Pharmacy is an information intensive profession. The information explosion and the emphasis on evidence-based medicine are forcing changes in pharmacists’ roles. Affordable computers combined with the advancement of information technology can now provide extremely useful clinical applications for pharmacists in their own working conditions. Computers can enhance practice by providing a rapid and effective means of accessing, retrieving, analyzing, sharing and storing large volumes of information pertinent to patient care. Several examples of the effective use of informatics tools in a hospital intensive care unit are presented such as: rapidly retrieving information to solve an urgent case; creating a personal Internet library, efficiently browsing the Internet, using computerized patient care worksheets and integrating hand-held portable computing tools into the pharmaceutical care process. These examples can be applied to any practice setting. Informatics is an emerging academic discipline in the health sciences. Essential informatics skills for pharmacists are reviewed. We describe a proposed medical informatics syllabus for the clinical pharmacist to provide the knowledge and skills in informatics essential for today’s practice.
Pharmacy is an information intensive profession that demands effective use of technology to manage an ever-expanding body of knowledge. “Information anxiety” is described as the frustration of being inundated by an overabundance of information sources while being unable to navigate them to find specific needed information. In order to minimize information anxiety, pharmacists must be competent in the use of computers to collect; store, retrieve and send drug and patient related data for both administrative and clinical purposes. The importance of information technology to the future of pharmacy practice has been well described in the literature. Information technology has always influenced pharmacy practice, but now with the availability of inexpensive yet powerful computers, and rapid communication via the Internet and other networks, this technology will exert an increasing force in changing roles for pharmacists. An understanding of some information technology principles may help practitioners avoid being “buried alive” in the streams of data that now permeate the health care setting.
The term medical informatics has been defined as “the field concerned with the cognitive, information processing, and communication tasks of medical practice, education, and research, including the information science and technology to support these tasks.”
The informatics field also includes advanced research initiatives that can be used in clinical practice including:
i) expert clinical decision analysis and decision support initiatives;
ii) electronic medical records;
iii) data warehousing and analysis of collaborative data sets;
iv) computer automated drug interaction, adverse drug reaction and drug usage monitoring systems and;
v) telecommunication advances such as video conferencing via Internet and intranet connected systems.
Advancements in hospital decision support systems and electronic medical records have been slow and are not as yet widely used as these systems have been more difficult to implement than previously anticipated. There are; however, currently available off-the-shelf technologies that can be utilized by individual clinical practitioners. It would be prudent for all clinicians to familiarize themselves with these resources and learn how to apply them to their practice in a practical fashion. Primers on Internet use and online clinical resource utilization regularly appear in the medical literature.
Pharmacists need to develop a set of practical informatics skills to manage the data and information challenges in their practice. This article focuses on some available computer resources that can augment clinical practice. Informatics skills considered essential for pharmacists to learn and examples of how these skills apply to clinical practice are provided.
Essential Informatics Skills for Pharmacists
The evidence-based practice paradigm increases clinician information needs and to meet these needs, clinicians require rapid access to resources that provide content that is relevant, valid, and can be obtained with minimal effort. Ideal information resources are electronic, portable, connected to valid databases and servant to the user. While pharmacists may not need to be experts in information systems, they do need sophisticated end-user knowledge of technologies that are available and applicable to research and clinical practice. These technologies include personal and network computing; hospital information systems; personal digital assistants; the Internet; word processing; and presentation, statistical analysis and database management software.
Those practitioners who do not incorporate some of these tools into their practice will undoubtedly have difficulty keeping up with the clinical information necessary for evidence-based practice. As other health care professionals continue to incorporate available technology into their practices, pharmacists need to advance at least as quickly to ensure that they are at the forefront of this movement. Only by doing so will they be able to ensure that they continue to be the drug expert in the health care team. The development of automated drug dispensing, clinical monitoring and clinical decision support systems is evolving rapidly and these developments challenge the pharmacist to maintain an evidence-based and patient-centered role in the healthcare system.
Essential clinical informatics skills have previously been identified from a medical perspective. Coiera proposes that, in addition to having basic computer skills, ten essential clinical informatics skills are needed in order for clinicians to properly manage information (Table 1).
Upon reviewing the American College of Clinical Pharmacy position statement describing the practice guidelines for a pharmacotherapeutic specialist, one could infer that many of these same skills are integral to pharmacy practice. It is clear that effective information management requires more than basic computer literacy. Computer skills are fundamental to integrating technology and clinical practice and to facilitating the effective transformation of data to useable clinical information.
Table 1: Ten Essential Clinical Informatics Skills
Understand the dynamic and uncertain nature of medical knowledge and know how to keep personal knowledge and skills up-to-date.
Search for and assess knowledge according to the statistical basis of scientific evidence.
Understand some of the logical and statistical models of the diagnostic process.
Interpret uncertain clinical data and deal with artifact and error.
Analyze and structure clinical decisions in terms of risks and benefits.
Adapt and apply clinical knowledge to the individual circumstances of patients.
Access, assess, select and apply a treatment guideline; adapt it to local circumstances; and communicate and record variations in treatment plan and outcome.
Structure and record clinical data in a form appropriate for the immediate clinical task, for communication with colleagues, or for epidemiological purposes.
Select and utilize the most appropriate communication method for a given task (e.g. face-to-face conversation, telephone, e-mail, video, voice-mail, letter).
Structure and communicate messages in a manner most suited to the recipient, task and chosen communication medium.
Student and Clinicians Needs for Informatics Training
Medical Informatics is fervently being addressed as an emerging academic discipline in medicine, nursing and dentistry. Many medical schools and residency programs are including informatics training in their programs. Dentistry schools likewise consider informatics essential in their training.(34,35) Nursing has developed informatics to the point of debating “nursing informatics” as a distinct discipline. (36-40) Pharmacy is certainly one of the most information-intensive professions and yet we have not taken the lead in developing informatics specific for our needs and where medicine and nursing needs overlap ours. Currently there is a lack of research addressing informatics needs in any area of pharmacy practice and pharmacy education.
Certainly anxiety is produced by the continuous statements that health care technology will change the role of pharmacists and create expanded opportunities for pharmacists in the future. Unfortunately such statements about future capabilities of technological advances do nothing to aid in defining what the roles will be or how to get there from our present state. Now that computer equipment has finally reached a stage of being affordable, user friendly, and that evidenced-based information is readily available and easily accessed via the world wide web, we felt it was urgent to develop an informatics course for undergraduate pharmacy students. While a number of organizations have developed recommendations for medical informatics education, none are directed specifically for pharmacists needs. Upon accepting the reality that health care technology is in a state of rapid transition, we attempted to design an essential informatics knowledge and skills course for a clinical pharmacy practitioner today.
The central guiding question was how could computers be used to make the clinical pharmacists’ role easier yet more effective in improving patient care?
The overall goals of the course that we propose are:
1) to develop an awareness of the usefulness and limitations of computers and informatics tools in pharmacy practice;
2) to demonstrate and facilitate the development of essential skills for the use of technology to meet the increasing and evolving demands of pharmacy practice today;
3) to provide a framework for life-long technology-assisted continuing education and clinical practice; and
4) to develop an appreciation of the impact of automation on pharmacy practice.
Our proposed syllabus includes computer literacy, and software applications; communication via the Internet; pharmacy automation; and information management. Throughout the development of this syllabus we attempted to prioritize topics that are applicable in practice today and yet remain comprehensive in the variety of informatics topics addressed.
Currently their exists great interest in learning about informatics. This was revealed in a recent continuing educational needs survey of 2,500 Canadian physicians in general or family practice. This survey revealed that almost 55% of respondents selected informatics and computers over other professional or clinical options as the highest priority topic for improvement in knowledge and skills. Interestingly, 63% of respondents indicated that they had no access to computer support for practice. This confirms our experience that there is a recognized interest in informatics training. Over the past year, we have had many requests from pharmacy students, faculty, pharmacists and family physicians to be taught informatics skills. Consequently we have given separate presentations encompassing introductory applied informatics material for both pharmacy students and family physicians in both university-based and hospital-based computer labs. These sessions have resulted in numerous requests for additional training topics. Based upon our personal experience, the perception that the majority of health professionals has access to and use information readily available through computers is not a reality. The challenge of educating future and current health professionals in informatics must be addressed now.
Examples of the Effective Use of Informatics Tools in Everyday Practice
Here are some practical examples how readily available computer hardware and software can be integrated into every day clinical practice.
Rapid Retrieval of Drug Information
You are in the Intensive Care Unit preparing for morning interdisciplinary rounds. The patient just admitted to Bed-1 is a 38-year-old female with septic shock secondary to bacteremia. The patient has multiple loculated hepatic abscesses and is receiving high doses of inotropic drugs. Fluid balance has been optimized and she is maintaining a mean arterial pressure of 55 mmHg with a regimen of dopamine 20 mcg/kg/min and norepinephrine 20 mcg/min. You have been keeping up with the critical care literature and realize that a viable therapeutic alternative for pressor support in this patient may be a vasopressin infusion. Rounds start in 5 minutes and you can’t remember the dosing protocol nor the specific inclusion criteria reported for the studied patient population. You know that you have the relevant papers in your “files” somewhere but locating them will likely take some time.
This is a common scenario for all practicing clinicians who need to have rapid access to previously retrieved reference material that is now located personal library files. One potential solution to this problem is to create your own digital library that is portable and readily accessible. Resources are available to electronically file publications. Many journals are now available on-line with full text access to personal and institutional subscribers. Journal articles that are not available online can be converted to electronic format with a scanning device and the appropriate file storage software. Key articles can be made readily retrievable by electronically filing the digital version on your computer or a network hard drive. A common format for digital document distribution is the portable document format (“PDF”) that has been created by Adobe Systems Inc. (http://www.adobe.com). Portable document format files can be read by anyone who has installed the free reader software. These files can be stored locally and organized in a directory structure that is logical to the user such as a head-to-toe systems approach. Adding relevant PDF format journal articles takes seconds with basic file management techniques. The advantage of having your personal reference files stored digitally is that you can quickly access the files from your PC or any networked PC in your hospital.
Revisiting the above case scenario, 5 minutes is ample time to log on to a networked PC, locate and retrieve your relevant files pertaining to the use of vasopressin for septic shock and be prepared for a bedside discussion about the possibility of instituting this mode of therapy. Occasionally it may be difficult to recall the folder in which the file is located. In such cases, the “find file or folder” function of your computer operating system can be used to search your references by file name. This will provide you with a list of the relevant files on your computer. Some third party file indexing software can be used to search your files by key words throughout the text of the document. An example of the authors (RMB) networked electronic library pertaining to the above case scenario is outlined in Figure 1. Once located, the relevant paper can be printed or viewed on screen.
Figure 1. Directory structure of a digital reference library on a personal computer
Integrating on-Line Resources into your Daily Practice
A family physician calls you asking about pharmacotherapeutic options to assist in removing a Bot Fly that is embedded in a patients scalp. The patient is a 40-year-old botanist who was contracted to do some work on a farm in Central America. Upon returning home she was noted to have a swollen 2 cm diameter itchy boil-like erythematous area on top of her head. Being familiar with the parasite hazards in Central America and having experienced Bot Fly problems in the past, the patient was suspicious about this itchy area on her scalp.
A solution to this problem would be may be readily available and accessible on the Internet. The advantage of electronic over paper-based information resources is the convenience of access and the efficiency of the search and retrieval capability. Numerous health and medical information sites are available on the Internet and several can be of tremendous value to the practicing clinician. Sometimes a general Internet search can retrieve useful information that can be evaluated for use on a case-by-case basis. Considering the above scenario one could use an Internet search engine such as altavista (http://www.altavista.com) and key in the search term “human bot” or “human bot fly” in quotation marks. A rapid visual scan of the approximately 70 “hits” (as of July 2000) reveals a link to the University of Missouri College of Veterinary Medicine (http://web.missouri.edu/~vmicrorc/Arthropods/Diptera/Dermatob.htm). Upon accessing the link you find a page which outlines the taxonomic classification, host spectrum, geographic distribution, morphology, life cycle, sites of infection, pathogenesis, clinical signs, diagnosis, treatment, and public health significance of the Human Bot Fly. The treatment options for humans are documented as being surgical removal or topical application of 1% trichlorfon.
To investigate the status and availability of trichlorfon in Canada you can search the Health Canada Drug Product Database (http://www.hc-sc.gc.ca/hpb-dgps/therapeut/htmleng/dpd.html). Entering “trichlorfon” into the search module for active ingredients you quickly discover that the product is available as a veterinary paste and thus is not likely to be stocked at a local pharmacy nor is it likely to be labeled for human use. This information can be obtained in minutes using current Internet resources.
Some authors have proposed that creating a personal “Internet library” can augment your information resources. An Internet library can be as simple as a list of links to valid and reliable Internet resources bookmarked on your Internet browser. Alternatively, with the availability of free website hosting sites and free website authoring software it may be more convenient to create a web page devoted to meeting your clinical and other professional practice information needs. An example of an Internet library developed to augment the authors (RMB) critical care practice can be viewed at http://myinforx.homestead.com. The advantage of the Internet library web page approach is that your menu of Internet resources can be accessed from any computer with Internet accessibility.
Using the Internet to Keep up with Literature: Effective Browsing
A large volume of new drug information is being published on a continuous basis. Much of this literature; however, will not fundamentally change clinical practice. As any clinical pharmacist knows, staying current with the developments in any field of practice can be difficult. Your practice may require that you stay current with publications that may not be readily accessible.
Information technology can provide a solution to this problem. Email is a tremendous way of effectively browsing the literature for information that may alter or supplement your practice. Many journals now have a feature referred to as an e-mailed table of contents (ETOC). Clinicians can access the homepages of journals that are relevant to their practice areas, subscribe to the ETOC service provided by the publishers and expect to have the journal index delivered by e-mail (often before the library even receives the hardcopy of the issue). If the clinician uses the filtering features available on most e-mail software, they will be able to file these notifications in a specific email folder for future access. Most email programs incorporate search engines and this also permits the clinician to conduct a table of contents search within their own email records. In some cases free or subscriber limited full text access to articles of interest can also bedownloaded and added to a local electronic filing system. Full text access to many clinical journals is now becoming available through hospital and University libraries. Pharmacy colleges and associations should be encouraged to provide this service to members.
Pharmacy managers may encounter situations in which there are too few pharmacists to provide a high level of pharmaceutical care to all patients in a particular clinical area. Some pharmacists may therefore be responsible for providing services to multiple hospital wards. Time and resource limitations make it prohibitive to review all patients. Consequently, pharmacists may be spending a significant portion of their time locating and prioritizing patients who would most likely benefit from having a pharmacist involved in their care. Clinicians need to prioritize patients to ensure that those who are in greatest need receive immediate attention. Typically, those patients at greatest risk of drug-related problems are the elderly, those receiving multiple drugs or drugs with a narrow therapeutic index, and patients with compromised organ function that can be expected to alter drug disposition. Identifying such patients may necessitate reviewing data from a number of different sources such as a ward census lists, laboratory indicators of organ function, and drug profiles. This approach may require time consuming manual assimilation of these data. Time spent prioritizing work reduces the amount of time that clinicians have available to provide patient care.
Information technology applied to workload prioritization can help pharmacists make more time available for direct patient care activities. In collaboration with a hospital information system programmer, the pharmacy department at the Royal Columbian Hospital (RCH) in New Westminster, British Columbia, has developed a computer generated clinical work list (Figure 2). This work list assimilates data from the admissions, pharmacy, nursing, and laboratory modules of the hospital information system and presents these data as information in a format that is useful for the clinician. The work list can be extracted from the hospital system on a ward specific basis according to the needs of the pharmacist providing services to the area. Currently the work list aids in prioritizing patient care activities by outlining key patient features that may be markers of drug related problem risk. In addition to demographic and diagnostic identifiers, the work list includes; patient allergy status, a partial medication profile of target drugs, serum creatinine, calculated creatinine clearance values, and all drug level and coagulation assay results. Historical information dating back 5 days can be included on the list.
The work list can also include pharmacy consult notifications, such as patient teaching requests, ordered by ward. In its current form the worksheet provides a useful way of scanning a large number of patients in order to identify those patients who may be most in need of pharmaceutical care. Also, the work list is used as a passive means of workload measurement. We are currently working on expanding this tool to include nutrition support data, decision support information such as drug dosing guidelines for renal impairment, documentation of pharmacists assessments and two-way synchronization with palm computing devices.
Figure 2. Royal Columbian Hospital Pharmacy Clinical Work List (patient identifiers have been removed).
* Indicates new information since previous compilation of work list, ALB = serum albumin, CARB = carbamazepine, Coll= collection CR=serum creatinine, CRCL=creatinine clearance CSA = cyclosporin, DIG = digoxin, DIL=phenytoin, HICU = Intensive Care Unit , Ht = height, INR = international normalized ratio, LI= lithium, NAPA = N-acetyl procainamide, PHENO = phenobarbital, PROCN = procainamide, PTT = partial thromboplastin time, Quin = quinidine, , Rand = random, THEO = theophylline, VALP = valproic acid, Wt = weight.
Integrating Palm-top Technology into the Pharmaceutical Care Process
Monitoring forms are prevalent in pharmacy practice but have some inherent problems. These problems include data redundancy where information already be available in electronic format in the hospital computer system requires manual transcription onto the monitoring form. Other problems are that data on paper forms cannot be automatically sorted, analyzed or retrieved according to user defined criteria, and information transfer is difficult. Often pharmacists are required to document their patient care interventions and tabulate certain indicators for review. One such intervention that pharmacists are required to document at RCH are cost savings. This refers to any drug cost savings that may result when a pharmacist makes a pharmacotherapy recommendation such as a dose adjustment for renal failure or an alternative antibiotic regimen. Tabulation of cost savings, or clinical outcome indicators, from paper monitoring forms can be cumbersome.
Personal digital assistants (PDAs) can provide a solution to some of the problems inherent to the paper-based monitoring form. Personal digital assistants are hand-held portable computing tools. These devices are becoming ubiquitous in the business world and are making some inroads into the health care sector. Some key capabilities of the PDA include web access, communication, and form development for data management. At RCH we are in the process of integrating palm-top computing technology into the pharmaceutical care process for patients in the intensive care unit. With inexpensive and widely available software, traditional paper monitoring forms can be replicated in electronic format. We are using an electronic palm-top template for the pharmacist work-up of drug therapy, identification of drug related problems, point of care capture and calculation of cost saving drug therapy recommendations with automatic exporting of the information to a spreadsheet for review (Figure 3). We are expanding our efforts to encompass automating the transfer of targeted patient data from the hospital computer system to the PDA.
Figure 3. PDA electronic patient monitoring template and cost savings report
Potential Shortcomings and Limitations of Current Information Technology
Although information technology can provide many benefits in clinical practice, clinicians need to be aware of some of the negative aspects of the state of this technology today. Probably the single greatest problem facing clinicians practicing in a health care facility is the lack of standardization within and across institutions. Many hospitals use multiple independent databases (e.g. pharmacy, laboratory, radiology) that are poorly integrated and result in an inability to combine patient information from various sources into a meaningful record. For example, the system in use at RCH only recently involved distinct computer hardware vendors and operating systems for the laboratory and pharmacy systems. One hardware vendor eventually combined these systems but even then each module, laboratory and pharmacy, concurrently functioned under separate operating systems. In addition, the operating system had limited ability to share data. This system complexity necessitated the involvement of a programmer in order to generate the daily clinical pharmacist work list described above. Incomplete information can result when data that a customized hospital program requires is moved, or given another internal reference, from one part of a non-integrated hospital system to another. We experienced this difficulty when the laboratory changed the coding system for some drug assay samples to better meet the needs of the laboratory. In this case certain drug level assay results were not captured by the RCH clinical work list described above. A corporate decision to change hardware or software vendors could suddenly render such customized efforts non-available.
Over dependence on technology can be a drawback and computers cannot do the job that is required of the pharmacist. Technology aids us in the acquisition, sorting, and formatting of data into information yet the clinician still must analyze the data, make an assessment and formulate a plan. There is a limit to how much information can be presented to the human mind for interpretation. The technology if not monitored and applied appropriately can provide too much data and this can worsen the information overload that many practitioners may feel. These potential negative aspects of information technology need to be considered, as computer resources are integrated into practice.
Getting started with integrating computer resources into your clinical practice need not be onerous. Computer literacy from an end user perspective is the fundamental starting point. File management techniques for storing and accessing your information are necessary. Internet connectivity and e-mail ability is required in order to draw upon the clinical resources available on the Internet. Take advantage of software tutorials and course offerings, as they become available in your community or institution. If you do not have Internet connectivity from your practice area consider implementing some of the free services that are available. Free Internet connectivity via modem is available to some geographical areas through AltaVista http://www.altavista.com or Excite http://www.excite.com and alternatives for free e-mail are numerous. For a free e-mail account combined with on-line free file storage space visit http://www.visto.com. You may find that the palm-computing platform can be of value to your practice for both patient monitoring and as a portable reference or resource station. Examine http://www.pdamd.com or http://www.healthypalmpilot.com for examples of clinical applications for these devices. A step by step integration of technology targeted at solving an existing problem or improving an existing process could be a tremendous benefit to you.
The evidence-based practice paradigm has increased the information needs of the clinician to such an extent that it is simply unmanageable by traditional paper-based methods. Progress in communications and computing technology has lead to the evolvement of medical informatics as a new discipline of study for all health professionals. With proper instruction or simple guidance, clinicians can incorporate informatics tools into their daily practice to improve the way in which they harness data and manage information. The modern pharmacist must be competent in specific computer skills to collect, store, retrieve and send drug and patient related data for administrative and clinical applications in practice. Basic computer literacy combined with a targeted use of existing software and Internet resources can help accomplish these goals.