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INTRODUCTION

Responding to drug information questions accurately and efficiently is an essential part of pharmacy practice, underscoring the importance of pharmacy technicians becoming more familiar with key drug resources. As the responsibilities of pharmacists shift toward direct patient care, expanding the roles of pharmacy technicians is critical to evolving the pharmacy practice model. Therefore, advancing pharmacy technicians’ knowledge with regard to the safe and effective use of drug information resources will facilitate communication between the technician and pharmacist, resulting in more timely and improved patient care.

Medical literature resources are categorized as primary, secondary, or tertiary, depending on the originality of the information that is presented.¹ For instance, clinicians who conduct clinically-oriented research may present their findings at medical conferences or they may attempt to publish their findings in medical journals. This type of information is considered primary because the data have not been influenced or interpreted by other individuals at this point—it is original data. However, once these research findings are published, the information may be professionally indexed in a database or other health care professionals may interpret or comment on the data, possibly compiling elements of the original study results into a review article. These types of data are considered secondary sources. Lastly, when data are compiled into a textbook or a reference book format, for example, they are considered tertiary sources. The following article provides a concise review of primary, secondary, and tertiary literature sources; tips to keep in mind when searching for health information on websites and mobile applications (apps); and offers guidance on the process of responding to drug information requests.

TERTIARY RESOURCES

Tertiary resources are readily accessible, efficient, and familiar to many, making them top resources to consult for drug information questions.^1-2 These are resources in which information on a topic has been compiled by an author or an editor. Rather than searching for the source of the material—in the form of original research—one could search for a tertiary resource that contains relevant information in a summary format. Additionally, the authors and editors of a tertiary resource may provide interpretation of data. With regard to tertiary sources, the overviews or summaries of a topic should be thorough yet concise, an important combination to make the resource most useful for the end user. Tertiary resources are often considered first-line resources when looking up information on a given topic because they are used to gain a better understanding of an unfamiliar topic before developing additional research strategies. 

Further, tertiary resources can be general or specialized in scope.^1-2 For example, some tertiary resources contain specific drug information related to pregnancy and breastfeeding, drug interactions, compounding, pediatrics, geriatrics, nutrition support, adverse drug reactions, infectious diseases, and natural medicines—just to name a few. General resources are often more comprehensive and include resources such as medical textbooks or drug databases. Depending on the practice site, a pharmacy technician may or may not have access to some of these types of resources.

General Tertiary Drug Information Resources

In general, drug information resources consist of individual drug monographs that are organized by sections, including (but not limited to) a product list, indications, administration and dosage, pharmacology, pharmacokinetics, warnings/precautions, drug interactions, adverse drug reactions, toxicology, pregnancy/lactation, and clinical evidence.^3-9 Dosing adjustments for special populations, including those who have renal or hepatic impairment, are typically provided at the end of the dosing section. Each monograph usually lists both US Food and Drug Administration (FDA)-approved and off-label indications. Also, many electronic databases contain patient counseling information, Risk Evaluation Mitigation Strategies (REMS), do not crush lists, pronunciation guides, and tablet identifiers among other tools.^3-5,7 These databases are usually updated daily or periodically throughout the month. In many circumstances, a list of updated content is included on the home page. Several drug information resources that are frequently used in pharmacy practice are briefly described in the following section.

Facts & Comparisons

Facts & Comparisons is a widely used drug resource by pharmacists, pharmacy benefit managers, manufacturers, and academic institutions that contains information on more than 22,000 prescription medications as well as 6000 over-the-counter (OTC) products.³ The print version, Drug Facts & Comparisons, is organized by therapeutic class and features tables and a monograph for each class. The electronic version, Facts & Comparisons eAnswers, also contains comparative drug tables, which are easily sortable and allow for the selection of specific sections to be viewed side-by-side. Individual drug monographs have separate tabs for different formulations of the drug, if applicable, and are organized into major sections. Other tools and references that exist within this resource are briefly summarized in Table 1.³

IBM Micromedex with Watson

The IBM Micromedex with Watson is an electronic database that is used by various health care professionals.⁴ It is subscription-based and contains drug information, limited disease state data, and a comprehensive toxicology/poisoning resource and has been combined with IBM’s Watson artificial intelligence engine to accelerate searches and answers. Additionally, the following electronic databases may be added to a subscription: Neofax (a pediatric drug resource), Trissel’s IV compatibility, Martindale’s (an international drug resource), Physician’s Desk Reference (electronic version with FDA-approved package inserts, drug alerts and safety information) and the Red Book (a drug pricing resource). Other tools and references that exist within this resource are briefly summarized in Table 1.⁴

Clinical Pharmacology

Clinical Pharmacology is a subscription- and web-based compendium containing monographs for prescription, OTC, and investigational medications, as well as nutritional and herbal supplements.⁵ One unique function of this database is the ability to generate various reports that focus on adverse drug reactions, product comparisons, intravenous (IV) compatibilities, and clinical comparisons. These reports allow users to create succinct drug lists or side-by-side comparisons of selected medications in a short amount of time. Additionally, the user can locate a drug, or list of drugs, by manufacturer, indication, precautions, adverse reactions, or national drug code (NDC). Additional tools and references that exist within this resource are briefly summarized in Table 1.⁵

Lexicomp/Drug Information Handbook

The Drug Information Handbook is organized in a dictionary-like format and contains an alphabetical list of more than 1600 drug monographs.⁶ Although brief, each monograph includes up to 40 sections of information. The print copy has a useful appendix that contains treatment guidelines, clinical recommendations, comparison charts, and an index. The drug monographs are also available electronically through the subscription-based Lexicomp database, which has additional drug information tools that are similar to other online drug databases. These tools are listed in Table 1.⁷

American Hospital Formulary Service (AHFS) Drug Information (DI)

AHFS DI is an electronic book, rather than a database, so it contains drug monographs without additional tools and functionalities⁸; it is also published annually in print.² The drug monographs in AHFS are arranged by class and contain specific information about dosing in special populations and situations. US Congress has designated the AHFS DI as a resource to determine reimbursement for the unlabeled use of medications.²

Intravenous Medications: A Handbook for Nurses and Health Professionals

Gahart’s Intravenous Medications: A Handbook for Nurses and Health Professionals is a spiral-bound book that is an alphabetical compilation of more than 400 IV drug monographs.⁹ It is updated annually and contains information specific to preparing and delivering medications for IV administration, including dilution, administration rates, pH, incompatibilities, and antidotes. General drug information is given as well, including indications, standard drug dosing, precautions, and interactions.⁹

Prescribers’ Digital Reference (PDR)

The former Physician’s Desk Reference is now the Prescriber’s Digital Reference and it is no longer published as a bound textbook but is available online and through a mobile app. It contains FDA-approved package inserts, drug alerts and safety information, as well as REMS programs for specific drugs.¹⁰ This resource is published with financial support from participating manufacturers. Also, as only the package inserts comprise this resource, there is no information regarding off-label uses of medications. These characteristics limit the completeness and objectivity of this resource. Notably, a free electronic book version is available on the website.¹⁰

SPECIALTY TERTIARY DRUG INFORMATION RESOURCES

Pregnancy & Lactation

Several resources are specific to the topics of pregnancy and lactation.²Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, commonly known as “Briggs” because of the author’s name, is available as a textbook (or mobile app) that includes fetal risk and breastfeeding summaries and recommendations for the use of 1200 drugs.¹¹ Hale’s Medications and Mothers’ Milk is a textbook that contains information regarding the transfer of over 1300 medicines into human milk, in addition to suggestions for alternative therapies when appropriate.¹² A free resource, Lactmed, is a website database maintained by the National Institutes of Health.¹³ Updated monthly, a peer review panel reviews scientific literature to determine the transfer of substances into breast milk and infant blood, adverse events in the nursing infant, and suggested alternatives, if applicable. Lactmed is also available as a mobile app.

Pediatrics

There are several resources that are commonly used to search for pediatric-related drug information. The Pediatric and Neonatal Dosage Handbook is formatted like the Drug Information Handbook and contains over 1,100 monographs, 15-40 extemporaneous formulation recipes, and an extensive appendix.¹⁴ It is also available as a mobile app. The Harriet Lane Handbook is another pediatric reference that includes pediatric treatment and management recommendations, immunization schedules, therapeutic guidelines, as well as a comprehensive drug formulary. It is named after first lady Harriet Lane who endowed a children’s home at the Johns Hopkins Hospital in Baltimore, MD.¹⁵ It is reviewed by faculty members at the Johns Hopkins Hospital before publication and contains a large portion of drug information that is based on the formulary at that institution.¹⁶ It is also available as a mobile app. Pediatric Injectable Drugs, commonly known as the “Teddy Bear Book” because of the picture on its cover, is a resource that focuses on IV formulations of medications.¹⁷ It covers more than 250 drugs that are commonly used in neonates, infants, and children, with age-specific dosing and administration guidelines throughout.¹⁷

Nonprescription Drugs and Herbals

The Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care is a resource for OTC medications, nutritional and dietary supplements, medical foods, and complementary and alternative medicine.¹⁸ The text is arranged by disease state and content includes FDA indications and safety issues, market availability, product tables, treatment algorithms, case studies, and patient education information.¹⁸ Natural Medicines Comprehensive Database,¹⁹ Natural Standard,²⁰ and the Review of Natural Products²¹ are specific references that focus on herbal products. The Natural Medicines Comprehensive Database and Natural Standard have been combined and provide detailed monographs on herbal products, including relative safety and efficacy conclusions or evidence grades.² The Review of Natural Products focuses on the chemistry and pharmacology of natural products but also contains several patient-focused sections. Free websites that one may consider recommending to consumers who request additional information about herbals include: Medline Plus (http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html)²² and the National Center for Complementary and Alternative Medicine (http://nccam.nih.gov/).²³

Compounding

The Extemporaneous Formulations for Pediatric, Geriatric, and Special Needs Patients is a collection of formulations that contains stability information.²⁴ Most of the recipes are for oral formulations, and some information on legal and technical aspects of compounding are given. Trissel’s Stability of Compounded Formulations is a textbook that has information centered on the preparation of both sterile and nonsterile dosage forms; it also includes stability data.²⁵ Lastly, the International Journal of Pharmaceutical Compounding, its online website CompoundingToday.com and U.S. Pharmacist are journals and websites that offer compounding information and drug recipes.²

USEFUL WEBSITES—TERTIARY DRUG INFORMATION

Drug Shortages

Pharmacy personnel rely on websites that are frequently updated to keep up with a rapidly changing field. For example, many pharmacy personnel are faced with managing drug shortages. The American Society of Health-System Pharmacists (ASHP) Drug Shortages Resource Center website (http://www.ashp.org/menu/DrugShortages) is a comprehensive resource that lists drug shortages, updated management strategies, and therapeutic alternatives, when possible.²⁶ The following FDA website also lists drug shortages and is a useful resource: http://www.fda.gov/Drugs/Drugsafety/DrugShortages/default.htm.²⁷

Vaccination Recommendations and Information

The recommended schedule of vaccinations from the Advisory Committee on Immunization Practices is available at the Centers for Disease Control and Prevention (CDC) website (http://www.cdc.gov/vaccines/hcp/acip-recs/index.html).²⁸ This website also includes general recommendations on immunization, immunization of health care personnel, guidance for vaccine recommendations for pregnant and breastfeeding women and vaccine guidelines and recommendations for emergency situations. Additionally, the CDC website is the location of the CDC Health Information for International Travel (commonly known as the Yellow Book) and the Epidemiology and Prevention of Vaccine-Preventable Diseases (commonly known as the Pink Book).²⁸ The Yellow Book is published every two years and includes the latest health recommendations for international travel. In general, the Yellow book provides an in-depth look at travel health risks and ways to prevent them; it also provides advice for people with special travel health needs.²⁸ The Pink Book provides updated information on routinely used vaccines and the diseases they prevent and may be accessed here: https://www.cdc.gov/vaccines/pubs/pinkbook/index.html.

Orange Book

The Approved Drug Products with Therapeutic Equivalence Evaluations (commonly known as the Orange Book) is an FDA publication that lists approved brand-name and generic drug products.²⁹ This reference is often used for questions regarding product substitution (ie, substituting a generic drug for a brand-name product). This publication is not a legally binding document; however, some state laws require pharmacists to use the Orange Book for drug product selection (ie, generic substitutions). Certain drugs, however, are not included if they were marketed before 1938 or were approved on the basis of safety, not efficacy. This resource is also available as a website (http://www.accessdata.fda.gov/scripts/cder/ob/). The Orange Book is also helpful when determining if a drug has been discontinued. Also, patent and exclusivity information is provided for each medication. All searches can be conducted by using either the active ingredient (generic name) or the proprietary (brand) drug name. Additionally, details about the dosage form, strength, and manufacturer are shown initially, but information regarding the approval date and patent information require additional clicks to access. The online version is updated daily or whenever a generic is newly approved. A print version is available on the FDA website (as a PDF) and is published annually with periodic supplements and a mobile app called the Orange Book Express 2.0 is also available.²⁹

Gluten-free Medications

The Food Allergen Labeling Consumer Protection Act of 2004 requires packaged food labels to identify all ingredients containing wheat and other common allergens—yet no similar requirement exists for medication labels.³⁰ The FDA released draft guidance on gluten in drug products and labeling recommendations in December 2017 noting that the vast majority of orally administered drug products contain no or virtually no gluten.³⁰ Patients who have gluten allergies or intolerances, including those who have Celiac disease, must follow a gluten-free diet for life. Therefore, pharmacists and technicians should be familiar with websites and other references that contain data regarding gluten in medications. Two websites that may be of assistance on this topic include the following: the National Foundation for Celiac Awareness has a resource page on their website regarding medications that contain gluten http://www.celiaccentral.org/gluteninmeds/ and a list of drugs created and maintained by a clinical pharmacist can be found at http://www.glutenfreedrugs.com/.³¹ Neither of these resources represents a comprehensive guide; however, information about inactive ingredients can help one determine the likelihood that gluten exists in a specific product.

ASSESSING TERTIARY RESOURCES

Not all tertiary resources are equal.^1-2 In order to evaluate a tertiary resource, one must consider factors that could potentially limit the use and application of drug information found in that particular source. Perhaps the most important limitation of many tertiary resources is the lag time to publication. Because the medical field is rapidly evolving, information is often outdated by the time the editorial and publication process is complete. One benefit to electronic databases is that they may be updated more frequently than a print resource. For this reason, purchasing print resources may be cost-prohibitive, considering one would have to continually purchase updated editions, whereas a single subscription to an electronic resource would allow access to frequent updates.^1-2 

In addition to the concerns related to cost and lag time, one must assess the actual contents and authorship of the resource.^1-2 By checking the credentials of the authors or editors, one can gain a sense of the expertise of those who contribute to the resource. Potential human bias and overall completeness of the information is difficult to assess amongst tertiary resources. Thus, tertiary resources are not the only constituents of drug information. In fact, it is best practice to check 2 to 3 resources when answering a drug information question because of the above-mentioned limitations and potential conflicting information.^1-2 

Another important factor to consider when evaluating tertiary resources is the overall format.^1-2 For instance, a resource may be most useful if it is written from a point-of-care perspective. For example, Clinical Pharmacology provides patient handouts for much of the content.⁵The Handbook of Nonprescription Drugs has many diagrams and visual learning tools that may help patients understand how to administer medications.¹⁸ Lexicomp and the Drug Information Handbook have charts and tables in the appendix, which can be a quick and easy way to find information at times.^6-7 Also, many electronic resources offer an indexing or search function, which can prove helpful when evaluating large compilations of material.^3-5,7 

SECONDARY RESOURCES

The goal of secondary resources is to direct the user to relevant primary literature (original data).^1-2 Unlike tertiary resources, which summarize primary literature, the major function of a secondary resource is to organize or index the primary literature. In this manner, it is more like a filing system than a compilation of materials. However, secondary resources also summarize information, but these summaries are typically abstracts of a single published article or they are newsletter articles, which function to direct the user to recent primary literature.^1-2 Secondary resources are evaluated for usability by the number of journals reviewed and included in the indexing system, lag time, ease of use, and cost.^1-2 If one was trying to find information on pharmaceutical compounding, then one would want to be confident that pharmacy-related journals were indexed in the secondary resource consulted. Several commonly used secondary resources are listed below.

Medline

The database of the US National Library of Medicine is called Medline.^2,32 More than 810,000 citations from 5200 science- and health-related journal articles are indexed in this searchable database, which has existed since the 1960s. The database can be searched for free using a platform called PubMed. However, access to individual articles is limited to those that are archived in PubMed Central or to other sites that offer free article retrieval. Otherwise, articles can only be retrieved through a paid subscription.^2,32

International Pharmaceutical Abstracts

The International Pharmaceutical Abstracts (IPA) is a secondary resource that is more limited in scope than Medline.² This database includes information from over 800 pharmaceutical, medical, and health-related journals published worldwide since 1970. IPA provides comprehensive coverage of pharmaceutical information and drug therapy so researchers and health care professionals, including pharmacists, toxicologists, and medical librarians, can easily locate answers to drug-related questions or concerns. For pharmacy personnel, this database may be more appropriate to search when looking for information from pharmacy-specific journals and magazines that are not indexed in Medline.²

Cumulative Index to Nursing and Allied Health Literature

The Cumulative Index to Nursing and Allied Health Literature (CINAHL) is a database that contains topics relevant to nursing and 17 allied health professions, including pharmacy.² CINAHL provides access to health care books, nursing dissertations, selected conference proceedings, and nursing standards of practice. On occasion, pharmacy personnel must answer medication-related questions that are applicable to nurses’ duties, and relevant citations can be found in CINAHL.² 

Cochrane Library

Extensive reviews of current literature are published by the Cochrane Collaboration.² These systematic reviews help to determine if a therapy causes more benefit than harm by pooling together all relevant publications concerning a specific drug or intervention. Cochrane Reviews are indexed in Medline, or the Cochrane Library can be searched separately.²

Pharmacist’s Letter & Pharmacy Technician’s Letter

The Pharmacist’s Letter is a subscription service that started in 1985 and provides updated drug therapy news on a monthly basis.³³ The same editors provide newsletters for pharmacy technicians, physician assistants, nurse practitioners, and other professionals as well. Many of the topics covered in the newsletter have accompanying detail-documents, which expand on the topic, summarize practical considerations, give comparison charts, or provide patient counseling information. Both Pharmacist’s Letter and Pharmacy Technician’s Letter are independently published and funded entirely by subscribers.³³ 

PRIMARY LITERATURE

Primary literature consists of original data, usually in the form of clinical trials or observational studies.² Importantly, the most current information on a topic is identified by searching primary literature. In order to continually expand the available information on a selected topic, primary literature should build on current data with minimal duplication and repetition. Primary literature can be peer-reviewed, which means the articles are reviewed by content experts before the article is published.¹ The peer review process helps improve the overall quality of published information; however, this sometimes causes a delay in important publications. Original research can also be inconclusive, which is considered a limitation of primary literature. Also, the reader must interpret these data on their own, which can be difficult and time consuming. Conversely, tertiary references are beneficial because they compile multiple primary literature sources and provide some interpretation of the data. This can be especially helpful when there are conflicting or inconclusive studies. Narrative review articles, guidelines, editorials, and commentaries can be identified by searching secondary resources, but these are not true primary sources; these would be considered tertiary or secondary resources.² Finally, access to primary literature is often expensive because many publishers charge a fee per article or require institutional subscriptions, which can be cost-prohibitive for some pharmacies or institutions.¹

WEBSITES AND MOBILE APPS

Evaluating Websites

In 2013, an estimated 59% of adults in the US admitted to searching the Internet for health information.^34,35 Specifically, 35% of those adults sought to self-diagnose or diagnose a friend or family member; one-third consulted a health care professional at the conclusion of their searches. Further, a research team conducted a study that evaluated disease-specific information listed in Wikipedia and compared those findings with information listed in standard peer-reviewed medical resources. Notably, many errors of fact were found, and there was a statistically significant discordance in 9 of the 10 disease states that were evaluated.³⁶ As a result, it is becoming increasingly important that pharmacists and pharmacy technicians know how to evaluate the quality of health-related information found on the Internet.

When evaluating the content of a website, one should identify the sponsor.³⁵ Websites that are sponsored by educational institutions (.edu), professional societies or organizations, and government agencies (.gov) are considered more dependable and accurate compared with those whose sponsors are unknown. Also, websites should clearly indicate the most recent update, considering health information can change daily. There are organizations that aim to certify websites that offer reliable medical information.³⁵ For example, the Health on the Net Foundation (HON) is a non-governmental group that was created to encourage Internet distribution of high-quality, medical information to the general public, health care professionals, and web developers.³⁷ This foundation developed a code of ethical conduct in the health information field called the HONcode. For those websites in compliance with the HONcode, a special seal is issued and placed on the certified website, which is directly linked to a corresponding certificate located on the HON website. This certificate specifies how the website complies with the HONcode principles, which is helpful for verification purposes. An alternative method for those who are interested in verifying the reliability of health information, the HONcode toolbar, which automatically checks the certification of each website that is viewed during a search, can be downloaded from the HON website. The HONcode seal would appear in color if the website is in compliance with the HONcode.³⁷

It is important to note that the HONcode is not meant to guarantee completeness or accuracy of a website. The certification is based on compliance with 8 ethical principles: authority, complementarity, confidentiality, attribution, justifiability, transparency, financial disclosure, and advertising. A website with an HONcode seal is certified for 1 year; the website must be recertified by an HONcode expert team annually. In addition, HON relies on user reports of noncompliance, which are then reviewed by the team before a decision is made.³⁷ Currently, the HONcode is used by over 7300 certified websites, covering 102 countries. Additional resources for evaluating health information on the Internet can be found at the following links: https://ods.od.nih.gov/Health_Information/How_To_Evaluate_Health_Information_on_the_Internet_Questions_and_Answers.aspx ³⁸ and http://www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html.³⁹

Websites—Consumer and Patient Health Information

As mentioned above, many patients research their medical conditions through the Internet. In addition to educating patients on how to determine if health-related websites are reliable, pharmacists and pharmacy technicians should have a few website suggestions to offer patients to help direct their online research. The Medical Library Association (MLA) has a section for consumer and patient health information that is available at http://www.mlanet.org/p/cm/ld/fid=398.⁴⁰ MLA evaluates the quality of information that is listed on websites for several health-related areas, such as general health, cancer, diabetes, eye disease, heart disease, HIV/AIDS, and stroke. Under each particular health topic, MLA has identified consumer-friendly websites that are freely accessible via the Internet at http://www.mlanet.org/p/cm/ld/fid=397. In addition, many health conditions have a supporting association or foundation that can be identified via an Internet search by entering the name of the condition alone (ie, glaucoma) or by entering the condition in combination with the terms organizations or associations (ie, glaucoma associations). These website uniform resource locators (URLs) will often end in .org.⁴⁰

Websites and Mobile Apps—Tools for Adherence and Affordability

Pharmacy technicians can impact medication adherence. For instance, The National Council on Patient Information and Education released the Adherence Action Agenda in 2013, and pharmacy technicians can contribute to 2 of the defined action items: (1) reduce the cost-sharing barriers for patients by reducing copayments for certain prescriptions and (2) accelerate the adoption of new health information technologies that promote medication adherence.⁴¹ The National Community Pharmacy Association’s findings in its national report card on medication adherence supports these two strategies since the top four self-reported reasons for poor medication adherence among respondents were: 1) forgetting to refill, 2) running out of medication, 3) being away from home and 4) trying to save money.⁴²

In addition to contacting individual manufacturers to inquire about patient assistance programs, pharmacy personnel should have a few website suggestions to help direct patients who need financial assistance with medications. These websites are listed in Table 2. Each program is dedicated to helping patients overcome financial obstacles, as well as other barriers, to ensure they receive prescribed treatments and overall care that best meets their needs. In addition, the pharmacy technician may recommend patients purchase a 90-day supply of medication if it is less costly and may reduce co-pays.⁴³

Additionally, pharmacists and technicians can recommend smartphone apps (mobile apps) that are centered on improving medication adherence; technicians can also help patients input their medications into these programs, when possible. In one study, 10 mobile adherence apps for selected smartphones were ranked in order of desirable attributes as determined by pharmacy practitioners.⁴⁴ Notably, 2 mobile apps, MyMedSchedule and MyMed, received high ratings because of their basic reminder features combined with their superior levels of functionality.⁴⁴ However, because mobile apps may still contain inaccurate information and are not subject to FDA oversight (ie, mobile apps that are not considered medical devices), it is vital that patients are educated on how to verify the quality of the apps they are using. One website, iMedicalApps (http://www.imedicalapps.com/), reviews health-related mobile apps for usability, accuracy, and reliability for selected smartphone platforms.⁴⁵ Recently published study findings reviewed the content of all 805 free medication adherence apps available and results found a variety of reminder and game strategies being used to assist patients.⁴⁶

MOBILE MEDICAL APPS AND REGULATION

An estimated 500 million smartphone users were estimated to be using at least 1 health-related app by 2015 and 50 percent of the more than 3.4 billion smartphone and tablet users were estimated to have downloaded mobile health applications by 2018.⁴⁵ These apps are available to consumers and health care providers, and there are 2 different types of mobile apps that pharmacy technicians should be familiar with: (1) mobile apps and (2) mobile medical apps.

• Mobile app: Mobile apps are software programs that run on mobile communication devices (smartphones). They can also be accessories that attach to a smartphone or other mobile communication devices, or they can be a combination of accessories and software.⁴⁷The previously mentioned medication adherence apps would fall under this basic mobile app category—they are not considered medical devices. One smartphone app used to improve medication adherence is called Mango Health.⁴⁸ This app allows users to schedule pill reminders and earn reward points when correctly taking scheduled medications.
• Mobile medical app: Mobile medical apps are medical devices that are mobile apps. An app is considered to be a device if the intent is to diagnose, cure, mitigate, treat, or prevent a disease, or if it will affect the structure or function of the body. Mobile medical apps are either intended to be used as an accessory to a regulated medical device or to transform a mobile platform into a regulated medical device.⁴⁵Mobile medical apps are the focus of the FDA’s regulatory oversight. Notably, each mobile medical app is placed into 1 of 3 classes: Class 1, Class 2, or Class 3—mobile medical apps that are considered Class 3 devices require the most regulatory oversight and must obtain premarket approval.

Mobile medical apps are those that: are an extension of a medical device, which are used to control, display, store, analyze, or transmit patient-specific data; use attachments, display screens, or functions that transform the app into a medical device; can diagnose or give treatment recommendations based on patient-specific data. Several examples of the nearly 300 FDA-approved mobile medical apps are listed in Table 3.⁴⁷ 

Some mobile apps that meet the definition of a medical device pose minimal risk to the general public; as a result, the FDA will not enforce the requirements for medical devices as outlined in the Food Drug & Cosmetic Act.⁴⁷ This category of regulation is called enforcement discretion. Mobile apps that fall under the category of enforcement discretion are those that help individuals manage, organize, and track health information without specific suggestions on treatment; those that allow individuals to research their disease states or treatments; those that provide a platform for individuals to communicate with their health care providers; and those that automate simple tasks for health care providers.⁴⁵ Several app functions that fall under enforcement discretion are listed in Table 4.

The FDA does not regulate mobile apps that provide reference materials related to health care, such as electronic textbooks, medical abbreviations and dictionaries; translations of medical terms; medical training videos, quizzes, or study tools; tablet identifiers; and medical facility location services.⁴⁷

SYSTEMATIC APPROACH TO ANSWERING DRUG INFORMATION QUESTIONS

Once a pharmacy technician becomes familiar with various tertiary, secondary, and primary resources, a method for selecting and reviewing the appropriate resource for a given request becomes necessary. Without a systematic approach to finding drug information, the timeliness, accuracy, and completeness of the response could be jeopardized. The following approach, as described by Wright et al, is the method that many drug information specialists use to answer drug information questions.¹

• Step 1: Secure the demographics of the requester
• Step 2: Gather background information
• Step 3: Determine and categorize the ultimate question
• Step 4: Develop a search strategy and conduct the search
• Step 5: Evaluate and analyze the information, and begin synthesizing the response
• Step 6: Formulate and provide the response to the requester
• Step 7: Document the encounter and conduct follow-up

A pharmacy technician can gather a lot of background information before deciding which resource to search. The first 3 steps in the above-mentioned systematic approach are to secure the demographics of the requestor, obtain background information, and determine or categorize the ultimate question.¹ Let’s work through the following drug information query to further explain this process.

Pharmacy practice

While putting away refrigerated items from a new shipment of medications, a pharmacy technician in a community pharmacy stops to answer the telephone. A male caller says, “Can my cholesterol medication cause high blood pressure?” One approach to responding to this question would be to locate the specific cholesterol medication in the Clinical Pharmacology online database and search the precautions/side effect profile for the term hypertension. Upon finding no mention of hypertension in the Clinical Pharmacology database and choosing not to obtain any additional information from the requester, one could potentially miss an opportunity to make an important intervention. Importantly, with further investigation and the application of a systematic approach when gathering information, a clinically appropriate drug information response can be formulated.

When responding to a drug information question, it is important to determine the identity of the requester.¹ For example, is the caller a patient? Is the caller a nurse? Is the caller asking about his or her own medication or on behalf of a friend? If this is a patient rather than a health care professional, perhaps it is best to avoid words like hypertension and use high blood pressure instead. Gathering this type of general demographic information from the onset can help guide the rest of the process and will often aid in choosing the most effective communication style once the response is formulated.¹ Secondly, it is important to obtain background information.¹ For adverse reactions, it would be relevant to ask when the perceived elevated blood pressure started; if the blood pressure has been measured recently; when did the patient begin taking the medication in relation to the onset of elevated blood pressure; are symptoms of hypertension such as headache present; does the patient take any OTC medications or any other prescription medications. At the conclusion of these queries, one might discover that the patient started venlafaxine for depression approximately 3 weeks ago. When looking up information on venlafaxine, it is reported that elevated blood pressure is a potential side effect. After collecting this information, an appropriate next-step is to inform the pharmacist of one’s findings. The pharmacist, in this particular case, would likely recommend for the patient to seek follow-up with their physician. However, many drug information queries require a more in-depth analysis.

Further, in order to decide which resource is likely to be most helpful in formulating a clinically appropriate response, the ultimate question must be decided and categorized.¹ Referring back to the caller (patient) at the beginning of the pharmacy practice example, his particular question focused on adverse effects related to a cholesterol medication. The goal now becomes selecting the resource that has the highest probability of containing the relevant information. In this particular situation, most general tertiary resources would contain information on adverse effects related to medications. However, it is up to the individual to decide which resource he or she is most comfortable with when performing a drug information search. Importantly, for the majority of drug-related requests, the search strategy often starts with a tertiary resource.¹ If the information is not found in a tertiary resource, using a secondary resource to locate primary literature may be appropriate.¹ 

The next 2 steps in the systematic approach—evaluating information and formulating a response—are related.¹ It is recommended to check at least 3 different resources to confirm drug information responses because conflicting information is occasionally reported in different resources. Knowing this conflicting information is helpful, and sometimes critical, when developing a drug information response. Once the data have been interpreted and a response has been formulated, the drug information case (ie, the caller’s ultimate question and the research that has been collected) would need to be presented to the pharmacist so he or she can determine the following: the drug information question was interpreted correctly; the necessary patient-specific information was obtained; the appropriate resources were consulted; and the medical information was interpreted correctly. If all of these steps are accurately performed, the drug information response can then be communicated to the requester. Importantly, in most circumstances, drug information responses must be communicated by the pharmacist.

When delivering a drug information response, it is recommended to repeat the ultimate question and any background information used to form the question; this method confirms with the requester that the question was interpreted correctly. Then, the drug information response should be communicated in such a way that the requester will understand the overall message. Finally, it may be appropriate to document these interventions. Documentation of the entire process provides legal protection and justifies the roles of pharmacy personnel. In addition, a phone call to follow up with the requester may be beneficial in order to guide additional actions from the pharmacy or to self-evaluate the process and find ways to improve on future questions.¹ 

CONCLUSION

Patients depend on pharmacy personnel to accurately and quickly answer drug information queries in all pharmacy practice settings. As pharmacy technicians are often the staff members who initially interact with patients, a structured approach to gathering information and selecting an appropriate resource can greatly improve workflow. Many times, patients are interested in researching health conditions for themselves or family members. In these cases, pharmacy technicians are uniquely positioned to show patients how to find safe, accurate, and reliable information on the Internet. Technicians can also identify patients who may be candidates for using mobile apps. For more complex questions involving the properties and therapeutics of medications, pharmacy technicians can work with the pharmacist to gather background information, define the ultimate question, and select the appropriate resources in which to find the desired information. This approach to answering drug information requests optimizes pharmacy workflow and, ultimately, enhances patient care.^1,2

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