| Donna West, Sheryl Szeinbach, and Spencer Harpe |
With increasing numbers of Medicare beneficiaries enrolling in health maintenance organizations (HMOs), long-term care providers find themselves face to face with a growing need to expand services beyond traditional care models such as nursing facilities. Increasingly sophisticated information technologies-devices that store, process, or transmit data-will enable these providers to link financial, operational, and clinical data together and expand and coordinate patient services.
The authors recently completed a nationwide study of computer software vendors and measured their progress in the development of software in three major areas. The study, which was funded by Novartis Pharmaceuticals Corporation, focused on the extent to which software functions have been integrated among health care providers, particularly providers of long-term care and community pharmacy services.
Study Background
Health care reform has created a new approach to health care delivery that calls for what one observer called "the establishment of integrated provider networks linking multiple service delivery points, a holistic, patient-driven system with an emphasis on prevention and health maintenance, fixed financing, and an enlarged consumer role."2 The health care system is also placing increased importance on the outcomes of patient care services and has expressed a strong commitment to measuring and evaluating these economic, clinical, and humanistic outcomes.
Providers are turning to computerized databases and communication technologies to integrate data and evaluate outcomes. Outcome databases in particular are becoming increasingly important in conducting outcome assessments for patients receiving long-term care services.
These outcome assessments include both quality improvement components and monitoring programs designed to reduce variations in the process of care. Health care providers, including long-term care providers, are adopting continuous quality improvement (CQI) initiatives as a way to achieve optimal outcomes through continual process improvement.
Quality assurance and improvement programs are becoming mandatory in many instances, as employers, third-party payers, and managed care organizations step up requirements that health care providers monitor and improve the quality of care.
Groups like The National Committee for Quality Assurance (NCQA) have developed systems such as the Health Plan Employer Data and Information Set, which consists of clinical performance measures that employers can use to compare health care plans.3 In 1996, the Agency for Health Care Policy and Research released its own computerized database, titled CONQUEST 1.0 (Computerized Needs-Oriented Quality Measurement Evaluation System), which summarizes clinical performance measures.4
Besides being seen as a way to help improve quality, computerization is being explored as a way to enhance the continuity of care. When the Tax Equity and Fiscal Responsibility Act of 1982 created the prospective payment system-including diagnosis-related groups (DRGs)-for Medicare patients, hospitals sometimes manipulated diagnoses and shifted patients to different care settings in order to benefit financially,5 resulting in service fragmentation. As a result, patients today often face obstacles when leaving the hospital for an ambulatory care setting or when changing providers. One way long-term care providers can address this problem is by using computer technology to exchange patient data, thus reducing service fragmentation.
Computer vendors are meeting the challenge by designing and developing software that supports and integrates these expanding pharmacy functions. The nationwide study conducted by the authors assessed the abilities of computer software in three areas:
Information was gathered by mailing a self-administered survey to 52 pharmacy computer system vendors in the United States. Thirty-five of the surveys (69%) were completed and returned.
Results
Vendors were asked to indicate whether they had a software system that supported specific financial, operational, and clinical functions. On average, the vendors who responded indicated they had software systems that supported 6.4 of the 9 financial management functions listed, 7.6 of the 9 operational management functions, and 3.7 of the 9 outcome management functions. (See Tables 1, 2, and 3 respectively for the number and percentage of software systems supporting each function. Tables 1, 2, and 3 also indicate whether at least one vendor has a system to support the exchange of a specific type of information such as financial, operations, or outcome management data.)
System Integration
Because anecdotal information had suggested more data were being exchanged between community pharmacies and managed care organizations than between community pharmacies and long-term care facilities, the researchers also asked vendors to indicate whether the type of information for each function supported could be electronically transferred between specific organizations.
Survey responses revealed that the progress of software systems in supporting clinical functions and in facilitating the electronic interchange of data with other health care entities was disappointing. Most of the data transferred were between a community pharmacy and a managed care organization, confirming the speculation that managed care is currently driving the electronic integration of the health care system.
Very small amounts of data were exchanged between community pharmacies and long-term care facilities. Frequently, however, software was available to support certain activities, even though no electronic data exchange pertaining to these activities was occurring. The authors
speculate that it is possible that pharmacists are obtaining and providing such data by other communication means such as telephone, mail, or fax. Ideally, as more electronic links are established, an increasing amount of patient care data will be transferred electronically.
The survey also elicited responses to determine the importance of several items in the development of electronic links between pharmacies and other health care providers. Using a six-point Likert-type scale where 1 = "not at all important" and 6 = "very important," computer vendors indicated the following as most important: reimbursement for cognitive services (5.69±0.72), development of standard computer interfaces (5.46±0.95), adoption of computers by clinicians (5.34±0.94), and resolution of patient confidentiality issues (5.29±1.05).
A few long-term care and community pharmacy software packages are described in this article; these packages contain features that can help integrate community and consultant pharmacy and enable patient care services to be coordinated appropriately within and across organizations.
Long-Term Care Pharmacy Software
The focus of HealthObjects Corporation's Accessible Clinical Environment (ACE) is on financial management, inventory control, and clinical screening functions. Financial functions are performed concurrently and include extensive collections, accounts receivable, and billing and claims adjudication services. The ACE pharmacy system also contains a sophisticated general ledger system capable of performing double-entry accounting tasks.
ACE automatically selects items from inventory according to predetermined requirements. During autoselection, the system checks inventory levels from the appropriate inventory pools and also considers payer coverage of the item. Clinical screening functions reduce transcription errors by presenting smart prompts to the user, ensuring a complete and correct order. This function also reduces the potential for the administration of wrong or inappropriate orders to a resident.
Pharmacy Data Systems, Inc. has created a number of software programs with financial management capabilities that include real-time automated data transfer (ADT), billing, laboratory, and drug-dispensing systems, microbiology interface, and drug wholesaler selected access within your Local Area Network. Inventory management functions include complete perpetual inventory and purchase order systems, fractional inventory calculation, and generation of reports on outdated inventory.
Integrated systems can streamline the transfer of patients between acute and long-term care providers by offering a clear discharge and readmission audit trail while retaining patient demographics and drug profiles. Pharmacy Data Systems, Inc.'s NurPro II provides for Medicaid Title 19 claim submission for your state. The pharmacist can review outcomes, interventions, or Joint Commission on Accreditation of Healthcare Organizations and OBRA indicators and compliance (HL-7 Version 2.3). The pharmacist can also display a patient's historical profile, including interventions, drug interactions, and allergies. ICD-9 diagnosis and DRG analyses are incorporated into review capabilities.
SCP Systems, a company dedicated to providing clinical expertise in the areas of therapeutic monitoring, documentation, team consulting, and quality assurance, offers programs specifically for drug regimen review. RxPertise, available from the University of Southern California, is used nationwide by both independent consultant pharmacists and by large long-term care nursing service organizations. With this system, pharmacists can quickly view the relevant facts relating to each patient's drug regimen, as well as scan the history of previous comments, allowing more time for effective consulting. Documentation of comprehensive services provided by consultant pharmacists is generated in the form of reports and graphic modules.
Other medical software comes from Medical Technology Systems, which offers a system specifically designed to manage benefits, perform drug use evaluations and drug use reviews, and provide cost updates and cost modeling. SFI Systems' Getsmart is an inventory management system that maintains inventory levels and provides labels and forms customized to organizational needs. Mosby/Physicians GenRx also offers several programs that might be useful to consultant pharmacists.
Consultant pharmacists in search of programs that provide full literature support might want to look into Gold Standard Multimedia's Clinical Pharmacology, a drug reference program that contains specific updates about investigational drugs and nutritional products, as well as more general drug information. Other capabilities include the calculation of clinical values, generation of reports for adverse drug reactions and duplicate therapies, and the classification of medications by generic and brand name.
Konsult Data Systems offers software with extensive drug regimen review capabilities, including the ability to identify inconsistencies in therapeutic regimens.
Lexicomp, Inc.'s Clinical Reference Library provides educational leaflets for patients on drug use and other relevant topics, custom formulary services for large long-term care organizations, and interfacing support with other systems.
Many of these systems have assembly-line approaches to workflow processes. Typical capabilities include filling bingo cards, bulk filling of liquids, I.V. compounding, batch processing of orders, printing of labels, pharmacist verification, and pre-delivery queries of work in progress. Complete support for pricing information is provided by either MediSpan or First DataBank.
Many of these systems rely on a file server and connected work stations to operate. The servers are compatible with Microsoft Windows NT and require 64 MB or more of RAM and at least one gigabyte of hard drive memory. ACE allows the addition of a CruisePAD wireless remote terminal for data display and touch-screen data entry. Systems accommodate laser and dot-matrix printers for printing labels, reports, and other documents.
Community Pharmacy Software
Many community pharmacy software packages are marketed in the United States. These systems may support dispensing functions, patient care functions, or both. Some vendors offer support services to assist the pharmacist in providing patient care, including newsletters, networking opportunities, professionally designed programs, marketing materials, consulting services, or workflow design advice. As the role of consultant pharmacists expands, these software packages or services may be of value to them as well.
Etreby Computer Company offers a pharmaceutical care software package called Apothecare 2000, that supports the documentation of interventions, patient care plans, and patient outcomes. The software generates the SF-36 quality-of-life instrument, scores it, and displays the results in graphical form, enabling the pharmacist to monitor humanistic as well as clinical and economic outcomes. Using the Apothecare 2000 software, the pharmacist can bill for cognitive services using either the Pharmacist Care Claim Form (PCCF) or the HCFA 1500 form.
HealthCare Computer Corporation (HCC) markets Alpha-Care, a pharmaceutical care package integrated into a dispensing system. Medi-Span, USP-DI, and First DataBank databases are included in the software package to support drug information retrieval and drug interaction screening. This system also includes the PCCF and the HCFA 1500 form for cognitive service billing.
Responding to the growing popularity of disease management as a tool to help chronically ill patients manage their care, HCC has introduced a series called Mentor Rx. The series includes a variety of disease management programs from which pharmacists can select specific modules to incorporate into another system.
CarePoint markets a pharmaceutical care package to help pharmacists establish a patient care practice; one component of the package is a computer system called Cognicare. This is a Windows-based, stand-alone system; however, it can interface with various dispensing systems. Cognicare supports pharmacist intervention documentation, outcome documentation, compliance monitoring, patient care plan development, and disease management initiatives.
AmeriSource also offers a stand-alone pharmaceutical care software package. Encara is a Windows-based program that supports intervention documentation, disease management activities, patient monitoring, and cognitive services billing.
Taking a different approach, QS/1 incorporates pharmaceutical care software into its dispensing system. The software contains databases from USP-DI and First DataBank to detect drug therapy problems and support patient education. The system also supports intervention documentation, patient monitoring, disease management activities, and cognitive services billing.
To operate with optimal efficiency, most of the pharmaceutical care software packages require a Pentium processor, a 4X CD-ROM, 16 MB RAM, a 28.8 modem, and one gigabyte of hard drive memory. Some of the packages operate in the Windows environment, which enables multi-tasking and provides a graphical, user-friendly interface. Vendors choose one or more databases from different companies such as Micromedex, Medi-Span, First DataBank, or USP-DI to include in their packages. In addition, the systems may be able to interface with other clinical software packages such as DynaPulse.
Conclusion
Information technologies are becoming essential in supporting the transfer of medical records, in coordinating patient care, in standardizing quality of care, and in decreasing service fragmentation. As these technologies evolve, they will also be increasingly valuable in linking community and consultant pharmacy practices.
However, in order to achieve this goal, several barriers identified both in this study and in the literature must be overcome. For example, patient confidentiality has become a critical issue in the development of an electronic health care infrastructure, and computer vendors are faced with the problem of finding ways to secure systems and protect patient privacy. This issue is specifically identified in a section of the Health Insurance Portability and Accountability Act of 1996, which supports the development of "privacy rules." 7,8
Another challenge involves software standardization. Several groups are working to develop communication standards, a critical element in governing the transfer of data from one health care organization to another.
A third potential roadblock in the development of electronic links between pharmacies and other health care providers is the possible lack of adoption by clinicians. Decisions on whether to adopt electronic links will probably be influenced by environmental pressures, type of technology, and length of service.
Despite the flexibilities of these systems, another challenge still facing the industry is standardization of product packaging and product handling. Uniform packaging will be necessary to expedite the distribution of pharmaceutical products, reduce distribution costs, and increase product accessibility. Standardization will be essential in developing and producing the pharmaceutical product packages of the future, which will likely be plastic, easy to mail, and delivered predominantly in the form of convenient blister packs.
Although these and other barriers are very real, community and consultant pharmacy practices can be linked together by means of information technologies. In fact, given the continued expansion of managed care, the logical location for medication processing, data integration, and outcome assessment would be at the community and long-term care pharmacy levels.
As these technologies become more sophisticated and more widespread, consultant and community pharmacists will have access to information systems that allow the exchange of information needed to coordinate patient care. The integration of operational and financial functions into the clinical database will support a system capable of distributing bulk medications, generic drug products, and other products, including liquids.
Under this emerging model, the role of community pharmacists will parallel that of consultant pharmacists, and the distribution of most medications will be outsourced to organizations with tremendous market distribution power and direct access to consumers. Pharmacists and providers will form partnerships with these large distribution centers for the purpose of sharing profits, risks, and-most important-the responsibility of patient care.
Making Contact | |
| Software vendors may be reached at the following numbers: | |
| AmeriSource | 800-595-4927 |
| CarePoint | 800-296-1825 |
| Etreby Computer Company | 800-292-5590 |
| Gold Standard Multimedia | 813-287-1775 |
| HealthCare Computer Corporation | 817-531-8992 |
| Health Objects Corporation | 714-964-2470 |
| Konsult Data Systems | 414-236-6031 |
| Lexicomp, Inc. | 216-650-6506 |
| Medical Technology Systems | 813-576-6311 |
| Mosby/Physicians GenRx | 800-325-4177 |
| SFI Systems | 800-634-2173 |
| Pharmacy Data Systems, Inc. | 800-343-4962 |
| QS/1 | 800-882-3815 |
| University of Southern California (RxPertise) | 800-282-9250 |
References
1. Huber GP. A theory of the effects of advanced information technologies on organizational design, intelligence, and decision making. Academy of Management Review 1990;15(1):47-71.
2. Anderson R. Nursing leadership and health care reform-part III: nurse executive role in a reformed health care system. J Nurs Admin 1993;23(12):8-9.
3. Sennett C. An introduction to HEDIS-The Health Plan Employer Data and Information Set. J Clin Outcomes Measurement 1996;3(2):59-61.
4. Agency for Health Care Policy and Research. AHCPR Releases Conquest 1.0 Database. Research Activities 1996;192:1-2.
5. Iglehart, JK. The new era for prospective payment for hospitals. New Engl J Med 1982;307(20):1288-92.
6. West, D.S. Information technologies in community pharmacy practice, thesis, University of Mississippi, 1997.
7. Goldman J and Mulligan D. Legislation ensuring patient confidentiality in the electronic age. Drug Benefit Trends 1996;10-16.
8. Wechsler J. Electronic transmission, sharing of health information raising patient privacy concerns. Formulary 1996;31:989-90.
