Medication interventions get a boost from a powerful tool

An important aspect of patient management is documentation of medication interventions, and pharmacists in health-system settings have followed this practice for many years. Interventions documented in the United States and abroad have concerned critically ill and other hospitalized patients,^1-3 elderly outpatients,^4,5 residents in geriatric nursing facilities,⁶ patients in hospital emergency departments,⁷ and others.

Pharmacists' mission in patient care, according to the Statement on Pharmaceutical Care issued by the American Society of Health-System Pharmacists (ASHP), involves the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient's quality of life.⁸ Pharmacists can improve patient outcomes by following 3 major functions: identification of potential and actual medication-related problems (MRPs), resolution of actual MRPs, and prevention of potential MRPs.

The best way to achieve these goals is through accurate documentation, and one of the chief obstacles to this is time-or rather the lack of it.

Various software programs have been developed to help pharmacists reduce time spent identifying opportunities for interventions. Among them, from Pharmacy OneSource, is Sentri7: a real-time, electronic patient-surveillance and clinical support system.^9,10 This program can be used by pharmacists, quality/case managers, performance-improvement personnel, infectious-disease specialists, risk managers, nutritionists, and others to optimize performance toward fulfillment of such quality measures as those outlined by Centers for Medicare and Medicaid Services (CMS) and the Joint Commission's National Patient Safety Goals. The program can also be applied to Healthcare Effectiveness Data and Information Set (HEDIS) measures for National Committee for Quality Assurance (NCQA) performance improvement in managed-care organizations (MCOs) and pharmacy benefit management (PBM) settings.

Sentri7 is a web-based prospective system that integrates hospital data such as laboratory values, patient demographics, and medications (but not retrospective data) using real-time patient surveillance. With defined rules, clinical interventions can be easily tasked and performed. A sample patient profile can be seen in Figure 1.

Types of clinical interventions include:
• Use of antidotes throughout the hospital;
• Monitoring of pneumococcal vaccination;
• Use of aspirin and beta-blockers after myocardial infarction;
• Tracking of positive cases of influenza and other communicable diseases for report to public health departments;
• Alerts for any patients with positive cultures for methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, or other hospital-acquired infections;
• Tracking of patients who are on total parenteral nutrition;
• Allergy-avoidance interventions;
• Tracking of patients with International Normalized Ratios (INRs) out of range;
• Lists of patients on inhalers or nebulizers;
• Identification of patients at high risk for falls (eg, by matching demographics with medication lists);
• Identification of patients taking warfarin for diets low in vitamin K;
• Identification of patients in need of pain consults;
• Identification of patients in need of stress-ulcer prophylaxis;
• Identification of patients taking heparin or other drugs that can cause thrombocytopenia;
• Identification of patients taking drugs with potential to cause serious adverse reactions;
• Identification of patients receiving drugs with boxed warnings;
• Flagging of certain laboratory tests for patients receiving certain drugs (eg, low albumin, serum digoxin levels, low potassium);
• Identification of candidates for renal dose adjustments (eg, by demographics and laboratory monitoring);
• Identification of patients on intravenous (IV) medications who may be switched to oral medications;
• Identification of patients taking erythropoiesis-stimulating agents (ESAs) who have hemoglobin values >12 g/dL; and
• Identification of allergy targets (eg, latex, penicillin, sulfa drugs, iodine, anti-inflammatory agents, aspirin, etc).

The system is capable of identifying many other types of interventions, as well. Drugs such as linezolid, vancomycin, and carbapenems can be targeted for intervention. Culture and sensitivity data and antibiograms can be linked to the dashboard for quick review, as can suggested actions for potential interventions-along with such documentation as literature support and links to actual references. Targets can be set for positive infections or laboratory parameters such as vancomycin-resistant Enterococcus, C difficile, and MRSA.

In Figure 2, the sample dashboard displays opportunities for potential clinical intervention. Note the tabs at the top for IV-to-oral conversion opportunities, renal dosing, anticoagulation, and other information.

Similar systems of clinical intervention include TheraDoc,¹¹ Premier's SafetySurveillor-Infection Control,¹² CareFusion's MedMined for infection control,¹³ McKesson's Horizon Expert Documentation,¹⁴ and others. According to Charles Westergard, BS Pharm, MBA, vice president of clinical affairs for Pharmacy OneSource in Bellevue, Washington, these programs have certain limitations. Some require onsite servers and hardware calling for maintenance and upgrades; some may not be well integrated into clinical documentation tools. Most have a focus on infection control that can limit implementation of more pharmacy-centered programs such as anticoagulation management, IV-to-oral conversion, and renal and target-drug monitoring.

"Sentri7 allows a healthcare organization to leverage data within existing legacy information systems to do quality and compliance interventions without a huge outlay for all-in-one health-information technology. It can be up and running in as little time as 60 to 90 days and is priced on an admission basis,"; said Westergard.

According to Christopher Virgilio, PharmD, clinical coordinator of pharmacy services at Washington County Hospital in Hagerstown, Maryland, "Sentri7 has allowed us to perform clinical duties on a more consistent basis because it is constantly searching our massive patient population for certain types of situations. We could expand current IV-to-oral conversions and renal dosing programs and begin new anticoagulation and antimicrobial stewardship programs, because the additional workload was easily absorbed by Sentri7. Our patients are safer, staff satisfaction is higher, and our workflow is more streamlined since implementation of the Sentri7/Quantifi clinical decision support system. We have been using the system since February 2008 and have made a total of 8,610 interventions, saving $749,736. The system is always looking for interventions...It doesn't call in sick, it isn't short-staffed, it isn't too overworked, etc. Basically the system took our hospital from being good to being great"

Pharmacy OneSource's Quantifi, its original product, is the intervention-documentation system used with Sentri7. Sentri7 sets up the prepopulation of the data-in essence, the documentation-in Quantifi. It assigns relative financial impact (based on published literature), pharmacist time, and relative value units for specific interventions. Then Quantifi tracks these events. It can provide feedback about clinical interventions and can be used during performance reviews to identify interventions and their outcomes for staff members. Reports are easily created, customized, and downloaded.

According to Steve Pickette, BS Pharm, BCPS, director of system pharmacy clinical services at Providence Health & Services, a not-for-profit health system serving Alaska, Washington, Montana, Oregon, and California,"We continue to work with Pharmacy OneSource to further develop features of the clinical decision-support program that are similar to those of other products that have been on the market longer. We find the clinical documentation program, Quantifi, to be the best available. It is integral to our multihospital [26 hospitals] pharmacy strategy to enhance the quality and scope of pharmacy clinical services. We believe that the workflow-receiving an alert, review of the information by a clinical pharmacist, documentation for follow-up, and reporting-works best with our practice model. In a pilot program in a 600+-bed tertiary-care community teaching hospital, we had over 1,500 interventions monthly, with an associated monetary value of more than $1 million in estimated cost-avoidance over a 1-year period."

Nearly 800 hospitals in the United States are using Quantifi to perform clinical documentation; more than 160 of them thus far have signed on to add Sentri7.

Sentri7/Quantifi can be used not only by larger hospitals and integrated health systems, but also by MCOs and PBMs. Pharmacy OneSource will consult with interested MCOs and PBMs to determine how its system can be used to best advantage in these settings.

References
1. MacLaren R, Bond CA, Martin SJ, Fike D. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infection. Crit Care Med. 2008;36:3184–3189.
2. Kopp BJ, Mrsan M, Erstad BL, Duby JJ. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J Health Syst Pharm. 2007;64:2483–2487.
3. Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: A randomized controlled trial. Arch Intern Med. 2009;169:894–900.
4. Vinks TH, Egberts TC, de Lange TM, de Koning FH. Pharmacist-based medication review reduced potential drug-related problems in the elderly: The SMOG controlled trial. Drugs Aging. 2009;26:123–133.
5. Kaufman MB, Brodin KA, Sarafian A. Effect of prescriber education on the use of medications contraindicated in older adults in a managed Medicare population. J Manag Care Pharm. 2005;11:211–219.
6. Cooper JW, Wade WE, Cook CL, Burfield AH. Consultant pharmacist drug therapy recommendations acceptance and rejection from monthly drug regimen reviews in a geriatric nursing facility: Fourth year results and cost analysis. Hosp Pharm. 2007;42:729–736.
7. Lada P, Delgado G Jr. Documentation of pharmacists’ interventions in an emergency department and associated cost avoidance. Am J Health Syst Pharm. 2007;64:63–68.
8. American Society of Health-System Pharmacists. Statement on pharmaceutical care. http://www.ashp.org/DocLibrary/BestPractices/PharmaceuticalCare.aspx. Accessed September 9, 2009.
9. Pharmacy OneSource. Sentri7. http://www.sentri7.com. Accessed September 9, 2009.
10. Pharmacy OneSource. Quantifi. http://www.pharmacyonesource.com/applications/quantifi. Accessed September 9, 2009.
11. TheraDoc. Intervention Assistant. http://theradoc.com/products/esp_intervention.cfm?gclid=CJ7u_Zv2kZsCFQJN5QodNkT4og. Accessed September 9, 2009.
12. Premier. Safety Surveillor. http://5millionlives.premierinc.com/SafetySurveillor.html. Accessed September 9, 2009.
13. CareFusion. MedMined. http://www.carefusion.com/products-and-services/products-services-categories/infection-prevention/medmined-data-mining-surveillance-service.aspx. Accessed September 9, 2009.
14. McKesson. Horizon Expert Documentation. http://www.mckesson.com/en_us/McKesson.com/For+Healthcare+Providers/Hospitals/Clinical+Quality+Improvement+Solutions/Horizon+Expert+Documentation.html. Accessed September 9, 2009.

Figure 1Sample patient card from Sentri7

Figure 2 Dashboard for Sentri7