[dropcap color=”white” background=”black” style=”rectangle” size=”big”]A[/dropcap]t Our pharmacies, we put a great deal of emphasis on performing clinical services while working on the dispensing counter and we call this process continuous medication monitoring (CMM). By this, I mean that the pharmacist, while verifying that the prescription was filled correctly, is also responsible for an in-depth look at the patient’s medication profile each and every time the patient has a prescription filled. To accomplish this, we have developed a software platform for our clinical pharmacists to work with while on the counter called PharmClin.
While the PharmClin package contains a comprehensive array of features including documentation for the clinical pharmacist, one of its core features is the patient profile. The single most important piece of information that a pharmacist has to make clinical assessments is the patient’s medication profile. The remainder of this post will look at the importance of the profile and how a logically formatted profile can aid the pharmacist in CMM on the fly.
A dispensing profile
Before looking at a clinically oriented profile, consider that a PMS (Pharmacy Management System) also maintains a patient profile. The user experience when trying to use most PMS profiles to perform CMM, however, quickly deteriorates. A Pharmacy Management System (PMS) is designed to facilitate dispensing. The PMS profiles are, therefore, optimized for dispensing activities, and not CMM. Consider a PMS like McKesson’s Pharmaserv below (click to enlarge).
This screen grab is fairly typical of most any commercial PMS in that it shows the history most current at the top. The level of detail visible, though is limited, and one has to select a prescription to see the previous dates (in the split window below). In all, the information visible is related primarily to dispensing.
This begs two questions: 1) what information displayed by the PMS do we not require when making clinical determinations and 2) what is missing that we would want to see? Taking these questions in order, our clinical pharmacists were less interested in:
- Original Date (because it does not related to the first date the patient started taking the drug)
- Refill number
- Strength and form (because it is duplicate information)
- Price
- Facility
- NDC
- Coverage / Insurance
- RPh and Tech
Keep in mind that almost all of these have significant value when considering the dispensing aspects of pharmacy, they just are not relevant to the most common clinical issues.
Our clinical pharmacists were interesting in seeing a few other details without having to drill down into the record. These included:
- Days Supply
- SIG or directions
- Recent Refill Summary
- A selective profile representing only the most recent therapies
Our clinical pharmacists were also interested in being to quickly spot
- Specific therapeutic drug categories (e.g. those in the EQuIPP measures)
- Drug interactions
- Compliance Issues
A Clinical Profile
With this in mind, we pared our clinical profile view down to the following (for sake of comparison, this is the same profile as listed above): (again, click to view the image)
Besides some small differences in sorting and the scale size of the screen capture, the profiles represent the same exact data. One of the first things you might notice is that the profile is narrower (taking up much less space across the screen). The changes represent most of the important items on our clinical staff’s wish list for the profile.
Some things in this profile may not be initially obvious, but are exceptionally helpful to a clinical pharmacist performing rapid CMM on the counter. To simplify the profile , only the last three dispensing incidences for each given drug are displayed, and these are all displayed together, without respect to Rx number, NDC or other drug product changes. This saves the clinical pharmacist time as they do not need to hunt thru the profile. One advantage to this method is that the pharmacist can review compliance over the last three dispense occurrences quickly.
Other simplification were made to the profile. To reduce the amount of data to be interpreted, only the last 180 day are displayed, significantly reducing clutter in the profile. If a clinical situation requires a complete history, that option is available.
Another key difference is the addition of color. While the color-key is not visible in this screen capture, the drugs are color coded as follows:
- Statins in GREEN
- ACE / ARBs in RED
- Diabetic medications in BLUE
- Drugs listed as high risk (Beer’s List) in PURPLE
- Drugs that precipitate drug interactions in ORANGE
All of the above color-coding relates directly to the current CMS 5-STAR rating guidelines, and allow our pharmacist to quickly make 5-star related determinations on compliance, high risk drugs, and drugs that are known to precipitate interactions.
Besides color-coding drugs that are known to precipitate drug interactions, the profile has drug interaction column that highlights any interactions flagged by the PMS. This column is kept minimal and does not show the details of the interaction by design. We decided that if we did not know what was going on, we could click to look, but for the most part, knowing that an interaction was flagged was enough for our clinical pharmacist to make their assessment. Interaction pairs are easy to spot this way. Drug – Alcohol and Drug – Food interactions sometimes create an ODD number of interactions, but after a bit of practice, spotting problems becomes very easy.
The profile above is not perfect, and has changed with time as we work thru our CQI process. One of the things that would be most helpful to us would be an accurate listing of medical conditions. Unfortunately, while PharmClin and our PMS do have the capability of entering this information, we often do not have documentation of actual diagnoses. For the purposes of “on the fly” clinical work, therefore, we use implied diagnoses, and the color coding is helpful in this.
I should point out that our clinical system does a lot more than just show the pharmacist a patient profile. The patient profile is important to start the process, but once the pharmacist has identified a problem, they have to document it efficiently. Once the pharmacist notes something worth documenting, they can document an intervention system for the next pharmacist or even write a quick SOAP note to send to the prescriber. Interventions and SOAP Notes can be flagged for follow-up.
Notes on PharmClin
PharmClin (patent pending) was developed as an in-house documentation tool for a clinically oriented retail pharmacy. The product currently integrates with McKesson’s Pharmaserv, but integration with other PMS vendors is being pursued. More details about PharmClin are available on the Innovative Pharmacy Solutions website. Web demonstrations can be arranged from that website.
