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January 16, 2015

New EHR Improves Outcomes at The University of Kansas Hospital

Filed under: Ambulatory Care,Clinical,Current Issue,Feature Stories,Managers,Quality — Tags: , , — jmilford @ 5:34 pm
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The new Clinical Efficiency System that is part of the EHR used by pharmacists at The University of Kansas Hospital ensures that clinicians see the most critical patients first.

CLINICAL PHARMACISTS BEGIN THEIR SHIFTS much the same way as most clinicians: They examine patients under their care and proceed from there.

But when faced with dozens of patients, each one with different needs and clinical complexities, which ones need immediate attention? Which can wait? Sorting out the choices subjectively is time-consuming and inefficient, and reduces the amount of time a pharmacist can spend with patients.

“We want our pharmacists to come in and, based on patients’ clinical acuity, examine their most critical patients first. Choosing patients alphabetically or by room number won’t achieve that,” said Samaneh T. Wilkinson, M.S., Pharm.D., Assistant Director of Pharmacy at The University of Kansas Hospital in Kansas City.

“Instead, we wanted to have the electronic health record (EHR) guide pharmacists based on a patient’s clinical needs, with the primary goals of improved efficiency, clinical consistency, and better patient outcomes.”

To that end, Dr. Wilkinson spearheaded implementation of the Clinical Efficiency System (CES), a complex software package developed by the hospital’s IT department and integrated with the hospital’s existing EHR.

Flow Sheets Provide a Snapshot of Patients

The system instantly provides pharmacists with a “snapshot” of each patient in real time, immediately registers updates as a patient’s condition changes or when he or she receives treatment, and alerts pharmacists when interventions may be needed. The CES comprises three principal components: flow sheets for daily documentation and clinician hand offs, a pharmacy scoring list, and a rounding navigator.

Samaneh T. Wilkinson, M.S., Pharm.D.

Samaneh T. Wilkinson, M.S., Pharm.D.

Flow sheets track pharmacist-managed therapies that require detailed documentation, including antimicrobial stewardship, anticoagulation monitoring, and venous thromboembolism (VTE) prophylaxis assessment.

Similar to a Microsoft Excel spreadsheet, flow sheets display rows labeled with key parameters and patient-specific data, and allow users to add notes. The display ensures that daily documentation is up to date during hand-offs between clinicians.

For example, a drop-down menu allows pharmacists to quickly assess a patient’s VTE risk. If necessary, the pharmacist can quickly relay the information to the patient-care team to initiate VTE prophylaxis. Flow sheets also include hyperlinks to other pertinent information, such as lab values and current anticoagulant therapy.

“The connectivity is very useful,” said Lucy Stun, Pharm.D., a critical care pharmacist at KUMC. “From the VTE flow sheet, I can easily see when the last TPA or aspirin was given, and what time the next dose of heparin can be given safely.”

The scoring list provides an overview of patients monitored by a particular pharmacist, guiding each clinician through his or her caseload based on clinical acuity as calculated by intricate algorithms.

This process, according to Dr. Wilkinson, reduces subjective determinations and the attendant time they require and ensures that pharmacists focus on patients most in need of their expertise. The scoring list, said Dr. Stun, “also creates a more efficient workflow because the pharmacist knows what major changes happened overnight and what they need to take care of first.”

Augmenting the scoring list is a rounding navigator that provides an in-depth review of each patient with a large amount of specific, pertinent clinical information, with more hyperlinks to reports, summaries, and documentation.

A Boon to Efficiency

According to Dr. Stun, the CES dramatically improves efficiency and streamlines workflow.

“I can now glance at my color-coded screen and see what’s completed or what needs to be done based on the color coding—green, yellow or red,” she said.

“At the end of rounds, I always look at the screen to see what’s left to do. That may be checking if a patient has had DVT prophylaxis or if we’ve completed a medication reconciliation. It’s right in front of us.”

Dr. Stun said the system is particularly helpful in keeping the pharmacy team focused during rounds, when there are typically multiple, concurrent distractions.

Allie D. Woods, Pharm.D.

Allie D. Woods, Pharm.D.

“If someone on the care team asks me about a patient’s status, all I have to do is look at the screen to get a complete picture,” she said.

Allie D. Woods, Pharm.D., director of ASHP’s Section of Pharmacy Informatics and Technology, said the scope and results of the project are impressive.

“Hospital pharmacists are often responsible for dozens of patients every day. Setting priorities and deciding which patients to see and when can be very difficult, especially with all of the distractions that come up throughout the day,” she said.

“The scoring list alone helps pharmacists work more efficiently. They are able to triage patients more rapidly, and then adjust the amount of time they spend with patients based on their specific clinical needs. This system results in better patient care.”

Ensuring that Patients Know Pharmacists are on Their Care Team

The CES has also led to increased interaction between pharmacists and patients.

“It carves out more time during the day for face-to-face contact that previously might have been spent looking for information and evaluating a patient’s status,” said Dr. Wilkinson. “Our pharmacists can meet more patients and say ‘Hello, I’m your pharmacist. Do you have any questions about your medications? Can I clear up anything for you before you leave the hospital?’

“We want every patient who leaves our hospital to know that a pharmacist took care of them during their stay.”

Dr. Stun acknowledges that since CES implementation, she spends more time at bedside, particularly when conducting medication reconciliation or preparing patients for discharge.

“We used to just counsel patients who were taking high-risk medications,” she said. “Now we also counsel patients who have heart failure, COPD, pneumonia, or myocardial infarction, or if they have had an organ or bone marrow transplant.”

We want every patient who leaves our hospital to know that a pharmacist took care of them during their stay.

Success has also been quantified: Pharmacy admission history capture and pharmacist-supported discharges have increased by 96.4 percent and 85.6 percent, respectively. Dr. Wilkinson has determined that patients who were discharged after pharmacists educated them about their medications and conducted medication reconciliation are 30 percent less likely to be readmitted to the hospital within 30 days.

Readmission rates for patients with conditions that predispose them to repeat hospital stays (e.g., acute myocardial infarction, chronic heart failure, and COPD) also have fallen. During the last Joint Commission accreditation review, the reviewers noted the exceptional quality of the hospital’s medication reconciliation process. “The CES made that possible,” she said.

One unexpected, but welcome outcome, was a 30 percent jump (from 62 percent to 92 percent) in the number of positive responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) question about patient perceptions of how well they were prepared to go home.

“Now, more than 90 percent of our patients feel adequately prepared for discharge. That was eye opening,” said Dr. Stun.

As with any major organizational change, the system planners encountered some resistance. Abundant training and a grace period were critical for overcoming anxiety associated with the change. After the initial roll-out, pharmacists had more than three months to become familiar with the system before its use became mandatory.

Now, the CES is an integral part of the culture for the hospital’s 54+ FTE staff pharmacists, and Dr. Wilkinson’s team is continually soliciting user feedback and looking for ways to improve it.

— By Steve Frandzel

August 28, 2014

More Pharmacists in ER Mean Better Patient Care

Drs. Katelyn Dervay, Pharm.D. and Mary Finocchi, Pharm.D., BCPS

Pharmacists in the ER bring much-needed medication expertise to often-chaotic and complex medical situations. Above, Katelyn Dervay, Pharm.D., BCPS, and Mary Finocchi, Pharm.D., BCPS, prepare to treat a patient.

IMAGINE A HOSPITAL EMERGENCY ROOM (ER) with no radiology services available. To emergency physician Tim Meehan, M.D., MPH, an ER or ED without an on-site pharmacist makes about as much sense.

“I don’t think you can provide appropriate emergency care without pharmacists present, or, at the very least, with 24-hour access to a pharmacist” if the facility is too small to support a dedicated ED position, said Dr. Meehan, who practices primarily at the University of Illinois Hospital in Chicago. “I find them to be indispensable team members. During periods when we didn’t have a dedicated ED pharmacist, it was rough going.”

A Growing Trend

Dr. Meehan’s assessment of the critical role that pharmacists play in the ED reflects a rising consensus among healthcare providers in hospitals and health systems across the country. Although pharmacists have long provided medication consultations to ED healthcare teams, the push for dedicated pharmacist positions within the setting itself is a growing trend.

“As members of interdisciplinary ED healthcare teams, pharmacists improve patient outcomes by ensuring appropriate and cost-effective medication use and leading system changes to reduce or eliminate medication errors,” said Erika L. Thomas, MBA, B.S.Pharm, director of ASHP’s Section of Inpatient Care Practitioners, adding that ASHP believes every hospital should include pharmacy services in the ED.

Dr. Katelyn Dervay, Pharm.D.

Katelyn Dervay, Pharm.D., BCPS

The addition of pharmacists to the ED or ER is often the result of other healthcare practitioners’ requests. After witnessing the range and scope of standard pharmacy services, ER staff at Tampa General Hospital asked for an augmented pharmacy presence, according to Katelyn Dervay, Pharm.D. BCPS, a clinical pharmacy specialist in emergency medicine and incoming chair of the ASHP Section Advisory Group for Emergency Care.Now, at least one ER pharmacist is on duty around the clock, and a satellite pharmacy serves the department, which treats more than 85,000 patients annually.

In addition to ensuring safe and effective medication use, Dr. Dervay and her colleagues assume less common tasks as well, such as geriatric consultations. Those consultations have twice revealed that a patient’s symptoms resulted from medication misuse, not illness. Her assessment precluded unnecessary tests and admission to the hospital.

“It’s always a big change for nurses who are new to our ER and aren’t used to having pharmacists on staff,” said Dr. Dervay. “At first, there’s a sense of losing control, but soon they realize the benefits that we provide and appreciate the fact that we free them up to focus on other acute duties while the pharmacist handles medication issues.” During a typical 24-hour weekday last spring, pharmacists conducted 45 consults, including medication adjustments, IV/PO conversions, and attending traumas and strokes.

The pharmacists also serve as information conduits—informally by answering drug-related questions from other ER staff, and more formally through inservices for nursing staff, residents, and staff physicians. In addition, she and her colleagues monitor antibiotic regimens and ensure that prescribed drugs are the best choices to treat a particular condition.

“Hybrid” Roles Showcase What Pharmacists Can Do

Megan Musselman, Pharm.D., BCPS, a clinical pharmacist specialist in emergency medicine and critical care, is the only ER pharmacist on staff at North Kansas City Hospital in Kansas City, MO, which treats more than 100,000 patients annually.

“I’m in a hybrid role and split my time between the ER and intensive care. It’s a great way to show the value of the ER pharmacy services,” said Dr. Musselman.

Dr. Megan Musselman, Pharm.D., BCPS

Megan Musselman,
Pharm.D., BCPS

Dr. Musselman sometimes feels like a frontline medication safety officer in a high-risk arena. “There are huge medication safety issues in the ER. It’s a fast-paced, high-acuity area. You need to be quick on your feet and recognize situations in which medication errors are likely to arise,” she said.

From April through June 2014, Dr. Musselman participated in an average of 202 interventions monthly.Another key responsibility is procuring drugs that may be in short supply. “If a medication is unavailable, and we need a different but equally effective choice, I research the options, put the medications in place, and educate other healthcare providers about how to use them safely and effectively,” she said.

Quantifying the Value of ED Pharmacy Services

Showing the C-Suite that pharmacists make a difference in patient outcomes can be challenging, according to Dr. Musselman, because the monetary impact often comes primarily through cost avoidance, such as preventing an adverse drug event, vs. income.

But increasingly, hospitals recognize that ED pharmacists lead to more robust patient care and income statements, said Brenda Darling, Pharm.D., clinical pharmacy manager at Children’s Medical Center in Dallas.

The ER at Children’s treats more than 140,000 patients annually and employs 10 full-time emergency pharmacists, more than any hospital in the country.

“If a pharmacist catches one potentially serious error before it reaches the patient, that alone justifies their entire salary,” said Dr. Darling.

Rustin Morse, M.D., a pediatric emergency medicine physician and the hospital’s chief quality officer, has practiced for more than 15 years and joined the ER at Children’s two years ago. This is the first time that he has worked in an ER where pharmacists work side by side with physicians around the clock.

Dr. Megan Musselman, Pharm.D., BCPS, works with Emergency Department team to ensure medication safety

Katelyn Dervay, Pharm.D., BCPS and Mary Finocchi, Pharm.D., BCPS, works with the Tampa General Hospital ER team to ensure that a patient’s medication needs are met.

“They’re in the same locations, they see and talk to the patients and their families, so they have a full understanding of the clinical situation, instead of simply reviewing charts,” said Dr. Morse. “There’s also a world of difference between having a personal relationship with a pharmacist vs. just talking to him or her by phone.”

Sometimes that depth of understanding encompasses small details that make big differences, noted Dr. Darling, citing examples such as when a pharmacist learned that a child was more likely to take a crucial medication when it was mixed with applesauce, or that a drug prescribed for nighttime dosing caused fewer side effects if it was taken in the afternoon.

Such knowledge can be gleaned only by direct interaction with patients and families, according to Dr. Morse.

“ED pharmacists also play an important role in ensuring that the right medication gets to the right patient at the right time,” said Vicki Basalyga, Pharm.D., BCPS, director of ASHP’s Section of Clinical Specialists & Scientists.

ED pharmacists can ensure that important medications such as first-dose antimicrobials in septic-appearing patients are available, dosed, and administered correctly, she said. When speaking with patients, a pharmacist obtaining  a medication history can identify time-sensitive medications such as anti-epileptics and avoid potential adverse events if a dose is missed, Dr. Basalyga added.

And the benefits to the patient and fellow healthcare providers don’t stop there, according to Dr. Morse, adding that oral-to-intravenous dose conversions calculated by pharmacists are invaluable, time-saving measures for medical residents. ER pharmacists at Children’s train with respiratory therapists and conduct pre- and post-respiratory therapy assessments as well as review all positive bacterial cultures that originate in the ER and recommend suitable antibiotic treatment.

“Someone with this kind of expertise makes my life a lot easier by recommending the appropriate antibiotics,” said Dr. Morse.

The benefits of having pharmacists in the ER or ED can be as individual as the care setting and as dynamic as the healthcare problem that a patient is presenting. For example, Dr. Meehan at the University of Illinois Hospital in Chicago values many of the contributions of his ER pharmacist, including:

 

  • Quickly performing accurate dose calculations and expediting delivery of essential drugs from the central pharmacy during the treatment of stroke or cardiac arrest patients who may need thrombolytic therapy,
  • The ability to prepare medication doses quickly and accurately during code situations, and
  • The fact that for  polypharmacy patients, pharmacists are naturally on heightened alert for the threat of dangerous drug interactions as well as complementary drug combinations. “Those considerations aren’t at the forefront for physicians, but pharmacists are intimately aware of them and able to intervene when necessary,” said Dr. Meehan.

The expansion of ED and ER pharmacy services is just beginning, added Dr. Musselman: “It’s becoming a necessity, and we’ll see the trend accelerate. Accrediting bodies will start asking why a hospital doesn’t have ER pharmacists rather than why they do.”

–By Steve Frandzel

July 22, 2014

ASHP Members Offer Special Expertise to Med-Use Panels

ASHP members are contributing pharmacists's point of view to a number of national healthcare quality efforts.

ASHP members are contributing pharmacists’s point of view to a number of national healthcare quality efforts.

MEASURING, MONITORING, AND IMPROVING PATIENT CARE is becoming increasingly important in today’s healthcare environment, and the opportunity for pharmacists to influence the quality measures that are used has never been greater.

Multi-stakeholder groups such as the National Quality Forum (NQF) are a vital part of this process, endorsing standards for performance measurement and validating quality measurements used in federal payment programs. Through ASHP’s Quality Advocates, pharmacist participation in these groups is helping to shape the reimbursement landscape and improve patient care.

“Our members help build consensus in the rigorous environment of the steering committees,” said Shekhar Mehta, Pharm.D., M.S., ASHP’s director of clinical guidelines and quality improvement. “They assess the feasibility, reliability, validity, and scientific acceptability of proposed measures, and other committee members value pharmacists’ ideas on how a given measure could be implemented in real practice.”

Immediate Impact

It didn’t take long for Starlin Haydon-Greatting, M.S., B.S.Pharm., FAPhA, clinical pharmacist consultant at SHG Clinical Consulting and the IPhA’s Patient Self-Management Program in Springfield, Ill., to have an impact on NQF’s endorsement process. She began her two-year term on the Endocrine Steering Committee in January, and she has already provided influential feedback on several measures that address drug adherence. Haydon-Greatting partnered with another committee member, a researcher for a pharmaceutical company, to explain ways of calculating adherence to other committee members.

Starlin Haydon-Greatting, M.S., B.S.Pharm., FAPhA, is working on drug adherence measures as part of the NQF’s Endocrine Steering Committee.

“Clinicians such as nurse practitioners want to know how they can ensure that patients are adhering to the prescriptions they write. They generally don’t know if the patient has been taking medications until the next visit, so they want to know how to create [patient] accountability,” Haydon-Greatting said.

“I made the point that pharmacists can see if patients are filling their prescriptions, and that pharmacists can take the lead on tracking that kind of data.”

Haydon-Greatting drew upon her work as pharmacy network coordinator for Taking Control of Your Health, an offshoot of the Diabetes 10-City Challenge in which pharmacists lead treatment programs for employees with diabetes.

“We have electronic medical records and web-based programs, and I was able to speak from experience and say that once you have those, the data is already there.”

She added that her input has not only been well-received, but actively solicited by other members of the group. “There are over 20 physicians on this committee, and once they found out I was the only pharmacist, every time a question came up about medication use or adherence, all heads turned to me.”

Winning Recognition

Haydon-Greatting’s experience may be testimony to how far pharmacists have come in the eyes of other clinicians. Five years ago, Steven M. Riddle, Pharm.D., BCPS, FASHP, director of clinical development for Pharmacy OneSource/Wolters Kluwer Health in Seattle, had to prove his mettle on the NQF’s Ambulatory Care Steering Committee.

Steven M. Riddle, Pharm.D., BCPS, FASHP

Steven M. Riddle, Pharm.D., BCPS, FASHP

“I was on a panel with some well-known people in positions of authority [in their fields], national leaders who were not easy-going, subtle folks. There I was, [then] just a pharmacist from the University of Washington to them, and they challenged me. I had to earn a little credibility,” Riddle said.

He earned their respect by applying his background and training as a pharmacist to the four key criteria the committee used in deciding whether to endorse a measure—its importance, scientific acceptability, usability, and feasibility.

“Pharmacists are trained in evidence-based medicine, understanding the trials, and determining whether the clinical and technical evidence is valid. That’s part of what [NQF Committees] must look at when evaluating a measure,” said Riddle, who served until recently the chair for ASHP’s Section of Ambulatory Care Practitioners. “There were times when I swayed opinion by going back to the four criteria, but it was tricky to negotiate. For example, something could be highly valuable but completely unfeasible.”

As with Haydon-Greatting, once Riddle demonstrated his knowledge, the other committee members were quick to tap him for input. “I was able to hold my own and bring forward my concerns. Then when they had questions about medication use, they would ask me, ‘Well, what do you think, Steve?’ ”

Looking to the Future

Pharmacists have their work cut out for them on these committees, said Jannet Carmichael, Pharm.D., FCCP, FAPhA, BCPS, VISN 21 Pharmacy Executive at the Department of Veterans Affairs in Reno, Nev. She encourages young pharmacists to look into systems development and healthcare analytics, noting how her experience with the VA’s clinical data warehouse proved invaluable when she served on the NQF’s Medication Management Steering Committee in 2009.

Jannet Carmichael, Pharm.D., FCCP, FAPhA, BCPS

Jannet Carmichael, Pharm.D., FCCP, FAPhA, BCPS

“The VA is a data utopia. Knowing that I came from an environment with a mature electronic medical record system, the committee members were willing to give me a bit of a bye in presenting my views on evaluating and collecting health data,” she said.

“As electronic medical records become the norm, and the business of metrics and quality measurements becomes more important, the ability to load data sets and analyze the information will become essential.”

Recognizing the need for pharmacist representation in groups like the NQF, ASHP is bolstering efforts for more participation among its membership.

“We’ve been trying to bring more pharmacists into the various committees,” said Christopher J. Topoleski, ASHP’s director of federal regulatory affairs. “Younger pharmacists are more and more interested in informatics. They’re a tech-savvy generation, and as they get experience in using data in the implementation of quality improvement measures, we’ll have a larger crop of people to choose from.”

–By Terri D’Arrigo

Editor’s note: The above story is the second part of a two-part series on how ASHP members are influencing and steering national quality measures. Click here to read the first story.

June 9, 2014

ASHP Quality Advocates Influencing National Quality Measures

Close to 40 percent of clinical quality measures are related either directly or indirectly to medication use.

IN THE POST-AFFORDABLE CARE ACT (ACA) era, quality in healthcare is one of the most important concepts in patient care. To promote accountability and evidence-based care, the ACA allows multi-stakeholder groups to provide input to the Department of Health and Human Services on selecting quality and efficiency measures.

As part of ASHP’s Pharmacist Accountability Measures, a group of ASHP members known as Quality Advocates have become integral parts of these groups. The advocates serve on various committees, work with administrators and clinicians from other health professions to build consensus, and use their knowledge and training to provide the pharmacist’s point of view on quality measurements that will affect patient care.

“Close to 40 percent of clinical quality measures are related either directly or indirectly to medication use. Pharmacists have the background to assess the scientific reliability and applicability of these quality measures, and are well-suited for offering ideas on how a proposed measure would be implemented in real practice,” said Shekhar Mehta, Pharm.D., M.S., ASHP’s director of clinical guidelines and quality improvement.

One of the ways that ASHP promotes quality healthcare measures is by being a member of the Pharmacy Quality Alliance (PQA), an organization that promotes appropriate medication use and measures and reports performance related to medications.

“We have at least one member in each of seven workgroups and a few on special task forces,” said Mehta. “The director approaches us specifically if there is a gap in clinician involvement because the PQA recognizes the insights that only frontline pharmacists can provide.

“That is one example of why it’s so important to have an organization with ASHP’s resources, experience, and historical perspective invited to the table,” he added. “We’re fortunate to have so many members involved in driving quality improvement.”

The National Quality Forum

ASHP was one of the founding members of the National Quality Forum (NQF), a nonprofit consensus development organization that endorses quality measures and provides recommendations for programs. Much of this work is done through various workgroups and committees on which several ASHP members serve.

Joel C. Marrs, Pharm.D., FNLA, BCPS, BCACP, CLS

“ASHP is very proactive in promoting involvement in these committees,” said Joel C. Marrs, Pharm.D., FNLA, BCPS, BCACP, CLS, assistant professor at the University of Colorado’s Skaggs School of Pharmacy in Denver. Marrs serves on the NQF’s Cardiovascular Steering Committee. “I’m not aware of other organizations that promote membership involvement and encourage their members to apply and serve in these roles like ASHP does.”

ASHP helps to identify pharmacists with specialized experience in particular practice areas and who have experience with quality improvement. Practitioners who are interested in participating in an NQF committee must undergo a rigorous application process to ensure no conflicts of interest. Once on a committee, participants review proposed measures and provide insight based on their practice areas.

“The caveat is that you’re not representing ASHP, yourself, or your employer. You’re acting as an expert in your field,” Marrs said. “But ASHP does a good job of identifying members who would do well on these committees and who will support pharmacy in general.”

Participating in an NQF committee requires time and dedication, said Keith M. Olsen, Pharm.D., FCCP, FCCM, professor and chair in the Department of Pharmacy Practice at the University of Nebraska College of Pharmacy in Omaha. Olsen served on the NQF Surgery Steering Committee.

“We have weekly teleconferences to discuss the measures, and it takes time to prepare for them,” Olsen said. “You have to read the measures and study the literature as well as the format you have to use to do the evaluations. It’s a commitment, not something you should take lightly. Know what you are getting into.”

Pharmacists Excel at Identifying Quality Measures

Olsen said that pharmacists, in particular, often excel at prepping for the evaluations. “It goes along with our training in learning how to read the literature, perhaps more than in other professions,” he said. “We are trained to look for high-quality evidence and good methodologies.”

Curtis D. Collins, Pharm.D., M.S., BCPS AQ-ID, FASHP

That ability to recognize whether a measure is supported by evidence served Curtis D. Collins, Pharm.D., M.S., BCPS AQ-ID, FASHP, clinical pharmacy specialist in infectious diseases at St. Joseph Mercy Health System, in Ann Arbor, Mich., well in his work on the NQF’s Infectious Disease Endorsement Maintenance in 2012.

“Each of us would give preliminary recommendations on six or seven measures, and there were important criteria to measure,” he said. “We needed to ask ourselves if the measures had the potential to drive improvements. If so, what is the scientific acceptability of the measures? Could we make valid conclusions about what we were collecting? Was it usable? Feasible?”

The answer was not always “yes,” according to Collins. “There were a few measures that were very ingrained in healthcare that I initially thought would pass, but once we looked at the actual evidence, it required re-review.”

CMS Technical Expert Panels

Karen B. Farris, Ph.D., the Charles R. Walgreen III professor in pharmacy administration at the University of Michigan College of Pharmacy, Ann Arbor, has worked with two technical expert panels funded by the Centers for Medicare & Medicaid Services (CMS)—one on MTM and one on care transitions.

Her current TEP work focuses on hospital outcomes measures for care transitions for patients hospitalized with acute myocardial infarction, heart failure, and pneumonia. Farris, who also had previous experience on NQF committees and was recommended by ASHP to serve on the TEP for care transitions lead by the Yale Center for Outcomes Research & Evaluation, now sees the process from the payer’s side.

Pharmacists' involvement on national quality groups is key to better medication-use policies.

Pharmacists’ involvement on national quality groups is key to better medication-use policies.

“We all recognize that there are pros and cons to any proposed measure or change, but it’s not a closed process at all,” she said. “We need insights from clinicians, administrators, and researchers who think about these measures and whose practices these measures will affect before the measures are opened for public comment and ultimately approved for use.”

Farris stressed the importance of pharmacists having a voice.

“Pharmacy professional organizations like ASHP must be at the table during discussions of quality indicators because all of our institutions will be affected by them,” she said.

“Even on the primary care side, we have pharmacists involved in improving care in physicians’ offices and across the range of care that ASHP represents.”

Farris believes that pharmacist involvement is crucial for her TEP in particular. “We need to ensure that pharmacists are involved because care transitions can be affected by medications. We need to ensure that the right care team is involved in transfers, and pharmacists are a key part of that team.”

Getting Involved

Mehta noted that ASHP is always seeking the involvement of members who have experience with quality improvement and performance measures for participation in these groups.

“This an optimal time to get involved because we are seeing healthcare realize the benefits of integrated  team-based care  that includes pharmacists,” he said. “As medication-use experts, pharmacists’ involvement in measurement development or quality improvement is a critical component of advancing healthcare quality and patient care.”

Although competition is stiff for NQF, CMS-TEP, and PQA participation, and most who are appointed to committee positions are at least mid-level in their careers, there are ways that young pharmacists can get involved, according to Collins.

“This is something you can work on locally and even at the level of your own health system or hospital,” he said. “Some of the measures that [NQF and others] consider were conceived by people who initially tried to improve the care of patients within their own departments or care settings.”

Interested in serving on a quality measurement group? Email smehta@ashp.org or quality@ashp.org.

–By Terri D’Arrigo

Editor’s note: The above story is the first of a two-part series on how ASHP members are influencing and steering national quality measures. Click here to read the second story.

June 3, 2014

The Constant in the Patient Care Equation

Christene M. Jolowsky,
M.S., R.Ph., FASHP

Editor’s Note: The following inaugural address was given by new ASHP President Christene M. Jolowsky, M.S., R.Ph., FASHP, at ASHP’s Summer Meetings in Las Vegas, June 3, 2014. Jolowsky is Executive Director for Applied and Experiential Education and assistant professor at the University of Minnesota, College of Pharmacy in Minneapolis. Her full address will appear in the August 15 issue of the American Journal of Health-System Pharmacy

I AM EXCITED TO BE HERE TODAY and for the opportunity to serve as ASHP’s President.

We all know that journeys like this are not made alone. So, at the very outset, I would like to thank my peers, mentors, work colleagues, my family, and my pharmacy friends for being there with me and for me. You know you all mean a lot to me.

And a special shout out to the ASHP staff, whom I have gotten to know well these past years.

I have a few specific people to mention, and I am so thrilled that they are able to be here today.

My three sisters… Terry with her husband, Ken; Ellie with her husband, Scott, and their son, Ben; and Julie who is here with her husband, Marty, and their daughters, Sandy and Sam. Although my older brother Steve couldn’t be here today, I know that he supports me fully.

Also here today are my in-laws Eileen and Allen Jolowsky, and my husband’s sister, Jeri and her husband Lloyd, and their children Brianna and Jared; and my cousin, Jackie!

My parents are gone, but I know they are here in spirit. They were always very proud of me and my brother and sisters and our accomplishments, and today is no exception.

Last, but obviously not least, I want to thank my husband, Mike, and my lovely daughters, Claire and Nora, who mean so much to me. You are my joy, my rock, and my sanity when things get hectic.

The Cheshire Cat

Today represents the chance to share my point of view and philosophy, and to let you know a little about who I am and to promote ASHP. In preparing, I turned to the wisdom of a favorite author from childhood, Lewis Carroll, who wrote one of my favorite books, Alice in Wonderland.

Carroll’s writings are known to be a little quirky but also thought-provoking. I’d like to share this conversation between Alice and The Cheshire Cat that I think is quite instructive for us, as pharmacists today:

Alice: “Would you tell me, please, which way I ought to go from here?”
The Cheshire Cat: “That depends a good deal on where you want to get to.”
Alice: “I don’t much care where.”
The Cheshire Cat: “Then it doesn’t much matter which way you go.”

This brings me to THE question for us to think about today: Where are we going, as pharmacists, as a profession? This question is followed by: How should we get there? And who do we need with us along the way?

Where Are We Going?

Unlike Alice, we care very much about where we’re going.

My destination—and from talking to my colleagues, I understand it’s your destination, too—is recognition for the value and the work we do as pharmacists…. recognition through provider status, to validate pharmacists as full members of the patient care team.

So, if “provider status” is the where, how will we get there?

We can best build a road map by paying close attention to the landmarks we need to hit along the way. What are the basic requirements for patient care? What are the practice models and patient care marks we need to pay attention to?

Of course, if we just want to get “somewhere” near provider status, then we can afford to wander around a bit.  But that’s not our goal. “Somewhere near” isn’t close enough for us or for our patients.

Solving for “X” 

We have a very clear destination in mind: a place of better patient care and more recognition for the value we bring as medication experts. Which means we must be very deliberate and strategic about the steps we take to get there. Advocacy will be a key part of our success, and ASHP plays a crucial role in this.

The Society is helping to create a roadmap that we can all navigate together. Even if we are traveling at different speeds, we must all be heading in the same direction.

To do this, ASHP is guided by the expanding practice in ambulatory care, identifying new practice models, and creating tools to get us there. But first, let me give you a little background about where I’m coming from.

I mentioned earlier that my parents are no longer with us. But as with all parents, they shaped who I am. And their guidance helped to shape the pharmacist I’ve become.

There are three main values that my parents instilled in me and my siblings:

First was the importance of getting involved and helping others. These were not just words to them. They really lived it. Both of my parents were active in the community. My father gravitated to leadership positions, especially within the American Legion. My mother didn’t want her name in lights, but she rolled up her sleeves and helped wherever it was needed. Her mantra was,”You’re here, make yourself useful.” My brother and sisters and I learned the importance of leadership and service as well as the value of participation and teamwork.

Second, my parents shared their true passion for getting involved and the important role that passion plays in our work. If we are passionate about something, we will be motivated to get involved and stay involved. And, lastly, they always stressed the importance of education. All of us kids knew we were going to college—it was not even an option! This instilled in us the passion for life-long learning and growth.

Which is why I always made sure I was available to help my girls with their homework (whether they liked it or not!). And math was where I could help them the most. But this presented some challenges because math when my kids were little was taught differently than how I learned it! Yet the math problems are still the same even if we approach it in different ways, right?

We had to get on the same page if I was going to help them understand these complex math problems without too much frustration.

For me, math could always be distilled to small, simple equations. In each equation, there is always some “constant,” some “variable,” and some element that is missing. And we are all familiar with “solving for x.”

I was thinking about the different approaches to math problems, and I started to look at my professional life through this same prism. My first thought was to “solve for what’s missing.”

“Solve for x.” What does that mean for pharmacy practice? Well, during a recent intraprofessional meeting, we discussed who the members of the healthcare team are and their roles. I looked at the participants and started wondering who was missing. Who else should have been there? Who NEEDS to be present to learn from what we are doing? And how do we bring our value, as pharmacists, to those people who were not in the room?

The same could be asked from an organizational perspective for ASHP. As we continue to advance practice across the continuum, who needs to be at the table? Are we fully engaging our members? Potential members? Students? Pharmacy technicians? And other stakeholders?

What else do we need to do to make sure we are connected with each other within ASHP, as well as with external stakeholders, to be most successful in moving practice forward?

In my work at the college, I talk to students all the time. They often ask me about how I got involved with ASHP. I share the decisions I made as my career developed to follow my passion for advancing practice.

I stress the value of networking with peers and potential mentors. And I emphasize the importance of tapping into the knowledge and expertise of those around you. These are all values that lead us where we want to be.

Which brings us back to Alice in Wonderland: If you don’t know your destination, “Then it doesn’t matter which way you go.” It is the involvement, the sharing, and the passion that helped define that destination for me.

New Pharmacy Equation

So all this thinking about life in the context of math problems brings me to this new equation: Pharmacist involvement in “X” times passion = Better patient care and more recognition of pharmacists’ value.

In solving this equation, we are faced with many variables:

  • ­   Grassroots advocacy efforts,
  • ­   Support from decision makers,
  • ­   Recognition from payers,
  • ­   The need for quality improvement, and
  • ­   The need to follow patients along the ENTIRE continuum.

There are also several constants in our equation, including the strength of our practitioners, including new and future pharmacists, and advanced clinical practices.

What other information is missing, in order to solve the equation?

  • ­   Recognition as providers?
  • ­   A common understanding of the value of pharmacists?
  • ­   The need to continue to advance our knowledge and training?

All of these variables, once figured out, multiplied by passion make this equation solvable!

Pharmacists as the “Constant”

Let’s take this to another level. I believe that pharmacists are the “constant” in the patient-care equation. We are present in every care transition and practice setting.

Not too long ago, pharmacists’ approach to care was focused on the patients when they were in front of us. But that didn’t take into account what was going on in the whole life of our patients. Often, we didn’t have that information.

Our patients are no longer “snapshots in time” as they come in and out of our care.

But today, our focus is on the whole patient and their entire life, along the full continuum. This is going to shift our mindset regarding patient care. Our patients are no longer “snapshots in time” as they come in and out of our care. We were accustomed to handing our patients off to other healthcare settings. But increasingly, we are in those other settings. We need a consistent patient care delivery model that includes discharge planning and follow-up care for patients… a model that extends from the hospital to long-term care to ambulatory clinics and back, as necessary.

And what are we doing at ASHP to support this? ASHP is focused on achieving provider status, working at the state level to expand our scopes of practice, and growing its tools and resources to help us be better practitioners.

Now, some of these settings may represent environments that we are not familiar with. Yet this is exactly where our value is amplified by working with other members of the healthcare team.

Pharmacists as the constant in solving patient care problems provided me with a new way of thinking about my own career. I served in leadership positions in health-system pharmacies for more than 25 years. Early in my career, I knew that I wanted to be in a position that would create change. And it was clear that leadership roles would provide me with that opportunity.

One of the things I especially enjoy is organizational management—figuring out what works to improve patient care and safety and what doesn’t, whether it has to do with education, engineering, or technology.

How does my career path, which took me in a direction I did not originally foresee, reconcile with my imperative today that we must keep our destination in mind? It demonstrates that we must be open to adjusting the path to get to our destination.

At my college, I find that students are certainly focused on their destination—graduating, residencies, finding their first jobs, and making themselves marketable—all of which is understandable.

Yet in their rotations and into their residencies, I encourage these students and new practitioners to focus on the skills they are learning which will serve them well into the future. That’s why I am very passionate about promoting residency training because it provides a positive and supportive environment that fosters the critical thinking and decision making skills that are needed in pharmacists today.

Likewise, ASHP is working hard to expand residencies and support board certification, understanding that these skill sets will help students stand out in their future careers, and provide a framework for employers to see what is special about them as individual practitioners.

Solving the Problem

So, let’s go back to the time I sat at the table helping my daughters Claire and Nora with their math homework. When we want to solve our professional pharmacy problems, we need to ask the same questions that I asked my daughters:

  • ­What is the value that we are given?
  • ­What is the known entity or constant in the equation?
  • ­And what (or who) is the missing element in the equation?

To solve the problem, I hope I have you thinking about the value of the role of pharmacists. We have to establish ourselves as the constant in the equation. That means we must have a handle on some big concepts, such as:

  • ­What are the needs of the patient?
  • ­Where is the pharmacist?
  • ­What are the gaps in our care delivery system?

This equation analogy continues with finding the missing element. What, or in our case, who, is missing from the equation?

Ask this question as you participate in the meetings here this week. We have the Medication Safety Collaborative, the Informatics Institute, and the Pharmacy Practice and Policy meetings.

Look around while you are in these meetings and ask yourself, how can we reach out to people who are unable to attend and connect them with the rich content of the meeting?

There are people who need to be here so that they can benefit from the great information and networking that are available. Are we doing all we can to bring them into the equation?

Specifically, where are the students, residents, preceptors, fellow colleagues (maybe in different practice settings), staff pharmacists, and technicians? There is value here for them all:

  • ­Value in participating, or even simply observing, our policy process through the House of Delegates,
  • ­Value in hearing the inspirational words from our Whitney award recipient and ASHP Past-President John Murphy,
  • ­Value in the education that’s offered here this week,
  • And, of course, value in the unique networking opportunities.

And you can ask these same questions about ASHP. How do we involve more pharmacists as members? How do we involve more ASHP members in the organization’s activities and initiatives so that they get the full value of belonging to ASHP? You truly only get out of membership what you put into it. We need to encourage more members to be fully engaged so that they get the most value from their membership.

And let’s keep going with this part of the equation. Who is missing from our practice experiences? Are all of the stakeholders accounted for? What about the patients and their caregivers? Are we including them in the decision-making about their own care?

What about our own administrators, and regulators, and legislators—both local and national—who hold so much sway over what we can do and how we do it? We need to make sure that all missing elements are solved and in place. That way, we’ll be able to work together to achieve the best outcomes for our patients.

Clearly, this is a complex, seemingly endless equation that few have actually solved. We are still working on it! It is critical that we do NOT give up on this one.

As we make important decisions about policies, therapies, and what the future of pharmacy should be like, we must ask ourselves: Are we fulfilling our role as the constant in the patient-care equation?

When decisions are being made about medication use in our practice settings, are we present, visible, and easily available wherever the patient is? In today’s healthcare environment, we need to focus on the patient’s care across the entire spectrum. The days of treating a patient for a few days in the hospital and waving goodbye with best wishes as they leave clutching their prescriptions are over.

Equivalent Equation

All of this brings me to another equation I want to share with you today. It’s an equivalent equation: The Future of ASHP = the Future of Practice.

As I start my presidential year, I am absolutely thrilled with the direction of ASHP. There is so much to be excited about:

  • Our new mission, vision, and strategic plan, which focuses on all patients and all aspects of care.
  • ­ The Pharmacy Practice Model Initiative, including its recent work in the ambulatory care arena.
  • Our efforts to achieve provider status.
  • Our new brand and logo, which represents us as a contemporary, strong, forward-thinking organization.
  • Our growth in members, which means that more and more practitioners are finding the value of being part of ASHP.
  • Our work to help members manage critical practice issues like drug shortages and compounding.
  • The tools and resources ASHP creates to help us in our daily practice.
  • And ASHP’s work to partner with others to further our influence on public health policy and advance your role as healthcare providers.

Where Are You in the Pharmacy Equation?

So, let’s go back to my first pharmacy equation. First, I want you to ask yourself: How do I fit into the equation?

Are you the constant of the patient-care equation in your work site? And what about your professional associations? Are you fully engaged at the state and national level? There are so many ways to get involved to advocate for your patients, advocate for change, and improve your patient care setting.

One great way to do that is to make your presence known on ASHP Connect, the organization’s social network, where you can contribute to profession-wide discussions about critical practice issues. Always ask yourself, “How can I share my knowledge, experience, and wisdom with others to improve their patient-care practices?”

Next, make sure you know where you are going! Find your path, and adjust it as needed. When I started my career, I didn’t set out to lead key professional initiatives, or to be a director of pharmacy, OR president of ASHP. I did, however, set out to do something I was passionate about. I wanted to make an impact.

When I started my remarks today, I talked about Alice in Wonderland and the idea that if you don’t have a destination, you’ll certainly wind up SOMEWHERE, but maybe not where you’d LIKE to be.

Well, I can assure you that as a profession, we know who we are and where we are going! We are the members of the healthcare team who need to be part of every decision regarding medication use.

And as an organization, ASHP also knows who it is and where it is going, leading the way on PPMI; provider status; our vision, mission and strategic plan; and our focus on the entire continuum of care (including ambulatory practice).

We are moving hand-in-hand with you toward providing the best care for our patients and ensuring that pharmacists are recognized as the constant.

So, let me end with one more equation to solve, with pharmacists as the constant:

   Pharmacists

+ Residents

+ Students

+ Technicians

+ The healthcare team

+ Patients

= Best Patient Care

Today, I’ve asked a lot of questions. And I have just two more.

In looking at this, where are you in this equation? Are you the constant in your practice setting? It’s time to take our place as the constant in patient care!

Let me know what you are doing to improve patient care in your organization. Be sure to email me at prez@ashp.org.

Thank you for all that you do to keep pharmacists as the constant in the patient-care equation!

June 2, 2014

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