e-Interconsultations between a hospital pharmacy service and primary care pharmacy units in Spain

Abstract

Purpose

To analyse the profile of consultations made using an electronic platform system (e-Interconsultation) of communication between the hospital pharmacy service and primary care pharmacy units.

Method

Descriptive and retrospective analysis of the number and type of e-Interconsultations for 3 years in a health area. Data source: data mining of the e-Interconsultation platform (Microsoft Sharepoint software).

Results

A total of 1152 interconsultations have been made and 90.6% (88.9%–92.4% 95% CI) solved. 477 (41.1%) of them were referrals from hospital care to primary care in addition to 675 (58.6%) from primary to hospital care. The validation of prescriptions and the need for drug monitoring in primary care are among the main reasons for consultation.

Conclusion

This two-way electronic platform of communication is a good mechanism that collaborates in patients’ transit between different healthcare levels because it allows us to facilitate, normalise and document consults, referrals and pharmaceutical interventions between hospital care and primary care. Therefore, it helps us provide better quality pharmaceutical care to our patients.

INTRODUCTION

The Spanish National Health System has progressively evolved from a compartmentalised model formed by two large-scale structures, hospital care (HC) and primary care (PC), into a cross-sectional, horizontal, integrating model. In this new model, patients must receive continuous care regardless of which health level.¹ This change in the care-providing model has also been incorporated and promoted in Spain’s different Regional Health Systems, especially over the past 10 years, to remove healthcare-related barriers and the management of chronic care.^2–6 Consequently, hospital pharmaceutical care has become more continuous and focused on the patient because transitions between levels of care are a critical point in the quality and safety of pharmacotherapy. In this regard, some reference professional scientific societies (Spanish Society of Hospital Pharmacy and American Society of Health-system Pharmacists) are developing initiatives and strategies promoting integral pharmaceutical care for patients (in-hospital and outpatient) via the incorporation of the new technologies for achieving the care-providing objective.^{7 8}

The University Hospital Complex in our study is a high-level 1450-bed hospital covering a health area with approximately 550 000 inhabitants. Twenty-eight hospital pharmacist staff work at the Pharmacy Department who are also responsible for the pharmaceutical care at several geriatric facilities (approximately 1200 beds). Similarly, there are 12 PC pharmacists distributed among primary medical centres (71) spread throughout the health area. Both levels (primary and hospital) are integrated under one Integrated Management Administration called Xerencia de Xestión Integrada A Coruña (XXIAC).

The mission of the Pharmacy Service at our hospital has been determined to “contribute to improve the health results of the population, in cooperation with the multidisciplinary team, by providing personalised, integrated, coordinated, safe and quality pharmaceutical care”. Reaching this continuous healthcare and incorporating new technologies are among the bases of the new pharmaceutical care model in the Pharmacy Service. Thus, it is necessary for HC and PC pharmacists to communicate in providing continuous pharmaceutical care to the patients. Improving communication and documentation at hospital discharge is something we must all work harder on to reduce patients’ drug-related problems at discharge.⁹

Before the implementation of the e-Interconsultation platform, communications between PC and HC pharmacists concerning specific patients in our health area were carried out without any officially approved procedure, usually by telephone or e-mail.

In January 2015, in order to develop the electronic platform of communication, a multidisciplinary team was formed: three HC pharmacists; one PC pharmacist as the spokesperson for all those belonging to our healthcare area XXIAC; a PC administration executive (to whom the PC pharmacists report); and a computer engineer of the Information Systems and Technologies Department. The computer tools selected as the basis for developing the platform was Microsoft Sharepoint, which is based on web technology, where the two-way functions between hospital care and primary care were configured. During a period of 6 months, the team determined the structure, characteristics and requirements of the electronic communication platform, namely: codified access, codified patient identification, standardised purposes and results of the consultations, an alerts system to notify the participants when a new consultation is created, and allow data mining and be fast, intuitive and easy to use.^{10 11} The channelling of consultations from PC to HC is by pharmacotherapy area and from HC to PC by primary medical centre. Given that most of the e-Interconsultations would be motivated by discrepancies on the validation of hospital prescriptions, a maximum 72 hours' timeframe for completion was agreed in line with Regional health-system regulations.¹² After that, pilot trials and drills of consultations in both directions were carried out in order to validate the platform: then, accesses for all participants were created (33 in all) and informative and training sessions were held. The new two-way electronic platform (e-Interconsultation) was launched in June 2015.

The purpose of this study is to analyse the results obtained after 3 years of implementation of the e-Interconsultation platform.

METHOD

Descriptive, retrospective study of pharmacist consultations made through the e-Interconsultation platform in the period 1 January 2016 to 31 December 2018 (36 months).

Sixteen pharmacotherapy areas were used to channel e-Interconsultations directed from PC to HC: cardiology and heart or vascular surgery, transplant and immunosuppression, neurology, oncology and haematology, paediatrics, internal medicine, gynaecology, pneumology, clinical trials, continuous and palliative care, pharmaceutical compounding, nutrition, rheumatology, geriatrics and others. The channelling of e-Interconsultations directed from HC to PC was by primary medical centre. Reasons for consultation from HC to PC were standardised in: drug adherence, medication reconciliation, hospital prescriptions' validation, drug interactions, off-label medications, need for drug monitoring in PC and others. Reasons for consultation from PC to HC were standardised in: drug adherence, medication reconciliation, drug interactions, clarification of medical prescriptions, off-label medications, authorisation of prescriptions, incorrect dose and others. To make a new e-Interconsultation, users must complete online forms from either HC or PC as shown in figures 1 and 2.

Figure 1.

Online form for making HC to PC e-Interconsultations.

Figure 2.

Online form for making PC to HC e-Interconsultations.

The data source has been the e-Interconsultation platform using Microsoft Sharepoint software. Inclusion criteria: all e-Interconsultations made during the study period in both ways.

RESULTS

1152 e-Interconsultations have been made during the study period. Of them, 477 (41.4%) were HC to PC referrals and 675 (58.6%) PC to HC. The global rate of solved e-Interconsultations has been 90.6%. This rate, by care level was 82.4% (393) in HC to PC vs 96.5% (651) from PC to HC. The rate of consultations solved within 72 hours was 63.3% (62.5% in 2016, 59.87% in 2017 and 67.6% in 2018). The increase of this rate has been statistically significant when comparing years 2018 vs 2017 (P=0.04), but no more statistical differences have been observed in other periods (2017 vs 2016 p=0.53; 2018 vs 2016 P=0.18). Tables 1 and 2 provide the main results of this study as shown in the following:

Table 1.

Results of e-Interconsultations solved from HC to PC. n=393

	n (%)
Reason for consultation
Need for drug monitoring in PC	224 (57.0%)
Medication reconciliation	68 (17.3%)
Validation of hospital prescriptions	30 (7.6%)
Drug interactions	26 (6.6%)
Off-label medications	15 (3.8%)
Drug adherence	19 (4.8%)
Others	11 (2.9%)
Results
Drug therapy monitoring in PC	163 (41.5%)
Clarification of medical prescriptions	47 (11.9%)
Medication reconciliation	69 (17.4%)
Others	114 (29.2%)

Table 2.

Results of e-Interconsultations solved from PC to HC. n=651

	n (%)
Reason for consultation
Authorisation of prescriptions	275 (42.2%)
Medication reconciliation	96 (14.7%)
Incorrect dose	95 (14.6%)
Off-label medication	95 (14.6%)
Others	90 (13.9%)
Drug therapy area-related
Cardiology/heart surgery and vascular surgery	85 (12.9%)
Neurology	86 (13.2%)
Transplant-immunosuppression	81 (12.4%)
Oncology/haematology	81 (12.4%)
Paediatrics	43 (6.6%)
Internal medicine	34 (5.2%)
Gynaecology	26 (4%)
Others	215 (33.3%)
Results
Clarification of prescriptions	328 (50.4%)
Authorisation report and/or prescriptions	113 (17.4%)
Medication reconciliation	58 (8.8%)
Off-label medication	37 (5.7%)
Change in dosage	31 (4.8%)
Others	84 (12.9%)

Referrals from hospital care to primary care

Three PC pharmacists received 45% (177) of the consultations managed by way of this platform (one pharmacist 19% (75) and two pharmacists 13% (51)). The others each covered 3%–5%. The major reason for consultation was the need for drug therapy monitoring in PC, followed by medication reconciliation, validation of hospital prescriptions and drug interactions. Concerning requests, the main result was drug-therapy monitoring in PC which included patients who needed to be closely monitored by physicians. The majority of these patients were treated with narrow therapeutic index medicines, for example, antiepileptic drugs such as valproic acid, phenytoin, carbamazepine or levetiracetam, antiarrhythmic drugs such as digoxin or theophylline, and immunosuppressants such as tacrolimus, sirolimus, everolimus or cyclosporine. The rest of the results included the need for clarification of PC medical prescriptions, medication reconciliation between PC medicines and medicines prescribed at hospital. Other results included dealing with off-label treatments, patients’ medical education or changing the medication.

Referrals from primary care to hospital care

The 50.9% (333) of these consultations were managed by hospital pharmacists assigned to four pharmacotherapy areas: cardiology/heart surgery and vascular surgery, neurology, transplant-immunosuppression and oncology/haematology. The main reason for the consultation was related to the Legal Health System of authorisation of prescriptions of patients discharged from the hospital or following an out-of-hospital consultation to the in-hospital medical specialist. Other reasons for consultation were the need for medication reconciliation, especially after hospital discharge, identification of incorrect dosage or posology, and identifying prescriptions of off-label medicines that needed to be dispensed by hospital pharmacists. Among the main results of the derivation of the consultation were the need for clarification of hospital-prescribed medicines (posology or patient’s pathology), managing authorisation reports and/or prescriptions contacting with hospital care doctors, medication reconciliation, off-label medicines' management and dosage changes. Other situations included a wide array of results for the consultation lsuch as changing medication, and adding or withdrawing medications.

DISCUSSION

Providing comprehensive care, helped by the new information technologies is among the strategic purposes of our regional healthcare system (Servizo Galego de Saúde, Sergas)³ and also scientific societies.⁷ This e-Interconsultation platform has been the first electronic communication system in Spain between pharmacists of different healthcare levels.

In other countries, similar experiences have taken place. In England, an electronic communication system between hospital pharmacy services and community pharmacies included similar patient groups as in our study such as cardiovascular illness, patients with four or more medications and/or patients who experimented changes on their treatment at hospital discharge, which are important critical points we also wanted to highlight.¹³ In this study, authors’ purpose was to follow-up those patients who might benefit after hospital discharge from better understanding of the issues related to their condition and medication. This study showed that those patients who received a follow-up consultation had lower rates of readmissions than those without it. However, we have not analysed this outcome measure and it is an aspect that we should consider in future studies.

We believe our information system is easy to access, simple and user-friendly as all participants agreed, and most importantly, it makes it possible to normalise, standardise and document pharmaceutical interventions that take place in the patients’ transitions between PC and HC. Our results are very similar to those previously obtained after 1 year of the e-Interconsultation start-up.¹⁴ Thus, consultations from HC to PC have been mostly motivated by the need for drug monitoring at PC of medications prescribed at hospital or interventions related to medication reconciliation. These aspects have been mainly related to medicines with narrow therapeutic index as antiepileptic drugs or digoxin, or the presence of drug interactions between hospital medicines and the patients’ baseline treatment. For both items, appropriate pharmacokinetic drug monitoring of narrow index drugs such as digoxin and tracing of polymedicated patients has shown to reduce complications due to medication-related problems in chronic patients.^15–17 This communication platform collaborates with the strategy of the Pharmacy Service of providing patients’ integrated pharmaceutical care during hospital admission and after discharge¹⁸ and is similar to other experiences that also have shown that providing integrated pharmaceutical care reduces drug-related problems which often originate during care transitions.^19–22

On the other hand, consultations from primary care to hospital care have been mainly motivated by the prescription of new medicines at hospital or for the monitoring of the immunosuppression in transplanted patients.

The main limitation of this e-Interconsultation platform is that consultations are kept in an isolated web portal and are not integrated in patients’ electronic medical records. For this reason, the e-Interconsultations can only be consulted by HC or PC pharmacists but not by other professionals who also provide patients' healthcare such as physicians or nurses. Integrating the report of the e-Interconsultations in patients’ medical records is an aspect that in our opinion would improve the utility of this communication platform. Nowadays, the computer application where patients’ medical data are recorded (IANUS) only allows communications from PC to HC but does not allow making consultations from HC to PC: that is the main reason why we prefer this bidirectional e-Interconsultation platform rather than IANUS, which is being used now by other hospitals in our region. ²³

The global rate of solved e-Interconsultations has been similar to other experiences²⁰ but if we analyse the e-Interconsultations from HC to PC, this level needs to be improved. Although the rate of responding in 72 hours or less has increased in the past year, we consider that it should be higher. Among the causes of responding to delay and unsolved consultations are forgetting to close the e-Interconsultation (need to click the consultations as “solved”) and the absence of the assigned pharmacist (for example, during holiday periods). We believe that responding on time is the major aspect on which we should work, and it is necessary to make organisational efforts in order to improve it. More involvement of PC pharmacists in patients’ medication management improves health outcomes, as some studies have shown.^24–26

CONCLUSIONS

We consider that this web platform of communication constitutes a valid system of communication between professionals allowing pharmacists to solve medication problems, mainly those related to the legal health system of authorisation of prescriptions, drug monitoring, off-label uses of medicines and clarification of drug prescriptions or posology, achieving better quality pharmaceutical care.

What this paper adds.

What is already known on this subject?

• Digital transformation concerning the heath system invites us to incorporate new information technologies in order to help us to improve cost-effectiveness, safety and quality.

• Transitions between healthcare levels are critical points where drug-related problems could happen due to poor communication and/or coordination between professionals or with patients.

• Pharmaceutical care promotes care safety through procedures such as medication reconciliation, drugs information at hospital admission/discharge or continuous drug monitoring. Care models that incorporate interdisciplinary working and effective communication between hospital and community pharmacists, and with other health professionals of different care levels, have shown lower rates of hospital readmission in their patients.

What this study adds?

• This electronic communication system between hospital care and primary care pharmacists facilitates pharmaceutical care focused on the patient. It also makes it possible to normalise, standardise and register consultations, and maintain patients’ confidentiality.

• In addition, this study shows that the major reasons for making a consultation in our health area are the need for drug monitoring at the PC level, problems related to the authorisation of hospital drug prescriptions and also the need for medication reconciliation at both healthcare levels.

Data availability statement

Data may be obtained from a third party and are not publicly available. All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not required.