Local HIE, regional EHR, interoperability all over the place -- get your pharmacy ready. They're practically here.
Software programs that receive prescriptions and aid in dispensing medications are already in wide use in community pharmacies. These programs help manage inventory, workflow, accounts, and assist in record keeping. But the next wave of pharmacy technology and software is coming-programs that will allow community pharmacies to communicate with local physicians and hospitals in health information exchange (HIE) and give them access to local or regional electronic health records (EHR).
Such systems will help pharmacies to meet criteria established by the Centers for Medicare and Medicaid Services (CMS), which is pushing for optimization and meaningful use of EHRs. Criteria for Stage 3 of CMS’s meaningful use of HER, which include regional integration of health records, must be met by 2018. In addition, Medicare’s Star Ratings, which rate health plans, are making insurance companies put pressure on pharmacies to increase their performance in quality measurements-the kind of measurements that can be helped by EHR/HIE technology.
Interoperability and bidirectionality
Do community pharmacies currently have systems that can make meaningful secure exchange of health information as seamless as possible, and that allow for communications with all healthcare practitioners in a given region? Not as yet, said Shelly Spiro, RPh, FASCP, executive director of the Pharmacy Health Information Technology Collaborative in Alexandria, VA. The focus of the Pharmacy HIT Collaborative is to assure meaningful use of standardized EHRs to support safe and effective medication use and care, and to provide access to the services of pharmacists with other members of a patient’s care team.
Few pharmacies have systems that are interoperable, meaning they can work with other systems, or bidirectional, meaning that the secure exchange of information goes to and from the pharmacy, she said.
The collaborative, formed in 2010 by nine pharmacy professional associations, works to help guide how the pharmacist fits into the national health information infrastructure. “The collaborative focuses more on the clinical aspects of what pharmacists do,” she said. Systems that automate dispensing help pharmacists deal with counseling a patient on one prescription. Those that allow for exchange of health information bring in more information that allows pharmacists to improve their clinical services-especially medication therapy management (MTM).
Pharmacy systems need to be interoperable; they need to be able to share the pharmacy’s clinical information about a patient with other healthcare providers, such as physicians and hospitals, said Spiro. Information needs to move as seamlessly as possible, without the need for manual entry of data from one system into another. A system has to have the functionality to allow the pharmacist to access and easily use information about a patient for actions in addition to dispensing medications, and to be able to share pharmacy information as well, she said.
Pharmacists do not currently have the incentives in place that are pushing hospitals and physicians’ offices toward a greater exchange of clinical information, Spiro said.
What’s out there?
Several companies offer pharmacy management systems-the software that helps both the business and clinical workings of a pharmacy. These systems can be used to maintain the records for new and refilled prescriptions, drug databases, verification of prescriptions, patient medication records, and prescriber records, said Will Lockwood, director of editorial content at Computer Talk for the Pharmacist. They can be used to review and submit claims for reimbursement to third-party payers, review paid and rejected claims, manage inventory and ordering, and manage delivery. They can track the workflow of the dispensing process-including which employee completed which steps and when; manage clinical tasks, such as MTM interactions; track adherence data; track and reconcile receivables; and record that prescriptions have been picked up and paid for, said Lockwood. “The more up-to-date a system is, the more likely it is to include many of these functions,” he added.
Creating useful exchanges of information will require pharmacists to have systems that allow them to expand the record of their interactions with patients beyond the traditional medication profile and prescription history, Lockwood said. They will need to include more details of the patient’s clinical history. These details may come from the pharmacy’s interaction with a patient during MTM sessions, for example, or from information such as lab data that the pharmacy can pull from other health IT systems.
“There are a number of different vendors out there,” said Lockwood. “There are several with a substantial national footprint of installations and others with smaller and/or regional installation bases.”
Several technology companies have created products or systems for use in pharmacies, such as PDX, QS/1, PioneerRx, Rx30, Computer Rx, McKesson, and Surescripts.
What system-or portions of a system-that a community pharmacy chooses to buy will vary greatly depending on its own needs, Lockwood said. There may not be a one-size-fits-all system.
Many large chains and some smaller ones have created their own systems. A “home-grown” system, as Spiro called them, is more customized for a given location. There are some pharmacists who work closely with a physician’s office or an accountable care organization and who have come up with solutions that work for them and allow them access, she said. They may have written software that can interface between different systems from different vendors, which gives them access to a patient’s medical records and the ability to communicate seamlessly.
However, many of these systems are not seamless, Spiro said. A pharmacist may say he or she has access because they can log into a hospital or a regional system and look at medical records, but then they still have to print out the information they need and enter it into the pharmacy’s own system by hand.
Low(ish) tech can still be a help
Sometimes, even a comparatively low-tech EHR/HIE system gives a pharmacy a big advantage. Beauchamp & O’Rourke Pharmacy in Rutland, VT, has been using McKesson’s pharmacy management system for 12 years, said Marty Irons, BSPharm, managing pharmacist. But it is using a simple internet browser to access information at Rutland Regional Medical Center.
“We are using Google Chrome with no additional software,” he said. Each day he gets a fax from the hospital that lists the pharmacy’s patients who are in the hospital or who have been discharged within the last 24 hours. Irons then goes online to the hospital’s website to access data on those patients. This information includes their diagnosis, lab results, the physicians’ notes, drug allergies, and discharge plans, among other information.
Having this EHR access has been extremely useful, Irons said. Beauchamp & O’Rourke has transitioned from dispensing medications in vials to creating comingled blister packs that give their patients a week’s worth of their medications in 28 compartments marked by the day and time they should be taken. Medication reconciliation was often a problem. “Having access to a patient’s HER has dramatically cut down on unreconciled medications,” Irons added.
The biggest benefit of this system has come from the ability to see a patient’s lab results. Irons often advises that a patient’s medications be stopped because the lab work shows it is not needed.
But Rutland is a small community and Rutland Regional Medical Center is used by 95% or more of local people, which is why this uncomplicated EHR/HIE system works, Irons said. “I can’t imagine doing this with more than two hospitals.”
High(er) tech access
In contrast to a browser-based access system, Amina Abubakar, PharmD, AAHIVP, owner of Rx Clinic Pharmacy in Charlotte, NC, has a lot of direct access to a system that gives her bidirectional communications and interoperability.
Her pharmacy uses Pioneer Rx’s pharmacy management system “for everything,” Abubakar said, including internal communications, and also for access to EHR/HIE. She uses the software to log on to the Community Care of North Carolina’s Pharmace Home website that allows her to share information about Medicaid and Medicare patients. Pharmace Home connects pharmacies, physicians, and care managers. “I document my findings in the pharmacy home and they go to the doctor. They can see my notes. They can see drug therapy problems,” she said. There is a single sign-on to get into the system and it then operates with her software.
Information goes both ways. The pharmacy’s software connects to Pharmace Home and Abubakar does not have to log out of one to get into the other. “I don’t have to leave Pioneer to get into the pharmacy home and look at history of the patient and look at what the care managers have done.”
The system also allows her to send texts to patients and keeps track of it as an MTM action until they respond.
“I like the fact that we can connect these different pieces in order to help our patients,” Abubakar said, adding that this communication allows for proper care coordination which saves the healthcare system money. “We are working with the patients that cost the health system the most.”
There are still steps where information must be put in by hand, however. Patient care managers fax discharge summaries to the pharmacy and they must be uploaded into the pharmacy’s system, Abubakar said.
Replacing a system
With every type of technology or software, continuing innovation and plain old wear and tear on hardware may lead to a need to replace or update a pharmacy’s system. This can mean anything from minor updates and tweaks to complete top-to-bottom replacement.
“Switching systems can be a chore simply because these software platforms are so business critical, and processes and protocols are developed around their functionality,” Lockwood said. But pharmacies will switch systems if they decide that they need new or different or better features. “There are companies that specialize in moving databases over for this kind of switch.” Regional and national pharmacy chains say that they revisit their software systems and upgrade them regularly, and may install a new product every three years or so. Smaller pharmacies may be less likely to switch, and may use the same software packages for years, he added.
For the most part, upgrading a pharmacy’s management system takes the form of software updates, which most vendors issue. Abubakar noted that she gets frequent updates of software from Pioneer Rx that are incorporated without difficulty or any need to shut down for a time.
What comes next?
Pharmacy management systems that offer better EHR/HIE solutions are still evolving. “There’s not a great deal of communication between pharmacy software and other health IT systems. But I think this is changing and that pharmacies understand the need for better information exchange among health IT systems.” Lockwood said.” I think this will be driven at a level above the pharmacy system itself, by standardization of data exchange through the efforts represented by a group like the Pharmacy HIT Collaborative.”
Marty Irons would like to see more interoperability between the hospital’s system and his pharmacy. But even having his pharmacy’s relatively simple access to the patient’s EHR has been revelatory for him and has shown how much more a pharmacist can do with greater access to information.
“I had no idea how much I did not know. Now I realize that I was fumbling in the dark,” Irons said.