DOCUMENTATION OF PHARMACIST PATIENT CARE

To promote the use of standardized, integrated documentation of pharmacist care provision in a patient’s health record; further,

To advocate that documentation by pharmacists in the medical record be used for billing and attribution of value without requiring additional documentation from other clinicians; further,

To advocate for standardized measurement of pharmacist care provision and the attribution of those activities to patient-centered outcomes.

Rationale

ASHP has advocated for the importance of documentation of pharmacist care in patient medical records to ensure accurate and complete documentation of the care and services provided to the patient. However, differences in pharmacy practice within and across health systems make it hard to standardize such documentation in the electronic health record (EHR). The differences are caused by diverse clinical practices, EHR permissions, and documentation elements of the care provided by pharmacists. Documentation by the pharmacist may change depending on care settings, the level of care provided, or in respect to reimbursement. As a result, it is hard to validate and evaluate pharmacists’ impact on patient outcomes due to the incomplete measurement and attribution of such care and lack of standardized documentation.

Other healthcare providers have released similar statements on documentation within their fields. The American College of Physicians states that physicians should define professional standards regarding clinical documentation and use macros and templates appropriately (Kuhn T, Basch P, Barr M et al. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015; 162:301-3). The American Nurses Association (ANA) Principles for Nursing Documentation states that if patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient’s care to use the documentation (ANA’s Principles for Nursing Documentation: Guidance for Registered Nurses. 2010. www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf). The American Speech-Language-Hearing Association (ASHA) states that speech-language pathologists should participate in the development of the templates that they will use for billing and clinical documents so that the information that is necessary is provided (ASHA. Documentation in health care. www.asha.org/PRPSpecificTopic.aspx?folderid=8589935365&section=References).

Other healthcare providers have recognized the benefits of requiring their documentation to be recorded in a standardized form that allows other healthcare stakeholders to quickly access the information. Employing accessible, standardized documentation improves communication and knowledge sharing between providers. Pharmacists are valuable members of the healthcare team that contribute significantly to patient care. More consistency and standardization of a pharmacist’s documentation can provide essential information on a patient’s care, such as therapeutic drug monitoring, appropriateness and effectiveness of patient’s medications, or pain and antibiotic management, for example. Standardized notes enable healthcare team members to review the pharmacist note and become aware of the medication plan. Implementing standardized and integrated documentation across all healthcare providers, especially pharmacists, will allow for increased interactions and information to be shared between healthcare providers to improve overall patient care. In addition, such standardized and integrated documentation by pharmacists should be used for billing and attribution of value without additional documentation requirements from other clinicians.

Implementing a standardized clinical pharmacy documentation system will also inform and enable a measurement approach for evaluation of the impact of pharmacist services. Many institutions use different tools for operational internal and external benchmarking to meet these measures; however, the tools are limited in their use for clinical benchmarking (Rough SS, McDaniel M, Rinehart JR. Effective use of workload and productivity monitoring tools in health-system pharmacy, pt 1. Am J Health Syst Pharm. 2010; 67:300–11). Institutions have tried to implement their own clinical pharmacy productivity measures tools to help demonstrate the value of de-centralized pharmacists on patient care teams. However, no current measure or measure set accurately identifies the impact pharmacists have on patient care outcomes or allows comparison and benchmarking across institutions. In response to this need, the ASHP Pharmacy Accountability Measures (PAM) Work Group seeks to identify pharmacy-related clinical quality measures that institutions could use for benchmarking (Andrawis MA, Carmichael J. A suite of inpatient and outpatient clinical measures for pharmacy accountability: recommendations from the Pharmacy Accountability Measures Work Group. Am J Health Syst Pharm. 2014; 71:669-78).

The PAM Workgroup evaluated quality measures endorsed by the National Quality Forum (NQF) and curated those selected into six therapeutic areas, which include antithrombotic safety, cardiovascular control, glycemic control, pain management, behavioral health, and antimicrobial stewardship (Andrawis M, Ellison C, Riddle S et al. Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group. Am J Health Syst Pharm. 2019; 76:874–87). Using the NQF-endorsed measures along with appropriate documentation of the care may allow institutions to more readily benchmark performance.

After determining the most appropriate pharmacy quality measures, the documentation of the care provided should be standardized and efficient. Implementing standardized templates and more retrievable data fields in the documentation process has been shown to improve workflow for pharmacists. One study demonstrated that by implementing EHR note templates that allowed retrievable data to be incorporated, pharmacists increased the amount of time providing value-added services from 47% to 72% and in providing direct patient care from 27% to 53% (Ekstrand MJ, Kobany JM, Pestka DL. Leveraging quality improvement principles in comprehensive medication management pharmacy practice: a case example. J Am Pharm Assoc. 2020; 60:509-15.e1.).

Finally, pharmacists must also be properly educated on how to use a standardized pharmacy documentation system. In one study, a health system that implemented an improved pharmacist documentation process found that a focused education initiative increased the number of pharmacist-delivered services by 120% while also imrpoving cost avoidance (Rector KB, Veverka A, Evans SK. Am J Health-Syst Pharm. 2014; 71:1303–10). Overall, research has shown that focused education has helped improve the standardized documentation of pharmacist care, leading ultimately to better care for patients and demonstrating the value of pharmacy services.