Once patient information has been documented appropriately, it should be made available to other healthcare providers for review when necessary. Without a universal electronic documentation system in place for pharmacists, various means of communication (e.g., mail, fax, phone, or e-mail) can be used to communicate with other healthcare providers and patients where appropriate. One patient may have several patient files at different sites of care (e.g., the hospital, various physicians' offices, and community pharmacies), thus complicating the manner of communication. However, it is critical to determine what information must be passed on to fellow healthcare providers.
An integral part of providing pharmaceutical care is monitoring patient response to therapies and outcomes. To follow patients effectively throughout the course of their therapy, monitoring parameters/surrogate endpoints and desired outcomes must be determined and documented. Examples of monitoring parameters include reducing the blood pressure in a hypertensive post—myocardial infarction patient to less than 120/80 mm Hg and reducing the low-density lipoprotein cholesterol to less than 100 mg/dL (2.59 mmol/L). Properly documenting this information assists other pharmacists and healthcare professionals during follow-up appointments because the preestablished monitoring parameters and recommended changes (based on collected data from all providers) can be reviewed readily.
Documentation and Seamless Care
Although the exact terminology may vary, seamless care is a concept that has been viewed widely as a fundamental component of the optimal delivery of healthcare services. Several different health professions, including nursing, occupational therapy, and others, have published studies in which seamless care was provided within the context of their own practice environments.17 Where seamless care is provided, effort is placed on developing multidisciplinary teams that work together across any transitions of care that may arise.18
In recent years, the average length of hospital stays has shortened, and consequently, patients are being discharged into the ambulatory setting and long-term care facilities at a higher level of acuity. Regrettably, in most health systems, an effective means of communication regarding patients' medication therapy has not been established across the continuum of care. Such communication is vital since medications may be added to or discontinued from a patient's medication regimen during hospitalization, or dosing regimesn may be altered. It is precisely these “handoffs” in care that the 2006 IOM report described as needing systematic attention.5 Specifically the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and its Canadian equivalent (Canadian Council on Health Services Accreditation) now require the process of medication reconciliation (MedRec) to take place for hospitalized patients.19 In their National Patient Safety Goals, JCAHO began requiring that medication reconciliation be provided for every patient, thus requiring that hospitals “accurately and completely reconcile medications across the continuum of care.”20 It includes obtaining a complete list of patient medications from the time of admission, through transfers, and ultimate discharge from the hospital. This includes taking a medication history and ensuring that medications and doses are appropriate, and if discrepancies (e.g., omissions, duplications, potential interactions) are encountered, that the presriber is contacted and these are resolved.
Patients, caregivers, community pharmacists, family physicians, and other community healthcare professionals may be unclear as to what medication changes have been made in the inpatient setting and the reasons for these changes. Subsequently, there may be DRPs in the patient's medication regimen that will not be identified or resolved in a timely fashion. In one study of 122 transfers from long-term care facilities to hospitals, a mean of 3.1 medications were changed on hospital admission.21 A mean of 1.4 medications were changed on readmission to the long-term care facilities. These changes did not include the addition of a new medication to a patient's regimen. Medication changes that were assessed as having caused an adverse drug event occurred during 20% of transfers.
The community pharmacist, who may fill discharge prescriptions, generally is not privy to information regarding the patient's diagnosis and laboratory test results. In essence, the community pharmacist is uninformed and at a disadvantage to monitor for future DRPs that may result from previous medication regimen alterations. A study in the United Kingdom indicated that 95.7% of community pharmacists surveyed would not even know if one of their patients had been admitted recently to a hospital.22
Problems stemming from care that is not seamless are not limited to patients who are moving from a hospital to the community or long-term care setting. Equally important is the provision of seamless care from the community pharmacy to the hospital pharmacy setting and documentation or follow-up within the same setting. In Halifax, Nova Scotia, a study examining discrepancies between the physician's handwritten order, nursing transcription onto the handwritten medication administration record, and pharmacists' order entry into the electronic profile found that approximately one in eight medication orders had a discrepancy.23 In Iowa, a review of 754 care plans submitted by 160 community pharmacists found that only 31% of care plans documented actual follow-up.24 Overall 42.2% care plans documented intent to follow-up, but either no follow-up occurred or it was not documented and the remaining 26.8% of care plans did not document any intent to follow-up.
Studies Involving the Evaluation of Documentation by Pharmacists Across the Continuum of Care
Several studies evaluating the impact of the provision of proper documentation by pharmacists across the continuum of care have been conducted in Australia, Canada, the United Kingdom, the United States, and beyond. The examples presented are not meant to be a comprehensive list of all such activities but rather are reviewed to give an indication of the state of pharmacist documentation in each country.
Pharmacist-Directed Documentation Initiatives in Australia
Pharmacist-directed documentation activities in Australia have been the center of considerable attention in recent years. The need for these services has been articulated in the Australian Journal of Hospital Pharmacy: “hospital-based services developed with little thought to what happens to patients before they come to the hospital and after they leave. This has placed hospital pharmacy in a dangerously isolated position,” and “presently Australia has no system that effectively manages information relating to medications. This lack of timely and accurate medication information remains a significant barrier to ensuring the quality use of medications by the community at large.”25 The Department of Pharmacy at the Royal North Shore Hospital in Sydney reported on a practice guide for the provision of pharmaceutical care that, among other things, helped to educate the patient at the time of discharge to promote seamless care as the patient returned back into the community.26
The Pharmacy Continuity of Care Project, a study by the Faculty of Pharmacy at the University of Sydney, promoted the use of patient discharge forms that were sent by the hospital pharmacist to (1) the community pharmacist and (2) case conferences between these two individuals and the patient's general practitioner.27 A study at three Adelaide hospitals randomized patients to receive discharge planning from a pharmacist transition coordinator or usual care prior to discharge to a long term care facility.28 The discharge planning intervention consisted of a medication summary faxed to the community physician and pharmacist outlining changes that had occurred in hospital and future monitoring that would be required. The transition coordinator also coordinated a medication review performed by the community pharmacist within 14 days of discharge and a case conference with him/herself and the facility's care providers within 1 month of discharge. At 8 weeks follow-up, the study investigators found that use of appropriate medications was maintained in the intervention group, but declined significantly from baseline in the control group.
One of the more significant developments in Australia has been the publication of the Australian Pharmaceutical Advisory Council's Guiding Principles to Achieve Continuity in Medication Management. This 2005 publication describes 10 principles that are recommended to be followed to help to attain a high level of seamless pharmaceutical care (Table 7–3).29
Table 7-3 Ten Principles of the Australian National Seamless Care Guidelines |Favorite Table|Download (.pdf)
Table 7-3 Ten Principles of the Australian National Seamless Care Guidelines
|Principle 1||Health service managers should ensure that systems support, and resources are provided for, medication management continuum.|
|Principle 2||Health service managers should participate in all aspects of medication management in partnership with consumers.|
|Principle 3||Health service managers should be accountable for ensuring implementation of medication management continuum services.|
|Principle 4||Accurate medication histories should be obtained and documented at the time of admission.|
|Principle 5||Medicines should be assessed throughout the episode of care to ensure Quality Use of Medicines (QUM).|
|Principle 6||Treatment plans should be developed and reviewed during a patient's hospital stay and form an integral part of the care plan.|
|Principle 7||Sufficient information in an appropriate manner should be supplied to patients in order for them to effectively use their medications.|
|Principle 8||Consumers should be provided with adequate supplies of medications.|
|Principle 9||All relevant details of information should be communicated to the patients' healthcare provider(s) responsible for ongoing care.|
|Principle 10||Healthcare providers to whom the patient's care is transferred are responsible for implementing policies and procedures to ensure that continuum has been achieved.|
Pharmacist-Directed Documentation Initiatives in Canada
The profession of pharmacy in Canada also has been active in documentation activities across the continuum of care. Riley and Wozny30 developed a fax document for transfer of information to the family physicians and community pharmacists of 70 hemodialysis patients in Ontario. The document consisted of contact information, a patient's medication and allergy list, a list of medications to avoid or adjust for renal dosing and a survey to evaluate the project. Of those who responded to the survey, 95% of physicians and 81% of pharmacists would use the information to update their own records; and 95% of physicians and 93% of pharmacists believed the fax document improved communication from the dialysis unit. Cesta et al.31 developed the EMITT (Electronic Medication Information Transfer Tool) to facilitate the transferring of medication information between healthcare professionals in different practice settings. Patient outcomes were not measured as part of their feasibility study, but the authors estimated that 348 DRPs could have potentially been prevented in 40 discharge letters that were created using the EMITT. Other researchers have evaluated Canadian use of hospital discharge prescription summary forms in Halifax, Nova Scotia,32 and Montreal, Quebec.33 Seamless care pilot projects also have been undertaken in Calgary Alberta Montreal, Quebec and Pictou County, Nova Scotia.
A randomized controlled study was carried out at the Moncton Hospital in Moncton, New Brunswick, to determine the impact of a pharmacist-directed seamless care program on economic, clinical, and humanistic outcomes and processes of care.34 A total of 253 patients (119 in the control group and 134 in the intervention group) completed the study. A mean of 3.59 drug therapy problems per intervention patient was identified, and 72.1% of these problems were scored as having a significant or very significant clinical impact level. Participating community pharmacists who were surveyed believed that seamless care service helped them to provide enhanced pharmaceutical care and improved efficiency in their pharmacies. The study researchers argued that a pharmacist-directed seamless care service can effectively resolve many medication therapy problems and improve medication-related processes of care in hospital and community pharmacies. On a national level, the Canadian Society of Hospital Pharmacists and the Canadian Pharmacists Association have had a joint task force on seamless care for several years.
Pharmacist-Directed Documentation Initiatives in the United Kingdom
In the United Kingdom, some health researchers have concluded that the medication-use system requires seamless care services to improve communication and safety. A study conducted in a large general hospital in England showed that breakdowns in the present discharge system can create problems for patients.35 Thus 13% of participants had at least one discrepancy in their take-home prescriptions transcribed from the discharge notes. When the discharge letter was compared with the discharge notes, 27% of the patients' letters had a medication discrepancy. The researchers found that the mean time for the discharge letter to arrive from the hospital to the general practitioner's office was 26.9 days, and one-half took longer than 32 days. At follow-up, 57% of patients were experiencing a DRP that by clinical pharmacists' standards required intervention.
The results of the completed surveys from 163 U.K. Trust Hospitals showed that a wide variation still exists among various institutions in their ability to meet patients' needs.36 Pharmacists were involved in the preparation of discharge prescriptions in only one-third of the hospitals, and their impact there was close to negligible. Alarmingly, 95% of institutions did not have their clinical pharmacists communicating with their community counterparts. The authors made the following recommendations: implementation of medication compliance charts, telephone medicine help lines, additional copies of discharge prescriptions for the general practitioner and the community pharmacist, regular involvement of the pharmacist in preparation of discharge medications (checking against the ward chart), and directly faxing copies of the prescriptions (complete with reasons for changes) to the general practitioner's office.
Studies that have evaluated pharmacist-directed seamless care services in the United Kingdom have had mixed results. In a randomized controlled trial of 362 patients that evaluated the effectiveness of a pharmacy discharge plan in hospitalized older adults, no impact on patient outcomes was found.37 A smaller study of 32 patients found a positive impact on unintentional medication discrepancies in the intervention group.38 A randomized controlled trial comparing the use of a pharmacist transition coordinator to usual discharge care has also been conducted in the United Kingdom.39 Patients in the intervention group were significantly more knowledgeable about their medication therapy and experienced significantly less medication discrepancies at discharge.
The Royal Pharmaceutical Society of Great Britain has recently published guidelines for pharmacists' documentation40 and discharge planning.41 Pharmacists in the United Kingdom also have begun to take an expanded role in primary care groups, working closely with physicians and nurses.
Pharmacist-Directed Documentation Initiatives in the United States
Many of the activities in the United States in this area relate to initiatives regarding the expanded scope of practice of pharmacists in the hospital, community, and managed care settings. Most states now allow pharmacists to enter into collaborative prescribing agreements with physicians. The ASHP Statement on the Pharmacist's Role in Primary Care advocates a larger role for pharmacists, including participation in multidisciplinary reviews of patients' progress, initiating or modifying medication therapy on the basis of patient responses, and performing limited physical assessments.42 The American College of Physicians—American Society of Internal Medicine put forward a pharmacist's scope of practice, including the pharmacist's role in collaborative practice with physicians; pharmacist involvement in patient education and hospital medical rounds; pharmacist prescribing, immunizing, and therapeutic substitution; and reimbursement for pharmacists' cognitive services.43 This expanded scope of practice also has legal implications; as Brushwood and Belgado explain, “The expanding availability of knowledge will expand professional responsibilities—and legal duties will not be far behind.”44 Despite the expanding role of pharmacists, a 2006 survey of hospital pharmacy practices found that only 81.3% of hospitals employed pharmacists that routinely documented medication therapy monitoring.45 Overall 70% of these pharmacists documented in the pharmacy profile, but only 63.5% of pharmacists documented in the patients' medical record to be viewed by other healthcare professionals.
Some pharmacist-directed seamless care evaluation studies have been conducted in the United States. Community and ambulatory care pharmacists who received a referral form from the hospital pharmacist when patients were discharged believed that the form helped them to tailor patient counseling to the needs of the patients and positively affected the pharmacist—patient relationship.46 One study that evaluated the impact of a hospital pharmacist providing pharmaceutical care at the time of discharge revealed the service to be well received by patients.47 Kramer et al.48 reported an improvement in patient satisfaction with the discharge process after use of an electronic medication reconciliation system by pharmacists and nurses. Kuehl, Chrischilles, and Sorofman reported on a novel pharmacist-directed seamless care program among ambulatory care, hospital care, and long-term care pharmacists in five pharmacies in the midwestern United States.49 In this study of 156 patients, patient-specific information significantly increased the number of interventions by the hospital and ambulatory care pharmacists.
One goal of the ASHP 2015 Initiative is to “increase the extent to which health systems apply technology effectively to improve the safety of medication use.”50 ASHP has defined several objectives to aid in achieving this goal including increased use of CPOE, increased pharmacy use of EMRs, and improved information access and communication across settings of healthcare. By 2005 pharmacists in only 19% of health systems were transferring information to promote seamless care of patients with complex medication regimen. The objective is to increase this number to 70% by the year 2015.
Pharmacy to Pharmacy Communications
Most research projects to date have focused on the transfer of information from hospital pharmacies to community-based facilities primarily involving the general practitioner and the community pharmacist. These projects have clearly addressed a real need. In a survey of community pharmacists in the United Kingdom, almost one-third had never seen a copy of the discharge information provided to patients and their general practitioners.22
Far fewer initiatives have focused on the transfer of information from the community pharmacist to other members of the healthcare team. This is unfortunate because the community pharmacist often possesses valuable patient information by virtue of seeing the patient regularly for prescription refills and other self-care needs. Developing stronger ties between the community pharmacy and other sites of care can only serve to increase communication to improve the quality of patient care delivered.
Pharmacy Communication with Physicians
Communication between the pharmacists and a patient's physician(s) is crucial to the delivery of high-quality care, but such relationships can be threatened by perceived turf battles and misunderstandings. As discussed by Buerger, improving the pharmacist—physician relationship requires effort and understanding on the part of both parties. Various stresses inherent in healthcare delivery make effective communication rather challenging in certain situations. To strengthen ties between physicians and pharmacists, all parties should focus on improving their communication skills and exercising their conflict-resolution skills.51
Pharmacists are trained to assess prescription records and profiles, review relevant clinical and laboratory data, and elicit pertinent patient medical histories to assist in the clinical management of patients. One pharmacy-student intervention study involving over 30,647 interventions in both community and hospital locations reported that a patient condition warranted medical attention in 4.9% of cases and a lab value warranted attention 6.1% of total interventions.10 In this study, acceptance of pharmacy recommendations (or clarification achieved) was 71%. Similar findings were corroborated in an Internet-based study of pharmacy students resulting in 5,031 interventions, which the rationale was a referral for a medical attention in 4.7% of interventions in the community pharmacy setting and a lab value warranted further attention in 9.8% of hospital interventions.52 The majority (87.1%) of all recommendations provided were accepted.
Pharmacists are in an opportune position to refer patients back into the healthcare system for attention they may be in need of, as well as identifying lab data that necessitates further assessment. Hence pharmacists can serve as an important ally to patients and their medical providers. While such oversight by pharmacists does occur, all too often the process by which pharmacists in community and hospital settings document and communicate their clinical interventions as described above is all but absent. Pharmacist-initiated contributions to a patient's care plan, which assist in achieving defined therapeutic objectives and/or identification or avoidance of DRPs whenever possible, must be documented and shared alike.
Pharmacy Communication with Patients
In this era of an ever-increasing desire on the part of patients to be involved in their own healthcare, an increasing number of self-care products (e.g., diagnostic, pharmaceutical, and nutraceutical) in the marketplace, and advanced communication technologies available to consumers (e.g., cell phones, personal digital assistants, e-mail, and the Internet), community pharmacists have a unique opportunity to assume a pivotal role among other healthcare providers and patients in communicating, interpreting, and monitoring for the desired health outcomes. While not commonplace today, pharmacists should begin to communicate more regularly with their patients with respect to their healthcare needs and, where possible, should refer those patients back to healthcare providers when necessary. For example, how often has a patient presented himself or herself to a community pharmacy describing a condition or possible DRP in which the recommendation of the pharmacist following a brief triage is to refer the patient to his or her physician or other caregivers (e.g., dentist or optometrist) for follow-up? Unfortunately, this interaction seldom involves documentation by the pharmacist to the patient or other provider involved, and more than likely, follow-up with either party is by serendipity. This situation in the medical community would result in what is commonly known as a referral from one healthcare provider to another. Clearly, anecdotal reports of patients who have presented to a pharmacist, and describe significantly negative health outcomes and possibly death were averted because of this interaction with the pharmacist. However, such actions commonly went undocumented and therefore were not reported or traceable and possibly underappreciated or undervalued. Many patients have not experienced such formal and consistent documentation from the pharmacy profession, and it would prove valuable. Once these activities are consistent and valued by patients and providers alike, this may begin to set the parameters for patient payments directly to pharmacists while ultimately contributing to beneficial health outcomes of the patients served.