Emphasizing Electronic Medical Records in Toxicity Management

Ryan Haumschild, Doctor of Pharmacy, MS, MBA: When talking about ways to create good standards and predictability in ordering medications, as pharmacists, the [EMR] is a tool we use with vendors to ensure that we verify that we are reviewing processing parameters. Dr. Moore, tell us a bit about how you leverage your electronic medical record EMR and how it plays into the breast cancer patient treatment paradigm.

Heather N. Moore, PharmD, BCOP, RPC: We certainly use our EMR, especially for our intravenous injections [IV] therapies and chemotherapy, making sure that certain parameters are respected, that we have pre-medications accordingly, that things are administered as they should be and that everything is set up in such a way that it is simple and streamlined for our providers, nurses and general infusion team. Some of the oral agents also have certain advantages from a toxicity standpoint as they become more complex. I’m thinking of agents like alpelisib, as we discussed. It’s helpful to have these built-in prescriptions for a glucometer, test strips, lancets, and metformin, along with parameters to check or monitor these patients. He provides good guidance there, even for some of our CDK4/6 inhibitors.

We think about ribociclib with QTc interval prolongation and think about when ECGs [electrocardiograms] need to be added or monitored. We think of baseline, mid-cycle, end-of-cycle. It provides general metrics and guidance as therapies become more complex to ensure that we track all monitoring parameters and assess patients for toxicity. The integration of some of these more complex therapies into the EMR is very useful not only for academic medicine, but especially for communities.

Susan Faye Dent, MD, FRCPC, FICQS: What’s important about oral therapies is that they are so different from IV therapies, but that doesn’t mean they are less toxic. As clinicians and health care providers, we sometimes forget that. We write the script and they go off with their oral therapy, thinking they’ll be fine. The role of a pharmacist and working with a team – Dr. Moore is instrumental in this work – is to call the patient. I know you do that, because I can hear you all the time on the phone next to me at the clinic.

It is important to get in touch with this patient a few days or a week after the start of the therapy to ask him: “How are you? Is everything alright? Do you experience any of these toxicities? This contact is so important, [as is] check with the patient to try to prevent them from developing significant toxicities. Because my experience has been that patients will wait. They’ll wait until it’s serious, then they’ll call. It doesn’t matter how many times we say, “Call us. Don’t wait for it to get serious”, they tend to wait because they don’t want to bother us, etc. Having this proactive approach to a recall system is important in managing these toxicities.

Ryan Haumschild, Doctor of Pharmacy, MS, MBA: It’s important to proactively reach out, as you mentioned. Before a refill you want to make sure you don’t give a patient 6 refills because some outside pharmacies will send and send and they will get that ratio of drug possession. But when we have specialty pharmacies in an integrated distribution network or in-office dispensaries, you have someone who knows the patient, like Dr. Moore. They can screen that patient and make sure they don’t refill that oral agent which is just as toxic as the IV in many cases until they really need it. If there is peripheral neuropathy, fatigue, or diarrhea, intervene early so the patient can get treatment. It’s a great take-out meal.

I agree with you. The [EMR] is a future takeaway to make sure we rely on these supportive care drug supplies and that it’s predictable for these patients so subspecialists and community oncologists remember and ultimately we have this follow-up which is necessary to document .

Heather N. Moore, PharmD, BCOP, RPC: Monitoring is also useful for thinking about changing the dose. You raise a good point about some of these outside pharmacies that just fill and then send to patients. Then we start a patient, and we’ll usually know pretty quickly when we check their lab results whether we’re going to have to change the dose, whether we need to drop their alpelisib or their palbociclib. It gives us the ability, especially to have our own specialty pharmacy, to have modifications and make direct changes and avoid patients getting redundant therapies and continuing them, where it’s a general waste of resources.

Transcript edited for clarity.