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.

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