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.

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.

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.

Work Group Report: COVID-19: Unmasking Telemedicine.

Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic. Telemedicine provides increased access to medical care and helps to mitigate risk by conserving personal protective equipment and providing for social/physical distancing to continue to treat patients with a variety of allergic and immunologic conditions. During this time, many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in their practices while studying the complex and variable issues surrounding its regulation and reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with patient care in the setting of COVID-19. Other changes are ongoing at the time of this publication. Members of the Telemedicine Work Group in the American Academy of Allergy, Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub Med resources through May 9, 2020, to detail Pre-COVID-19 telemedicine knowledge and outline up-to-date telemedicine material. This work group report was developed to provide guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine landscape.

To Reform Pharmacy Reimbursement Begin with the Basics.

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

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.

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.

Examining associations between action game play and motor control.

The effects of playing action video games have been investigated across a wide range of attentional and cognitive abilities. However, few studies have examined the association between motor control and action gaming experience. We report data from two discrete pointing tasks, manipulating the index of difficulty (ID) by movement distance and target size, respectively. Participants' gaming experience ranged from non-players to individuals who played several hours a night. Our results indicated greater experience playing action games, but not video games in general, was associated with shorter movement times (MT), higher velocities, and shallower ID-MT slopes when difficulty was manipulated across increasingly further distances and smaller target sizes. Additionally casual players, those who only play action games a couple times a week, were able to achieve a similar level of performance as more experienced players.

The role of individual differences on perceptions of wearable fitness device trust, usability, and motivational impact.

Lack of physical activity is a severe health concern in the United States with fewer than half of all Americans meeting the recommended weekly physical activity guidelines. Although wearable fitness devices can be effective in motivating people to be active, consumers are abandoning this technology soon after purchase. We examined the impact of several user (i.e. personality, age, computer self-efficacy, physical activity level) and device characteristics (trust, usability, and motivational affordances) on the behavioral intentions to use a wearable fitness device. Novice users completed a brief interaction with a fitness device similar to a first purchase experience before completing questionnaires about their interaction. We found computer self-efficacy, physical activity level, as well as personality traits indirectly increased the desire to use a fitness device and influenced the saliency of perceived motivational affordances. Additionally, trust, usability, and perceived motivational affordances were associated with increased intentions to use fitness devices.

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.

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.

Searching for Affective and Cognitive Restoration: Examining the Restorative Effects of Casual Video Game Play.

OBJECTIVE: We investigated the effects of a passive break, relaxation activity, and casual video game on affect, stress, engagement, and cognitive performance. BACKGROUND: Reducing stress and improving cognitive performance is critical across many domains. Previous studies investigated taking a break, relaxation techniques, or playing a game; however, these methods have not been compared within a single experiment. METHOD: Participants completed a baseline affective and cognitive assessment (ACA), which included the Positive and Negative Affect Schedule, shortened version of the Dundee Stress State Questionnaire, and backward digit-span. Next, participants completed a vigilance task, followed by another ACA. Participants were then assigned at random to complete a break or relaxation activity or play a casual video game, followed by a final ACA. RESULTS: Participants who played the casual video game exhibited greater engagement and affective restoration than the relaxation condition. The break condition slightly decreased affect and prevented cognitive restoration. CONCLUSION: Playing a casual video game even briefly can restore individuals' affective abilities, making it a suitable activity to restore mood in response to stress. However, future research is needed to find activities capable of cognitive restoration. APPLICATION: Many activities in life require sustained cognitive demand, which are stressful and decrease performance, especially for workers in performance-critical domains. Our research suggests some leisure activities are better than others for restoring fatigued affective processes.

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.