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Information Technology and Pharmaceutical Care
FEATURE
Information Technology and Pharmaceutical Care Information systems provide the keys to implementation ofpharmaceutical care services. Here are the key trends in information capture and exchange in community pharmacy. Donna S. West and Sheryl Szeinbach
Pharmacists of the 1990s are moving well beyond their "traditional" roles and becoming involved in patient counseling and care, case management, and disease management. Emerging responsibilities include collecting patient data, screening for drug-related problems, monitoring therapies, documenting outcomes, and educating patients. Using information technology, pharmacists can accurately and completely document the value of their interventions and the resulting patient outcomes-and even use the system to bill for those services. 1 Although many pharmacists are moving forward on their own with these and other pharmaceutical care activities, a commonly encountered obstacle is the lack of software that seamlessly integrates the emerging activities with traditional drug dispensing and patient counseling tasks. Professional pharmacy organizations and individual practitioners have encouraged the development of computer software that can support pharmacists' increasing roles in patient care. For example, the American Pharmaceutical Association has made a commitment to work with vendors to "develop the software pharmacists need to collect patient data, design medication plans, and structure ongoing patient monitoring and case management.,,2 Fortuitously or not, information technologies are advancing rapidly, becoming faster and more powerful. The Internet is continually evolving, making electronic communication-routine in the banking, transportation, and automobile industries-more common in the health care industry. However, this "revolution" of new technologies is not without problems. The purchase of new technologies used to be relatively simple. Now training manuals regularly exceed 50 pages, the technology itself is often incompatible with other systems, and extra attachments designed exclusively for a particular system must be purchased separately. Based on these experiences, it is no surprise that individuals may be reluctant to adopt and use new technologies; most potential users need to be convinced of the usefulness of the new technologies and their contributions to performance and productivity.
Vol. NS37, No.5
September/October 1997
In addition, more training is needed before users can effectively
use the hardware and software they purchase. Moreover, the return on investment and the contributions of these technologies to organizational performance and productivity in the health care system are subject to much debate. And, finally, although it is easy to access information on the Internet, patients and providers must be aware of the potential for finding inaccurate information. Four main trends now resonate within the changing practice of pharmacy: (1) rapid development of software to support patient care activities; (2) increased software integration and computer interfacing; (3) shortened computer system life cycles as technologic advances continue; and (4) increased use of electronic data interchange. This article discusses these trends as theJ. pertain to community pharmacy and reviews a broad sampling of stand-alone pharmacy systems designed by vendors of computers and pharmacy systems.
Trend 1: Software for Patient Care Activities Initially, vendors developed software to facilitate the documentation and billing of pharmaceutical care services. However, pharmacists are finding that pharmaceutical care, a multistep process, requires increasingly comprehensive systems. Systems that help pharmacists store patient data, screen for problems, document interventions, develop patient care plans, evaluate outcomes, and educate patients are becoming essential. Table 1 lists available pharmaceutical care software systems and the functions supported by each. Of course, different systems offer unique features. Pharmacists can test different software packages on the Health Education Learning and Information Exchange (HELIX) home page of the World Wide Web (www.helix.com).This article focuses more on the capabilities of the systems than on their ease of use and reliability.
Journal of the American Pharmaceutical Association
497
FEATURE
Pharmaceutical Care Technology
Table 1. Pharmaceutical Care Systems and Functions
Software Package
Care Plans
Disease Management
Supports Therapeutic Outcome Documentation
Apothacare (800) 736-8456
DMRx (consulting software)
Yes
Yes
Yes
No
Yes (PCCF, HCFA)
ComCoTec (800) 282-3232
RxCaliber
Yes
Yes
Yes
Yes
Yes (PCCF, HCFA)
Compute-Rx (800) 879-1987
Care-Trak
No
No
No
Yes
Yes (PCCF, HCFA)
Encara (program of AmeriSource) (800) 595-4927
MedAssess Patient Management Systems
Yes
Yes
Yes
No
Yes (PCCF, HCFA)
Etreby Computer Co. (800) 292-5590
Apothecare 2000
Yes
Yes
Yes (Gal)
Yes
Yes (PCCF, HCFA)
OPUS-CORE Corp. (914) 698-8444
CARE PLAN
Yes
Yes
Yes (Gal)
Yes
Yes (PCCF, HCFA)
HealthCare Computer Corp. (817) 531-8992
Alpha-Care
Yes
Yes (AIM)
Yes
Yes
Yes (PCCF, HCFA)
as/1 (800) 882-3815
NA
Yes
Yes
Yes
No
Yes
POX Inc. (800) 433-5719
Cognitive Service Module
Yes
Yes (PCM)
Yes (Gal)
Yes
Yes
CarePoint (800) 296-1825
Cognicare
Yes
Yes
Yes
Yes
Yes (PCCF, HCFA)
jASCorp (800) 344-5922
Encounter
Yes
Yes
Yes
Yes
Yes (PCCF, HCFA)
Company
SOAP Notes
Cognitive Service Billing*
*System has a cognitive service invoice. AIM = Asthma Integrated Management (a separate disease management module); HCFA = Health Care Financing Administration; NA = not applicable; PCCF = Pharmacist Care Claim Form; PCM = patient care module (separate disease management module); GOl = quality of life; SOAP = subjective, objective, assess, plan.
Because a major thrust of pharmaceutical care is assessing drug therapies and screening for drug-related problems, all of the systems listed in Table 1 support clinical screening and decision making in some manner. Medical information companies have expanded their clinical databases and developed products to detect drug-related problems other than the traditional drug-drug interactions, and pharmacy computer software vendors have integrated selected databases into their dispensing or patient care software systems. But this integration occurs in different ways and serves different purposes. For instance, some systems alert the pharmacist when patients may be eligible for a disease management plan, whereas other systems with the same database are not programmed to do so. The most common databases used in the pharmaceuti,cal software packages are products of the following companies: Medi-Span, First Data Bank, MicroMedex, and U.S. Pharmacopeia Drug Information (see Table 2). Many programs incorporate several databases from different companies. Each system is therefore unique in the interactions it can detect and the information it will provide. Table 3 contains a sampling of some of the databases available. The ability of the pharmaceutical care systems to document clinical interventions is important for clinical, financial, and legal
498
Journal of the American Phannaceutical Association
reasons. All of the systems listed in Table 1 provide some method of documentation. Most of the vendors format their software to document using the SOAP (~ubjective, Qbjective, fl,ssess, and ~lan) note system. However, in today's health care system, outcome assessment is extremely important, and few systems support this process. Documenting clinical, economic, and human outcomes-those desired and those achieved-is a vital step in pharmaceutical care and disease management. System support for clinical outcome management (e.g., blood pressure, physical function) is more extensive than for economic and human outcomes management. Only three companies market systems that do the latter. Etreby's system includes a general quality of life instrument (QOL), the SF-36, a 36-item instrument. The system scores the items, displays the results in graphical form, and stores the data for later comparisons. The system also supports evaluation of patient satisfaction. PDX and OPUSCORE also have systems that support QOL measurements. Pharmacists' ability to evaluate patients' QOL over time is a valued outcome measure as third party payers demand evidence of the effects of pharmacists' interventions on improved patient care. To obtain these measures and associate them with outcome
September/October 1997
Vol. NS37, No.5
Pharmaceutical Care Technology
Table 2. Pharmaceutical Care Systems Database Support Company
Database Support
Apothacare
Vendor
ComCoTec
Medi-Span
Compute-Rx
First DataBank
Encara
Medi-Span
Etreby Computer Co.
Vendor
OPUS-CORE Corp.
First DataBank, MicroMedex, Medi-Span
HealthCare Computer Corp.
USP 01, First DataBank, Medi-Span
OS/1
USP 01, First DataBank
PDX Inc.
Medi-Span, First DataBank
CarePoint
USPDI
jASCorp
Medi-Span, First DataBank
USP 01 = United States Pharmacopeia Drug Information.
assessment and organizational performance, administrative and financial functions must be considered in the design of software systems. Ultimately, information technologies that support both process and outcome documentation-and link the data-will be the successful systems. A drug therapy plan to achieve favorable outcomes is a crucial component of pharmaceutical care. Computer software offers clinical support by displaying a patient care plan for the pharmacist to follow, prompting the pharmacist to engage in certain processes, and reminding him or her of specific steps of care. Some computer companies are designing systems that allow the pharmacist to create customized patient protocols or to modify existing ones. Disease management is being used increasingly in the therapy of chronically ill patients. Many computer companies are marketing vendor-developed care guidelines as disease management programs or modules. Some programs provide predefined disease management support, whereas other systems allow pharmacists to create their own customized programs. One program that combines the two approaches is HealthCare Computer Corporation's MentorRx series, which allows pharmacists to select specific guidelines from a variety of disease management programs for incorporation into the active software. Most pharmacy software systems also support patient education. Some systems provide drug monographs or information leaflets for the patient. For example, First DataBank sells The Patient Health Advisor, which can be integrated into pharmacy systems. Other software programs have graphic capabilities that help the pharmacist explain clinical results and progress phases to patients. All comprehensive patient care systems enable the pharmacist to bill for cognitive services; however, several different billing
Vol. NS37, No.5
September/October 1997
FEATURE
forms are in use. The development of standardized codes by the National Council for Prescription Drug Programs (NCPDP) has enabled the electronic documentation and transmission of clinical information and billing data related to professional pharmacy services. 3 The Pharmacist Care Claim Form (PCCF) of the National Community Pharmacists Association (formerly NARD) contains these codes and has been incorporated into several computer systems, to be used as a standard way to bill for cognitive services. The Health Care Financing Administration (HCFA) 1500 form is the other standard billing format available on several of the systems. Unfortunately, a few systems do not provide either format. Some vendors provide services to help pharmacists establish a patient care practice. These services include newsletters, networking opportunities, professionally designed programs, marketing materials, consulting, training in pharmaceutical care, media kits, workflow design advice, and continuing education materials.
Trend 2: Increased Software Integration and Computer Interfacing Unresolved to date is whether pharmaceutical care software systems should stand alone or be integrated into the dispensing systems (see Table 4). Combining pharmaceutical care software
Table 3. Examples of Database Products Product (Company)
Description
Drug-Reax System (MicroMedex)
Screens for drug-drug, drug-food, drug-disease, drug-ethanol, drug-labs, drug-allergy interactions; provides information on interaction, effect, and clinical significance
UltiMedex (MicroMedex)
Windows-based clinical decision support system for disease management: drug-drug interaction screening, drug information, warnings on adverse drug effects, cost comparisons, dosing
OUR Database (Medi-Span)
Screens for drug-drug, drug-allergy, drug-disease interactions, duplicative therapy, and incorrect dosages
Drug Therapy Screening (Medi-Span)
Screens for drug-drug, drug-food, drug-alcohol, and prior adverse reaction interactions; provides information on onset, severity, references, mechanism of action, management, and effects
RxTriage (First DataBank)
Screens for drug-drug, drug-food interactions; supports decision making, duplicative therapy checking, and patient education; provides information on significance, mechanism of action, and clinical effects of interactions
Drug Interaction Decision Tree (First DataBank)
Helps pharmacist select most appropriate action to solve drug therapy problems
Journal of the American Pharmaceutical Association
499
FEATURE
Pharmaceutical Care Technology
Table 4. Integration of Patient Care Systems with Dispensing Systems Company
Stand-Alone or Integrated
Apothacare (consulting software)
Stand-alone
ComCoTec
Stand-alone or interface with dispensing systems
Compute-Rx
Integrated
Encara
Stand-alone
Etreby Computer Co.
Stand-alone or interface with dispensing systems
OPUS-CORE Corp.
Integrated (can interface with other dispensing systems)
HealthCare Computer Corp.
Integrated
OS/1
Integrated
POX Inc.
Integrated
CarePoint
Stand-alone or interface with dispensing systems
jASCorp
Stand-alone or interface with dispensing systems
with the pharmacy dispensing system allows the files within both systems to be updated simultaneously; separating the systems means that data must be entered twice. Use of a single platform makes data entry easier and more convenient for the pharmacist; yet separating the systems offers an advantage: detaching the pharmacist from the dispensing process so that he or she may focus more on patient care. 4 Whether stand-alone or integrated, these pharmaceutical care systems have the capability to interface with other technologies in the burgeoning field of medical informatics. Many individual programs and computer-based instruments have been designed to assist pharmacists in physical assessment measures and disease monitoring. For example, the DynaPulse 200M by PulseMetric, Inc. , measures systolic and diastolic blood pressure, mean arterial pressure, and heart rate, and displays the results on the computer monitor in a graphical format. The automatic storage of these data permits pharmacists to monitor a patient's health status over time. Some blood glucose monitoring devices and peak flow meters can interface with computer systems. Encara, HealthCare Computer Corporation, and OPUS-CORE Corporation are examples of computer companies that promote their systems' ability to interface with these disease-indicator devices. Current computer systems are usually equipped with CDROM drives that permit use of educational or drug information packages provided in this format. A few pharmaceutical care systems provide linkage to a word-processing program or the Internet. These methods ease communication among health care providers and patients. As previously mentioned, databases and drug information are also being integrated into patient care systems.
500
Journal of the American Phannaceutical Association
Trend 3: Rapid Technologic Change and Short Computer Lives Like other users, pharmacists are finding it necessary to upgrade their hardware frequently to keep up with spiraling advances in software. Most pharmaceutical care software packages require Pentium processors for best results. For optimal operation, computers need these minimum capacities: 4X CDROM, 16 MB RAM, a 28.8 Kbps modem, and 1 GB for hard drive storage. Additional RAM is required as larger databases are stored, more interfacing with CD-ROMs or disease indicator instruments occurs, and more decision-making support is needed. Most new software is being written for the Microsoft Windows environment. The Windows environment enables multitasking, which is extremely valuable to the pharmacist providing care. The ability to access drug information or a word-processing package without closing a patient profile saves time. The graphical user interface is more user-oriented and easier to learn. Several pharmacy computer companies have marketed programs to run on the powerful Windows 95 platform (see Table 5).
Trend 4: Increased Use of Electronic Data Interchange The pharmacy profession must react to increased electronic exchange of information among providers, payers, and patients. The Health Insurance Portability and Accountability Act of 1996 provides for electronic exchange of information, including prescription orders. Therefore, the controversy is not whether electronic data interchange will be used in health care systems, but how and when it will be used. Adoption of communications technologies throughout the health care system holds the promise of enhancing patient care and decreasing fragmentation of services. For pharmacists to realize the full benefit of their pharmaceutical care software system, they must have access to complete patient data, including diagnosis, laboratory values, and medication profile. Electronic communication is the easiest and most convenient way to obtain these data. However, before an electronic infrastructure is developed, patient confidentiality issues must be addressed. Rights to privacy and access to medical information have piqued the interest and concern of patients, consumer groups, and health care providers. These groups will rely on political action to ensure that patient confidentiality and privacy issues are considered when information technologies are used to integrate health care providers and health care plans. Policies that guarantee the privacy of medical records and guarantee authorized access to medical information will expedite the adoption of the information technologies and facilitate the integration of health care systems. Through the Internet, pharmacists can use E-mail to send refill reminders and correspond on other matters, too. Through the World Wide Web and other on-line services, pharmacists can obtain medical information, communicate with professional pharmacy associations, or complete a continuing education program.
September/October 1997 Vol. NS37, No.5
Pharmaceutical Care Technology
Table 5. Windows-Based Systems (Company) DMRx (Apothacare) RxCaliber (ComCoTec) MedAssess Patient Management Systems (Encara) CAREPLAN (OPUS-CORE Corp.) CogniCare (CarePoint) Encounter (jASCorp)
The pharmacy profession continues to ponder the issue of electronic delivery of prescription orders. Computer vendors are incorporating the software necessary to transmit prescription orders electronically. Many have faced the dilemma of whether to use the EDI-FACT MEDPRE or the SCRIPT electronic communication standard. The EDI-FACT MEDPRE standard, developed by the American Society for Automation in Pharmacy, provides electronic connectivity between physician and pharmacy computers, with no third party involvement. Etreby Computer Company and HealthCare Computer Corporation have incorporated the MEDPRE standard into their software. In competition with this program is SCRIPT, the standard developed by the NCPDP. This standard allows third party access to the electronic prescription data.
FEATURE
providing patient care. 5 However, computers can and do support patient care processes and provide the tools for optimizing patient health outcomes and improving patient care and satisfaction. State-of-the-art software also increases the productivity of the pharmacy-allowing pharmacists to work more efficiently in today's high-workload environment, engage in a proactive approach to care, deliver continuous care, and document the value of their interventions for reimbursement purposes. Donna S. West, MS, is a graduate student and Sheryl Szeinbach, PhD, is associate professor, Department of Pharmacy Administration and Management and Marketing, School of Pharmacy, University of Mississippi, University.
References 1. Zimmerman CR, Smolarek RT, Stevenson JG. A computerized system to improve documentation and reporting of pharmacists' clinical interventions, cost savings, and workload activities. Pharmacotherapy. 1995; 15(2):220-27. 2. Stover K. Annual Meeting Highlights-Re-engineering for Pharmaceutical Care. JAm Pharm Assoc. 1996;NS36:387-95. 3. Whittemore K. Billing for patient care. ComputerTalk. 1995; 15(5):34-5. 4. Banahan BF. What are you doing with that computer? ComputerTalk. 1993;13(1):6-8. 5. Winkler C. The day ofthe aha! American Druggist. 210(1):53-6.
Refining Pharmacy's Tools for the Twenty-First Century For two decades, pharmacists have thought of computers more as a way to automate dispensing tasks and less as a resource for
Vol. NS37, No.5
September/October 1997
Journal of the American Phannaceutical Association
501
Information Technology and Pharmaceutical Care Information systems provide the keys to implementation ofpharmaceutical care services. Here are the key trends in information capture and exchange in community pharmacy. Donna S. West and Sheryl Szeinbach
Pharmacists of the 1990s are moving well beyond their "traditional" roles and becoming involved in patient counseling and care, case management, and disease management. Emerging responsibilities include collecting patient data, screening for drug-related problems, monitoring therapies, documenting outcomes, and educating patients. Using information technology, pharmacists can accurately and completely document the value of their interventions and the resulting patient outcomes-and even use the system to bill for those services. 1 Although many pharmacists are moving forward on their own with these and other pharmaceutical care activities, a commonly encountered obstacle is the lack of software that seamlessly integrates the emerging activities with traditional drug dispensing and patient counseling tasks. Professional pharmacy organizations and individual practitioners have encouraged the development of computer software that can support pharmacists' increasing roles in patient care. For example, the American Pharmaceutical Association has made a commitment to work with vendors to "develop the software pharmacists need to collect patient data, design medication plans, and structure ongoing patient monitoring and case management.,,2 Fortuitously or not, information technologies are advancing rapidly, becoming faster and more powerful. The Internet is continually evolving, making electronic communication-routine in the banking, transportation, and automobile industries-more common in the health care industry. However, this "revolution" of new technologies is not without problems. The purchase of new technologies used to be relatively simple. Now training manuals regularly exceed 50 pages, the technology itself is often incompatible with other systems, and extra attachments designed exclusively for a particular system must be purchased separately. Based on these experiences, it is no surprise that individuals may be reluctant to adopt and use new technologies; most potential users need to be convinced of the usefulness of the new technologies and their contributions to performance and productivity.
Vol. NS37, No.5
September/October 1997
In addition, more training is needed before users can effectively
use the hardware and software they purchase. Moreover, the return on investment and the contributions of these technologies to organizational performance and productivity in the health care system are subject to much debate. And, finally, although it is easy to access information on the Internet, patients and providers must be aware of the potential for finding inaccurate information. Four main trends now resonate within the changing practice of pharmacy: (1) rapid development of software to support patient care activities; (2) increased software integration and computer interfacing; (3) shortened computer system life cycles as technologic advances continue; and (4) increased use of electronic data interchange. This article discusses these trends as theJ. pertain to community pharmacy and reviews a broad sampling of stand-alone pharmacy systems designed by vendors of computers and pharmacy systems.
Trend 1: Software for Patient Care Activities Initially, vendors developed software to facilitate the documentation and billing of pharmaceutical care services. However, pharmacists are finding that pharmaceutical care, a multistep process, requires increasingly comprehensive systems. Systems that help pharmacists store patient data, screen for problems, document interventions, develop patient care plans, evaluate outcomes, and educate patients are becoming essential. Table 1 lists available pharmaceutical care software systems and the functions supported by each. Of course, different systems offer unique features. Pharmacists can test different software packages on the Health Education Learning and Information Exchange (HELIX) home page of the World Wide Web (www.helix.com).This article focuses more on the capabilities of the systems than on their ease of use and reliability.
Journal of the American Pharmaceutical Association
497
FEATURE
Pharmaceutical Care Technology
Table 1. Pharmaceutical Care Systems and Functions
Software Package
Care Plans
Disease Management
Supports Therapeutic Outcome Documentation
Apothacare (800) 736-8456
DMRx (consulting software)
Yes
Yes
Yes
No
Yes (PCCF, HCFA)
ComCoTec (800) 282-3232
RxCaliber
Yes
Yes
Yes
Yes
Yes (PCCF, HCFA)
Compute-Rx (800) 879-1987
Care-Trak
No
No
No
Yes
Yes (PCCF, HCFA)
Encara (program of AmeriSource) (800) 595-4927
MedAssess Patient Management Systems
Yes
Yes
Yes
No
Yes (PCCF, HCFA)
Etreby Computer Co. (800) 292-5590
Apothecare 2000
Yes
Yes
Yes (Gal)
Yes
Yes (PCCF, HCFA)
OPUS-CORE Corp. (914) 698-8444
CARE PLAN
Yes
Yes
Yes (Gal)
Yes
Yes (PCCF, HCFA)
HealthCare Computer Corp. (817) 531-8992
Alpha-Care
Yes
Yes (AIM)
Yes
Yes
Yes (PCCF, HCFA)
as/1 (800) 882-3815
NA
Yes
Yes
Yes
No
Yes
POX Inc. (800) 433-5719
Cognitive Service Module
Yes
Yes (PCM)
Yes (Gal)
Yes
Yes
CarePoint (800) 296-1825
Cognicare
Yes
Yes
Yes
Yes
Yes (PCCF, HCFA)
jASCorp (800) 344-5922
Encounter
Yes
Yes
Yes
Yes
Yes (PCCF, HCFA)
Company
SOAP Notes
Cognitive Service Billing*
*System has a cognitive service invoice. AIM = Asthma Integrated Management (a separate disease management module); HCFA = Health Care Financing Administration; NA = not applicable; PCCF = Pharmacist Care Claim Form; PCM = patient care module (separate disease management module); GOl = quality of life; SOAP = subjective, objective, assess, plan.
Because a major thrust of pharmaceutical care is assessing drug therapies and screening for drug-related problems, all of the systems listed in Table 1 support clinical screening and decision making in some manner. Medical information companies have expanded their clinical databases and developed products to detect drug-related problems other than the traditional drug-drug interactions, and pharmacy computer software vendors have integrated selected databases into their dispensing or patient care software systems. But this integration occurs in different ways and serves different purposes. For instance, some systems alert the pharmacist when patients may be eligible for a disease management plan, whereas other systems with the same database are not programmed to do so. The most common databases used in the pharmaceuti,cal software packages are products of the following companies: Medi-Span, First Data Bank, MicroMedex, and U.S. Pharmacopeia Drug Information (see Table 2). Many programs incorporate several databases from different companies. Each system is therefore unique in the interactions it can detect and the information it will provide. Table 3 contains a sampling of some of the databases available. The ability of the pharmaceutical care systems to document clinical interventions is important for clinical, financial, and legal
498
Journal of the American Phannaceutical Association
reasons. All of the systems listed in Table 1 provide some method of documentation. Most of the vendors format their software to document using the SOAP (~ubjective, Qbjective, fl,ssess, and ~lan) note system. However, in today's health care system, outcome assessment is extremely important, and few systems support this process. Documenting clinical, economic, and human outcomes-those desired and those achieved-is a vital step in pharmaceutical care and disease management. System support for clinical outcome management (e.g., blood pressure, physical function) is more extensive than for economic and human outcomes management. Only three companies market systems that do the latter. Etreby's system includes a general quality of life instrument (QOL), the SF-36, a 36-item instrument. The system scores the items, displays the results in graphical form, and stores the data for later comparisons. The system also supports evaluation of patient satisfaction. PDX and OPUSCORE also have systems that support QOL measurements. Pharmacists' ability to evaluate patients' QOL over time is a valued outcome measure as third party payers demand evidence of the effects of pharmacists' interventions on improved patient care. To obtain these measures and associate them with outcome
September/October 1997
Vol. NS37, No.5
Pharmaceutical Care Technology
Table 2. Pharmaceutical Care Systems Database Support Company
Database Support
Apothacare
Vendor
ComCoTec
Medi-Span
Compute-Rx
First DataBank
Encara
Medi-Span
Etreby Computer Co.
Vendor
OPUS-CORE Corp.
First DataBank, MicroMedex, Medi-Span
HealthCare Computer Corp.
USP 01, First DataBank, Medi-Span
OS/1
USP 01, First DataBank
PDX Inc.
Medi-Span, First DataBank
CarePoint
USPDI
jASCorp
Medi-Span, First DataBank
USP 01 = United States Pharmacopeia Drug Information.
assessment and organizational performance, administrative and financial functions must be considered in the design of software systems. Ultimately, information technologies that support both process and outcome documentation-and link the data-will be the successful systems. A drug therapy plan to achieve favorable outcomes is a crucial component of pharmaceutical care. Computer software offers clinical support by displaying a patient care plan for the pharmacist to follow, prompting the pharmacist to engage in certain processes, and reminding him or her of specific steps of care. Some computer companies are designing systems that allow the pharmacist to create customized patient protocols or to modify existing ones. Disease management is being used increasingly in the therapy of chronically ill patients. Many computer companies are marketing vendor-developed care guidelines as disease management programs or modules. Some programs provide predefined disease management support, whereas other systems allow pharmacists to create their own customized programs. One program that combines the two approaches is HealthCare Computer Corporation's MentorRx series, which allows pharmacists to select specific guidelines from a variety of disease management programs for incorporation into the active software. Most pharmacy software systems also support patient education. Some systems provide drug monographs or information leaflets for the patient. For example, First DataBank sells The Patient Health Advisor, which can be integrated into pharmacy systems. Other software programs have graphic capabilities that help the pharmacist explain clinical results and progress phases to patients. All comprehensive patient care systems enable the pharmacist to bill for cognitive services; however, several different billing
Vol. NS37, No.5
September/October 1997
FEATURE
forms are in use. The development of standardized codes by the National Council for Prescription Drug Programs (NCPDP) has enabled the electronic documentation and transmission of clinical information and billing data related to professional pharmacy services. 3 The Pharmacist Care Claim Form (PCCF) of the National Community Pharmacists Association (formerly NARD) contains these codes and has been incorporated into several computer systems, to be used as a standard way to bill for cognitive services. The Health Care Financing Administration (HCFA) 1500 form is the other standard billing format available on several of the systems. Unfortunately, a few systems do not provide either format. Some vendors provide services to help pharmacists establish a patient care practice. These services include newsletters, networking opportunities, professionally designed programs, marketing materials, consulting, training in pharmaceutical care, media kits, workflow design advice, and continuing education materials.
Trend 2: Increased Software Integration and Computer Interfacing Unresolved to date is whether pharmaceutical care software systems should stand alone or be integrated into the dispensing systems (see Table 4). Combining pharmaceutical care software
Table 3. Examples of Database Products Product (Company)
Description
Drug-Reax System (MicroMedex)
Screens for drug-drug, drug-food, drug-disease, drug-ethanol, drug-labs, drug-allergy interactions; provides information on interaction, effect, and clinical significance
UltiMedex (MicroMedex)
Windows-based clinical decision support system for disease management: drug-drug interaction screening, drug information, warnings on adverse drug effects, cost comparisons, dosing
OUR Database (Medi-Span)
Screens for drug-drug, drug-allergy, drug-disease interactions, duplicative therapy, and incorrect dosages
Drug Therapy Screening (Medi-Span)
Screens for drug-drug, drug-food, drug-alcohol, and prior adverse reaction interactions; provides information on onset, severity, references, mechanism of action, management, and effects
RxTriage (First DataBank)
Screens for drug-drug, drug-food interactions; supports decision making, duplicative therapy checking, and patient education; provides information on significance, mechanism of action, and clinical effects of interactions
Drug Interaction Decision Tree (First DataBank)
Helps pharmacist select most appropriate action to solve drug therapy problems
Journal of the American Pharmaceutical Association
499
FEATURE
Pharmaceutical Care Technology
Table 4. Integration of Patient Care Systems with Dispensing Systems Company
Stand-Alone or Integrated
Apothacare (consulting software)
Stand-alone
ComCoTec
Stand-alone or interface with dispensing systems
Compute-Rx
Integrated
Encara
Stand-alone
Etreby Computer Co.
Stand-alone or interface with dispensing systems
OPUS-CORE Corp.
Integrated (can interface with other dispensing systems)
HealthCare Computer Corp.
Integrated
OS/1
Integrated
POX Inc.
Integrated
CarePoint
Stand-alone or interface with dispensing systems
jASCorp
Stand-alone or interface with dispensing systems
with the pharmacy dispensing system allows the files within both systems to be updated simultaneously; separating the systems means that data must be entered twice. Use of a single platform makes data entry easier and more convenient for the pharmacist; yet separating the systems offers an advantage: detaching the pharmacist from the dispensing process so that he or she may focus more on patient care. 4 Whether stand-alone or integrated, these pharmaceutical care systems have the capability to interface with other technologies in the burgeoning field of medical informatics. Many individual programs and computer-based instruments have been designed to assist pharmacists in physical assessment measures and disease monitoring. For example, the DynaPulse 200M by PulseMetric, Inc. , measures systolic and diastolic blood pressure, mean arterial pressure, and heart rate, and displays the results on the computer monitor in a graphical format. The automatic storage of these data permits pharmacists to monitor a patient's health status over time. Some blood glucose monitoring devices and peak flow meters can interface with computer systems. Encara, HealthCare Computer Corporation, and OPUS-CORE Corporation are examples of computer companies that promote their systems' ability to interface with these disease-indicator devices. Current computer systems are usually equipped with CDROM drives that permit use of educational or drug information packages provided in this format. A few pharmaceutical care systems provide linkage to a word-processing program or the Internet. These methods ease communication among health care providers and patients. As previously mentioned, databases and drug information are also being integrated into patient care systems.
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Journal of the American Phannaceutical Association
Trend 3: Rapid Technologic Change and Short Computer Lives Like other users, pharmacists are finding it necessary to upgrade their hardware frequently to keep up with spiraling advances in software. Most pharmaceutical care software packages require Pentium processors for best results. For optimal operation, computers need these minimum capacities: 4X CDROM, 16 MB RAM, a 28.8 Kbps modem, and 1 GB for hard drive storage. Additional RAM is required as larger databases are stored, more interfacing with CD-ROMs or disease indicator instruments occurs, and more decision-making support is needed. Most new software is being written for the Microsoft Windows environment. The Windows environment enables multitasking, which is extremely valuable to the pharmacist providing care. The ability to access drug information or a word-processing package without closing a patient profile saves time. The graphical user interface is more user-oriented and easier to learn. Several pharmacy computer companies have marketed programs to run on the powerful Windows 95 platform (see Table 5).
Trend 4: Increased Use of Electronic Data Interchange The pharmacy profession must react to increased electronic exchange of information among providers, payers, and patients. The Health Insurance Portability and Accountability Act of 1996 provides for electronic exchange of information, including prescription orders. Therefore, the controversy is not whether electronic data interchange will be used in health care systems, but how and when it will be used. Adoption of communications technologies throughout the health care system holds the promise of enhancing patient care and decreasing fragmentation of services. For pharmacists to realize the full benefit of their pharmaceutical care software system, they must have access to complete patient data, including diagnosis, laboratory values, and medication profile. Electronic communication is the easiest and most convenient way to obtain these data. However, before an electronic infrastructure is developed, patient confidentiality issues must be addressed. Rights to privacy and access to medical information have piqued the interest and concern of patients, consumer groups, and health care providers. These groups will rely on political action to ensure that patient confidentiality and privacy issues are considered when information technologies are used to integrate health care providers and health care plans. Policies that guarantee the privacy of medical records and guarantee authorized access to medical information will expedite the adoption of the information technologies and facilitate the integration of health care systems. Through the Internet, pharmacists can use E-mail to send refill reminders and correspond on other matters, too. Through the World Wide Web and other on-line services, pharmacists can obtain medical information, communicate with professional pharmacy associations, or complete a continuing education program.
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Table 5. Windows-Based Systems (Company) DMRx (Apothacare) RxCaliber (ComCoTec) MedAssess Patient Management Systems (Encara) CAREPLAN (OPUS-CORE Corp.) CogniCare (CarePoint) Encounter (jASCorp)
The pharmacy profession continues to ponder the issue of electronic delivery of prescription orders. Computer vendors are incorporating the software necessary to transmit prescription orders electronically. Many have faced the dilemma of whether to use the EDI-FACT MEDPRE or the SCRIPT electronic communication standard. The EDI-FACT MEDPRE standard, developed by the American Society for Automation in Pharmacy, provides electronic connectivity between physician and pharmacy computers, with no third party involvement. Etreby Computer Company and HealthCare Computer Corporation have incorporated the MEDPRE standard into their software. In competition with this program is SCRIPT, the standard developed by the NCPDP. This standard allows third party access to the electronic prescription data.
FEATURE
providing patient care. 5 However, computers can and do support patient care processes and provide the tools for optimizing patient health outcomes and improving patient care and satisfaction. State-of-the-art software also increases the productivity of the pharmacy-allowing pharmacists to work more efficiently in today's high-workload environment, engage in a proactive approach to care, deliver continuous care, and document the value of their interventions for reimbursement purposes. Donna S. West, MS, is a graduate student and Sheryl Szeinbach, PhD, is associate professor, Department of Pharmacy Administration and Management and Marketing, School of Pharmacy, University of Mississippi, University.
References 1. Zimmerman CR, Smolarek RT, Stevenson JG. A computerized system to improve documentation and reporting of pharmacists' clinical interventions, cost savings, and workload activities. Pharmacotherapy. 1995; 15(2):220-27. 2. Stover K. Annual Meeting Highlights-Re-engineering for Pharmaceutical Care. JAm Pharm Assoc. 1996;NS36:387-95. 3. Whittemore K. Billing for patient care. ComputerTalk. 1995; 15(5):34-5. 4. Banahan BF. What are you doing with that computer? ComputerTalk. 1993;13(1):6-8. 5. Winkler C. The day ofthe aha! American Druggist. 210(1):53-6.
Refining Pharmacy's Tools for the Twenty-First Century For two decades, pharmacists have thought of computers more as a way to automate dispensing tasks and less as a resource for
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