ANAHEIM, CALIF.—Pharmacists perform many interventions that improve patient outcomes and reduce costs for their organizations, but the activities often go unheralded because they are not adequately documented.

Three years ago, the Corporate Pharmacy Department at Saint Barnabas Health Care System in New Jersey decided to demonstrate the clinical as well as financial contributions of the 144 pharmacists at the integrated eight-hospital healthcare system—the state’s largest. Using a Web-based software application purchased by the department in January 2003, pharmacists were able to document clinical interventions and activities that saved the system more than $2.2 million over a three-year period (Figure 1).

A study presented at the American Society of Health-System Pharmacists' Midyear Clinical Meeting showed that as pharmacists’ interventions increased year by year, savings and cost avoidance grew proportionally. In 2005, pharmacists documented 57,130 interventions and activities, resulting in $941,503 in cost savings, compared to 31,340 interventions and $575,231 saved two years earlier (Figure 2).

The trend gained momentum in 2006, according to Robert T. Adamson, PharmD, corporate clinical pharmacy director, who reported the three-year results in a poster presentation. By early December of this past year, he said, Saint Barnabas pharmacists had documented approximately 104,000 interventions and $920,000 in cost savings.

Indu Lew, PharmD, director of education and research, Corporate Pharmacy Services, explained the slight drop in dollars saved in 2006 compared to the previous year. “The reason is that one intervention [in 2005] resulted in an influx of almost $250,000 to our system,” she said. That intervention was a successful appeal of a Medicare Fiscal Intermediary’s denial of payments for Aranesp [darbepoetin alfa, Amgen], ordered to treat myelodysplastic syndrome.

The documentation software used to record these results was not particularly exclusive. Saint Barnabas chose a clinical documentation and reporting tool called Quantifi from Pharmacy OneSource. The Web-based application is designed to be customized to the needs of individual hospital and health system pharmacies and modified as the clinical environment evolves.

Dr. Lew described the tool as “a shell.” If a pharmacist carries out a “certain intervention,” she said, “it is built into the shell, which everyone within our eight-hospital system can use.”

Nine Global Interventions Targeted

Before the program was launched, Saint Barnabas’s pharmacy departments developed a consensus on the nine global intervention categories used in the application. The categories and the proportion of interventions attributed to each over three years were as follows: medication order clarification, 29.9%; quality assurance, 18.7%; automatic therapeutic substitutions, 18.3%; therapeutic interventions, 8.8%; education, 8.4%; laboratory analysis, 5.9%; renal dose adjustment, 4.9%; intravenous (I.V.) to oral therapy, 4.5%; and committee work, 0.6%.

During the study period, I.V. to oral therapy accounted for the greatest cost savings ($690,835), followed by therapeutic interventions ($646,265), automatic therapeutic substitution ($467,985) and renal dose adjustment ($423,415). “Our cost savings were based on the actual contract dollars,” Dr. Lew said. “It’s not a fluffy number; it’s based on what we pay.”

Dr. Lew cited one intervention category—laboratory analysis—to show how cost savings were being captured. She said pharmacists often interceded when unnecessary lab tests were ordered, suggesting, for instance, that a patient’s cyclosporine level might only be required every three days rather than once a day because of the time it takes for the drug to reach a certain level in the body.

Pharmacy’s goal was not just to save money, Dr. Lew said. “Pharmacists perform tasks that may not have a direct monetary value attached to them, but have a huge impact on patient care,” she pointed out. So, for example, some of the most frequent interventions centered around clarification of orders, including those with unapproved abbreviations, duplicative therapies and incorrect dosages.

Saint Barnabas pharmacists have all been trained in the use of the application. However, more important than the training, Dr. Lew said, was instilling motivation. “If you just train them to do an act, they’re not going to do it unless they buy into the whole concept and philosophy behind it.”

An important reason for the increasing number of interventions documented, she said, was the “passion” of the pharmacists for the program, as well as the competitive spirit and peer pressure that have developed. “A hospital pharmacy department does not want to be last in the number of interventions and activities documented. You want your department to be No. 1,” she said.

Documenting interventions has also helped to reinforce pharmacists’ value to those who might not always be aware of what they do on a day-to-day basis, Dr. Lew said. “We can use Quantifi to build reports many different ways to satisfy so many different departments, i.e. Patient Safety and Quality, Infectious Diseases, Standards....It’s the old adage, ‘if you didn’t document it, you didn’t do it.’”

Informatics a ‘Backbone’ Technology

Karl F. Gumpper, RPh, BCNSP, BCPS, FASHP, director of the Pharmacy Informatics Section at the American Society of Health-System Pharmacists, noted that “informatics is the backbone of managing our patients.” Studies like the one conducted by the Saint Barnabas team show that “these tools can make the documentation of pharmacist interventions more useful [in the effort] to justify the expanded role of the pharmacist as part of the healthcare team,” he said.

But documentation of these interventions is not enough, Mr. Gumpper added. “Taking the data and showing cost savings and improved patient outcomes will justify the need for expanded pharmacy services,” he stressed.

Brent I. Fox, PharmD, PhD, visiting professor at Auburn University Harrison School of Pharmacy, Auburn, Ala., said the Quantifi software program has several benefits, such as a default clinical intervention list that is preloaded with time requirements and cost savings values.

“The presence of these values, derived from the literature, allows pharmacy departments and professional pharmacy programs to immediately begin using the application once it is obtained,” Dr. Fox pointed out. “Additionally, documentation of interventions across multiple sites within a single system provides a wealth of data. These data can be used to identify areas for education of practitioners, to compare healthcare delivery across sites, and to create opportunities to recognize pharmacists for their contributions to patient care.”