Every member of the health care team shares a common goal of optimizing patient outcomes. Yet each specialty and position of the healthcare team has a unique workflow facilitated by various tools, from an operative report to a progress note. In this regard the pharmacist plays a pivotal function in medication management and requires documentation specific to that role. The Pharmacist eCare Plan (PeCP) allows for an interoperable note to be used in the pharmacy to assist in the exchange of patient information, including active medication list, laboratory results, and payer information. To allow for this, a new type of clinical document architecture for the PeCP was created and standardized for use across pharmacies.
Clinical Document Architecture (CDA) are standards for how data elements are captured, stored, displayed, and transmitted electronically. While CDA does not specify how the documents are transported; it is the standard for how the data is presented and encoded to aid in interoperability. The standards specify that documentation is split into 4 parts: the header, body, sections, and narrative/entry blocks. The header will specify which type of document follows (e.g. progress note or H&P). The body and section blocks assist in the presentation of the note. Lastly, the content of the note is populated in the narrative or entry blocks, for human and machine readability respectively. Soon after the increase of electronic documentation began, separate standards development organizations presented differing implementation guidelines for CDA which gave rise to conflicting or ambiguous information.
Consolidated Clinical Document Architecture (C-CDA) was created as a single implementation guideline with hopes to address these errors and ambiguity. The framework provided by C-CDA outlines 9 documentation types, with 60 distinct types of section templates and 82 entry templates. This allows for consistency not only among similar notes, but throughout documentation as a whole. For example, the same “medications” template can be utilized in a continuity of care note as well as the H&P. Many of the already existing sections would be utilized in the PeCP note and function as an additional note template among the others. Based off of the Health Level Seven (HL7), a series of international standards for the transmission of clinical data, C-CDA has essentially become the standard of standards. The most recent iteration of HL7 standards, Fast Healthcare Interoperability Resources (FHIR, pronounced "fire"), aims to facilitate interoperability between healthcare systems, allow for integration of third-party developed applications, and increase accessibility on a variety of platforms., The adoption of standards, including C-CDA and FHIR is a pivotal step to provide efficient and seamless data transmission between system and payers in healthcare.
Similarly, the PeCP represents a milestone in the effort to exchange patient’s health data electronically. Presently the focal use case for the PeCP is in the retail pharmacy setting. A pilot program launched in North Carolina in 2017 demonstrated the successful use of the PeCP. Several software solutions targeted to community pharmacy use the PeCP standards for embedded, integrated, or standalone clinical documentation systems. The next phase of activity related to the PeCP is encouraging more vendors to adopt the PeCP standards, and for pharmacies to leverage the functionality permitted by the standards to communicate with other members of the care team, as well as payers. Advocating for the next steps with the PeCP promotes the role pharmacists can play in caring for patients, including addressing adverse events and encouraging medication adherence. Of mention the average patient visits a pharmacy more often than a care clinic, thereby providing a prime opportunity to capture clinical data for a patient’s chronic care.
Adoption of the PeCP by the dispensing pharmacy systems, specialty pharmacy applications, Medication Therapy Management (MTM) programs, and ambulatory/hospital electronic health records is a significant hurdle. Many of these systems have proprietary assessment documentation features that are used to attract and retain customers, and therefore adopting a standard language poses a potential threat to market positioning. Ensuring security of the data is as important as ever with OAuth, which uses tokens to validate access without having to share passwords, being the standard for FHIR. Unfortunately, many pharmacy system startups still have basic password authentication leading to security concerns. Even if several systems started using PeCP, the infrastructure and expertise to implement and maintain FHIR/C-CDA can be cost prohibitive if value cannot be found by without wider adoption. Another issue surrounds the data each system currently collects, and the format it is stored leading to mapping issues. Being able to transmit and transform data to the receiving system in a valid and useful form can often be difficult and consume resources. Additional database mappings or interface calls due to differences in data vocabularies may be required by either the sending/receiving application to make data useful; the additional demands on the software to make these translations may even slow down the entire program.
Realizing the full potential of the PeCP standards relies on vendors and health care providers coming together for further demonstrations of use. This seems like a tall order based on the number of disparate software solutions in the retail pharmacy setting, let alone the major vendors in the acute care space. Pharmacists working across boundaries of business and care settings are likely the best positioned to imagine and promote these efforts.
Please take a moment to suggest a use case, and especially if you have personal experience with the PeCP.
Brendan R. Begnoche, PharmD
Beth E. Prier, PharmD, MS
AJ Teare, PharmD, CAHIMS
References
- Brull, Rob. “Three Challenges FHIR 4 Faces”. CorePoint. Published May 28, 2019. https://corepointhealth.com/three-challenges-fhir-4-faces/. Accessed February 9, 2020.
- Murphy, Kyle. “Longstanding IT Challenges Still Limit Potential of FHIR”. EHR INTELLIGENCE. Xtelligent Healthcare Media, LLC. https://ehrintelligence.com/news/longstanding-it-challenges-still-limit-potential-of-fhir. Accessed February 9, 2020.