Advancing HIT to improve medication use and safety
Meaningful use requirements for electronic medical record systems and electronic prescribing (e-prescribing) standards, along with new payment approaches that stress care coordination—including accountable care organizations, bundled payment options, and patient-centered medical homes—are motivating providers to adopt technology capable of storing and sharing medical information. While technology continues to advance, it is imperative that health care providers and health information technology (HIT) vendors continue to evaluate and strive for best practices that also consider health care providers’ workflow and patient outcomes within a financially viable operationalized framework.
To that end, APhA convened an impressive and diverse group of stakeholders and thought leaders from medicine, nursing, pharmacy, HIT vendors, federal regulatory agencies, and consumer groups to examine technology optimization strategies that will support and continue to improve medication use and safety. APhA held a 1-day stakeholder meeting at APhA headquarters in Washington, DC, on April 21, 2014. The meeting included several presentations and group discussions on the following topics:
- Assessing the current level of physician–pharmacist–patient engagement and defining best practices necessary to minimize risk for medication errors and optimize practice
- Outlining new and emerging technology solutions, resources, and methods for evaluating and implementing a system of interoperable HIT systems, pathways, structured documents, Direct Connect (secure messaging pathway), and bidirectional health information exchanges (HIEs) that are congruent with both the practice of medicine and pharmacy
- Identifying strategies for physicians, pharmacists, HIT vendors, and HIE intermediaries to ensure the most advanced delivery platforms and user best practices to maximize medication safety and promote enhanced patient care delivery
Based on stakeholder discussions and input, APhA developed a comprehensive strategy guide outlining key objectives and tactics to facilitate stakeholder engagement and collaboration. Following the initial live meeting, a series of four teleconferences was held with stakeholders to discuss the strategy guide goals, objectives, and tactics. The strategy guide is not intended to be a comprehensive plan of action. Rather, it focuses on four primary goals around stakeholder collaboration, communication, and action that will advance the use of HIT to improve medication safety and outcomes (see Table 1).
HIT Strategy Goal 1. Increase access and utilization of existing medication use–related data sources.
Multiple access points and formats containing medication use data are presently collected, stored, and shared in electronic health records, pharmacy dispensing systems, and prescription benefit management and payment platforms. However, the ability to share and exchange that information in a useful way has not yet been fully optimized. Increasing access and utilization would be realized through the following:
- Transmitting the patient’s diagnosis with electronic prescriptions. Providing pharmacists with the diagnosis as part of the prescription filling process would offer greater opportunity to more effectively and accurately educate and counsel patients.
- Implementing more efficient and useful platforms for provider access to prescription drug monitoring program data. Multiple platforms and varied state requirements hinder prescriber and pharmacist access to accurate prescription history to better address potential abuse and misuse of controlled substances.
- Expanding electronic health record formulary checks to include real-time prescription benefit and pricing data at the point of prescribing. Access to information to aid in drug selection prior to executing a written or e-prescription would reduce the inefficiencies that result when patients arrive at the pharmacy to obtain their medications but are unable to afford the cost of noncovered drugs or those with high copayments.
- Creating system interoperability that ensures completeness and accuracy of the patient’s current medication list. Being able to access and update accurate medication lists in provider electronic health records and prescription systems can better support medication reconciliation and ultimately reduce costly hospital readmissions.
- Requiring more frequent and complete updates to e-prescribing system drug product information sources. Delays in updating e-prescribing systems with new dosage forms, warnings, adverse effects, or approved indications can result in prescribing errors or cause delays in initiation of intended medication regimens.
HIT Strategy Goal 2. Optimize collection and evaluation of medication use data.
While considerable volumes of data already populate electronic health records and pharmacy and payment systems, impediments to collecting and aggregating medication use and safety data in ways that allow for national aggregation and comprehensive evaluation of medication safety and outcomes still remain. In recent years, major efforts to improve provider and patient self-reporting of adverse drug events have been initiated and proven successful. However, reporting is generally not fully integrated within electronic medical record systems and pharmacy systems in ways that could increase the frequency and provide a more accurate assessment of drug experience and safety. Allowing providers to document adverse drug events within existing electronic health records that transmit standardized information packets to national databases may further increase reporting. Similarly, the development of systems to collect and share patient safety data and adverse events would support FDA’s Nonprescription Drug Safe Use Regulatory Expansion initiative. Finally, the greater utilization of HIT may allow providers to more effectively and consistently integrate FDA’s Risk Evaluation and Mitigation Strategies into existing workflow and patient care processes.
HIT Strategy Goal 3. Maximize exchange of data among pharmacists, prescribers, and patients to improve coordination of care.
Coordination of care and provider collaboration have repeatedly demonstrated clinical benefits for patients, reduction of costs, and improvement of overall quality of care. To achieve these benefits, consensus among providers, payers, and patients on the value of data exchange is imperative and will require rigorous evaluation of financial, legal, and liability concerns associated with data exchange/sharing. In addition, widespread dissemination of existing and growing evidence demonstrating the value of data sharing must be aggressively pursued. Specific data elements to be exchanged should be determined by carefully identifying pharmacist care processes for medication therapy management and reconciliation, patient/consumer access and expected utilization of data, prescriber decision-making processes, and workflow components for initiating monitoring and modifying of individual patient pharmacotherapy. Comprehensive mapping of these numerous processes to data sharing capabilities and options can help identify synergies and efficiencies.
Expanding the use of e-prescribing communication and messaging capabilities may also offer greater potential to identify and resolve problems with medication use and safety. Maximizing secure messaging that exists among providers and their patients through existing electronic health record systems is also important. Pilot evaluations of e-prescribing messaging would help identify when prescriptions are actually filled, changed, or canceled. Greater provider awareness of patient prescription behavior could potentially improve medication adherence and even drug selection that best meets patient clinical needs and personal circumstances. Efforts to completely phase out free-text e-prescribing formats should be continued.
HIT Strategy Goal 4. Increase provider and patient adoption of medication use data sharing and access capabilities.
While large numbers of providers have already adopted use of electronic medical records and e-prescribing, interoperability challenges and provider concerns related to patient privacy, real and/or perceived legal risks, and uncertain financial return on investment continue to hamper exchange of data between prescribers, pharmacists, and patients. Overcoming these barriers will require all HIT stakeholders to undertake provider and consumer education to minimize opposition to data sharing and access. All stakeholders would benefit from quantification of financial benefits to data sharing that will support capital, business, consumer, and human resource investments needed for expanded data sharing, collection, and access. The need for and impact of regulatory mandates and provider payment incentives should continue to be evaluated. Interdisciplinary education should be expanded to include the need for and value of data sharing on care delivery, medication safety, and outcomes. Additional education and training may be needed to ensure pharmacists and prescribers are ready to apply clinical evidence to support outcome-based medication management.
Stakeholder meeting follow-up and next steps
On November 6, 2014, an invitational webinar was conducted for stakeholders who participated in the live meeting. The webinar included updates on efforts to advance the use of HIT to support pharmacist–prescriber communications and data sharing along with presentations on HIT utilization by pharmacists in community and health-system settings. It is evident that significant progress is being made to integrate pharmacist documentation and data sharing within electronic health record systems in a manner that will further support pharmacist and prescriber collaboration. Additionally, the use of HIT offers opportunities for pharmacists to analyze drug utilization and safety data to support providers in making evidence-based decisions.
Continued stakeholder engagement and leadership by the Pharmacy HIT Collaborative will be invaluable in helping pharmacists establish themselves as providers of care and allow for coordination of care with other members of the health care team. APhA also encourages all pharmacists to embrace the use of HIT and assume leadership roles to advance adoption within their own organizations and patient care activities. For additional information, the complete strategy guide and audio recordings of the webinar presentations are available on pharmacist.com.
This activity was supported by grants from Amgen Inc., Merck & Co., Novo Nordisk, Purdue Pharma L.P., and Teva Pharmaceuticals. This activity was sponsored by Boehringer Ingelheim Pharmaceuticals Inc.