Clinical Documentation Critical to Pharmacy`s Success

The newly developed health care environment demands the use of standardized terminologies and coding systems for clinical documentation; however, pharmacy is lagging in this area, according to data presented at ASHP 2016 Summer Meetings & Exhibition.

“We need to have a call to action for pharmacists as we move into the provider role in terms of our ability to do adequate clinical documentation and the technological relationships to that [clinical documentation],” said Robert L Stein, PharmD, JD, professor of practice for pharmacy law & ethics and interim coordinator of health information technology certificate program, Keck Graduate Institute School of Pharmacy, Claremont, CA, during a presentation. “Medical coding and classification systems form part of the current move toward implementing a standardized language for health.”

SNOMED-CT (Systemized Nomenclature of Medicine-Clinical Terms), for example, represents a standard terminology that is used to a classify a diagnosis or procedure, and a required standard for interoperability between various systems. The value SNOMED-CT provides includes facilitating decision support, statistical reporting, outcomes measurement, public health surveillance, health research, and cost analysis. It also helps make strong population-based analyses possible. Medication therapy management services also have specific SNOMED-CT codes available for use in documentation, according to Dr Stein.

ICD-10 is used by providers, coders, information technology professionals, insurance carriers, and government agencies. The value of ICD-10 is that it accurately reports the severity and complexity of patient conditions, measures quality and quantity of health care services, enhances clinical decision-making, tracks public health issues, conducts medical research, and designs payment systems to ensure services are appropriately paid, explained Dr Stein.

“Pharmacy needs to establish a standardized coding system and documentation terminology so we can play at the table like everyone else right now who is having their activities tracked and recorded,” said Steve Riddle, PharmD, BCPS, FASHP, director of clinical development, Wolters Kluwer Health.

By applying the standard terms and codes (eg, ICD-10, SNOMED-CT) into pharmacy clinical documentation can increase pharmacist accuracy and the consistency of the documentation. With the evolving landscape of health care, it is critical for pharmacists to be part of the broader medical team and demonstrate value as a team member, across all care settings and across patient populations. Additionally, pharmacists need to improve documentation to support clinical and financial value as new payment models take hold.

Drs Stein and Riddle acknowledged pharmacy challenges with clinical documentation. These include lack of formal training and understanding related to clinical documentation, absence of poor integration into the medical team setting that may reduce exposure to clinical documentation methods, and current documentation systems are not optimized to support pharmacist care.

Steps pharmacists can take to overcome these barriers involve pharmacy leaders engaging with key stakeholders and advocating for the value of pharmacist documentation. Pharmacists also need to request resources to support documentation.

“Poor documentation and data quality will be amplified within the age of information sharing and exchange,” said Dr Stein. “Health care organizations must manage information as an asset and put in place structures and processes to achieve data trustworthiness.”—Eileen Koutnik-Fotopoulos