Integration of New Technologies

Computer technology has changed drastically, but positively, the ability to store and access information. Even though the amount of literature is much larger today than earlier, it is more manageable. The Internet has grown into a vast network of computers that millions of users can access in most countries. The World Wide Web (WWW), a method of sharing information over the Internet, allows the user to easily access the scientific literature, government publications, items in the news, and many other things. The information may be purely in textual form, or include graphics (e.g., GIF, JPEG), video (e.g., MPEG), or sound (e.g., WAV, MP3). Patients and health care practitioners can find information on nearly every disease and treatment, and virtual health communities and forums provide a mutually supportive environment for patients, family, and friends. A pharmacist in a local community pharmacy or rural hospital can communicate with health care professionals or their patients locally or can obtain information about a medication found only in another country. Although drug information centers have ready access to the Internet, and specialists use information from this resource on a daily basis, businesses have yet to take full advantage of this technology. This is likely to change in the near future. Local area networks are frequently used to interconnect computers within a drug information center, building, or neighboring areas. The use of wide area networks will grow as institutions merge and interconnect data management functions.

There is an increasing need by health professionals, as well as consumers, to get more information about medications sooner. Information is needed quickly when a new medication becomes commercially available because of the potential for health and cost implications, when a product is withdrawn from the market for safety reasons, or when data from a new study are released that could have an impact on how common ailments are treated. The lag time that occurs with the print format may not be acceptable for many direct patient care issues. The Internet allows medical information to be available sooner to both health care professionals and the public. Online repositories for articles, such as BioMed Central (http://www.biomedcentral.com) and PubMed® (http://www.pubmedcentral.nih.gov) have allowed individuals to access millions of articles quickly, easily, and free of charge. The site http://www.freemedicaljournals.com provides a comprehensive list of medical journals that are free of charge. The availability of e-journals has helped speed up the publication process to allow articles to be available electronically sooner than the print version. Hypertext links between reference lists from an article in one online journal to the original article eliminate the need to travel to a library. When the journals e-mail a table of contents (TOC) or provide an automatic alert about articles on a particular topic, this results in a more effective method of keeping up to date. E-textbooks are also available on the World Wide Web; however, the majority of printed medical textbooks with an online version require a subscription. For instance, Harrison's Principles of Internal Medicine (http://www.harrisonsonline.com) is a continually updated and expanded version of the printed text. Other textbooks are available for purchase as a CD-ROM.

Registries of ongoing clinical trials, such as http://www.ClinicalTrials.gov, provide information on the purpose and criteria for participation in these trials. This has allowed pharmacists to anticipate new therapies, and perhaps help their patients receive medications not yet FDA approved through enrollment in a clinical trial.

There are a variety of websites sponsored by different companies and individuals. In a recent survey, 85% of physician respondents had experienced a patient bringing Internet information to a visit. Ninety percent of respondents perceived that the majority of these patients had brought them information because they wanted to ask their opinion. Wide availability of this information should be tempered with the need to evaluate the validity of information obtained, especially for the public. Information is many times incomplete or inaccurate. Because misinformation may result in harmful behavior (e.g., discontinuing medication, increasing the doses), the availability of quality information is important. There is currently no valid instrument available to assess the quality of a website, although there are many proposed methods. However, there are some common sense criteria that can be used to examine the quality of information (accurate, up to date, authoritative authorship) on a website. One site that may be helpful in providing patients with information on a range of medical conditions and management is http://www.healthfinder.gov. However, if misinformation or inaccurate information is shared, organizations exist to monitor fraud on the World Wide Web (e.g., http://www.quackwatch.com).

Mailing lists, newsgroups, bulletin boards, web forums, and chat rooms have simplified the way in which peers can exchange news and share opinions. E-mail has been an effective method to keep up to date with a journal's e-mailed table of contents (eTOC), which are often sent before print publication. Several professional organizations (e.g., American Society of Health-System Pharmacists, http://www.ashp.org) have websites that offer e-mail alert services to maintain awareness of important news affecting pharmacy, drug shortages, and awareness of their meetings.

Drug information centers have created their own sites to post information about their center and services, provide links to related sites considered to be of acceptable quality, and as a convenient means of receiving and answering drug information questions. The advantage of having a request form for answering drug information questions on the web is that physicians, pharmacists, or other health professionals can access computers at their practice site. Many times, this is accessible only through an institution's Intranet. An Intranet is a network that belongs to an organization and is designed to be accessible only by the organization's members, employees, or others with authorization. The website looks and acts just like other sites, but has a firewall surrounding it, and therefore the center can provide easy access to their primary patrons without receiving extraneous questions from people outside their defined clientele.

Likewise, the use of personal digital assistants (PDAs) has grown. A PDA offers the convenience of collecting and accessing information from a unit that can be carried in a user's pocket. There are several examples of the use of PDAs in pharmacy practice. In certain situations, these systems can be used more conveniently than a desktop computer for online searching, to provide medication profiles, to set appointments, as a time-management tool, and to search drug information databases (e.g., general drug information text and drug interaction resources). The PDA can provide access to the formulary, order entry and verification, medication error and ADR reporting, and medication use guidelines. One area where several institutions have found PDAs to be a valuable tool in their facility is in the documentation of clinical interventions by pharmacists. One study compared the efficiency of using a PDA for documentation of clinical interventions compared to paper. The number of new interventions performed by pharmacists was divided by the number of new orders written during a 6-month period. When the PDA was used to document interventions, there was consistently more complete information and more interventions documented than when data were collected on paper (7.43% [697 PDA-documented interventions/15,979 new orders written] vs. 4.36% [919 paper-documented interventions/13,184 new orders; P < 0.001]). An additional advantage of using a PDA for documentation of clinical interventions is that it decreases the time needed to aggregate the data into a database, rather than retrospectively entering data into the database. This may have some advantages in documenting reimbursement for services. In another study, authors calculated their potential claims using their Medicaid reimbursement rate for pharmacists' cognitive services documented with PDAs. The amount was more than $1 million in 6 months, assuming a 100% reimbursement rate. This cost reflects total reimbursement and was not compared to paper documentation. There are some limitations to PDAs. In general, they are not considered to be secure at this time and, therefore, may not protect proprietary or confidential information. Also, the unit may compromise usability by trying to present too much information on a small screen. The advantage, however, is that this system offers a convenient and, in many cases easily updated, information tool at the bedside. Frequently, in a clinical setting, the use of a mix of desktop, laptop, or hand-held devices is optimal based on the particular clinical scenario.

Although technology affords remote-site access to medication information sources, it is critical that pharmacists have the skills to perceive, assess, and evaluate the information, and apply the information to the situation. One of the most rapidly changing technologies in health care is information technology. It is important that pharmacists not only keep up with medication use concepts, but that they also stay abreast of developments in the area of information technology in an effort to integrate new and valuable systems in a timely and efficient manner. The need for this type of training is emphasized in a recent IOM report.

Future technology developments are likely to further enhance access and use of information. The medical record, including administrative information, laboratory data, and pharmaceutical information are becoming more commonly accessible in patient care areas. A properly configured medical record provides decision support, facilitates workflow, and enables the routine collection of data for performance feedback. This offers opportunities for pharmacists, and in particular medication information specialists, to take a leadership role in planning and implementing computerized intervention programs that automatically educate at the point of prescribing. The use of computer-based clinical support systems that provide patient information with recommendations based on the best evidence has shown to be valuable in the patient care setting, including a reported decrease in length of hospital stay. In one study that examined the value of using a decision support program to assist physicians in using anti-infective agents, the length of hospital stay of patients who used the recommendations was compared with a group of patients who did not always use the recommendations, and compared against a group of patients who were admitted to the unit 2 years before the intervention program. The length of hospital stay was statistically different with an average of 10, 16.7, and 12.9 days, respectively.

Although the Internet has been used to transfer information instantaneously to clinicians and researchers, its value as a patient care resource and professional education tool is only starting to be tested. One of the concerns in using the Internet for transfer of patient information is patient confidentiality. Virtual private networks (VPNs) are used to eliminate many of the technical issues surrounding security of information. Confidentiality has been addressed with new legislation referred to as the Health Insurance Portability and Accountability Act (HIPAA) to make sure that covered entities (e.g., health plans, health care providers, and health care clearing houses) limit disclosure of an individual's protected health information. Once the legislation has been implemented for several years, the implications of this legislation will be more clear.