The Impact of Electronic Health Records on Pharmacy Practice

Home , Electronic health record, Medical record

CREDIT: 2.0 Continuing Education EARN CE CREDIT FOR THIS ACTIVITY AT WWW.DRUGTOPICS.COM AN ONGOING CE PROGRAM OF THE UNIVERSITY OF CONNECTICUT educationaL oBJectiVeS SCHOOL OF PHARMACY AND DRUG TOPICS

Goal: To assist pharmacists and pharmacy technicians in understanding the impact of electronic health record (EHR) systems on pharmacy practice, as the use of EHR systems continues to increase. After participating in this activity, pharmacists will be able to: ● Summarize the impact on pharmacy practice of the new HHS rules governing the use of electronic health record (EHR) systems. ● Identify the ways in which EHR systems will increase the effi ciency of pharmacy practice with respect to continuity of care, formulary checks, drug-to-drug and drug-to-allergy interactions, and medication reconciliation. ● Summarize the challenges pharmacists face as EHR systems come into increasingly wider use. ● Apply the process of pharmacists using EHRs to case scenarios

After participating in this activity, pharmacy technicians will be able to: ● Recognize the impact on pharmacy practice of the new HHS rules governing the use of EHR systems. the impact of electronic ● Identify the ways in which EHR systems will increase the effi ciency of pharmacy practice with respect to continuity of care, formulary health records on checks, drug-to-drug and drug-to-allergy interactions, and medication reconciliation. pharmacy practice ● Recognize the challenges pharmacists face as EHR systems come into increasingly wider use. Rachelle Spiro, RPh, FASCP The University of Connecticut School of DIRECTOR, PHARMACY E-HEALTH INFORMATION TECHNOLOGY COLLABORATIVE, ALEXANDRIA, VA; CEO Pharmacy is accredited by the Accreditation AND PRESIDENT, SPIRO CONSULTING, INC., LAS VEGAS, NV Council for Pharmacy Education as a provider of continuing pharmacy education. Pharmacists are eligible to participate in both the ith the American Recovery At the bill’s enactment in 2009, only knowledge-based and application-based activities, and Reinvestment Act (ARRA), 11.9% of hospitals made any use of EHRs, and will receive up to 0.2 CEUs (2 contact hours) for which was signed into law in with only 2% meeting what would be stage W 4 completing the activity/activities, passing the quiz/ 2009, Congress set ambitious goals for 1 meaningful use criteria. Only 21.8% of quizzes with a grade of 70% or better, and completing an online evaluation. Statements of credit are available the nation to integrate information technol- offi ce-based physicians had basic electronic via the online system. ogy into healthcare delivery.1,2 A segment systems and only 6.9% had fully functional Pharmacy technicians are eligible to participate in of ARRA, the Health Information Technol- electronic systems.5 The U.S. Department the knowledge-based activity and will receive 0.1 ogy for Economic and Clinical Health Act of Health & Human Services (HHS) fi nal- CEU (1 contact hour) for completing the activity, passing the quiz with a grade of 70% or better, and (HITECH), authorized incentive payments ized the meaningful use criteria for the fi rst completing the online evaluation. Statements of through Medicare and Medicaid to provid- 2 years of the 3-stage incentive program credit are available via the online system. ers that use certified electronic health in mid 2010.5 The bill’s health information ACPE #0009-9999-12-007-H04-P/T (Part 1) records (EHRs) to achieve specifi ed im- technology (HIT) component followed the ACPE #0009-9999-12-008-HO4-P (Part 2) provements in healthcare delivery and earlier Offi ce of the National Coordinator Grant Funding: Funding for this activity was provided by: implement a nationwide EHR system by (ONC) for Health Information Technology Cephalon; Endo Pharmaceuticals, Inc.; Purdue Pharma L.P. 2014.3 created by presidential executive order in Activity Fee: There is no fee for these activities. Initial release date: 4/10/2012 Faculty: Rachelle Spiro, RPh, FaScP Expiration date: 4/10/2014 Ms. Spiro is Director, Pharmacy e-Health Information Technology Collaborative, Alexandria, VA, and CEO and President, Spiro Consulting, Inc., Las Vegas, NV. Editorial assistance was provided by Deborah To obtain immediate CPE credit, take the test online Kaplan. Ms. Kaplan’s revisions were reviewed and approved by Ms. Spiro. at www.drugtopics.com/cpe. Just click on the link you Faculty Disclosure: Ms. Spiro has no actual or potential confl ict of interest associated with this article. find under Free CPE Activities, which will take you to the CPE site. For first-time users, please complete the Disclosure of Discussions of Off-Label and Investigational Uses of Drugs: This activity may contain discussion registration page. For those already registered, log of unlabeled/unapproved use of drugs. The content and views presented in this educational program are in, find, and click on this lesson. Test results will be those of the faculty and do not necessarily represent those of Drug Topics or University of Connecticut displayed immediately. Complete the evaluation form School of Pharmacy. Please refer to the offi cial prescribing information for each product for discussion and you will receive a printable statement of credit by of approved indications, contraindications, and warnings. GETTY IMAGES/PHOTODISC/MACIEJ FROLOW e-mail, showing your earned CPE credit. For questions concerning the online CPE activities, e-mail: [email protected]. 46 Drug topics April 2012 DrugTopics.com continuing education

glossary of terms Abstract ACO Accountable care The American Recovery and Reinvestment Act of 2009 set ambitious goals for organization the nation to integrate information technology into healthcare delivery. The ADEs Adverse drug events Health Information Technology for Economic and Clinical Health Act segment of ARRA American Recovery and the bill provides incentives for Medicare and Medicaid providers to use certi ed Reinvestment Act electronic health records (EHRs) to achieve speci ed improvements in healthcare CAH Critical access hospital and implement a nationwide EHR system by 2014. Meaningful use criteria CCD Continuity-of-care document are being promulgated in 3 stages. Medicare and Medicaid incentive payments CDS Clinical decision support will total $27 billion over a 10-year period with $17 billion designated for EHR development. Pharmacists will not receive direct funding or incentives but CMR Comprehensive medication pharmacy schools may receive grants for incorporating electronic personal health review technology into clinical education. The nation’s goal for EHRs is to reduce costs CMS Center for Medicare and through less paperwork, improved safety, and reduced duplication of testing, and Medicaid Services improve health by gathering a patient’s entire health information in a single CPOE Computerized provider order location. Electronic connectivity through e-prescribing—the paperless, real-time entry transmission of standardized prescription data among prescribers, pharmacies, CPT Current procedural and payers—places pharmacists squarely within the healthcare technology team. terminology The Pharmacy e-Health Information Technology (HIT) Collaborative, a group of DEA Drug Enforcement Agency 9 national pharmacy organizations and associate members, advocates integrating EHR Electronic health record the pharmacist’s role of providing patient care services into the national HIT EMR Electronic medical record interoperable framework. The greatest challenge that pharmacists face in the new EPCS Electronic prescribing for era of electronic health information is to be recognized by Medicare and Medicaid controlled substances as eligible providers of medication-related patient care services and as meaningful ePHR Electronic personal health use contributors to electronic health information. record HHS U.S. Department of Health & The primary goals of improving the na- physician offi ces by 2019.8 The Congres- Human Services tion’s HIT infrastructure are to: sional Budget Office has projected that HIPAA Health Insurance Portability • Ensure protection and privacy of HITECH will reduce federal and private sec- and Accountability Act healthcare information; tor spending on health services during the HITECH Health Information • Improve patient care by reducing next decade by tens of billions of dollars 9 Technology for Economic medical errors; by increasing effi ciency. By October 2011, Clinical Health • Reduce costs by removing administra- $1.2 billion incentives had been paid.7 Pre- HIE Health information exchange tive barriers that result in duplicative claims liminary data for 2011 show the use of and services; and EHRs growing, but the goals for 2019 are HIT Health information 10 technology • Improve coordination of care among considered ambitious. healthcare providers. Pharmacists will not receive direct fund- HL7 Health Level Seven To achieve these goals, as much as $27 ing or incentives for adopting electronic LTC Long-term care billion over 10 years was designated in Medi- medical record technology. Pharmacy MTM Medical therapy management care and Medicaid incentive payments for schools, however, are included among the ONC Offi ce of the National eligible providers who use EHRs and demon- list of approved graduate schools that may Coordinator strate “meaningful use” of HIT.3 In addition, receive grants for incorporating electronic PCP Primary care physician (or HIT systems have to be certifi ed as meet- personal health technology into clinical edu- provider) ing certain technologic standards. A total of cation.1 Stage 1 of the 3-stage meaningful PHR Personal health record $19 billion was designated to implement HIT use program launched in 2010 focuses PMS Pharmacy management regional health information exchange (HIE) on the integration of electronic healthcare system networks.1,3 Of this amount, $17 billion in- among patients, providers, government PP-EHR Pharmacy/pharmacist cludes the incentive payments to physicians agencies, and insurers. There are 25 Medi- provider electronic health and hospitals to develop personal healthcare care and Medicaid meaningful use criteria, record records by 2014. The remaining $2 billion of which eligible professionals must adopt is allocated to developing and improving the 15 professional core objectives to qualify 2004.6 ONC works with the Center for Medi- nation’s HIT infrastructure.1,3 for the incentives (Table 1, page 48).7 care and Medicaid Services (CMS) to set the The Congressional Research Service Eligible professionals can receive as much policies relevant to incentive payments under expects that the incentives will promote as $44,000 over a 5-year period through meaningful use requirements.7 EHR use in 70% of hospitals and 90% of Medicare. For Medicaid, eligible profession-

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TABLE 1 TABLE 2 proFessional core oBJecTives required For Medicare and BeneFiTs oF MeaningFul Medicaid incenTives use oF ehrs 1. Use CPOE By adopting EHRs in a meaningful way, healthcare providers can: 2. Implement drug-drug and drug-allergy interaction checks » Know more about their patients. 3. Maintain an up-to-date problem list of current and active diagnoses Information in EHRs can be used to 4. Generate and transmit permissible prescriptions electronically coordinate and improve the quality 5. Maintain an active medications list of patient care. 6. Maintain an active medications allergy list » Make better decisions. With more comprehensive information readily 7. Record demographics (preferred language, gender, race, ethnicity, date of birth) and securely available, healthcare 8. Record vital signs and chart changes (height, weight, blood pressure, BMI, growth charts for providers will have the information children aged 2 to 20 years) they need about treatments and 9. Record smoking status for patients aged 13 years or older conditions – even best practices for 10. Report ambulatory clinical quality measures patient populations – when making treatment decisions. 11. Implement clinical decision support rule as determined by the eligible professional » Save money. EHRs require an 12. Provide patients with an electronic copy of their health information initial investment of time and 13. Provide clinical summaries for patients for each offi ce visit money, but healthcare providers 14. Capability to exchange key clinical information electronically (eg, problem list, medication list, who have implemented them have diagnostic test results) among care providers and patient-authorized entities reported reductions in the amount of time spent locating paper fi les, 15. Protect electronic health information by use of certifi ed technology Abbreviations: BMI, body mass index; CPOE, computerized provider order entry. transcribing, and spending time on Source: Ref 7 the phone with labs or pharmacies; more accurate coding; and als can receive as much as $63,750 over 6 emphasis on having electronic systems reductions in reporting burden. years.11 The fi rst incentives were scheduled that are interoperable or can commu- Abbreviations: EHR, electronic health record. Source: Ref 11 for October 2011 based on 2010 perfor- nicate with each other. Thus, the 2012 mance. By 2015, physicians who are not stage 2 rules require that systems be able information on an individual that can be using certifi ed EHRs could be penalized by to transfer patient information including a drawn from multiple sources and that is Medicare and Medicaid.12 patient’s notes, medications list, allergies, managed, shared, and controlled by and In February 2012, federal offi cials re- and diagnostic and laboratory test results for the individual.”11 The EHR differs from leased the stage 2 guidelines for mean- across platforms. The information should the EMR in that it contains information that ingful use.11 The proposed stage 2 rules, also be available to patients to view their is shared among healthcare providers using which are undergoing review at this time, records online as well as download and interoperability standards.6 The EHR is an require physicians and hospitals to sig- transfer information. Additionally, patients individual patient’s medical record in digital, nifi cantly increase their use of electronic should be able to communicate with their interoperable format that includes the pa- health information, as well as better en- physicians through a secure, online sys- tient’s demographics, medical history, aller- gage patients and improve the transfer- tem or patient portal.13 gies, medications, progress notes, labora- ability of records.13 The meaningful use tory and diagnostic test results, scans, and approach requires identifi cation of stan- integrating pharmacy advance directives. It contains data from dards structured in uniform ways so that health information in many sources and can communicate with EHR systems can deliver the information u.s. healthcare various health and medical entities.6 just as commonly used automated teller Often the terms electronic medical record An electronic tool that is initiated by the machines depend on uniformly structured (EMR) and electronic health record (EHR) patient is the electronic personal health re- data.7 If data cannot be captured uniform- technology are used interchangeably. cord (ePHR).6 In contrast to the EHR, which ly, electronic systems cannot communi- EHR is defi ned as “an electronic record of is generated by healthcare providers, the cate or are not interoperable.14,15 Stage 2 health-related information on an individual ePHR can be generated by physicians, pa- meaningful usage will require that at least that is created, gathered, managed, and tients, hospitals, pharmacies, and other 60% of patients have their medications consulted by authorized healthcare clini- sources but is managed by the patient.11 and laboratory tests ordered electronically cians and staff.”11 The personal health Ultimately, it is the ePHR that healthcare instead of the 30% required by the stage record (PHR) is defi ned as “an electronic analysts consider the best electronic tool 1 regulations. The government is placing record of individually identifiable health to address concerns about privacy issues

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with electronic health information.16 TABLE 3 tions were being routed electronically.20 The nation’s goal for EHRs is to reduce inTerneT resources For More than half of offi ce-based physicians costs through less paperwork, improved safe- e-prescriBing in the United States are reported to use ty, reduced duplication of testing, and improve www.cms.hhs.gov/eprescribing e-prescribing.21 The number of pharma- health by gathering a patient’s entire health cies connected electronically also contin- www.ehealthinitiative.org information in a single location. Additionally, ues to increase. According to Surescripts, EHRs can compute the information. For ex- www.himss.org 91% of community pharmacies in the ample, a qualifi ed EHR not only contains a www.nationalerx.com United States in 2010 were connected record of a patient’s medications or allergies for prescription routing compared with www.surescripts.com but also automatically checks for problems 76% in 2008. For independently owned whenever a new medication is prescribed and pharmacies, 73% were connected in 2010 alerts the clinician to potential confl icts.7 The ity. Each provider type can adopt a standard compared with 46% in 2008.20 meaningful use of EHRs and HIEs can help HL7 EHR functional profi le (e.g., pharma- A national survey reported that commu- clinicians provide higher quality and safer care cists can adopt a pharmacist EHR specifi c nity pharmacists and technicians were gen- for their patients (Table 2, page 48).11 for documentation of pharmacist-provided erally satisfi ed with e-prescribing because For the purposes of the Medicare and patient care information). These are differ- of the improved legibility of electronic pre- Medicaid incentive programs, eligible pro- ent from claims-based standards used by scriptions and more effi cient processing.22 fessionals, eligible hospitals, and critical ac- pharmacists for billing prescriptions such Pharmacists in the survey also noted that cess hospitals (CAHs) must use certifi ed as NCPDP version D.0. refi ll prescriptions and new prescriptions EHR technology. The federal government required less staff time. Prescribing errors has established certification standards were the most commonly cited negative consistent with requirements for meaning- feature of e-prescribing, particularly those ful use.17 Certifi ed EHR technology gives Each provider which called for a wrong drug or gave er- assurance to purchasers and other users roneous directions.22 that an EHR system or module offers the type can adopt a In more than 100 interviews with physi- necessary technologic capability, function- cian practices and pharmacies nationwide ality, and security to help them meet the standard HL7 EHR this past year, researchers at the Center meaningful use criteria. Certifi cation also for Studying Health System Change noted helps providers and patients be confi dent functional pro le. fl aws and inconsistencies concentrated in that the electronic HIT products and sys- 3 critical areas in e-prescriptions. These in- tems they use are secure, can maintain clude prescription renewals, connectivity be- data confi dentially, and can work with other e-prescribing: use, tween physician offi ces and mail-order phar- systems to share information.11 beneﬁ ts, challenges macies, and manual entry of prescription The PP-EHR is the pharmacy/pharma- Electronic connectivity through electronic information by pharmacists.23 Moreover, cist provider electronic health record. The (e)-prescribing—the paperless, real-time pharmacies and physicians report dupli- Pharmacy e-HIT Collaborative, a group of transmission of standardized prescription cate or confl icting messages. Signifi cantly, 9 national pharmacy organizations and as- data among prescribers, pharmacies, and short-cut features fail to aid that message sociate members, continues to work with payers—places pharmacists squarely and communication fi elds that complete national EHR certifi cation organizations and within the healthcare technology team.19 automatically often require follow-up calls pharmacy system vendors to assure that E-prescribing communicates medications or manual entry by pharmacists to clarify a the PP-EHR functionality is adopted with history, new prescriptions, changes, refi lls, physician’s orders, verify quantities and sig the development of certifi cation criteria to and other prescription data. In 2000, the codes (pharmacy terminology), or provide meet the meaningful use of EHR concepts Institute of Medicine recommended that patient-friendly instructions.23 related to pharmacy services.18 Members e-prescribing be in place for all prescrip- One barrier to e-prescribing—mainte- of the Collaborative were involved in working tions by 2010. Although short of that goal, nance of a parallel paper system for con- with a joint Health Level Seven (HL7) and Na- by 2010 more than 300 million prescrip- trolled substances—essentially ended tional Council for Prescription Drug Programs (NCPDP) work group in the development of the PP-EHR functional profi le, an HL7 func- pause&ponder tional profi le that represents “the functional- according to a national survey, community pharmacists ity required and desired for a care setting or and technicians were generally satisfi ed with application, or refl ect the functionality incor- e-prescribing because of the improved legibility of porated in a vendor’s EHR system.”18 electronic prescriptions. However, are you still following To elaborate further, from a standards up frequently with physicians to clarify orders? perspective, all EHRs follow HL7 functional-

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TABLE 4 TABLE 5 10 goals For pharMacy inTegraTion in healThcare sysTeM vocaBulary sTandards For elecTronic healTh 1. Ensure HIT supports pharmacists in healthcare service delivery inForMaTion (code seTs) 2. Achieve integration of clinical data with electronic prescription (e-prescribing) information Codes sets are used for encoding 3. Advocate pharmacist recognition in existing programs and policies data elements, such as medical 4. Ensure HIT infrastructure includes and supports MTM services concepts, diagnoses, or procedures. (Nonmedical code sets, also known 5. Integrate pharmacist-delivered immunizations into the EHR as administrative code sets, encode 6. Achieve recognition of pharmacists as meaningful users of EHR quality measures nonmedical data, including ZIP code, 7. Advance system vendor EHR certifi cation state abbreviations.) » Clinical terms. Systematized 8. Promote pharmacist adoption and use of HIT and EHRs Nomenclature of Medicine Clinical 9. Achieve integration of pharmacies and pharmacists into health information exchanges Terms (SNOMED CT) » Diagnosis codes: ICD-10 (coding 10. Establish the value and effective use of HIT solutions by pharmacists Abbreviations: EHR, electronic health record; HIT, health information technology; MTM, medication therapy management. for all providers covered by the Source: Ref 18 Health Insurance Portability and Accountability Act (HIPAA) when the prohibition against e-prescribing 4).18 The Collaborative states that phar- » Laboratory test results. Logical for controlled substances (EPCS) was macists have an important role in optimal Observation Identifi ers Names and amended in 2010 when the U.S. Drug En- therapeutic outcomes and safe and cost- Codes (LOINC) forcement Administration (DEA) issued new effective medication use and that the clini- » Medications. RxNorm, a standardized regulations that provide practitioners with cal services of pharmacists are a critical nomenclature for clinical drugs and the option of EPCS. The revised DEA regu- component of the U.S. healthcare system. drug delivery devices, is produced by lations also permit pharmacies to receive, For example, the ability to report adverse the National Library of Medicine. dispense, and archive electronic prescrip- drug events (ADEs) within the EHR and in- » Immunizations. Code set for tions.24 It is important to note, however, that tegrate reports on a national level allows vaccines administered (CVX) Source: Ref 7 not all states have authorized EPCS, par- for tracking ADEs and early identifi cation ticularly Schedule II controlled substances. of potentially dangerous medication side MTM core elements service model illus- For more information on e-prescribing, effects.18 trates how pharmacists can interface with please consult the websites listed in Table Medication therapy management (MTM), the patient care process (Figure 1, page 3, page 49. which can optimize therapeutic outcomes 51). The process begins with medication for individual patients, is a unique area of therapy review. The patient interview is EHr systems increase contribution for pharmacy.25 Pharmacists conducted and a database with patient efﬁ ciency of pharmacy are key information providers in MTM, in- information is created. Medications are re- practice, improving patient cluding medication reconciliation and care viewed for indication, effectiveness, safety, outcomes transitions, medication adherence, medi- and adherence. A list of medication-relat- The Pharmacy e-HIT Collaborative advo- cation monitoring, medication safety, and ed problems is generated and prioritized, cates integrating the pharmacist’s role of evaluation of medication errors.18 generating a MTM plan. Intervention and/ providing patient care services into the MTM core elements include: medication or referrals involve patient, physician, phar- national HIT interoperable framework.18 therapy review; personal medication record; macist, or other healthcare professionals. The Collaborative has issued a 10-goal medication-related action plan; intervention It is estimated that more than half of plan entitled “The Roadmap for Pharmacy and referral; and documentation.18 Sharing medication errors occur during patient care Health Information Technology Integra- components of MTM between providers by transitions.26 The proposed 2012 stage 2 tion in U.S. Health Care” to promote the means of the continuity-of-care document meaningful use objectives require that medi- inclusion of pharmacists as recognized (CCD) demonstrates the value of meaning- cation reconciliation be conducted by 65% providers of the CMS HIT strategy (Table ful use of the EHR by pharmacists. The of care transitions by the receiving providers.18 Therefore, medication reconciliation pause&ponder at transitions of care should be part of the EHR documentation process in all practice Pharmacists have an important role in optimal 18 therapeutic outcomes and safe and cost-effective settings. At a minimum the following infor- medication use. are pharmacists in your practice setting mation should be communicated electroni- utilized appropriately to help during transitions of care? cally to pharmacists at transitions of care: medications list, medical condition, and aller-

50 Drug topics April 2012 DrugTopics.com continuing education

FIGURE 1

The Medication Therapy Management Core Elements Service Model The diagram depicts how the MTM Core Elements (❖) interface with the patient care process to create an MTM Service Model.

❖ MEDICATION THERAPY REVIEW ❖ INTERVENTION AND/OR REFERRAL

Interview patient and create Possible referral of patient ❖ to physician, another phar- PERSONAL a database with patient Create/Communicate MEDICATION information macist or other healthcare RECORD (PMR) professional

Review medications for indica- ❖ tion, effectiveness, safety, and Interventions directly with patients Implement MEDICATION- adherence Create/Communicate RELATED ACTION Plan PLAN (MAP)

List medication-related problem(s) & Prioritize Interventions via collaboration Complete/Communicate ❖ Physician and other healthcare & Conduct Create a plan DOCUMENTATION & professionals FOLLOW-UP

Used with permission. Copyright © 2008 by the American Pharmacists Association and the National Association of Chain Drug Stores Foundation. All rights reserved. Source: Ref 18 gies. For optimal medication management, under use. Because of their professional pharmacies and 350 Take Care Clinics pharmacists should receive the full content knowledge and capabilities, pharmacists nationwide will use the Surescripts clinical of the CCD including laboratory values, pre- should be recognized as meaningful users interoperability network to deliver immuniza- scriber information, and medication history.18 of the EHR in matters of Medicare Part D.18 tion records to the patient’s primary care The process of medication reconciliation provider.27 Currently, records such as in- includes comparing a patient’s medication Challenges pharmacists pharmacy immunizations have been sent orders to all the medications that the pa- face as EHR systems come to physicians by fax or traditional mail. By tient has been taking, and it should be un- into increasingly wider use using the electronic network, pharmacists dertaken at every transition of care in which The greatest challenge that pharmacists and pharmacy healthcare providers contrib- new medications are ordered or existing or- face in the new era of electronic health ute to the compilation of more complete ders are rewritten. The principles of medi- information is to be recognized as eligible medical histories for their patients.27 cation reconciliation must be incorporated providers by Medicare and Medicaid and In the 2011-2012 flu season, more into EHR systems, and to ensure that it is by accountable care organizations (ACOs) than 27,000 certified immunizing pharma- done appropriately, professional guidelines of medication-related patient care services cists, nurse practitioners, and physician should be implemented and overseen by and as meaningful users and contributors assistants at Walgreens and Duane Reade pharmacists.18 to EHR. As a first step, the Collaborative pharmacies and Take Care Clinics adminis- Medication adherence is a basic com- of pharmacy organizations urges that tered more than 5.5 million immunizations. ponent of comprehensive MTM. The Collab- e-prescribing be adopted in all practice Surescripts will use a standard format to orative states that with access to electronic settings. Further, pharmacists should capture immunization details and send health information from the CCD, pharma- exchange clinical information with each the record to the patient’s primary care cists and other providers can better as- other and other healthcare providers in a physician in whatever form the provider is sess medication adherence outcomes and bidirectional manner. Pharmacists need able to receive it, electronically or via fax address medication-related problems such to work with pharmacy system vendors to or mail. Physicians using a Surescripts- as drug-drug and drug-allergy interactions.18 set communications standards and build certified EHR, however, will have the op- Further, CMS recognizes the role of awareness of the standardized certified tion of receiving immunization records via pharmacists as MTM providers under the pharmacist EHR functional profile.18 Such the Surescripts Clinical Interoperability Medicare Part D program. This includes alliances support meaningful use and en- Network.27 pharmacist-provided education counseling able pharmacies to support improvements The pharmacy profession is actively for beneficiaries, compliance programs in care, safety, cost, and health outcomes. contributing to quality patient care through such as refill reminders and special pack- A recent example of such collaboration MTM services that identify and prevent aging, and detection of adverse events and is the announcement by Walgreens that all medication-related problems, improve medi- patterns of prescription drug overuse and of the 7,800 Walgreens and Duane Reade cation use, and optimize individual patient

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therapeutic outcomes. As MTM programs ting: hospital or ambulatory; no studies References continue to expand within the healthcare related to the long-term care setting were 1. American Recovery and Reinvestment Act of 2009. system, however, the lack of standardiza- identified. In 5 (50%) of the 10 studies, http://www.recovery.gov/About/Pages/The_Act. aspx#act. Accessed March 20, 2012. tion for documentation and billing of MTM CPOE with CDS contributed to a statisti- 2. Gold MR, McLaughlin CG, Devers KJ, Berenson services is limiting its use and is a barrier cally signifi cant decrease in ADEs P( ≤.05). RA, Bovbjerg RR. Obtaining providers’ ‘buy-in’ and 28 establishing effective means of information exchange to MTM service delivery for patients. To Four studies (40%) reported a nonstatisti- will be critical to HITECH’s success. Health Aff allow for the interchange of electronic in- cally signifi cant reduction in ADE rates, and (Millwood). 2012;31(3):514–526. formation, pharmacists need to champion 1 study (10%) demonstrated no change in 3. Health Information Technology for Economic and 32 Clinical Health (HITECH) Act, Title XIII of Division A and e-prescribing standards and use current ADE rates. Title IV of Division B of the American Recovery and procedural terminology (CPT) billing codes At a study at a 700-bed academic medi- Reinvestment Act of 2009 (ARRA), Pub. L. No. 111- 6 5 (Feb. 17, 2009), codifi ed at 42 U.S.C. §§300jj et for MTM services. Table 5 (page 50) iden- cal center in Chicago, clinical staff pharma- seq.; §§17901 et seq. Updated September 28, 2011. tifi es common code sets.7 cists saved all orders that contained a pre- http://healthit.hhs.gov/portal/server.pt/community/ 33 healthit_hhs_gov__regulations_and_guidance/1496. Pharmacy organizations large and small scribing error for a week in early 2002. Accessed March 20, 2012. must recognize that implementing HIT re- The investigators classified drug class, 4. Jha AK, DesRoches CM, Kralovec PD, Joshi MS. A progress quires designing workfl ow management to error type, proximal cause, phase of hos- report on electronic health records in US hospitals. Health Aff (Millwood). 2010;29(10):1951–1957. overcome the disruption that arrives with pitalization, and potential for patient harm 5. Hsiao C-J, Hing E, Socey TC, Cai B. Electronic medical new technologic practices.6 The negative and rated the likelihood that CPOE would record/electronic health record systems of offi ce-based physicians: United States, 2009 and preliminary 2010 impact of HIT implementation on care pro- have prevented the prescribing error. A total state estimates. Health E-Stats. Hyattsville, MD: National cesses, workfl ow, and safety is known and of 1,111 prescribing errors were identifi ed Center for Health Statistics. 2010. http://www.cdc. was the subject of a Joint Commission alert (62.4 errors per 1,000 medication orders), gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.pdf. Accessed March 20, 2012. 29 in 2008. Stresses placed on healthcare most occurring on admission (64%). Of 6. Webster L, Spiro RF. A new world for pharmacy. providers and staff when workfl ow is com- these, 30.8% were rated clinically signifi - Pharmacy Today. 2010;16:32–44. promised by new technology systems can cant and were most frequently related to 7. Centers for Medicare and Medicaid Services. CMS EMR meaningful use overview. Baltimore, MD: CMS. Last 6 produce technology-related adverse events. anti-infective medication orders, incorrect modifi ed December 8, 2011. https://www.cms.gov/ The USP MEDMARX for 2006 reported that dose, and medication knowledge defi cien- EHRIncentivePrograms/01_Overview.asp#TopOfPage. Accessed March 20, 2012. one-quarter of more than 175,000 medica- cy. Of all verifi ed prescribing errors, 64.4% 8. Redhead CS. The Health Information Technology for tion errors involved some aspect of comput- were rated as likely to be prevented with Economic and Clinical Health (HITECH) Act: CRS report 30 for Congress. Washington, DC: Congressional Research er technology. For example, an actual in- CPOE (including 43% of potentially harmful Service; February 23, 2009. creased risk for HIT-related medication errors errors), 13.2% unlikely to be prevented with 9. Stark P. Congressional intent for the HITECH act. Am J was reported in a study of a computerized CPOE, and 22.4% possibly prevented with Manag Care. 2010;16(12 Suppl HIT):SP24-SP28. provider order entry (CPOE) system.31 Ex- CPOE depending on specifi c CPOE system 10. Hsiao C-J, Hing E, Socey TC, Cai B. Electronic health record systems and intent to apply for meaningful use incentives amples included fragmented CPOE displays characteristics. The investigators concluded among offi ce-based physician practices, United States that conveyed erroneous information about that although prescribing errors are com- 2001–2011. Hyattsville, MD: National Center for Health Statistics; 2011, Data Brief No. 79. Revised February 8, patient medications and orders. mon in the hospital setting, CPOE systems 2012. http://www.cdc.gov/nchs/data/databriefs/DB79.pdf. To evaluate the effects of CPOE with could improve practitioner prescribing. The Accessed March 20, 2012. 11. U.S. Department of Health & Human Services. Offi ce clinical decision support (CDS) on ADEs, design and implementation of a CPOE sys- of the National Coordinator for Health Information researchers reviewed the medical literature tem should focus on errors with the great- Technology. Health IT. Washington, DC: HHS. Updated February 18, 2011. http://www.healthit.hhs.gov/. for original investigations, randomized and est potential for patient harm. Pharmacist Accessed March 20, 2012. nonrandomized clinical trials, and observa- involvement, in addition to a CPOE system 12. Healthcare Finance News. Eligible provider tional studies.32 They found studies that with advanced CDS, is vital for medication meaningful use criteria. December 31, 2009. www. 33 healthcarefi nancenews.com/news/eligible-provider- identified the type of computer system safety. meaningful-use-criteria. Accessed March 20, 2012. used, drug categories evaluated, types of 13. Torres C. Electronic health records program advances ADEs measured, and clinical outcomes. conclusion to ‘stage 2.’ Capsules, KHN blog. Kaiser Health News, February 24, 2012. http://capsules.kaiserhealthnews. Of the 543 citations identifi ed, 10 studies As members of the electronically con- org/index.php/2012/02/health-it-coordinator-release- met inclusion criteria. These studies were nected healthcare team, pharmacists of- stage-2-guidelines-a-push-ahead/. Accessed March 20, 2012. grouped into categories based on their set- have the unique knowledge, expertise, 14. Diamond CC, Shirky C. Health information technology: and responsibility to assume a signifi cant A few years of magical thinking? Health Aff (Millwood). Download or take the test online at role in electronic health information. And 2008;27(5):383–390. www.drugtopics.com/cpe 15. Hammond WE, Bailey C, Boucher P, Spohr M, Whitaker as governments and the healthcare com- P. Connecting information to improve health. Health Aff once there, click on the link below (Millwood). 2010;29(2):284–288. Free cpE Activities munity develop strategic plans for the widespread adoption of HIT, pharmacists 16. Healthcare Information and Management Systems Society. HIMSS’ PHR and ePHR defi nition and position must use their knowledge of information statement. http://www.himss.org/asp/topics_news_item. systems and the medication use process asp?cid=67200&tid=34. Accessed March 20, 2012. 17. Bean C. Certifi cation programs. Presentation at: Offi ce to ensure that the new technologies lead of the National Coordinator for Health Information to better patient outcomes.

52 Drug topics April 2012 DrugTopics.com continuing education

Technology Annual Meeting; Washington, DC, test questions November 16–18, 2011. 18. Pharmacy e-Health Information Technology 1. Results from a study evaluating prescribing errors d. No study met the inclusion criteria of Collaborative. The Roadmap for Pharmacy Health during 1 week in 2002 at a 700-bed academic computer system, drug categories, types of Information Technology Integration in U.S. Health Care. http://www.pharmacyhit.org/pdfs/11-392_ medical center showed that: ADEs, and clinical outcomes. RoadMapFinal_singlepages.pdf. Accesssed March a. Most prescribing errors occurred at 20, 2012. discharge from the hospital. 7. The American Recovery and Reinvestment Act, 19. Spiro RF, Gagnon JP, Knutson AR. Role of health b. Of all verified prescribing errors, 64.4% were which was signed into law in 2009, authorizes: information technology in optimizing pharmacists’ likely to be prevented with a computerized a. $10 billion designated to implement health patient care services. J Am Pharm Assoc (2003). provider order entry (CPOE) system. information technology (HIT) regional health 2010;50(1):4–8. c. Prescribing errors are uncommon in a large information exchange networks 20. Surescripts. The National Progress Report on academic setting. b. As much as $6,750 over 6 years for eligible E-Prescribing and Interoperable Healthcare 2010. d. The errors rated clinically significant were pharmacists http://www.surescripts.com/pdfs/national-progress- most frequently related to antihypertensive c. $27 billion over 10 years designated in report.pdf. Accessed March 20, 2012. medication. Medicare and Medicaid incentive payments 21. Surescripts. Surescripts announces that majority of doctors in U.S. now use e-prescribing. http:// for eligible providers who use EHRs and www.surescripts.com/news-and-events/press- 2. The goals of “The Roadmap for Pharmacy Health demonstrate “meaningful use” of HIT releases/2011/november/0911_saferx.aspx. Information Technology Integration in U.S. Health d. As much as $144,000 for eligible Accessed March 20, 2012. Care” include: physicians over a 5-year period through 22. Rupp MT, Warholak TL. Evaluation of e-prescribing a. Ensure federal incentives for pharmacists Medicare in chain community pharmacy: Best-practice b. Ensure medication standards for hospital recommendations. J Am Pharm Assoc (2003). formularies 8. In February 2012, federal officials released the 2008;48(3):364–370. c. Achieve unique pharmacy coding for stage 2 guidelines for meaningful use including: 23. Enderle L. The pitfalls of e-prescribing. Pharmacy Times. pharmacy-provided immunizations a. Requiring physicians and hospitals to November 29, 2011. http://www.pharmacytimes.com/ d. Achieve recognition of pharmacists as significantly increase their use of electronic web-exclusives/The-Pitfalls-of-E-Prescribing. Accessed March 20, 2012. meaningful users of electronic health record health information (EHR) quality measures b. Meaningful usage requiring that at 24. U.S. Department of Justice. Drug Enforcement Administration. Office of Diversion Control. Electronic least 80% of patients must have their prescriptions for controlled substances clarification. 3. The 15 professional core objectives required for medications and laboratory tests ordered http://www.deadiversion.usdoj.gov/fed_regs/ Medicare and Medicaid incentives include: electronically notices/2011/fr1019.htm. Accessed March 20, 2012. a. Record smoking status for adults (aged 20 c. Requirements for stage 2 meaningful use to 25. Bluml BM. Definition of medication therapy years or older) only be in place immediately management: Development of professionwide b. Record vital signs and chart changes for d. Pharmacy HIT systems become consensus. J Am Pharm Assoc (2003). children from newborn to 20 years interoperable by 2014 2005;45(5):566–572. c. Use a CPOE system 26. National Transitions of Care Coalition. Transitions d. Provide patients with paper and electronic 9. The nation’s goal for EHRs is to reduce costs of Care Measures, Paper by the NTOCC Measures Work Group, 2008. http://www.ntocc.org/Portals/0/ copies of their health information through less paperwork, improved safety, TransitionsOfCare_Measures.pdf. Accessed March and reduced duplication of testing, and to 20, 2012. 4. According to Surescripts, what percentage improve health by gathering a patient’s entire 27. Surescripts. Walgreens and Surescripts improve of community pharmacists in the United health information in a single location. EHRs coordination of care by electronically delivering States are connected for routing prescriptions accomplish this by: immunization and patient summary records to electronically? a. Being “an electronic record of health-related primary care providers. March 12, 2012. http:// a. 73% information on an individual that is created, www.surescripts.com/news-and-events/press- b. 76% gathered, managed, and consulted by releases/2012/march/312_walgreens.aspx. Accessed March 20, 2012. c. 82% authorized healthcare clinicians and staff.” d. 91% b. Being “an electronic record of individually 28. Millonig MK. Mapping the route to medication therapy management documentation and billing identifiable health information on an standardization and interoperabilility within the health 5. Because of recent changes in Drug Enforcement individual that can be drawn from multiple care system: meeting proceedings. J Am Pharm Assoc Agency regulations, which of the following is no sources and that is managed, shared, and (2003). 2009;49(3):372–382. longer a barrier to electronic prescribing? controlled by and for the individual.” 29. The Joint Commission. Safely implementing health a. Short-cut features that automatically c. Restricting data from certain defined sources information and converging technologies. Sentinel complete information fields and health and medical entities. Event Alert, Issue 42, December 11, 2008. http://www. b. Pharmacists’ investment in electronic d. Being generated by physicians, patients, jointcommission.org/sentinel_event_alert_issue_42_ software hospitals, pharmacies, and other sources safely_implementing_health_information_and_ converging_technologies/. Accessed March 20, 2012. c. Manual prescription information entry but initiated and managed by the patient. d. Prohibition against electronic prescribing for 30. USP U.S. Pharmacopeial Convention. MEDMARX 2006 data report. www.usp.org/products/medMarx. controlled substances 10. In more than 100 interviews with physician Accessed March 20, 2012. practices and pharmacies nationwide this past 31. Isaac T, Weissman JS, Davis RB, et al. Overrides of 6. The results of a review of the medical literature year, researchers at the Center for Studying medication alerts in ambulatory care. Arch Intern Med. to evaluate the effects of CPOE on adverse drug Health System Change noted flaws and 2009;169(3):305–311. events showed that: inconsistencies concentrated in 3 critical areas 32. Wolfstadt JI, Gurwitz JH, Field TS, et al. The effect of a. CPOE with clinical decision support in e-prescriptions. These include: computerized physician order entry with clinical decision contributed a statistically significant a. New prescriptions support on the rates of adverse drug events: A systematic decrease in adverse drug events (ADEs) in b. Volume of electronic prescriptions review. J Gen Intern Med. 2008;23(4):451–458. 50% of the studies. c. Connectivity between physician offices and 33. Bobb A, Gleason K, Husch M, Feinglass J, Yarnold PR, b. Three studies reported a nonstatistically mail-order pharmacies Noskin GA. The epidemiology of prescribing errors: significant reduction in ADE rates. d. Computerized entry of prescription The potential impact of computerized prescriber order entry. Arch Intern Med. 2004;164(7):785–792. c. Four studies demonstrated no change in information by pharmacists ADE rates.

DrugTopics.com April 2012 Drug topics 53 Continuing Education caSe StudieS case a electronic prescription for a Schedule C-II controlled substance was transmitted to the patient’s local pharmacy using an e- A primary care physician (PCP) electronically prescribes 5 medi- prescribing network. Using the pharmacist EHR, which does cations for a Medicare Part D patient post yearly physician visit. not have to be confi ned to the four walls of a pharmacy, the Four of the medications were continued from the previous visit. clinical pharmacist electronically queried the patient’s hospital This patient qualifi es for a yearly comprehensive medication re- discharge summary and electronically coordinated a pain medi- view (CMR) as defi ned by the Part D plan’s medication therapy cation action plan with the PCP and the home healthcare nurse. management (MTM) program. The pharmacist receives the electronic prescriptions, and the 1. Which of the following statements is correct? pharmacy management system (PMS) alerts the pharmacist that a. Controlled substance prescriptions cannot be sent via e-prescribing. the patient’s prescription drug plan will authorize a CMR using the b. Only Schedule C-II medications can be sent via e-prescribing. National Council for Prescription Drug Programs (NCPDP) standard- c. Pharmacies can receive electronic prescriptions for controlled sub- ized transaction (an electronic transaction for a payer to request stances from a hospital. MTM services from a provider). Mail and fax are other ways to d. All of the above. receive a CMR request. Under the Part D plan’s business agree- ment, the clinical pharmacist in charge of the pharmacy’s MTM 2. . In which of the following situations can a pharmacist query a hospital’s EHR? service programs messages the patient and the PCP that a CMR a. Pharmacist working in a community pharmacy is needed. The PMS adopted a pharmacist electronic health record b. Pharmacist working in a chain pharmacy (EHR) functionality, and the PMS is certifi ed for the meaningful use c. Pharmacist not working within the four walls of a pharmacy of the EHR criteria. d. All of the above Using the pharmacy’s e-prescribing network, the PMS queries the PCP’s EHR, the patient’s personal health record (PHR), 3. The medication action plan should be discussed with which of the following and the state health information exchange (HIE) for the patient’s individuals: continuity-of-care documents (CCD), which contain allergies, chief a. PCP b. Patient c. Nurse d. All of the above complaints, active medications list, diagnosis, family history, immunizations, functional status, social history, vital signs, laboratory case c data, etc. The patient schedules a CMR with the clinical pharma- An elderly patient asks her local chain pharmacy about getting cist. The result of the CMR is electronically exchanged with the her fl u shot. The pharmacist is not familiar with this patient and PCP’s EHR and the medication action plan is electronically sent notices that the patient displays symptoms of mild confusion. to the patient’s PHR. Using the PMS’s EHR, the pharmacist queries the PCP’s EHR and the public health department for the patient’s immunization 1. Which of the following statements is correct? a. Only e-prescribing networks can electronically connect with PMS. history, allergy information, and other pertinent information in b. PMS can connect with e-prescribing networks and HIEs. the form of a CCD. The query indicates that the patient has no c. Pharmacists are not allowed to access patient information through an known allergies, received a fl u vaccine last year, and a pneumo- HIE. coccal immunization the previous year. The pharmacist admin- d. Only physicians can access patient information through an HIE. isters the fl u vaccines and electronically transmits the new fl u vaccine information to the PCP and the public health department. 2. How is a request for a CMR transmitted? 1. If a pharmacist is unfamiliar with a patient’s vaccination history, the a. Electronically using an NCPDP standardized transaction following may be conducted: b. Fax a. Patient should be asked about their vaccination history. c. Mail b. Using a CCD, a pharmacist can query a PCP’s EHR. d. All of the above c. Allergy information is available in a CCD. d. All of the above 3. A PMS can query which of the following: a. PCP’s EHR c. All of the above 2. Which of the following information can be found in the CCD? b. Personal health records d. None of the above a. Immunization history c. Active medications list b. Allergy information d. All of the above case B A patient in a car accident and post hospital surgery was 3. Which of the following statements is correct? discharged home with a broken arm and leg. The patient’s a. Pharmacists providing immunizations should only electronically transmit discharge summary in the form of a CCD, which contains al- fl u vaccine information to the PCP. lergies, chief complaints, active medications list, diagnosis, b. The public health department should not be notifi ed of patient im- family history, immunizations, functional status, social history, munization updates. vital signs, laboratory data including electronic x-ray images, c. Pharmacists providing immunizations should provide vaccine informa- was electronically transmitted to the PCP and home health- tion to the patient’s PCP and the public health department. care agency coordinating the patient’s rehabilitation therapy. An d. None of the above

54 Drug topics April 2012 DrugTopics.com