NP and Pharmacist Collaboration in Ambulatory Care
NP and Pharmacist Collaboration in Ambulatory Care
Treatment guidelines provide a sound starting point for the management of patients with chronic disease such as diabetes. In clinical practice, each patient's circumstances, case history, lifestyle, finances, and comorbidities play a role in determining the appropriate treatment. These factors, along with guidelines, must be taken into account when deciding treatment options. As guidelines are updated and revised, it is prudent for clinicians to revisit them as a benchmark and to remain current.
We found it especially helpful for NPs and pharmacists to review these guidelines together with regard to medication choices. This restored a baseline for the treatment strategy of each patient seen by the team. An example, shown in Figure 1, was developed by the pharmacist based on current treatment guidelines at the time of the pilot project. Similar guidelines for hypertension and cholesterol were also developed and kept on hand in the clinic as a convenient reference for NPs.
(Enlarge Image)
Figure 1.
Pharmacist-developed guideline for type 2 diabetes
The third area of pharmacist contribution to the clinic arose during the implementation of a new electronic health record (EHR) system. The use of health information technology and clinical decision support (CDS) systems are expected to improve patient safety, reduce unnecessary and redundant procedures, and reduce health care costs. Such tools can aid diagnosis and treatment decisions. While adopting EHR and CDS has the potential for safety and efficiency improvement, realizing that potential requires more than simply purchasing the technology.
Drug alerts are provided by computer prescriber order entry (CPOE) systems that can be programmed to detect dangerous combinations of drugs for patients on multiple medications or prevent drug allergies. The need for such systems is highlighted by research findings that up to 19% of patient injuries in an academic medical center were caused by a drug interaction. Another study of a CPOE system found that interoperability problems, missing patient information, and human-machine interface deficiencies were associated with an increase or exacerbation of ADEs.
Many impediments have been observed in the application of CPOE, electronic prescribing (ERx), and CDS. By habitually overriding alerts when prescribing, clinicians are more likely to ignore important and dangerous errors that the system is designed to prevent. For computerized safety systems to be effective, they need to be accepted by clinicians. For this reason, some argue that a CDS system and drug alerts should be highly customized to the setting, the practice, and the patient population. Pharmacists are well suited to assist prescribers in the interpretation of alerts so that alert fatigue is minimized and patients benefit from the CDS system.
During our pilot project, a new EHR software program was concurrently being developed. One of its features was a drug-drug interaction (DDI) alert. This module was provided by the manufacturer with a default drug library of potential DDIs. The NP and the pharmacist determined the validity of the alerts and determined if an override was safe. Table 2 summarizes a list of adverse reactions assessed by the pharmacist and NP.
The reactions to alerts were sent to the software developer for incorporation into the knowledge base for the clinic. The alerts were triggered by a single drug prescription and alerted the clinician to a possible interaction or allergy based on patient history. The team was able to suggest actions in each case and determine if the alert should be suppressed in the future.
DDI alerts produced only by computerized systems have natural flaws. Perhaps first and foremost is the sensitivity level of the alert system. Intuition might cause a clinician to request the most conservative alerts and request notification for anything that might be of concern for their patient. In reality, drug interaction software is a tool that doesn't always provide the clinician with actionable alerts. For example, alerts that warn the prescriber about the concurrent use of hormones in women of child-bearing age when oral contraceptives are ordered can cause a type of "noise" that can lead to the clinician ignoring warnings in the future. In addition to the development of robust EHR systems and electronic CDS tools, the interdisciplinary team of providers resulted in not only better care for patients but was absolutely critical for evaluating patient needs 1 encounter at a time.
Table 3 summarizes a series of DDI alerts generated by the new EHR system and which the pharmacist and NP were able to evaluate and suggest appropriate action. The suggestions were also shared with the software developer to improve the alerting system. The customizations to the EHR system were then incorporated in a subsequent implementation at a different clinic.
YAZ is manufactured by Bayer HealthCare Pharmaceuticals, Inc, Wayne, NJ. Motrin IB is manufactured by McNeil Consumer Healthcare (a Johnson & Johnson company), Ft. Washington, PA. Excedrin Migraine is manufactured by Novartis Consumer Healthcare, Parsippany, NJ.
Management of Treatment Guidelines
Treatment guidelines provide a sound starting point for the management of patients with chronic disease such as diabetes. In clinical practice, each patient's circumstances, case history, lifestyle, finances, and comorbidities play a role in determining the appropriate treatment. These factors, along with guidelines, must be taken into account when deciding treatment options. As guidelines are updated and revised, it is prudent for clinicians to revisit them as a benchmark and to remain current.
We found it especially helpful for NPs and pharmacists to review these guidelines together with regard to medication choices. This restored a baseline for the treatment strategy of each patient seen by the team. An example, shown in Figure 1, was developed by the pharmacist based on current treatment guidelines at the time of the pilot project. Similar guidelines for hypertension and cholesterol were also developed and kept on hand in the clinic as a convenient reference for NPs.
(Enlarge Image)
Figure 1.
Pharmacist-developed guideline for type 2 diabetes
Interpretation of Computerized Drug Alerts
The third area of pharmacist contribution to the clinic arose during the implementation of a new electronic health record (EHR) system. The use of health information technology and clinical decision support (CDS) systems are expected to improve patient safety, reduce unnecessary and redundant procedures, and reduce health care costs. Such tools can aid diagnosis and treatment decisions. While adopting EHR and CDS has the potential for safety and efficiency improvement, realizing that potential requires more than simply purchasing the technology.
Drug alerts are provided by computer prescriber order entry (CPOE) systems that can be programmed to detect dangerous combinations of drugs for patients on multiple medications or prevent drug allergies. The need for such systems is highlighted by research findings that up to 19% of patient injuries in an academic medical center were caused by a drug interaction. Another study of a CPOE system found that interoperability problems, missing patient information, and human-machine interface deficiencies were associated with an increase or exacerbation of ADEs.
Many impediments have been observed in the application of CPOE, electronic prescribing (ERx), and CDS. By habitually overriding alerts when prescribing, clinicians are more likely to ignore important and dangerous errors that the system is designed to prevent. For computerized safety systems to be effective, they need to be accepted by clinicians. For this reason, some argue that a CDS system and drug alerts should be highly customized to the setting, the practice, and the patient population. Pharmacists are well suited to assist prescribers in the interpretation of alerts so that alert fatigue is minimized and patients benefit from the CDS system.
During our pilot project, a new EHR software program was concurrently being developed. One of its features was a drug-drug interaction (DDI) alert. This module was provided by the manufacturer with a default drug library of potential DDIs. The NP and the pharmacist determined the validity of the alerts and determined if an override was safe. Table 2 summarizes a list of adverse reactions assessed by the pharmacist and NP.
The reactions to alerts were sent to the software developer for incorporation into the knowledge base for the clinic. The alerts were triggered by a single drug prescription and alerted the clinician to a possible interaction or allergy based on patient history. The team was able to suggest actions in each case and determine if the alert should be suppressed in the future.
DDI alerts produced only by computerized systems have natural flaws. Perhaps first and foremost is the sensitivity level of the alert system. Intuition might cause a clinician to request the most conservative alerts and request notification for anything that might be of concern for their patient. In reality, drug interaction software is a tool that doesn't always provide the clinician with actionable alerts. For example, alerts that warn the prescriber about the concurrent use of hormones in women of child-bearing age when oral contraceptives are ordered can cause a type of "noise" that can lead to the clinician ignoring warnings in the future. In addition to the development of robust EHR systems and electronic CDS tools, the interdisciplinary team of providers resulted in not only better care for patients but was absolutely critical for evaluating patient needs 1 encounter at a time.
Table 3 summarizes a series of DDI alerts generated by the new EHR system and which the pharmacist and NP were able to evaluate and suggest appropriate action. The suggestions were also shared with the software developer to improve the alerting system. The customizations to the EHR system were then incorporated in a subsequent implementation at a different clinic.
YAZ is manufactured by Bayer HealthCare Pharmaceuticals, Inc, Wayne, NJ. Motrin IB is manufactured by McNeil Consumer Healthcare (a Johnson & Johnson company), Ft. Washington, PA. Excedrin Migraine is manufactured by Novartis Consumer Healthcare, Parsippany, NJ.
