How Electronic Health Records Have Revolutionized the Pharmacy

Dinesh Yogaratnam, PharmD, BCPS, BCCCP

It’s 2 a.m., and you are the only pharmacist working in the hospital at this late hour. The fax machine whirs to life and spits out a physician orders form. You grab the paper and decipher the blurry handwriting, which reads, “Cipro 400 mg IV q12hr.” Other than the patient’s name, medical record number and date of birth, there’s no other information provided. You start asking the typical questions to determine the appropriateness of the medication order: Why ciprofloxacin? Why intravenous? Why this dose and frequency? Fortunately, the answers to some of these essential questions can be found in the patient’s medical chart. Unfortunately, the patient is all the way up on the sixth floor, while you are all the way down in the basement pharmacy. However, you have access to the patient’s electronic health record (EHR)! This means no waiting your turn to read or document within a single paper chart. All the information you need is at your fingertips. With a few quick clicks, you scan the history of drug allergies, interactions, pre-existing conditions, providers’ notes, nursing flow charts, medication administration records and laboratory results, confidently confirming that the antibiotic is safe and appropriate for your patient.

Quick decision-making is especially important in an emergency room setting. The EHR enables instant access to pertinent patient data, allowing pharmacists to quickly provide detailed drug therapy recommendations. According to Mike Dinapoli, an emergency room pharmacist at UMass Memorial Medical Center, “In a matter of seconds, I’m able to quickly access a patient’s medical history, including records at outside hospitals that use a similar EHR. We receive a ton of questions about patients with penicillin/cephalosporin allergies,” Mike explains, “I’m able to dig into the chart and quickly see if they have previously tolerated cefazolin or ceftriaxone. This helps prevent the unnecessary use of broader spectrum agents.” The EHR also gives pharmacists the ability to better scrutinize the accuracy of a patient’s medication list. “As an ED pharmacist,” Mike explains, “this helps tremendously with medication reconciliation. For example, access to a patient’s dispense history at an outside pharmacy can help verify whether an unconscious trauma patient with an intracranial hemorrhage may have been taking Eliquis. Of course, we still call pharmacies to confirm this info, but this gives us a better starting point.”

The EHR also allows pharmacists to provide a broader range of drug therapy services on a scale that simply wasn’t possible in the age of paper charts. Drug dosing services, medication discharge counseling and other labor-intensive pharmacy tasks are now facilitated by computerized processes and templates, drastically reducing the time needed to gather, communicate and document pertinent information. With the EHR, Mike explains, “we’ve been able to customize the ED trackboard to focus on the pharmacists’ workflow. We can quickly see which patients need a medication reconciliation, a vancomycin dosing adjustment or a review and approval for a restricted antibiotic.”

Not only does the EHR allow for a more streamlined approach to clinical pharmacy services, it also simplifies pharmacy operations and drug formulary management. Lorie Gull, a Pharmacy Manager at UMass Memorial, describes how the EHR helps with pharmacy operations, formulary management and patient safety. “The EHR allows for barcode scanning when receiving, storing, preparing and administering medications.” This helps to ensure safety and accuracy at each critical step of the medication use process. Furthermore, Lorie explains, “the EHR helps drive the provider towards preferred formulary agents.” By leveraging the EHR system’s computerized physician order entry (CPOE) feature, we can more rapidly communicate updates regarding formulary-preferred agents and evidence-based drug therapy guidelines. In addition, the EHR helps the pharmacy quickly react to drug shortages. Lorie appreciates how much the EHR helps in this regard, noting that “it alerts providers of new or worsening drug shortages and guides them towards alternatives. It also allows better reporting capability to assess usage of an agent in different patient populations or within different service lines and guides our mitigation strategies to where they will be most impactful.”

The outpatient pharmacy has benefited from EHRs as well. Electronic prescribing and renewal requests for medications, including controlled substances, has reduced the risk of transcription error and prescription tampering. Electronic cancellation notices from the EHR have reduced the risk of inappropriate refills. And with more advanced pharmacy systems, patients have enjoyed the ability to request refills online and automatically be notified when their prescriptions are ready.

Despite the EHR’s positive contributions to both clinical and operational pharmacy services, there are still areas where it could be improved. The EHR often presents redundant, pre-populated information. As a result, pharmacists spend unnecessary time hunting for pertinent information in order to perform drug therapy services. There is also a constant blaring of irrelevant drug alerts, which can lead to alert fatigue and a potential for accidentally overriding important drug safety checks. The EHR also has a frustrating reliance on inflexible electronic templates that limit the ability of the pharmacist to create more personalized medication care plans. The ease of creating errors can also be amplified with an EHR. Mike Dinapoli explains, “The simple click of something makes life easier. However, that also means that with a simple click you can completely order the wrong drug, frequency, et cetera.” According to Lorie Gull, the EHR could do a better job at helping to streamline pharmacy inventory management by “increasing interoperability between inventory and patient care systems, which would allow for better forecasting the need for increasing or decreasing certain agents based on utilization.”

By allowing access to a complete medical record, the EHR gives pharmacists the ability to provide timely medication reviews and deliver comprehensive, evidence-based drug therapy recommendations. The EHR allows for more efficient communication, both among pharmacists and between pharmacists and healthcare staff, which allows for a more efficient resolution of medication related problems. Drug safety and formulary management have also been revolutionized by the EHR with the incorporation of CPOE, bar-code assisted medication administration and formulary management systems. While far from perfect, the EHR is still a step in the right direction for pharmacists. As Ifeoma Asoh, a critical care pharmacist from UMass Memorial asserts, “Has it truly been game-changing? Perhaps. If one counts the higher accuracy in medication prescribing as a result of prebuilt order sets, the improved accessibility to pertinent data, such as vital signs, the increased flow of data from outside sources…then yes . The current state is a far cry from the days of pen and paper that saw us squinting at illegible handwriting, chasing down patient charts and wondering what effect the metoprolol we recommended had on the patient’s heart rate. I still prefer how tables or algorithms are displayed on paper. However, my fondness isn’t strong enough to return to the old days.”

Dinesh Yogaratnam, PharmD, BCPS, BCCCP is Associate Professor of Pharmacy Practice at Massachusetts College of Pharmacy and Health Sciences’s School of Pharmacy.