Knowledge, Skills, and Resources for Pharmacy Informatics Education

Prescribing

Pharmacy student instruction about the first step in the medication use process, prescribing (ordering), should include the informatics topics related to the prescribing process found in Appendix 1. Future pharmacists should understand what information is necessary to best support medication-related decision-making and also to evaluate medication-related decisions. Pharmacy students also should be instructed to understand the available science of the physicians’ approach to probabilistic medical decision-making. How physicians make decisions affects how they prescribe medications. Recommended educational approaches for understanding prescribing begin with conceptual discussions of how differential diagnoses lead to refinement of disease potentials and, ultimately, to decisions to prescribe prophylactic, empiric, and definitively indicated medication therapies. Medical decision-making and pharmacy informatics are directly related. We currently apply the knowledge of pharmacists in clinical information systems to guide, advise, and otherwise inform clinician decision-making during prescribing. Also, after prescribing, physician medication selection rationale is typically tacit or obscured. Pharmacy informatics can assist in documenting medication-use indications online as part of the ordering process. Documented indications will then assist pharmacists in the assessment of medication use and outcomes of therapy.

Education also should be provided regarding the known dangers of illegible handwriting and verbal transmission of prescriptions. These are unsafe but common practices. Regulatory mandates are intended to minimize misunderstandings from written or spoken prescribing practices. There also are electronic prescribing technologies intended to eliminate the need for handwritten and verbal orders altogether. The principal prescribing technologies that students will encounter and must understand are computerized provider order entry (CPOE) and electronic prescribing (e-prescribing). With both CPOE and e-prescribing, research with respect to clinician-computer interaction during prescribing is ongoing. CPOE and e-prescribing research often focuses on the use of clinical decision support alerting systems and the determination of best practices for onscreen medication-related information representation design. Order sets are but one example of an onscreen information representation design intended to help improve the overall prescribing practices of clinician users.

Students also should be familiar with the literature regarding the safety benefits and new types of medication errors associated with CPOE and e-prescribing systems (Appendix 1). Nowhere within the domain of medication use technologies is there a better example than CPOE of the complex “trade-offs” associated with medication use information technologies. Whereas CPOE greatly diminishes problems with prescription legibility and completeness, it may, in particular instances, actually facilitate ordering medications for the wrong patient, polypharmacy, and other consequential medication use misadventures. Students should be taught that technologies can be faulty in their design or misused. Information systems, like all human tools, remain subject to human error; therefore, the tight coupling of medication use technologies can lead to dangerous results. Furthermore, sociotechnical aspects of information system use, such as the power of suggestion of onscreen drug information, must be recognized and respected by all pharmacists.

Pharmacy students should be taught about the significant role pharmacists have in providing drug information and having medication therapy-related patient information onscreen to support safe, effective, evidence-based prescribing. In the past, most information support for safe and effective drug selection and dosing came from reference books carried by providers. Today, CPOE and e-prescribing systems are capable of providing the same information onscreen during the medication ordering process. Pharmacists are well-suited to interpret and manage drug information and often are enrolled in the process of adding select drug information to online ordering systems. Because pharmacists also know the best practices for monitoring medications, they instruct and counsel organizations in the application of demographic and clinical patient data within the medication use process. Clinical decision support for medications, with its emphasis on providing the right information to the medication therapy decision-maker at the right moment in their workflow, is a growing area of importance for all pharmacists.

Pharmacist Prescription Review

Pharmacists have a traditional role of reviewing prescriptions created by prescribers (Appendix 1). There are many types of pharmacy information management systems (PIMS) used in both ambulatory and acute care settings, whose functions students should understand. Typically, these systems bring together much, but not all, of the information needed for the pharmacist to review a prescription for safety and efficacy.

A limited amount of research has been published on how pharmacists analyze prescriptions; nevertheless, students should be familiar with the available information. Further, pharmacy students should be introduced to the available data on pharmacist interventions made during prescription review. Students should be able to list and describe the kinds of analyses that may be required to determine appropriateness, including analyses of allergy information, laboratory results, indications, dose, routes of administration, prescription instructions, drug-drug interactions, drug-food interactions, side effects, intolerance, clinical objectives, and expected and apparent outcomes. Clinical decision support tools and techniques, such as onscreen alerts and reminders, also should be used during pharmacist order verification and need to be addressed in the classroom.

The decision-making process involved in drug product selection to fulfill individual prescriptions also should be included in the curriculum. The automation of drug product selection by established algorithms is deserving of consideration, along with discussion of the many factors that pertain to drug product selection. Faults and problems with automating drug product selection should be highlighted as an area of concern in pharmacy informatics.

Because the prescription review process leads immediately to the generation of computer-printed labels and patient charges, these 2 aspects also should be mentioned by instructors teaching the technologies of the medication use process. In particular, pharmacy labels on dispensed products offer an excellent opportunity to introduce basic concepts of information representation design and readability. Automated billing is another area deserving of consideration, especially because the efficiency benefits of automated billing are often hampered by the challenges of achieving an accurate list of medication charges.

Compounding and Dispensing

Compounding and dispensing are associated with a host of newer technologies. A list of related pharmacy informatics topics is found in Appendix 1. Pharmacies have been automating their supply chains for several decades in an effort to achieve optimal, perpetual inventory management. Automation now is used to improve the safety of the supply chain by inserting barcode validation steps as products are received, stored, retrieved, and dispensed. Students should be provided with a general overview of the pharmaceutical supply chain for consumers (through retail channels) and for hospitals and clinics (through wholesale channels). With respect to the medication use process, compounding and dispensing is the step where patient prescription information is associated for the first time with actual, physical dosage forms in order to create finished, dispensed products.

Robotics in pharmacy practice can be addressed while teaching current compounding and dispensing practices. More than one type of automated, individualized syringe-filling robot has been brought to market. These technologies are deserving of study, especially as robotic drug selection and syringe filling clearly depict the varied and exceptional requirements that must be met to properly produce dosage forms ready for administration to patients. For example, after viewing a video demonstration of a syringe-filling robot, students could be asked to identify the required steps in the compounding process, the safety controls applied, and the compounding environment created and maintained by robotic technologies.

Automated identification of drug products, usually through the use of barcode scanning, is another important technology being applied to compounding and dispensing workflows. Students should become familiar enough with the basics of barcodes so that they can troubleshoot the most common barcode printing and scanning problems. Automated counting machines, packaging machines, inventory management technologies, and dispensing machines all rely on barcodes as medications move from the pharmacy to patients.

Students should be aware of the unique role that automated dispensing machines play in clinic and acute care settings. The ongoing debate about the optimal operational use of these technologies should be reviewed, along with the benefits and challenges of using computerized drug distribution cabinets for dispensing on nursing units and away from the pharmacy.

Medication Administration

The administration of medications, whether self-administered by patients and family members at home, administered by caregivers in clinics, or administered within the context of episodic acute care is associated with several informatics topics (Appendix 1). Pharmacy students should understand how the nursing and medical professions approach medication administration, including how the concept of the “5 rights” pertains to pharmacy practice. Nurses are taught that for each medication they administer to a patient they are to confirm that the right medication is being given to the right patient in the right dose by the right route at the right time. However, as medication administration workflow research continues, additional best practice medication administration imperatives are being identified. An ideal medication administration practice would include the elements of safety, quality, patient assessment, documentation, and patient education and engagement in their own care.

Computerized infusion devices with drug error reduction systems are now available to improve the safety of intravenous infusions of various types, including continuous infusions, patient-controlled analgesia, total parenteral nutrition, epidural infusions, and intermittent infusions from syringes. Typically, regulated medical devices known as computerized infusion pumps require pharmacists to develop or validate drug library files listing the drug items that can be managed by “smart” infusion pumps. These technologies often inspire a consolidation of available, dispensed drug product concentrations for the same drug from hospital pharmacies, which is intended to reduce complexity and improve safety by preventing confusion of dispensed product concentrations. An example exercise to illustrate the pharmacist's role in developing a smart infusion pump drug library would require students to consolidate a list of available medications based primarily on usage data and best practice criteria. Students also should be familiar with the data supporting the use of, the current inadequacies, and the predicted future developments for smart infusion pump systems.

Automated drug product identification, typically using barcode scanning to identify products using drug product databases, is now a fundamental medication use process technology. Much has been written about using barcodes to identify unit-of-use medications. Pharmacy students being introduced to pharmacy informatics should be instructed in both the benefits and the challenges of successfully using barcode scanning to identify drug products. Pharmacy students also must be taught to understand the basic safety, technology, and workflow elements of barcode medication administration conducted at the patients’ bedside. Most new pharmacists will encounter some type of barcoding in their practice, regardless of the setting.

The electronic medication administration record (eMAR) is another key medication administration-related technology. Pharmacy students should be provided comparative examples of a paper-based and electronic medication administration record. Students should be taught to extract information from the electronic medication administration record and to identify doses not given, as they may require follow-up. An examination of medication regimen compliance management tools used by community pharmacies and by patients also is advisable.

Monitoring of Ongoing Medication Therapies

Monitoring of ongoing medication therapies used for both acute and chronic needs is critical to achieving the best possible medication use outcomes. Optimal monitoring of ongoing drug therapies is anticipated to lead to further improved prescribing by creating a cycle through which medication therapy outcomes are better documented and therefore more obvious to prescribers when determining medication therapy needs. Medication therapy monitoring is associated with several topics found in Appendix 1.

Before pharmacy students can be taught about technology-enabled monitoring of ongoing medication therapies, they must first learn about the large, integrated clinical information system platforms being used to manage most aspects of patient care. These include electronic health records (EHRs) and electronic medical records (EMRs). Furthermore, pharmacy students should be instructed in the US federal government's support for widespread deployment, connectedness, and interoperability of electronic records to create a nationwide health information network. Some of the most discussed and most expensive developments in the field of informatics involve integrating patient health data from multiple provider sources into exchangeable clinical summaries for patients and into de-identified population health databases to be used by public health professionals. Many information privacy and security concerns pertain to these initiatives and should be considered by future pharmacists.

Pharmacy students should be introduced to the concept of medication-related public health informatics (ie, population-based surveillance of prescribing and medication use trends). Pharmacoepidemilogy will be facilitated by the deployment and further development of electronic records. Students should be challenged to identify potential population-based uses for medication use process data outputs from all stages of the medication use process.

Using continuously operating conditional (ie, if-then) logic commonly associated with computers, it is possible to create CDS surveillance rules in an electronic record intended to identify potential adverse drug events. For example, a CDS system can be programmed to alert when a patient is receiving a potassium-sparing diuretic and their latest potassium level exceeds a predetermined threshold. Clinical decision support rules for medication therapy monitoring with this level of specificity are often created and managed by pharmacists because pharmacists are well versed in medication therapy management (MTM). As an exercise, students can be presented with a complex drug regimen and be asked to create potential CDS medication therapy monitoring rules to protect patients from potential problems with the assigned medication(s).

The documentation of medication therapy outcomes using online tools is an important feature of electronic records. This documentation may include, but is not limited to, success or failure of attempted medication treatments, individualized successful dosing information, patients’ experiences with drug therapy, allergic reactions, adverse events, and rationale for continuing or discontinuing medications. Students should be challenged to consider optimal medication therapy practices with respect to documentation of medication therapy outcomes. Students also should be instructed on the reasons for the current gross incompleteness and inadequacy of pharmaceutical outcomes documentation. Medication reconciliation also should be discussed in light of the present difficulties associated with gathering necessary information to ensure a complete understanding of the patients’ medication use and related behaviors.

Finally, pharmacy students should be supplied with real-world examples of how medication-related outcomes can inform the medication use process to influence MTM, including terminating an ongoing drug therapy, making dose adjustments, adding additional medications for a presently treated indication, and substituting or switching medications based on patient response. While not well-documented and obvious, patients’ past experiences with specific medication therapies may influence the prescribers’ medical decision analysis when considering what to offer or prescribe next. This feedback loop, from medication therapy outcome to future medication use, is implied by models of the medication use process depicted as feedback loops.

Future pharmacists in both acute and ambulatory settings will have many opportunities to leverage informatics to support their practice and improve care. In discussing the informatics education needs of students, we identified topics that can be considered technology focused, but we identified other topics, such as electrolyte monitoring, that were not technology focused. The goal is to develop pharmacists who understand and are prepared for a practice supported by informatics throughout the medication use process. Future pharmacists need to understand the role of informatics in medication safety and improving patient outcomes. We believe that a variety of instructional approaches can be used to bring informatics into the curriculum. In this paper we have included a table of key source materials for inclusion in curricula (Appendix 1) and details on suggested pharmacy informatics learning activities (Table 1).

Workflow Mobility

Mobile devices (smartphones, tablets, etc) will enable the practice model of the future in which pharmacists have access to referential and patient-specific information whenever and wherever they need it. Pharmacists will become more visible and accessible within health systems and community pharmacy settings because of mobile health as they will no longer be tethered to fixed workstation computers. Telepharmacy also will allow increased access to pharmacy services.

Interoperability

The goal of interoperability is to share usable health information electronically. Desired is a closed loop medication process between the inpatient and outpatient settings, as well as the inclusion of patient-generated information. Information to be shared will come from the EMR, PIMS, the personal health record (PHR), and other systems housing patient-specific information.

Patient-centered Technologies

Patient-centered technologies reflect a growing emphasis on elevating the role of patients to that of collaborators in their own care. These technologies include personal health records, health-related social media resources, online medical information, home monitoring devices, and interfaces that can routinely monitor patient outcomes, such as blood pressure/blood glucose. These technologies will serve as rich resources to gain insight into patients’ medication-related experiences.

Analytics

Health systems are implementing electronic work queue systems to ensure compliance with various parameters, such as the Joint Commission Core Measures. These systems provide alert reminders, or patient acuity scorecards based on custom triggers for variables such as laboratory values and antibiotic susceptibility data that require follow-up and potential intervention. Pharmacists must understand the role of these tools as enablers of safe and efficacious medication therapy.

Automation

Automation has been a hallmark of pharmacy practice for many years. Its role will continue to increase as the profession works to deploy pharmacists to direct patient care activities. Technologies such as automated workflow systems, robotics (oral and IV), medication tracking systems, and barcode/radio frequency identification (RFID) capabilities will significantly impact the role of both the pharmacist and the pharmacy technician. Pharmacists should be prepared for the changes in practice that will accompany increased use of automation.