Electronic Record Exchange: The New Normal

Target Audience: Pharmacists ACPE#: 0202-0000-18-028-L04-P Activity Type: Application-based

Disclosures Suzanne Higginbotham no conflicts to disclose Amina Abubakar no conflicts to disclose The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Learning Objectives 1. Describe the legal requirements for maintaining accurate, perpetual patient care records for all patient care services. 2. Explain the concepts and application of Systemized Nomenclature of Medicine Clinical Terms and its relationship to standardized documentation, exchange, and reporting of patient care services. 3. Develop accurate and concise patient care documentation using a patient case example for both initial Target and follow-up Audience: care. 4. Describe methods for electronic exchange of information, including DIRECT and the use of health information exchanges ACPE#: 5. Explain the functionality of the Pharmacist ecare Plan and the system functionality being built by pharmacy management system vendors to enable pharmacists to create and exchange patient Activity care information. Type: 6. List the components of the Pharmacy Care Note template and identify appropriate information to include in each section.

1. Assessment Question Pharmacists are required to maintain patient health records that A. Are retained for five years B. Are stored physically on site C. Accessible to patients D. Include only medications and information related to the medication use

2. Assessment Question SNOWMED CT coding is a required form of documentation in which platform? A. JCCP Pharmacists Patient Care Process B. Diabetes self management education (DSME) sessions C. Tobacco cessation group facilitation sessions D. Pharmacist ecare Plan

3. Assessment Question Which of the following is a component of the assessment section in a clinical soap note A. Patient blood pressure is 132/88 B. Uncontrolled on current therapy of HCTZ 25mg once daily C. Initiate lisinopril 25mg once daily D. Patient reports eating foods high in sodium

4. Assessment Question Which of the following is not a core section of the Pharmacist ecare Plan? A. Goals B. Vital Signs C. Interventions D. Payer

5. Assessment Question Which of the following acts as an intermediary on behalf of an information exchange participant? A. HISP B. TITRS C. MIPS D. ACO

6. Assessment Question Pharmacy management systems have evolved to allow for this type of functionality as community pharmacists are offering more clinical services. A. Ability to create actions and tasks B. Utilization of care templates C. Ability to collect labs D. All of the above

Introduction Evolution of Healthcare Data Exchange Care Coordination Preparation for Provider Status Graphic retrieved from http://www.clipartmasters.com/patient-centered-care-clipart-xljavr.html on January 8, 2018.

Describe the legal requirements for maintaining accurate, perpetual patient care records for all patient care services Suzanne Higginbotham

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

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

Documentation and 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 http://jcpp.net/wp-content/uploads/2016/03/patientcareprocess-with-supporting-organizations.pdf

The Pharmacists Patient Care Process

Legal Requirements Pharmacists are required to maintain medical records that are Complete Accurate Accessible Stored appropriately Retained https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/index.html?redirect=/ehrincentiveprograms/

Patient Health Records Complete and Accurate Information Legible Promptly completed

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 www.ahima.org. Accessed January 2, 2018

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

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 https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html accessed January 2, 2018

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

Health Records Electronic patient health records should be maintained for a minimum of Six years under HIPAA law 45CFR164.530(j)(2) By the governing state board of pharmacy Whichever notes the longer period of time https://www.gpo.gov/fdsys/pkg/cfr-2011-title45-vol1/pdf/cfr-2011-title45-vol1-sec164-530.pdf

Explain the concepts and application of Systemized Nomenclature of Medicine Clinical Terms and its relationship to standardized documentation, exchange, and reporting of patient care services Suzanne Higginbotham

Systemized Nomenclature of Medicine Clinical Terms (SNOWMED 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) https://www.snomed.org/snomed-ct/what-is-snomed-ct accessed January 2, 2018 SKH1

Slide 25 SKH1 Suzanne Higginbotham, 1/16/2018

Systematized 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 Implementing SNOMED CT in Practice: A Beginner s Guide, Pharmacy Health Information Technology Collaborative, retrieved from https://www.pharmacyhit.org/ accessed December 12, 2016.

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

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 In August 2017, The Pharmacy HIT Collaborative announced an updated release of SNOWMED CT value sets (originally published 2016) Over 20 pharmacy software vendors have adopted 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 https://www.amcp.org/snomed/ accessed December 12, 2016.

SNOMED CT Examples SNOMED CT Concept SNOMED CT ID Referred by primary care physician 2021000124102 Patient unable to obtain medication 429611000124105 Medication dose too low 448152000 Hypertension medication review 473225006 Rheumatologic disorder education 413084000 Recommendation to increase dose 428811000124101 Medication reconciliation by pharmacist 428701000124107 Hemoglobin A1c <7% 165679005 Adverse reaction to drug 62014003 UMLS SNOMED CT Browser. National Library of Medicine, National Institute of Health. 2014.

SOAP Note Documentation with SNOMED CT Codes Embedded Electronically HIE Documentation Sample

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 = 263.6 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.

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 = 263.6 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.

Develop accurate and concise patient care documentation using a patient case example for both initial and follow-up care Suzanne Higginbotham

Documentation If it isn t documented, it isn t done!

Parts of a Documentation Note-Subjective Information from patient perspective Chief complaint (CC) History of present illness (HPI) Past medical history (PMH) Medication use and history Allergies Social or family history (SH or FH) Review of systems (ROS) Lauster CD, Srivastava SB. Fundamental Skills for Patient Care in Pharmacy Practice. Burlington, MA: Jones and Martlett Learning; 2013

Subjective vs. Objective Current list of medications From patient interview or pharmacy system Adherence Adverse effects REMEMBER OTC, immunizations, and complementary/alternative medicines and supplements Lauster CD, Srivastava SB. Fundamental Skills for Patient Care in Pharmacy Practice. Burlington, MA: Jones and Martlett Learning; 2013

Parts of a Documentation Note-Objective Data that can be measured objectively Vital signs Blood pressure, heart rate, respiratory rate, temperature, weight, height Screening results Risk assessment Laboratory test results CBC, CHEM-7, Lipid panel, INR, serum drug concentration Findings from other tests Lauster CD, Srivastava SB. Fundamental Skills for Patient Care in Pharmacy Practice. Burlington, MA: Jones and Martlett Learning; 2013

Parts of a Documentation Note-Assessment and Plan Summarizes the pharmacist s evaluation Current status of patient Based on subjective & objective data Provides rationale for plan Goals set utilizing evidence based medicine (and referenced) Lauster CD, Srivastava SB. Fundamental Skills for Patient Care in Pharmacy Practice. Burlington, MA: Jones and Martlett Learning; 2013

How Much Data to Include 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 Prescription template

Patient Case Example Steven Jones is a 60-year-old white man with a 10-year history of T2DM. He reports to your ambulatory care center today for help managing his diabetes. He tests his blood glucose before meals and at bedtime. There have been no substantial changes in diet, stress, or illness within past 3 months. Please create a care plan based on the information below. Current Medications Metformin extended release (XR) 2 g daily Novolog 2 units with each meal Lantus 20 units at bedtime Amlodipine 5mg each morning Citalopram 40mg once daily

Glucose Log 7:00 a.m. 12:00 p.m. 5:00 p.m. 10:00 p.m. Monday 99 115 157 115 Tuesday 97 110 148 118 Wednesday 100 111 153 117 Thursday 96 116 160 220 Friday 105 104 162 115 Saturday 98 103 155 111 Sunday 107 111 156 119

Labs (taken 2 days ago) Hemoglobin A1c: 8.2 Microalbumin: 13.4 Gluc BUN Creat NA K CL CO2 160 10 1.2 138 4.4 101 32.0 CHOL TG HDL LDL LDL/HDL 236 172 19 103 3/3

Vitals and Vaccine History BP:132/80 Height:72 Weight:310 lbs Vaccine History IIV4 on 9/14/201 Td on 4/1/2010 * Up to date on all childhood vaccines

Let s Practice Documenting!

Describe methods for electronic exchange of information, including DIRECT and the use of Health Information Exchanges Amina Abubakar

Health Information Exchange (HIE) Allows healthcare providers and patients to appropriately access and securely share information electronically Reduces the need for the patient to transport or relay health information Improves speed, quality, safety, and cost of patient care What is HIE?, retrieved from https://www.healthit.gov/providers-professionals/health-information-exchange/what-hie accessed December 5, 2016.

Nationwide HIE Strategy Provider participation motivation Meaningful use requirements New payment approaches (ACOs, bundled payment options, PCMHs) MACRA & MIPS Congress allocated $548 million to states under the State HIE Cooperative Agreement Program in 2010 Administered by the Office of the National Coordinator for Health Information Technology (ONC) 2016 Report To Congress on Health IT Progress, The Office of the National Coordinator for Health Information Technology (ONC) Office of the Secretary, United States Department of Health and Human Services, retrieved from https://www.healthit.gov/ accessed December 13, 2016.

Forms of HIE DIRECTED Exchange Ability to send and receive secure information electronically between care providers to support coordinated care QUERY-BASED Exchange Ability for providers to find and/or request information on a patient from other providers, often used for unplanned care CONSUMER MEDIATED Exchange Ability for patients to aggregate and control the use of their health information among providers What is HIE?, retrieved from https://www.healthit.gov/providers-professionals/health-information-exchange/what-hie accessed December 5, 2016.

Health Information Services Provider (HISP) Private service provider offering information exchange capabilities Manages security and transport of health information Acts as an intermediary on behalf of exchange participant Functions: Issue security certificates Issue Direct addresses DIRECT Project, retrieved from https://www.healthit.gov/policy-researchers-implementers/direct-project accessed December 12, 2016.

The DIRECT Project Enables simple, secure electronic transport of health information Encrypted messaging to ensure safety and security of exchanged information Available through EHR vendors, State HIE entities, regional/local HIE entities, and HISPs Push messaging with known and trusted Direct addresses Allow information exchange between multiple vendors Recipient s Direct address and public certificate required to exchange DIRECT Project, retrieved from https://www.healthit.gov/policy-researchers-implementers/direct-project accessed December 12, 2016.

EHR message EHR HISP/HIE DIRECT EHR Affiliated HISP/HIE Understanding and Leveraging MU2 Optional Transports, The Office of the National Coordinator for Health Information Technology (ONC), retrieved from https://www.healthit.gov/ accessed December 12, 2016.

Role of HIE in Community Pharmacy Example Rx Clinic Pharmacy Partnered with local primary care providers to offer Chronic Care Management (CCM) Goals: improve patient outcomes through pharmacy engagement

Community Pharmacy CCM Integration Chronic Care Eligible Patient identified All eligible patients tagged in Pharmacy Management System Community pharmacy clinical services provided Service billed monthly for tasks completed in the pharmacy Platform shares ecare Plan with medical providers though HIE Services documented in platform in ecare Plan

Ambulatory Care CCM Integration Chronic Care Management eligible patients identified Clinical pharmacist completes required activities in clinic Clinical pharmacist documents activity in vendor platform Service billed monthly for tasks completed by the clinical pharmacist Vendor platform shares information with EHR via ecareplan and HIE Vendor platform tracks time spent and activities accomplished with patient

Barriers of HIE Implementation in the Community Data Governance Agreements Patient Consent Technical Difficulties Physician Communication Burden of Documentation Cost and Sustainability

Explain the functionality of the Pharmacist ecare Plan and the system functionality being built by pharmacy management system vendors to enable pharmacists to create and exchange patient care information. Amina Abubakar

Pharmacist ecare Plan Clinically-minded pharmacists utilizing their medication expertise to craft a comprehensive care plan Serves as the foundation for longitudinal coordination of care Template used to exchange information between patients and their care team to optimize medication-related decision support Goal: Create a comprehensive, multi-disciplinary longitudinal care plan that promotes interoperability Pharmacist ecare Plan: Guidance on the Use of the HL7 CDA Consolidated Templates for Clinical Notes R2.1 Care Plan (Version 1.0), National Council for Prescription Drug Programs (NCPDP), retrieved from https://www.hl7.org/ accessed December 5, 2016.

The Role of ecare Plans Community Pharmacists are the most accessible providers Trusted relationships Access to social determinants of health that can be valuable to care team Maximizing documentation for services that pharmacists have been providing for decades Networks are seeing the value Additional layer to coordination of care Improved communication of valuable health information

Documenting Encounter with Patient Patient report Counseling points Goals both clinician-guided and personal SMART Goals Specific Measurable Achievable Realistic Timely

The Role of Pharmacy Management Systems Systems are evolving to accommodate the changing role of community pharmacists Collect labs Create actions Utilize care templates Integrate with MTM platforms Partnerships with other programs when functionality is lacking

Use in Practice Enhanced Services Network Transitions of Care Chronic Care Management Medication Therapy Management

List the components of the Pharmacy Care Note template and identify appropriate information to include in each section Amina Abubakar

Community Pharmacy in Care Management MTM ecare Plans Steady State Model

Comparison of Care Plans for Other Health Care Professionals Traditional Care Plan Pharmacist Care Plan Health Concerns Identified health or risk concerns such as problems, allergies, or social issue, etc Interventions Includes active medication list, medications administered, and planned medications Goals Health Status Evaluation and Outcomes Health Concerns (Pharmacist Care Plan) In addition to traditional care plan will include documentation of medication therapy problems. Interventions (Pharmacist Care Plan) In addition to traditional care plan will include medication history. Goals (Pharmacist Care Plan) Payer Health Status Evaluation and Outcomes (Pharmacist Care Plan)

Subjective and Objective Information Encounter Type and Reason Demographics History of Allergies and Adverse Effects Medication Reconciliation Fill History Patient Goals

Assessment Pharmacist assesses collected information Analysis of clinical effects of therapy Identification and prioritizing of problems Goal of Optimal Care

Plan Identification of Drug Therapy Problems Personalized Education and Interventions Coordination of Care

Follow-Up Identification of New Drug Therapy Problems and Resolution of Previously Identified Drug Therapy Problems Updates of Personal Goals Ongoing Assessment

The New Normal EHRs that communicate Connectivity and alerting Standardized documentation Complete with clinical coding Pharmacist integration in clinical services Ability to increase patient impact

Helpful Resources C-CDA Pharmacist Care Plan Implementation Guide https://www.hl7.org/documentcenter/public_temp_072da3b4-1c23-ba17-0c16d127a520eabb/wg/structure/cdar2_ig_ccda_mtm_careplan_r1_o1_2017sep_t emplates_and_supporting.pdf FHIR Pharmacist Care Plan Implementation Guide http://hl7.org/fhir/us/phcp/

4. Assessment Question Which of the following is not a core section of the Pharmacist ecare Plan? A. Goals B. Vital Signs C. Interventions D. Payer

5. Assessment Question Which of the following acts as an intermediary on behalf of an information exchange participant? A. HISP B. TITRS C. MIPS D. ACO