Prescriber and pharmacist attitudes toward inclusion of diagnosis or clinical indication on prescription orders.

BACKGROUND: Pharmacy and medication safety organizations have long recommended that diagnosis or clinical indication be required on medication orders to improve the safety and effectiveness of care. OBJECTIVE: To assess attitudes of Arizona prescribers and pharmacists toward the inclusion of the clinical indication or the diagnosis on prescription orders and perceived barriers to its implementation in Arizona. METHODS: Data were obtained by questionnaires from pharmacists and primary care prescribers after a continuing pharmacy education presentation on the value of including a clinical indication or a diagnosis on prescription orders. The survey was distributed to licensed pharmacists who attended the Arizona Pharmacy Association's Southwest Clinical Pharmacy Seminar. The survey was distributed to primary care providers with active Arizona licenses who attended the Arizona Osteopathic Medical Association Annual Convention and to nurse practitioners after an Arizona Nurse Practitioner Council educational webinar. Prescriber and pharmacist responses were compared using the Mann-Whitney U test. An a priori alpha of 0.05 was used, and in the cases of multiple comparisons, a Bonferroni correction was employed. RESULTS: A total of 74 complete questionnaires were submitted by prescribers and 54 by pharmacists. Approximately 71% of the prescribers and 66% of the pharmacists agreed that they would support voluntary inclusion of a diagnosis or a clinical indication on prescription orders (P = 0.81). However, the 2 groups disagreed on whether the inclusion of the diagnosis or clinical indication should be a requirement (44% of prescribers agreed vs. 96% of pharmacists, P < 0.001). Two perceived barriers revealed statistically significant differences, with the prescribers being more concerned about possible insurance rejections than pharmacists (P = 0.005, whereas the pharmacists were more concerned about potential software transmission accuracy than prescribers (P < 0.001). CONCLUSION: Arizona prescribers and pharmacists in our convenience sample supported the voluntary inclusion of a diagnosis or a clinical indication on prescriptions orders but disagreed as to whether it should be required. Prescribers especially indicated they have a variety of concerns that need to be overcome before they could support a statewide mandate.

10 ways to improve medication safety in community pharmacies.

DATA SOURCES: Not applicable. SUMMARY: Since at least the time of Hippocrates, health care providers have recognized their responsibility to protect patients from potential harm resulting from the care they provide. In pharmacy, such harm typically results from a violation of any of the "5 rights" of safe medication use. However, a memorable adage stops short of providing operational guidance to improve medication safety. Specific actionable recommendations are needed to identify changes that, if implemented, would significantly improve the safety of medication delivery and use. CONCLUSION: Most threats to medication safety result from weaknesses or failures in one or more of the key system elements identified by the Institute for Safe Medication Practices. Pharmacists should be advocates for implementing targeted recommendations to strengthen their practice systems and improve medication safety.

Apocalypse Now?

Despite the wishful thinking of those who have long prophesied an imminent surge in demand for clinical pharmacists, the tipping point for healthy supply-demand balance in pharmacy has almost certainly been surpassed. Imprudent overbuilding of pharmacy programs has combined with trends toward increasing automation and consolidation in pharmacy practice to create an existential threat in pharmacy education. Surviving the looming industry shakeout will require schools and colleges of pharmacy to do what our colleagues in practice and the private sector have always done: compete.

Check it out: A practical tool for improving medication safety.

OBJECTIVE: To recommend incorporation of a prospective drug utilization review (DUR) checklist into the routine processing of prescription orders in the community practice setting to improve the quality and safety of pharmaceutical care. PRACTICE INNOVATION: We proposed a checklist that was designed to include all the elements of a prospective DUR required by the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) and most pharmacy practice acts. CONCLUSION: If properly incorporated into workflow and supported by company policies and procedures, a simple DUR checklist like that proposed in this study could significantly improve the quality of pharmacists' prospective DUR activities and the safety of medication therapy provided to patients. We also recommend that future quality metrics be created and implemented to ensure that pharmacists consistently perform this key professional responsibility.

Stakeholder views on requiring diagnosis or clinical indication on e-prescriptions.

BACKGROUND: Medication safety organizations have been recommending the inclusion of diagnosis or clinical indication on prescription orders for decades. However, this information is typically not provided by prescribers and shared with pharmacists, despite the availability of data fields in the most commonly used standard for electronic prescriptions. OBJECTIVE: To elucidate the views of selected industry stakeholders relative to perceived barriers to including diagnosis or indication on all electronic prescriptions. METHODS: Semistructured concept elicitation interviews identified key issues. Survey items were refined iteratively by the research team. The final instrument consisted of 34 questions intended to elicit the importance and relative priority of perceived barriers and potential solutions. A link to the Internet survey was emailed to members of the National Council for Prescription Drug Programs in February 2023, with biweekly follow-up reminders. RESULTS: A total of 139 surveys were analyzed for a response rate of 9.6%. On the importance of resolving issues related to the inclusion of diagnosis or indication on e-prescriptions, a majority of respondents indicated "extremely important" or "very important" for all items except one. On level of agreement with statements about how to implement such a requirement, a majority indicated "strongly agree" or "agree" for 10 of 17 items. CONCLUSIONS: Although clearly exploratory, the results of our survey suggest industry stakeholder agreement that uniform inclusion of diagnosis or clinical indication on all e-prescriptions would improve patient safety and health outcomes. A number of important questions and potential barriers must be resolved for implementation to be successful.

A Critical Look at Student Evaluations of Teaching.

Student evaluations of teaching are used at many schools and colleges of pharmacy as the primary, often exclusive, means of assessing the quality of instruction and instructor performance. As such, they can be pivotal in annual performance evaluations and rank and tenure decisions. However, serious concerns have been raised about these ubiquitous surveys and how, or even if, they should be used to measure the quality of instruction or the performance of the instructor. This commentary discusses concerns that have been raised about using student evaluations of teaching scores to assess teaching performance and offers recommendations for how they can be better interpreted and used in schools and colleges of pharmacy.

Analyzing the costs to deliver medication therapy management services.

OBJECTIVES: To provide pharmacy managers and consultant pharmacists with a step-by-step approach for analyzing of the costs of delivering medication therapy management (MTM) services and to describe use of a free online software application for determining costs of delivering MTM. PRACTICE DESCRIPTION: The process described is applicable to community pharmacies and consultant pharmacists who provide MTM services from nonpharmacy settings. PRACTICE INNOVATION: The PharmAccount Service Cost Calculator is an Internet- based software application that uses a guided online interview to collect information needed to conduct a comprehensive cost analysis of any specialized pharmacy service. In addition to direct variable and fixed costs, the software automatically allocates indirect and overhead costs to the service and generates an itemized report that details the components of service delivery costs. RESULTS: The service cost calculator is sufficiently flexible to support the analysis of virtually any specialized pharmacy service, irrespective of whether the service is being delivered from a physical pharmacy. The software application allows users to perform sensitivity analysis to quickly determine the potential impact that alternate scenarios would have on service delivery cost. It is therefore particularly well suited to assist in the design and planning of a new pharmacy service. CONCLUSION: Good management requires that the cost implications of service delivery decisions are known and considered. Analyzing the cost of an MTM service is an important step in developing a sustainable business model.

Indication or diagnosis should be required on prescriptions.

Although prospective drug utilization review and patient counseling have long been recognized as professional and ethical responsibilities of pharmacists, the implementation of the Omnibus Budget Reconciliation Act of 1990 made them legal responsibilities. Ensuring the safety and effectiveness of prescription pharmaceutical care requires that all members of the prescriber-patient-pharmacist triad are equally informed about the therapeutic plan for which the pharmacist is professionally, ethically, and legally responsible for properly implementing. Providing pharmacists with the clinical indication or diagnosis is an important and long overdue first step. DISCLOSURES: No funding was received for the writing of this article. Warholak has received grant funding through the University of Arizona from Sinfonia Rx, Pharmacy Quality Alliance, and the Arizona Department of Health Services, unrelated to this work. The other authors have nothing to disclose.

To Reform Pharmacy Reimbursement Begin with the Basics.

DISCLOSURES: No funding supported the writing of this commentary. The author has nothing to disclose.

Analysis of community chain pharmacists' interventions on electronic prescriptions.

OBJECTIVE: To measure the incidence and nature of prescribing errors on electronic prescriptions (e-prescriptions) that required active intervention by dispensing pharmacists to correct. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: 122 chain community pharmacies that met a prior minimum dispensing volume of five e-prescriptions per day in five states during July through September 2006. PARTICIPANTS: Pharmacists in participating pharmacies. INTERVENTION: A panel of participating pharmacists reported their medication therapy interventions using a standardized documentation protocol. MAIN OUTCOME MEASURES: Number, type, and reason for pharmacist interventions on e-prescriptions. RESULTS: Data were reported from 68 participating chain pharmacies in five states during 312 work shifts. During the study pharmacists reviewed 2,690 e-prescription orders (new, 83.0%; refill, 17.0%) and took action 102 times for an intervention rate of 3.8%. The rate at which pharmacists identified problems on new e-prescriptions was found to be nearly twice that of refills (4.1% and 2.2%, respectively). The most common reason for pharmacists' interventions on e-prescriptions was to supplement omitted information (31.9%), especially missing directions. Dosing errors were also quite common (17.7%). The most common response by pharmacists to e-prescription problems was to contact the prescriber (64.1%), consult the patient's profile or medication history (12.8%), or interview the patient or the patient's representative (9.4%). In most cases (56%), the e-prescription order was changed and the prescription was ultimately dispensed. In 15% of cases the e-prescription was dispensed as written following clarification by the prescriber. In 10% of cases the prescription was not dispensed. An additional 12% of prescription issues remained unresolved. Pharmacists required an average of 6.07 minutes to conduct their interventions on problematic e-prescription orders, representing an incremental dispensing cost of $4.74. CONCLUSION: Electronic prescribing can improve the safety and effectiveness of patient care. As currently implemented in the community practice setting, this still-emerging technology maintains selected threats to both medication safety and effectiveness, although probably less than handwritten prescriptions. The adoption of selected best practice recommendations by prescribers could improve the safety, effectiveness, and efficiency of e-prescribing.

Assessing the Quality of Pharmacy Care: It's Not About Adherence.

DISCLOSURES: No funding supported the writing of this article. The author has nothing to disclose.

Encouraging Students to Challenge Assumptions.

Sound logical reasoning requires a critical examination of all available evidence and the willingness and ability to challenge key assumptions implicit in the conclusions we reach and the informed decisions we make. Student pharmacists should be encouraged to recognize and challenge assumptions that practicing pharmacists frequently make, which threaten patient safety.

Evaluation of e-prescribing in chain community pharmacy: best-practice recommendations.

OBJECTIVES: To measure the attitudes and beliefs of community-based pharmacists and technicians toward electronic prescribing (e-prescribing) and the processing of e-prescriptions and to generate best-practice recommendations for changes to improve e-prescribing in the community setting. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: 422 chain community pharmacies in six states that met a minimum dispensing volume of five e-prescriptions per day. Data were collected between April and July 2006. PARTICIPANTS: Pharmacists, technicians, and student interns. INTERVENTION: Receiving, processing, and dispensing of e-prescriptions assessed via self-administered survey and follow-up interviews of key pharmacy operations and information technology management in each participating chain pharmacy organization. MAIN OUTCOME MEASURES: Attitudes, beliefs, and satisfaction of pharmacy personnel regarding e-prescribing, compared with conventional prescribing, and recommendations for improving e-prescribing in the community practice setting. RESULTS: 1,094 surveys were returned from pharmacy personnel practicing in 276 chain community pharmacies. Pharmacy personnel preferred e-prescriptions over conventional prescriptions on each of seven desired outcomes of care. Pharmacists were found to view e-prescribing more positively than technicians (P < 0.05) for its net effect on three key outcomes: patient safety, effectiveness of care, and efficiency of care. A total of 2,235 written comments were received on the returned surveys. Of these, 57% (1,277) mentioned negative features of e-prescribing, while 43% (958) noted positive features. Improved clarity and/or legibility of prescriptions was the most frequently cited advantage of e-prescribing, followed closely by improved speed or efficiency of processing. Prescribing errors were the most commonly cited negative feature of e-prescribing, particularly those stating a wrong drug or wrong directions. CONCLUSION: Pharmacy personnel were generally satisfied with the current status of e-prescribing, but they also perceive key weaknesses in how it has been implemented in physicians' practices and their own organizations. A total of 11 best-practice recommendations are offered to improve e-prescribing in the chain community pharmacy setting.

Assessing Quality of Care in Pharmacy: Remembering Donabedian.

While some incremental and fragmented progress has been made in recent years, assessing the quality of care provided by pharmacists and pharmacy organizations remains an elusive goal. Revisiting the simple, elegant model of quality assessment originally proposed by physician and scholar Avedis Donabedian can assist pharmacy quality managers to develop a more comprehensive approach to measuring, monitoring, and managing the quality of care. DISCLOSURES: No funding supported the writing of this article. The author has no relevant conflicts of interest to disclose.

Quality and Variability of Patient Directions in Electronic Prescriptions in the Ambulatory Care Setting.

BACKGROUND: The prescriber's directions to the patient (Sig) are one of the most quality-sensitive components of a prescription order. Owing to their free-text format, the Sig data that are transmitted in electronic prescriptions (e-prescriptions) have the potential to produce interpretation challenges at receiving pharmacies that may threaten patient safety and also negatively affect medication labeling and patient counseling. Ensuring that all data transmitted in the e-prescription are complete and unambiguous is essential for minimizing disruptions in workflow at prescribers' offices and receiving pharmacies and optimizing the safety and effectiveness of patient care. OBJECTIVES: To (a) assess the quality and variability of free-text Sig strings in ambulatory e-prescriptions and (b) propose best-practice recommendations to improve the use of this quality-sensitive field. METHODS: A retrospective qualitative analysis was performed on a nationally representative sample of 25,000 e-prescriptions issued by 22,152 community-based prescribers across the United States using 501 electronic health records (EHRs) or e-prescribing software applications. The content of Sig text strings in e-prescriptions was classified according to a Sig classification scheme developed with guidance from an expert advisory panel. The Sig text strings were also analyzed for quality-related events (QREs). For purposes of this analysis, QREs were defined as Sig text content that could impair accurate and unambiguous interpretation by staff at receiving pharmacies. RESULTS: A total of 3,797 unique Sig concepts were identified in the 25,000 Sig text strings analyzed; more than 50% of all Sigs could be categorized into 25 unique Sig concepts. Even Sig strings that expressed apparently simple and straightforward concepts displayed substantial variability; for example, the sample contained 832 permutations of words and phrases used to convey the Sig concept of "Take 1 tablet by mouth once daily." Approximately 10% of Sigs contained QREs that could pose patient safety risks or workflow disruptions that could necessitate pharmacist callbacks to prescribers for clarification or other manual interventions. CONCLUSIONS: The quality of free-text patient directions in e-prescriptions can vary dramatically. However, more than half of all patient directions sent in the ambulatory setting can be categorized into only 25 Sig concepts. This suggests an immediate, practical opportunity to improve patient safety and workflow efficiency for both prescribers and pharmacies. Recommendations include implementing enhancements to Sig creation tools in e-prescribing and EHR software applications, adoption of the Structured and Codified Sig format supported by the current national e-prescribing standard, and improved usability testing and end-user training for generating complete and unambiguous patient directions. Such quality improvements are essential for optimizing the safety and effectiveness of patient care as well as for minimizing workflow disruptions to both prescribers and pharmacies. DISCLOSURES: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Yang, Ward-Charlerie, Dhavle, and Green are employed by Surescripts. Rupp reported receiving consulting fees from Surescripts during the conduct of this study. No other disclosures were reported. The content in this article is solely the responsibility of the authors and does not necessarily represent the official views of Surescripts and Midwestern University or any of the affiliated institutions of the authors. Study concept and design were contributed by all the authors. Yang and Ward-Charlerie collected the data, and data interpretion was performed by Yang, Ward-Charlerie and Dhavle. The manuscript was primarily written by Yang, along with Dhavle and Green, and revised by Yang, Dhavle, Rupp, and Green.

Improving Clinical Decision Support in Pharmacy: Toward the Perfect DUR Alert.

The cornerstone of every health care profession is decision making. Historically, the decisions made by pharmacists have focused on ensuring the accuracy and physical integrity of the pharmaceutical product delivered to the patient in strict compliance with the prescriber's order. As the role of the pharmacist evolved over the past half century, the focus of decision making progressively shifted from a product-centric orientation to optimizing the interaction that occurs between the pharmaceutical product and the patient. Toward that end, prospective drug utilization review (pro-DUR) represents, perhaps, the quintessential expression of the pharmacist's contemporary clinical role. Fueled by evolving practice standards, innovations in information technology, and legal mandates such as The Omnibus Budget Reconciliation Act of 1990, computer-assisted pro-DUR systems have become a ubiquitous component of pharmacy practice. While these data-driven clinical decision support systems have clearly demonstrated their ability to improve the quality and safety of medication delivery and use, they have yet to fully achieve their promised potential. Doing so will require recognition of continuing shortcomings and a shared commitment by all stakeholders to develop and adhere to best practice guidelines that will better ensure that alerts received by practitioners are valid, interpretable, clinically significant, and actionable. DISCLOSURES: The authors received no funding for this article. Rupp discloses consultancy fees from Surescripts unrelated to this manuscript. Both authors contributed equally to concept, analysis, and manuscript preparation.

Evaluation of a guided continuous quality improvement program in community pharmacies.

BACKGROUND: The importance of creating and sustaining a strong culture of patient safety has been recognized as a critical component of safe medication use. This study aims to assess changes in attitudes toward patient safety culture and frequency of quality-related event (QRE) reporting after guided implementation of a continuous quality improvement (CQI) program in a panel of community pharmacies in the United States (U.S.). METHODS: Twenty-one community pharmacies volunteered to participate in the project and were randomly assigned to intervention or control groups. Pharmacy staff in the intervention group received guided training to ensure full implementation of a CQI program while those in the control group partially implemented the program. Pharmacy staff in both groups completed retrospective pre-post safety culture questionnaires and reported medication errors and near misses that occurred in their practices. Rasch analysis was applied to assess questionnaire validity and reliability and to confirm if the ordinal level data approximated interval level measures. Paired t-tests and repeated measure analysis of covariance tests were subsequently used to compare observed changes in the attitudes of subjects and frequency of QREs reporting in intervention and control groups. RESULTS: Sixty-nine employees completed the questionnaire, a 43.9% response rate. Improvement in attitudes toward patient safety was statistically significant in the intervention group in six domains: staff, training, and skill (p = 0.017); patient counseling (p = 0.043); communication about mistakes (p < 0.001); response to mistakes (p < 0.001); organizational learning - continuous improvement (p < 0.001); and overall patient safety perceptions (p = 0.033). No significant differences were observed in QRE reporting rates between intervention and control groups. However, differences were observed in the types of QREs reported (e.g., incorrect safety cap) and the point in the prescription processing workflow where a QRE was detected (e.g., partner check station, and drug utilization review station) in the intervention group (p < 0.001). CONCLUSION: Guided CQI program implementation increased the self-reported patient safety culture attitudes among staff.

Analysis of Prescribers' Notes in Electronic Prescriptions in Ambulatory Practice.

IMPORTANCE: The optional free-text Notes field in ambulatory electronic prescriptions (e-prescriptions) allows prescribers to communicate additional prescription-related information to dispensing pharmacists. However, populating this field with irrelevant or inappropriate information can create confusion, workflow disruptions, and potential patient harm. OBJECTIVES: To analyze the content of free-text prescriber notes in new ambulatory e-prescriptions and to develop recommendations to improve e-prescribing practices. DESIGN, SETTING, AND PARTICIPANTS: We performed a qualitative analysis of e-prescriptions containing free-text prescriber notes for conformance to the intended purpose of the free-text field as established in the national e-prescribing standard. The study sample contained 26 341 new e-prescriptions randomly selected from 3 024 737 e-prescriptions containing notes transmitted to community pharmacies across the United States during a 1-week period (November 10-16, 2013). The study e-prescriptions were issued by 22 549 community-based prescribers using 492 different electronic health record (EHR) or e-prescribing software application systems. Data analysis was conducted from February 23, 2014, to November 4, 2015. MAIN OUTCOMES AND MEASURES: Reviewers classified free-text prescriber notes as appropriate, inappropriate (content for which a standard, structured data-entry field is available in the widely implemented national e-prescribing standard), or unnecessary (irrelevant to dispensing pharmacists). We developed and applied a classification scheme to further characterize and quantify types of appropriate and inappropriate content. RESULTS: Of the 26 341 free-text notes, 17 421 (66.1%) contained inappropriate content, 7522 (28.6%) contained appropriate content, and 1398 (5.3%) contained information considered to be unnecessary. Further characterization of inappropriate content resulted in 20 192 classification codes, of which 3841 codes (19.0%) were assigned because of patient directions that conflicted with directions included in the designated standard field intended for this purpose. Characterization of appropriate content resulted in 7785 classification codes, of which 3685 (47.3%) contained information that could be communicated using structured fields already approved in a yet-to-be implemented version of the e-prescribing standard. An additional 745 (9.6%) were prescription cancellation requests for which a separate e-prescribing message currently exists but is not widely supported by software vendors or used by prescribers. CONCLUSIONS AND RELEVANCE: The free-text Notes field in e-prescriptions is frequently used inappropriately, suggesting the need for better prerelease usability testing, consistent end user training and feedback, and rigorous postmarketing evaluation and surveillance of EHR or e-prescribing software applications. Accelerated implementation of new e-prescribing standards and rapid adoption of existing ones could also reduce prescribers' reliance on free-text use in ambulatory e-prescriptions.