Health-System Pharmacy in 2011 and Beyond
AS PHARMACY PRACTICE EVOLVES from a profession that primarily supervises medication distribution to one that provides services such as medication therapy management and disease prevention, one of the main questions that remains unanswered is, “how long will this transformation take?”
Although no one can predict how fast it will happen or what path it will take, practice model change is being driven by economic realities, safety and quality concerns, political influences, and pharmacists who desire to be more involved in the care of patients in their institutions.
David Chen, ASHP’s director of pharmacy practice sections, said that despite the fact that pharmacists provide direct patient care in many practice settings across the country, services offered and distribution are uneven.
“We know that outcomes are better for patients when there is pharmacist involvement, but now we have to support pharmacy practice leaders in determining the most effective way to implement pharmacy, technicians, and technology in their settings,” he said.
Although each hospital and health system will need to tailor practice models to meet its own goals, the consensus is that there is ample opportunity for pharmacists to shape the future of their profession. Many have already begun to seize the day.
Work Flow and Collaboration
Pharmacists’ success in providing direct patient care hinges on their ability to collaborate with other health professionals. As part of its patient-centered practice model, the University of Wisconsin Hospital and Clinics has decentralized its pharmacy staff. Every pharmacist is assigned to a unit or group of patients for which he or she provides medication order review, pharmacokinetic dosing, medication reconciliation, and medication education.
“This model forges relationships between pharmacists and physicians and establishes trust between pharmacists and medical staff,” said Steve Rough, M.S., B.S.Pharm, director of pharmacy. “Medical staff comes to trust that we are consistently going to optimize what is best for the patient’s care in the process of making our recommendations.”
Rough added that demonstrating value and accountability ensures continued pharmacist involvement in multidisciplinary teams. “When we need buy-in for integrating pharmacists into a new care team or service, we prepare a succinct business case demonstrating the value proposition for the hospital,” he said. “Then, once we add additional pharmacist resources to the budget, we document and present the promised outcomes.”
Technology has been a boon to pharmacists by increasing patient medication safety and enabling pharmacists to delegate task-oriented work to highly trained pharmacy technicians. Automation such as robotic dispensing cabinets frees up pharmacists’ time, while analytics enhance clinical decisions.
Christopher R. Fortier, Pharm.D., manager of pharmacy support and services and clinical assistant professor in the Department of Pharmacy Services at the Medical University of South Carolina, Charleston, notes the increasing importance of mobile technology in the hospital setting.
“Remote and mobile technologies such as iPads, tablets, and smart phones enable us to take information with us to the patient’s bedside,” said Fortier. “We’re not stuck behind a desktop computer, and with real-time information at hand, we don’t have to go to five different places to get information and provide care to patients.”
Barbara Giacomelli, Pharm.D., M.B.A., director of pharmacy at Shore Memorial Hospital in Vineland, N.J., believes pharmacists are well suited to take leadership roles in developing technology for use in practice models.
“We can partner with medical staff in developing rules and setting up order entry screens to be user-friendly and provide the correct levels of alerts,” she said.
Informatics is an expanding field in which pharmacists will find plenty of opportunity, Giacomelli added. “Most of the people I have spoken with have developed into an informatics role by having a strong interest in it,” she said. “However, if you don’t have a pharmacist who understands it, you’ll have to recruit for it. There are limited resources out there, but this specialization is in demand, and the demand will only increase with time.”
If new pharmacy practice models are to take hold, it is critical that pharmacy students and residents are prepared for the hands-on work in direct patient care that awaits them. At the University of Colorado in Aurora, students and residents work together with pharmacists. Residents assist with consultations, particularly with respect to chronic disease states such as hypertension, dyslipidemia, and diabetes. Students assist with data collection and medication reconciliation to the extent allowed by law.
“While students can’t practice independently, they are licensed interns and can certainly provide a significant amount of help in providing clinical patient care under the guidance of pharmacists,” said Joseph Saseen, Pharm.D., FCCP, BCPS, professor at the University of Colorado Schools of Pharmacy and Medicine, Aurora. “They can do more than just shadow. “Students must be supervised, but collecting data, providing medication reconciliation, interpreting patient care data, and drafting clinical recommendations are all valuable roles that can be filled by students.”
According to Rough, of the University of Wisconsin Hospital and Clinics, residents offer an excellent return on investment, particularly when it comes to the aforementioned technology.
“We have 16 pharmacy residents on board, and everything we do involves them,” he said. “The complexity of drug preparation and distribution technology oversight has increased drastically over the last five years. Overseeing pharmacy operations is now seen as a patient care role, and we are currently developing residents with expertise in that area.”
Evolving Technician Roles
Pharmacy technicians with the appropriate education, training, and credentials stand poised to take on more responsibility and perform tasks that were once solely the domain of pharmacists. By dispensing medications, taking prescriptions over the phone, and documenting patients’ medication information for pharmacist review, technicians free up pharmacists’ time for direct patient care.
“When you talk about staffing and resources, you have to ask where you get the most value out of each of the key participants,” said Brian T. Marden, Pharm.D., director of pharmacy at Maine Medical Center in Portland. “Clearly, a pharmacist’s best value is direct patient care, but unfortunately, in many systems that does not happen because a lot of pharmacists are still doing things that well-trained technicians could do easily and safely.”
According to Marden, pharmacists have to be prepared to let go of traditional nonclinical roles, and pharmacy leaders should create the technician infrastructure to allow for it.
“One strategy that has proven to be very effective for Maine Medical Center was the decision two years ago to hire the necessary staff to decentralize our pharmacy technicians,” he said, adding that the decision “created a sense of pride amongst our technicians that they were truly having a positive impact on patient care, right on the front lines.”
Education is of the utmost importance, not only for getting value from pharmacy technicians but also for maintaining adequate staffing, Rough believes. He speaks from experience.
“We had problems with tech turnover,” Rough said. “When we went to Human Resources, we learned that during exit interviews, the techs said that the job was not professional enough, and that they didn’t feel adequately trained for the work we were demanding of them.
“So, we made a business case for expanding technician training, showing how it was an investment in patient care,” he said. Now the University of Wisconsin system offers a nine-month ASHP-accredited pharmacy technician program.
“If you are looking for ways that pharmacists can take care of a larger population without adding more staff, the key is technician education,” Rough added.
Learning From Best Practices
The future of pharmacy depends on making the most of the resources you have, said ASHP’S Chen. “There aren’t unlimited resources, so the question comes back to, What is the most effective way to deploy allocated staff and technology? We can learn from best practices in the field, and, while recognizing that every hospital will be at a different point in the process and every state has different laws, working together, we can determine the best direction for the profession.”
In 2009, ASHP and the ASHP Foundation launched the Pharmacy Practice Model Initiative (PPMI), with the goal of developing new practice models that support the most effective use of pharmacists as direct patient care providers. Last November, thought leaders throughout hospital and health- system pharmacy came together at the PPMI Summit in Dallas to take stock of the Initiative’s progress, discuss challenges and opportunities in pharmacy, and reach consensus on next steps. In the above article, InterSections talks with some of the key leaders who attended the Summit to get their thoughts on what the future of the profession might hold.