ASHP InterSections ASHP InterSections

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.

January 21, 2010

A Year to Remember

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Lynnae M. Mahaney, M.B.A., FASHP

AS WE GREET THE NEW YEAR, I have to admit that, in some ways, I am glad that 2009 is behind us. It was a year of unprecedented economic challenges. We watched as Congress struggled with the critical issue of health care reform. And many of us who work in emergency departments (EDs) dealt with the ongoing challenge of an H1N1 pandemic. This first issue of 2010 reflects some of these challenges and sheds light on what may be coming around the corner. It also shows how far we have come as a profession and the many ways in which we contribute to quality patient care.

Our cover story, on page 8, is about how health care reform may affect hospital pharmacists, and it is eye-opening and full of hope. ASHP has advocated for many years that pharmacists need to be recognized as health care providers. Although the bill that passed the House in November doesn’t explicitly allow for that designation, it does open the door for pharmacists to demonstrate their medication management expertise as part of innovative care models such as “medical homes.” As the saying goes, although we are just at the “beginning of the beginning,” this is very good news.

As you will see on page 12, pharmacists around the country are approaching the pandemic of H1N1 in new and novel ways, finding opportunities for patient counseling, education, and emergency preparedness. For example, after a change in a New York state law allowed pharmacists to administer influenza and pneumococcal vaccines, the pharmacy department at Montefiore Medical Center in the Bronx stepped up to the plate, initiating a series of immunization training programs. Conducted by faculty members from Touro College of Pharmacy in Harlem, the programs have certified more than 60 pharmacists since the fall.

Quality health care is a team affair, and at the Carolinas Medical Center-NorthEast, in Concord, North Carolina, a team of pharmacists is changing how infectious disease cases are handled in the ED. Take a look on page 17 to see how pharmacists are reducing hospital re-admissions caused by infection.

As you can see here, this issue of ASHP InterSections is full of stories about pharmacists who are making a difference. We hope you enjoy it! Drop me a line at prez@ashp.org or contact me on the new ASHP Connect Blog, and let me know what you think.

Lynnae M. Mahaney, M.B.A., FASHP

Pharmacy in the Time of H1N1

Pharmacy students at the University of Houston College of Pharmacy administered more than 2,500 flu vaccines this fall.

HOSPITAL AND HEALTH-SYSTEM PHARMACISTS around the country are struggling to keep up with demands being put on emergency rooms by increasing numbers of patients who are walking in with H1N1 flu symptoms.

“This virus has been a huge burden to our emergency room, and there have been a number of areas where our pharmacists have been asked to step up,” said Heather Draper Eppert, Pharm.D., BCPS, clinical specialist in emergency medicine and an assistant professor at the University of Tennessee College of Pharmacy, Knoxville. “Our ICUs are full, both with the usual high-acuity conditions but also with younger patients on the verge of respiratory failure.”

The H1N1 influenza outbreak officially reached pandemic proportions in November 2009, moving into high gear with the advent of the school year. According to the Centers for Disease Control and Prevention (CDC), by mid-November, nearly 22 million people in the U.S. had fallen ill with the virus. Close to 99,000 people had been hospital- ized, with almost 6,000 deaths reported.

Adding to the burden caused by the outbreak has been the media hype regarding the safety of the vaccines to help prevent its spread. The combination of these factors has driven even healthy patients to come to the ER to be checked, further stretching the limits of the nation’s medical infrastructure.

Yet the story has one bright spot: The challenges of H1N1 have also provided openings for hospital pharmacists to demonstrate their skills and knowledge, according to Draper Eppert, including patient education, vaccination administration, and emergency preparation.

Pharmacists as Advocates

One of the more alarming aspects of the H1N1 outbreak is the misunderstanding about the safety of the vaccines that can help prevent its spread. An October 2009 ASHP poll of hospital pharmacy directors found that most hospital workers are not vaccinated. According to the study, only 37 percent of the responding hospitals reported staff vaccination rates that topped 70 percent.

Mary Andrawis, Pharm.D., M.P.H., director of ASHP clinical guidelines and quality improvement, believes pharmacists should become flu vaccine advocates.

The problem, it appears, is that even hospital staffs have been misinformed about the safety of the vaccine despite recommendations from the CDC that all health care and emergency services personnel be vaccinated.

“If we aren’t successful at convincing hospital workers to get vaccinated, how can we convince patients?” said Mary Andrawis, Pharm.D., M.P.H., director of ASHP clinical guidelines and quality improvement. “This is an area where pharmacists need to become advocates for everyone to get vaccinated for the seasonal flu as well as H1N1.”

Pharmacists as Vaccinators

An area where pharmacists’ skills have proved invaluable during the outbreak is in their role in dispensing and administering vaccines and antivirals like Tamiflu®. Draper Eppert noted that one of the challenges her team of pharmacists face is making tough decisions regarding the potential rationing of drugs like Tamiflu during an inventory shortfall.

“We even have healthy patients who want a prescription just in case they get sick,” she said. “We have to make tough decisions about whether someone else needs it more.”

With the campaign for immunization under way, pharmacists from around the country have stepped up to administer vaccines. “ASHP has actively been encouraging hospitals and health systems to consider using pharmacists to administer vaccines in order to increase vaccination rates,” said ASHP president Lynnae Mahaney, M.B.A., FASHP.

Even pharmacy students have gotten involved. In Texas, students at the University of Houston College of Pharmacy who completed an immunization course administered more than 2,500 vaccines in a partnership with the Harris County health department.

“The students and faculty preceptors have been excited to get involved and to use their skills for something as important as preventing the further spread of a pandemic influenza virus,” said Kevin  Garey, Pharm.D., M.S., initiator of the program and chair of the department of clinical sciences and administration at the university.

Pharmacists and Emergency Preparedness

%%SIDEBAR%%Emergency preparedness has become a priority for hospitals and health systems in the wake of September 11, and pharmacists continue to play a critical role in such planning. The outbreak of H1N1 and other potential pandemics require planning in terms of vaccine and antiviral stocking and the skills necessary to monitor mass dispensations of those medications. Pharmacists have begun to play an even greater role in assisting public health departments in their planning efforts, according to Andy Stergachis, Ph.D., professor of epidemiology and global health and adjunct professor of pharmacy at the University of Washington School of Public Health, Seattle.

“Public health departments can’t do this alone for two reasons,” said Stergachis, who is also the pharmacy adviser to the public health department of Seattle and King County. “First, health departments have been losing personnel due to the recession. Second, health departments have never had the capability to conduct mass dispensations. This means that public-private partnerships offering pharmacists’ expertise in medicines and distribution are critical to meet community needs.”

Since 1979, the state of Washington has recognized pharmacists’ capabilities to prescribe and administer medications. That year, it created a collaborative drug therapy agreement providing pharmacists with prescriptive authority.

This has allowed pharmacists to play a major role in administering vaccines and to establish relationships with public health departments.

“Pharmacists were brought into the planning process early on and have been able to rapidly assume responsibility for providing oral antivirals and vaccine during the pandemic,” said Tim Fuller, M.S., FASHP, pharmacist consultant to the Washington State Department of Health Board of Pharmacy, which helps manage the state’s stockpile of vaccines and antivirals.

October 9, 2009

Speaking the Language of Health Literacy

SPEAK SLOWLY AND REPEAT information. Avoid complicated medical terms. Use pictures instead of written descriptions.

These are just some of the methods Pamela L. Stamm, Pharm.D., BCPS, CDE, uses to communicate effectively with patients who have low health literacy.

Stamm, a clinical pharmacy specialist who treats patients with diabetes and dyslipidemia at the Central Alabama Veterans Health Care System in Columbus, Georgia, also uses the “teach-back” method, in which patients repeat instructions.

“If patients can put it in their own words, there’s a greater chance they’ll be able to do what I’m asking them to do. My whole goal is to ensure that patients take their medications,” said Stamm.

Stamm’s effort to foster health literacy is just one example of how ASHP members are working to ensure that patients understand what medications they are taking, when and how they should take their medications, and what the medications treat.

“It’s important to remember that not every patient is going to read a pamphlet from the pharmacy, or a graph or table,” said Gina Ryan, Pharm.D., BCPS, CDE, clinical pharmacist at Grady Health System Diabetes Clinic in Atlanta. “If you’re going to give someone a table for blood-sugar values as a reference for adjusting insulin, you can’t just assume the patient understands it.”

A Growing Problem

A reduced capacity to understand medical instructions is a significant, and growing, problem in the U.S., experts say. According to the Institute of Medicine, 90 million people, including elderly patients, minority and immigrant populations, low-income patients, and people with chronic mental or physical health conditions, have difficulty understanding and using health information.

Gina Ryan, Pharm.D., BCPS, CDE , left, clinical pharmacist at Grady Health System Diabetes Clinic counsels a patient, right, at the clinic, as pharmacy student Rhondolyn Jones, takes notes.

The American Medical Association reports that this inability to understand instructions on prescriptiondrug bottles, appointment slips, medical education brochures, a doctor’s directions, and consent forms is “a stronger predictor of a person’s health than age, income, employment status, education level, and race.”1

ASHP and the ASHP Research and Education Foundation are trying to step into the gap, providing tools like “My Medicine List™” on both ASHP’s consumer Web site SafeMedication. com and the Foundation’s Web site.

This free, downloadable tool, which helps patients track the prescription medications, vitamins, ?and other dietary supplements they take daily, was created utilizing health literacy guidelines.

“‘My Medicine List’ is a really great tool to help facilitate that all-important conversation between pharmacists

and their patients,” said ASHP president Lynnae Mahaney, M.B.A., FASHP. “We know from national efforts like Healthy People 20102 that health literacy is a large and growing area of concern, and pharmacists can play a critical role in ensuring patients understand what medications they are taking and how to take them correctly.”

ASHP’s House of Delegates approved a policy in 2002 encouraging health literacy efforts among pharmacists. And it conducts educational programming to help members improve their medication counseling skills related to literacy. At the 2008 Summer Meeting, for example, ASHP offered a session called “Prescription for Confusion: Health Literacy and the Rx Label.” Attendees identified problems related to patients’ misunderstanding of common dosage instructions and learned the keys to drug-label design that ensure patient understanding.

Assessing for Literacy

Steven Chen, Pharm.D., FASHP, a clinical pharmacist at the JWCH Medical Clinic, Los Angeles, checks the blood pressure of a patient.

Pharmacists utilize a variety of tools to assess and respond to low health literacy. For example, a patient who says he can’t see the medication directions because he left his reading glasses at home may be hiding the fact that he can’t read. In this instance, a test such as the Rapid Estimate of Adult Literacy in Medicine (REALM) may be helpful. Pharmacists are also turning to the Ask Me 3 program, which empowers patients to ask and understand the following questions:

1. What is my main problem?

2. What do I need to do?

3. Why is it important for me to do this?

Ryan recommends that patients complete the REALM test during their initial visit. This assessment ensures that patients don’t feel they are being profiled for their reading abilities while giving health care providers insights into the health literacy challenges that may be present.

REALM test results help determine next steps, including using the teach-back method, arranging for relatives to help read instructions once the patient goes home, or informing physicians of the challenges that may be present through medical chart notes.

“I have encountered a significant number of patients who can’t read. It really is a big challenge,” Ryan said. “I’m always trying to figure out how to be effective and efficient. If I’m handing out pamphlets, I don’t want to just check a box to say I gave a person a piece of paper. I want it to work for them.”

Fotonovelas tell stories through the use of photos and word bubbles.

%%SIDEBAR%%But no matter how simple written instructions are, there is nothing better or more effective than face-to-face counseling with pharmacists, said Michael J. Miller, DrPH, who has researched health literacy as an associate professor at the University of Oklahoma College of Pharmacy in Tulsa.

“We have a tendency to communicate in the written word. We want to use that as a substitute for personal communication. But there’s no substitute for one-on-one questions,” Dr. Miller said.

ASHP members also use the unique medium of “fotonovelas” to educate patients on health issues such as diabetes. Similar to graphic novels or comic books, fotonovelas tell stories via photos and word bubbles and use limited text.

As a clinical pharmacy specialist at the JWCH Institute Center for Community Health, Los Angeles, Steven Chen, Pharm.D., FASHP, is very familiar with the appeal and effectiveness of fotonovelas among Hispanic patients.

Chen, who is also an assistant professor in the Department of Clinical Pharmacy and Pharmaceutical Economics and Policy, University of Southern California School of Pharmacy in Los Angeles, worked with colleague Mel Baron, Pharm.D., M.P.A., to create a fotonovela about the dangers of untreated diabetes.

Entitled Sweet Temptations, the fotonovela has effectively broken down a number of health literacy barriers among patients, according to Chen. The booklet was funded by a combination of university, industry, nonprofit, and local community pharmacy grants.

“We have to understand that different cultures have different methods that work better,” Chen said. “When you start talking about relatives with the disease, who are struggling with dialysis or facing the prospect of losing a leg, we speak to their values. Personalizing the problem and making it simple is the most important thing we can do for patients.

Living in the Digital World

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Lynnae M. Mahaney, M.B.A., FASHP

WELCOME TO THE NEW DIGITAL EDITION of ASHP InterSections! I hope you are as excited as I am by the debut of a more interactive, easy-to-read magazine. As a digital publication, InterSections is now tapping into the power of the Web by offering readers relevant Web, audio, and video links embedded within the stories.

Our intention is that you find this to be a value-added experience, as you are able to search and read more about each topic than was possible with a print-only publication.

This new format also continues ASHP’s commitment to environmental and economic stewardship—no trees were harvested for this publication, and a digital format eliminates the burden of ever-increasing postage.

Since its founding in 2006, ASHP Inter-Sections has sought to bring you stories about fellow practitioners who are on the leading edge of practice and hot topics such as work-life balance, as well as information about what your society is doing for you.

This issue is no exception. Our cover story on the importance of health literacy—and the tools pharmacists can use to help patients understand their medications better—is eye-opening and something you won’t want to miss.

As the number of schools of pharmacy increases, more and more students are seeking introductory experiential education slots. If your hospital is considering implementing this type of program, check out the story on page 12. You will find information on the many benefits for institutions that are reaching out to students in this way.

How has the sputtering economy impacted your hospital or health system? On page 14, you will be able to see how fellow practitioners are dealing with reduced inpatient numbers, hiring freezes, and budgets that have come under increased scrutiny.

All of us here at ASHP look forward to your feedback and suggestions about the new ASHP InterSections. Drop me a line at prez@ashp.org or contact me on the new ASHP blog and let me know what you think.

Lynnae M. Mahaney, M.B.A., FASHP

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