ADVANCED PHARMACIST PRACTITIONER SERIES

Pharmacy Informatics: Where Medication Use

and Technology Meet
Daniel Cortes, Jodie Leung, Andrea Ryl, and Jenny Lieu

INTRODUCTION ing needs. By the late 2000s, the health informatics field was
emerging, with specialization in pharmacy practice ultimately

A s technology and innovation continue to rapidly shape health

care and medication management, the need for specialized
roles to support and optimize clinical workflows, system usage, and
defining the pharmacy informatics role. Pharmacy informaticists
became a natural fit to engage health technology advancements,
evaluate system limitations and risk, educate pharmacy end-users,
data capture is ever more important.1 Health informatics is an
and investigate system issues related to medication safety, while
established field that bridges health care with information technol-
supporting pharmacy practice. The American Society of Health-
ogy as a means to improve clinical care, ensure patient safety, and
System Pharmacists (ASHP) first described the pharmacist’s role,
increase the efficiency and effectiveness of organizational processes.2
responsibilities, and competencies in informatics in 2006, with a
Pharmacy informatics, a subset of health informatics, leverages both
recent statement update in 2016.7
clinical expertise and knowledge about information technology
to improve medication management processes and drug adminis-
ENABLING GROWTH: COMPETENCIES
tration safety.3 Pharmacy informaticists are pharmacists with a
OF PHARMACY INFORMATICISTS
solid background in clinical pharmacy practice, knowledge of
pharmacotherapy, and extensive working knowledge of clinical The diversity in skills and pathways of those who work in
information systems and drug distribution systems. pharmacy informatics has prompted the definition of core
competencies that promote a technologically optimized medica-
EVOLUTION OF PHARMACY INFORMATICS tion-use process that is safe, effective, efficient, and timely. The
ASHP defined 5 major competencies critical for pharmacy infor-
Hospital pharmacies are well known to embrace technology
and automation to support drug distribution. Between the 1980s maticists to successfully contribute to any health care organization:
and the 1990s, information systems were primarily used to data, information, and knowledge management; information and
manage pharmacy inventory and produce financial reports; then, knowledge delivery; practice analytics; applied clinical informatics;
in the early 2000s, hospitals adopted computerized practitioner and leadership and management of change7 (Table 1).
order entry (CPOE) and other computerized systems with clinical In the remainder of this article, we discuss the advanced
decision support* (CDS) software.4 Clinicians were required to practice of a pharmacy informaticist within our own Canadian
oversee and tailor these systems to actualize their utility, yet the hospital network by highlighting past work completed and
early experience and research of these investigators described only projects currently underway within our hospital organization.
general benefits, and they could not report or measure the systems’ Using these interrelated core competencies, as outlined below, we
effectiveness or value.5,6 During this period of rapid technological describe how pharmacy informatics aligns people, processes, and
growth, hospital pharmacy departments were challenged to technologies with medication management.
manage and maintain new hardware and software, employing
technical analysts to support the devices and applications, while Data, Information, and Knowledge Management
pharmacy staff optimized system use to meet clinical and dispens- Pharmacy informaticists support the medication-use process
through best practice management of data, information,
*Bold indicates terms that are defined in Appendix 1. and knowledge. Health care data, such as patients’ birthdates,

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Table 1. Core Competencies for Pharmacy Informaticists8*
Competency Definition Example of Roles and Responsibilities
Data, information, and knowledge The management of medication-related • Data governance and stewardship
management information while promoting integration, • Control terminology, standards, and reference data
interoperability, and information exchange • Ensure data accuracy
• Audit and evaluate
• Ensure data are easily understood
• Maintenance
• Corrective
• Customized
• Enhancement
• Preventive
Information and knowledge delivery The delivery of medication-related information • Deliver clinical knowledge
and knowledge through the clinical • Proactively
knowledge life cycle: • Interactively
• Information and knowledge delivery • Passively
• Knowledge application and delivery • Analyze data to understand performance, reporting,
• Knowledge asset management evaluation, prediction, and harvesting of new
information to improve outcomes
• Optimize use of clinical decision support and tool
development
• Reduce information overload to provider
• Manage, support, and govern medication information
• Cataloguing, encoding, versioning, updating,
disseminating, and maintaining inventory of
information
Practice analytics The development of point-of-business analytic • Ensure data are standardized, structured, and modelled
solutions to improve decision-making to support business intelligence goals
• Create effective tools that allow for multiple formats
and layers of analysis
• Develop, maintain, and ensure the quality of these
tools to guide the achievement of treatment and
strategic goals
• Drive analytics to the front line by creating greater
end-user accessibility
• Monitor the effectiveness of tools and information
to deploy or further develop point-of-care and
analytical systems
Applied clinical informatics The application of user experience, research, • Acquire professional perspective by understanding the
and theory of informatics to clinical practice profession’s history and values and its relationship to
and system usability other fields
• Analyze problems
• Produce solutions
• Articulate rationale
• Implement, evaluate, and refine
• Innovate by creating new theories, frameworks,
and processes to address informatics problems
• Work collaboratively within and across all disciplines
• Educate, share, and discuss with students and
other disciplines
Leadership and management of change The provision of leadership and management • Lead local and external organizations to sound
in the procurement, development, conclusions regarding use of technology in medication
implementation, customization, evaluation, management
and continuous improvement of clinical • Lead and manage the risk/benefit evaluation and
information systems communication of a newly implemented technology
• Translate user requirements into safe and effective
designs
• Implement project management best practices
• Attain key leadership roles within the health care
information technology industry and organizations,
as well as pharmacy practice associations
*Bold indicates terms that are defined in Appendix 1.

laboratory test results, or drug doses, are represented by discrete glucose reading cannot compare (in terms of usefulness for
numbers, descriptions, or measurements. Information is a diagnosis and treatment) to an assessment of the patient’s blood
collection of data that has been interpreted via relationships within glucose trend, family history, oral glucose tolerance test result, and
and between separate data points, with knowledge transforming hemoglobin A1c (HbA1c) level. When considering these data
information into deliberate action.8 For example, a single blood points and information together, a clinician develops knowledge

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 about the patient’s blood glucose control, which can be used software, which obscured the critical information required for the
to determine if the patient is diabetic. Related information is nurse to select the correct product right before medication
organized into records and files, which make up a database. administration. In response to this incident, a comprehensive risk
Pharmacy informaticists manage the databases that support reduction review was completed, which led to the renaming of
the pharmacist’s clinical and administrative role, which is guided multiple medications to ensure that key drug data needed for
by the pharmacist’s practice setting and responsibilities. It is identification would always be visible to clinicians at the time of
necessary that the databases, electronic medical records (EMRs), medication ordering, dispensing, and administration.
and drug distribution systems are built to promote the safe use of
high-risk medications, to highlight therapeutic order sets or dosing Information and Knowledge Delivery
guidelines for clinicians, and to deliver and document best
The next core competency, information and knowledge
practices in pharmaceutical care. The other core competencies
delivery, involves how the databases are utilized. Pharmacy
(described in subsequent sections) are critically dependent on how
informaticists ensure that there is interoperability between the
data, information, and knowledge are managed, and the various
pharmacy information system and all other medication-related
examples we discuss later will relate back to this competency. The
systems. With constant changes to clinical practice and complex-
remainder of this section focuses on management of the drug
ities within health care, integrated systems are needed to support
database.
the delivery of accurate medication-related information to the
Developing standardized drug and order set nomenclature
end-user at the point of clinical decision-making. Pharmacy
in the drug database is important, to provide a consistent descrip-
informaticists support best practices and apply knowledge of
tion of a medication regardless of which system is being used.
informatics principles, human factors, and systems design to the
Standardized nomenclature avoids confusion within and between
systems and ensures that a clinician who is ordering, validating, user interface, to ensure that there is no confusion or incorrect
or administering a drug can safely identify the intended information at the point of care. This information delivery can
medication. In our organization, we faced numerous challenges be provided before decisions are made or passively as reference
in creating a safe medication-use system, such as identifying drugs information. Pharmacy informaticists not only support and
despite character limits within our pharmacy and prescriber oversee the creation, application, delivery, and management of
systems, using a US National Drug Code system for Canadian clinical information and knowledge, but they also inform how
drug content, and integrating data between overlapping clinical systems should be developed and why interoperability is essential
information systems. As such, it was necessary to develop guiding to safe medication management.7
principles and standard operating procedures that specified the CDS software aids clinicians during the decision-making
use of generic names (versus brand names), an approval process process by way of event-driven alerts, forcing functions, care
for use of medication abbreviations, and truncation rules that plans, evidence-based order sets, documentation templates, and
prioritized the display of a drug’s salt, formulation, extended- patient data summaries. With in-depth knowledge of EMR
release modifier, or strength. For example, new drug additions to functionalities and limitations, pharmacy informaticists can
the medication databases must undergo an evaluation process to translate clinical requirements and determine the best way to
ensure alignment with the database conventions and to prevent incorporate CDS to meet the needs of clinical workflows and
selection errors by the end-user. In a recent review for subcuta- patient safety. Considerations of national practice standards or
neous (SC) rituximab (Rituxan SC 120 mg/mL), we mitigated locally created policies and procedures should also drive the selection
the risk of erroneously selecting intravenous (IV) rituximab of the types of CDS tools that are best suited to specific clinical
(10 mg/mL) by adding the concentration and route to the drug scenarios, such as managing high-risk medications or guiding dose
name. We also employed this strategy when new biosimilar drugs adjustments in special populations.
were recently added to the formulary. In the case of filgrastim, the One such example involves using evidence-based research
brand names Grastofil and Neupogen were displayed and and clinical quality outcome data for thromboprophylaxis risk
capitalized in all systems. The naming convention we chose also assessment to develop preprinted order sets or guideline-based risk
aligns with Health Canada’s policy statement9 on the naming of assessment models10 and thus to reduce the unnecessary use of
biologic drugs, which was released earlier this year. pharmacologic thromboprophylaxis. One of the sites within our
In another example from our organization, pharmacy organization implemented a mandatory CPOE module for
informaticists discovered a system limitation that led to a database venous thromboembolism (VTE) prophylaxis within all admission
improvement. In a case of a “wrong drug” administration error, a order sets, whereby the prescriber is required to document if
patient incorrectly received Humalog instead of the intended pharmacologic thromboprophylaxis is required or contraindi-
order Humalog Mix 25. A review highlighted that, because of a cated. This mandatory module serves as a forcing function
limit on the number of characters available, the “Mix 25” text for assessment and documentation for VTE prophylaxis within
wrapped to a second line in the medication administration 24 hours of admission.

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 At another site in our organization, the use of medical logic As an opportunity to evaluate and measure pharmacy
modules allows flexibility to develop and customize electronic practice and services, one of the sites in our organization recently
CDS tools, such as custom pop-up alerts that prompt independ- launched documentation of clinical pharmacy key performance
ent double checks to be completed by nursing staff for specific indicators (cpKPIs)16 within our EMR. The existing pharmacist
medications or automatic display of important patient-specific assessment form was enhanced, piloted, and implemented.
laboratory values (e.g., serum creatinine) or key findings (e.g., Our updated documentation tool allowed clinical pharmacists to
weight) on the order screen to aid with decision-making at the document their initial patient assessment with follow-up notes,
point of order entry. In our organization, pharmacy informaticists and now they can select which cpKPIs have been completed
worked with the Antimicrobial Stewardship Program to create throughout a patient’s admission. The data from this electronic
custom reports that consolidate unit-specific treatment courses form can be easily extracted and audited with the intention of
and antibiotic information to trigger prompt reassessment on the improving clinical pharmacy services and achieving optimal
basis of specified criteria, such as critical care patients presenting patient care and safety.17
with sepsis.11 CDS has also been developed to guide antibiotic Another major undertaking at one of our sites involved
prescribing based on indication, renal function, and clinical the development of an enterprise data warehouse. Pharmacy
criteria for use. informaticists were involved in this project as subject matter
Although the use of CDS systems is an asset to clinicians and experts, collaborating with the decision support, project manage-
their workflows, it is important to monitor and evaluate the ment, and research departments. The warehouse will provide
effectiveness of these systems on the basis of ordering practices or clinicians with easier access to a large repository of business,
user feedback, and adjust when required. Pharmacy informaticists operational, and clinical data that can be used for research, quality
play an integral role in reviewing medication safety incidents to improvement initiatives, and predictive analytics. Data generated
determine whether the root cause is information system–based. from the enterprise data warehouse are reviewed by the
They also identify opportunities to incorporate changes that will pharmacy informaticists to provide background understanding,
prevent potential medication incidents in the future. Given to ensure queries are accurate, and to ensure that data are used in
the quantity of alerts presented to clinicians, including drug the correct context.
interactions, allergy verification, and critical laboratory values,
alert fatigue can develop. It has been reported that the override Applied Clinical Informatics
rate for medication alerts often exceeds 80%–90%, which can The next core competency of pharmacy informatics practice
result in preventable adverse events leading to morbidity or is applied clinical informatics, which improves clinical practice
mortality.12 Guidelines exist on how to effectively use and monitor and the usability, efficiency, and safety of systems by applying “user
alerts, given that alerts with low effectiveness and ones upon experiences, research, and theoretical informatics principles”.7
which clinicians may not agree can lead to the creation of work- Applied clinical informatics focuses on providing solutions that
around solutions.13 To mitigate these issues, it is necessary for are advantageous to clinical workflows and improve every stage
pharmacy informaticists to take alert fatigue and data overload of medication use: ordering, processing, dispensing, and
into account when designing CDS. At our organization, retro- administration. Pharmacy informaticists leverage their clinical
spective data are collected concerning alert use and overrides experiences to identify and evaluate the feasibility of technology-
associated with medical incidents; these data are then reviewed by based solutions, identify gaps, and determine risks to support
both a committee and the clinicians who commonly override departmental and organizational initiatives related to medication
alerts. It is necessary to continually perform system maintenance use and electronic systems. At one of our sites, pharmacy
to ensure that CDS remains clinically appropriate, relevant, and informaticists recently led the implementation of automated
effective for the end-user.14 dispensing units (ADUs) on inpatient and outpatient clinical
units, collaborating with nursing leadership to develop key
Practice Analytics
principles for system configuration and decisions surrounding
The third core competency of pharmacy informaticists is emergency overrides and discrepancy management.
to play a significant role in practice analytics with respect to Although ADUs represent one of our latest improvements
medication management. Practice analytics refers to a business in stock management, our pharmacy informaticists continue to
intelligence process that uses technology and database creation collaboratively manage back orders, nonformulary ordering, and
to study clinical and fiscal processes and to improve decision-mak- the use of autosubstitution or therapeutic interchanges. With
ing in these areas.15 Pharmacy informaticists must understand the increased integration of technology in the drug procurement
capabilities of their system, as well as the “big picture”, to help process, system changes have a broader impact, and careful
drive pharmacy practice improvements and increase performance consideration is required before such changes are implemented.
in the medication-use process. Drug shortages and back orders have become increasingly difficult

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 to manage in the hospital setting and require that pharmacy A recent example of our pharmacy informaticists being leaders
informaticists work alongside pharmacy technical operations staff. in change involved revision of IV bag labels to include diluent
The severity of each shortage is assessed by evaluating existing volume plus overfill. This labelling change was evaluated by
inventory, estimated usage patterns, and availability of alternative the committee, and a clear communication plan was developed
products, while considering the impact or degree of changes on to address changes to the clinical systems, batch labelling,
order entry and medication administration. CDS may be added worksheets, and IV pumps to ensure that all parties involved were
to CPOE or pharmacy order processing systems to alert system aware and on board.
users to the shortage and offer alternative actions as appropriate. Our pharmacy informatics team has also worked on national
For example, one site in our organization followed best practices initiatives such as Choosing Wisely Canada. A recently imple-
and customized various strategies during a recent shortage of IV mented recommendation consisted of decreasing unnecessary
levofloxacin that considerably affected multiple clinical areas and blood work monitoring (e.g., international normalized ratio
medical specialties. Depending on the clinical scenario, prescribers [INR], HbA1c, and thyroid-stimulating hormone [TSH]),
were instructed to change the order to oral levofloxacin, use a improving formulary management, and revising order sets. Work
different IV antibiotic, or use some of the limited supply of IV efforts included decoupling the laboratory orders for INR and
levofloxacin if indicated. Pharmacy informaticists updated all activated partial thromboplastin time, and the addition of CDS
systems to provide guidance and information to prescribers, and to affected admission order sets helped prescribers to select the
careful monitoring and ongoing collaboration with distribution suggested options. Also, routine orders for TSH and HbA1c were
team members enabled pharmacy informaticists to respond discouraged, both to educate prescribers about the utility of these
rapidly when the back order was lifted. tests and to disallow repeat ordering within specified time frames.

Leadership and Management of Change FUTURE DIRECTIONS

The final core competency calls upon pharmacy informati- There are many more interesting areas within health and
cists to be engaged and to participate in impact analyses and pharmacy informatics to learn about and further develop. We have
change initiatives while also providing oversight of and leadership described only some examples of a pharmacy informaticist’s
concerning the medication management systems.7 Pharmacy operational responsibilities and current initiatives, but we foresee
informaticists can manage and lead change through their involve- that the future holds many exciting changes.
ment in project work, engagement at any stage of the project life The health informatics curriculum is well established in
cycle (from initiation to closing), and participation in a variety medical and nursing training; however, in pharmacy, it has been
of tasks such as building, testing, and optimizing a solution. A slower to evolve.18 A 2017 survey of pharmacy curriculums in the
pharmacy informaticist’s scope of practice includes clinical United States showed that only 36% included an informatics
and policy knowledge, change management skills, project course, which was not much of an improvement from 10 years
management, and also an understanding of systems technology before.19 Pharmacy or health informatics courses are now offered
enabling participation in or leadership of projects and initiatives in most Canadian pharmacy faculties; however, many of those
within or across all sites. currently working in the field entered with little to no formal
Over the last few years within our organization, pharmacy education or training. Rather, skills have been gained through
informaticists have contributed their specialized knowledge and on-the-job experience, by working alongside nonpharmacy
strong guidance to corporate projects such as the implementation clinical informatics colleagues, through education provided by
of CPOE, IV smart pumps, ADUs, and electronic medication information system vendors, by attending public interest confer-
reconciliation. They continue to work with stakeholders in drug ences, or through continuing education. There is a recognized
distribution, drug information and utilization, pharmacy clinical need for advanced training in the pharmacy informatics field to
and technical operations, and corporate medication safety. To support systems innovation to “enable a shift to a more fully
facilitate change management processes and knowledge transfer, system-supported pharmacy practice”.20
one of the sites in our organization formed a committee to “Big data”, a term referring to large and complex data sets
coordinate upcoming changes to clinical systems, determine from many data sources,21 is being leveraged to improve clinical
potential impacts on end-users, support upcoming initiatives, and decision-making and pharmacy research.22 Artificial intelligence
manage issues related to drug shortages or formulation changes. and machine learning are becoming the future of health care,
The committee includes staff members involved in medication whereby computers are used to simulate learning, analysis, and
management, such as pharmacists, pharmacy technicians, nurses, prediction.23 In terms of application to pharmacy and medication
informatics specialists, and managers, and acts as a forum for management, development is currently underway to assist in
continuous process improvement through biweekly meetings, many areas, such as drug design,24 formulary selection, choice of
which ensure that issues arising are addressed in a timely manner. drug therapy,25 treatment predictions and results, health care data

324 CJHP – Vol. 72, No. 4 – July–August 2019 JCPH – Vol. 72, no 4 – juillet–août 2019
processing (e.g., diagnostic tests, wearable devices, and natural 8. Fox BI, Thrower MR, Felkey BG, editors. Building core competencies in
pharmacy informatics. Washington (DC): American Pharmacists
language processing26), potential drug interactions or adverse event
Association; 2010.
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pharmacy informaticists will be essential to the development and Ottawa (ON): Health Canada; 2019 [cited 2019 Jul 19]. Available from:
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The creation of larger hospital networks will prompt the 10. Rafizadeh R, Turgeon RD, Batterink J, Su V, Lau A. Characterization
work of understanding needs across various clinical and financial of venous thromboembolism risk in medical inpatients using different
systems for the affected institutions. Challenges to harmonize the clinical risk assessment models. Can J Hosp Pharm. 2016;69(6):454-9.
11. Taggart LR, Leung E, Muller MP, Matukas LM, Daneman N. Differential
practices of multiple hospitals of different sizes, using different outcome of an antimicrobial stewardship audit and feedback program in
information systems and with different levels of patient acuity, two intensive care units: a controlled interrupted time series study. BMC
must be anticipated, and it is important that pharmacy informat- Infect Dis. 2015;15(1):480.
12. Brodowy B, Nguyen D. Optimization of clinical decision support
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CONCLUSION 15. Dumitru D, editor. The pharmacy informatics primer. Bethesda (MD):
American Society of Health-System Pharmacists; 2009.
Although it is not new, the practice of pharmacy informatics 16. Fernandes O, Toombs K, Pereira T, Lyder C, Bjelajac Mejia A, Shalansky
S, et al. Canadian consensus on clinical pharmacy key performance
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 Competing interests: None declared.
Daniel Cortes, BScPhm, RPh, is with the Pharmacy Department and
Clinical Informatics, St Michael’s Hospital, Unity Health Toronto, Toronto, Address correspondence to:
Ontario. Daniel Cortes
Pharmacy Department, Clinical Informatics
Jodie Leung, BScPhm, RPh, is with the Pharmacy Department and Clinical St Michael’s Hospital, Unity Health Toronto
Informatics, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario. 30 Bond Street
Andrea Ryl, BScPhm, RPh, is with the Pharmacy Department, St Michael’s Toronto ON M5B 1W8
Hospital, Unity Health Toronto, Toronto, Ontario. e-mail: [email protected]
Jenny Lieu, BScPhm, ACPR, RPh, is with Clinical Informatics, St Joseph’s Acknowledgements: The authors are grateful to Linda Stoyanoff for her
Health Centre, Unity Health Toronto, Toronto, Ontario. contributions to content research, writing assistance, technical editing,
and proofreading in advance of submission.

Appendix 1. Definitions of key terms

Term Definition
Alert, event-driven An urgent, patient-specific notice generated by a CDS system and directed to clinicians at their
decision-making point. Some alerts are prompted when an event or a series of events has
occurred. Some require a response before the clinician can continue. Examples:
• A warning regarding a documented action/decision (or lack thereof)
• A notification of a new clinical condition, circumstance, or change in a patient, test, or drug
status that requires immediate attention
Alert fatigue A state of irritability, exhaustion, or bewilderment triggered in clinicians who have been exposed
to too many alerts, or alerts with perceived irrelevance, causing the user to ignore some or all
of the alerts. This situation reduces the safety benefit of the CDS system.
Automated dispensing unit (ADU) A secure storage unit typically in a decentralized location in patient care units. An ADU is capable
of maintaining medication inventory via an audit trail of activity, automating drug cost charging
of medication products when dispensed for patient use, and reporting the need for inventory
replacement according to usage and par levels.
Business intelligence A term to describe the strategic integration of technology and process that enables organizations
to leverage their data to make better decisions.
Clinical decision support (CDS) The provision of basic clinical knowledge and appropriate patient-specific information to aid
health care providers in making the appropriate or best possible clinical decision.
Enterprise data warehouse (EDW) A large database containing data from numerous systems, designed to provide real-time
information to support organizational decision-making.
Forcing function A design that prevents the user from taking an action without consciously considering
information relevant to that action. It forces the user’s attention upon something and deliberately
disrupts the efficient or automatic performance of a task.
Interoperability The ability of different information technology systems and software applications to
communicate; to exchange data accurately, effectively, and consistently; and to use the
information that has been exchanged.
Medical logic module (MLM) An encoded clinical rule that contains enough logic to make a single clinical decision. Examples:
• Clinical alerts, recommendations, reminders, informational notices, interpretations, diagnoses,
quality assurance functions, continuous quality improvement, biosurveillance, administrative
support, and clinical research
Sources
American Society of Health-System Pharmacists. ASHP statement on the pharmacist's role in clinical informatics. Am J Health Syst Pharm.
2016;73:410-3.
Lam JH, Ng O. Monitoring clinical decision support in the electronic health record. Am J Health Syst Pharm. 2017;74(15):1130-3.

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