. We will explore model systems where the entire medication prescribing, dispensing, and administration process has been automated, and we will look at the general impact on adoptions, workflow, implementation, and patient outcomes.
In summary, we live in a historic time in which the electronic revolution that has already greatly improved the safety record in certain industries is now being applied to health care. As a key member of the health care delivery team, the pharmacist should be thoroughly immersed in and familiar with these technologies.
1. Einarson TR. Drug-related hospital admissions. Ann Pharmacother. 1993;27:832-840.
2. The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alert. 2006;35. www.jointcommission.org/