Dr. Steven k. Magid, MD, CMIO, Hospital for Special Surgery (HSS)
The separation of the pharmacist’s role from the healer’s is probably a relatively modern concept. In many cultures, it was the knowledge of medicinals that made the “Medicine Man” a healer. As the role of the pharmacist evolved, it became necessary to communicate specific instructions for the preparations of medicines–which of course were done by the written prescription. It is said that the pharmacist Isaac Smith was the first person to establish a “health information exchange” between pharmacists and physicians, when in 1877 he arranged a telephone connection between his drugstore in Hartford, Connecticut and 21 local physicians. After the advent of computers, computer-based pharmacy information systems made their appearance early on because of the importance of charge capture. An automated system to capture drug to drug interactions dates back to 1970 [Applied Clinical Informatics].
Today, a large portion of the electronic medical record (EHR) is devoted to the ordering, verification, preparation and administration of medications. Anyone who has had the experience of implementing and using an EHR recognizes the importance of working closely with pharmacists. While there are well defined roles for Chief Medical Informatics Officers (CMIOs) and Chief Nursing Informatics Officers (CNIOs), this is less true for Chief Pharmacy Informatics Officers (CPIOs), and in fact, very few CPIOs exist. However, having a partnership with someone acting as a pharmacy informatacist is crucial.
Their role is not just to build and valid a content, but also to map and optimize work flow. Content starts with individual orders. These must represent the hospital formulary whenever possible, and include accurate dosing. Clinical decision support (CDS) begins with offering the right drugs on drop down lists, and in the best order, either by dose, alphabet or class. Order Sets require careful thought, giving prescribers only those choices which foster best practices. They should prompt prescribers to “do what is right”.
Another important area of collaboration between prescribers and pharmacy informaticists involves “alerting”. These messages alert the prescriber in real time to a problem, such as an allergy to a drug, an incorrect dose, or an interaction between the drug being ordered and one already being taken. Such alerts are one of the key safety features of the EHR.
"Pharmacy informatics displayed a key role in our quality initiatives"
However, “over alerting” can be as dangerous as no alerts. If there are too many alerts that are of low value, prescribers tend to tune out all the “noise” and might miss the key “signal”. Striking this “sweet spot” requires careful analysis and review between pharmacy and the clinical team. Furthermore, the decisions regarding content and alerts going live is just a starting point. Continued collaboration is required to optimize the implementation.
I believe that it is important for the pharmacy informaticists to be practicing clinicians, and to work for the pharmacy and not for IT. Clinicians have a better knowledge of hospital workflows and ordering habits. Due to their close connection with prescribers, problems that surface can be more easily understood and handled. Service requests can be submitted in real time with complete information, and problems are resolved more quickly.
Pharmacists also play a key role in today’s regulatory environment. Programs such as Meaningful Use, PQRS, MIPs, and oversight by the TJC, CMS, and State Department of Health have large portions related to the proper and safe administration of medications. Examples include vaccinating for influenza and pneumonia as well as the timing of beta blockers and antibiotics in relation to surgery. Such metrics are often publicly reported, but are also crucial to patient safety.
Pharmacy informatics displayed a key role in our quality initiatives. There is an abundance of metrics and reports that are tracked with respect to near misses as well as adverse events. They proactively mine and trend data particularly in high-risk areas to prevent future safety events. They work closely with IT to optimize the EHR content and workflow. In addition they are key members of both our hospital safety committee and our EHR safety committee.
The opioid epidemic has reached critical proportions. Pharmacists have played a key role in implementing and integrating I-Stop and electronic prescription of controlled substances with our EHR. At HSS, they are working with prescribers to create literature-based discharge order sets in which the appropriate opioid and dose is tailored to the type of operation as well as the expected level and duration of post-op pain.
In addition, they work hand in hand with prescribers to assure proper downtime procedures. Pharmacist involvement in IT also includes antibiotic stewardship, where prescribers are “nudged” to order the most effective and cost effective drug, which is least likely to promote antibiotic resistance.
Also, close coordination with nursing is extremely important. One such project was the implementation of bar coding- to ensure the “5 rights” other areas of coordination include the Pyxis machine and perfecting doses of meds.
In conclusion, whether they have a formal title of Chief Pharmacy Information Officer or not, pharmacists play a key role in the design, implementation, optimization and success of an EHR. They have a complex role to play and a close association with the CMIO, CNIO and others ensures that patient safety is preserved. For those interested in reading more about this subject, see the excellent paper in Task Force Report on CCIO Knowledge, Education, and Skill sets.