Genomics and electronic health record systems.

Several reviews and case reports have described how information derived from the analysis of genomes are currently included in electronic health records (EHRs) for the purposes of supporting clinical decisions. Since the introduction of this new type of information in EHRs is relatively new (for instance, the widespread adoption of EHRs in the United States is just about a decade old), it is not surprising that a myriad of approaches has been attempted, with various degrees of success. EHR systems undergo much customization to fit the needs of health systems; these approaches have been varied and not always generalizable. The intent of this article is to present a high-level view of these approaches, emphasizing the functionality that they are trying to achieve, and not to advocate for specific solutions, which may become obsolete soon after this review is published. We start by broadly defining the end goal of including genomics in EHRs for healthcare and then explaining the various sources of information that need to be linked to arrive at a clinically actionable genomics analysis using a pharmacogenomics example. In addition, we include discussions on open issues and a vision for the next generation systems that integrate whole genome sequencing and EHRs in a seamless fashion.

Comparisons of immunization records between a community pharmacy, a regional registry, and a health system.

OBJECTIVES: To compare the completeness of immunization records for 6 vaccines between a community pharmacy database, a regional immunization information system (IIS), and a health system's electronic health record (EHR). METHODS: In a community pharmacy immunization program, 2 pharmacists and a community pharmacy resident performed a needs assessment for 6 vaccines (tetanus-diphtheria-acellular pertussis vaccine for adults or diphtheria-tetanus-acellular pertussis vaccine for children and adolescents, zoster vaccine live, 13-valent pneumococcal conjugate vaccine, 23-valent pneumococcal polysaccharide vaccine, hepatitis B vaccine series, and human papillomavirus vaccine) for more than 2400 patients from August 2016 to March 2017. This was a retrospective study to review immunization records for 243 patients. Inclusion criteria included patients from the community pharmacy immunization program who also had at least 1 medication prescribed by an academic health system provider. Immunization records for 6 vaccines were collected from the community pharmacy database, the regional IIS, and the EHR. RESULTS: A total of 186 of 243 patients (77%) had additional immunization records in the regional IIS or EHR that were not found in the community pharmacy database. Among those 186 patients, 108 (58%) had additional immunization records for 2 or more unique vaccines. In total, 378 additional immunization records were identified for the 6 vaccines. For all 6 vaccines, the regional IIS and EHR possessed more complete immunization records than the community pharmacy database (P < 0.05 for HPV and P < 0.001 for the remaining 5 vaccines). CONCLUSION: Our study showed that immunization records were more complete in a regional IIS and health system EHR compared with a community pharmacy database. If all 3 sources were used by the pharmacist during the needs assessment, the community pharmacy team would have made fewer vaccine recommendations, which would have reduced the potential for duplicate or inappropriate vaccines.

Agreement Between Maternal Report and Medical Records During Pregnancy: Medications for Rheumatoid Arthritis and Asthma.

BACKGROUND: There are limited data regarding the comparability of medication exposure information during pregnancy from maternal report and medical records, including for rheumatoid arthritis and asthma-related medications. METHODS: This study included pregnant women with rheumatoid arthritis (n = 216) and asthma (n = 172) enrolled in the MothertoBaby Pregnancy Studies (2009-2014). Women reported types and dates of medications used through semi-structured telephone interviews up to three times during pregnancy and once after delivery, and medical records were obtained. We calculated Cohen's kappa coefficients and 95% confidence intervals (CIs) and per cent agreement for agreement between report and records. RESULTS: For rheumatoid arthritis, prednisone was reported most frequently (53%). During pregnancy, kappa coefficients for rheumatoid arthritis medications ranged from 0.32 (95% CI 0.15, 0.50) for ibuprofen, with 84.3% agreement, to 0.90 (95% CI 0.84, 0.96) for etanercept with 95.4% agreement, and was 0.44 (95% CI 0.33, 0.55) for prednisone, with 71.3% agreement. For asthma, albuterol was reported most frequently (77.9%). During pregnancy, kappa coefficients for asthma medications ranged from 0.21 (95% CI 0.08, 0.35), with 64.5% agreement for albuterol to 0.84 (95% CI 0.71, 0.96) for budesonide/formoterol, with 96.5% agreement. Where kappas for any use during pregnancy were less than excellent (i.e. ≤0.80), medication use was more frequently captured by report than record. CONCLUSIONS: Agreement was higher for medications typically used continuously than sporadically. Information on medication use from medical records alone may not be adequate when studying the impact of intermittently used medications during pregnancy on perinatal outcomes.

Longitudinal trajectories of antidepressant use in pregnancy and the postnatal period.

Studies of antidepressant safety in pregnancy typically do not address complex patterns of use throughout pregnancy. We performed longitudinal trajectory modeling to describe patterns of antidepressant use in the first 32 weeks of pregnancy, and test whether these trajectories are associated with a reduction in birth weight or gestational age at delivery. Our study included 166 pregnant women with deliveries between 2011 and 2015 who were prescribed an antidepressant between 91 days prior to last menstrual period and 32 weeks of gestation. From electronic medical records, we estimated average daily dose and cumulative dose per week for the first 32 weeks of gestation and for the first 13 weeks postnatal. We clustered women with similar utilization patterns using k-means longitudinal modeling and assessed the associations between trajectory group and birth weight and gestational age at delivery. We identified four cumulative dose trajectory groups and three average daily dose trajectory groups in each period. Relative to the lowest trajectory group, the highest trajectory group during pregnancy was associated with reduced birth weight in multivariable analysis (average daily highest trajectory vs. lowest trajectory ß - 314.1 g, 95% CI - 613.7, - 15.5) adjusted for depression severity score, maternal age, race, and pregnancy smoking. Trajectory groups were not associated with gestational age at delivery. The highest trajectory group of antidepressant use in pregnancy was associated with a modest reduction in birth weight but not with gestational age at delivery. Longitudinal trajectories allow for a dynamic visualization and quantification of medication use among pregnant women.

Pharmacist training in suicide prevention.

OBJECTIVE: Suicide in the United States is a major preventable public health problem. Pharmacists need to be educated on suicide prevention strategies so that they can increase their own awareness and identify patients at-risk. A training program for pharmacists was used to provide skills necessary to recognize a crisis and the warning signs of suicide. The program's effect on the participant's general perception, self-efficacy, and attitude towards suicide prevention was examined. SETTING: Various academic, health care, and professional meetings throughout San Diego County. PRACTICE INNOVATION: First Question, Persuade, and Refer training program targeting pharmacists. EVALUATION: A self-administered presurvey, postsurvey and, Program Outcome Evaluation were given to participants of the suicide training program. Items included demographics, general perception, self-efficacy, and attitude toward suicide prevention. Descriptive statistics were used to describe participants' demographics. t tests were used to compare general perception, attitudes, and self-efficacy scores between pretest and post-program evaluation survey responses. Nonparametric Wilcoxon signed rank analyses for matched pairs were used to compare survey responses that asked about attitudes before and after trainings. Regression analyses were conducted to assess factors associated with general perception, self-efficacy, and attitudes. RESULTS: Participants were more likely to update knowledge after training and reported more confidence to make an intervention for a patient at risk for suicide. CONCLUSION: Our findings suggest that a suicide prevention training program helped pharmacist respondents build confidence in several self-efficacy areas relating to detection of suicide signs, response to patients with suicidal thoughts, reassurance for patients, and provision of resources and referrals.

Pharmacogenomics competencies in pharmacy practice: A blueprint for change.

The emerging use of genomic data to inform medication therapy populates the medical literature and provides evidence for guidelines in the prescribing information for many medications. Despite the availability of pharmacogenomic studies, few pharmacists feel competent to use these new data in patient care. The first pharmacogenomics competency statement for pharmacists was published in 2002. In 2011, the Pharmacogenomics Special Interest Group of the American Association of Colleges of Pharmacy led a process to update this competency statement with the use of a consensus-based method that incorporated input from multiple key professional pharmacy organizations to reflect growth in genomic science as well as the need for pharmacist application of genomic data. Given the rapidly evolving science, educational needs, and practice models in this area, a standardized competency-based approach to pharmacist education and training in pharmacogenomics is needed to equip pharmacists for leadership roles as essential members of health care teams that implement clinical utilization strategies for genomic data.

Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients.

OBJECT This study explored antibiotic prophylaxis (AP) in pediatric patients undergoing intrathecal baclofen pump (ITBP) surgery and factors associated with perioperative AP compliance with clinical guidelines. METHODS Data were obtained from the Pediatric Health Information System. The study cohort comprised patients who underwent ITBP surgery within 3 days of admission, between July 1, 2004, and March 31, 2014, with a minimum prior screening period and follow-up of 180 days. Exclusion criteria were prior infection, antibiotic use within 30 days of admission, and/or missing financial data. Chi-square tests and multivariate logistic regressions were used to determine factors associated with compliance with AP guidelines in ITBP surgeries. RESULTS A total of 1,534 patients met the inclusion criteria; 91.5% received AP and 37.6% received dual coverage or more. Overall bundled compliance comprised 2 components: 1) perioperative antibiotic administration and 2) < 24-hour postoperative antibiotic course. The most frequently used antibiotics in surgery were cefazolin (n = 873, 62.2%) and vancomycin (n = 351, 25%). Documented bundled AP compliance rates were 70.2%, 62.0%, 66.0%, and 55.2% in West, South, Midwest, and Northeast regions of the US, respectively. Compared with surgeries in the Northeast, procedures carried out in the West (OR 2.0, 95% C11.4-2.9, p < 0.001), Midwest (OR 1.6, 95% C11.1-2.3, p = 0.007), and South (OR 1.5, 95% C11.1-2.0, p = 0.021) were more likely to have documented AP compliance. Black (OR 0.74, 95% CI 0.55-1.00, p = 0.05) and Hispanic (OR 0.63, 95% CI 0.47-0.86, p = 0.004) patients were less likely to have documented AP compliance in ITBP surgeries than white patients. There were no significant differences in compliance rate by age, sex, type of insurance, and diagnosis. AP process measures were associated with shorter length of stay, lower hospitalization costs, and lower 6-month rates of surgical infection/complication. One of the 2 noncompliance subgroups, missed preoperative antibiotic administration, was correlated with a significantly higher 6-month surgical complication/infection rate (27.03%) compared with bundled compliance (20.00%, p = 0.021). For the other subgroup, prolonged antibiotic use > 24 hours postoperatively, the rate was insignificantly higher (22.00%, p = 0.368). Thus, of direct relevance to practicing clinicians, missed preoperative antibiotics was associated with 48% higher risk of adverse complication/infection outcome in a 6-month time frame. Adjusted hospitalization costs associated with baclofen pump surgery differed significantly (p < 0.001) with respect to perioperative antibiotic practices: 22.83, 29.10, 37.66 (× 1000 USD) for bundled compliance, missed preoperative antibiotics, and prolonged antibiotic administration, respectively. CONCLUSIONS Significant variation in ITBP antibiotic prophylaxis was found. Documented AP compliance was associated with higher value of care, showing favorable clinical and financial outcomes. Of most impact to clinical outcome, missed preoperative antibiotics was significantly associated with higher risk of 6-month surgical complication/infection. Prolonged antibiotic use was associated with significantly higher hospital costs compared with those with overall bundled antibiotic compliance. Future research is warranted to examine factors associated with practice variation and how AP compliance is associated with outcomes and quality, aiming for improving delivery of care to pediatric patients undergoing ITBP procedures.

The Effect of Health Literacy on Medication Knowledge and Medication Discrepancy in Chinese Americans.

Background. Functional health literacy (FHL) is increasingly recognized as a useful predictor of health outcomes in different populations. However, the effect of FHL on medication knowledge and medication discrepancy in Chinese Americans is not well defined. Objectives. To examine the effects of FHL on medication knowledge and medication discrepancy in Chinese American patients. Methods. This was a cross-sectional study conducted at an academic internal medicine clinic. The Short Test of Functional Health Literacy in Adults was used to assess participants' FHL. Data for patients' demographic information, medication knowledge, and medication discrepancy (direction discrepancy and name discrepancy) were collected through patient interviews and chart reviews. The primary outcome was medication knowledge of purpose and the secondary outcomes included medication direction discrepancy and medication name discrepancy. Results. Of the 158 Chinese American patients who participated in the study, 54% had adequate FHL. More participants with adequate FHL had correct medication knowledge compared to participants with inadequate FHL (87% vs 56%, respectively, odds ratio = 3.4, 95% confidence interval = 1.2-9.7). Fewer participants with adequate FHL had medication direction discrepancy compared to those with inadequate FHL (42% vs 62%, odds ratio = 0.18, 95% confidence interval = 0.06-0.55). Both adequate and inadequate FHL groups had high prevalence of medication name discrepancy (77% vs 89%) even though the between-group difference was insignificant. Conclusions. Adequate FHL among Chinese American patients is significantly associated with increased medication knowledge of purpose and decreased medication direction discrepancy. Both adequate and inadequate FHL groups had high prevalence of medication name discrepancy.

Organizational values: Essential substrate for professional identity formation.

Core organizational values are essential for any organization, including academic institutions. Formal and informal leaders can have a positive, or negative, impact on shaping their culture through the core values. Members of an organization, including students, can be shaped by the organizational values in ways that strengthen, or impede, their professional identity formation. Here, we discuss the use of organizational values as vital substrates needed to shape the desired behaviors and attitudes that will help describe the organizational culture and identity. We define and discuss various types of core values, identify the benefits and challenges of core values alignment, and offer strategies for leaders at all levels to reflect on their own organization's core values and their current approach to their contribution to an effective and sustainable workplace that supports the professional identity formation of all members.

Pharmacist education in the era of genomic medicine.

Pharmacists are increasingly expected to incorporate an understanding of the genomic contributions to medication management in their daily practice,and a general consensus exists that many pharmacists are not adequately prepared to effectively make use of genomic information. In November 2011, the National Human Genome Research Institute of the National Institutes of Health convened a meeting to discuss the status of genomics education for pharmacists. A variety of pharmacist organizations and other stakeholder groups attended the 2-day event and explored the current status of pharmacist genomic education, barriers and facilitators to enhanced education, and important next steps to ensure that pharmacists are prepared for the coming decades. This report summarizes the background, content,and outcomes from this meeting.

Development of a pharmacist-psychiatrist collaborative medication therapy management clinic.

OBJECTIVE: To describe a needs assessment, practice description, practice innovation and reimbursement of a psychiatric pharmacist medication therapy management (MTM) clinic with related challenges and opportunities. SETTING: An MTM clinic established in collaboration with the Outpatient Psychiatric Services (OPS) at the University of California San Diego (UCSD), under contract with the San Diego County Health and Human Services Agency Adult and Older Adult Mental Health Services (A/OAMHS). PRACTICE DESCRIPTION: Two board-certified psychiatric pharmacists provided direct patient care using a collaborative practice protocol 3 days per week. Clinical services included pharmacotherapy management, laboratory monitoring, medication counseling, and psychosocial referrals to other providers. PRACTICE INNOVATION: Payment to UCSD OPS for clinical services was based on a contract between the San Diego County A/OAMHS and the clinic. Two pharmacists co-managed mental health patients and billed for medication management based on face-to-face contact time (medication minutes) and documentation time with each patient. MAIN OUTCOME MEASURES: Number of patients comanaged, dropout rates, visit duration, and billed minutes. RESULTS: From May 2009 to December 2010, two pharmacists comanaged 68 patients, mean (± SD) age 48.6 ± 11.6 years, diagnosed with major depressive, schizophrenic, schizoaffective, and/or bipolar disorder. A total of 56 (82.3%) patients were clinically stable and remained on the pharmacist caseload, but 12 (17.6%) patients were lost to follow-up (10 lost contact, 1 moved, 1 expired). On average, patients had 7.7 patient visits , for 491 total visits (with an average of 26 minutes per visit) that were billed at a rate of $4.82 per minute for medication minutes, translating to $84,542.80. CONCLUSION: With provider education and appropriate physician champions, pharmacists are able to work collaboratively with psychiatrists in a mental health clinic.

Research and Scholarly Methods: Implementation Science Studies.

Traditional research focuses on efficacy or effectiveness of interventions but lacks evaluation of strategies needed for equitable uptake, scalable implementation, and sustainable evidence-based practice transformation. The purpose of this introductory review is to describe key implementation science (IS) concepts as they apply to medication management and pharmacy practice, and to provide guidance on literature review with an IS lens. There are five key ingredients of IS, including: (1) evidence-based intervention; (2) implementation strategies; (3) IS theory, model, or framework; (4) IS outcomes and measures; and (5) stakeholder engagement, which is key to a successful implementation. These key ingredients apply across the three stages of IS research: (1) pre-implementation; (2) implementation; and (3) sustainment. A case example using a combination of IS models, PRISM (Practical, Robust Implementation and Sustainability model) and RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance), is included to describe how an IS study is designed and conducted. This case is a cluster randomized trial comparing two clinical decision support tools to improve guideline-concordant prescribing for patients with heart failure and reduced ejection fraction. The review also includes information on the Standards for Reporting Implementation Studies (StaRI), which is used for literature review and reporting of IS studies,as well as IS-related learning resources.

The interface between U.S. primary care clinics and pharmacies for HPV vaccination delivery: A scoping literature review.

Completion of the Human Papilloma Virus (HPV) vaccine series remains low. Partnerships between primary care (PC) clinics and local pharmacies could boost vaccination rates. We conducted a scoping literature review to address what is known and what gaps exist on the interface between U.S. primary care clinics and pharmacies for HPV vaccination. We searched Ovid MEDLINE ALL file and Cumulative Index to Allied Health Literature for articles published between 1/1/2010 and 12/31/2020. Search subjects included: 1) Pharmacy HPV Vaccination, 2) Pharmacy/PC Collaboration, and 3) Pharmacy/PC Collaboration vaccination. We developed an abstraction form to collect information on research methods, settings, strengths, weaknesses and findings. We screened 407 articles for inclusion; 17 met inclusion criteria: 13 (76.5%) reported on observational/descriptive studies; 4 articles (23.5%) reported on intervention studies, none of which were conducted in rural areas. Observational studies focused on willingness to be vaccinated for HPV and facilitators and barriers for vaccination, especially at pharmacies. Many studies concluded that knowledge about and comfort with HPV vaccine administration were needed for all vaccination stakeholders (clinicians, pharmacists, parents, and patients). Intervention studies were small with weak study designs, many of which revealed that pharmacists were not successful in integrating services into broader primary care systems. Challenges included getting physicians to sign standing order protocols, poor service delivery due to engagement barriers, and low parental demand for pharmacists to administer the vaccine. In conclusion, larger more discerning studies are needed to fully understand the potential of primary care and pharmacy interactions for HPV vaccination.

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System--MEADERS.

PURPOSE: In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices. METHODS: We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. RESULTS: A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting. CONCLUSIONS: It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.

Pharmacogenomics: bridging the gap between science and practice.

OBJECTIVE: To educate pharmacists about principles and concepts in pharmacogenomics, clinical applications of pharmacogenomic information, and the social, ethical, and legal aspects of pharmacogenomics and to describe a Centers for Disease Control and Prevention (CDC)-supported pharmacogenomics education program for pharmacists and other health professionals. DATA SOURCES: Primary literature from PubMed, recommendations from the Food and Drug Administration and Evaluation of Genomic Applications in Practice and Prevention Working Group, prescribing information, websites of government agencies and professional organizations, and relevant textbooks. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Principles and concepts of pharmacogenomic nomenclature, polymorphism types, and systematic approach to understanding polymorphisms were reviewed. Drug therapy for select therapeutic areas that highlight the applicability of pharmacogenomics are presented, including abacavir, selective serotonin reuptake inhibitors, tamoxifen, and warfarin. Challenges of translating pharmacogenomics into clinical practice included ethical, social, legal, and economic issues. We have developed a pharmacogenomics education program to disseminate evidence-based pharmacogenomics information and provide a resource for health professionals, including pharmacists. CONCLUSION: Pharmacists play a critical role in the education of patients and health professionals in the area of pharmacogenomics.

Development of an innovative adult attention-deficit hyperactivity disorder clinic.

Pharmacist-psychiatrist collaborative clinic models in specialty mental health clinics are limited, and there has been only 1 report of a clinic focused on adult attention-deficit hyperactivity disorder (ADHD). In this article, we describe the successful implementation of a pharmacist-psychiatrist collaborative practice agreement in an adult ADHD clinic at an academic medical center. Adult patients diagnosed with ADHD after a comprehensive assessment, including a full neuropsychological evaluation, were enrolled in the collaborative treatment clinic. The collaboration was a partnership between a psychiatry department and a school of pharmacy at a public university. We report the details of 58 patients and 774 patient encounters at the collaborative pharmacist-psychiatrist practice from March 2015 through June 2018. The visits were billed using traditional medical billing codes for follow-up visits. Pharmacist practice opportunities included psychiatric evaluation, medication management, counseling, and referral to auxiliary services. Challenges to the clinic's success included limited pharmacist time, prescriptive authority, and reimbursement for services from payors. A collaborative practice model targeted at adult ADHD patients may be a unique clinic setting for psychiatric pharmacists.

Development of a community-academic collaborative pharmacy residency program.

PURPOSE: To describe the development of a collaborative community-academic postgraduate year 1 pharmacy residency program in San Diego that provides a hybrid experience of opportunities in community practice, ambulatory care, and teaching. SUMMARY: Residency training programs are being developed to better match the evolving role of the community pharmacist. In 2016, the University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences partnered with Ralphs Pharmacy, a division of the Kroger Co., to launch a 1-year community residency to develop community-based pharmacists with diverse patient care, leadership, and education skills. Learning experiences include pharmacy operations, clinical services focusing on chronic disease management and education, teaching, and practice-based research. Training settings include community pharmacy, corporate pharmacy, ambulatory care, and academia. Graduates are prepared to work in these settings as well as capitalize on advanced training opportunities, including postgraduate year 2 residencies and professional certifications. The program has been successfully accredited, and graduates have completed the program: one completed a postgraduate year 2 residency, and both have obtained a management or clinical pharmacist position. CONCLUSION: An innovative community-academic residency program preparing postgraduate year 1 learners for careers in community-based pharmacy, corporate, ambulatory care, and academic settings was developed, with positive preliminary outcomes.

Conducting medication safety research projects in a primary care physician practice-based research network.

OBJECTIVE: To describe a roadmap for developing a practice-based research network (PBRN) through the experience of conducting medication safety research projects in a primary care physician PBRN. SETTING: Southern Primary-care Urban Research Network (SPUR-Net) in Houston, Tex., from 2000 to 2007. PRACTICE DESCRIPTION: SPUR-Net is a partnership of six health care organizations in Houston and includes 32 clinics with 313 primary care clinicians (50% family physicians, 25% general internists, and 25% pediatricians) who provide care for approximately 1 million patient encounters annually. PRACTICE INNOVATION: The pharmacist principal investigator collaborates with physicians and researchers in primary care clinics to investigate medication safety practice in SPUR-Net. MAIN OUTCOME MEASURES: (1) A roadmap for PBRN research and (2) initiation of a research program focusing on medication safety through the PBRN. RESULTS: A roadmap with 10 steps for conducting practice-based research is recommended: (1) form collaborative partnership, (2) develop research infrastructure, (3) formulate research questions, (4) design study methods, (5) obtain funding support, (6) develop study instruments, (7) implement the study, (8) manage and analyze data, (9) disseminate results, and (10) translate research into practice. Four research projects focusing on medication safety were conducted in SPUR-Net from 2002 to 2007. Medication outcomes include improved medication use, increased awareness for medication counseling, decreased medication errors, and identification of best practices for medication reconciliation. CONCLUSION: Practice-based research conducted in primary care settings identifies, studies, and evaluates common problems encountered in busy clinic practice. With feedback from stakeholders, best practices and improved practice can be identified and "translated" back to practice. Grant funding for research projects helps sustain PBRNs. The implementation of medication safety research projects has helped primary care clinics, clinicians, and patients increase appropriate medication use and explore ways to further improve medication safety.

Evaluation of a shared pharmacogenomics curriculum for pharmacy students.

AIM: This national dissemination study evaluated pharmacy students' self-reported overall ability, self-efficacy and attitudes toward applying pharmacogenomics and perceptions of Pharmacogenomics Education Program, a shared pharmacogenomics curriculum. PATIENTS & METHODS: Following a series of train-the-trainer programs for pharmacy faculty, pre- (n = 2674) and post-training surveys (n = 2542) were administered to Doctor of Pharmacy students (n = 43 pharmacy schools). RESULTS: Students reported increased (pre- vs post-training) overall ability to educate patients about pharmacogenomics (17 vs 63%; p < 0.0001) and pharmacogenomic testing (11 vs 60%; p < 0.0001) and increased self-efficacy for identifying therapeutic areas for which pharmacogenomic testing is required (20 vs 75%; p < 0.0001). Most (92%) agreed that students at other schools would benefit from receiving the same, or similar, pharmacogenomics education. CONCLUSION: A shared curriculum is an effective approach for broadscale curricular dissemination. Original submitted 17 October 2014; Revision submitted 19 December 2014.

A system to build distributed multivariate models and manage disparate data sharing policies: implementation in the scalable national network for effectiveness research.

BACKGROUND: Centralized and federated models for sharing data in research networks currently exist. To build multivariate data analysis for centralized networks, transfer of patient-level data to a central computation resource is necessary. The authors implemented distributed multivariate models for federated networks in which patient-level data is kept at each site and data exchange policies are managed in a study-centric manner. OBJECTIVE: The objective was to implement infrastructure that supports the functionality of some existing research networks (e.g., cohort discovery, workflow management, and estimation of multivariate analytic models on centralized data) while adding additional important new features, such as algorithms for distributed iterative multivariate models, a graphical interface for multivariate model specification, synchronous and asynchronous response to network queries, investigator-initiated studies, and study-based control of staff, protocols, and data sharing policies. MATERIALS AND METHODS: Based on the requirements gathered from statisticians, administrators, and investigators from multiple institutions, the authors developed infrastructure and tools to support multisite comparative effectiveness studies using web services for multivariate statistical estimation in the SCANNER federated network. RESULTS: The authors implemented massively parallel (map-reduce) computation methods and a new policy management system to enable each study initiated by network participants to define the ways in which data may be processed, managed, queried, and shared. The authors illustrated the use of these systems among institutions with highly different policies and operating under different state laws. DISCUSSION AND CONCLUSION: Federated research networks need not limit distributed query functionality to count queries, cohort discovery, or independently estimated analytic models. Multivariate analyses can be efficiently and securely conducted without patient-level data transport, allowing institutions with strict local data storage requirements to participate in sophisticated analyses based on federated research networks.