Digital Strategies for Documenting and Sharing Patient Information Suzanne Higginbotham, PharmD, BCACP Olivia Bentley, PharmD, CFts, AAHIVP

Transcription

1 Digital Strategies for Documenting and Sharing Patient Information Suzanne Higginbotham, PharmD, BCACP Olivia Bentley, PharmD, CFts, AAHIVP Annual Meeting & Exposition Seattle, Washington March 22 25

2 Disclosures The speakers of this presentation have no conflicts of interest regarding this presentation 2

3 CPE Information Target Audience: Pharmacists ACPE#: L04 P Activity Type: Application based 3

4 Learning Objectives At the completion of this application based activity, participants will be able to: Describe the legal requirements for maintaining accurate, perpetual patient care records for all patient care services Develop accurate and concise patient care documentation using scenarios for both initial and follow up care List the components of a e care plan and identify appropriate information to include in each section Describe methods for the electronic exchange of information, including DIRECT and the use of Health Information Exchanges 4

5 Assessment Questions 1. Electronic health records must be maintained for a minimum of A. 4 years B. 6 years C. 8 years D. 10 years 5

6 Assessment Questions 2. Which of the following is an example of a written communication template commonly used by pharmacists to document patient interventions A. SBAR B. MAR C. TITRS D. SOAP 6

7 Assessment Questions 3. Which of the following statements is NOT true regarding ecare Plans? A. An ecare Plan is a standard, not a platform, that is designed for data exchange and electronic care coordination B. Should consist of patient specific information including medication therapy problems, interventions, referrals, and payer information C. For the national standard of exchange of healthcare information, SNOMED codes are not used in ecare Plans, only in EMRs D. There are a variety of platforms designed for pharmacist use that comply with the standard of information exchange used in ecare Plans 7

8 Assessment Questions 4. Which of following is true regarding the various methods of health information exchange? A. Directed exchange is when providers can securely send patient information to another healthcare provider B. Query based exchange provides patients with access to their own healthcare information allowing them to manage their healthcare online C. Consumer mediated exchange is used by clinicians to search and discover clinical resources on a patient D. An example of directed exchange is if a pregnant patient goes into the hospital and the provider obtains the patient's healthcare record in this unplanned care situation 8

9 Things to Consider How do we communicate with each other? How do you communicate information in healthcare? How do you identify, gather, and transmit data at your current practice site? 9

10 Automation and Technology Automation and information systems in pharmacy practice evolved in the 1960 s Drivers included Regulatory and legal requirements Customer satisfaction Need to streamline services 10

11 Paradigm Shift in Pharmacy Practice 1990 s introduction to medication therapy management Shift from traditional dispensing services to patient centered pharmaceutical care More dramatic increase in early 2000 s Large demand in automation and technology to improve productivity as pharmacists were moved from dispensing to clinical roles 11

12 Health Information Technology Provides the capability to electronically move clinical information from one information system to another while maintaining the meaning of the information being exchanged Allows health care professionals and patients to appropriately access and securely share medical information electronically Goal is Enhanced care coordination Improved access to appropriate information Improved efficiency and reliability Improved quality and safety HealthIT.gov. Health Information Exchanges. professionals/health information exchange/what hie. Accessed February 1,

13 The legal requirements for maintaining accurate, perpetual patient care records for all patient care services Suzanne Higginbotham Annual Meeting & Exposition Seattle, Washington March

14 Purpose of Documentation Serves as a record of what has been done Efforts to achieve desired patient outcomes Evaluates patient progress Legal requirement Compliance with laws & regulations of patient records Billing purposes 14

15 Purpose of Documentation Form of communication among health care professionals Enhances continuity of care Standardized systematic process of care Demonstrates value of pharmacist provided MTM services Clinical, economic and humanistic outcomes 15

16 The Pharmacists Patient Care Process Foundational component of the Pharmacists Patient Care Process Led by Joint Commission of Pharmacy Practitioners (JCPP) Provides a consistent process for pharmacist delivered care Applicable to any practice setting and any patient service where pharmacists provide care content/uploads/2016/03/patientcareprocess with supporting organizations.pdf 16

17 The Pharmacists Patient Care Process 17

18 Legal Requirements Pharmacists are required to maintain medical records that are Complete Accurate Accessible Stored appropriately Retained and Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/ 18

19 Patient Health Records Complete and Accurate Information Legible Promptly completed 19

20 Patient Health Records Should include at a minimum Patient identification Pertinent medical history and results of physical examination Allergies and known drug reactions Patient consent Notes by authorized staff members and individuals who have been granted clinical privileges Written recommendations/instructions given to the patient Significant medical advice given to a patient by telephone AHIMA EHR Practice Council. "Developing a Legal Health Record Policy: Appendix A." Journal of AHIMA 78, no. 9 (Oct. 2007): Web extra. Available online in the AHIMA Body of Knowledge at Accessed January 2,

21 Patient Health Records Accessible To patients or patient designees Given access or as a copy To other health care professionals Given access to necessary information for intended purposes 21

22 Patient Health Records Medical records should be stored to provide protection from loss, damage or unauthorized access Under HIPAA, covered entities must Have safeguards to protect private information Limit use and sharing to the minimum necessary to accomplish intended purpose Establish agreements with service providers to perform functions or activities on their behalf Establish policies and procedures outlining who can access patient health information professionals/privacy/laws regulations/index.html accessed January 2,

23 Patient Health Records Retention of information is controlled by Federal legislation Provincial standards of practice Health Information Act 23

24 Patient Health Records Electronic patient health records should be maintained for a minimum of Six years under HIPAA law 45CFR (j)(2) By the governing state board of pharmacy Whichever notes the longer period of time title45 vol1/pdf/cfr 2011 title45 vol1 sec pdf 24

25 Develop accurate and concise patient care documentation using scenarios for both initial and follow up care Suzanne Higginbotham Annual Meeting & Exposition Seattle, Washington March

26 Things to Consider 26

27 Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT) A standardized, multilingual vocabulary of terminology Used by healthcare professionals for the electronic exchange of clinical health information Owned and maintained by the International Health Terminology Standards Development Organization (IHTSDO) Can be mapped to other coding systems, such as ICD 10, which helps to facilitate semantic interoperability Codes are searchable and available for free from the National Library of Medicine (NLM) ct/what is snomed ct accessed December1,

28 Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT) Used for documenting and communicating diagnoses, procedures, and clinical information A pharmacy progress note is mapped as numbers backed to clinical terms or concepts Data must be codified into discrete data points that can be shared between providers and healthcare settings Standardization is key to interoperability Contains 300,000+ codes within value sets to streamline documentation 28

29 Standardized Framework for Cross Walking MTM Services to SNOMED CT Codes Consensus document developed by a broad array of pharmacy stakeholders SNOMED CT codes are mapped to medication related terms and definitions Codes can be incorporated into healthcare software to facilitate electronic documentation of patient care services Medicare Part D Enhanced MTM model and Pharmacist ecare Plan project both require SNOMED CT codes for documentation Standardized Framework for Cross Walking Medication Therapy Management (MTM) Services to SNOMED CT Codes, Joint Commission of Pharmacy Practitioners Workgroup, retrieved from accessed December 12,

30 Written Documentation No one standardized approach to the evaluation and documentation of pharmacotherapy applicable to all types of pharmacy practice settings Formats vary and depend on Patient visit type Reasons for documenting Formats may be Structured Unstructured 30

31 Structured Documentation Styles SOAP Subjective, objective, assessment, plan Focuses on evaluation, management, and plan TITRS Title, introduction, text, recommendation, signature Focuses on assessment FARM Findings, assessment, recommendations, monitoring Focuses on monitoring Lauster CD, Srivastava SB. Fundamental Skills for Patient Care in Pharmacy Practice. Burlington, MA: Jones and Martlett Learning;

32 Documentation Elements Patient demographics Subjective observations Objective observations Assessment Plan Education Collaboration Follow up Billing Lauster CD, Srivastava SB. Fundamental Skills for Patient Care in Pharmacy Practice. Burlington, MA: Jones and Martlett Learning;

33 Information Overload Include only pertinent data Patient background information Control of disease state Identification of potential/actual ADE Assessment of medication use List form vs paragraph Actionable steps of assessment and plan Monitoring steps and follow up 33

34 Pharmacists and Documentation Pharmacists document in a variety of practice settings Progress notes are utilized to note patient assessments and findings Capture and measure the value of the care provided SNOMED CT codes allow pharmacists documentation to become more standardized Efficient and precise billing for services Effective communication of medication related problems, medication history, and associated service activities with other care team members 34

35 SOAP Note Documentation with SNO MED CT Codes Embedded Electronically HIE Documentation Sample Annual Meeting & Exposition Seattle, Washington March

36 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing doage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

37 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing doage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

38 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing doage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

39 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing doage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

40 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing doage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

41 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing doage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

42 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing doage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

43 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing dosage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

44 S: PH is a 64 y.o. female, reported to the XYZ Pharmacy for a follow up MTM session. CC: Patient sprained her left knee on Sunday (pain reported 8/10) PMH: Gout and HTN SH/FH: no changes since last visit HPI: No s/sx of gout noted after d/c of colchicine. Patient stated last uric acid lab was WNL. Preventive Care: Up to date on vaccines (PNU 2013, Zoster 2013, Flu 2016, Tdap 2015) DXA 2015 Medication: Glucosamine 500 mg, take 3 capsules three times daily Aspirin 81 mg daily Losartan 50 mg daily Atenolol 50 mg every 12 hours KlorCon Tablet 10 meq daily Furosemide 20 mg every morning Calcium Carbonate 600 mg + D 400 IU at bedtime Fluticasone NS twice daily during winter Loratadine 10 mg every night Aleve every 12 hours Adherence: Pt reports adherence with all meds except Atenolol only been taking morning doses b/c out of refills and trying to save pills O: Height: 64.5 in, Weight = lbs, BMI = 44.7, BP = 174/90 mmhg, Pulse = 83, Pulse Ox = 98% A/P: 1. Hypertension Uncontrolled on current therapy (goal < 150/90, JNC VIII). Advised patient to take Atenolol twice daily and Atenolol refilled at pharmacy. Pharmacist will follow up with patient in 1 week with BP check. If BP is still elevated, pharmacist will contact Dr. Johnson to adjust hypertensive regimen. 2. Pain Uncontrolled on current therapy and inappropriate therapy. Received cortisone injection Friday and sprained left knee on Sunday. Recommend to Dr. Levin to reinitiate Meloxicam 7.5 mg daily and d/c Aleve. If pain is not controlled by Meloxicam 7.5 mg after two weeks, consider increasing dosage to Meloxicam 15 mg daily (per American College of Rheumatology Osteoarthritis guidelines). Patient is a candidate for PPI therapy while on NSAIDs (medium risk d/t hypertension + ASA use). Recommend Omeprazole 20 mg daily while on Meloxicam therapy.

45 Documentation and Communication in Community Pharmacy Olivia Bentley Annual Meeting & Exposition Seattle, Washington March

46 Evolution to Support the Changing Role of Community Pharmacy Vitals, Labs Function Medicine Care Plans Pharmacogenetics MTM Insulin Pump Training Immunization Diabetic Foot Assessments Chronic Care Management (CCM) Diabetes Education Transition of Care Management (TCM) 46

47 Why ecare Plans? Click to add text Annual Meeting & Exposition Seattle, Washington March the extra mile in customer service 47

48 Demystify the ecare Plan Standardized, interoperable document for exchange of consensus driven prioritized medication related activities, plans and goals for an individual needing care from pharmacists work in multiple environments The Pharmacist ecare Plan is a Standard, not a Platform Contains your latest clinical data for a given patient Vendor agnostic works with any system that has adopted it "Open standard anyone can use and adopt it, specs are published and sharing care plans a single clinical context plan/ 48

49 Components of the ecare Plan 1. Patient Demographic 2. Encounter Reasons & Type 3. Payer Information 4. Allergies 5. Medications (fill history and/or active medications) 6. Medication Therapy Problems (MTP) 7. Interventions and Education 8. Referrals 9. Care Coordination 10. Patient Goals 11. Outcomes 49

50 Advantages of the ecare Plan Pharmacy choice of technology vendor Specifically designed for data exchange Captures pharmacist's interventions and translates that into data for exchange National standard for exchange of healthcare data e.g. SNOMED codes Allows the value of pharmacist's work to be shared with others Data enabled care coordination 50

51 Example ecare Plan #1 51 Screenshot of a sample ecare Plan from DocsInk. Accessed on 12/30/

52 Components of the ecare Plan 1. Patient Demographic 2. Encounter Reasons & Type 3. Payer Information 4. Allergies 5. Medications (fill history and/or active medications) 6. Medication Therapy Problems (MTP) 7. Interventions and Education 8. Referrals 9. Care Coordination 10. Patient Goals 11. Outcomes 52

53 Example ecare Plan #1 53 Screenshot of a sample ecare Plan from DocsInk. Accessed on 12/30/

54 Adding Medication Therapy Problems 54 Screenshot of a sample ecare Plan from DocsInk. Accessed on 12/30/

55 Adding to the ecare Plan 55 Screenshot of a sample ecare Plan from DocsInk. Accessed on 12/30/

56 Example ecare Plan #1 Final Document 56 Screenshot of a sample ecare Plan from DocsInk. Accessed on 12/30/

57 Example ecare Plan #2 57 Screenshot of a sample ecare Plan from Strand. Accessed on 12/30/

58 Example ecare Plan #2 58 Screenshot of a sample ecare Plan from Strand. Accessed on 12/30/

59 Example ecare Plan #2 59 Screenshot of a sample ecare Plan from Strand. Accessed on 12/30/

60 Example ecare Plan #2 Final Document 60 Screenshot of a sample ecare Plan from Strand. Accessed on 12/30/

61 Example ecare Plan #3 ECare Plans are built through Care Goals and Care Actions within this dispense software system 61 Screenshot of a sample ecare Plan from PionerrRx. Accessed on 12/30/

62 Example ecare Plan #3 All of the patient s Care Goals, along with the patient s allergies, medical history, vaccines, and comments can be accessed through the patient s MTM profile. 62 Screenshot of a sample ecare Plan from PionerrRx. Accessed on 12/30/

63 Example ecare Plan #3 This system's Care Goals address identified Drug Therapy Problems (DTPs) with attributed SNOMED and patient condition. 63 Screenshot of a sample ecare Plan from PionerrRx. Accessed on 12/30/

64 Example ecare Plan #3 Care Actions are transactional interventions that solve the identified Drug Therapy Problem or Care Goal, with attributed SNOMED. 64 Screenshot of a sample ecare Plan from PionerrRx. Accessed on 12/30/

65 Example ecare Plan #3 ecare Plan Preview 65 Screenshot of a sample ecare Plan from PionerrRx. Accessed on 12/30/

66 Using the Different Types of Health Information Exchange in Community Pharmacy Olivia Bentley Annual Meeting & Exposition Seattle, Washington March

67 Types of Health Information Exchange are different types health information exchange 67

68 Basics Levels of Communication Exchange 68

69 Strong Systems of Communication is Key to a Successful Team Create System For Effective Communication Train Staff and Reinforce Documentation Etiquette Be Consistent on Where Messages are Located Avoid Message Overload and Fatigue Hold Team Accountable to Follow Your Systems 69

70 Data Capture and Communication Prescription verification: Yields most Drug Therapy Problem opportunities but limited time for interventions Enhanced Services Care Team: Communicate with Prescribers, Care Managers and Patients to coordinate care Clinical Pharmacist for face to face consults and interventions Ex: PGx, POCT, Immunizations, DSMT, Medical Equipment Training 70

71 Internal Communication Adding reminders to Calibrate or Reconstitute medications before dispensing Shared Tasks for groups or individuals for problem solving patient issues or workflow 71 Screenshot from PionerrRx. Accessed on 04/01/

72 Internal Communication Med Sync Profile Notes Majority of documentation for patient s profile status remains here Documentation of Sync Calls Patient reached Medications to be filled Date expecting pick up or delivery Any notes from patient Screening Snippets Allows for med sync tech to gather data related to clinical questions for pharmacist Out of range responses trigger MTM Actions by tech Actions followed up by pharmacist Clinical Services team bills appropriately if applicable 72

73 Internal Communication Creating Facilities for Grouping Patients Patients can only belong to one facility but each facility may have wings Benefits Allows for techs or pharmacists to work on groups of patients Run reports or sort patients by groups or wings E.g. Red, Yellow, Green for levels of adherence Green = patients that are adherent and usually take all of their medications E.g. CCM patient (facility) belongs to Dr. Smith (wing) 73

74 Internal Communication Pharmacist Check Station Legal Electronic Documentation on a Script (Sticky Notes) Confirmation from physicians/nurses for verifying dose or sig Checking NCCSRS for controls When you print the rx during audit, it has a time stamped sticky note for support Alert Codes provides status information for the patient/prescription (Area for customization) PR = profit rejection MPR MTM WP = waiting for pick up FS = waiting for fill RP = renew pending Care Actions that need to be completed 74

75 Internal Communication Add Custom Alerts for different points of the patient checkout process Select POS Action to have the alert show up at the POS AND for the driver at the time of download or at the time of delivery E.g. Ok to leave with daughter, patient paying by check, patient needs change, call pharmacy to complete MTM 75 Screenshot from PionerrRx. Accessed on 04/01/

76 Prescriber Communication Direct Fax Documents in Patient Profile Reports Patient adherence report care Patient Medication List Secure Messaging Message with attachments Provider Requirements* Direct practice address Call and turn on functionality Sometimes $ per provider 76 Screenshot from PionerrRx. Accessed on 04/01/

77 Reality of Effective Communication 77 Screenshot from Athena Health EHR Accessed on 04/01/

78 External Communication Direct Fax of Documents in Patient Profile Mirixa and OutcomesMTM alerts NC Health Connex Requirement by June 2018 Connected HIE at all levels of healthcare industry Removes silos between providers to improve patient care and outcomes Creates efficiencies in state funded programs like Medicaid 78

79 External Communication What programs come to mind in your pharmacy that this patient could be eligible for? How are you going to document for your interventions for this person? Screenshot from PionerrRx. Accessed on 04/01/ How will you share this information? 79

80 Layering the Pieces Together: Immunization Record HIE Immunization status impacts quality measures for prescribers Providers require administration details to clear quality measures from EHR After immunizing, upload to Documents tab on patient s profile Enter immunization in the patient s ecare Plan Run weekly report of immunization performed in Pioneer and send to provider so they can update their records to meet quality metrics Brings value and builds on a trusting relationship with that provider 80

81 Layering the Pieces Together: Community Pharmacy TCM HIE Transitions of Care Management billable through patient s PCP Requires Medication Reconciliation 2 business days post discharge Patient presents to pharmacy after hospital stay to fill new medications Tech/Pharmacist perform Med Rec with Discharge Summary Med Rec is saved under Documents in patient profile Send Med Rec through ecare Plan to PCP Or fax Med Rec and Discharge Summary to patient s PCP Coordinate patient s appointment within 7 14 days of discharge WIT to keep patient out of the hospital for 30 days 81

82 Layering the Pieces Together: Community Pharmacy CCM HIE Chronic Care Management (CCM) eligible patient identified All eligible patients tagged in Pharmacy Management System Enhanced clinical services provided Services documented in ecare Plan Platform Platform shares ecare Plan with medical provider through HIE CCM services reconciled and billed for tasks completed in the pharmacy 82

83 Adapting Your Dispensing Infrastructure to Support Enhanced Community Services Are you Med Sync'ed? Are you maximizing your Med Sync with clinical value? How are you capturing interventions in dispensing to bill for MTM and eventually CCM or beyond? Does everyone in your pharmacy perform services the same way? What is the single point of failure for your programs? 83 content/uploads/2015/06/buildingvalue.jpg

84 Where to begin? Get the education, resources and tools Get the right people on the bus Get each person in the right seat Get the right systems in place Get going! 84 UZrEA8bkLbQ/Vw6UIqb5fYI/AAAAAAAABuI/u3JK5lp4S5wUh6rLj4ew2GxTrdjD6mIJQCLcB/s1600/paving the way.jpg

85 Assessment Questions 1. Electronic health records must be maintained for a minimum of A. 4 years B. 6 years C. 8 years D. 10 years 85

86 Assessment Questions 2. Which of the following is an example of a written communication template commonly used by pharmacists to document patient interventions A. SBAR B. MAR C. TITRS D. SOAP 86

87 Assessment Questions 3. Which of the following statement are not true regarding ecare Plans? A. An ecare Plan is a standard, not a platform, that is designed for data exchange and electronic care coordination B. Should consist of patient specific information including medication therapy problems, interventions, referrals, and payer information C. For the national standard of exchange of healthcare information, SNOMED codes are not used in ecare Plans, only in EMRs D. There are a variety of platforms designed for pharmacist use that comply with the standard of information exchange used in ecare Plans 87

88 Assessment Questions 4. Which of following is true regarding the various methods of health information exchange? A. Directed exchange is when providers can securely send patient information to another healthcare provider B. Query based exchange provides patients with access to their own healthcare information allowing them to manage their healthcare online C. Consumer mediated exchange is used by clinicians to search and discover clinical resources on a patient D. An example of directed exchange is if a pregnant patient goes into the hospital and the provider obtains the patient's healthcare record in this unplanned care situation 88