Catalyst Corner

Documenting and Sharing Clinical Information — Key to Pharmacy’s Future

Pharmacy has been at the forefront of the electronic exchange of information for years. This industry leadership started with the first electronic claims submission (via “dumb” terminals) decades ago and followed with the advent of electronic prescribing. These efforts have been incredibly valuable for the industry. Electronic claims submission today is used for nearly all of the approximately 4 billion prescriptions dispensed each year in the United States. These claims are processed in seconds and determine a patient’s eligibility, apply a myriad of coverage rules, and inform the pharmacy of its reimbursement. Drug utilization edits applied by pharmacy and payer systems support patient safety, alerting patients to potentially dangerous interactions or dosing levels.

Electronic prescribing has improved patients’ speed to therapy, allowed for productivity increases, and also enables patient safety through codification and clinical decision support functionality. In 2016, approximately 1.6 billion, or 73% of all prescriptions, were transmitted electronically. And due to increased awareness and mandates in some states, e-prescribing of controlled substances (EPCS) is also increasing. The use of EPCS is commonly viewed as an important tool in addressing the misuse and abuse of opioids that is rampant in the country today. There are certainly still opportunities to do more with electronic prescribing, such as ensuring that the pharmacist receives the diagnosis or indication associated with the prescription, and greater use of messages to communicate desired changes, cancel prescriptions, and exchange structured and codified SIG information.

A New Challenge

While pharmacy has led the way, it is at risk of lagging behind the rest of the industry when it comes to the electronic storage and exchange of clinical information. The profession needs to look beyond prescriptions and claims. Pharmacy must be able to send and receive clinical information with other care providers — whether physicians, labs, nursing facilities, or other pharmacies. Clinical information includes discrete data such as lab and biometric values and medication administration data (including vaccines), as well as subjective information like progress notes. Much of this information relies upon standardized nomenclature or terminologies, such as LOINC (Logical Observation Identifiers Names and Codes) for lab values, SNOMED CT (Systematized Nomenclature of Medicine — Clinical Terms), and RxNorm for drug identification. Pharmacy systems will have to evolve to support sending, receiving, and using these vocabularies

Tremendous work has been done to develop recommended elements of a pharmacist/pharmacy provider electronic health record (EHR) functional profile — an outline for what a pharmacy system needs to support so that pharmacists can effectively document and bill for their services and share information with other providers. This functional profile was jointly developed by two healthcare standards development organizations, HL7 and NCPDP, to facilitate the capture, maintenance, and sharing of point-of-care prescription and medication-related clinical data. NCPDP’s efforts historically have been in the U.S. pharmacy space, such as claims, e-prescribing, drug identification to support billing, and rebates.

HL7 has focused on electronic health information that supports clinical practice and the management, delivery, and evaluation of health services, in the United States. and internationally. Work continues on the profile to ensure that it aligns with the EHR certification requirements associated with the meaningful use program. The Pharmacy HIT Collaborative is actively involved in these efforts and in providing information on them to the industry and profession. Use of the functional profile will enhance pharmacists’ ability to care for patients, often while practicing at the top of their license, and put pharmacists on a more even technical standing with other providers, something that can only help in efforts to achieve provider status under Medicare or state authority.

In addition to implementation of the EHR functional profile, advances have been made to support the exchange of information related to medication therapy management services (MTM). Pharmacies that are providing MTM services most likely would love to receive electronic referrals for those services and submit their clinical documentation to the referring provider, and the payer, electronically. This is another area where standards organizations have come together to develop the technical standards to support the electronic exchange of service requests, referrals, and documentation of services rendered. There is also guidance on the use of CDA (clinical document architecture) templates for pharmacy transition of care and pharmacy care notes. Again, all of these advances are designed to ensure that pharmacists are able to function fully as members of the care team, supporting and managing the patient’s care.

All of these technical tools are meaningless if they aren’t implemented and used. These have been designed by industry volunteers to ensure that pharmacy stays on the leading edge of using technology to support patient care. We live in a world of big data, and pharmacy has a treasure trove of information that must be digitized in order to maximize its benefit. Think for a moment of the information you have stored about any given patient. You know their demographics, their medication history (including immunizations you’ve administered), their allergies, and possibly lab values and biometrics such as blood glucose, cholesterol, height, weight, and blood pressure. You know who their doctors are, and what language they speak most fluently. You might also have information about other services you’ve provided, such as medication reviews and lifestyle and behavior counseling.

Now imagine having all of that information available in structured, discrete fields that can also be codified. How would you use that to improve the care you provide? You could generate reports, attach those in a message to a physician, include them as evidence for billing, review them to improve internal processes and operations, and even publish findings based on your work. This is where pharmacy needs to be, and this type of vision and action is part of our history. We have the opportunity to harness the tools that are available now, and being developed, to ensure that we continue to lead in leveraging technology to improve patient care, improve our operations, and enhance our standing with our provider partners and payers. CT

Marsha K. Millonig, B.Pharm., M.B.A., is president of Catalyst Enterprises LLC in Eagan, Minn. The firm provides consulting, research, and writing services to the healthcare industry. The author can be reached at