Abstract
Pharmacists' clinical interventions have been the subject of a substantial body of literature that focuses on the process and outcomes of establishing an intervention documentation program within the acute care setting. Few reports describe intervention documentation as a component of doctor of pharmacy (PharmD) programs; none describe the process of selecting an intervention documentation application to support the complete array of pharmacy practice and experiential sites. The process that a school of pharmacy followed to select and implement a school-wide intervention system to document the clinical and financial impact of an experiential program is described. Goals included finding a tool that allowed documentation from all experiential sites and the ability to assign dollar savings (hard and soft) to all documented interventions. The paper provides guidance for other colleges and schools of pharmacy in selecting a clinical intervention documentation system for program-wide use.
INTRODUCTION
The clinical interventions of pharmacists have a positive impact on patient care and decrease cost.1-12 Intervention documentation is important for justifying pharmacists' salaries, providing information to healthcare administrators and providers, conducting performance evaluations, and tracking workload. Electronic systems for documentation of clinical pharmacy interventions are more efficient than paper systems.1 There are several commercial products that can be used in the hospital setting, as well as software packages that allow users to build their own documentation applications.
Although the value of commercial and customized clinical documentation programs in the clinical setting has been demonstrated,13-28 few studies have described use of these software applications in the academic environment of colleges and schools of pharmacy. Documentation of patient care interventions by student pharmacists, pharmacy residents, and pharmacy faculty members is important for several reasons. As colleges and schools continue to strive for more quality training sites and learning opportunities for their students, it is important to demonstrate to administrators the value of having pharmacy students involved in patient care. Student pharmacists also need to develop the habits of providing appropriate documentation and justification of their work early in their training. Early application of documentation skills can promote this. Students also need to document learning experiences for experiental directors to assess competency achievement, and may choose to include intervention data in a portofolio for certifications, residency applications, or other employment. Having students use a personal digital assistant (PDA) database to document clinical work significantly improved their perception of the value and importance of documentation.29 The 2007 Accreditation Council for Pharmacy Education (ACPE) Accreditation Standard 14 on Pharmacy Practice Experiences states that student “experiences must include direct interaction with diverse patient populations in a variety of practice settings and involve collaboration with other health care professionals”.30 Documentation of student clinical interventions throughout the experiential curriculum can provide schools with valuable assessment data to ensure ACPE standards are met.
Documentation of the impact of clinical pharmacy services is important to further the profession as a whole. At some clinical sites, faculty members are required to justify their presence by showing their impact on patient care. Additionally, outreach outcomes are important for routine performance evaluations as well as promotion and tenure of most clinical practice faculty members. However, most colleges and schools of pharmacy do not have a central database for capturing interventions at experiential locations, as students and faculty members are placed in multiple institutions with different intervention systems. For these reasons, we explored possible options for school-wide documentation of clinical interventions.
This paper describes our experiences in choosing a school-wide clinical intervention documentation system. It is intended to inform readers of the process of selecting an application to capture data describing the clinical and financial impact of an experiential program. We also provide a review of the literature of intervention documentation and outcomes from an academic perspective.
LITERATURE REVIEW
Only findings from small studies on the value of student pharmacist documentation of interventions at clinical sites have been published.31-46 The types of documentation methods described included computer software, software for handheld devices, and online documentation systems. The clinical interventions by pharmacy faculty members and students and/or residents using electronic documentation systems have been described qualitatively and quantitatively.31-36 The outcomes associated with the interventions supported onsite pharmacy education to health care institutions as a means to cost-justify academic partnerships. Additionally, the impact of academia in patient care has been described in terms of cost-avoidance relating to medication errors and potential adverse drug reactions through such documentation.35
The documentation programs described in the literature either have been customized or were in place at the affiliated healthcare institution.31,33,34,36 Electronic systems using handheld technology or Web-based programs provide consistency and efficiency and a broad application to an entire school of pharmacy. All of the studies identified in our review were small and involved a limited number of students during pre-specified advanced pharmacy practice experiences (APPEs). None described the process of selecting a single, school-wide clinical intervention documentation system for use longitudinally by all pharmacy practice faculty members and students in both inpatient and outpatient academic settings.
SELECTION AND IMPLEMENTATION OF A DOCUMENTATION SYSTEM
Determining the Features Needed
An evaluation team was convened by the dean of the Auburn University Harrison School of Pharmacy to select a school-wide clinical intervention documentation system to be used by students and faculty members. The team consisted of 7 faculty members from varied practice settings (eg, inpatient, outpatient) and specialty areas, including the experiental education director. The team reported and made recommendations directly to administration.
The first challenge in adopting an intervention system to serve the school of pharmacy at large was the capability to document both inpatient and outpatient interventions. Such an intervention system should accommodate faculty members in all practice settings, while providing a means of evaluating/assessing a variety of interventions associated with introductory and advanced pharmacy practice experiences (IPPEs/APPEs). The ability to customize the intervention list was a critical feature that affected our decision.
The team began by defining the purpose(s) for documenting clinical interventions at the school. Specific data necessary to achieve these objectives were considered and a list of desirable key features was developed and organized into 4 categories: documentation form, platform, exporting/reporting, and management/administration (Appendix 1).
The documentation form features are the characteristics of the tool that have the most direct impact on the users' experiences. Features should provide an easy-to-use form for all users, regardless of their role and setting. An important focus of the documentation form is the ability to quickly document interventions using as few keystrokes as possible, while capturing all the required data.
The platform features address the structure and function of the tool, focusing on the capabilities of the software. Important platform attributes allow documentation to occur from any Web-enabled device, with flexibility in terms of partial and collaborative documentation. Security of both patient and student information is also an important platform feature, as is the ability to communicate with other information systems. This last feature is not currently a reality and is a significant obstacle for colleges and schools of pharmacy with IPPEs and APPEs in a variety of locations. The core of an intervention documentation tool should be a database to allow maximum flexibility in data capture, analysis, and reporting.
The exporting/reporting features focus on the sharing of intervention data within and outside the pharmacy program. Pharmacy faculty members, administration, and students all have valid needs for accessing and sharing intervention data. Documentation tools should support these needs by providing customizable reporting and exporting functions. Colleges and schools should explore the possibility of having commercial vendors run predefined reports at predetermined times and then send the reports to the college or school. The ability to share intervention data with experiential training sites is an important and growing need for administrators.
The management/administration features of the documentation tool support the college or school's efficient maintenance and oversight of the system. With potentially hundreds of users, colleges and schools should ensure that user account maintenance can be performed not only in batch (or by the vendor), but also by individual users (eg, the ability to update their profile). Cost and support were obvious considerations, as was users' ability to access an up-to-date drug reference. Cost was difficult to pinpoint and compare between products. Some products were available as an academic suite or integrated with an e-portfolio system and not priced separately. The commercial standalone products traditionally are marketed to institutions, and do not have set pricing for academic use. We discovered that cost could not be directly compared between products; thus, colleges/schools may need to negotiate with individual vendors. While gathering information on commercial products, team members also deliberated the option of building a customized clinical intervention documentation system. A critical consideration in the selection of any software product is the availability of technical support for updating the database and resolving technical difficulties. While this is typically not an issue with commercial software products, it is a vital concern when purchasing a customized product.
Handheld devices.
There was considerable deliberation on identifying a product with versatility of working with handheld devices. Over time, the perspective shifted from selecting a product with this capability to a greater value being placed on the overall efficiency characteristics in the documentation process. For there to be buy-in from practice faculty members, the product needed to be as user friendly as possible. The clinical intervention documentation system that was chosen is Web-based with handheld versions available. Colleges and schools should determine the compatibility of potential products with the current generation of portable devices, including smartphones and tablets. All of our users enter their interventions using the Web-based form and there have been few complaints by faculty members and students regarding this method of documentation. The Web-centric nature of the tool is a primary strength for our usage because it allows documentation from any device that has an Internet connection and Web browser. Feedback from faculty members and students indicated that due to the workflow in patient care, it is often typical and preferred to document interventions at a later time, rather than during patient care activities. They preferred to have an application with a variety of entry points and the ability to access it from multiple Web-enabled devices.
Tools included in PIMSs.
Typically, some intervention tools are existing components of pharmacy information management systems (PIMS) that integrate with a hospital's clinical information system. These integrated systems and other similar interfaced systems can present clinical data housed within the hospital clinical information system to the pharmacist to help identify potential interventions for subsequent evaluation and documentation. While a system's ability to automatically present presorted data to users is valuable, the technical complexity, administrative logistics, and financial costs of interfacing a documentation tool with literally hundreds of experiential training sites would prevent/prohibit most colleges/schools from pursuing this option, as it did our school.
Researching Software Options
Once the needs assessment was complete, the team began researching potential software products in the literature, on the Internet, and at national pharmacy organization meetings. The team also considered recommendations elicited from practice-based listservs (eg, practice and research newtorks, special interest groups), pharmacists practicing at experiential education sites, and personal experience.
After potential products were identified, the features of each program were critically analyzed for practical utility in the academic setting and a pro/con list for each product was developed. Table 1 lists institutional goals for documentation and the corresponding desirable features of each program. The assessment process was expanded through online product demonstrations and personal product testing by faculty members via temporary access to products. Based on the information gathered, the team narrowed the list of potential clinical intervention documentation software systems and presented the results to school administrators. Table 2 lists sample commercial intervention documentation tools and database development applications that can be used to develop homegrown intervention documentation tools. It does not include intervention tools that are components of PIMs because a college or school of pharmacy would not normally purchase these tools independent of a PIMS.
Clinical Intervention Documentation Goals and Representative Corresponding Key Features
Example Intervention Documentation Tools
Product Selection
The desired features and goals of a school-wide intervention documentation tool vary for each institution. Some intervention documentation products will be easily eliminated as possibilities if they do not have critical features to meet the school's goals. The vision of our school of pharmacy was to adopt an intervention documentation tool which would serve to describe the patient care activities of the school as well as a means to educate and incorporate pharmacy students on the importance of this process. In consideration of all of the features of the intervention system, coupled with the goals of the academic program in using such a system, there has been much reflection and subsequent continuous quality improvement associated with our use of the current tool. While e-portfolios are growing in importance among pharmacy programs, existing commercial intervention tools for acute care settings are not designed to share data with e-portfolios. Additionally, there is inconsistency among the large, academic software suites in terms of providing an intervention documentation component that integrates with the suite's e-portfolio module. Schools should carefully evaluate any demonstrations of this feature.
After discussing and ranking the desired features and soliciting input from school administrators, we chose Quantifi (Pharmacy OneSource, Bellevue, WA) because it fit our needs, we had an existing relationship with the software provider, and we did not have the time and resources to develop a custom tool. As with other commercial intervention documentation tools, Quantifi is designed to support documentation of pharmacists' interventions in the acute care setting. The majority of inpatient interventions that we would use already were included in Quantifi; however, the outpatient interventions required substantial development. We were aware of this limitation as it was common across all of the software applications we considered. In our school, Quantifi serves the distinct purpose of intervention documentation and is separate from our e-portfolio system.
Implementation
At Auburn University Harrison School of Pharmacy, Quantifi is used both administratively and academically. As part of their performance evaluation, all pharmacy practice faculty members are expected to document and annually report their patient care activities (quantitatively and financially) using this system. Such information is helpful in discussions with associated health systems and pharmacies. The data are used to demonstrate the outreach efforts by full-time faculty members and justify these positions or potential new positions, and to describe the school's clinical and financial impact for institutions that do not have an intervention documentation system. Additionally, the information is annually collated and reported to the university at large to demonstrate the collective outreach services by the school of pharmacy.
The documentation system is used in IPPE and APPE programs to acclimate the students to the process prior to their fourth year. In the first 3 years of the longitudinal IPPE program, students document interventions associated with identification of medication-related problems under the guidance of faculty members. In the fourth academic year, pharmacy students are required to document patient care interventions on all patient-care APPEs regardless of practice setting or preceptor. This information is reviewed periodically by the director of experiential learning and regional faculty coordinators to ensure that documentation is occurring and that it is accurate. These data can then be shared with affiliate preceptors and practice sites upon request. Full-time faculty members have the opportunity to use the documentation system to proactively explain the level of professional service in the patient care setting, as well as to review with students the quality of interventions and provide feedback related to professional performance over the course of the APPE. At times, a percentage of their APPE grade is dedicated to these interventions to describe the value of their work and mirror an actual performance evaluation. By participating in this process, the students also learn about the cost-avoidance measures associated with their patient care activities.
DISCUSSION
Several aspects/features of Quantifi have been important to our success. The ability to customize the application to match our academic and professional documentation needs has been essential for our institution. We have been able to demonstrate the interventions by individuals (faculty and staff members) as well as the IPPE and APPE programs. The flexibility of the intervention list allowed us to develop a documentation form that represented the documentation needs of our school. Also, the time required to complete documentation using Quantifi is minimal, which is crucial given the time constraints encountered in practice settings and in pharmacy practice experiences.
The current intervention system has been in place at our school for more than 3 years and during this time many modifications have been implemented as a result of use and continuous feedback by faculty members and students. From an intervention entry perspective, the intervention list has been reduced to eliminate duplication and confusion due to subtle differences. Additionally, measures have been taken to expedite the documentation process for repetitive tasks, and account for professional services related to outpatient visits and missed opportunities (eg, chart review and patient no-shows). Also, much time has been devoted to the review of reporting by fourth-year APPE students.
There have been several efforts to improve the consistency of documentation by faculty members and students. Prior to fourth-year APPEs, students are instructed on how to document their patient care activities by the director of experiential learning using scenarios and then again by full-time faculty members during individual APPEs. All faculty members attend an annual training session to ensure consistency, review any changes or customizations made, review training scenarios, and solicit feedback.
Initially, the reporting feature allowed individual faculty members to retrieve desired quantitative and qualitative information pertaining to their patient care interventions. Because of the way data were entered by APPE students, however, retrieving faculty or preceptor-specific data that was entered by students was nearly impossible. In June 2010, the way in which data were entered by the APPE students was modified. This allowed the retrieval of student-entered data associated with specific faculty members or preceptors. Currently, the vendor provides monthly reports to the school which can be sorted to provide specific intervention data and cost savings data in aggregate or for specific faculty, students, or practice sites. Manipulation of these reports requires experience with and knowledge of pivot tables, which we had to develop through technical assistance from Pharmacy OneSource. This has improved our ability to provide outcomes data to affiliate preceptors and health-systems partnering with the school of pharmacy. Other maintenance aspects, such as updating the drug database, must be performed manually by Auburn personnel as the software company does not provide this service.
CONCLUSIONS
The process of choosing a school-wide clinical intervention documentation system requires a systematic, multi-step process and many factors must be considered. The implications of choosing and implementing a system to meet the specific needs of a college or school of pharmacy can be far reaching. Data obtained may be used to justify faculty positions, solicit new experiential training sites, be included in student and faculty portfolios, be considered in faculty evaluation processes, and be distributed to multiple stakeholders. The steps in selecting an application to capture data describing the clinical and financial impact of an experiential program include assigning a team responsible for recommending a product, developing the goals for using the product, developing a list of desired features, identifying and reviewing available products, making recommendations to the decision maker, and negotiating with the vendor. After implementation, we recommend continued evaluation of the system and how it is used, as well as longitudinal training for faculty members and students.
Appendix 1. Desired Features of an Intervention Documentation Tool
Footnotes
↵* At the time of the study, Dr. Byrd's affiliation was with the Harrison School of Pharmacy. Her current affiliation is with the University of Tennessee College of Pharmacy, Knoxville.
- Received September 27, 2010.
- Accepted December 6, 2010.
- © 2011 American Association of Colleges of Pharmacy
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