The pharmacist and the EHR

Abstract

The adoption of electronic health records (EHRs) across the United States has impacted the methods by which health care professionals care for their patients. It is not always recognized, however, that pharmacists also actively use advanced functionality within the EHR. As critical members of the health care team, pharmacists utilize many different features of the EHR. The literature focuses on 3 main roles: documentation, medication reconciliation, and patient evaluation and monitoring. As health information technology proliferates, it is imperative that pharmacists’ workflow and information needs are met within the EHR to optimize medication therapy quality, team communication, and patient outcomes.

INTRODUCTION

Pharmacists have a history of early information system adoption, such as telephonic health information exchange in 1877,¹ electronic patient profiles and inventory management systems in the 1960s,² and automated drug interaction checking in the 1970s.³ However, pharmacists are frequently left off the list when it comes to informatics research, design, decision making, and leadership.

Pharmacists are in expanded clinical roles of participation in direct patient care in many clinical settings. Clinical pharmacy is defined as providing patient care to optimize medication therapy and promote health, wellness, patient safety, and disease prevention.⁴ This has improved patient care, and in the inpatient setting, clinical pharmacists have been shown to improve the quality, safety,^5,6 and efficiency of patient care,⁷ and thus they are recognized as critical members of the health care team.^7–12

The adoption of EHRs across the United States has impacted the ways in which physicians, nurses, and pharmacists provide care for patients.¹³ While there is a concerted effort going on, pharmacists are not currently considered eligible providers by the Centers for Medicare and Medicaid Services (CMS). They do not receive incentive funds directly based on Meaningful Use through the adoption of EHRs¹⁴; however, they are active users of EHRs and play a key role in some core measures such as medication reconciliation, computerized physician order entry (CPOE), e-prescribing, clinical decision support, and immunizations.

HOW DO PHARMACISTS USE THE EHR?

While pharmacists use many different advanced functions in the EHR, the literature describes 3 main uses: (1) documentation,^13,15–33 (2) medication reconciliation,^18,34–53 and (3) patient evaluation and monitoring.^{25,32,40,54–64}

Documentation in the EHR

In 2007, 90.7% of hospitals with an EHR provided pharmacists with access to view parts of the EHR for medication therapy management, and only about half of those hospitals allowed pharmacists to document in the EHR.¹⁵ However, a recent survey showed that 62.3% of hospitals in 2013 required pharmacists to document recommendations and progress notes in medical records, up from 54.9% in 2011.^16,17 Documentation tasks performed by pharmacists include medication reconciliation notes,³³ allergy documentation,²⁴ clinical progress notes, notes on medication therapy (such as reasons for discontinuation²⁰ or proactive recommendations²¹), and “interventions” for financial justification.^25,29,30,32 Some barriers that have been identified in pharmacists’ documentation in the EHR include the fear of litigation or criticism from other professionals, time constraints, perceived significance or appropriateness of documentation, acceptance by doctors, and ownership of the health record.^19,23 There are also questions about what pharmacists need to document; how to document; who reads or uses the documentation; how the documentation is used in communication between pharmacists, other health care professionals, and patients; and whether this documentation can be used somehow for financial justification of clinical pharmacists’ costs and benefits, similar to “intervention” documentation.^23,65 However, there should also be careful consideration concerning how data is captured from pharmacists and whether structured or unstructured (free-text) fields best suit the specific use case and workflows to meet the needs of the institution.^31,66

The expanded role of clinical pharmacists has served to emphasize the need for increased documentation by pharmacists in the EHR,¹⁸ and pharmacists now require access to the entire patient record, regardless of where care was received.¹³ As pharmacists’ documentation in the EHR increases, it is important that they know how to find information in the EHR and document their assessments or recommendations.^26,27

Medication reconciliation

During the medication reconciliation process, a pharmacist checks the EHR for consistency and correctness of the medication history, and performs systematic interviews with patients to obtain additional information.^34,35 In one study, 74% of patients had medication discrepancies between their patient reports and the EHR.³⁶ Of those discrepancies, 51.5% were due to medications reported by patients not being listed in the EHR (such as over-the-counter medications), patients forgetting to report use, medications from outside prescribers, etc.³⁶ Another study found that the patient population had an average of 6 medication discrepancies in the EHR, with inactive medications listed in the EHR being the most common error (41%).³⁷ Pharmacists use the EHR to compare and contrast medication lists, link medications to patient problems, evaluate effectiveness and adverse drug events (ADEs), and make documentation recommendations to provide a complete history of the patient’s medications.^18,35 Medication reconciliation tasks are significantly dependent on information technology,⁴² and medication reconciliation could benefit greatly from the sharing of medication lists between organizations, such as through health information exchange (HIE).^67,68 However, HIE can only provide lists of potential medications that patients are taking; therefore, medication reconciliation still requires interviews with patients to evaluate how they are really taking their medications, and this is a role well suited to pharmacists.⁴⁶

Patient evaluation and monitoring

Pharmacists in the inpatient setting spend large amounts of time using the EHR to evaluate or work up their patients.¹² These evaluations typically consist of identifying potential medication problems, reviewing medication regimens, checking drug-drug and drug-disease interactions, monitoring ADEs, evaluating the therapeutic effectiveness and dosing appropriateness of medications based on the context of disease states and lab values, managing medication therapies, performing medication reconciliation, and evaluating patients’ medication adherence.^{25,32,54,56–64} Additionally, in many institutions, clinical pharmacists attend patient rounds and participate in other aspects of interdisciplinary patient care, which goes beyond medication issues in many cases. Some clinical decision support tools using EHR data have been designed to help support pharmacists, especially for antibiotic stewardship or ADE detection^25,69–72; however, there are many opportunities for improvement.

Additionally, there is a serious disconnect between hospitals, retail community pharmacies, and other enterprises regarding patient data, which may result in patient harm.⁷³ There is a need for timely and accurate HIE between EHRs and community pharmacies, especially in transitions of care and medication reconciliation.⁷⁴ For example, in some countries, community pharmacists have access to national EHR data so they can monitor patient therapy.⁷⁵ While this type of access has the potential to expand the role of pharmacists and improve patient safety, there are still concerns about reimbursement, time constraints, responsibility, patient consent, and liability,⁷⁵ along with additional challenges and barriers in the retail/community pharmacy setting.⁷⁶

There are many studies reviewing the information needs and information-seeking behaviors of nurses and physicians, but we have found none for pharmacists. Nurses seem to seek information about protocols and procedures, while physicians seek information related to diagnosis.⁷⁷ Other studies show that physicians tend to focus more on the “Assessment and plan” part of clinical notes, and give very little attention to the “Medication profile” part.^78,79 It is understandable, then, why it is important for pharmacists to focus on medication and monitoring related information in the clinical notes and EHR. However, more research is needed to understand pharmacists’ information needs as a critical source of medication information.^17,80

In summary, the evidence suggests a gap between the role of pharmacists and their need for information. It is imperative to design the EHR to support those needs, as missing, incomplete, or inaccurate information can lead to medication errors, ADEs, failure to provide prophylactic treatment, and other potential patient harm.

IMPLICATIONS AND FUTURE OPPORTUNITIES

Interdisciplinary informatics organizations are recognizing the importance of including pharmacists and of designing EHRs to support pharmacists’ cognitive needs. There is a critical need for pharmacists in informatics and informatics in clinical pharmacy. While there are pharmacists in the informatics realm and informatics tools have been developed to support pharmacists, they seem to be few and far between. Generally, there appears to be a misunderstanding of what informatics is in the pharmacy world, perhaps due to the casual use of the word “informatics” in various titles and activities associated with computers.^81,82 Additionally, pharmacy informatics education is lagging behind current practice and is inconsistent across the nation.^83,84 To change this, some colleges of pharmacy are now training pharmacists in informatics and offering PharmD and master’s dual degrees. This suggests that the shortage of pharmacists in informatics research and development may be due to a lack of awareness and training.

Many health IT applications seem to be designed to automate tasks or business processes, or even to mimic paper-based charts; however, the EHR allows for opportunities to support pharmacists’ cognitive tasks and workflows.⁸⁵ Few tools currently exist for pharmacists, yet these tools could help increase problem identification, speed and efficiency of workups, and speed and completeness of medication reconciliation, and improve patient outcomes by reducing ADEs. Clinical decision support (CDS) tools could help pharmacists perform their clinical responsibilities, such as evaluating patients or performing medication reconciliation,^86–88 and working up patients, as they typically go back and forth between sources in the EHR to get the most up-to-date information.⁸⁹ However, CDS for clinical pharmacists remains understudied and underutilized,⁷¹ and there are very few studies evaluating the usability of EHRs or HIE from the pharmacist's perspective.

The use of EHRs and CPOE has helped to provide pharmacists with real-time, and legible, patient information and medication orders.⁹⁰ The use of CPOE has increased pharmacists' productivity, thus allowing them to focus on more clinical duties beyond order entry or verification.⁹¹ While CPOE and e-prescribing can reduce transcription and legibility errors,⁹² there is the potential for different or new types of medication errors, such as selecting the wrong drug or the wrong patient, creating internal prescription discrepancies, or interrupting workflow.^93–97

Finally, the role and scope of practice for pharmacists will evolve as they work toward recognition as eligible providers, and as meaningful users and contributors to the EHR.^{14,54,98–102} Health care leaders have realized or are realizing the importance of having pharmacists on informatics teams, working along with physicians and nurses, to achieve meaningful use goals and to develop and implement health IT systems. Leaving pharmacists out of the informatics team is a recipe for implementation failure.^88,103

CONCLUSION

Pharmacists provide care to patients across the health care continuum and are active participants in the EHR, seeking and documenting information. EHR use and implementation are driven by funding and policy changes, and pharmacists need to be part of the design and implementation teams. As health information technology proliferates and EHRs are designed and implemented in the health care setting, it is imperative that pharmacists’ workflow and information needs are met within EHRs to optimize medication therapy quality and patient outcomes. Since informatics is an interdisciplinary science, pharmacists need to be included on the list as important members of the health care team.

CONTRIBUTORS

S.N. reviewed the literature and prepared the manuscript. J.P., T.R., D.E., and C.W. helped in review, revision, and addition to the manuscript.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.

COMPETING INTERESTS

The authors have no competing interests to declare