ASHP InterSections ASHP InterSections

June 6, 2011

Starting Point

 

Stan Kent, M.S., FASHP

AS I BEGIN MY YEAR as ASHP president, I’ve been struck by the depth and variety of issues that the Society has taken on. From drug shortages to pharmacy practice model improvement to specialty certification, ASHP continues to reach toward a better future for both patients and pharmacists.

ASHP InterSections is a wonderful asset for members, as it showcases trends in the field of health-system pharmacy, highlights the important work of pharmacists, and connects the dots for members about what ASHP is doing on their behalf.

This issue includes some great future-Focused articles, including a cover story about how information technology and the emerging field of pharmacy informatics are affecting practice. It’s exciting to read how complex technologies that are designed properly and implemented thoughtfully can reduce errors, streamline medication-related processes, and give health care providers critical information they need right at the bedside.

Credentialing and privileging is a subject that more and more pharmacists are talking about. As health care reform takes hold and accountable care models are adopted, the profession of pharmacy is starting to wake up to the fact that board certification is the wave of the future. In our story “Credentialing and Specialization: Health-System Pharmacy Coming into Its Own,” we look at how interest in this field is growing by leaps and bounds. ASHP has led the way on board certification, because we believe that everything is moving in the direction of higher skill and knowledge bases.

Have you ever wondered what it would be like to partner with ASHP to publish a drug information resource? Pamela K. Phelps, Pharm.D., FASHP, shares her three-year experience writing and editing a new book in the story “Diving into the World of ASHP Publishing.” The book, Smart Infusion Pumps: Implementation, Management, and Drug Libraries, features the work of 19 writers and is the only independent guide to smart infusion pump technology.

Finally, we take a look at the experiences of members who have attended the Pharmacy Leadership Academy (developed by the ASHP Foundation’s Center for Health-System Pharmacy Leadership) in “Pharmacy Leadership Academy Opens New Horizons.” The course, which consists of nine six-week modules stretched over 15 months, empowers pharmacists to grow into effective leaders.

As always, ASHP InterSections captures the pulse of what’s happening in hospital and health-system pharmacy today. I hope you enjoy this issue!

Editor’s Note: New ASHP President Stan Kent, M.S., FASHP, who was installed at the second meeting of the ASHP House of Delegates June 14, is assistant vice president, NorthShore University Health System Evanston, Ill.

March 28, 2011

ACOs in the Age of Health Care Reform

Multidisciplinary teamwork is a key feature of Accountable Care Organizations.

THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 provides a plethora of opportunities for pharmacists to optimize their patient-care services. As health systems and physicians, groups create accountable care organizations (Acos) to reach the performance measures laid out in the medicare Shared Savings Program, they are turning to pharmacists to fine-tune the management of chronic diseases, reduce hospital readmissions, and improve medication safety.

Med Management and the Medical Home

The medical home model can provide a foundation for an ACO. In this model, pharmacists, working as members of the interdisciplinary care team, concentrate on medication management as a way of not only improving patient care but also curtailing costs.

For example, Baylor Health Care System in Dallas is creating an ACO in which chronic disease management is a core competency. Pharmacists will be involved in several key areas: medication compliance, polypharmacy management, and reduction of unnecessary medication. Baylor is integrating hospital electronic health records with outpatient electronic health records to facilitate medication reconciliation, as well.

Baylor also operates a medication assistance program for indigent patients at high risk for hospital readmission. Pharmacists help patients in the program apply for free medications from pharmaceutical manufacturers.

“We started that many years ago, and originally focused on the transplant patient population to help them get medications to prevent organ rejection, but the program has been so successful in realizing savings that we plan to use it heavily in our ACO,” said Michael D. Sanborn, vice president, cardiovascular services. “If we are able to get high-risk patients free or reduced medications, we can reduce hospital admissions and reduce overall cost.”

At four clinics, Fairview Health Services, an eight-hospital health system in Minnesota, is also incorporating the medical home model into its ACO. Fairview is establishing medical homes in which the goals are to reduce costs, increase patient satisfaction, place 50 percent more patients under a clinic physician’s care, and improve quality-of-care measures.

Efficient work flow is a cornerstone of Fairview’s efforts, said Scott Knoer, Pharm.D., M.S., director of pharmacy at the University of Minnesota Medical Center. “We want to have the right people doing the right thing. Anything with medication should involve the pharmacy, either pharmacists or pharmacy technicians, as appropriate.”

For example, pharmacy technicians interview patients and enter patient histories into the electronic health record. Standardizing medical histories enhances medication reconciliation and can help smooth the transition from inpatient to ambulatory care. Meanwhile, pharmacists have more time for direct patient care and education, such as helping patients manage their blood pressure and control their diabetes. These efforts will combine to improve patient care and rein in costs, Knoer said.

Above, Kevin J. Colgan, M.A., FASHP

Waiting for Guidelines

The Department of Health and Human Services hasn’t yet laid out guidelines or rules governing ACOs. But there are several things to keep in mind as health systems forge ahead to provide higher quality while lowering costs, said former ASHP President Kevin J. Colgan, M.A., FASHP, corporate director of pharmacy at Rush University Medical Center in Chicago.

“It’s important to set parameters to determine risk for readmission or problems with adherence and incorporate pharmacy services as appropriate,” Colgan said, pointing to a study of 58 readmitted patients at the medical center that revealed each patient was taking, on average, 11 different medications.

“It’s obvious what the role of the pharmacist is there,” Colgan said. “Pharmacists should be providing medication education and assistance with managing therapy so that you get good outcomes.”

Health systems in the process of creating ACOs will also have to determine which patients should be enrolled, he added, noting that the opportunity to reduce overall cost shrinks for those at low risk who require fewer services.

Finally, ACOs will need to determine where to concentrate resources to provide the best care. “Theoretically, the idea would be to transition patients to prevent unnecessary hospital readmissions and lower costs that way,” said Colgan. “It may mean that you move some resources to an ambulatory setting to help patients avoid hospitalization.”

He added that overall, there is room for variation in ACO development. “There will be different forms and structures, with room to shape what the pharmacist’s role will be,” he said.

Reforms in the Middle East, Changes in Pharmacy

Diane Ginsburg, M.S., FASHP

AS I WRITE THIS, the world is witnessing amazing changes in the Middle East. Citizens from Tunisia to Egypt–and now in Libya–are rising up, demanding an end to totalitarian regimes that have long suppressed their human rights. What has struck me as I’ve watched the news reports is just how organic the changes have been, how they started with ordinary citizens, and how no one seems to have been able to fully predict the swiftness or totality of changes that are happening.

This relates to pharmacy in a very real way, I believe. We are on the cusp of huge changes in our country’s health care system. Health care reform is pushing many of us to look with new eyes at the ways in which we ensure patient safety and quality of care. This issue of InterSections offers a peek into the future of our profession in several different, and fascinating, stories.

The cover story, “Gazing Into the Crystal Ball” features conversations with top pharmacy leaders about the ways in which ASHP’s Pharmacy Practice Model Initiative might potentially change the way we work. From a better use of properly educated, well-trained technicians; to improved work flow and collaboration with other health-care providers; to the introduction and deployment of new technologies, the world of pharmacy will look much different in the coming years from what many of us know.

Another story, “ACOs in the Age of Health Care Reform,” reveals how the Patient Protection and Affordable Care Act of 2010 provides a plethora of opportunities for pharmacists to optimize their patient-care services. As health systems and physicians, groups create ACOs (Accountable Care Organizations) to reach the performance measures laid out in the Medicare Shared Savings Program, they are turning to pharmacists to fine-tune the management of chronic diseases, reduce hospital readmissions, and improve medication safety.

Sometimes in looking at where we’re going, it helps to look backward and see where we’ve been. The pace of change in pharmacy is readily apparent when you look at the innovations revealed by ASHP’s National Survey of Health-System Pharmacy Practice in the story titled “Use of Technology Growing, Pharmacists’ Roles Changing.” Each year, half of the survey focuses on two of six aspects of the medication-use system: prescribing, transcribing, dispensing, administration, monitoring, and patient education. The other half focuses on staffing or current hot topics and evolving issues. This story is a fascinating overview of just how far we’ve come in terms of pharmacists’ roles.

I hope you enjoy this issue of InterSections. It offers a real glimpse into the ways in which our profession is changing for the better!

December 26, 2010

Pharmacists Integral to Creating Medical Home Models

Stephen M. Setter, Pharm.D., CDE, CGP, FASCP, speaks with an elderly patient.

AS HEALTH CARE REFORM GETS UNDER WAY, hospitals and health systems across the country are looking into the viability of implementing the Primary Care Medical Home (PCMH) model. In PCMHs, provider-led teams of health care professionals provide coordinated, patient-centered care. The provider is often a physician, whose office acts as a kind of care hub, but much of the direct care is delivered by a multidisciplinary team.

Pharmacists’ Roles Changing

With more than 18 states currently participating in PCMH pilots, the model stands to make a deep impact on the way that care is provided and on the pharmacist’s role as an allied health professional.
Stephen M. Setter, Pharm.D., CDE, CGP, FASCP, associate professor of pharmacotherapy at Washington State University, Spokane, sees the PCMH model as a golden opportunity for pharmacists.
“Pharmacists will be able to use their training to the utmost in this model,” he said, adding that the challenge is simply getting a foot in the door with providers. “Pharmacists are often reactive in the way we provide care,” he said. “We find errors or interactions, but that is downstream. In the medical home model, we can be right at the point of care.”

L. David Harlow III, R.Ph.

Pharmacists need to be more proactive in communicating their expertise to providers, according to L. David Harlow III, R.Ph., director of pharmacy operations at the Carilion Clinic’s New River Valley Medical Center, Christiansburg, Va., and Tazewell Community Hospital, Tazewell, Va.

“Physicians are just not familiar with what pharmacists are qualified to do,” said Harlow, “and that’s just as much our fault, because we have not gotten
the word out.”

Evidence and Incentives

The evidence is there to support pharmacist involvement in multidisciplinary models like PCMH. Studies have shown that pharmacist-provided direct patient care improves patient outcomes across several disease states, and that patients cared for by a team that includes a pharmacist have fewer hospital readmissions.1

Troy Trygstad, Pharm.D., MBA, Ph.D.

Troy Trygstad, Pharm.D., MBA, Ph.D.

As the Centers for Medicare and Medicaid Services roll out “accountable care” projects, the financial incentive for including pharmacists in care teams will grow, as well. Accountable care makes providers responsible for ensuring that patients do not return with preventable complications, such as venous thromboembolisms after orthopedic surgery. If a patient returns with a condition noted under accountable care, the provider will not be reimbursed.

“That changes the equation completely,” said Troy Trygstad, Pharm.D., MBA, Ph.D., director of the Network Pharmacist Program at Community Care of North Carolina in Raleigh. “Now you have business reasons for a multidisciplinary team. Physicians need help in providing the deliverable, and they’re asking, ‘Who can you give me?’” Harlow notes how pharmacists are a natural choice for reining in health care costs.

“Twenty percent of the patient population uses 80 percent of the dollars in health care,” he said. “They are the patients with chronic diseases like diabetes and cardiovascular disease—the same things that account for the drug dollars. If you think about that in primary care, those patients take the most time, their medication regimens need the most tweaking, and they are most likely to relapse to the hospital if their medication issues are not corrected.”

Even in smaller medical practices, scheduling patients to come in and see a pharmacist can go a long way toward addressing those issues, he added.

Cushioning the Impact of Health Care Reform

The cost-effectiveness of involving pharmacists in the PCMH model is one reason ASHP worked so hard to obtain appropriate recognition for pharmacists in health care reform legislation, said Joseph M. Hill, ASHP’s director of federal legislative affairs.

Gretchen Tong, Pharm.D., discusses a patient’s medications with a University of North Carolina Family Medicine physician.

“Our initial accomplishment was the inclusion of pharmacists in the Affordable Care Act, which mentions pharmacists as part of the care team,” he said. “The Act sets out to develop and test delivery and payment models in health care, and [the PCMH model] could potentially be the first step.”

The PCMH model may prove to be a boon to patient care by driving health professionals together, even as it gives providers a cushion for absorbing the impact of health
care reform.

“It’s a holistic model,” said Setter of Washington State University. “From my perspective, that’s the way pharmacists should be practicing and the way medicine needs to move forward.”

Trygstad predicts that as physicians begin to lead multidisciplinary teams, they will see the value in such intense collaboration. The signs are already there, he said, reflecting on a conversation he recently had with a physician in a small town. “He was the sole doctor in the town” said Trygstad, adding that the doctor told him, “I’ve been practicing medicine for nearly 30 years, and it has taken me this long to realize how much I could have been learning from other professionals like pharmacists.’”

1. Chisholm-Burns MA, Graff Zivin JS, Lee JK, et al. US pharmacists’ effect as team members on patient care: Systematic review and meta-analyses. Medical Care. 2010;48:923–933

September 28, 2010

Health Care Reform: What’s Next For Pharmacists?

Henri R. Manasse, Jr., Ph.D., Sc.D.

Henri R. Manasse, Jr., Ph.D., Sc.D.

AS WE GO TO PRESS with the fall 2010 edition of InterSections, nearly 100 ASHP members have just finished an intensive day lobbying congressional representatives and their staff members on issues critical to our profession.

It has been a busy, but important, time for ASHP members and the patients they serve. With the passage of the Patient Protection and Affordable Care Act, as modified by the Health Care and Education Reconciliation Act, Congress showed its support for expanding access to affordable health care, improving quality, and reducing health care costs.

Health care reform offers pharmacists a number of great opportunities to expand patient-care services. It specifically addresses delivery systems reform, payment reform, and quality, comparative effective- ness research, work-force issues, and the 340B Drug Pricing Program.

When you look through the proposed delivery models, almost all of them mention the need to involve pharmacists in solving medication-related issues. That is an exciting change in perception on the national level and one that will help ensure that patients receive better, safer care. ASHP played a vital role for inclusion of pharmacists throughout the legislation.

At ASHP, our efforts to get the legislation passed have now evolved into a focus on working with the federal agencies responsible for developing the regulations to implement the law. We are keeping in close contact with members of Congress to encourage them to sufficiently fund the programs included in the law. We have nominated pharmacists to serve on the newly created Health Care Workforce Commission and other committees. And we are continuing our efforts to expand funding for postgraduate pharmacy residency training.

Although we don’t yet have a clear sense of how the entire process will play out, health-system pharmacists will have many opportunities over the next several years to influence how reform is implemented within their own institutions.

For example, begin a conversation with your institutional leaders and administrators about the importance of improved quality and reduced costs. What is your hospital doing or planning to do to implement reform-related changes, and what can you do to make those changes come to life?

Seek opportunities to include pharmacists in efforts by your organization to create accountable care organizations and “medical homes,” and to meet quality improvement requirements that align payment with quality.

Just as important is staying engaged in the public discourse surrounding health care reform. We all need to be more aware of and get more involved in the regulatory process. Although the new law is a complex document (nearly 2,000 pages with about 400,000 words), it is actually only a skeleton of what is to come. Regulators will flesh out the law, and we need to have a voice in that process to ensure that there are no negative consequences for patient care or for our profession.

Every ASHP member can be a player in this next phase of health care reform by participating in a number of ways:

  • Stay informed about the law’s progress both by connecting to your state affiliate and signing up for ASHP’s Grassroots Network,
  • Join ASHP’s Political Action Committee and help support members of Congress who understand pharmacists’ critical patient-care role,
  • Get to know your federal and state representatives, and invite them to your institution to demonstrate what you do each day to care for patients, and
  • Work within your own spheres of influence to ensure that your hospital or health system involves pharmacists in efforts to improve quality and reduce costs.

Please know that ASHP is behind you every step of the way, as a national advocate for the profession and as a resource for you to advocate for pharmacy within your own hospital or health system. Together, we really do make a great team!

April 9, 2010

Blazing a New Trail for Pharmacy

TWENTY-FIVE YEARS after the influential Hilton Head conference, ASHP and the ASHP Foundation are once again embarking on a groundbreaking national effort to guide the future of hospital and health-system practice.

The Pharmacy Practice Model Initiative (PPMI), officially launched in 2009, will revisit the hard consensus-building work of Hilton Head and other ASHP-hosted legacy conferences as pharmacists in all practice settings debate what the future of the profession should look like.

“National health care reform, constantly evolving technologies, massive amounts of new drugs entering the market every year, scientific breakthroughs… All of these and more are demanding that we, as pharmacists, really step up and begin to own the medication-use policies and procedures within our institutions,” said ASHP president Lynnae Mahaney, M.B.A., FASHP, chief of pharmacy services at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.

Expectations Versus Actual Opportunities

“We’re in an environment where there is national concern about the future state of health care,” said David Chen, R.Ph., M.B.A., director of ASHP Pharmacy Practice Sections. “Additionally, we’re seeing growing demand for enhanced pharmacy services and increasing pressure to integrate technology advances. We really need a self-critical analysis of the state of pharmacy practice.”

Although the Hilton Head conference and other ones like it successfully laid the groundwork for the all-Pharm.D. degree and many of the professional opportunities that pharmacists now enjoy, there is much more to achieve, according to Doug Scheckelhoff, M.S., ASHP vice president of professional development.

“Hilton Head was focused on the clinical profession of pharmacy and the types of training needed to get there,” Scheckelhoff said. “It was really pivotal in setting a clear direction. The PPMI will be just as important, but in a different way.”

A joint project of ASHP and the ASHP Foundation, the PPMI will comprise three components: an invitational summit this fall, a campaign to promote change, and demonstration projects funded by Foundation grants. At press time, McKesson Corporation had signed on as a Leadership-Level sponsor of the Initiative, and Omnicell, Inc. and CareFusion had signed on as Gold-Level sponsors.

An Unsettling Trend

The Initiative reflects a powerful movement within ASHP’s membership. The need for a new practice paradigm has surfaced again and again during the past several years in ASHP’s policymaking Councils and membership Sections, as well as during strategic planning for the Society’s Leadership Agenda.

“We’ve been monitoring a trend in which professionals other than pharmacists are taking roles that have traditionally been pharmacists’ roles, both by design and by direct competition,” Chen said, adding that the movement is troubling because pharmacists have the knowledge and skills to conduct direct patient care and medication management.

“We need to put our stake in the ground and become the recognized experts among our medical peers on drug therapy and medication-use processes,” he said. “We also have to start taking into consideration external influences that we don’t directly control but that will ultimately affect our opportunities.” 

The issue is particularly stark when one considers the scientific breakthroughs happening today, according to Karl Gumpper, R.Ph., BCPS, director of ASHP’s Section of Pharmacy Informatics and Technology. The Section recently published a Vision Statement on Technology-Enabled Practice, acknowledging many of the challenges and opportunities that lie ahead for pharmacists.

“Medication management eventually will move toward genetics and genomics,” Gumpper noted. “All of that science will go into dosing and even picking a medication. There is no one more qualified than pharmacists to do that job.”

Finding the Right Balance

Ultimately, the best pharmacy practice models are those that find optimal balance, matching the work to the skills of the individual and using automation and technology wherever possible to improve safety and efficiency, according to Scheckelhoff. “What are technicians capable of doing and what should they be doing?” he asked. “How can we use technology to improve our processes? And how can pharmacists directly impact the care of patients?”

Scheckelhoff noted the disparities that currently exist among pharmacy services at different types of hospitals and health systems across the country. ASHP’s National Survey has repeatedly shown that “innovator hospitals” offer high levels of pharmacy services. In contrast, less progressive hospitals still provide the same kinds of  services that they provided 30 to 40 years ago.

“We need to look for ways to close that gap,” Scheckelhoff said. “Our patients need it, and they deserve it.” ASHP created a website just for the Initiative and is encouraging members to disseminate their thoughts on the best practice models via ASHPConnect discussion boards.

The first major activity will be a multidisciplinary invitational summit this fall that will focus on developing a framework of pharmacy practice that takes into consideration the internal and external factors that will affect patient care in the future.

From there, a synopsis of proceedings will help members do their own critical analysis about what types of pharmacy services they are offering. This process will, in turn, drive the development of new practice models.

“To actually change our practice models, we will need leadership at every level of pharmacy…from the pharmacy director, to the clinician at the bedside, to the technician,” said Daniel J. Cobaugh, Pharm.D., FAACT, DABAT, the Foundation’s senior director for research and operations. “It won’t be easy, and it will take time and commitment, but we all need to be engaged in this exciting process.”

Summit Dates Announced
To kick off the PPMIMI, ASHP will host an invitational consensus conference Nov. 7-9, 2010, in Dallas. The conference will bring together thought leaders throughout hospital and health-system pharmacy to reach consensus on optimal practice models.

For more information on ASHP’s Pharmacy Practice Model Inititiave, go to www.ashp.org/ppmi.

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