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Implementation and use of an electronic health record in a charitable community pharmacy
SCIENCE AND PRACTICE Journal of the American Pharmacists Association xxx (2019) 1e8
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ADVANCES IN PHARMACY PRACTICE
Implementation and use of an electronic health record in a charitable community pharmacy Andrew Faiella, Kristin A. Casper*, Lisa Bible, Jennifer Seifert a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 May 2018 Accepted 4 December 2018
Objectives: To describe the implementation of enhanced health information technology (HIT), specifically an electronic health record (EHR), into the workflow of a charitable community pharmacy and to highlight the impact of the EHR on clinical service advancement, student and resident learning, research, and grant support for the pharmacy. Setting: The Charitable Pharmacy of Central Ohio (CPCO) is a nonprofit community pharmacy that provides medications and pharmacy services for uninsured and underinsured patients. Practice description: CPCO has adopted a practice model in which patients discuss their medications and health conditions in a private counseling area with a pharmacist or pharmacy student. Counseling sessions incorporate point-of-care testing, medication therapy management, and community program referrals, with documentation of the visit in the patient’s chart. Practice innovation: This article describes the implementation of a cloud-based EHR in a charitable community pharmacy. Evaluation: The decision-making process for converting from a paper-based chart to an EHR is described. Feedback from stakeholders, discussions at staff meetings, and a quality improvement project led by 2 pharmacy residents helped to inform and improve the process. Results: Implementation of an EHR has allowed CPCO to improve documentation of patient encounters and communicate more effectively and efficiently with other health care professionals. Student and resident learning has been enhanced, and reporting tools have facilitated additional opportunities for successful funding and more robust research. Conclusion: The use of an EHR at CPCO has provided opportunities to enhance patient care and improve other areas of practice. Community pharmacies should consider the utilization of HIT and EHRs to demonstrate the impact on patient care, elevate the standard of practice, and offer support for provider status. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
The use of electronic health records (EHRs) has expanded greatly since the passing of the American Recovery and Reinvestment Act (ARRA) of 2009.1 A section of the ARRA titled the “Health Information Technology for Economic and Clinical Health (HITECH) Act” instructed Medicare and Medicaid to create financial incentives for certain health care providers to help increase the rate of adoption of EHRs.2-4 Pharmacists were excluded from receiving incentive payments because they are not considered eligible providers in statute.2,4 Despite this
Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. * Correspondence: Kristin A. Casper, PharmD, BCACP, Associate Professor of Clinical Pharmacy, The Ohio State University College of Pharmacy, 500 West 12th Avenue, Columbus, Ohio 43210. E-mail address: [email protected] (K.A. Casper).
exclusion, pharmacists based in health system practice settings have seen an increased access to EHRs to document and make recommendations.5,6 Pharmacists have also used EHRs to help manage hospital system drug formularies and improve medication use in the hospital setting.7 In addition, pharmacists in a variety of settings continue to explore opportunities to document their care in EHRs and expand pharmacists’ services, with the hope of developing new payment models, improving patient care, and allowing better integration as an essential member of the health care team.8-10 While some segments of the pharmacy profession have seen expanded roles with the use of EHRs, there is limited information regarding how community pharmacists have been able to access and implement EHRs into their practice settings. In 2008, Fuji et al.11 conducted a survey of pharmacists from multiple practice settings that explored their views
https://doi.org/10.1016/j.japh.2018.12.004 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE A. Faiella et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Key Points Background: The use of electronic health records (EHRs) has expanded since the passing of the American Recovery and Reinvestment Act (ARRA) of 2009. Pharmacists were excluded from incentive payments for implementation of EHRs because of lack of provider status. There is limited information regarding how community pharmacists use EHRs in their daily practice. Findings: EHR implementation has improved documentation of patient care activities and enhanced consistency of pharmacists’ interventions. Pharmacist preceptors are better able to assess learners’ progress and improvement with documentation of patient care activities. The EHR reporting tools have provided the pharmacy with an opportunity to better understand its patients, allowed for more robust research, and improved the pharmacy’s ability to communicate the impact of patient care with outside stakeholders.
of EHRs. The results of the survey revealed that a majority of pharmacists had no plans to adopt an EHR.11 Bonner12 described a community pharmacy with the capability to access patient information through a partnership with a local health system EHR and a health information exchange, which resulted in pharmacists being better able to reconcile medications before refilling patients’ blister packaging and performing medication therapy management (MTM). Keller et al.13 described a pilot experience between a supermarket chain and a local physicians’ office. Pharmacists were initially given access to the EHR to read provider notes with the hope of increasing continuity of care.13 The pilot eventually led to the pharmacist having read/write access to the physician's EHR to improve communication between the pharmacy and the physician's office.13 As community pharmacists continue to expand their services and participate more fully in patient care, the need for increased access and documentation privileges in patient health records becomes more relevant. One way that the pharmacy profession has responded to this need is through the creation of a Pharmacy Health Information Technology (HIT) Collaborative. The goal of the Pharmacy HIT Collaborative is to help pharmacists implement the use of HIT and to ensure that pharmacists are included in the National HIT interoperable framework.14 In the spring of 2016, the Pharmacy HIT Collaborative published a guide specifically for community pharmacists.15 The guide suggests that pharmacists discuss the recommendations made by the Office of the National Coordinator (ONC) for HIT with their pharmacy system vendors so that system vendors can develop EHRs that could be certified by ONC.15 By using ONC recommendations, pharmacists would ensure access to an EHR that could
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retrieve, capture, upload, and integrate patient-related information.15 The recognition of standard EHR components and implementation of compatible EHRs that can document and communicate clinically relevant data becomes increasingly important as pharmacists expand services. Community pharmacists in North Carolina, as part of a Centers for Medicare and Medicaid Innovationefunded grant, are currently developing a model alongside pharmacy management system vendors.16 Together, they are working to integrate the EHR and meaningful use criteria into pharmacy management systems that will allow pharmacists to create an electronic pharmacy care plan in their own pharmacy management systems that can be shared with other members of the patient’s care team.16,17 This developing model has an additional goal of improving interoperability between existing pharmacy management systems and EHRs, which can help to generate additional payment opportunities for community pharmacy services.16 A robust EHR that can adequately document pharmacists’ services can lead to enhanced communication with other health care providers, increased access to patient health information to help improve clinical outcomes, and improved opportunities for pharmacist reimbursement for patient care services. As a unique model of community pharmacy that integrates medication dispensing with enhanced patient care services, the Charitable Pharmacy of Central Ohio (CPCO) saw a need to develop or adapt a system that would allow for improved documentation of interventions to enhance the overall care of vulnerable patients. This article describes the process used by CPCO to explore and implement an EHR that would ultimately enhance the pharmacist care for underserved patients in Central Ohio. Objectives The objectives of this article are to describe the implementation of enhanced HIT, specifically an EHR, into the workflow of a charitable community pharmacy and to highlight the impact of the EHR on clinical service advancement, student and resident learning, research, and grant support for the pharmacy. Setting The Charitable Pharmacy of Central Ohio (CPCO) is a nonprofit, community pharmacy that provides medications for patients in Franklin County, Ohio, who are at or below 200% of the federal poverty level and are either uninsured or underinsured. Practice description The Charitable Pharmacy of Central Ohio has served over 6700 unique patients and filled 400,000 prescriptions at a value of over $32 million since opening in 2010. The pharmacy is staffed by 1 full-time and 2 part-time pharmacists, 2 pharmacy technicians, 2 PGY-1 community pharmacy residents, and 4-5 Advanced Pharmacy Practice Experience (APPE) students per month who participate in experiential rotations throughout the year. The pharmacy serves an average of 690 unduplicated patients per month, which includes approximately 50 new patients. New patients meet with a patient services coordinator who collects
SCIENCE AND PRACTICE EHR in community pharmacy
demographic data and ensures that the patient qualifies for pharmacy services. In addition to being provided medications, patients sit down for 20-30 minutes in a private counseling area with either a pharmacist or an APPE student to discuss their medications and current health conditions. During these counseling sessions, CPCO provides point-of-care testing for blood glucose and blood pressure, MTM, health and wellness education, medication counseling, and community program referrals, as needed. At the end of the patient interview, the pharmacist or student pharmacist documents the patient encounter, including drug-related problems, using a modified subjective, objective, assessment, and plan (SOAP) note format in the patient’s record.
goal of creating an advanced yet efficient system for documenting patient care activities. OutcomesMTM, an established documentation platform that allows pharmacists to receive reimbursement for specific patient care activities including MTM services, was carefully considered, but utilization was ultimately limited by cost and lack of customizability. Practice Fusion seemed to be the most viable option, as the system had many characteristics such as ease of use, no cost, and the ability to generate reports that could improve the pharmacists’ understanding of CPCO’s patient population.
Practice innovation
Practice Fusion is an ONC-certified, web-based EHR established in 2005 and used by more than 112,000 health care providers.19,20 This makes Practice Fusion one of the largest cloud-based EHRs in the United States.19 CPCO staff members first encountered the use of Practice Fusion at a free clinic in Columbus, Ohio, which shared a similar nonprofit model, had a potentially overlapping patient population, and had a large number of student users. One important note is that Practice Fusion has the potential to document a patient’s disease states, but for CPCO this information was obtained directly from the patient, and it was decided that CPCO would not use the prepopulated ICD-10 codes. The flexibility of Practice Fusion became an important feature because the pharmacy was able to create a system using the MTM Core Elements as a foundation, which allowed for tracking of pharmacists’ interventions in a language already accepted by the profession.21 Specifically, the completion of an MTM at CPCO resulted in a medication therapy review and the patient receiving both a personalized medication record and a medication action plan.21 Appropriate provider follow-up could also be performed or recommended and then documented within Practice Fusion. After multiple discussions with pharmacy management and external stakeholders, a small pilot program led by 2 postgraduate-year-1 pharmacy residents was initiated in December 2015 to determine the feasibility of documenting MTM encounters and patient visits within Practice Fusion. During this 2-month period, pharmacy residents used Practice Fusion exclusively for patient care documentation, while the rest of CPCO staff members and students used the existing paper chart system. Pharmacy residents collaborated to ensure that they used standardized codes to track specific disease states, drug-related problems (DRPs), and intervention outcomes. Reports were routinely run to assess whether the terminology was capturing the targeted outcomes that CPCO wished to track, including resolution of DRPs and percentage of the CPCO population with specific disease states. This trial period allowed for the creation of a user manual for all staff and students to ensure that documentation was standardized during the rollout period. After completion of the pilot program, CPCO decided to move forward with the implementation of Practice Fusion, because documentation could be standardized, implementation was feasible, reports could be generated to track outcomes and patient characteristics, and there was no cost associated with the system.
CPCO had historically used paper charts and a traditional dispensing system to document patient encounters. The patient care activities documented in the paper charts were instrumental in providing continuity of care and tracking the impact of the care provided for the patients being served. The paper charts included an up-to-date medication list that was derived from an Excel spreadsheet and patient notes including recent blood pressure and blood glucose readings and MTM documentation. The notes did not always include a subjective, objective, or formal assessment, but students and pharmacists often included a plan to help with continuity of care when the patient returned. Pharmacists would review the patient’s medication list and recent notes when completing the drug utilization review during the checking step of the medication dispensing process. This would help the pharmacist communicate pertinent information to the APPE student and ensure that the student was adequately prepared to conduct the patient visit. At the end of each patient visit, the student or pharmacist would record a note in the patient’s chart summarizing the visit. This note did not have a formal structure, and it often varied based on the care provider documenting the visit. Because paper charts had limitations and did not fully meet the needs of the pharmacy, CPCO began to explore the possibility of moving to an electronic system in the fall of 2015 with the primary goal of more efficient and organized documentation. This article describes the process that CPCO used to select an EHR and summarizes the benefits of this decision for the pharmacy. Decision-making process A needs assessment was conducted using a model that was adapted from a program conducted by longitudinal APPE students at the Ohio State University College of Pharmacy called “Partner for Promotion.”18 This model guides students through a business plan template and includes a description of the problem; a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis; and a basic plan for implementation of a new or enhanced patient care service. The SWOT analysis for CPCO was performed in December 2015, and a meeting of internal and external pharmacy stakeholders was held to discuss the results. During the meeting, the pros and cons of several documentation systems were discussed (Table 1). The documentation systems included the paper charting system, the pharmacy’s dispensing system (QS/1), OutcomesMTM, and a cloud-based EHR called “Practice Fusion.” The paper charting system and the documentation capabilities of QS/1 had limitations that would prevent the pharmacy from meeting its
Selection and implementation of an EHR
Implementation process Starting at the end of January 2016, all additional pharmacists created their own accounts with the goal of becoming 3
SCIENCE AND PRACTICE A. Faiella et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Table 1 Pros and cons of documentation systems Documentation system Paper chart
Dispensing system (QS/1)
Outcomes MTM
Practice Fusion
Pros
Cons
Effective documentation of daily patient care activities Low cost Familiar for staff members because it is used to document patient care activities since pharmacy opened in 2010 Easy to train new pharmacists, residents, and APPE students Patient information (medications and patient visit information) stored in one place Ability to run reports based on medications dispensed Improved organization and ease of access to patient data Well known across the profession for documentation of MTM encounters Students and pharmacists familiar with system Ability to create pharmacist care plan Ability to document patient’s medications and disease states Improved opportunities for collaboration and research Allowed for structured documentation Ability to document point-of-care testing results No cost for documentation system Customizable to pharmacy’s needs ONC certified Ability to create care plan Patient information searchable and easier for pharmacy staff to access Improved opportunities for collaboration and research with more usable data Increased pharmacists’ ability to precept residents and APPE students
Difficult to track pharmacists’ interventions Difficult to standardize documentation Difficult to keep organized
Documentation tool difficult to navigate Unable to customize to meet pharmacy’s needs Lacked mechanism to document pharmacists’ interventions in trackable manner Difficult to track non-MTM encounters Reporting system unable to create customizable reports to fit the pharmacy’s needs Cost prohibitive
Not specific to pharmacy Transition could be time intensive Required 2 separate systems (1 for medication dispensing and 1 for documentation of patient care services) Potential for subscription fee, which could be cost prohibitive
Abbreviations used: APPE, advanced pharmacy practice experience; MTM, medication therapy management; ONC, Office of the National Coordinator.
more familiar with Practice Fusion and providing feedback to the residents about the processes being developed. Student logins were created in March 2016 so that students could begin to document their MTM encounters in the system and to help CPCO determine the scalability of Practice Fusion. A standardized list of diagnosis codes and intervention codes was created during the pilot and refined during the implementation phase. These codes were added to the accounts of students and pharmacists to encourage consistency among users and to allow for more streamlined reports that provided better clinical data. The goal of a universal diagnosis list was to prevent one user from documenting hypertension and another user from documenting high blood pressure for the same condition, as an example. In addition, a new patient intake guide was created (Figure 1) to help ensure standard documentation at the beginning of the patient care process. A new workflow was also developed for pharmacists completing the drug utilization review. Pharmacists at CPCO were already familiar with reviewing both a paper chart and the pharmacy’s dispensing system and the Excel chart for the patient’s medication list. The use of Practice Fusion reduced the inputs with this system and only required toggling between 2 screens on the computerdthe dispensing system and Practice Fusion. Pharmacists compared medication lists between the 2 systems, identified potential DRPs using data from both systems, and produced an updated medication list that could be highlighted with counseling points used by the APPE students conducting the patient visit. After continued addition of new patients and review of the system by pharmacy staff members and students at monthly staff meetings, the decision to implement and convert fully to Practice Fusion was made in May 2016. Student volunteers 4
were used to help transcribe all existing pharmacy patients into Practice Fusion, and all new and existing CPCO patients were successfully integrated into Practice Fusion by October 2016. Figure 2 depicts the timeline of implementation. As Practice Fusion was being implemented, a user manual was also simultaneously created by the pharmacy residents to ensure continuity of the project with new APPE students each month. This manual allowed for the development of policies and procedures for implementation and use of the system, with opportunities for updates as needed. The main focus of the user manual was to make sure that the pharmacists and students had clear expectations and guidelines related to the documentation of DRPs and MTM encounters. The user manual also included step-by-step instructions about how to perform daily tasks, how to run reports, how to effectively transition between providers, with specific emphasis on the pharmacy residents who were spearheading implementation, and ideas for future direction and expansion. To allow for standardized training among students, a student orientation manual with sample patient cases was also created. The manual and accompanying materials allowed for pharmacist preceptors to instruct, model, and coach students about Practice Fusion each month. The manual and accompanying materials also described synergies with workflow and indicated how the QS/1 dispensing system could be used in conjunction with Practice Fusion. Evaluation Evaluation of the implementation and impact of Practice Fusion occurred through a variety of continuous quality improvement initiatives. APPE students were asked at their midpoint and final evaluations to provide verbal feedback to
SCIENCE AND PRACTICE EHR in community pharmacy
Figure 1. New patient intake guide.
their pharmacist preceptors about challenges they encountered with the system. This consultation identified the need for a training video that is now reviewed by APPE students at the beginning of each month before starting their rotations.
Pharmacy staff members also discussed documentation opportunities at monthly meetings to address challenges and to suggest ways to improve efficiency. This has resulted in documentation of additional demographic data historically 5
SCIENCE AND PRACTICE A. Faiella et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Pracce Fusion pilot program led by pharmacy residents
December 2015
All pharmacists document MTM encounters in Pracce Fusion
January 2016
APPE student logins created, and all new paents added to Pracce Fusion
March 2016
Business plan created to help with May 2016 transion to Pracce Fusion
All CPCO paents added to Pracce Fusion
October 2016
Figure 2. Implementation process for Practice Fusion.
recorded in a different database to allow for efficiency and consistency among patient services coordinators. The pharmacists identified that a more consistent process was needed to review DRPs and document resolution; therefore, a pharmacy resident’s quality-improvement project focused on development of a standardized method to differentiate acute DRPs within Practice Fusion. Lastly, reports from Practice Fusion are generated monthly and used by the patient services coordinators to update the patient data dashboard. These data are incorporated in the CPCO annual report and presented to the CPCO governing board at quarterly meetings.22 In addition, the aggregate data are used to generate reports for external partners, including area health systems and local funding agencies. Implications The impact of implementing Practice Fusion for CPCO has been valuable in enhancing the care of patients. The patient care documentation process has become more efficient and standardized to allow for greater consistency in patient visits. Specifically, information such as disease states and DRPs, which were documented only during patient intake at the initial visit when using the paper chart, is now included in the patient profile on Practice Fusion and reviewed at each 6
pharmacy visit. DRPs can be tracked longitudinally and can be marked as acute if resolution is needed, with a goal of resolving the problem at the current or subsequent visit. For example, pharmacists are now able to document an acute DRP and record that a telephone call to a physician’s office was made requesting therapeutic interchange of one controller inhaler such as budesonide/formoterol to a therapeutically appropriate alternative such as mometasone/formoterol. When the physician e-prescribes the alternative medication, the pharmacist or pharmacy student can document in Practice Fusion that the DRP has been resolved. The patient can then be contacted to pick up the medication and will therefore not go without the medication. In addition, the pharmacist or pharmacy student who counsels the patient the following month can assess the effectiveness of the new medication, and the continuity of the patient’s care will likely have been improved. From a student and resident learning perspective, Practice Fusion allows CPCO preceptors to evaluate students’ and residents’ performance with written communication, particularly related to SOAP notes and patient care plans. Students often struggle when implementing the SOAP note process into practice, but Practice Fusion provides the preceptor with an opportunity to review notes and to provide feedback about patient encounters throughout the month. This precepting practice has helped students and residents to identify areas of
SCIENCE AND PRACTICE EHR in community pharmacy
Table 2 Examples of documentation options Documentation tools Pharmacy dispensing systems17 Electronic medical records25 Open source25
Examples Computer-Rx, PioneerRx, QS/1, RX30, VIP Pharmacy Systems, Prescribe Wellness VistA, One Touch EMR OpenMRS, OpenEMR, NOSH, Solismed
documentation that are being clearly communicated and areas that might need further development. The creation of a patient-centered care plan is also often an area of growth for new practitioners. Practice Fusion allows for documentation of a care plan to be reviewed by a preceptor before giving the plan to the patient. Care plans are also longitudinal tools that promote effective follow-up of DRPs and patient counseling. With the paper charting system, SOAP notes and care plans were not structured and were not easily reviewed by preceptors. Preceptors can now help students and residents identify areas of growth and improve care for patients. In terms of funding, recognition, and future research, the implementation of Practice Fusion has provided CPCO with a better understanding of the patient population being served by the pharmacy. This understanding has resulted in an enhanced ability to communicate success stories with external collaborators and to request funding for additional needs. Aggregate data from Practice Fusion and a previous residency project by Babaeux et al.23 identified that more than 40% of patients seen at CPCO have diabetes. Using these data, CPCO was able to secure a grant of more than $45,000 from Women and Philanthropy at Ohio State University to provide medications and self-care counseling for women with diabetes. In addition, data from Practice Fusion helped CPCO submit meaningful applications that resulted in the inaugural Pharmacy Quality Alliance and the Community Pharmacy Foundation national award for Community Pharmacy Innovations, as well as the 2018 Excellence in Community Partnership Award from The Ohio State University. Pharmacy residents’ research projects have also become more robust because of data from Practice Fusion, as the documented DRPs were used to evaluate estimated cost avoidance to better demonstrate economic impact and to identify opportunities for future funding models.24 Discussion As other community pharmacies consider the process of implementing HIT and incorporating an EHR as part of their practices, the process we have described can be applied. We found that EHR implementation was feasible and took approximately 10 months to complete. We also found that using an EHR led to consistency in documentation of interventions and efficiency with patient follow-up. This might be particularly helpful for other charitable pharmacies, as their practice model often allows for additional counseling time with the patient and an opportunity to improve consistency across care providers through documented communication and resolution of DRPs. As the literature described, shared documentation is the ultimate goal for improving continuity with patient care, and implementation of an EHR has helped to bring CPCO one step closer to this opportunity. As community
pharmacies consider HIT and EHR implementation, the uniqueness of each practice site and the clinical services provided at the site should encourage contemplation of a variety of systems to help select a system that is best suited for the site. Examples of EHRs and other documentation systems that could be considered are included in Table 2.25 Characteristics of EHRs that could be considered include varying levels of customizability, varying technical skill levels to integrate the EHR for use, and varying levels of support for continued development and quality improvement that can allow for evolution as the health care system changes.25 Some limitations exist to the model as described. Practice Fusion has recently converted to a subscription-based system, which might hinder utilization in some pharmacy models, especially charitable or nonprofit pharmacies. CPCO also had limited disruption in workflow because of the opportunity to use students and pharmacy residents to assist with conversion to Practice Fusion. Implementation might be more difficult if multiple locations are included or if the use of technical staff members and students is limited. Although transitioning to 2 systems (dispensing and Practice Fusion) reduced the number of inputs and steps in our workflow, the need to use 2 distinct systems simultaneously might not fit other pharmacy practice settings. Lastly, the needs of each community pharmacy are somewhat unique. Therefore, applicability of all aspects of EHR implementation might be limited based on legal regulations and local practice opportunities. Conclusion The implementation and use of an EHR have provided a charitable pharmacy with opportunities to improve the quality and consistency of patient care through improved documentation, better understanding of the patient population, and improvements in the learning environment for student pharmacists and pharmacy residents through enhanced and targeted feedback. Community pharmacies and charitable pharmacies should consider adoption of HIT and the use of EHRs as an opportunity to augment their practices and create new avenues for communication that can enhance the care of their patients. The ability of community pharmacists to provide data that demonstrate their role in the improved care of patients will support the case for provider status and the opportunity for improved reimbursement models that will allow the practice of pharmacy to adapt and remain relevant in an ever-changing health care landscape. Acknowledgements The authors would like to acknowledge Melanie Boyd, Holly Fahey, Erin Gordon, and Laura Poling for their assistance with the project. References 1. 2016 Report to Congress on health information technology progress: examining the HITECH era and the future of health IT. Available at: https:// dashboard.healthit.gov/report-to-congress/2016-report-congress-examining-hitech-era-future-health-information-technology.php. Accessed May 24, 2018. 2. Spiro R. The impact of electronic health records on pharmacy practice. Drug Topics. April 2012. Available at: http://www.pharmacyhit.org/pdfs/ Article.pdf. Accessed January 21, 2019.
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3. Steinbrook R. Health care and the American Recovery and Reinvestment Act. N Engl J Med. 2009;360(11):1057e1060. 4. Medicare and Medicaid health information technology: Title IV of the American Recovery and Reinvestment Act. Published May 17, 2013. Available at: https:// www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2009-Factsheets-items/2009-06-16.html. Accessed May 24, 2018. 5. Fox BI, Pedersen CA, Gumpper KF. ASHP national survey on informatics: assessment of the adoption and use of pharmacy informatics in U.S. hospitalsd2013. Am J Health Syst Pharm. 2015;72(8):636e655. 6. Pedersen CA, Gumpper KF. ASHP national survey on informatics: assessment of the adoption and use of pharmacy informatics in U.S. hospitalsd2007. Am J Health Syst Pharm. 2008;65(23):2244e2264. 7. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribingd2016. Am J Health Syst Pharm. 2017;74(17):1336e1352. 8. Fixen DR, Linnebur SA, Parnes BL, Vejar MV, Vande Griend JP. Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic. Am J Health Syst Pharm. 2018;75:1805e1811. 9. Hensler D, Richardson CL, Brown J, et al. Impact of electronic health record-based, pharmacist-driven valganciclovir dose optimization in solid organ transplant recipents. Transpl Inefect Dis. 2018;20(2):e12849. 10. Jeon N, Sorokina M, Henriksen C, Staley B, Lipori GP, Winterstein AG. Measurement of selected preventable adverse drug events in electronic health records: Toward developing a complexity score. Am J Health Syst PharmI. 2017;74(22):1865e1877. 11. Fuji KT, Gait KA, Siracuse MV, Christoffersen JS. Electronic health record adoption and use by Nebraska pharmacists. Perspect Health Inf Manag. 2011;8(Summer):1d. 12. Bonner L. Pharmacists inch closer to accessing EHRs and HIEs. Pharm Today. 2016;22(5):44e47. 13. Keller ME, Kelling SE, Cornelius DC, Oni HA, Bright DR. Enhancing practice efficiency and patient care by sharing electronic health records. Perspect Health Inf Manag. 2015;12(Fall):1b. 14. Pharmacy Health Information Technology Collaborative. Available at: http://pharmacyhit.org/. Accessed March 27, 2018. 15. Electronic Health Record certification. Making the pharmacist’s case to system vendors by practice specific settings. Available at: http://www. pharmacyhit.org/pdfs/workshop-documents/WG4-Post-2016-01.pdf. Accessed March 27, 2018. 16. Bonner L. Model will better connect community pharmacy systems to EHRs and more. Available at: http://www.pharmacist.com/article/model-willbetter-connect-community-pharmacy-systems-ehrs-and-more. Accessed March 27, 2018.
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17. Empowering Community Pharmacies to Improve Care Coordination and Health Outcomes with Use of Electronic Care Plans, CPESN USA. Available at: https://www.cpesn.com/ecare-plan/. Accessed May 27, 2018. 18. Rodis JL, Legg JE, Casper KA. Partner for promotion: an innovative advanced community pharmacy practice experience. Am J Pharm Educ. 2008;72(6):134. 19. The Latest on Electronic Health Records. Practice Fusion Blog. Available at: https://www.practicefusion.com/. Accessed May 24, 2018. 20. EHR Meaningful Use Certification. Practice Fusion Blog. Available at: https:// www.practicefusion.com/certified-meaningful-use-ehr/. Accessed May 24, 2018. 21. Medication therapy management in pharmacy practice: core elements of an MTM service model. Available at: https://www.pharmacist.com/sites/default/ files/files/core_elements_of_an_mtm_practice.pdf. Accessed May 24, 2018. 22. 2017 Charitable Pharmacy of Central Ohio Annual Report. Charitable Pharmacy of Central Ohio. Available at: https://charitablepharmacy.org/2 017-CHARITABLE-PHARMACY-ANNUAL-REPORT.pdf. Accessed October 21, 2018. 23. Fahey Babeaux HP, Hall LE, Seifert JL. Charitable pharmacy services: impact on patient-reported hospital use, medication access, and health status. J AM Pharm Assoc (2003). 2015;55(1):59e66. 24. Schmuhl K, Casper K, Seifert J, Fahey H, Shine J, Newland B. Defining value of clinical interventions made by pharmacists and student pharmacists at a charitable pharmacy. Poster presention at: Nashville, TN: American Pharmacists Association Annual Meeting. March 2018. 25. The Top 7 Free and Open Source EMR Software Products–Capterra Blog. Available at: https://blog.capterra.com/top-7-free-open-source-emrsoftware-products/. Accessed May 27, 2018.
Andrew Faiella, PharmD, BCACP, PrimaryOne Health. At time of study: PGY-1 resident at The Ohio State University College of Pharmacy and Charitable Pharmacy of Central Ohio, Columbus, OH Kristin A. Casper, PharmD, BCACP, Associate Professor of Clinical Pharmacy, Division of Pharmacy Practice and Science, The Ohio State University College of Pharmacy, Columbus, OH Lisa Bible, PharmD, Walgreens Pharmacy. At time of study: PGY-1 resident at The Ohio State University College of Pharmacy and Charitable Pharmacy of Central Ohio, Columbus, OH Jennifer Seifert, MS, RPh, BCGP, Executive Director, Charitable Pharmacy of Central Ohio, Residency Program Director, PGY-1 Community-based Program, The Ohio State University College of Pharmacy, Columbus, OH
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
ADVANCES IN PHARMACY PRACTICE
Implementation and use of an electronic health record in a charitable community pharmacy Andrew Faiella, Kristin A. Casper*, Lisa Bible, Jennifer Seifert a r t i c l e i n f o
a b s t r a c t
Article history: Received 31 May 2018 Accepted 4 December 2018
Objectives: To describe the implementation of enhanced health information technology (HIT), specifically an electronic health record (EHR), into the workflow of a charitable community pharmacy and to highlight the impact of the EHR on clinical service advancement, student and resident learning, research, and grant support for the pharmacy. Setting: The Charitable Pharmacy of Central Ohio (CPCO) is a nonprofit community pharmacy that provides medications and pharmacy services for uninsured and underinsured patients. Practice description: CPCO has adopted a practice model in which patients discuss their medications and health conditions in a private counseling area with a pharmacist or pharmacy student. Counseling sessions incorporate point-of-care testing, medication therapy management, and community program referrals, with documentation of the visit in the patient’s chart. Practice innovation: This article describes the implementation of a cloud-based EHR in a charitable community pharmacy. Evaluation: The decision-making process for converting from a paper-based chart to an EHR is described. Feedback from stakeholders, discussions at staff meetings, and a quality improvement project led by 2 pharmacy residents helped to inform and improve the process. Results: Implementation of an EHR has allowed CPCO to improve documentation of patient encounters and communicate more effectively and efficiently with other health care professionals. Student and resident learning has been enhanced, and reporting tools have facilitated additional opportunities for successful funding and more robust research. Conclusion: The use of an EHR at CPCO has provided opportunities to enhance patient care and improve other areas of practice. Community pharmacies should consider the utilization of HIT and EHRs to demonstrate the impact on patient care, elevate the standard of practice, and offer support for provider status. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
The use of electronic health records (EHRs) has expanded greatly since the passing of the American Recovery and Reinvestment Act (ARRA) of 2009.1 A section of the ARRA titled the “Health Information Technology for Economic and Clinical Health (HITECH) Act” instructed Medicare and Medicaid to create financial incentives for certain health care providers to help increase the rate of adoption of EHRs.2-4 Pharmacists were excluded from receiving incentive payments because they are not considered eligible providers in statute.2,4 Despite this
Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. * Correspondence: Kristin A. Casper, PharmD, BCACP, Associate Professor of Clinical Pharmacy, The Ohio State University College of Pharmacy, 500 West 12th Avenue, Columbus, Ohio 43210. E-mail address: [email protected] (K.A. Casper).
exclusion, pharmacists based in health system practice settings have seen an increased access to EHRs to document and make recommendations.5,6 Pharmacists have also used EHRs to help manage hospital system drug formularies and improve medication use in the hospital setting.7 In addition, pharmacists in a variety of settings continue to explore opportunities to document their care in EHRs and expand pharmacists’ services, with the hope of developing new payment models, improving patient care, and allowing better integration as an essential member of the health care team.8-10 While some segments of the pharmacy profession have seen expanded roles with the use of EHRs, there is limited information regarding how community pharmacists have been able to access and implement EHRs into their practice settings. In 2008, Fuji et al.11 conducted a survey of pharmacists from multiple practice settings that explored their views
https://doi.org/10.1016/j.japh.2018.12.004 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE A. Faiella et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Key Points Background: The use of electronic health records (EHRs) has expanded since the passing of the American Recovery and Reinvestment Act (ARRA) of 2009. Pharmacists were excluded from incentive payments for implementation of EHRs because of lack of provider status. There is limited information regarding how community pharmacists use EHRs in their daily practice. Findings: EHR implementation has improved documentation of patient care activities and enhanced consistency of pharmacists’ interventions. Pharmacist preceptors are better able to assess learners’ progress and improvement with documentation of patient care activities. The EHR reporting tools have provided the pharmacy with an opportunity to better understand its patients, allowed for more robust research, and improved the pharmacy’s ability to communicate the impact of patient care with outside stakeholders.
of EHRs. The results of the survey revealed that a majority of pharmacists had no plans to adopt an EHR.11 Bonner12 described a community pharmacy with the capability to access patient information through a partnership with a local health system EHR and a health information exchange, which resulted in pharmacists being better able to reconcile medications before refilling patients’ blister packaging and performing medication therapy management (MTM). Keller et al.13 described a pilot experience between a supermarket chain and a local physicians’ office. Pharmacists were initially given access to the EHR to read provider notes with the hope of increasing continuity of care.13 The pilot eventually led to the pharmacist having read/write access to the physician's EHR to improve communication between the pharmacy and the physician's office.13 As community pharmacists continue to expand their services and participate more fully in patient care, the need for increased access and documentation privileges in patient health records becomes more relevant. One way that the pharmacy profession has responded to this need is through the creation of a Pharmacy Health Information Technology (HIT) Collaborative. The goal of the Pharmacy HIT Collaborative is to help pharmacists implement the use of HIT and to ensure that pharmacists are included in the National HIT interoperable framework.14 In the spring of 2016, the Pharmacy HIT Collaborative published a guide specifically for community pharmacists.15 The guide suggests that pharmacists discuss the recommendations made by the Office of the National Coordinator (ONC) for HIT with their pharmacy system vendors so that system vendors can develop EHRs that could be certified by ONC.15 By using ONC recommendations, pharmacists would ensure access to an EHR that could
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retrieve, capture, upload, and integrate patient-related information.15 The recognition of standard EHR components and implementation of compatible EHRs that can document and communicate clinically relevant data becomes increasingly important as pharmacists expand services. Community pharmacists in North Carolina, as part of a Centers for Medicare and Medicaid Innovationefunded grant, are currently developing a model alongside pharmacy management system vendors.16 Together, they are working to integrate the EHR and meaningful use criteria into pharmacy management systems that will allow pharmacists to create an electronic pharmacy care plan in their own pharmacy management systems that can be shared with other members of the patient’s care team.16,17 This developing model has an additional goal of improving interoperability between existing pharmacy management systems and EHRs, which can help to generate additional payment opportunities for community pharmacy services.16 A robust EHR that can adequately document pharmacists’ services can lead to enhanced communication with other health care providers, increased access to patient health information to help improve clinical outcomes, and improved opportunities for pharmacist reimbursement for patient care services. As a unique model of community pharmacy that integrates medication dispensing with enhanced patient care services, the Charitable Pharmacy of Central Ohio (CPCO) saw a need to develop or adapt a system that would allow for improved documentation of interventions to enhance the overall care of vulnerable patients. This article describes the process used by CPCO to explore and implement an EHR that would ultimately enhance the pharmacist care for underserved patients in Central Ohio. Objectives The objectives of this article are to describe the implementation of enhanced HIT, specifically an EHR, into the workflow of a charitable community pharmacy and to highlight the impact of the EHR on clinical service advancement, student and resident learning, research, and grant support for the pharmacy. Setting The Charitable Pharmacy of Central Ohio (CPCO) is a nonprofit, community pharmacy that provides medications for patients in Franklin County, Ohio, who are at or below 200% of the federal poverty level and are either uninsured or underinsured. Practice description The Charitable Pharmacy of Central Ohio has served over 6700 unique patients and filled 400,000 prescriptions at a value of over $32 million since opening in 2010. The pharmacy is staffed by 1 full-time and 2 part-time pharmacists, 2 pharmacy technicians, 2 PGY-1 community pharmacy residents, and 4-5 Advanced Pharmacy Practice Experience (APPE) students per month who participate in experiential rotations throughout the year. The pharmacy serves an average of 690 unduplicated patients per month, which includes approximately 50 new patients. New patients meet with a patient services coordinator who collects
SCIENCE AND PRACTICE EHR in community pharmacy
demographic data and ensures that the patient qualifies for pharmacy services. In addition to being provided medications, patients sit down for 20-30 minutes in a private counseling area with either a pharmacist or an APPE student to discuss their medications and current health conditions. During these counseling sessions, CPCO provides point-of-care testing for blood glucose and blood pressure, MTM, health and wellness education, medication counseling, and community program referrals, as needed. At the end of the patient interview, the pharmacist or student pharmacist documents the patient encounter, including drug-related problems, using a modified subjective, objective, assessment, and plan (SOAP) note format in the patient’s record.
goal of creating an advanced yet efficient system for documenting patient care activities. OutcomesMTM, an established documentation platform that allows pharmacists to receive reimbursement for specific patient care activities including MTM services, was carefully considered, but utilization was ultimately limited by cost and lack of customizability. Practice Fusion seemed to be the most viable option, as the system had many characteristics such as ease of use, no cost, and the ability to generate reports that could improve the pharmacists’ understanding of CPCO’s patient population.
Practice innovation
Practice Fusion is an ONC-certified, web-based EHR established in 2005 and used by more than 112,000 health care providers.19,20 This makes Practice Fusion one of the largest cloud-based EHRs in the United States.19 CPCO staff members first encountered the use of Practice Fusion at a free clinic in Columbus, Ohio, which shared a similar nonprofit model, had a potentially overlapping patient population, and had a large number of student users. One important note is that Practice Fusion has the potential to document a patient’s disease states, but for CPCO this information was obtained directly from the patient, and it was decided that CPCO would not use the prepopulated ICD-10 codes. The flexibility of Practice Fusion became an important feature because the pharmacy was able to create a system using the MTM Core Elements as a foundation, which allowed for tracking of pharmacists’ interventions in a language already accepted by the profession.21 Specifically, the completion of an MTM at CPCO resulted in a medication therapy review and the patient receiving both a personalized medication record and a medication action plan.21 Appropriate provider follow-up could also be performed or recommended and then documented within Practice Fusion. After multiple discussions with pharmacy management and external stakeholders, a small pilot program led by 2 postgraduate-year-1 pharmacy residents was initiated in December 2015 to determine the feasibility of documenting MTM encounters and patient visits within Practice Fusion. During this 2-month period, pharmacy residents used Practice Fusion exclusively for patient care documentation, while the rest of CPCO staff members and students used the existing paper chart system. Pharmacy residents collaborated to ensure that they used standardized codes to track specific disease states, drug-related problems (DRPs), and intervention outcomes. Reports were routinely run to assess whether the terminology was capturing the targeted outcomes that CPCO wished to track, including resolution of DRPs and percentage of the CPCO population with specific disease states. This trial period allowed for the creation of a user manual for all staff and students to ensure that documentation was standardized during the rollout period. After completion of the pilot program, CPCO decided to move forward with the implementation of Practice Fusion, because documentation could be standardized, implementation was feasible, reports could be generated to track outcomes and patient characteristics, and there was no cost associated with the system.
CPCO had historically used paper charts and a traditional dispensing system to document patient encounters. The patient care activities documented in the paper charts were instrumental in providing continuity of care and tracking the impact of the care provided for the patients being served. The paper charts included an up-to-date medication list that was derived from an Excel spreadsheet and patient notes including recent blood pressure and blood glucose readings and MTM documentation. The notes did not always include a subjective, objective, or formal assessment, but students and pharmacists often included a plan to help with continuity of care when the patient returned. Pharmacists would review the patient’s medication list and recent notes when completing the drug utilization review during the checking step of the medication dispensing process. This would help the pharmacist communicate pertinent information to the APPE student and ensure that the student was adequately prepared to conduct the patient visit. At the end of each patient visit, the student or pharmacist would record a note in the patient’s chart summarizing the visit. This note did not have a formal structure, and it often varied based on the care provider documenting the visit. Because paper charts had limitations and did not fully meet the needs of the pharmacy, CPCO began to explore the possibility of moving to an electronic system in the fall of 2015 with the primary goal of more efficient and organized documentation. This article describes the process that CPCO used to select an EHR and summarizes the benefits of this decision for the pharmacy. Decision-making process A needs assessment was conducted using a model that was adapted from a program conducted by longitudinal APPE students at the Ohio State University College of Pharmacy called “Partner for Promotion.”18 This model guides students through a business plan template and includes a description of the problem; a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis; and a basic plan for implementation of a new or enhanced patient care service. The SWOT analysis for CPCO was performed in December 2015, and a meeting of internal and external pharmacy stakeholders was held to discuss the results. During the meeting, the pros and cons of several documentation systems were discussed (Table 1). The documentation systems included the paper charting system, the pharmacy’s dispensing system (QS/1), OutcomesMTM, and a cloud-based EHR called “Practice Fusion.” The paper charting system and the documentation capabilities of QS/1 had limitations that would prevent the pharmacy from meeting its
Selection and implementation of an EHR
Implementation process Starting at the end of January 2016, all additional pharmacists created their own accounts with the goal of becoming 3
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Table 1 Pros and cons of documentation systems Documentation system Paper chart
Dispensing system (QS/1)
Outcomes MTM
Practice Fusion
Pros
Cons
Effective documentation of daily patient care activities Low cost Familiar for staff members because it is used to document patient care activities since pharmacy opened in 2010 Easy to train new pharmacists, residents, and APPE students Patient information (medications and patient visit information) stored in one place Ability to run reports based on medications dispensed Improved organization and ease of access to patient data Well known across the profession for documentation of MTM encounters Students and pharmacists familiar with system Ability to create pharmacist care plan Ability to document patient’s medications and disease states Improved opportunities for collaboration and research Allowed for structured documentation Ability to document point-of-care testing results No cost for documentation system Customizable to pharmacy’s needs ONC certified Ability to create care plan Patient information searchable and easier for pharmacy staff to access Improved opportunities for collaboration and research with more usable data Increased pharmacists’ ability to precept residents and APPE students
Difficult to track pharmacists’ interventions Difficult to standardize documentation Difficult to keep organized
Documentation tool difficult to navigate Unable to customize to meet pharmacy’s needs Lacked mechanism to document pharmacists’ interventions in trackable manner Difficult to track non-MTM encounters Reporting system unable to create customizable reports to fit the pharmacy’s needs Cost prohibitive
Not specific to pharmacy Transition could be time intensive Required 2 separate systems (1 for medication dispensing and 1 for documentation of patient care services) Potential for subscription fee, which could be cost prohibitive
Abbreviations used: APPE, advanced pharmacy practice experience; MTM, medication therapy management; ONC, Office of the National Coordinator.
more familiar with Practice Fusion and providing feedback to the residents about the processes being developed. Student logins were created in March 2016 so that students could begin to document their MTM encounters in the system and to help CPCO determine the scalability of Practice Fusion. A standardized list of diagnosis codes and intervention codes was created during the pilot and refined during the implementation phase. These codes were added to the accounts of students and pharmacists to encourage consistency among users and to allow for more streamlined reports that provided better clinical data. The goal of a universal diagnosis list was to prevent one user from documenting hypertension and another user from documenting high blood pressure for the same condition, as an example. In addition, a new patient intake guide was created (Figure 1) to help ensure standard documentation at the beginning of the patient care process. A new workflow was also developed for pharmacists completing the drug utilization review. Pharmacists at CPCO were already familiar with reviewing both a paper chart and the pharmacy’s dispensing system and the Excel chart for the patient’s medication list. The use of Practice Fusion reduced the inputs with this system and only required toggling between 2 screens on the computerdthe dispensing system and Practice Fusion. Pharmacists compared medication lists between the 2 systems, identified potential DRPs using data from both systems, and produced an updated medication list that could be highlighted with counseling points used by the APPE students conducting the patient visit. After continued addition of new patients and review of the system by pharmacy staff members and students at monthly staff meetings, the decision to implement and convert fully to Practice Fusion was made in May 2016. Student volunteers 4
were used to help transcribe all existing pharmacy patients into Practice Fusion, and all new and existing CPCO patients were successfully integrated into Practice Fusion by October 2016. Figure 2 depicts the timeline of implementation. As Practice Fusion was being implemented, a user manual was also simultaneously created by the pharmacy residents to ensure continuity of the project with new APPE students each month. This manual allowed for the development of policies and procedures for implementation and use of the system, with opportunities for updates as needed. The main focus of the user manual was to make sure that the pharmacists and students had clear expectations and guidelines related to the documentation of DRPs and MTM encounters. The user manual also included step-by-step instructions about how to perform daily tasks, how to run reports, how to effectively transition between providers, with specific emphasis on the pharmacy residents who were spearheading implementation, and ideas for future direction and expansion. To allow for standardized training among students, a student orientation manual with sample patient cases was also created. The manual and accompanying materials allowed for pharmacist preceptors to instruct, model, and coach students about Practice Fusion each month. The manual and accompanying materials also described synergies with workflow and indicated how the QS/1 dispensing system could be used in conjunction with Practice Fusion. Evaluation Evaluation of the implementation and impact of Practice Fusion occurred through a variety of continuous quality improvement initiatives. APPE students were asked at their midpoint and final evaluations to provide verbal feedback to
SCIENCE AND PRACTICE EHR in community pharmacy
Figure 1. New patient intake guide.
their pharmacist preceptors about challenges they encountered with the system. This consultation identified the need for a training video that is now reviewed by APPE students at the beginning of each month before starting their rotations.
Pharmacy staff members also discussed documentation opportunities at monthly meetings to address challenges and to suggest ways to improve efficiency. This has resulted in documentation of additional demographic data historically 5
SCIENCE AND PRACTICE A. Faiella et al. / Journal of the American Pharmacists Association xxx (2019) 1e8
Pracce Fusion pilot program led by pharmacy residents
December 2015
All pharmacists document MTM encounters in Pracce Fusion
January 2016
APPE student logins created, and all new paents added to Pracce Fusion
March 2016
Business plan created to help with May 2016 transion to Pracce Fusion
All CPCO paents added to Pracce Fusion
October 2016
Figure 2. Implementation process for Practice Fusion.
recorded in a different database to allow for efficiency and consistency among patient services coordinators. The pharmacists identified that a more consistent process was needed to review DRPs and document resolution; therefore, a pharmacy resident’s quality-improvement project focused on development of a standardized method to differentiate acute DRPs within Practice Fusion. Lastly, reports from Practice Fusion are generated monthly and used by the patient services coordinators to update the patient data dashboard. These data are incorporated in the CPCO annual report and presented to the CPCO governing board at quarterly meetings.22 In addition, the aggregate data are used to generate reports for external partners, including area health systems and local funding agencies. Implications The impact of implementing Practice Fusion for CPCO has been valuable in enhancing the care of patients. The patient care documentation process has become more efficient and standardized to allow for greater consistency in patient visits. Specifically, information such as disease states and DRPs, which were documented only during patient intake at the initial visit when using the paper chart, is now included in the patient profile on Practice Fusion and reviewed at each 6
pharmacy visit. DRPs can be tracked longitudinally and can be marked as acute if resolution is needed, with a goal of resolving the problem at the current or subsequent visit. For example, pharmacists are now able to document an acute DRP and record that a telephone call to a physician’s office was made requesting therapeutic interchange of one controller inhaler such as budesonide/formoterol to a therapeutically appropriate alternative such as mometasone/formoterol. When the physician e-prescribes the alternative medication, the pharmacist or pharmacy student can document in Practice Fusion that the DRP has been resolved. The patient can then be contacted to pick up the medication and will therefore not go without the medication. In addition, the pharmacist or pharmacy student who counsels the patient the following month can assess the effectiveness of the new medication, and the continuity of the patient’s care will likely have been improved. From a student and resident learning perspective, Practice Fusion allows CPCO preceptors to evaluate students’ and residents’ performance with written communication, particularly related to SOAP notes and patient care plans. Students often struggle when implementing the SOAP note process into practice, but Practice Fusion provides the preceptor with an opportunity to review notes and to provide feedback about patient encounters throughout the month. This precepting practice has helped students and residents to identify areas of
SCIENCE AND PRACTICE EHR in community pharmacy
Table 2 Examples of documentation options Documentation tools Pharmacy dispensing systems17 Electronic medical records25 Open source25
Examples Computer-Rx, PioneerRx, QS/1, RX30, VIP Pharmacy Systems, Prescribe Wellness VistA, One Touch EMR OpenMRS, OpenEMR, NOSH, Solismed
documentation that are being clearly communicated and areas that might need further development. The creation of a patient-centered care plan is also often an area of growth for new practitioners. Practice Fusion allows for documentation of a care plan to be reviewed by a preceptor before giving the plan to the patient. Care plans are also longitudinal tools that promote effective follow-up of DRPs and patient counseling. With the paper charting system, SOAP notes and care plans were not structured and were not easily reviewed by preceptors. Preceptors can now help students and residents identify areas of growth and improve care for patients. In terms of funding, recognition, and future research, the implementation of Practice Fusion has provided CPCO with a better understanding of the patient population being served by the pharmacy. This understanding has resulted in an enhanced ability to communicate success stories with external collaborators and to request funding for additional needs. Aggregate data from Practice Fusion and a previous residency project by Babaeux et al.23 identified that more than 40% of patients seen at CPCO have diabetes. Using these data, CPCO was able to secure a grant of more than $45,000 from Women and Philanthropy at Ohio State University to provide medications and self-care counseling for women with diabetes. In addition, data from Practice Fusion helped CPCO submit meaningful applications that resulted in the inaugural Pharmacy Quality Alliance and the Community Pharmacy Foundation national award for Community Pharmacy Innovations, as well as the 2018 Excellence in Community Partnership Award from The Ohio State University. Pharmacy residents’ research projects have also become more robust because of data from Practice Fusion, as the documented DRPs were used to evaluate estimated cost avoidance to better demonstrate economic impact and to identify opportunities for future funding models.24 Discussion As other community pharmacies consider the process of implementing HIT and incorporating an EHR as part of their practices, the process we have described can be applied. We found that EHR implementation was feasible and took approximately 10 months to complete. We also found that using an EHR led to consistency in documentation of interventions and efficiency with patient follow-up. This might be particularly helpful for other charitable pharmacies, as their practice model often allows for additional counseling time with the patient and an opportunity to improve consistency across care providers through documented communication and resolution of DRPs. As the literature described, shared documentation is the ultimate goal for improving continuity with patient care, and implementation of an EHR has helped to bring CPCO one step closer to this opportunity. As community
pharmacies consider HIT and EHR implementation, the uniqueness of each practice site and the clinical services provided at the site should encourage contemplation of a variety of systems to help select a system that is best suited for the site. Examples of EHRs and other documentation systems that could be considered are included in Table 2.25 Characteristics of EHRs that could be considered include varying levels of customizability, varying technical skill levels to integrate the EHR for use, and varying levels of support for continued development and quality improvement that can allow for evolution as the health care system changes.25 Some limitations exist to the model as described. Practice Fusion has recently converted to a subscription-based system, which might hinder utilization in some pharmacy models, especially charitable or nonprofit pharmacies. CPCO also had limited disruption in workflow because of the opportunity to use students and pharmacy residents to assist with conversion to Practice Fusion. Implementation might be more difficult if multiple locations are included or if the use of technical staff members and students is limited. Although transitioning to 2 systems (dispensing and Practice Fusion) reduced the number of inputs and steps in our workflow, the need to use 2 distinct systems simultaneously might not fit other pharmacy practice settings. Lastly, the needs of each community pharmacy are somewhat unique. Therefore, applicability of all aspects of EHR implementation might be limited based on legal regulations and local practice opportunities. Conclusion The implementation and use of an EHR have provided a charitable pharmacy with opportunities to improve the quality and consistency of patient care through improved documentation, better understanding of the patient population, and improvements in the learning environment for student pharmacists and pharmacy residents through enhanced and targeted feedback. Community pharmacies and charitable pharmacies should consider adoption of HIT and the use of EHRs as an opportunity to augment their practices and create new avenues for communication that can enhance the care of their patients. The ability of community pharmacists to provide data that demonstrate their role in the improved care of patients will support the case for provider status and the opportunity for improved reimbursement models that will allow the practice of pharmacy to adapt and remain relevant in an ever-changing health care landscape. Acknowledgements The authors would like to acknowledge Melanie Boyd, Holly Fahey, Erin Gordon, and Laura Poling for their assistance with the project. References 1. 2016 Report to Congress on health information technology progress: examining the HITECH era and the future of health IT. Available at: https:// dashboard.healthit.gov/report-to-congress/2016-report-congress-examining-hitech-era-future-health-information-technology.php. Accessed May 24, 2018. 2. Spiro R. The impact of electronic health records on pharmacy practice. Drug Topics. April 2012. Available at: http://www.pharmacyhit.org/pdfs/ Article.pdf. Accessed January 21, 2019.
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3. Steinbrook R. Health care and the American Recovery and Reinvestment Act. N Engl J Med. 2009;360(11):1057e1060. 4. Medicare and Medicaid health information technology: Title IV of the American Recovery and Reinvestment Act. Published May 17, 2013. Available at: https:// www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2009-Factsheets-items/2009-06-16.html. Accessed May 24, 2018. 5. Fox BI, Pedersen CA, Gumpper KF. ASHP national survey on informatics: assessment of the adoption and use of pharmacy informatics in U.S. hospitalsd2013. Am J Health Syst Pharm. 2015;72(8):636e655. 6. Pedersen CA, Gumpper KF. ASHP national survey on informatics: assessment of the adoption and use of pharmacy informatics in U.S. hospitalsd2007. Am J Health Syst Pharm. 2008;65(23):2244e2264. 7. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribingd2016. Am J Health Syst Pharm. 2017;74(17):1336e1352. 8. Fixen DR, Linnebur SA, Parnes BL, Vejar MV, Vande Griend JP. Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic. Am J Health Syst Pharm. 2018;75:1805e1811. 9. Hensler D, Richardson CL, Brown J, et al. Impact of electronic health record-based, pharmacist-driven valganciclovir dose optimization in solid organ transplant recipents. Transpl Inefect Dis. 2018;20(2):e12849. 10. Jeon N, Sorokina M, Henriksen C, Staley B, Lipori GP, Winterstein AG. Measurement of selected preventable adverse drug events in electronic health records: Toward developing a complexity score. Am J Health Syst PharmI. 2017;74(22):1865e1877. 11. Fuji KT, Gait KA, Siracuse MV, Christoffersen JS. Electronic health record adoption and use by Nebraska pharmacists. Perspect Health Inf Manag. 2011;8(Summer):1d. 12. Bonner L. Pharmacists inch closer to accessing EHRs and HIEs. Pharm Today. 2016;22(5):44e47. 13. Keller ME, Kelling SE, Cornelius DC, Oni HA, Bright DR. Enhancing practice efficiency and patient care by sharing electronic health records. Perspect Health Inf Manag. 2015;12(Fall):1b. 14. Pharmacy Health Information Technology Collaborative. Available at: http://pharmacyhit.org/. Accessed March 27, 2018. 15. Electronic Health Record certification. Making the pharmacist’s case to system vendors by practice specific settings. Available at: http://www. pharmacyhit.org/pdfs/workshop-documents/WG4-Post-2016-01.pdf. Accessed March 27, 2018. 16. Bonner L. Model will better connect community pharmacy systems to EHRs and more. Available at: http://www.pharmacist.com/article/model-willbetter-connect-community-pharmacy-systems-ehrs-and-more. Accessed March 27, 2018.
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17. Empowering Community Pharmacies to Improve Care Coordination and Health Outcomes with Use of Electronic Care Plans, CPESN USA. Available at: https://www.cpesn.com/ecare-plan/. Accessed May 27, 2018. 18. Rodis JL, Legg JE, Casper KA. Partner for promotion: an innovative advanced community pharmacy practice experience. Am J Pharm Educ. 2008;72(6):134. 19. The Latest on Electronic Health Records. Practice Fusion Blog. Available at: https://www.practicefusion.com/. Accessed May 24, 2018. 20. EHR Meaningful Use Certification. Practice Fusion Blog. Available at: https:// www.practicefusion.com/certified-meaningful-use-ehr/. Accessed May 24, 2018. 21. Medication therapy management in pharmacy practice: core elements of an MTM service model. Available at: https://www.pharmacist.com/sites/default/ files/files/core_elements_of_an_mtm_practice.pdf. Accessed May 24, 2018. 22. 2017 Charitable Pharmacy of Central Ohio Annual Report. Charitable Pharmacy of Central Ohio. Available at: https://charitablepharmacy.org/2 017-CHARITABLE-PHARMACY-ANNUAL-REPORT.pdf. Accessed October 21, 2018. 23. Fahey Babeaux HP, Hall LE, Seifert JL. Charitable pharmacy services: impact on patient-reported hospital use, medication access, and health status. J AM Pharm Assoc (2003). 2015;55(1):59e66. 24. Schmuhl K, Casper K, Seifert J, Fahey H, Shine J, Newland B. Defining value of clinical interventions made by pharmacists and student pharmacists at a charitable pharmacy. Poster presention at: Nashville, TN: American Pharmacists Association Annual Meeting. March 2018. 25. The Top 7 Free and Open Source EMR Software Products–Capterra Blog. Available at: https://blog.capterra.com/top-7-free-open-source-emrsoftware-products/. Accessed May 27, 2018.
Andrew Faiella, PharmD, BCACP, PrimaryOne Health. At time of study: PGY-1 resident at The Ohio State University College of Pharmacy and Charitable Pharmacy of Central Ohio, Columbus, OH Kristin A. Casper, PharmD, BCACP, Associate Professor of Clinical Pharmacy, Division of Pharmacy Practice and Science, The Ohio State University College of Pharmacy, Columbus, OH Lisa Bible, PharmD, Walgreens Pharmacy. At time of study: PGY-1 resident at The Ohio State University College of Pharmacy and Charitable Pharmacy of Central Ohio, Columbus, OH Jennifer Seifert, MS, RPh, BCGP, Executive Director, Charitable Pharmacy of Central Ohio, Residency Program Director, PGY-1 Community-based Program, The Ohio State University College of Pharmacy, Columbus, OH