Process standardization of encounter labeling to characterize ambulatory care pharmacist activity

Background

Structured documentation of pharmacist-provided patient care activities within the electronic medical record is crucial for recording, continuity, billing, and collecting clinical outcome data. In chart notes, the encounter reason field allows multiple semistructured or free-text entries to describe the purpose for a patient interaction. Without standardization, reason entries could not be pooled for analysis without additional chart review.

Objective

The primary aim was to increase the utility of the encounter reason field by standardizing ambulatory care pharmacist encounter labeling and provide a template for adoption across a large academic health system. The resulting structured data are intended to better characterize pharmacist activity at individual, clinic, and system levels.

Methods

A report collected encounter reason entries for pharmacist encounters in 4 primary care settings from April to June 2022. After the review, an ambulatory care pharmacist workgroup created a procedure for entering encounter reason, requiring entry of both an indication and an action or pharmacist service. Pharmacists were trained on the new procedure in August. A post-implementation report was repeated for September-Nov 2022. Presence and description of encounter reason entries were analyzed with descriptive statistics and presented for comparison between pre- and postimplementation.

Results

Pre-implementation, 18.6% (n = 370) of total encounters had a generic entry that did not define the visit indication or the pharmacists' activity. Post-implementation, generic entries decreased to 3.9% (n = 88). After exclusion of anticoagulation encounters, the number of encounters with no reason decreased from 26.8% (n = 252) to 12.1% (n = 123). The number of encounters, unique patients, and disease states labeled did not change significantly from pre-to post-implementation.

Conclusion

Implementation of a procedure for labeling encounter reason allowed for more robust characterization of pharmacist services using congruent data across pharmacist practices. This approach may be useful for pharmacist practices with limited analytics resources for more sophisticated service metrics and dashboards.