Clinton Waight BPharm MSc MRPharmS
Senior Pharmacist Haematology/Oncology
Kirkcaldy, Fife, Scotland, UK
The delivery of chemotherapy carries with it the risk of severe consequences, with most anticancer drugs having a high toxicity profile and a narrow therapeutic index. This creates an enormous potential for the delivery of pharmaceutical care to cancer patients. With the advent of more novel agents every year, the prognosis for cancer patients is improving, transforming cancer therapy into a form of chronic disease management. This shift in the treatment paradigm is reflected in the delivery of cancer care, where chemotherapy and supportive care services are being redeployed from specialist centres, to chemotherapy units in outlying district hospitals and the community. This expansion of the cancer treatment network puts an emphasis on the need for improvements in the sharing of information between centres to ensure that treatment is delivered with optimal intent and with minimal risk to the patient.
Chemotherapy often involves the use of combinations of cytotoxic drugs, tailored to the individual patient, with doses dependent on physiological characteristics such as hepatic and renal function. Verification of such prescriptions and the ongoing monitoring required with their use must therefore be conducted by a specialist oncology pharmacist. One of the most important tools to enable an oncology pharmacist to deliver a high standard of pharmaceutical care is the pharmaceutical care plan (PCP). The PCP is a clinical tool that records the pharmacist’s actions when addressing identified problems with medications. In practice, when the clinical pharmacist assesses the patient prior to each chemotherapy cycle, a record of this assessment, along with any pharmaceutical care issues (PCIs) identified, is documented on the PCP to facilitate communication to other pharmacists involved in the patient’s care. The introduction of a standardised PCP for cancer patients in Scotland has improved the consistency of pharmaceutical care for all cancer patients by prompting pharmacists to check the same generic care issues, regardless of the tumour diagnosis or the treatment being given.
Documentation of PCIs, including clinical decisions and interventions at the point of care, is one of the key concepts of pharmaceutical care and is central to the practice of clinical pharmacy. The treatment of cancer frequently requires patients to be transferred to and from regional centres near their home to specialist centres for radiotherapy or surgical procedures. In order to ensure the seamless delivery of care, there should be communication of unresolved PCIs between pharmacists or from pharmacists to other healthcare professionals. However, PCPs are often stored separately from the patient’s notes and used only by other pharmacists at that hospital site. As the PCP is a form of quality assurance documentation for the practice of pharmaceutical care, it should accompany the patient on their treatment journey and efforts should be made for it to be used in a consistent manner by others involved in the patient’s care. While the transfer of PCPs between hospitals can reduce the duplication of work and ensure outstanding PCIs are addressed, the practicalities of transporting such documents between centres has often proved to be cumbersome or impractical.
Electronic pharmaceutical care plans
The development of electronic PCPs has been an objective for regional cancer networks in the National Health Service (NHS) in Scotland since the introduction of the standardised paper PCP in 2001.1 Attempts to develop an electronic care planning system have previously been in the form of stand-alone programs, which were incapable of interfacing with other clinical systems and have encountered difficulty in satisfying strict NHS data protection and patient confidentiality legislation. Unlimited access to computer terminals and the ability to capture data at the patient’s bedside are other essential aspects of electronic care planning that have previously been difficult to deliver. The ideal system for the seamless pharmaceutical care of cancer patients would be an electronic PCP system capable of capturing data at the point of care, and providing clinical pharmacists with instant access to the right information, in the right place at the right time.
The development of electronic health records, which represent a longitudinal record of a patient’s healthcare from cradle to grave, combine information about an individual patient’s care received in hospital and in the community. Each institution that contributes to the patient’s treatment journey will develop their own electronic patient record (EPR), which is more specific to their role but remains accessible to all healthcare providers as part of the electronic health record. In the hospital setting, the EPR can be populated by all members of the multidisciplinary team contributing to the care of the patient, through their own clinical pages. Other healthcare professionals are able to read, but not edit these clinical pages, reducing the need for duplication of data and providing a link between the often disparate documentation recorded by various multidisciplinary team members in their own respective care plans. Electronic patient records are in their infancy in Scotland and not yet able to operate at their full potential, but with further input from clinical staff to develop the clinical pages for the EPR, a complete record of each patient’s multidisciplinary care can be realised.
With this in mind, the concept of developing a clinical page for the pharmaceutical care of cancer patients as part of the EPR was considered as a viable option for the creation of an electronic care planning system. As the EPR system is compliant with patient confidentiality and information technology security requirements, it presented the ideal platform for the development of a secure care planning system. In addition to this, the advent of computer wireless technology and the use of more sophisticated hand-held computers, meant that previous barriers to the implementation of electronic PCPs could now be largely overcome. Hand-held, wireless-enabled tablet computers connected to the secure password-protected hospital network, provide access to the hospital intranet, the internet and department files, and allow pharmacists the mobility to capture data at the patient’s bedside.
Electronic PCPs as part of the electronic patient record
An electronic pharmaceutical care plan was designed in the format of a clinical page to be incorporated into the EPR system in NHS Scotland. The chemotherapy service in NHS Fife is delivered over two hospital sites, 20km apart, at which some patients may be required to attend both hospitals at different stages of their treatment journey. Between the two hospital sites, there are two outpatient chemotherapy units and one inpatient ward, where chemotherapy is delivered to approximately 1,500 haematology, lung, breast and colorectal cancer patients per year. Prior to the development on the electronic PCP, a retrospective audit was conducted over a five-week period, into the use of the paper PCP system. The audit had several objectives, including trying to determine the frequency of use of PCPs, the number of care issues recorded per cycle, the completeness of the PCP and the quality of the documented care issues. Following the development of the electronic PCP, all subsequent patients had their pharmaceutical care recorded on electronic PCPs, and an identical retrospective audit was conducted on the electronic system, some time after implementation.
The use of PCPs for cancer patients in NHS Fife is an efficient system. Preliminary analysis of the results of this audit (yet to be published) indicate paper and electronic systems were comparable in many aspects. Although paper PCPs were tedious, often requiring transport between two hospital sites, the frequency of use of paper PCPs was equivalent to that of the electronic system, with both care plans being used on more than 95% of chemotherapy episodes. In one hospital, where the pharmacy and chemotherapy units are a considerable distance apart, the increase in care plan use was more apparent, possibly due to the improved accessibility it offered. This was most evident in instances where pharmacists were presented with unscheduled chemotherapy to check, which would previously require them to return to the pharmacy to collect the paper care plan.
One of the most frequently used criteria in comparing the impact of electronic systems replacing paper systems is the completeness of the record. The electronic PCP considerably improved the degree of completion of all sections of the PCP, as essential fields have been built in to the program, making it impossible to close the record without entering data into them. While this may take the pharmacist more time, it significantly improved the level of completion of PCPs. While a greater proportion of the PCP is being completed, the electronic PCP does not necessarily lead to the recording of more care issues than the paper system, with the number of care issues recorded per episode being similar to the paper system.
Electronic documentation systems present the opportunity for clinicians and policy-makers to ensure that a standardised format and vocabulary are used for the documenting patient care. Since the electronic PCP has been developed as part of the EPR, other healthcare professionals will have access to its content, and therefore it is important to maintain consistency in the structure and terminology throughout. The electronic PCP was designed to have drop-down menus in the standard (Care Issue, Action, Outcome) format for documenting PCIs, which leads users to record care issues in a structured format and use consistent language.
A key area of interest in the comparison of electronic and paper systems is the amount of time spent completing the documentation. A study into the impact of the electronic PCP system on clinical pharmacists’ time used previous work by the Scottish Oncology Pharmacy Practice Group (SOPPG) as the standard.
The results (Table 1) showed that the electronic PCP did not increase the time taken by pharmacists to perform their clinical check, and improved pharmacists’ time efficiency by eliminating time spent looking for and filing paper PCPs. The times listed in Table 1 are inclusive of all duties performed when clinically checking and ordering chemotherapy for the patient groups described. The electronic PCP has given the oncology clinical pharmacists in NHS Fife immediate access to every chemotherapy patient’s pharmaceutical care history at the time of checking chemotherapy, anywhere within the Health Board’s region. The electronic PCP has proven equivalent to the established paper PCP system for data capture, has improved PCP completeness, and helped standardise the language used while recording PCIs. The success of the system in NHS Fife is transferable to other areas where the appropriate infrastructure is in place, such as a secure wireless network and hand-held computer equipment.
The future of clinical pharmacy necessitates instant access to pharmaceutical care information at the point of care. With an electronic hand-held pharmaceutical care planning program, the pharmacist can create a complete mobile workstation to enable optimal data capture of PCIs, which may reduce the risk of drug related problems for patients under their care. With electronic prescribing systems, electronic pharmaceutical references, access to laboratory systems online clinical guidelines, pharmacists are now equipped with a complete mobile electronic workstation to perform their clinical duties.
1. MacIntyre J, et al. Pharm J. 2003; 271: 266-267