CASE STUDIES
Pharmacist documentation
CASE STUDIES
ar Layar
Improving pharmacist documentation of clinical interventions through focused education
T
Katherine B. Rector, Angie Veverka, and Stacie Krick Evans
he role of pharmacists in the acute care setting continues to evolve from the traditional distributive function. Pharmacists provide pharmaceutical care by reviewing and monitoring patient-specific pharmacotherapy for appropriate drug and dosage selection, the presence of drug interactions, and the potential for adverse drug events (ADEs). Pharmacists are responsible for ensuring safe patient care by assessing adherence to the hospital formulary and enforcing policies and procedures that have been deemed best practices by the institution’s pharmacy and therapeutics committee. Pharmacists also help contain drug costs for the health system by recommending alternative, more cost-effective pharmacotherapy options. In addition, pharmacists serve as a resource of drug information for nurses, physicians, and other health care professionals.1 While the benefits of clinical pharmacy services are evident in the literature, justification and measurement
Purpose. The impact of a focused education initiative to increase pharmacists’ documentation of clinical interventions is described. Summary. A focused education initiative was developed to increase the consistency of pharmacists’ documentation of clinical interventions in order to achieve pharmacy goals and to demonstrate the value of pharmacy services at Carolinas Medical Center in Charlotte, North Carolina. Education was provided through weekly pharmacy newsletter publications, weekly huddles, and monthly staff meetings. Pharmacy clinical specialists were tasked with providing examples of activities that should be documented as interventions, reviewing the selection of intervention categories to best capture the specific activity, and emphasizing the need for appropriate documentation. Monthly progress was monitored, and results were posted publicly to incentivize staff and assist with accountability. Increases in the number of clinical interven-
of the impact of clinical pharmacy services in the acute care setting have been challenging.2 Declining health care reimbursement and increased
Katherine B. Rector, Pharm.D., BCPS, is Clinical Specialist, Internal Medicine, Department of Pharmacy; and Angie Veverka, Pharm.D., BCPS, is Pharmacy Residency Program Director and Clinical Specialist, Internal Medicine, Department of Pharmacy, Carolinas Medical Center, Charlotte, NC. Stacie Krick Evans, Pharm.D., is Pharmacy Implementation Manager, VHA Performance Services, Charlotte; at the time of writing she was Clinical Manager, Department of Pharmacy, Carolinas Medical Center. Address correspondence to Dr. Rector (katherine.rector@ carolinashealthcare.org).
tions was reported at monthly pharmacy staff meetings to reinforce the value of this process. The total number of pharmacy clinical interventions increased from an average of 12,493 per month in the first quarter of 2012 to an average of 27,978 per month in the second quarter of 2013, representing a 120% improvement. Associated cost-avoidance dollars also increased proportionally, such that the average costavoidance dollars in the second quarter of 2013 was $1.5 million per month. In addition, the pharmacy department far exceeded the health system’s division of pharmacy targets for established quality indicators. Effects were sustained during the 12 months after completion of the education initiative. Conclusion. Implementation of a focused pharmacist education initiative led to increased numbers of clinical interventions reported and increased documentation of costs avoided. Am J Health-Syst Pharm. 2014; 71:1303-10
cost containment have led to enhanced scrutiny of pharmacy resources. As a result, pharmacy leaders are facing growing pressure to justify clin-
Carleton B. Maxwell, Pharm.D., BCPS, and Said M. Sultan, Pharm.D., BCPS, are acknowledged for coordinating clinical intervention documentation education. The pharmacists at Carolinas Medical Center are also acknowledged for participating in this initiative. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130670
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CASE STUDIES
Pharmacist documentation
ical pharmacy services. The increased availability and use of advanced technology (e.g., computerized prescriber order entry, automated dispensing cabinets, medication carousels) can assist leaders with objective data to justify and validate pharmacists’ performance with operational or distributive functions; however, objective data supporting clinical functions can be more difficult to quantify. Demonstration of service can only be accomplished by consistent and accurate documentation of practices as well as accountability for the care provided. One method that many institutions use to assist with providing objective data regarding clinical services is the documentation of pharmacy interventions. Background Carolinas Medical Center (CMC) is an 874-bed acute care facility in Charlotte, North Carolina, and is the flagship hospital for Carolinas HealthCare System (CHS), which owns or manages 33 hospitals in North Carolina and South Carolina. CMC, 7 additional acute care facilities, and 1 rehabilitation hospital, all based in Charlotte or the surrounding area, comprise the CHS division of inpatient pharmacies. All 9 facilities use Cerner products (Cerner Corporation, Kansas City, MO) for health care information technology and for documenting clinical interventions. Pharmacy services at CMC are provided 24 hours a day and are decentralized from 7 a.m. to 11 p.m. Approximately 11,000 orders are verified and 18,000 doses are dispensed each day. There are 48.9 clinical staff pharmacist full-time-equivalents (FTEs), 15 clinical specialist FTEs, and 5 postgraduate year 1 pharmacy resident FTEs. At CMC, multiple strategies have been employed over time to capture and document pharmacist interventions, with varying degrees of success. In more recent years, available tools and technology have been 1304
enhanced, allowing documentation of pharmacy clinical interventions to be integrated into daily practice through the pharmacy order-entry and verification system. Problem With the implementation of an improved clinical intervention documentation system, one of the first goals of the CHS division of pharmacy was to establish quality indicators. In the fourth quarter of 2011, the quality indicator defined was the clinical benefit of pharmacist interventions in dollars divided by pharmacist labor costs in dollars. While literature suggests that for every $1 invested in clinical pharmacy services, more than $4 in benefit can be expected,3 pharmacy leadership chose a more conservative initial goal of 1.2, or a benefit of $2 for every $1 invested. During 2011, the CMC department of pharmacy averaged a score of 0.65, consistently falling below the established target. In early 2012, an additional quality indicator for pharmacist clinical interventions was established—the number of pharmacy interventions per 100 admissions. In the first quarter of 2012, the CMC department of pharmacy averaged 344 interventions per 100 admissions, slightly below the predefined CHS target of 350 interventions per 100 admissions. The most likely reason that our department was not meeting the established benchmarks was that pharmacists were not consistently using the intervention tool to document patient care activities, as expectations and rationale for documentation had not been clearly communicated to the pharmacy staff. The goal of our project was to encourage pharmacists to consistently document clinical interventions in order to achieve established benchmarks for the division of pharmacy and to demonstrate the value of pharmacy services. Success was determined by our department
Am J Health-Syst Pharm—Vol 71 Aug 1, 2014
as meeting the following objective measures: • Increase and sustain documentation of the total number of clinical interventions reported each month. • Increase and sustain the total costavoidance dollars per month as a result of documented clinical interventions. • Achieve or exceed the division of pharmacy target of 1.2 for the quality indicator “clinical benefit of pharmacist interventions in dollars divided by pharmacist labor costs in dollars.” • Achieve or exceed the CHS division of pharmacy target of 350 pharmacy clinical interventions per 100 admissions.
For our health care system, the cost avoidance assigned to each clinical intervention category was established based on unpublished data obtained from colleagues at a large acute care facility. Their method to gather this information included performing chart reviews to determine real cost savings using the hourly per diem physician rate to calculate cost avoidance associated with services that the physician could perform but had given responsibility to the pharmacist to manage (e.g., dosing and monitoring vancomycin or warfarin). For those interventions that are traditionally pharmacist initiated (e.g., automatic substitutions, i.v.-to-oral dosage form conversion), a clinical impact valuation of low, medium, high, or cost only was assigned, with an associated cost-avoidance amount based on anticipated cost savings resulting from the change in therapy. In 2011, pharmacists at each CHS facility attended a standardized 30-minute education session on maximizing the effectiveness of the clinical intervention tool developed by the CHS division of pharmacy. The focus of the education was to reinforce the importance of clinical intervention documentation as a means to quantify the clinical services that pharmacists provide in
CASE STUDIES
addition to the distributive services traditionally associated with pharmacists. While an initial increase in the number of documented clinical interventions was seen after the education session, it was not sustained at CMC. In early 2012, the importance of documenting clinical interventions was identified as an area of focus, and increasing documentation became a goal for our department. The appendix lists the pharmacy intervention categories that CHS developed within the Cerner Pharmacy MedManager application to document pharmaceutical care activities. Analysis and resolution Improvement process. To improve the consistency of documenting clinical interventions and to meet defined goals, a performanceimprovement project was initiated by the pharmacy clinical specialists using Plan–Do–Study–Act methodology. 4 The first step was to identify barriers to documentation. When feedback was solicited from pharmacists by our clinical manager and clinical specialists about the intervention tool and its place in pharmacists’ workflow, the most common barriers identified included time constraints and uncertainty in selecting the most appropriate intervention category within the Cerner Pharmacy MedManager. Feedback was discussed among the clinical specialist team, and a strategic process for focused education for pharmacists on the use of the intervention tool was implemented. Recognizing that a one-time education session had resulted in only short-term results, two clinical specialists were tasked with publishing an Intervention Spotlight section in the pharmacy’s weekly newsletter. Each week from April through July 2012, this section of the newsletter highlighted a different intervention category, describing the value of a specific clinical intervention and providing examples demonstrating
the appropriate use of the category. This information was then presented in 3- to 5-minute discussions during our weekly pharmacy huddles. The pharmacy huddle at CMC lasts 15–20 minutes and is conducted by pharmacy supervisors every Monday for all shifts to provide pharmacists and pharmacy technicians with information regarding procedure updates, formulary additions, and other news. Initial education emphasized the clinical interventions that the staff would encounter most frequently, as well as those that could be documented more rapidly and with fewer keystrokes. These intervention categories were highlighted in an effort to increase pharmacists’ confidence with integrating documentation into their workflow, since time constraints were identified as a major barrier to consistent documentation. To further address staff concerns related to time constraints, we included helpful hints within our education to assist with efficiency. One of the enhancements made to the clinical intervention tool was the addition of radio buttons (i.e., an option button, similar to a check box, that allows the user to select only one of a predefined set of options) within the clinical intervention categories, which either eliminated the need to type an explanation or allowed for a more-concise comment. We also encouraged completion of the intervention at the time of order verification instead of “stockpiling” interventions for documentation at the end of the shift. One of the major improvements to the documentation tool included an option for the pharmacist to leave an unresolved intervention open, or in progress, for follow up by pharmacists working during the next shift. This encouraged teamwork among the staff and allowed us to communicate more effectively during the overlap period between shifts. Pharmacist education on clinical interventions was also incorporated
Pharmacist documentation
into monthly pharmacy staff meetings. These meetings were used to review examples of inappropriate documentation of clinical interventions, as one of the concerns with this type of initiative was that staff would focus on the quantity of interventions documented without also focusing on the quality of the documentation. This review conveyed a consistent message from pharmacy leaders that the purposes of documentation are to demonstrate the impact of a pharmacist in the acute care setting and provide meaningful information about the types of clinical interventions pharmacists make. Success (an increase in the number of clinical interventions documented) was also reported during monthly staff meetings to reinforce and encourage continued integration of clinical intervention documentation into daily pharmacy practice. Progress was monitored using a Cerner intervention report that included the numbers and categories of clinical interventions documented per pharmacist. Information regarding the total number of clinical interventions each pharmacist documented and the associated cost avoidance was posted monthly in the main pharmacy. We also incorporated focused efforts regarding documentation of clinical interventions into the orientation and training period for new pharmacist employees. All new pharmacists were expected to review the presentation developed by the CHS division of pharmacy. This was supplemented with a discussion to review methods of incorporating documentation of clinical interventions into the daily standard workflow. Initially, clinical specialists provided the supplemental education to new pharmacists during their orientation period. This role was eventually transitioned to those clinical staff pharmacists who not only consistently documented high numbers of interventions but also were most successful in integrating
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CASE STUDIES
Pharmacist documentation
this activity into their daily practice. In addition, clinical staff pharmacist trainers worked one-on-one with new pharmacists during the orientation process and demonstrated strategies for successfully integrating the documentation of clinical interventions into their routines. This approach helped us to engage our entire pharmacist team. Results. An increase in the number of pharmacist-documented clinical interventions was observed shortly after initiating our education plan. From April to July 2012, the total number of interventions rose steadily (Figure 1). This effect was sustained through June 2013; the mean total number of interventions per month increased by 120% from the first quarter of 2012 (12,493 interventions) to the second quarter of 2013 (27,978 interventions). The most commonly documented intervention categories during a onemonth review included laboratory/ safety review (n = 5,473), frequency/ time/dose change (n = 3,100), discontinue therapy (n = 3,070), pharmacokinetic/warfarin consult (n = 2,583), medication reconciliation pharmacist (n = 2,034), order clarification (n = 1,669), chemotherapy review (n = 1,657), intravenous-tooral conversion (n = 1,138), and autosubstitution (n = 1,122). The increase in the total number of documented interventions per month translated into substantial increases in both the cost benefit and the clinical benefit of pharmacist interventions (Figures 2 and 3). When comparing outcomes for the CMC department of pharmacy with CHSestablished pharmacy targets for quality dashboard metrics, all goals were exceeded after the education plan was implemented. As previously stated, the CHS target for the “clinical benefit of pharmacist interventions in dollars divided by pharmacist labor costs in dollars” was set at 1.2. As a result of the focused education, the CMC 1306
department of pharmacy showed marked improvement from a mean score of 0.65 in the fourth quarter of 2011 to a score consistently above 2 through the second quarter of 2013 (Figure 2). The clinical benefit of pharmacist interventions was captured by the documented increase in the number of pharmacy interventions per 100 admissions; the CMC department of pharmacy far exceeded the CHS benchmark of 350 interventions per 100 admissions, with a sustained outcome of 600 interventions per 100 admissions through the second quarter of 2013. As anticipated, cost avoidance from the clinical interventions increased with the total number of documented clinical interventions, such that the average cost-avoidance dollars in the second quarter of 2013 was $1.5 million per month (Figure 4). Discussion Focused education on the value of appropriate documentation of clinical pharmacy interventions resulted in a substantial increase in the number of documented interventions and associated cost avoidance in the acute care setting. Using specific examples of both appropriate and inappropriate methods of documentation, and through enhanced training on clinical interventions during new pharmacist orientation, the number of documented clinical interventions increased, as did the thoroughness of the details the pharmacists included regarding their recommendations to providers. While many recent studies have demonstrated the value of documenting clinical pharmacy interventions, few detailed how to make such programs successful.5-9 Peshek and colleagues10 described an annual workshop-based competency program to assess clinical and distributive functions in pharmacy, but literature describing educational initiatives that do not involve student and resident education is lacking.
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Since each facility is unique in terms of size, range of clinical pharmacy services offered, and type of system used to document interventions, it is difficult to develop a one-size-fits-all approach to education. Despite this, there are elements of the education program we implemented that could work for all institutions. We feel that one factor that made our efforts so successful was the consistency with which we provided education. When implementing a new process and establishing targets, it is imperative to set appropriate and meaningful objective measures to evaluate the quality of the program. With regard to clinical interventions, metrics should be representative of the types of pharmacist activities and clinical services that a facility offers to assist with providing accurate justification for clinical pharmacy programs. Both the quality and quantity of clinical interventions are important for providing objective data regarding clinical services, and educating pharmacists regarding the value of documentation is crucial for success. One of the greatest limitations of our project was that we did not measure the quality of the interventions documented. Pharmacy managers utilize the monthly Cerner intervention report that includes the numbers and categories of clinical interventions documented by each pharmacist to evaluate trends in documentation, but at this time we do not have a system in place to evaluate the appropriateness of the completed interventions. Now that a robust program has been established, we intend to implement a continuous quality-improvement (CQI) initiative to assess the quality of the interventions documented. A similar approach as described by Zimmerman and colleagues,11 whereby a peer-review-based CQI process was implemented and demonstrated improvement in the appropriateness of pharmacists’ clinical interventions, will be considered.
CASE STUDIES
Throughout this process, we had opportunities to provide recommendations for modifications to current interventions as well as develop additional intervention categories. Recommendations from our phar-
macists were shared with the intervention committee to further enhance the documentation process for all of the facilities within our health care system. An example of this includes the addition of a
Pharmacist documentation
chemotherapy review category to capture the time required for initial review and double check of chemotherapy orders. This process involves high-risk medications and requires considerable pharmacist time to
Figure 1. Carolinas Medical Center pharmacy clinical interventions per month, 2011-13. 30,000
Total No. Interventions
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Figure 2. Cost benefit of pharmacist interventions. CHS = Carolinas HealthCare System, CMC = Carolinas Medical Center. 2.8
2.0 1.6
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CMC results 0.8 0.4
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Intervention $ Divided by Pharmacists’ Labor Costs in $
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Figure 3. Clinical benefit of pharmacist interventions. CHS = Carolinas HealthCare System, CMC = Carolinas Medical Center. 800
No. Pharmacy Interventions per 100 Admissions
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CMC results
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Figure 4. Cost avoidance from Carolinas Medical Center pharmacy interventions.
1,600,000
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verify the safety of therapy. Since this addition, the chemotherapy review category has been one of the most frequently documented clinical interventions at our facility each month. Another recommendation from our staff was to modify the ADE-avoided category to enhance appropriate use of the category and to assist with accurately identifying potential or actual ADEs. There are also plans for each facility to review this ADE category as a method of identifying pharmacists for “good catch” award nominations. This will also highlight the impact our pharmacists have on patient safety and encourage the reporting of medication events and near misses. One of the challenges of using clinical pharmacy interventions for justification of clinical pharmacy services is accurately estimating cost savings. Many institutions have defined the relative cost savings associated with each intervention category, but it is difficult to capture actual cost savings, and there are no accepted standards published in the literature. Brockmiller and colleagues12 published recommendations for calculating cost avoidance and cost savings based on retrospective chart reviews, acquisition costs, and estimated decreases in the duration of therapy to support the positive contributions of pharmacy student recommendations. Lee and colleagues9 detailed a cost-analysis process in which they estimated the cost of the original and recommended therapies to include the drug acquisition cost, the expected duration of therapy, and the anticipated labor cost for a pharmacist to make the recommendation and process and fill an order. This study was retrospective in nature, and the authors felt they may have underestimated cost avoidance for this reason. A similar strategy was used by Aldridge and colleagues13 to successfully demonstrate cost savings associated with documented pharmacist interven-
tions with the implementation of an emergency department pharmacy program. However, even within these studies it was sometimes difficult for the authors to agree on the extent of health care resources avoided by implementing a recommendation that prevents harm.9,13 For example, in the case of an ADE avoided, a decrease in the length of hospital stay is often assumed, but most facilities are unable to accurately estimate and calculate the cost savings due solely to the avoidance of an ADE as there are often other confounding factors to consider. Despite the lack of recognized standards, many institutions do rely on previously published economic analyses when determining a strategy for assessment.14 Although we demonstrated notable rates of cost avoidance in our analysis, the applicability of this savings is difficult to quantify. Another limitation we encountered, and one that has been documented in prior studies, is the inconsistency in how interventions are documented.7 For example, while most pharmacists review laboratory test results before dispensing electrolyte supplementation, some might not document this action as a clinical intervention unless the provider is contacted to recommend a dosage adjustment. The education developed by the division of pharmacy certainly assisted with standardizing the approach to documenting clinical interventions, but it can be difficult to adjust previously learned behaviors. Perhaps the most successful component of our initiative was incorporating detailed education on appropriate documentation of clinical interventions into orientation for new employees. By doing this, we were able to establish expectations during the training period, which not only helped with the development of preferred practices but also served to reinforce the new culture for pharmacy trainers.
Pharmacist documentation
Conclusion Implementation of a focused pharmacist education initiative led to increased numbers of clinical interventions reported and increased documentation of costs avoided. References 1. American Society of Health-System Pharmacists. ASHP guidelines: minimum standard for pharmacists in hospitals. Am J Health-Syst Pharm. 2013; 70:1619-30. 2. Perez A, Doloresco F, Hoffman JM et al. Economic evaluations of clinical pharmacy services: 2001-2005. Pharmacotherapy. 2008; 28:285e-323e. 3. Schumock GT, Butler MG, Meek PD et al. Evidence of the economic benefit of clinical pharmacy services: 1996-2000. Pharmacotherapy. 2003; 23:113-32. 4. Institute for Healthcare Improvement. Plan-Do-Study-Act (PDSA) worksheet. www.ihi.org/knowledge/pages/tools/ plandostudyactworksheet.aspx (accessed 2013 Jul 19). 5. McMullin ST, Hennenfent JA, Ritchie DJ et al. A prospective, randomized trial to assess the cost impact of pharmacistinitiated interventions. Arch Intern Med. 1999; 159:2306-9. 6. Anderson SV, Schumock GT. Evaluation and justification of clinical pharmacy services. Expert Rev Pharmacoecon Outcomes Res. 2009; 9:539-45. 7. Kaboli PJ, Hoth AB, McClimon BG et al. Clinical pharmacists and inpatient medical care. Arch Intern Med. 2006; 166:95564. 8. De Ridjt T, Willems L, Simoens S. Economic effects of clinical pharmacy interventions: a literature review. Am J Health-Syst Pharm. 2008; 65:1161-72. 9. Lee AJ, Boro MS, Knapp KK et al. Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health-Syst Pharm. 2002; 59:2070-7. 10. Peshek SC, Komorny KM, LettingMangira D et al. A site-specific, clinical and distributive based pharmacist competency workshop. Hosp Pharm. 2007; 42:46-51. 11. Zimmerman CR, Smolarek RT, Stevenson JG. Peer review and continuous quality improvement of pharmacists’ clinical interventions. Am J Health-Syst Pharm. 1997; 54:1722-7. 12. Brockmiller H, Abel SR, Koh-Knox CP et al. Cost impact of Pharm.D. candidates’ drug therapy recommendations. Am J Health-Syst Pharm. 1999; 56:882-4. 13. Aldridge VE, Park HK, Bounthavong M et al. Implementing a comprehensive, 24hour emergency department pharmacy program. Am J Health-Syst Pharm. 2009; 66:1943-7. 14. Schumock GT. Methods to assess the economic outcomes of clinical pharmacy services. Pharmacotherapy. 2000; 20:243S-252S.
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Appendix—Pharmacy clinical intervention categories • Add medication to regimen • Adverse drug event avoided • Auto-substitution • Change route • Chemotherapy review • Clinical consult • Clinical review • Computerized physician order entry troubleshooting • Dabigatran safety monitoring • Discontinue therapy • Dosing recommendation/consult • Drug allergy avoidance • Drug information • Erythropoietin stimulating agents risk evaluation mitigation strategy review • Frequency/time/dose change • Intravenous to oral conversion • Laboratory/safety review • Medication reconciliation • Medication renewal • Nutrition pharmacy • Order clarification • Patient education—non-warfarin • Pharmacy electronic teaching record • Pharmacokinetic/warfarin consult • Recommendation of alternative therapy • Surgical care improvement project • Therapeutic enoxaparin daily monitoring • Verifying home medications for use
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Pharmacist documentation
CASE STUDIES
ar Layar
Improving pharmacist documentation of clinical interventions through focused education
T
Katherine B. Rector, Angie Veverka, and Stacie Krick Evans
he role of pharmacists in the acute care setting continues to evolve from the traditional distributive function. Pharmacists provide pharmaceutical care by reviewing and monitoring patient-specific pharmacotherapy for appropriate drug and dosage selection, the presence of drug interactions, and the potential for adverse drug events (ADEs). Pharmacists are responsible for ensuring safe patient care by assessing adherence to the hospital formulary and enforcing policies and procedures that have been deemed best practices by the institution’s pharmacy and therapeutics committee. Pharmacists also help contain drug costs for the health system by recommending alternative, more cost-effective pharmacotherapy options. In addition, pharmacists serve as a resource of drug information for nurses, physicians, and other health care professionals.1 While the benefits of clinical pharmacy services are evident in the literature, justification and measurement
Purpose. The impact of a focused education initiative to increase pharmacists’ documentation of clinical interventions is described. Summary. A focused education initiative was developed to increase the consistency of pharmacists’ documentation of clinical interventions in order to achieve pharmacy goals and to demonstrate the value of pharmacy services at Carolinas Medical Center in Charlotte, North Carolina. Education was provided through weekly pharmacy newsletter publications, weekly huddles, and monthly staff meetings. Pharmacy clinical specialists were tasked with providing examples of activities that should be documented as interventions, reviewing the selection of intervention categories to best capture the specific activity, and emphasizing the need for appropriate documentation. Monthly progress was monitored, and results were posted publicly to incentivize staff and assist with accountability. Increases in the number of clinical interven-
of the impact of clinical pharmacy services in the acute care setting have been challenging.2 Declining health care reimbursement and increased
Katherine B. Rector, Pharm.D., BCPS, is Clinical Specialist, Internal Medicine, Department of Pharmacy; and Angie Veverka, Pharm.D., BCPS, is Pharmacy Residency Program Director and Clinical Specialist, Internal Medicine, Department of Pharmacy, Carolinas Medical Center, Charlotte, NC. Stacie Krick Evans, Pharm.D., is Pharmacy Implementation Manager, VHA Performance Services, Charlotte; at the time of writing she was Clinical Manager, Department of Pharmacy, Carolinas Medical Center. Address correspondence to Dr. Rector (katherine.rector@ carolinashealthcare.org).
tions was reported at monthly pharmacy staff meetings to reinforce the value of this process. The total number of pharmacy clinical interventions increased from an average of 12,493 per month in the first quarter of 2012 to an average of 27,978 per month in the second quarter of 2013, representing a 120% improvement. Associated cost-avoidance dollars also increased proportionally, such that the average costavoidance dollars in the second quarter of 2013 was $1.5 million per month. In addition, the pharmacy department far exceeded the health system’s division of pharmacy targets for established quality indicators. Effects were sustained during the 12 months after completion of the education initiative. Conclusion. Implementation of a focused pharmacist education initiative led to increased numbers of clinical interventions reported and increased documentation of costs avoided. Am J Health-Syst Pharm. 2014; 71:1303-10
cost containment have led to enhanced scrutiny of pharmacy resources. As a result, pharmacy leaders are facing growing pressure to justify clin-
Carleton B. Maxwell, Pharm.D., BCPS, and Said M. Sultan, Pharm.D., BCPS, are acknowledged for coordinating clinical intervention documentation education. The pharmacists at Carolinas Medical Center are also acknowledged for participating in this initiative. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130670
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CASE STUDIES
Pharmacist documentation
ical pharmacy services. The increased availability and use of advanced technology (e.g., computerized prescriber order entry, automated dispensing cabinets, medication carousels) can assist leaders with objective data to justify and validate pharmacists’ performance with operational or distributive functions; however, objective data supporting clinical functions can be more difficult to quantify. Demonstration of service can only be accomplished by consistent and accurate documentation of practices as well as accountability for the care provided. One method that many institutions use to assist with providing objective data regarding clinical services is the documentation of pharmacy interventions. Background Carolinas Medical Center (CMC) is an 874-bed acute care facility in Charlotte, North Carolina, and is the flagship hospital for Carolinas HealthCare System (CHS), which owns or manages 33 hospitals in North Carolina and South Carolina. CMC, 7 additional acute care facilities, and 1 rehabilitation hospital, all based in Charlotte or the surrounding area, comprise the CHS division of inpatient pharmacies. All 9 facilities use Cerner products (Cerner Corporation, Kansas City, MO) for health care information technology and for documenting clinical interventions. Pharmacy services at CMC are provided 24 hours a day and are decentralized from 7 a.m. to 11 p.m. Approximately 11,000 orders are verified and 18,000 doses are dispensed each day. There are 48.9 clinical staff pharmacist full-time-equivalents (FTEs), 15 clinical specialist FTEs, and 5 postgraduate year 1 pharmacy resident FTEs. At CMC, multiple strategies have been employed over time to capture and document pharmacist interventions, with varying degrees of success. In more recent years, available tools and technology have been 1304
enhanced, allowing documentation of pharmacy clinical interventions to be integrated into daily practice through the pharmacy order-entry and verification system. Problem With the implementation of an improved clinical intervention documentation system, one of the first goals of the CHS division of pharmacy was to establish quality indicators. In the fourth quarter of 2011, the quality indicator defined was the clinical benefit of pharmacist interventions in dollars divided by pharmacist labor costs in dollars. While literature suggests that for every $1 invested in clinical pharmacy services, more than $4 in benefit can be expected,3 pharmacy leadership chose a more conservative initial goal of 1.2, or a benefit of $2 for every $1 invested. During 2011, the CMC department of pharmacy averaged a score of 0.65, consistently falling below the established target. In early 2012, an additional quality indicator for pharmacist clinical interventions was established—the number of pharmacy interventions per 100 admissions. In the first quarter of 2012, the CMC department of pharmacy averaged 344 interventions per 100 admissions, slightly below the predefined CHS target of 350 interventions per 100 admissions. The most likely reason that our department was not meeting the established benchmarks was that pharmacists were not consistently using the intervention tool to document patient care activities, as expectations and rationale for documentation had not been clearly communicated to the pharmacy staff. The goal of our project was to encourage pharmacists to consistently document clinical interventions in order to achieve established benchmarks for the division of pharmacy and to demonstrate the value of pharmacy services. Success was determined by our department
Am J Health-Syst Pharm—Vol 71 Aug 1, 2014
as meeting the following objective measures: • Increase and sustain documentation of the total number of clinical interventions reported each month. • Increase and sustain the total costavoidance dollars per month as a result of documented clinical interventions. • Achieve or exceed the division of pharmacy target of 1.2 for the quality indicator “clinical benefit of pharmacist interventions in dollars divided by pharmacist labor costs in dollars.” • Achieve or exceed the CHS division of pharmacy target of 350 pharmacy clinical interventions per 100 admissions.
For our health care system, the cost avoidance assigned to each clinical intervention category was established based on unpublished data obtained from colleagues at a large acute care facility. Their method to gather this information included performing chart reviews to determine real cost savings using the hourly per diem physician rate to calculate cost avoidance associated with services that the physician could perform but had given responsibility to the pharmacist to manage (e.g., dosing and monitoring vancomycin or warfarin). For those interventions that are traditionally pharmacist initiated (e.g., automatic substitutions, i.v.-to-oral dosage form conversion), a clinical impact valuation of low, medium, high, or cost only was assigned, with an associated cost-avoidance amount based on anticipated cost savings resulting from the change in therapy. In 2011, pharmacists at each CHS facility attended a standardized 30-minute education session on maximizing the effectiveness of the clinical intervention tool developed by the CHS division of pharmacy. The focus of the education was to reinforce the importance of clinical intervention documentation as a means to quantify the clinical services that pharmacists provide in
CASE STUDIES
addition to the distributive services traditionally associated with pharmacists. While an initial increase in the number of documented clinical interventions was seen after the education session, it was not sustained at CMC. In early 2012, the importance of documenting clinical interventions was identified as an area of focus, and increasing documentation became a goal for our department. The appendix lists the pharmacy intervention categories that CHS developed within the Cerner Pharmacy MedManager application to document pharmaceutical care activities. Analysis and resolution Improvement process. To improve the consistency of documenting clinical interventions and to meet defined goals, a performanceimprovement project was initiated by the pharmacy clinical specialists using Plan–Do–Study–Act methodology. 4 The first step was to identify barriers to documentation. When feedback was solicited from pharmacists by our clinical manager and clinical specialists about the intervention tool and its place in pharmacists’ workflow, the most common barriers identified included time constraints and uncertainty in selecting the most appropriate intervention category within the Cerner Pharmacy MedManager. Feedback was discussed among the clinical specialist team, and a strategic process for focused education for pharmacists on the use of the intervention tool was implemented. Recognizing that a one-time education session had resulted in only short-term results, two clinical specialists were tasked with publishing an Intervention Spotlight section in the pharmacy’s weekly newsletter. Each week from April through July 2012, this section of the newsletter highlighted a different intervention category, describing the value of a specific clinical intervention and providing examples demonstrating
the appropriate use of the category. This information was then presented in 3- to 5-minute discussions during our weekly pharmacy huddles. The pharmacy huddle at CMC lasts 15–20 minutes and is conducted by pharmacy supervisors every Monday for all shifts to provide pharmacists and pharmacy technicians with information regarding procedure updates, formulary additions, and other news. Initial education emphasized the clinical interventions that the staff would encounter most frequently, as well as those that could be documented more rapidly and with fewer keystrokes. These intervention categories were highlighted in an effort to increase pharmacists’ confidence with integrating documentation into their workflow, since time constraints were identified as a major barrier to consistent documentation. To further address staff concerns related to time constraints, we included helpful hints within our education to assist with efficiency. One of the enhancements made to the clinical intervention tool was the addition of radio buttons (i.e., an option button, similar to a check box, that allows the user to select only one of a predefined set of options) within the clinical intervention categories, which either eliminated the need to type an explanation or allowed for a more-concise comment. We also encouraged completion of the intervention at the time of order verification instead of “stockpiling” interventions for documentation at the end of the shift. One of the major improvements to the documentation tool included an option for the pharmacist to leave an unresolved intervention open, or in progress, for follow up by pharmacists working during the next shift. This encouraged teamwork among the staff and allowed us to communicate more effectively during the overlap period between shifts. Pharmacist education on clinical interventions was also incorporated
Pharmacist documentation
into monthly pharmacy staff meetings. These meetings were used to review examples of inappropriate documentation of clinical interventions, as one of the concerns with this type of initiative was that staff would focus on the quantity of interventions documented without also focusing on the quality of the documentation. This review conveyed a consistent message from pharmacy leaders that the purposes of documentation are to demonstrate the impact of a pharmacist in the acute care setting and provide meaningful information about the types of clinical interventions pharmacists make. Success (an increase in the number of clinical interventions documented) was also reported during monthly staff meetings to reinforce and encourage continued integration of clinical intervention documentation into daily pharmacy practice. Progress was monitored using a Cerner intervention report that included the numbers and categories of clinical interventions documented per pharmacist. Information regarding the total number of clinical interventions each pharmacist documented and the associated cost avoidance was posted monthly in the main pharmacy. We also incorporated focused efforts regarding documentation of clinical interventions into the orientation and training period for new pharmacist employees. All new pharmacists were expected to review the presentation developed by the CHS division of pharmacy. This was supplemented with a discussion to review methods of incorporating documentation of clinical interventions into the daily standard workflow. Initially, clinical specialists provided the supplemental education to new pharmacists during their orientation period. This role was eventually transitioned to those clinical staff pharmacists who not only consistently documented high numbers of interventions but also were most successful in integrating
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this activity into their daily practice. In addition, clinical staff pharmacist trainers worked one-on-one with new pharmacists during the orientation process and demonstrated strategies for successfully integrating the documentation of clinical interventions into their routines. This approach helped us to engage our entire pharmacist team. Results. An increase in the number of pharmacist-documented clinical interventions was observed shortly after initiating our education plan. From April to July 2012, the total number of interventions rose steadily (Figure 1). This effect was sustained through June 2013; the mean total number of interventions per month increased by 120% from the first quarter of 2012 (12,493 interventions) to the second quarter of 2013 (27,978 interventions). The most commonly documented intervention categories during a onemonth review included laboratory/ safety review (n = 5,473), frequency/ time/dose change (n = 3,100), discontinue therapy (n = 3,070), pharmacokinetic/warfarin consult (n = 2,583), medication reconciliation pharmacist (n = 2,034), order clarification (n = 1,669), chemotherapy review (n = 1,657), intravenous-tooral conversion (n = 1,138), and autosubstitution (n = 1,122). The increase in the total number of documented interventions per month translated into substantial increases in both the cost benefit and the clinical benefit of pharmacist interventions (Figures 2 and 3). When comparing outcomes for the CMC department of pharmacy with CHSestablished pharmacy targets for quality dashboard metrics, all goals were exceeded after the education plan was implemented. As previously stated, the CHS target for the “clinical benefit of pharmacist interventions in dollars divided by pharmacist labor costs in dollars” was set at 1.2. As a result of the focused education, the CMC 1306
department of pharmacy showed marked improvement from a mean score of 0.65 in the fourth quarter of 2011 to a score consistently above 2 through the second quarter of 2013 (Figure 2). The clinical benefit of pharmacist interventions was captured by the documented increase in the number of pharmacy interventions per 100 admissions; the CMC department of pharmacy far exceeded the CHS benchmark of 350 interventions per 100 admissions, with a sustained outcome of 600 interventions per 100 admissions through the second quarter of 2013. As anticipated, cost avoidance from the clinical interventions increased with the total number of documented clinical interventions, such that the average cost-avoidance dollars in the second quarter of 2013 was $1.5 million per month (Figure 4). Discussion Focused education on the value of appropriate documentation of clinical pharmacy interventions resulted in a substantial increase in the number of documented interventions and associated cost avoidance in the acute care setting. Using specific examples of both appropriate and inappropriate methods of documentation, and through enhanced training on clinical interventions during new pharmacist orientation, the number of documented clinical interventions increased, as did the thoroughness of the details the pharmacists included regarding their recommendations to providers. While many recent studies have demonstrated the value of documenting clinical pharmacy interventions, few detailed how to make such programs successful.5-9 Peshek and colleagues10 described an annual workshop-based competency program to assess clinical and distributive functions in pharmacy, but literature describing educational initiatives that do not involve student and resident education is lacking.
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Since each facility is unique in terms of size, range of clinical pharmacy services offered, and type of system used to document interventions, it is difficult to develop a one-size-fits-all approach to education. Despite this, there are elements of the education program we implemented that could work for all institutions. We feel that one factor that made our efforts so successful was the consistency with which we provided education. When implementing a new process and establishing targets, it is imperative to set appropriate and meaningful objective measures to evaluate the quality of the program. With regard to clinical interventions, metrics should be representative of the types of pharmacist activities and clinical services that a facility offers to assist with providing accurate justification for clinical pharmacy programs. Both the quality and quantity of clinical interventions are important for providing objective data regarding clinical services, and educating pharmacists regarding the value of documentation is crucial for success. One of the greatest limitations of our project was that we did not measure the quality of the interventions documented. Pharmacy managers utilize the monthly Cerner intervention report that includes the numbers and categories of clinical interventions documented by each pharmacist to evaluate trends in documentation, but at this time we do not have a system in place to evaluate the appropriateness of the completed interventions. Now that a robust program has been established, we intend to implement a continuous quality-improvement (CQI) initiative to assess the quality of the interventions documented. A similar approach as described by Zimmerman and colleagues,11 whereby a peer-review-based CQI process was implemented and demonstrated improvement in the appropriateness of pharmacists’ clinical interventions, will be considered.
CASE STUDIES
Throughout this process, we had opportunities to provide recommendations for modifications to current interventions as well as develop additional intervention categories. Recommendations from our phar-
macists were shared with the intervention committee to further enhance the documentation process for all of the facilities within our health care system. An example of this includes the addition of a
Pharmacist documentation
chemotherapy review category to capture the time required for initial review and double check of chemotherapy orders. This process involves high-risk medications and requires considerable pharmacist time to
Figure 1. Carolinas Medical Center pharmacy clinical interventions per month, 2011-13. 30,000
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Figure 2. Cost benefit of pharmacist interventions. CHS = Carolinas HealthCare System, CMC = Carolinas Medical Center. 2.8
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Figure 3. Clinical benefit of pharmacist interventions. CHS = Carolinas HealthCare System, CMC = Carolinas Medical Center. 800
No. Pharmacy Interventions per 100 Admissions
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Figure 4. Cost avoidance from Carolinas Medical Center pharmacy interventions.
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verify the safety of therapy. Since this addition, the chemotherapy review category has been one of the most frequently documented clinical interventions at our facility each month. Another recommendation from our staff was to modify the ADE-avoided category to enhance appropriate use of the category and to assist with accurately identifying potential or actual ADEs. There are also plans for each facility to review this ADE category as a method of identifying pharmacists for “good catch” award nominations. This will also highlight the impact our pharmacists have on patient safety and encourage the reporting of medication events and near misses. One of the challenges of using clinical pharmacy interventions for justification of clinical pharmacy services is accurately estimating cost savings. Many institutions have defined the relative cost savings associated with each intervention category, but it is difficult to capture actual cost savings, and there are no accepted standards published in the literature. Brockmiller and colleagues12 published recommendations for calculating cost avoidance and cost savings based on retrospective chart reviews, acquisition costs, and estimated decreases in the duration of therapy to support the positive contributions of pharmacy student recommendations. Lee and colleagues9 detailed a cost-analysis process in which they estimated the cost of the original and recommended therapies to include the drug acquisition cost, the expected duration of therapy, and the anticipated labor cost for a pharmacist to make the recommendation and process and fill an order. This study was retrospective in nature, and the authors felt they may have underestimated cost avoidance for this reason. A similar strategy was used by Aldridge and colleagues13 to successfully demonstrate cost savings associated with documented pharmacist interven-
tions with the implementation of an emergency department pharmacy program. However, even within these studies it was sometimes difficult for the authors to agree on the extent of health care resources avoided by implementing a recommendation that prevents harm.9,13 For example, in the case of an ADE avoided, a decrease in the length of hospital stay is often assumed, but most facilities are unable to accurately estimate and calculate the cost savings due solely to the avoidance of an ADE as there are often other confounding factors to consider. Despite the lack of recognized standards, many institutions do rely on previously published economic analyses when determining a strategy for assessment.14 Although we demonstrated notable rates of cost avoidance in our analysis, the applicability of this savings is difficult to quantify. Another limitation we encountered, and one that has been documented in prior studies, is the inconsistency in how interventions are documented.7 For example, while most pharmacists review laboratory test results before dispensing electrolyte supplementation, some might not document this action as a clinical intervention unless the provider is contacted to recommend a dosage adjustment. The education developed by the division of pharmacy certainly assisted with standardizing the approach to documenting clinical interventions, but it can be difficult to adjust previously learned behaviors. Perhaps the most successful component of our initiative was incorporating detailed education on appropriate documentation of clinical interventions into orientation for new employees. By doing this, we were able to establish expectations during the training period, which not only helped with the development of preferred practices but also served to reinforce the new culture for pharmacy trainers.
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Conclusion Implementation of a focused pharmacist education initiative led to increased numbers of clinical interventions reported and increased documentation of costs avoided. References 1. American Society of Health-System Pharmacists. ASHP guidelines: minimum standard for pharmacists in hospitals. Am J Health-Syst Pharm. 2013; 70:1619-30. 2. Perez A, Doloresco F, Hoffman JM et al. Economic evaluations of clinical pharmacy services: 2001-2005. Pharmacotherapy. 2008; 28:285e-323e. 3. Schumock GT, Butler MG, Meek PD et al. Evidence of the economic benefit of clinical pharmacy services: 1996-2000. Pharmacotherapy. 2003; 23:113-32. 4. Institute for Healthcare Improvement. Plan-Do-Study-Act (PDSA) worksheet. www.ihi.org/knowledge/pages/tools/ plandostudyactworksheet.aspx (accessed 2013 Jul 19). 5. McMullin ST, Hennenfent JA, Ritchie DJ et al. A prospective, randomized trial to assess the cost impact of pharmacistinitiated interventions. Arch Intern Med. 1999; 159:2306-9. 6. Anderson SV, Schumock GT. Evaluation and justification of clinical pharmacy services. Expert Rev Pharmacoecon Outcomes Res. 2009; 9:539-45. 7. Kaboli PJ, Hoth AB, McClimon BG et al. Clinical pharmacists and inpatient medical care. Arch Intern Med. 2006; 166:95564. 8. De Ridjt T, Willems L, Simoens S. Economic effects of clinical pharmacy interventions: a literature review. Am J Health-Syst Pharm. 2008; 65:1161-72. 9. Lee AJ, Boro MS, Knapp KK et al. Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health-Syst Pharm. 2002; 59:2070-7. 10. Peshek SC, Komorny KM, LettingMangira D et al. A site-specific, clinical and distributive based pharmacist competency workshop. Hosp Pharm. 2007; 42:46-51. 11. Zimmerman CR, Smolarek RT, Stevenson JG. Peer review and continuous quality improvement of pharmacists’ clinical interventions. Am J Health-Syst Pharm. 1997; 54:1722-7. 12. Brockmiller H, Abel SR, Koh-Knox CP et al. Cost impact of Pharm.D. candidates’ drug therapy recommendations. Am J Health-Syst Pharm. 1999; 56:882-4. 13. Aldridge VE, Park HK, Bounthavong M et al. Implementing a comprehensive, 24hour emergency department pharmacy program. Am J Health-Syst Pharm. 2009; 66:1943-7. 14. Schumock GT. Methods to assess the economic outcomes of clinical pharmacy services. Pharmacotherapy. 2000; 20:243S-252S.
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Appendix—Pharmacy clinical intervention categories • Add medication to regimen • Adverse drug event avoided • Auto-substitution • Change route • Chemotherapy review • Clinical consult • Clinical review • Computerized physician order entry troubleshooting • Dabigatran safety monitoring • Discontinue therapy • Dosing recommendation/consult • Drug allergy avoidance • Drug information • Erythropoietin stimulating agents risk evaluation mitigation strategy review • Frequency/time/dose change • Intravenous to oral conversion • Laboratory/safety review • Medication reconciliation • Medication renewal • Nutrition pharmacy • Order clarification • Patient education—non-warfarin • Pharmacy electronic teaching record • Pharmacokinetic/warfarin consult • Recommendation of alternative therapy • Surgical care improvement project • Therapeutic enoxaparin daily monitoring • Verifying home medications for use
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