Access to a Health System's Electronic Medical Record

Electronic medical record access is vital to medication therapy management.

Over the past several years, community pharmacists have proven themselves experts in comprehensive medication therapy management (MTM), showing time and again that pharmacists have the ability to reduce health care costs.^1,2 In the typical MTM model, the pharmacist conducts a medication therapy review with a patient, provides a personal medication record, and develops a medication-related action plan, which is sent to the appropriate provider. This process is not without barriers. Many pharmacists face information gaps when identifying drug therapy problems without access to relevant lab values or a physician medication list. Furthermore, when problems are identified, avenues by which to efficiently address therapy concerns directly with the provider are lacking. Messages left via voicemail are often triaged by well-intentioned office staff, leading to miscommunication or lack of a response.

Gurley’s Pharmacy, an independent pharmacy located in Durham, North Carolina, has partnered with Community Care of North Carolina (CCNC) through their Community Pharmacy Enhanced Services Network (CPESN). With the help of a Centers for Medicare & Medicaid Innovation (CMMI) grant, CCNC and the CPESN have worked with tens of thousands of North Carolina Medicaid patients with the goal of reducing their overall cost of care through MTM. As a major provider of pharmacy services for patients seen at Duke University hospitals and clinics, Gurley’s Pharmacy was granted access to the Duke University Health System (DUHS) electronic medical record (EMR).

Epic Systems Corporation, the clinical systems developer for DUHS’ EMR, allows external providers read-only access to the DUHS EMR, as well as secure messaging features through the EpicCare Link product. Although Medlink was designed for external health care providers, the agreements for its use were written with medical practices as the intended users. The local CCNC network supported Gurley’s Pharmacy’s EMR access application and facilitated modifications to the required agreements to accommodate Gurley’s Pharmacy as a user. After several meetings, it became clear to hospital officials that community pharmacy access to the EMR was in the best interest of patients and was not a violation of patients’ HIPAA rights.

With this access, we are able to view discharge summaries, pertinent lab results, and physician medication lists in order to more accurately and efficiently perform MTM and other enhanced community pharmacy services. Moreover, such access allows for direct messaging of providers through the EMR to address medication-related problems. This mode of communication allows providers to respond to pharmacist concerns as part of their normal daily work flow. In our experience with large Duke-managed outpatient clinics, nearly all communications are responded to within 1 business day when sent via EMR messaging.

Discharge Medication Reconciliation

With the help of CCNC, Gurley’s Pharmacy now receives notification when one of our patients is discharged from the hospital. A pharmacist is then able to log into the EMR to review the discharge summary, associated provider notes, lab results, and any other pertinent information. With access to such information, we are able to better facilitate transitions of care. In particular, pharmacists are able to note relevant medication changes that occurred during the patient’s hospitalization, update the patient’s medication list within our dispensing software, address any medication-related concerns immediately, and ensure the patient receives the appropriate medication regimen in a timely manner after discharge. Based on the complexity of the medication reconciliation, our staff determines the need for a more comprehensive medication review, a service for which we can be compensated through the CMMI grant.

Beyond Transitions of Care

In a pilot attempt to implement EMR access outside of the transitions-of-care population, Gurley’s pharmacists conducted a comprehensive review of our HIV patient population. Access to data from the patient’s last appointment, including lab work, enabled us to work closely with our patients who had been lost to follow up. Compared with providers, our increased face time with patients not only promotes the development of strong pharmacist—patient relationships, but also creates a huge opportunity for referral for necessary care and monitoring. Upon review of patients’ lab work, our pharmacy staff has been able to recommend that several patients appropriately discontinue opportunistic infection prophylaxis, thereby reducing pill burden and preventing unnecessary side effects from long-term antibiotic use. It is clear that the potential exists to use EMR access for further disease state–management initiatives with other high-risk patient populations at our pharmacy, including heart failure, chronic obstructive pulmonary disease, and diabetes.

With the burden of rising health care costs on our economy, pharmacists are in a unique position to reduce the overall cost of care through a variety of interventions, including MTM. Without access to relevant data, however, community pharmacists are often unable to make high-level, clinically appropriate interventions that can have a significant impact on patient outcomes. In order to maximize pharmacist impact and optimize medication therapy outcomes, data accessibility, communication, and efficiency are key. This process must be incorporated in the daily work flow of both pharmacists and providers. To do so, it is imperative that community pharmacies be granted access to local health systems’ EMRs. Other health systems’ EMRs should similarly be accessible to external health care providers. Innovation in information technology must continue to connect individual providers of health care services in order to achieve a holistic model of care and mutually work toward a common goal: cost-effective, accessible, and improved health care for our patients.

Jay Vora is a clinical pharmacist and head of the medication therapy management program at Gurley’s Pharmacy in Durham, North Carolina. He is a graduate of the PharmD program at the University of North Carolina at Chapel Hill Eshelman School of Pharmacy and the Kerr Drug/Campbell University Community Resident Program

References

• Chrischilles EA, Carter BL, Lund BC, et al. Evaluation of the Iowa Medicaid pharmaceutical case management program. J Am Pharm Assoc (2003). 2004;44(3):337-349.
• Bunting BA, Cranor CW. The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma. J Am Pharm Assoc (2003). 2006;46(2):133-147