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Power in the palm of your hand: PDA's open window on pharmacy services
`We're better able to capture and quantify interventions'
Using a PDA-based system to document clinical interventions at a military treatment facility increased intervention reporting across all pharmacy points of service and yielded data pharmacy leadership could use to document the impact of pharmacist interventions on safety and quality of pharmacy care provided.
Such were the findings of a study by lead author Stephen Ford, PharmD, deputy director for clinical operations at Military Vaccine Agency in Falls Church, Va.1 The study was conducted when he was director of the department of pharmacy at Evans Army Community Hospital, Fort Carson, CO. Ford tells Drug Formulary Review that PDAs have been used in other healthcare settings to document clinical interventions and his team wanted to see how well they would work in a military treatment facility.
"Before this experiment, the quality of pharmacy services was measured by waiting time," he tells DFR. "We wanted to document the impact of interventions in delivering care in terms of patient waiting time. But we also wanted to reinforce with the hospital leadership that pharmacy quality can't simply be measured by patient waiting time. We needed to be more concerned with the quality of pharmacy services."
The literature indicates that PDA-based intervention programs are broad in scope and serve to improve intervention documentation and analysis and in assessing the value of pharmacists' cognitive services. Also, some institutions have used medical information tracked through PDA-based programs for physician profiling and renewing privileges. Studies, the report says, have shown that PDA-based programs are both more effective and more efficient than paper documentation in compiling, tracking, and analyzing intervention data.
Ford writes that although their program was originally designed to simply improve collection and reporting of intervention data, it was expanded to include documenting the value of pharmacist interventions in improving the quality and safety of the medication use system, compliance with approved clinical practice guidelines and related prescribing policies, and medication errors and adverse drug events. They also started a spin-off program for clinical pharmacists practicing in a disease management clinic.
The need for speed
Evans Army Community Hospital serves 145,000 eligible Department of Defense patients and beneficiaries living in the greater Colorado Springs area. The facility provides comprehensive inpatient and ambulatory clinic healthcare services. Ambulatory pharmacy services in the military go through three points of service: military treatment facility-based ambulatory pharmacies, a mail service pharmacy, and a network of community pharmacies. The Evans pharmacy is reported to be a high-volume ambulatory operation dispensing more than 2,000 new and refill prescriptions daily.
While most of the earlier clinical intervention studies used the Palm platform PDA, the Evans team chose the Dell Axim Pocket PC because of its reputation for sturdiness, storage capacity, and speed. All pharmacy interventions were documented in standard format using the Axim Pocket PC. A memory upgrade took place early in 2005 when the study team became aware that the 64 MB capacity of the PDAs was being taxed. The problem was solved by adding 128 MB compact flash memory cards to each PDA.
PDAs were synchronized and intervention data downloaded weekly to one computer. Elements of data collected included date of consult, clinic location, pharmacist location, patient's first and last names and Social Security number's last four digits, pharmacist name, healthcare provider, reason for intervention, drugs involved, suggested resolution, and whether the suggestion was accepted or rejected.
"Our presumption going into the project was that the number of reports would increase over the level documented using paper forms," the authors say. "But, we thought, as the pharmacy staff used documentation of their interventions to educate the professional staff, the number of interventions would plateau and perhaps even decline, medication errors would decrease and as a result, the quality of care would improve, with an associated increase in cost avoidance."
Future is improving outcomes
All pharmacists used their PDAs with the first iteration of software to record interventions for one month. The program underwent final design changes and then became the sole source for recording pharmacist interventions at Evans. Recognizing that the future of the pharmacy profession lies not in traditional distributive functions but rather in applying cognitive skills to improve patient outcomes, a pharmacy process action team was formed that included pharmacists, pharmacy technicians, and automation specialists. The team developed a time-phased plan to implement new PDA technology into pharmacist practice with the goal of using the technology to document clinical interventions. The team developed an implementation plan to prevent weakened resolve resulting from situations such as users becoming quickly overwhelmed.
Ford and colleagues report that implementing a PDA-based system for documenting pharmacist interventions across all points of service within the department "dramatically increased reporting for the first six months following implementation (August 2004-February 2005)."
After initial fielding, he says, clinical pharmacists in advanced practice settings such as a disease management clinic and anticoagulation clinic recognized a need to tailor the program to their specific activities, resulting in a spin-off program unique to their practice roles.
Before the change to PDA reporting, an average of 103 pharmacist interventions were reported each month. After the PDA effort was implemented, the mean increased to 268 reported interventions. More importantly, the authors say, the pharmacy leadership gained the capability of quantifying the time spent by pharmacists in patient-focused interventions to improve both the safety and quality of pharmaceutical care provided, in terms of number of prescribing errors, drug interactions, and contraindications.
During the first six months after implementation, a total of 417 hours of pharmacist time was spent in clinical intervention activities. That time was in addition to that spent in routine order evaluation, processing, and patient education/counseling activities. On average, the authors say, each intervention required about 15 minutes to complete, and 97% of suggested recommendations were accepted.
Interventions nearly tripled
Another important indicator to hospital leadership was the increase in interventions from 30 to 80 per month that resulted in a change in medication or was initiated to comply with an approved clinical practice guideline. Finally, they say, information obtained from documenting prescribing practices resulted in improved pharmacy-to-prescriber feedback on compliance with established formulary/prescribing policies and identification of potential risk management issues.
"Ideally," they say, "future program expansion will result in cost-avoidance estimates, medication-use evaluation data, and potentially a tool to use for billing purposes to charge for pharmacist services."
One of the side benefits of the program has been an improved quality of reporting, adds Stan Illich, BPharm, MHA, assistant director in the department of pharmacy, at Evans Army Community Hospital. He says the quality of reporting was poor with the legacy paper report system, but it's hard to track when it's not on a computer.
Another upside, according to Ford, was the ability to load reference software for pharmacists into the PDAs, which the pharmacists could use in educating providers.
Factors Ford and colleagues have identified for the success they have had include being able to overcome some initial resistance and have the program be part of an overall quality improvement initiative.
The program continues to be used at Evans, although the software may soon be changed along with the brand of PDAs. Until the changeover is complete, some pharmacists have had to return to manual reporting and the number of interventions has decreased, demonstrating again the program's value.
"We're better able to capture and quantify interventions," Mr. Illich says, "especially for medication errors. And we've been able to identify through physician profiles potential risk management issues and demonstrate an impact on compliance with local guidelines, which has produced improved outcomes and some cost-avoidance."
[Editor's note: Contact Mr. Ford at the Military Vaccine Agency in Falls Church, VA. Fax him at (703) 681-4692 or e-mail firstname.lastname@example.org.]