Improving medication management through health informatics information technology: The feasibility of representing pharmaceutical care services information using the Omaha System

Background: The pharmacy profession has become increasingly integrated into the patient care process with pharmacists actively engaged in providing pharmaceutical care services that are focused on the identification and prevention of medication-related problems, improvement of the medication-use process, as well as the optimization of individual therapeutic outcomes. However, the profession has not adopted a standardized approach to the assessment and documentation of pharmaceutical care services.  Methods are needed for communicating medication management activities and outcomes to patients and healthcare professionals that can easily be integrated into the electronic health record.  Utilization of the Omaha System, a standardized multidisciplinary practice and documentation taxonomy, provides a promising approach for improving pharmacists' communication within and outside of pharmacy practice settings.

Objective: To assess the feasibility of representing pharmaceutical care services information using the Omaha System.

Methods:  Two clinical experts, from nursing and pharmacy, mapped 10 de-identified pharmaceutical care services SOAP note narratives from an integrated ambulatory care clinic to the Omaha System using concept mapping methods. Clinical pharmacy and Omaha System experts validated the mapping results.

Results: In total, 9 Omaha System problems were mapped to the SOAP note narratives. On average patients had 4 medication-related problems, 6 signs/symptoms, and received 3 pharmacist-initiated interventions. The most commonly addressed problems in the sample were Medication Regimen, Substance Use, and Respiration. Gaps in documentation were identified in the narratives regarding appropriate monitoring and follow-up activities.

Discussion/Conclusion: Mapping pharmaceutical care services SOAP note narratives to the Omaha System was feasible and has potential to communicate  pharmaceutical care diagnoses, interventions and patient outcomes.  This will enable a more comprehensive and standardized data collection for the evaluation of cross-disciplinary clinical decision-making and improve communication across health care settings.