Minding the Gap: Why Access to Electronic Medical Records Matters in Specialty Pharmacy

In the data- and outcomes-driven paradigm that is shaping health care today, access to the electronic medical record (EMR) is a key factor that distinguishes health-system specialty pharmacies from their nonintegrated competitors.

This access is critical to managing the specialty patient population. For health systems, it means greater efficiency and better patient care. For individual patients, it means more integrated, responsive care.

In the aggregate, a seamless set of EMR data offers the opportunity to discover which therapies provide the best long-term outcomes. As part of the care team, the health-system pharmacist can gain immediate EMR access to all relevant patient data, including laboratory test values, progress notes, and clinic appointments.

The pharmacist can also add information to the EMR, as appropriate, and can communicate with the rest of the care team more easily and quickly than an outside pharmacist. Ideally, the record becomes seamless and the entire care team can access and learn from the data.

Unfortunately, when a health system has not implemented its own specialty pharmacy program—or the health system’s pharmacy does not have access to the drug, or the payer has carved out the benefit to a for-profit specialty pharmacy—the prescription is filled outside the health system by a remote specialty pharmacy without connectivity to the health system’s EMR.

The resulting EMR gap means the care team can lose sight of where and when a drug was dispensed. They might even be unaware of an adverse event unless that event results in hospitalization, for which the health system, in an accountable care environment, is responsible.

From the moment a physician prescribes a specialty drug, the pharmacist’s access to the EMR matters in terms of speed, accuracy, responsiveness, adherence, waste reduction, and the availability of data for determining long-term costs and outcomes. The telephone and the fax machine seem to be state-of-the-art technology where PAs are concerned.

Communication between providers, payers, patients, and pharmacies can feel like a step back to a time before today’s sophisticated EMR software existed. With access to the EMR, health-system specialty pharmacists can deal with PAs in the most efficient way possible, not only making life easier for providers and patients, but minimizing the potential for errors, omissions, and confusion. When a payer requires PA with each renewal, the time savings become substantial.

By speeding the process of requesting authorization, the health-system specialty pharmacy does all it can to minimize approval time and initiate therapy as quickly as possible. When access to the EMR is available, pharmacy staff can research all questions, attach appropriate clinic notes and lab data, and submit the information to the payer the same day the prescription is received. For example, for a patient with psoriasis, all previously tried and failed therapies—including topical, OTC remedies, nonbiologic, biologic, and phototherapy—can be retrieved and submitted.

This substantially reduces the time to first fill, allowing the patient to initiate therapy much more quickly. Remote specialty pharmacies operate with a built-in lag time. Communicating with them to reduce dosage, increase dosage, or change medication takes time. By the time the communication has passed through, an incorrect refill may already have been shipped.

In a specialty pharmacy operated by the health system, pharmacists can see lab results in the EMR and supply the correct dose, eliminating the possibility of a wasted refill. An example of the benefits of EMR integration can be found at The Johns Hopkins Hospital Sidney Kimmel Comprehensive Cancer Center, where clinical pharmacy specialists have been embedded into multidisciplinary ambulatory oncology teams.

Pharmacy specialists are involved in the design of comprehensive treatment plans, including adjunctive and supportive therapies, patient education, adherence support, and ongoing safety and efficacy monitoring. These specialists utilize the EMR extensively to coordinate care, monitor patients, and document all components of the treatment course. Access to critical information, such as laboratory values, appointment schedules, changes in level of care, and treatment history, allows these pharmacists to make decisions based on the most up-to-date and accurate clinical data.

In one case, a pharmacist prevented a likely hospital admission for febrile neutropenia by identifying a patient with a low absolute neutrophil count and coordinating discontinuation of therapy until counts recovered. In another case, a pharmacist identified the benefit that additional lab monitoring would provide in managing a patient receiving a second cycle of oral capecitabine.

In this scenario, the pharmacist was able to facilitate the ordering of appropriate labs, which led to the identification of significant renal impairment requiring dose adjustment. Without this information, the patient would have been at high risk for additional health care exposure related to toxicities from overdosing. Pharmacists interact with patients and families in ways that bring out important information—from something with serious treatment implications, such as excessive alcohol consumption, to something that is simply a matter of logistics, such as an upcoming vacation.

Pharmacists are in a strong position to learn about potential barriers to adherence that a patient might not share with a prescriber, such as lifestyle preferences, financial hardship, or medication side effects.¹ Health-system specialty pharmacists can easily communicate such critical information to the rest of the care team and enter it in the EMR if appropriate. Pharmacists often uncover important information even when it is not directly or intentionally stated by the patient. In a white paper published in 2015, health-system specialty pharmacy network Excelera cites an example of a health-system pharmacist whose first interaction with a patient with hepatitis C, prescribed $100,000 in drug therapy, raised red flags regarding the patient’s mental health.

With access to the EMR, this attentive pharmacist could, without delay, communicate with the care team regarding the concern. Thus, the patient’s underlying mental health issues could be addressed prior to the hepatitis C therapy, thereby minimizing the risk of noncompliance and unnecessary drug expense.² The health-system pharmacist’s ability to document communications with the patient in the EMR can be especially important if the patient has stopped taking medication because of serious side effects or drug interactions.

Although nonintegrated specialty pharmacies may do their best to support patients with therapy management programs and help lines, that support may be insufficient, impersonal, or delayed. Certainly, the ability of these pharmacies to track and measure adherence, compliance, and outcomes is limited. There is extraordinary potential for the EMR to be a rich source of data for measuring true health outcomes and the total cost of care.

At Fairview Health Services, several initiatives are underway to tap into this information. One project will measure the outcomes of patients with cystic fibrosis (CF) treated in the health system compared with industry clinical trial data and outcomes data from the national CF registry. Another will seek to quantify the extent to which pharmacist interventions with patients at the health system’s oncology clinics lead to better identification and management of adverse events.

To sum up, access to the EMR is important because it provides:

• a full view of the medication record, including current and previous medications
• a full view of the medical history, including allergies, access to clinic notes, hospitalizations, and historic lab values
• immediate access to most recent labs
• the ability to process insurance PAs more quickly because of access to all the data
• the ability to communicate logistics and fill information to the provider and have a record in the EMR
• the ability to communicate clinical information and assessment data to the provider and have the record of that communication in the EMR
• the ability to report response to a medication, as well as its dispensing information
• the ability to measure true health outcomes, including mortality, quality of life, and functional years
• the ability to measure total cost of care

Among the practical, clinical, and financial reasons for hospitals and health systems to implement their own specialty pharmacy programs, access to the EMR stands out as a key differentiator. Health-system decision makers can point to this key differentiator to support implementation of their own specialty pharmacy programs.

About the Author

Kyle Skiermont, PharmD, is the Chief Operating Officer for Fairview Pharmacy Services, a leading health system based pharmacy organization in Minneapolis, MN. He received his PharmD from the University of Nebraska Medical Center College of Pharmacy. As COO, Kyle is responsible for strategy and overall operations of Fairview Pharmacy’s specialty pharmacy, retail, mail order, long-term care, compounding, home infusion, and community infusion business units.