IPSA I FINAL EXAM

FINAL EXAM: DECEMBER 13 FROM 7:30-

9:30AM

 Format: 30 multiple choice and true/false questions

 Not comprehensive
 Breakdown:
 Week 7 and 8: Specimen Collection– 6 questions
 Week 9: PubMed– 6 questions
 Week 10: Motivational interviewing – 6 questions
 Week 11: Smoking Cessation– 6 questions
 Week 12: Introduction to Informatics – 6 questions
 Of note, there will be no questions regarding the Poverty Simulation
 Bring pencil (calculator not needed)
 All personal items should be left at the front or back of the room. Please
remove any hats, cell phones, smart watches, etc.
POINT-OF-CARE TESTING
GINELLE BRYANT, PHARMD, BCPS
IPSA FALL 2018
OBJECTIVES
 Describe the benefits of Point-of-Care testing in the community pharmacy setting
 Identify referral criteria for when testing should not be conducted, specifically
thresholds for oxygen saturation, temperature, and blood pressure
 Demonstrate the steps for appropriate use of a temporal thermometer
 Demonstrate the steps for appropriate use of a pulse oximeter
 Demonstrate the steps to complete a lymph node inspection
PHARMACY-BASED POINT-OF-CARE TESTING

 Point-of-care testing (POCT) is defined as laboratory testing conducted close to the

site of patient care
 Used by many health care providers
 Many types of tests available
 Self-testing by patients also available

Am J Pharm Educ. 2016 Oct 25; 80(8): 129.

POINT-OF-CARE TESTING IN IPSA
 POCT in IPSA will include:
 Bone Density*
 Blood Glucose*
 Cholesterol*
 Nasal Swab (Influenza)
 Throat Swab (Group A Streptococcus)
 Oral Swab (HIV, Hepatitis C Virus)
BENEFITS OF POINT-OF-CARE TESTING
 Potential Benefits for Patients
 Quick results
 Convenient locations
 Control over one’s own care
 Gather more health information
 May be less expensive depending on insurance
 May reduce disease exposure (ie. influenza)
 Potential to decrease costs to healthcare system
(reduced ER visits and hospitalizations)
BENEFITS OF POINT-OF-CARE TESTING
 Potential Benefits for Pharmacists and Pharmacies
– Opportunities to provide patient care services
– Increased revenue from screening services
– Increased revenue from Rx/OTC products
– Stimulate demand for other services
– Strengthen patient-pharmacist relationships
– Strengthen relationships between pharmacists and other healthcare
professional
– Expand access to care and Improve public health
OPPORTUNITIES FOR PHARMACISTS’ IN POINT-OF-CARE
TESTING

http://www.good4utah.com/news/local-news/flu-test-without-a-doctor
PHYSICAL ASSESSMENT
 All tests performed should be interpreted in context with the patient’s clinical
presentation
 Protocols often require physical assessment
 Evidence of instability triggers a referral for more advanced care
 May Include:
 Visual assessment of patient (how does the patient look?)
 Vital signs
 Weight
 Oxygen saturation
 Lymph node evaluation
Currents in Pharmacy Teaching and Learning. 7 (2015) 131–136. Available at: https://ac.els-cdn.com/S1877129714001282/1-s2.0-
S1877129714001282-main.pdf?_tid=58958cc4-2da3-4643-8f49-559e35c6fb49&acdnat=1539029597_9db62638b0c27b663ca21fb1e44fc04a
VITALS
Vital Sign Normal Readings Abnormal Readings
Pulse 60-100 bpm Tachycardia >100 bpm
Regular rhythm Bradycardia < 60 bpm
Irregular rhythm

Respirations 12-20 respirations/min Tachypnea >20 respirations/min

Regular depth and effort Bradypnea <12 respirations/min
Abnormal depth or effort

Blood Pressure < 120/80 mmHg > 120/80 mmHg

Referral warranted Hypertensive Urgency or
Emergency >180 and/or >120 mmHg

https://www.heart.org/-/media/data-import/downloadables/hypertension-guideline-highlights-flyer-ucm_497841.pdf
 BODY TEMPERATURE RANGE BASED ON SITE OF MEASUREMENT
Referral Warranted > 104 °F

Site of Measurement Normal Rangea Fevera

Rectal 97.9°F-100.4°F ≥100.4°F (38.0°C)
(36.6°C-38°C)
Oral 95.9°F-99.5°F ≥99.5°F (37.5°C)
(35.5°C-37.5°C)
Axillary 94.5°F-99.3°F ≥99°F (37.4°C)
(34.7°C-37.4°C)
Tympanic 97.5°F-99°F ≥100°F (37.8°C)
(36.4°C-37.2°C)
Temporal 97.9°F-100.1°F ≥100.7°F (38.1°C) for 0-2 months old
(36.6°C-37.8°C) ≥100.3°F (37.9°C) for 3-47 months old
≥100.1°F (37.8°C) for ≥4 years old
a Conversion formulas: Celsius = 5/9(°F - 32); Fahrenheit = (9/5 × °C) + 32.
Feret BM. Fever. Ch.6 Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 18th Edition
TEMPORAL THERMOMETER VIDEO
• Position Probe correctly
(brush hair aside, center of
forehead make T, behind ear)
• Keep button depressed all
throughout measurement

https://www.youtube.com/watch?v=tHiqdCKI00Q&feature=youtu.be
OXYGEN SATURATION (O2)

 Percentage of oxygen your blood is carrying compared to the maximum it is capable

of carrying.
 Pulse oximetry is a way to measure oxygen saturation without a blood test (arterial
blood gas study)
 Important to read directions on pulse oximeter prior to use

Normal Referral Warranted

95-99% <90%

https://www.thoracic.org/patients/patient-resources/resources/pulse-oximetry.pdf
PULSE OXIMETER

 Inaccurate measurements maybe caused by

 Significant levels of dysfunctional hemoglobin (such as carbonyl-hemoglobin or
methemoglobin)
 Intravascular dyes such as indocyanine green or methylene blue
 High ambient light. Shield the sensor area if necessary
 Excessive patient movement
 High frequency electrosurgical interference and defibrillators

Fingertip Pulse Oximeter. User Manual Ver 2.0 C1B

PULSE OXIMETER – REASONS FOR INACCURATE READINGS
CONTINUED

 Venous pulsations
 Placement of a sensor on an extremity with blood pressure cuff, arterial catheter, or
intravascular line
 The patient has hypotension, severe vasoconstriction, severe anemia, or hypothermia
 The patient is in cardiac arrest or is in shock
 Fingernail polish or fake fingernails
 Weak pulse quality (low perfusion)
 Low hemoglobin

Fingertip Pulse Oximeter. User Manual Ver 2.0 C1B

PULSE OXIMETER- OPERATIONAL INSTRUCTIONS

 Install two AAA batteries

 Open the clamp as illustrated in the picture
 Fully insert one fingertip into the silicone hole of the oximeter before releasing the
clamp
 Press the power switch button once on the front panel
 Keep your finger still during measurement
 Read corresponding data from display screen

Fingertip Pulse Oximeter. User Manual Ver 2.0 C1B

PULSE OXIMETER

• Pulse bar graph displays corresponds with the patient’s pulse beat, the height of
the bar graph shows the patient’s pulse strength

Fingertip Pulse Oximeter. User Manual Ver 2.0 C1B

FYI - PULSE OXIMETER- MAINTENANCE AND STORAGE

 Cleaning
 Use medical alcohol to clean silicon touching the finger inside the oximeter with a soft
cloth dampened with 70% isopropyl alcohol
 Clean the test finger using alcohol before and after each test
 Allow to dry before reuse
 Replace the batteries in a timely manner when low voltage lamp is lighted
 Clean surface of the fingertip oximeter before it is used in diagnosis for patients
 Remove batteries inside the battery cassette if the oximeter is not operated for a long time
 It is best to store product in -4F to 131F and ≤93% humidity
 Keep in a dry place. Extreme moisture may affect oximeter lifetime and may cause damage

Fingertip Pulse Oximeter. User Manual Ver 2.0 C1B

LYMPH NODE EVALUATION (HEAD & NECK)
 Palpate in a circular motion
 Use pads of most sensitive fingers
(middle)
 Perform assessment bilaterally
 Lymph Node Examination Video
(first 2:20 min shows head and neck
exam):
https://www.youtube.com/watch?v=
WSi42C9Nzv8
 Note: healthy individuals will likely
have undetectable lymph nodes on
Anterior cervical
Thyroid, larynx inspection
POINT-OF-CARE TESTING:
SPECIMEN COLLECTION
GINELLE BRYANT, PHARMD, BCPS
IPSA FALL 2018
OBJECTIVES
 Demonstrate the steps to complete a oral swab
 Demonstrate the steps to complete a throat swab
 Demonstrate the steps to complete a nasal swab
 Given a protocol, be able to determine if a patient is eligible for screening
 Given a protocol and a patient case, be able to determine appropriate steps (referral
or medication recommendations) following a positive or negative test
POINT-OF-CARE TESTING IN IPSA
 POCT in IPSA will include:
 Bone Density*
 Blood Glucose*
 Cholesterol*
 Nasal Swab (Influenza)
 Throat Swab (Group A Streptococcus)
 Oral Swab (HIV, Hepatitis C Virus)
 ORAL SWAB
1. Greet patient, introduce yourself, state title and ask permission
2. Tell patient what you are going to do and what to expect
3. Ensure that patient has not had anything to eat or drink prior to
testing or used any oral care products (e.g. 15 min for food/drink and
30 min for oral care products; varies)
4. Sanitize hands and put on gloves
5. Have patient tilt head back
6. Hold swab in dominant hand
7. Hold patient’s lips
8. Swabbed the patient’s gums under their lips (all four quadrants, both
upper and lower gums)
9. Remove swab from mouth as move from one quadrant to another to
avoid touching frenulum
10. Appropriately process and dispose of specimen
11. Sanitize hands
ORAL SWAB – SOME ADDITIONAL TIPS
 Oral Swab video:
https://www.youtube.com/watch?v=3wBGSB5s2tg
 Make sure patient has not had anything to eat or
drink for period of time specified by test
 Make sure to use gloves because grabbing the
patients lip
 Swab all four corners of patients mouth
 Remove swab from mouth when go from one
quadrant to another to avoid hitting the frenulum

http://lafayettedentistchauvin.com/anatomy-mouth-dental-structure/
THROAT SWAB
1. Greet patient, introduce yourself, state title and ask
permission
2. Tell patient what you are doing and what to expect
(may cause coughing or gagging)
3. Sanitize hands and put on gloves
4. Ask patient to tilt head back and stick tongue out
5. Hold tongue depressor in non-dominant hand and swab
in dominant hand
6. Collect specimen by passing the swab along the Uvula
tonsillar arches, striking the Uvula. Then swab the
reverse direction. Try not to touch the sides of the
mouth.
7. Appropriately process specimen and dispose of
materials
8. Sanitize hands
http://eclinicalworks.adam.com/content.aspx?productId=39&pid=1&gid=003746
THROAT SWAB – SOME ADDITIONAL TIPS
 Throat Swab Video:
https://www.youtube.com/watch?v=b
edJdXAK6F4
 Be careful not to touch the tongue
or lips due to possible contamination
 Tell patients to resist gagging and
closing their mouth when doing test.
 Tell patients to close eyes as they are
less likely to be anxious.
 Test should not be a painful. Your
patient may gag or cough but the
tests only takes a few seconds.
Drink of water afterwards may help.
https://www.graceer.com/what-is-strep-throat/strep-throat/
SAY “AHHH”
• “Ahh” Video:
https://www.youtube.co
m/watch?v=pvoZ04YIJzU
• Have the patient say
“ahh” to raise the uvula
and visualize the throat
better
• A short ah, ah, ah, ah is
more effective than a
long “ahhhhhh”
THROAT SWAB – SOME ADDITIONAL TIPS
 Easiest if the patient is sitting and you are standing
 Make sure you are using the recommended type of swab
for the specific test
 Tongue depressors help if not able to see throat well
 Hold swab like a pencil
 Collect specimen by starting at the base of the arch (at
level of tonsils), then swab along the tonsillar arch,
striking the Uvula, continuing along the arch and ending
at the opposite tonsil. Immediately swab in the reverse
direction.
 While it is optimal to swab in reverse direction, at least
get a solid swipe of the arch in one direction.
 Try not to touch the sides of the mouth.
 Don't need to get puss on swab from tonsil.
https://jcm.asm.org/content/53/2/573
 NASAL SWAB
1. Greet patient, introduce yourself, state title and ask permission
2. Tell patient what you are going to do and what to expect (may be mildly uncomfortable, but should
not be painful)
3. Ensure patient has not blown their nose prior to the procedure
4. Ask patient if they have a preferred nostril
5. Sanitize hands and put on gloves
6. Have the patient tilt their head back and use your non-dominant hand to steady the head
7. Hold the swab in the dominant hand
8. Insert the cotton end of the swab straight into the nasal cavity until reaching the turbinates (roughly
one inch). Go up at 45 degree angle, then go straight in for one inch (will be 2 inches in from the tip
of the nose), then rotate swab quick half turn (to ensure the swab collects cells as well as mucous)
and back out
9. Process sample appropriately, then dispose of materials
10. Sanitize hands
NASAL SWAB
 Nasal Swab Video: https://www.youtube.com/watch?v=ZK4xCbL0HWw
NASAL SWAB – SOME ADDITIONAL TIPS

 Easiest if you are both sitting or standing. Helps to be at same level as patient.
 Ask patient if they have a preferred nostril. Do you have anything that changes the
anatomy of the nose (for example, surgery on one side).
 Hold in dominant hand like throwing a dart. May use non-dominant hand to steady
chin so patient does not pull back from you
 You will feel a point of resistance, where hit the turbinates.
 Note, this is a nasal swab NOT a nasal pharyngeal.
 Should be mildly uncomfortable but not painful. Common to see patients wince or
eyes water.
 Never had any nose bleeds with this. May give patient a Kleenex just in case.
 PUTTING IT ALL TOGETHER
1. Collect: Patient interview to collect information regarding illness
2. Assess: Determine if they are a candidate for testing (do they meet
protocol criteria, are they likely to have the illness)
3. Collect: Perform appropriate physical assessment (vitals, pulse ox, lymph
node inspection)
4. Assess: Determine if candidate for testing (referral for critical
thresholds, etc)
5. Collect: specimen
6. Assess: Interpret results
7. Plan: Determine appropriate treatment
8. Implement: Prescribe medication based on protocol, recommends OTC
therapy for symptom management, administers vaccinations, and/or refer
patient to another health care provider, as appropriate
9. Implement: Document results and communicate as appropriate
10. Follow-up, Monitor and Evaluate: Follow-up with patient as
appropriate, for example call patient in 48 hours
 PHAR 154 IPSA1:
PUBMED
PRIYA SHENOY, GRADUATE HEALTH PROFESSIONS LIBRARIAN
CLASS LEARNING OBJECTIVES

• Students will be able to conduct appropriate search strategies for

finding drug and health information in PubMed.

• Students will be able to differentiate between AND & OR. And they
will use both to find information in PubMed.
CLASS LEARNING OBJECTIVES

• Students will be able to define the difference between PubMed vs.

MEDLINE.

• Students will be able to explain what MeSH is and why MeSH is

important to use when searching PubMed.
CLASS LEARNING OBJECTIVE

• Students will be able to list out and explain the PICO format for
creating a well built clinical question.

• Students will be able to identify the different levels of evidence in the

EBM pyramid.
THREE TOPICAL THEMES

1. EBM organization (EBM pyramid)

2. EBM question format - PICO
3. Mechanics of searching PubMed
RESOURCES COVERED

Books
• Drug Facts and Comparisons
• Trissel’s
• Briggs
• Sanford’s
• DI Handbook
• AHFS
RESOURCES COVERED

Electronic
• Micromedex
• Lexi Comp
• Access Pharmacy
• APhA Pharmacy Library
o Handbook of Non-Prescription Drugs
• Natural Medicines
• Dynamed
• Government websites
• Guidelines
WHY IS PUBMED IMPORTANT?

• Learning to search the biomedical literature yourself when you need to

answer a question
• Anecdotally
o P4 students say this is one of the harder DI skills
o Clinical Sciences Faculty say searching PubMed & using MeSH are difficult skills that they want their students
to be able to do
RATE OF PUBLICATIONS

http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000
326

75 Trials and 11 Review articles published a day

 EVIDENCE-BASED PRACTICE/MEDICINE

• http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021
 LEVELS OF EVIDENCE
EBM PYRAMID

• Levels of evidence: http://academicguides.waldenu.edu/healthevidence/evidencepyramid

2
ANOTHER DESCRIPTION (EBM PYRAMID)
Look for Meta-Analysis and
Systematic Reviews first

http://guides.dml.georgetown.
edu/ebm/ebmclinicalquestion
s

3
SYSTEMATIC REVIEWS/META-ANALYSES

• Systematic Review is NOT a literature review

o Exhaustive search (All articles that meet criteria)
• Systematic Reviews of RCTs are the most useful
• Meta-analysis – Statistical analysis – combines studies as one and then
evaluates results

• Randomized Control Trials – Gold Standard

REVIEW VS. SYSTEMATIC REVIEW

• http://guides.libraries.psu.edu/ld.php?content_id=36146097
• https://libguides.sjsu.edu/c.php?g=230370&p=1528399
SYSTEMATIC REVIEWS

• Systematic Reviews (SR)

o Effort made to evaluate studies for bias?
o Did the authors of the SR adhere to set standards and protocols?
 (Institute of Medicine, Cochrane Database of Systematic Reviews, PRISMA)

• Meta-analyses
o Should be attached to a systematic review
LEVELS OF EVIDENCE

• Hierarchy NOT set in stone

o Poorly conducted RCT or Systematic Reviews – not reliable
o Not every type of study can be randomized
 Legal drinking age and effect on automobile fatalities

o Some topics – not much research

o The levels at the top are different in different pyramids
EBM PYRAMID

Look for Meta-Analysis and Systematic Reviews first, then if not

available work your way down the pyramid.
LOOK FOR META-ANALYSIS AND SYSTEMATIC
REVIEWS FIRST,THEN IF NOT AVAILABLE:

http://libgui
des.gwumc.
4
edu/ebm/pi
cot
THERAPY/INTERVENTION QUESTION

• Most Pharmacy related questions = Therapy

• Determines which treatment leads to the best outcome
• Meta-analysis, Systematic Review, & then if you can’t find those
RCT
PUBMED VS. MEDLINE

• PubMed = Free interface or front end

• MEDLINE = database of abstracts

5
PUBMED CONTAINS :
6

Biomedical
publisher supplied
citations

MEDLINE
ePub ahead of
print

90% In process
citations

Other articles,
& NCBI/NLM
databases
PUBMED (MEDLINE)

• What you have access to when you graduate

• Free interface for MEDLINE
o PubMed free access: https://www.ncbi.nlm.nih.gov/pubmed/
o Access PubMed with Drake links: http://library.drake.edu/find/article-databases/goto/medline-
pubmed
PUBMED (MEDLINE)

• Database of abstracts
o Very limited full text
o Going through the Cowles Library websites increases what you have access to
 “Check for Full Text @ Drake”
 GET IT NOW VS. INTERLIBRARY LOAN

Get It Now
1. Articles only InterLibrary Loan
2. Articles = usually receive in 2-4 hours 1. Articles and books
2. Articles = usually receive in 2 days (up
to 5 days)
Books = usually receive in under 7 days
3. Sent to Drake email
3. Sent to ILL account
*If you can wait, choose ILL first
PUBMED

• Real world research can take time

• Different terms and search strategies get you to different results
• Better strategies vs. one right way
• Start broad then get specific
BACKGROUND VS. FOREGROUND QUESTIONS
Background questions concern general knowledge. These types of questions generally have only 2 parts:

• A question root (who, what, when, where, how, why) and

• a disorder, test, treatment, or other aspect of health care.
Often these questions can best be answered by using a textbook or consulting a clinical database. [ie: Micromedex, Briggs, DI
Handbook]

Foreground questions (patient specific question) are specific knowledge questions [PICO]

• that affect clinical decisions and

• include a broad range of biologic, psychological, and sociologic issues. These are the questions that generally require a search of
the primary medical literature
• Can also include systematic reviews [literature] and evidence based resources like Dynamed

http://researchguides.uic.edu/c.php?g=252338&p=3954402 3
 PICO (EVIDENCE BASED PRACTICE/MEDICINE)

• P = Patient/Population
• I = Intervention
• C = Comparison/Control
• O = Outcome

(more info: http://researchguides.uic.edu/c.php?g=252338&p=3954402 )

THERAPY/INTERVENTION – CLINICAL QUESTION

In _____________________ (P),
how does ______________ (I)
compared with _________ (C)
affect __________________ (O)?
 PICO (EVIDENCE-BASED PRACTICE/MEDICINE)

• PICO is written before you search

• In pediatric patients with allergic rhinitis are intranasal steroids more
effective than antihistamines in the management of allergic rhinitis
symptoms?
PICO DRIVES SEARCH

• A 2-year old female with burns on 10% of her body is rushed into the
ER.You have recently read that honey has been used in such cases, but
the more common treatment is Silvadene dressing. Is there evidence
that supports the use of honey?
PICO SEARCH QUESTION

• Background question: What is Silvadene?

• Foreground question (treatment question):
In _____________________ (P),
how does ______________ (I)
compared with _________ (C)
affect __________________ (O)?
PICO SEARCH EXAMPLE

• P Patient = Burn patient (child)

• I Intervention= Honey
• C Comparison = Silvadene dressing/SSD/ Silver Sulfadiazine
• O Outcome = decrease risk of infection/ (Improve wound healing
outcomes/ increase wound healing time)
AND/OR/(BRACKETS)

• AND & OR to combine search terms

• (Brackets) – group concepts together
Limit by:
Article Types
(Systematic Review,
Meta-Analysis, RCT)
Publication dates
5 years
Species
Human
Language
English

Filters
SEARCHING AS STRATEGIC
EXPLORATION
Initial Concepts 

Broader Terms 

Narrower Terms 

Related Terms 
 MESH= MEDICAL SUBJECT
HEADINGS
• Controlled vocabulary or standard language used to describe
key concepts in MEDLINE
• Defines content within an article
• Easier to search medical literature
MESH MAIN BRANCES

• MeSH Main Branches

o Can find more general terms further up
o Can find more specific terms further down
MESH

• MeSH term = Lou Gehrig’s

https://www.ncbi.nlm.nih.gov/pubmed?otool=iadrkulib
MESH

• Put in one search term at a time

• Try to apply your PICO search in PubMed
 PUBMED SEARCH WITH MESH

• P= ("Burns"[Mesh] OR "Burn Units"[Mesh])

• I= "Honey" [Mesh]
• C= "Silver Sulfadiazine"[Mesh]
• O= Decrease Infection rate (Maybe Wound healing?)
• Not much research on children specifically
USE MESH – THIS LECTURE/LAB

• So that you will be more comfortable using it for APPE’s and beyond
o Use keywords over MeSH only:
 Newer topics (No MeSH term yet)
 LONG COMPLICATED SEARCHES IN
PRACTICE
• Can take time to become a good searcher
• Searches take time too
• Using Keywords and MeSH
• Keyword Searching = Synonyms are useful (Use OR to combine)
 LONG COMPLICATED SEARCHES IN
PRACTICE
Similar Articles
LONG COMPLICATED SEARCHES IN
PRACTICE
What MeSH terms are applied to an article?
LONG COMPLICATED SEARCHES IN
PRACTICE
Understand what the database calls it
 OTHER DATABASES TO SEARCH -
COCHRANE DATABASE OF SYSTEMATIC
REVIEWS

• Cochrane Database of Systematic Reviews (Cochrane Library) – They

are known for their well designed and methodologically strict
Systematic Reviews.
 OTHER DATABASES TO SEARCH - INTERNATIONAL
PHARMACEUTICAL ABSTRACTS & CINAHL

• IPA (International Pharmaceutical Abstracts) – pharmacy/drug specific

research – 4 user limitation
• CINAHL – Nursing and Allied Health database – 4 user limitation
GOOGLE SCHOLAR

• Reliability?
• Quality?
• Peer Review?
• Finding Everything?
• Grey Literature

• Use PubMed first

SAVE TO COLLECTIONS

PubMed
THINGS TO REMEMBER WHEN SEARCHING PUBMED

• Need to select Filter twice; once to show up on the left

THINGS TO REMEMBER WHEN SEARCHING PUBMED

• Then select it again so that it gets applied

THINGS TO REMEMBER WHEN SEARCHING PUBMED

• Make sure that the blue check mark shows. This means the “Filter” has been
applied to your search.
THINGS TO REMEMBER WHEN SEARCHING PUBMED
• You can see what MeSH Terms have been assigned to this article as well as article type.
THINGS TO REMEMBER WHEN SEARCHING PUBMED
AMA MANUAL OF STYLE

• Understanding the pieces of the different journal citations that you see
in PubMed will help you to be able to find and retrieve article content.
The PharmD curriculum supports the AMA citation style.
AMA MANUAL OF STYLE

• AMA Manual of Style

o Section 1: Preparing an Article for Publication > 3. References > 3.15
Electronic References > 3.15.1 Online Journals (This link may not
work off-campus)
AMA MANUAL OF STYLE
• Section 1: Preparing an Article for Publication > 3. References
AMA MANUAL OF STYLE
• 3.15 Electronic References > 3.15.1 Online Journals.
OTHER RESOURCES

• **NEW Interactive Tutorials**

https://www.nlm.nih.gov/pubs/techbull/so17/brief/so17_pubmed_tutorial
s.html

• NLM PubMed Quick Tour https://www.nlm.nih.gov/bsd/disted/pubmedtutorial/cover.html

• PubMed Help Manual
https://www.ncbi.nlm.nih.gov/books/NBK3827/#pubmedhelp.Saving_citations_temporarily
THREE TOPICAL THEMES

1. EBM organization (EBM pyramid)

2. EBM question format - PICO
3. Mechanics of searching PubMed
• New Due Date for PubMed Quiz - 10/26/18 @5pm
• Bring laptops to lab
o We will also have some of the Fitch 102 laptops available
ASK A LIBRARIAN
Motivational Interviewing:
A Step Beyond Patient Counseling
Nora Stelter, PharmD, CHWC
Associate Professor of Pharmacy Practice
Drake University, College of Pharmacy and Health Sciences

Learning Objectives
At the completion of this activity,
students will be better able to:
4. Apply motivational interviewing skills to
100
1. Compare the provider-
centered and patient-centered
models of communication.
2. Define motivational interviewing
and describe how it can be used
in patient interactions
3. Describe key motivational
interviewing skills needed to drive
engaging, patient-focused
conversations.
assist patients in strengthening their
own motivation for change.
Prevalence of Self-Reported Obesity Among U.S. Adults by State, 2017

101
https://www.cdc.gov/obesity/data/prevalence-maps.html
Lifestyle Changes to Prevent/Manage
Chronic Disease

- Maintain a healthy weight

- Eat a healthy diet
- Exercise
- Avoid tobacco/nicotine
- Limit alcohol consumption
- Decrease stress
- (Medication adherence)

102
Reflection Checkpoint
What are some reasons
patients don’t make lasting
healthy behavior change?

103
“We are generally better
persuaded by the reasons
we discover ourselves than
by those given to us by
others.”

- Blaise Pascal, 1623-1662, French mathematician and

philosopher

104
Learning Objective #2:

Compare the provider-centered and

patient-centered models of
communication.

105
Engaging Patients:
Changing the Focus of Patient Communication

Provider-Centered Patient-Centered
I am the expert I am your partner

Here’s the advice you need to Asking rather than telling

hear…

You NEED to lose weight, stop What is the patient willing to do?
smoking, start taking all your meds What does the patient want and
on time, exercise… need?

106
It’s not about
what’s the matter with the patient
but what matters to the patient

Source: Patient-Centered Care: What It Means And How To Get There, avilaable at: http://healthaffairs.org/blog/2012/01/24/patient-centered-care-
what-it-means-and-how-to-get-there/. Accessed on August 20, 2017.
107
. 107
Learning Objective #1:
Define motivational interviewing and
describe how it can be used in
patient interactions.

108
Motivational
Interviewing
 Follow Up:
Monitor &
Evaluate
Engaging
Patients in the
Pharmacist Implement

Patient Care
Process

11
110
0
 Motivational interviewing
is a collaborative conversation style for
strengthening a person’s own motivation and
commitment to change.

Miller W. & Rollnick S. Motivational Interviewing: Helping People Change, 3rd Edition. New York, NY: Guilford Press; 2013.
111

111
Ambivalence and Resistance

MI helps patients explore and resolve:

ambivalence and resistance

Berger B, Vallaume W. Motivational Interviewing for Health Care Professionals: A Sensible Approach.
Washington, DC: American Pharmacists Association; 2013.
112
Resist the Righting Reflex

- Powerful desire to set things right,

heal, prevent harm, and promote
well-being

- Can have a paradoxical effect

- The PATIENT should be the one

doing the “righting”

Miller W. & Rollnick S. Motivational Interviewing: Helping People Change, 3rd Edition. New York, NY: Guilford Press; 2013. . P. 36
11
113
3
Learning Objective #3:
Describe key motivational
interviewing skills needed to drive
engaging, patient-focused
conversations.

114
Effective communication
creates an
information exchange
vs. an
information dump
Motivational Interviewing Involves:

- Doing more listening than talking

- Doing more reflecting than commenting

- Doing more asking then telling

116
Reflective
Listening
 Building Trust and Rapport
Through Reflective Listening
• Listening is an active process; hearing is a passive
process
• Each patient has unique concerns and beliefs
• Acknowledge what the patient tells you
• Treat the person, not the illness
• Avoid judging or evaluating the patient

Berger B, Vallaume W. Motivational Interviewing for Health Care Professionals: A Sensible

Approach. Washington, DC: American Pharmacists Association; 2013.
118
 Reflective Listening Process

Reflective
Listening
Process

Berger B, Vallaume W. Motivational Interviewing for Health Care Professionals: A Sensible

Approach. Washington, DC: American Pharmacists Association; 2013.
119
 Reflective Listening Process

Reflective
Listening
Process

Berger B, Vallaume W. Motivational Interviewing for Health Care Professionals: A Sensible Approach.
120 Washington, DC:
American Pharmacists Association; 2013.
Reflective Listening Opening Statements

It sounds like…”
“So, what I’m hearing you say is…”
“So, what I think you’re saying is…”

Never use “I understand”

121
Reflective Listening Example
- Pt: The doctor just gave me a huge laundry list of things I
need to do NOW for this diabetes… take this medicine, quit
smoking, change my whole diet, and exercise every day!
How in the world am I going to do this?

- RPh: It sounds like you’re overwhelmed. You’ve been

asked to make a lot of changes to control your diabetes and
it seems like it’s difficult to even know where to start.

122
Reflective Listening Example

- Pt: I’ve tried a lot of diets and manage to lose weight

for a while. But it always comes back again. So, I
don’t see the point in trying any more.

- RPh: It sounds like it feels pointless to you to try to

lose weight one more time. You’re wondering why
you should go to all that effort if you are just going to
gain it right back again.

123
Open-Ended
Questions
Open- vs. Closed-Ended Questions
OPEN
What concerns to you have about
your medication?
Tell me about how the past month
has gone with taking your
medication…
What may make it difficult for you to
remember to take your medications?
125
CLOSED
Are you concerned about your
medication?
Did you remember to take your
medication the past month?
Are you good at remembering to take
your medications every day?
 Asking Open-Ended Questions

- In the patient’s own words, how are they making sense of the illness?
What does it mean to them?
- What do they think of the treatment? Do they believe it will work? Do
they believe it is necessary?
- What is their understanding of what can happen if they don’t treat the
illness?
- If they are committed to treating the illness, especially a chronic
illness, what will keep them on track and what might get in the way
over the long term?
Berger B, Vallaume W. Motivational Interviewing for Health Care Professionals: A Sensible
126
Approach. Washington, DC: American Pharmacists Association; 2013.
Appreciative Inquiry:

An approach for motivating

change that focuses on
exploring and amplifying
strengths
 Appreciative
Inquiry:

Becoming mindful of
the questions we ask

AND

Directing those questions

toward strengths
and positive outcomes

128
1
2
9

VS.

129
Changing the Way We Ask Questions

Non-AI Appreciative Inquiry (AI)

How can you overcome your What strengths can you leverage to help
challenges? you in overcoming the challenges?

What is not working? What is working?

What has happened in the past? What successes have you had in the past
that you can leverage moving forward?
What do you want to avoid What would your future look like if you
replicating in the future? achieved your goals?

130
Learning Objective #4:
Apply motivational interviewing
skills to assist patients in
strengthening their own
motivation for change.

131
 Steps in
Motivational
Interviewing
1
3
3
Steps in Motivational Interviewing
(Berger and Villaume 2013)

1. Develop rapport
- Create a trusting relationship
- Show the patient that you care about their well-being and respect them
- Assess motivation and confidence
- Ask about their questions and concerns
- Find the root of their ambivalence or resistance

2. Reflect back our understanding of the patient’s sense making and reframe the
issue
- Clarify the issue
- Shine a new light on the problem
- Say “You’re wondering….”
Berger B, Vallaume W. Motivational Interviewing for Health Care Professionals: A Sensible Approach.
Washington,133
DC: American Pharmacists Association; 2013.
 Steps in Motivational Interviewing
1
3
4
(Berger and Villaume 2013)

3. Ask permission to provide information to address the patient’s sense making

- “That’s a great question you asked. Would it be okay if I give you some information to
answer your question and you can let me know what you think?”

4. Provide new information

5. Ask the patient what he/she thinks of this new information

- “Where does this leave you now?”

6. Summarize and discuss next steps

- Collaborate with the patient to make a plan

Berger B, Vallaume W. Motivational Interviewing for Health Care Professionals: A Sensible Approach.
Washington, DC: American Pharmacists Association; 2013.
134
MI Process in Action
Patient comes to refill lorazepam, but not simvastatin which are both due for
refills

Steps 1 & 2:
- RPh: “Hello, Mr. Smith. It looks like you’re due for your simvastatin too.
Would you like me to get that one ready for you too?”
Develop
Rapport
- Pt: “No, I’m not taking that one anymore. I feel fine and I’m tired of taking
it.” and Reflect
- RPh: “It sounds like you are frustrated with having to take the medication
every day, when you don’t feel any better or different when you take it.”
- Pt: “Right, it’s just one more thing I don’t need to have to do every day.”
- RPh: “Would you mind if I share some information and you tell me what
you think?”

135
MI Process in Action
Patient comes to refill lorazepam, but not simvastatin which are both due for
refills
- RPh: “Hello, Mr. Smith. It looks like you’re due for your simvastatin too.
Would you like me to get that one ready for you too?”
- Pt: “No, I’m not taking that one anymore. I’m feel fine and I’m tired of taking
it.”
- RPh: “It sounds like you are frustrated with having to take the medication
every day, when you don’t feel any better or different when you take it.”
- Pt: “Right, it’s just one more thing I don’t need to have to do every day.”
- RPh: “Would you mind if I share some information and you tell me what you
think?”
Step 3: Ask
Permission
136
1
3
7 MI Process in Action Steps 4 and 5: Provide
new info and ask patient
what they think
- Pt: Sure. That would be ok.
- RPh: High cholesterol is a condition that does not have any symptoms until
something serious happens. Usually the first symptom is a stroke or heart attack.
We know that by lowering your cholesterol by ~50%, your risk of having a stroke or
heart attack goes down a lot. Your cholesterol today is not as low as we want it yet.
That puts you at a much higher risk of stroke or heart attack. I would hate to see that
happen, especially when it is preventable. Where does that leave you now in
wanting to lower your cholesterol?
- Pt: Nobody ever explained it like that to me. Now that you put it that way, I don’t
want to have a heart attack, I’ll go ahead and take that simvastatin today.
- RPh: This is great news. It sounds like you’re willing to give the simvastatin a new
start and you’ll be taking it regularly. When you come in next month, we can talk
about how the month went taking the medicine every day and discuss more ideas on
how to be compliant! 137
1

MI Process in Action
3
8 Step 6: Summarize &
Discuss Next Steps
- Pt: Sure. That would be ok.
- RPh: Unfortunately, high blood cholesterol is a condition that does not have any
symptoms until something serious happens. Usually the first symptom is a stroke or
heart attack. We know that by lowering your cholesterol by ~50%, your risk of having a
stroke or heart attack goes down substantially, even if you have no symptoms. Your
cholesterol today is not as low as we want it yet. That puts you at a much higher risk of
stroke or heart attack. I would hate to see that happen, especially when it is
preventable. Where does that leave you now in wanting to lower your blood pressure?
- Pt: Nobody ever explained it like that to me. Now that you put it that way, I don’t want
to have a heart attack, I’ll go ahead and take that simvastatin today.
- RPh: That’s great news. It sounds like you’re willing to give the simvastatin a new
start. When you come in next month, we can talk about how the month went taking the
medicine every day. Would you like to discuss more ideas on how we can assist you
with remembering to take your medicine? 138
Additional Resources for MI Training
- Berger B, Vallaume W. Motivational Interviewing for Health Care
Professionals: A Sensible Approach. Washington, DC: American
Pharmacists Association; 2013.

- Miller W. & Rollnick S. Motivational Interviewing: Helping People Change,

3rd Edition. New York, NY: Guilford Press; 2013.

- comMIt: Comprehensive Motivational Interviewing Training for Health

Care Professionals. Available at: https://tinyurl.com/PurdueCE-MI-HCP

139
 Key Points!
• Motivational interviewing can be integrated
into all steps of the Pharmacist Patient Care
Process to provide a patient-centered
approach to patient care

• Motivational interviewing can assist

pharmacists in engaging their patients to
find their own motivation for change to make
lasting healthy behaviors
Smoking Cessation
The Tobacco Plant
(Nicotiana tabacum)
• Native to North and
South America
• Thought to be
cultivated since
6000BC
• Tobacco is prepared
from the leaves of the
plant, that is also
where the Nicotine is
found.
The Marketing
The Appeal
Hollywood
 Nicotine Products
(smoked tobacco)
• Cigarettes

• Cigars

• Pipes

• Water pipe/Hookah
 Nicotine Products
(smokeless tobacco)
• Chewing tobacco
• Dipping tobacco
• Snuff
• Snus
• Dissolvables
• Etc.
 Nicotine Products
(Electronic Delivery)

• Electronic cigarettes “e-cigs”

• Disposable (no charging~1000 puffs)
• Rechargeable and refillable

• Vape Pens
• Modified e-cigarettes
‘MODS’
• Electronic Water Pipe/ Hookah
Electronic Examples
 Juuling and Juul pods

Each cartridge contains 200 puffs and has as much nicotine as an entire
pack of cigarettes. Produces less ’smoke’, charges in a laptops USB port.
Pod flavors include tobacco, mint, mango, cucumber, crème, fruit, etc.
 Reasons for Tobacco
Use (Then and Now)

• Medicinal Purposes
• Ceremonial Purposes
• Social Purposes
• Stress Reliever
https://www.fda.gov/tobaccoproducts/guidancecomplianceregulatoryinfor
mation/ucm297786.htm
 Why all the junk?
• Naturally occurring
-Nicotine

• Additives
-Arsenic (found in soils, pesticides)

• By-Products
-Formaldehyde (due to burning)
 Reality:
Nicotine is Awesome
Dopamine Pleasure, appetite suppression

Norepinephrine Arousal, appetite suppression

Acetylcholine Arousal, cognitive enhancement

Glutamate Learning, memory enhancement

Serotonin Mood modulation, appetite

suppression

Beta-endorphin Reduction of anxiety and tension

GABA Reduction of anxiety and Tension

 The Smoking Cycle
 Nicotine is introduced

 Nicotine is quickly absorbed

 You relax and feel good (for awhile)

 Your nicotine level falls

 You feel a craving for more nicotine

 Your mind tells you it wants more (or you will

feel terrible)
 The cycle starts over again
 Why Smoking Can be Hard to
Quit

Nicotine is Addicting 
**Emotional
**Behavioral
**Physical
 Withdrawal
Psychological Physical
• Anxiety • Sweating
• Agitation • Shaky
• Trouble Sleeping • Racing Heart
• Depression • Difficulty
• Irritability breathing
• Headaches • Muscle tension
• Poor • Chest Tightness
concentration • Nausea
• Social isolation • Vomiting
• Etc. • Etc.
*Withdrawals reveal within 1-2 days, peaking in the first week, and will slowly
subside over 2-4 weeks. Increased appetite or weight gain can be seen for
upto 6 months after quitting.
 Health Benefits to Quitting
(Immediate)
• Inflated blood pressure and heart rate return to normal

• Decrease carbon monoxide level in the blood (within a

few hours)

• Improved blood flow (within a few weeks)

• Decrease in phlegm, decrease in episodes of cough or

wheeze (within a few weeks)

• Considerable improvement in lung function (within

several months)

• Decreased risk of cancer, heart disease, and long-term

illnesses than if they would continue (within a few years)
 Health Benefits to Quitting
(Long-term)
• Decreased risk of cancer, heart disease, and long-term
illnesses

• Gains in life expectancy (compared to continued

smokers)
•
Strategies
Hypnosis
to Quit
• Acupuncture

• Exercise

• Counseling
A combination above as well as/or…

• Medications (Rx) – Smoking Cessation

• Medications (Rx) – Nicotine Replacement

• Medications (OTC) – Nicotine Replacement

 Rx Medications
(Smoking Cessation)

• Chantix (varenicline)
• Zyban (bupropion)

Rx Medications
(Nicotine Replacement)
• Nicotrol Inhaler
• Nicotine Nasal Spray
 Chantix (Varenicline) tablets Rx
0.5mg, 1mg

Mechanism of Action : Blocks nicotine from attaching to receptors in the

brain. This results in decreased pleasure, less excitement.

Administration: Titrate up over the first week. Duration 12-24 weeks

depending on quit plan.

Day 1-3 Day 4-7

Day 8-end
1 tablet (0.5 mg) 1 tablet (0.5 mg) 1
tablet (1 mg)
po daily po bid
po bid
 Chantix (Varenicline) tablets Rx
Adverse Drug Reactions (a few)
• Nausea (30%) – manage with food, glass of water
• Abnormal dreams, insomnia
• Increased intoxicating effects with alcohol presenting as
aggressive behavior and having no memory

Warnings and Precautions (a few)

• Blackbox warning: Changes in mood, aggression, suicidal
ideation
• Serious skin reaction (Steven Johnson Syndrome)
• Angioedema, swelling of the face, mouth and neck
Zyban (bupropion SR) tablets Rx
150 mg

Mechanism of Action : Not fully understood. Works by inhibiting the

reuptake of dopamine, serotonin, and norepinephrine in the brain. The
neurotransmitters remain active.

Administration: After 3 days, titrate up. Duration 7-12 weeks, many

continue as it has positive effects on depression
Day 1-3
Day 4-end
1 tablet (150 mg) 1 tablet (150
mg)
po daily
po bid

Special Considerations: *Start the med 1-2 weeks before the quit date.
 Zyban (bupropion SR) tablets Rx
Adverse Drug Reactions (a few)
• Insomnia –sleep hygiene recommendations
• Dry Mouth – manage by ice chips, etc.
• Nausea - manage with food, glass of water

Warnings and Precautions (a few)

• Blackbox warning: Changes in mood, aggression, suicidal
ideation
• Decreases seizure threshold (related to patient factors, etc.)
• Concerning if going through abrupt discontinuation of
alcohol.
 Nicotrol Inhaler (Nicotine) Rx
10 mg per cartridge

*Differs from nicotine in cigarettes and other products by slower

absorption, smaller fluctuations in blood levels, and lower levels of nicotine.

Mechanism of Action : Nicotine binds to receptors in the brain. Pathways

are activated and neurotransmitters are released resulting in a reward
effect. Peaks = 30-60 minutes.

Administration: If possible, taper after 3 months. Duration not studied after

6 months. Dose reductions should occur between 6 to 12 weeks.
*Individualized dosing. Inhale deeply or puff in short breaths. Cartridge is
used up if continuous puffing for 20 minutes. Recommended cartridges
per day = 6-16. Max 16 cartridges per day. 4 mg available from a 10 mg
cartridge
 Nicotrol Inhaler (Nicotine) Rx

Adverse Drug Reactions (smoking/Nicotine related)

• Chest discomfort, hypertension, bronchitis, etc.

• Dyspepsia, nausea, throat irritation, etc.

• Headache, influenza-like symptoms, etc.

Warnings and Precautions (a few)

• Nicotine Toxicity characterized by pale skin, tremor, mental
confusion, cold sweats, salivation, seizure, etc.

• Controversial: Acute adult lethal dose of nicotine is reported to

be 40-60 mg or 0.5 g? (Nicotine in cigarettes = 1 mg to 16 mg)

• Concerning if going through abrupt discontinuation of alcohol.

Caution airway disease
 Nasal Spray (Nicotine) Rx
10 mg/mL

*100 mg Nicotine per 10 mL spray bottle. Each spray = 0.5 mg nicotine

Mechanism of Action : Nicotine binds to receptors in the brain. Pathways

are activated and neurotransmitters are released resulting in a reward
effect. Peak = 11-18 minutes.

Administration: Duration longer than 6 months has not been studied.

One dose = 1 mg nicotine, 2 sprays. Do not sniff, swallow, or inhale by
mouth. Tilt head slightly back.

Start at 1or 2 doses per hour upto 80 sprays (40 mg) per day.
Minimum = 8 puffs per day. Maximum doses per hour = 5.
 Nasal Spray (Nicotine) Rx
Adverse Drug Reactions (smoking/Nicotine
related)
• Nasal irritation that may go away. Peppery sensation
• Dyspepsia, chest tightness, smell changes
• Headache, runny nose, watery eyes, coughing

Warnings and Precautions (a few)

• Nicotine Toxicity characterized by pale skin, tremor,
mental confusion, cold sweats, salivation, seizure, etc.
• If the spray gets into the eyes, flush with water for 20
minutes
• To be used nasally; not recommended for those with
chronic nasal disorders.
 OTC Medication
(Nicotine Replacement)

• Nicotine Patches

• Nicotine Lozenge

• Nicotine Gum
*Upon initiation, patients
should completely stop smokin
 Nicotine Patches
Step 1 = 21 mg, Step 2 = 14 mg, Step 3 = 7 mg
Extended-release patch (OTC)
Nicoderm CQ Nicoderm CQ
>10 cigs/day <10 cigs/day
Step 1 x 6 weeks Step 2 x 6 weeks
Step 2 x 2 weeks Step 3 x 2 weeks
Step 3 x 2 weeks
Mechanism of Action : Nicotine binds to receptors in the brain. Pathways
are activated and neurotransmitters are released resulting in a reward
effect. Peak = 3-12 hours

Administration: Apply to a clean, dry, hairless area of skin on upper body or

upper outer part of the arm at same time each day , rotate and apply to a
different area of skin each day – do not reuse same area for 1 week. Apply
firm pressure with palm of hand for 10 seconds; ensure a good seal,
especially with edges. Wash hands before and after applying/removing
patient. No more than 24hrs on.

Regular swimming and bathing ok with patch.

 Nicotine Patches (OTC)

Adverse Drug Reactions (a few)

• Local skin reactions (itching, redness, burning)

• Vivid dreams (remove patch at night and reapply in the

morning, insomnia, headache

• Sleep disturbance (nocturnal absorption)

Warnings and Precautions (a few)

• Do not cut

• Remove the patch prior to MRI procedures; Proper disposal

• Caution, Increased absorption with hot tubs, prolonged hot

showers, and hot baths.
 Nicotine Lozenges (OTC)
2 mg, 4 mg
Various Flavors such as
Mint, Cherry, & Cinnamon
TTFC=Time to First Cigarette
*Peaks 30-60 minutes
*Max of 5 lozenges Q 6
hours (20 lozenges/day) on
any given week. 4mg If
TTFC is within 30 minutes of
waking. >30 min= 2 mg.

Administration: Place lozenge in mouth and allow to dissipate (20-30 minutes for
standard, 10 minutes for mini-lozenge
. 12 week dosing schedule
Weeks 1-6 Weeks 7-9
Weeks10-12
1 lozenge 1 lozenge
1 lozenge
Q 1-2 hours Q 2-4 hours
Q 4-8 hours
*For increased success, use
 Nicotine Lozenges (OTC)
Adverse Drug Reactions (a few)
• Mouth irritation- rotate (may need to check in with Dr.)

• Digestion issues (if persistent, speak with a provider)

• Severe sore throat (check in with a provider)

Warnings and Precautions (a few)

• Acidic drinks (coffee, juice, wine, etc) can decrease
nicotine absorption. Only water for 15 minutes before or
while using.

• Do not chew or swallow-can cause nausea and

heartburn
 Nicotine Gum
2 mg or 4 mg
*Max 24 pieces/day
(OTC)
* use while awake only
4mg If TTFC is within 30 minutes of
waking. >30 min= 2 mg.

Administration: Chew until the first sign of the flavor (15 chews). Park it between
the cheek and gum for absorption of the Nicotine. Repeat when taste or tingling
stops. 1 gum last approx. 30 minutes. Heavy smokers may need more pieces
Peaks 30-60 minutes

. 12 week dosing schedule

Weeks 1-6 Weeks 7-9

Weeks10-12
1 piece 1 piece
1 Piece
Q 1-2 hours Q 2-4 hours
Q 4-8 hours
*For increased success, use
 Nicotine Gum (OTC)
Adverse Drug Reactions (a few)
• Throat and mouth irritation- rotate (check in with Dr?)
• Jaw muscle soreness/fatigue, hypersalivation
• Lightheadedness, nausea, vomiting- chewing too fast?

Warnings and Precautions (a few)

• Acidic drinks (coffee, juice, wine, etc) can decrease
nicotine absorption. Only water for 15 minutes before or
while using.
• Do not chew or swallow-results in nausea and heartburn
• Carry it with you at all times
 Off Label Medications
• Pamelor – nortiptyline (generic) capsules

*Start 10-28 days before quit date

• Tenex – guanfacine (generic) Tablets

*0.1 mg po BID, increasing by 0.1 mg/d each

week if needed/tolerated to a total daily dose of
0.15 to 0.75 mg

• Catapres TTS – clonidine (generic) patch

*0.1 mg/d, increasing to 0.2 mg/d after one week (via

appropriate strength patch applied once every 7 days)
 Tools to Quit
• Counseling and Support
• Medications (Rx and OTC)
• Combination Methods (Counseling
+ Medications)
• Other Methods
• Internet Quitting Programs
• Self-help Guides
• Etc.
Introduction to Informatics

IPSA – November 13, 2018

Michael Daly, PharmD, MSCI, BCPS

Associate Professor of Pharmacy Practice
Drake University College of Pharmacy and Health Sciences
Michael.Daly@drake.edu 515-875-9212 (TIC)
Learning Objectives:
1. Differentiate pharmacy informatics from other core informatics terms and
disciplines.
2. Discuss the role of various health information technology tools (recognizing
them by abbreviation, as applicable) used to decrease medication errors at
each step of the medication use process, including ADC, BCMA, CDS/CDSS,
CPOE, eMAR, e-prescribing, PIMS, and smart infusion pumps.
3. Describe the three primary components of a clinical decision support system.
4. Differentiate between passive and active (including interruptive and
noninterruptive) clinical decision support and provide examples of each
type.
5. Discuss the phenomenon of alert fatigue, as well as strategies that
informaticists can use to mitigate or minimize it.
6. Describe the purpose of a clinical documentation system and discuss the
basic elements that one should have.
7. Discuss the role of various current standards (recognizing them by
abbreviation, as applicable) that are necessary to achieve interoperability,
including ICD-10, NCPDP SCRIPT, NDC, and RxNorm.
8. Define privacy, security, and confidentiality as they relate to protected health
information.
 Acronyms & Alphabet Soup
• ADC: Automated Dispensing Cabinets
• BCMA: Bar code medication administration
• CPOE: Computerized Provider Order Entry
• CDS (CDSS): Clinical Decision Support (Systems)
• DDI: Drug-Drug Interaction
• EHR (EMR): Electronic Health (Medical) Record
• eMAR: electronic Medication Administration Record
• FDA: Food and Drug Administration
• HIT (HIS): Health Information Technology (Systems)
• ICD-10: International Classification of Disease, 10th revision
• NCPDC: National Council for Prescription Drug Programs
• NDC: National Drug Code
• PHI: Protected Health Information
• PIMS: Pharmacy Information Management System
What is Informatics? People Information

• Simple: The use of computers to

manage data and information Technology

• Complex: Involves developing and utilizing

a broad range of information technology to
facilitate the collection, management, exchange, analysis, use
(and re-use) and storage of patient (including clinical and
genomic), fiscal, and administrative information to support
and improve (1) the quality of patient care and health
outcomes, (2) secure access to information, (3) professional
and organizational efficiency , and (4) the decision making
capabilities of health professionals, administrators and others
within the healthcare organization
BMC Med Inform Decis Mak. 2009;9(1):24
Berner, ES. Informatics Education in Healthcare, Lessons Learned.2014
 Under the Umbrella of Informatics
• Biomedical informatics
▫ The interdisciplinary field that studies and pursues the effective
uses of biomedical data, information, and knowledge for scientific
inquiry, problem solving, and decision making, motivated by
efforts to improve human health.
• Health informatics (ACPE Standard (2016))
▫ Effective and secure design and use of electronic and other
technology-based systems including electronic health records, to
capture, store, retrieve, and analyze data for use in patient care,
and confidentially/legally share health information in accordance
with federal policies.

BMC Med Inform Decis Mak. 2009;9(1):24

Am J Pharm Educ. 2013;77(3):Article 4.
 The Umbrella of Health Informatics
• Clinical informatics

• Medical informatics

• Nursing informatics

• Pharmacy informatics

• Public health informatics

https://www.amia.org/applications-informatics/clinical-informatics
 What is Pharmacy Informatics?
• Use of information, information systems, and automation
technology to ensure safe and effective medication usage.

• The effective management and delivery of medication-related

data, information, and knowledge across systems that support
the medication-use process.

BMC Med Inform Decis Mak. 2009;9(1):24

JAMA.
Am J Health-Syst 2002;288:1955-8.
Pharm. 2016;73:410-3.
Patient-Specific Knowledge-Based
Information Information
Medication &
Medical Histories Referential
Information
Lab Test Results
Clinical Practice
Guidelines
Immunization
Histories
Other Domains of
Physical Health and Medical
Assessments Knowledge

Medical informatics-improving health care through information.

JAMA.2002;288:1955-8.
What differentiates pharmacy informatics from other informatics disciplines is its focus on : (learning
objective 1)

• A. computerized provider order entry

• B. clinical decision support systems
• C. medication use process
• D. safe and effective clinical care
Medication Use Cycle
Prescribe

• A system of
interconnected Purchase
Transcribe
/Supply Chain
parts that work Management
/Verify

together to
achieve the
common goal of
safe and effective Prepare
Monitor
medication /Dispense

therapy.
Administer

Drug Information: A Guide for Pharmacists. Chapter 24

JAMA. 1995; 374:35-43.
 Pharmacy Informatics
(in the Medication Use Process)

Prescribing Verification Administration

Dispensing Monitoring

• CPOE • PIMS •BCMA

• ePrescribing • ADC •eMAR
• Barcode Medication Verification •Smart pump

CDSS
Informatics in Prescribing
• CPOE
Prescribe
▫ Pros and Cons
Purchase
Transcribe
/Supply Chain
Management
/Verify • CDS/CDSS
▫ Key components

• Alert fatigue
Prepare
Monitor
/Dispense
• E-prescribing

Administer
 Computerized Provider Order Entry (CPOE)
• Process allowing medical provider instructions to be entered
electronically for the treatment of patients under a provider’s
care

• Communicated to medical staff and appropriate departments

over a network

• Meaningful Use program (CMS) created strong incentive for

health systems to adopt CPOE/HIT

Arch Intern Med. 2003;163(12);1409-16.

JAMA. 1998;280(5):1311-6.
Pros and Cons of CPOE
Benefits
• Eliminates illegible handwriting
• Decreases medical errors
• Decreases delay in order
completion
• Improves patient care
BMC Med Inform Decis Mak. 2009;9(1):24
Drawbacks
• Can introduce new types of errors
• Learning curve for new or
inexperienced users
• Alert fatigue may lead to ignoring
or overriding CDSS messages
JAMA. 2005;293(10):1197-203.
 CDS Definition

• Providing clinicians, patients, or individuals with knowledge

and person specific or population information, intelligently
filtered or presented at appropriate times, to foster better
health processes, better individual patient care, and better
population health

• CDSS are the computing systems that provide CDS

BMC Med Inform Decis Mak. 2009;9(1):24

JAMA. 2002;288:1955-8.
The Main Goal of CDS (Pharmacy)
• Provide the right information

• To the right person

• In the right manner

• Through the right format

• At the right point in the clinical

workflow…

• To improve medication-related
decisions and outcomes
CDSS Primary Components
• Inference engine
▫ AKA reasoning engine – forms brain of the CDSS
▫ Links patient-specific information to knowledge base
• Knowledge base
▫ Composed of varied clinical knowledge
 Tx guidelines, diagnoses, DDI, drug-disease interactions
• Communication mechanism
▫ Allows entry of patient information
▫ Responsible for communicating relevant info back to clinician

BMC Med Inform Decis Mak. 2009;9(1):24

JAMA. 2002;288:1955-8.
Types of CDS in a CPOE System
• Passive: not patient-specific; directs use towards most
appropriate practices unobtrusively; derived from
population data or clinical guidelines
• Active: patient-specific; uses at least 2 pieces of patient
data to trigger an alert. The notification is active because a
change occurs in the system, but the action may be
noninterruptive or interruptive

ASHP Guidelines on the Design of Database-Driven Clinical Decision Support

ASHP Guidelines on the Design of Database-Driven Clinical Decision Support
Passive CDS for VTE/Immunizations
Active, Noninterruptive CDS
• Abnormal lab values

• Low-priority drug interaction information

Alert Fatigue

• Phenomenon caused by excess alerting that can lead to clinicians being

desensitized to the clinical significance of alerts, potentially leading to
disregard and overrides of important messages.

• Warning/alert overrides

• “Hard” stop vs. “soft” stop

Information Technology in Pharmacy: An Integrated Approach. 2013

Active, Interruptive CDS
Electronic Prescribing (E-prescribing)

• A prescription entered by a prescriber directly into an electronic format using

agreed-upon standards (NCPDP SCRIPT) that is securely transmitted to the
pharmacy that the patient chooses

• Referred to as ambulatory CPOE

• Faxes and printed Rx are NOT e-prescriptions

 Informatics in Transcription/Verification
• Goal: Transform the order
Prescribe into a dispensable form that
can be safely and correctly
Purchase Transcribe
interpreted at the
/Supply Chain
Management /Verify administration step

• Pharmacists use:
▫ CDSS
Monitor
Prepare
/Dispense
▫ PIMS

• Pharmacists can provide

Administer
various types of medication
decision support at this stage
Types of Medication Decision Support

• Drug allergy checking

• Basic dosing guidance
• Formulary decision support
▫ Therapeutic alternatives
▫ Preferred medications
• Duplicate therapy checking
• DDI/Drug-disease interaction checks
• Medication-related laboratory testing
• Advance dosing guidance (renal/hepatic)

CDSS: Theory and Practice.2nd ed. 2007

Drug Interaction Example
Drug Interaction Details Example
• Interacting drugs • Voriconazole + sirolimus

• Description of severity • Major-severe-contraindicated

• Description of drug interaction • Voriconazole inhibits metabolism

mechanism of sirolimus via CYP450 3A4
pathway

• Description of clinical effects • Significant  in plasma sirolimus

concentrations ~10x

• Recommended management • Do not use these drugs

strategy concomitantly
Active, Interruptive CDS
 Informatics in Preparing/Dispensing
• Acute care setting
Prescribe ▫ ADC
▫ Carousel
Purchase
/Supply Chain
Transcribe ▫ Robotic cart filling systems
/Verify
Management
▫ Sterile compounding tools
 TPN compounders
• Community setting
▫ PIMS
Prepare
Monitor
/Dispense
 Manage data for Rx, patients,
providers
 Integrated workflow systems
Administer
 Bar code scanning to track
▫ Automated counting systems
▫ Robotics
Informatics in Administering
• BCMA
Prescribe ▫ Ensure 5 patient “rights” at
point of care
Purchase
Transcribe
▫ Limitation: sometimes need
/Supply Chain
Management
/Verify
special bar codes
• “Smart” infusion pumps
• eMAR
▫ Eliminate need to handwrite
Monitor
Prepare medication changes
/Dispense
▫ Allow changes to be updated
in real time
Administer
 Patients off floor
 NPO
 Informatics in Monitoring
• Goal of monitoring: should
Prescribe result in interventions
▫ Act of interceding with intent
Purchase
Transcribe
of modifying medication use
/Supply Chain
Management
/Verify process
▫ Promote safety
▫ Promote quality
▫ Promote efficiency and cost-
Prepare effectiveness
Monitor /Dispense
• Clinical surveillance systems
• Need for documentation
Administer
▫ Easy to use/fit into workflow
▫ Add/modify interventions
▫ Searchable/shared record
Which of the following health information technology tools would be most appropriate to use to decrease
errors in the medication administration process : (learning objective 2)

• A. CPOE
• B. e-prescribing
• C. an ADC
• D. an eMAR
When a prescriber logs into the system to review her patient list, she notices a red flag on the column marked “labs”
for one of her patients. The notification indicates that the patient’s serum creatinine had increased from 0.9 to 1.5
mg./dL. What type of clinical decision support does this represent? (learning objective 4)

• A. passive
• B. Active noninterruptive
• C. action interruptive
• D. non-active
 Pharmacy Informatics/Pharmacotherapy

Prescribing Verification Administration

Dispensing Monitoring

• CPOE • PIMS • BCMA

• eMA
• ePrescribing • ADC
• Barcode Medication Verification

• Therapeutic treatment • ADE SurveillanceR

planning • ABX/Drug
• MTM
• Antimicrobial Stewardship
• Sma
Surveillance (AMS)
• Evaluation of
• Pharmacogenomics efficacy/safety rt
• Population Health
• Development of Evidence-
Based Order Sets
pum
• Formulary Management
Optimization CDSS p
Informatics in Purchasing/SCM
• Automation  perpetual
Prescribe inventory management
• Barcode validation for
Purchase receipt, storage, retrieval,
/Supply Transcribe
Chain /Verify and dispense
Management
• Carousel technology/ADC
can assist
• Par levels can trigger reorder
Monitor
Prepare • Wholesale channels vs. retail
/Dispense

Administer
Interoperability
• The ability of disparate computer systems to exchange
information in a manner that allows the information to be used
meaningfully

Communication
standards are
necessary to achieve
desired level of
meaningful data
exchange

National Alliance for Health Technology report to Office of National Coordinator for HIT, 2008
 Interoperability Standards
• NCPDP SCRIPT: e-prescribing standard for transmission of
prescription information
▫ Between prescribers, pharmacies and payers
• NDC: produced by manufacturers, registered with FDA

• RxNorm: produced by National Library of Medicine, provides

standard naming system for generic and branded drugs
• ICD-10: diagnosis and billing codes
 Spotlight on PHI
• Privacy: PHI is protected and free from unauthorized intrusions
▫ Policies for how data gathered, stored, and used
• Security: restricting access to PHI to everyone except those with
authorized access
▫ Electronic tools (Log-in, password protection)
• Confidentiality: provider-client privilege that any health-related
info communicated between provider/patient is private*
▫ *under most circumstances
▫ Written, oral or electronic

Building Core Competencies in Pharmacy Informatics. APhA 2010