Standardized documentation workflow within an electronic health record to track pharmacists' interventions in pediatric ambulatory care clinics

Abstract

Objectives: To describe the implementation of a standardized documentation workflow within an electronic health record (EHR) and to track pharmacists' interventions in pediatric ambulatory care clinics.

Setting: Ambulatory care clinics and a transitions-of-care (TOC) service within a pediatric health care system in central Ohio.

Practice description: Ambulatory clinical pharmacists work as integrated members of the health care team in 7 pediatric ambulatory care clinics and a TOC service to achieve the best medication-related outcomes for patients.

Practice innovation: A standardized documentation workflow was established among ambulatory clinical pharmacists to document the interventions made in their practice settings with the use of a tool in the EHR. A weekly report from the EHR was run by a technician to gather intervention data, identify reimbursable opportunities, and document and bill via a separate Internet-based medication therapy management platform.

Evaluation: The success of the new documentation workflow was evaluated, and continuous feedback was gathered from the pharmacists and the billing technician. Updates were provided to the ambulatory clinical pharmacist at monthly staff meetings and workflow changes implemented as needed.

Results: A total of 5210 interventions were documented by the pharmacists in various intervention categories. The 3 most common intervention categories included patient and medication education (1765), medication reconciliations (1170), and compliance assessments (795).

Conclusion: A standardized documentation workflow allowed for consistent tracking of interventions across ambulatory care clinics and a TOC service. Key elements to the successful implementation of this new documentation workflow included proper training and continuous feedback to the ambulatory clinical pharmacists, assistance from a billing technician, and consistent documentation by the ambulatory clinical pharmacists.