workflow of pharmacist clinical documentation … of pharmacist clinical documentation process in...
TRANSCRIPT
Workflow of Pharmacist Clinical
Documentation Process in
Pharmacy Practice Settings
July 28, 2014
WORKFLOW OF PHARMACIST CLINICAL DOCUMENTATION PROCESS IN PHARMACY PRACTICE SETTINGS 2
Table of Contents
1. PURPOSE .................................................................................................................................3
2. OVERVIEW ...............................................................................................................................3
3. DISCUSSION ............................................................................................................................3
3.1. PHARMACIST PROCESS OF CARE FOR CLINICAL DOCUMENTATION SYSTEM AND DATA FLOW ............................................................................................3
3.2. PROCESS-OF-CARE STRUCTURED DOCUMENTS ....................................................6
3.3. EXAMPLE OF PROCESS OF CARE IN PHARMACY PRACTICE SETTINGS ..............8
4. CONCLUSION ..........................................................................................................................8
5. APPENDIX: PHARMACISTS’ PATIENT CARE PROCESS ....................................................8
6. ACKNOWLEDGEMENTS .........................................................................................................8
WORKFLOW OF PHARMACIST CLINICAL DOCUMENTATION PROCESS IN PHARMACY PRACTICE SETTINGS 3
1. PURPOSEThis paper aims to help system vendors understand the flow of clinical data by defining the clinical documentation workflow of pharmacists in pharmacy practice settings.
The intent of the document is to demonstrate the usefulness of the process flow and how health information technology (HIT) can affect the process of care. Pharmacists are encour-aged to work with their system vendor to build functionality into their system to collect, doc-ument, and exchange clinical information using structured documents that follow electronic industry standards.
Appreciating fully the clinical utility of electronic health data, the pharmacy profession has positioned itself well ahead of the curve for standardized outcomes-related data collection and enhanced electronic data accessibility for delivering quality patient care services. The mission of the Pharmacy HIT Collaborative Work Group on Communication Standards is to further integrate pharmacists who provide patient care services into the national health information exchange framework.
2. OVERVIEWPharmacist workflow, as defined by system vendors, has traditionally focused on the dispensing process. As the pharmacist role changes to encompass patient care services, a clinical workflow model needs to be defined. This document will help system vendors un-derstand how pharmacists collect, document, and exchange clinical information during the process of care.
The creators of this document analyzed the process of care used by a pharmacist during di-rect patient care services in an ambulatory practice setting. This particular process of care was illustrated graphically using a workflow diagram or flowchart. Pharmacists and system vendors can use this document as a starting point to find ways of increasing system usabil-ity for clinical pharmacists in collecting, documenting, and exchanging clinical information outside of the dispensing workflow.
The purpose of this document is to develop a useful guide for pharmacists to explain to sys-tem vendors the workflow of clinical information during the pharmacist’s process of care.
3. DISCUSSION 3.1. PHARMACIST PROCESS OF CARE FOR CLINICAL DOCUMENTATION SYSTEM AND DATA FLOWUnder formal and informal collaborative practice agreements, pharmacists work in col-laboration with physicians and primary care providers to help patients, particularly those institutionalized in hospitals, long term care facilities, as well as ambulatory care patients with chronic conditions, manage their medication regimens in the following ways:
• Performing patient assessments and developing therapeutic plans
• Using their authority to initiate, adjust, or discontinue medications
• Ordering, interpreting, and monitoring appropriate laboratory tests
• Providing care coordination and other health care services for wellness and prevention
• Developing partnerships with patients for ongoing and follow-up care
WORKFLOW OF PHARMACIST CLINICAL DOCUMENTATION PROCESS IN PHARMACY PRACTICE SETTINGS 4
Diagram 1 depicts the process of care pharmacists follow during the clinical process. Diagram 2 outlines the flow of data during the process of care.
DIAGRAM 1:
Adapted from Pharmacists’ Patient Care Process, May 29, 2014. http://www.pharmacist.com/sites/default/files/JCPP_Pharmacists_Patient_Care_Process.pdf
*Visit is used in this document to describe a patient encounter or admission to a hospital, home care, or other health care organization
Pharmacists’ Process of Care for Clinical Documentation System
(before and during visit)*
WORKFLOW OF PHARMACIST CLINICAL DOCUMENTATION PROCESS IN PHARMACY PRACTICE SETTINGS 5
DIAGRAM 2:
Collect (before and during visit)
Assess
Plan
Implement
Follow-up (monitor and
evaluate)
Pharmacists’ Clinical Documentation Data FlowAmbulatory Clinic Setting
•Lab results•Discharge summary•Patient care summary•Patient reported data•Med dispensing history
•Demographics•History & physical•Vital signs
Data from External Sources
Data from Internal Sources
Data to External Sources
Data to Internal Sources
•Medication action plan•Patient care summary•Transition of care document with medication reconciliation
•Progress note•Med change •Lab recommendation
WORKFLOW OF PHARMACIST CLINICAL DOCUMENTATION PROCESS IN PHARMACY PRACTICE SETTINGS 6
3.2. PROCESS-OF-CARE STRUCTURED DOCUMENTSDiagram 3 outlines processes used by pharmacists for patient care. The superimposed circles show what a pharmacist may do from the standpoint of an electronic structured document. During the electronic process of collecting, documenting, and exchanging clinical information, the pharmacist uses the electronic system to create structured documents that are used at different points in the process of care.
• During the collection, assessment, phases, the pharmacist creates a pharmacy care note that incorporates the reconciled medication list. In turn, the pharmacy care note forms the basis of the medication action plan.
• The pharmacist uses the medication action plan as part of patient engagement during the implementation phase. During the evaluation phase, the pharmacist uses quality and value assessment documents.
• The pharmacist uses a pharmacy care transition document or other patient medical care documentation record (i.e EHR) during the monitor and transition phases.
DIAGRAM 3:
3.3. EXAMPLE OF PROCESS OF CARE IN PHARMACY PRACTICE SETTINGSDiagram 4 below presents examples of the steps accomplished during the process of care in an ambulatory clinic setting. The authors believe that the process-of-care steps would work in all pharmacy practice settings. The intent of the diagram is to assist system vendors with a process flow for collecting, documenting, and exchanging clinical information and to provide a process flow that ensures that the assessment and outcomes of patient care are enhanced in all pharmacy practice settings.
Pharmacy Care Transitions Document
Quality & Value Assessment
Medication Action Plan
Pharmacy Care Note with Reconciled Medication List
Adapted from Pharmacists’ Patient Care Process, May 29, 2014. http://www.pharmacist.com/sites/default/files/JCPP_Pharmacists_Patient_Care_Process.pdf
Pharmacists’ Patient Care Process Structure Documents
WORKFLOW OF PHARMACIST CLINICAL DOCUMENTATION PROCESS IN PHARMACY PRACTICE SETTINGS 7
Colle
ct
(bef
ore
and
durin
g vi
sit)
Asse
ss
Plan
Impl
emen
t
Follo
w u
p (m
onito
r an
d ev
alua
te)
Pre
-vis
it C
olle
ctio
n: C
onte
nt M
odul
e of
the
C83
(the
C32
, whi
ch is
a
subs
et o
f C83
).Con
tinui
ty o
f Car
e D
ocum
ent.
For
exam
ple,
pat
ient
’s
nam
e, d
emog
raph
ics,
pas
t med
ical
his
tory
, cur
rent
pre
scri
ptio
n an
d O
TC m
edic
atio
ns. R
evie
w o
f sym
ptom
s, e
tc. I
f the
pha
rmac
ist h
as th
e pr
ivile
ge a
nd a
ppro
val t
o up
date
this
info
rmat
ion,
he
or s
he s
houl
d do
so.
How
do
you
look
at w
hat y
ou c
olle
ct?
Col
lect
ed o
n pa
per/
elec
tron
ic
med
ical
rec
ord,
and
exa
mpl
e of
a u
ser
inte
rfac
e— a
“da
shbo
ard”
of
info
rmat
ion
coll
ecte
d fo
r re
view
pri
or to
the
asse
ssm
ent p
hase
.
Inst
ruct
ions
for
clin
icia
ns if
info
rmat
ion
is n
ot a
vail
able
: Ide
ntif
y m
issi
ng d
ata
and
seek
app
ropr
iate
sou
rces
.
Dur
ing-
Visi
t Col
lect
ion
(fac
e to
face
or
tele
phon
ic):
Thi
s is
info
rmat
ion
that
is n
ot c
olle
cted
via
tech
nolo
gy: t
alki
ng to
pat
ient
and
/or
care
give
r,
veri
fyin
g in
itial
dat
a, c
olle
ctin
g ne
w in
form
atio
n, a
nd v
alid
atin
g ol
d an
d pr
e-vi
sit i
nfor
mat
ion
(the
re is
a c
ontin
uous
cyc
le o
f col
lect
ion
of d
ata
and
asse
ssm
ent)
.
The
firs
t par
t of a
sses
s is
a p
rior
itiz
ed p
robl
em li
st. M
edic
al p
robl
em
(dis
ease
bas
ed),
drug
-rel
ated
pro
blem
. Ide
ntif
y an
y ga
ps in
car
e,
patie
nt h
ealt
h an
d sa
fety
; ide
ntif
y an
y ad
ditio
nal i
ssue
s su
ch a
s om
is-
sion
s; c
oord
inat
e an
y tr
ansi
tion-
of-c
are
issu
es. E
stab
lish
or
revi
ew
the
pati
ent’s
goa
l(s)
. Tak
en fr
om n
atio
nal g
uide
lines
and
indi
vidu
aliz
ed
for
the
patie
nt.
Exa
mpl
es:
Pro
blem
#1:
Dia
bete
s go
al A
1C <
7%
Pro
blem
#2:
Hyp
erte
nsio
n go
al 1
40/9
0
Rec
onci
le th
e pa
tien
t’s d
ata
agai
nst t
he g
oal f
or th
at p
robl
em. T
his
is a
rep
etit
ive
proc
ess;
the
phar
mac
ist r
eass
esse
s pl
an fo
r ev
ery
addr
esse
d pr
oble
m.
1. D
isea
se F
ocus
ed
stab
le/u
nsta
ble,
con
trol
led/
unco
ntro
lled
, adh
eren
t/no
n-ad
here
nt
2. M
edic
atio
n Fo
cuse
d
safe
ty, t
oler
abili
ty, e
ffec
tive
ness
, pri
ce, s
impl
icit
y
3. M
edic
atio
n M
anag
emen
t
appr
opri
aten
ess,
eff
ecti
vene
ss, s
afet
y,
tole
rabi
lity
The
plan
is b
roke
n up
into
sev
eral
sect
ions
.
Ever
y pr
oble
m w
ill h
ave
a pl
an
asso
ciat
ed w
ith
it.
Issu
e:
• M
edic
atio
n re
late
d
• N
on-m
edic
atio
n re
late
d
• P
atie
nt-b
ehav
ior
rela
ted
• P
atie
nt-k
now
ledg
e re
late
d
Solu
tion
:
• Li
fest
yle
or m
edic
atio
n m
odifi
catio
n
• P
atie
nt e
duca
tion
• M
onito
ring
• Fo
llow
up
(an
exte
nsio
n of
mon
itori
ng; i
nclu
des
refe
rral
s an
d ph
arm
a-ci
st/p
rovi
der
visi
ts)
• O
utco
me
mea
sure
s
Impl
emen
tatio
n is
the
docu
men
tatio
n, c
oord
inat
ion,
com
mun
icat
ion,
ed
ucat
ion,
trai
ning
, and
sup
port
for
the
plan
that
is b
eing
dev
elop
ed.
This
link
s th
e D
evel
op P
lan
phas
e to
the
Eval
uate
pha
se.
Col
labo
rate
with
sta
keho
lder
s (p
atie
nt, c
areg
iver
, pro
vide
r, e
tc.)
to
adop
t the
pla
n, a
nd to
pos
ition
the
plan
for
subs
eque
nt a
ccep
tanc
e.
Und
erst
andi
ng th
e po
sitio
n of
the
stak
ehol
ders
will
incr
ease
like
lihoo
d of
suc
cess
ful i
mpl
emen
tatio
n.
Reg
ulat
ory
Com
plia
nce:
Ens
urin
g
com
plia
nce
with
law
s an
d re
gula
tions
for
the
mai
nten
ance
of p
atie
nt
reco
rds.
Eval
uati
ng th
e pa
tien
t:
• A
dher
ence
to th
erap
y
• A
ppro
pria
tene
ss o
f the
rapy
(e.g
., si
de
effe
cts,
dru
g in
tera
ctio
ns)
• O
utco
mes
(e.g
., A1
C)
Mon
itor
and/
or tr
ansi
tion
is th
e pr
oces
s of
func
tiona
lly
send
ing
the
reco
ncile
d re
cord
off
to b
e co
nsum
ed b
y ot
her
part
ners
on
the
care
te
am a
nd o
ther
aut
hori
zed
entit
ies.
It w
ould
incl
ude
but n
ot b
e lim
ited
to u
ploa
ding
dat
a to
the
heal
th in
form
atio
n ex
chan
ge (H
IE) o
r m
akin
g th
e re
cord
ava
ilabl
e fo
r qu
ery
from
the
com
mon
rep
osito
ry. I
t is
the
final
doc
umen
tatio
n st
ep th
at w
ill m
ove
into
the
next
iter
atio
n of
car
e an
d m
ay o
ccur
at t
he s
ame
time
of p
re-c
olle
ctio
n of
dat
a in
the
next
ite
ratio
n
Sel
f-ev
alua
tion
for
the
phar
mac
ist (
i.e.,
oppo
rtun
ities
for
chan
ge in
the
way
pat
ient
s ar
e tr
eate
d, d
eter
min
ing
corr
ectio
ns a
nd im
prov
emen
ts
that
cou
ld b
e m
ade)
, the
pha
rmac
ist’s
com
mun
icat
ion
met
hods
, and
en
cour
agin
g H
IE u
se, s
eeki
ng n
ew o
ppor
tuni
ties
for
conn
ectin
g w
ith
the
patie
nt to
enh
ance
his
or
her
care
. Thi
s is
the
med
icat
ion
reco
ncil-
iatio
n pi
ece.
The
han
d-of
f to
othe
r pr
ovid
ers
mus
t be
smoo
th, w
ith n
o du
plic
atio
n of
eff
ort;
med
icat
ions
mus
t be
reco
ncile
d an
d in
form
atio
n se
nt to
HIE
s.
Eval
uati
ng th
e en
tire
pro
cess
(hig
her
leve
l vie
w).
Incl
udes
tim
e sp
ent,
pr
oces
s fl
ow, b
est a
venu
es fo
rcom
mun
icat
ion.
Coo
rdin
ate
the
tran
sitio
n of
pat
ient
info
rmat
ion
to th
e he
alth
car
e te
am
DIAGRAM 4:
WORKFLOW OF PHARMACIST CLINICAL DOCUMENTATION PROCESS IN PHARMACY PRACTICE SETTINGS 8
4. CONCLUSIONIn today’s health care environment, pharmacists are in a unique position to provide clinical services that manage medications and coordinate patient care to improve quality outcomes.
Pharmacists collect, document, and exchange clinical information with members of an inter-professional care team. The purpose of this document is to help system vendors understand the workflow of clinical information across the continuum. Outlining the clinical workflow by pharmacists will help ensure that medication-related information is shared with the entire patient care team in a way that maximizes patient outcomes.
5. APPENDIX: PATIENT-CENTERED COLLABORATIVE CARE PROCESSFigure 1 depicts a proposed standardized pharmacist patient-centered collaborative care process for pharmacists providing medication therapy management (MTM) services. The pharmacists’ patient care process described in this illustration was developed by examining a number of key source documents on pharmaceutical care and MTM. Patient care process components in each of these resources were catalogued and compared to create the follow-ing process that encompasses a contemporary and comprehensive approach to patient-cen-tered care that is delivered in collaboration with other members of the health care team.
(Source: Pharmacists’ Patient Care Process, May 29, 2014. http://www.pharmacist.com/sites/default/files/JCPP_Pharmacists_ Patient_Care_Process.pdf)
WORKFLOW OF PHARMACIST CLINICAL DOCUMENTATION PROCESS IN PHARMACY PRACTICE SETTINGS 9
5. ACKNOWLEDGEMENTSThe following representatives of the Pharmacy HIT Collaborative Work Group, which is devoted to Communication Standards, developed this document, “Workflow of Pharmacist Clinical Documentation Process in Pharmacy Practice Settings”:
COORDINATORShelly Spiro, Executive Director, Pharmacy HIT Collaborative
AUTHORSRobert Franz, Senior Clinical Account Executive, Clinical Services, Express Scripts
Sammuel Anderegg, Pharmacy Manager, Oncology Service Line, Georgia Regents University Cancer Center
Jeffrey M. Brewer, Associate Professor of Pharmacy Practice, School of Pharmacy and Pharmaceutical Science, Albany College of Pharmacy and Health Sciences
Mark Brueckl, Assistant Director, Pharmacy Affairs, Academy of Managed Care Pharmacy
Elizabeth Brusig, Clinical Pharmacy Specialist, Optima Health Plan
Özlem H. Ersin, Assistant Department Chair, Pharmaceutical Sciences Associate Professor, Pharmaceutical Sciences, Manchester College School of Pharmacy
Mike Case Haub, Senior Associate, Provider Services, OutcomesMTM
Clark Kebodeaux, Assistant Professor of Pharmacy Practice, St. Louis College of Pharmacy
Cynthia Kesteloot, Vice President of Technology, OutcomesMTM
Mary Ann Kliethermes, Vice Chair of Ambulatory Care, Professor, Chicago College of Phar-macy, Midwestern University
Patty Kumbera, COO, OutcomesMTM
James A. Owen, Associate Vice President, Practice and Science Affairs, American Pharma-cists Association
Robin Ripperger, Senior Associate, Data Management, OutcomesMTM
Leslie Rodriguez, Clinical Education Coordinator, University of Hawai’i Hilo College of Phar-macy
Nicole Russell NCPDP Government Affairs Specialist.
Rebecca Snead, Executive Vice President and CEO, National Alliance of State Pharmacy Associations