View on technology-enabled practice from ASHP

The September issue of the American Journal of Health-System Pharmacy contains a vision statement written by the ASHP Section of Pharmacy Informatics and Technology. The statement represents their thoughts on the current state of pharmacy practice and contains a healthy dose of ideas on how technology can help support and improve pharmacy practice.

The opening paragraph pretty much sums up the current state of pharmacy: ”Pharmacy practice, especially practice within the acute care setting, is largely unchanged from what it was 30 years ago. While it can be asserted that new drugs have entered the market, more pharmacists spend some or all of their time in clinical practice, and, to some degree, new technologies have become available, too many pharmacists continue to practice in the acute care settings that provide roughly the same services, using the same practice model now, that they did in 1976.” The article goes on to say that pharmacy is using “an obsolete practice model”. I happen to agree with this assessment. I have a unique job now, but spent over ten years in the trenches. Although my experiences from hospital to hospital varied slightly, the basic pattern looks something like this:

  • A physician, or other provider, sees the patient (sometimes) and writes an order.
  • The order is sent to pharmacy via fax, runner, digital scan, etc.
  • The pharmacist reviews and enters the order [into the pharmacy system]. Sometimes the order entry is done by a technician and verified by a pharmacist. During the order entry process the pharmacist reviews the order for problems; allergy, appropriateness of drug, dose, route, frequency, etc.
  • Problem orders general result in a call to the nurse. If the nurse can’t clear it up, a call is placed to the physician. In more severe cases, the nurse is bypassed and the call is placed directly to the prescriber.
  • Orders without problems are either dispensed directly from the pharmacy or available from automated dispensing cabinets on the nursing unit.
  • Overall the system outlined above is not very proactive. Sure, some pharmacists provide “clinical” services but are typically tied to overseeing drug distribution in one form or another. There are hospitals that don’t fit this model, but they are exceptions not the rule.

    The alternative model proposed by ASHP makes a lot of sense. They call for pharmacists to be involved in rational formulary management and drug use, prospective involvement in the design of medication therapy for each and every patient, continuous management of each patient’s medication therapy, and assessment and management of the quality of the overall medication-use system. I spent four years in pharmacy school getting an education that was designed to provide safe, effective and economically sound drug therapy for patients; basically what ASHP is calling for. Unfortunately, the dichotomy between the proposed model and the current practice model is staggering. ASHP recognizes this by stating that “such a model demands changes to both the assignment of tasks and the infrastructure in which those tasks are performed, within which is the information technology structure that supports such roles.”

    The technology mentioned in the article includes many familiar ideas such as access to electronic patient health records, provider order entry, and automation. A couple of technologies mentioned that I found especially interesting were clinical decision support and automated medication identification.

    Clinical decision support that can utilize logic to bypass the pharmacist is something I’ve thought about before. This may sound a little scary the first time you hear it, but shouldn’t frighten you once you’ve given it a little thought. Do you really need a pharmacist to review and verify an order for docusate sodium 100mg orally twice a day in a 30 year old woman with no comorbidities admitted to the hospital to delivery a baby? The obvious answer is “no”. You have a healthy adult female with no allergy to the medication and no condition that would prevent her from receiving such a benign drug. This order is very common in hospitalized patients. Decision support software could quickly and efficiently scan this order from a CPOE entry and automatically activate it on the patient profile. There are hundreds of orders like this every day in a hospital environment requiring unnecessary pharmacist review. Utilization of smart technology like that mentioned above could save countless hours and get the pharmacist out of the physical pharmacy and up on the nursing units where they belong.

    Automated medication identification and dispensing isn’t a novel idea, but one that I think is worth exploration. I’ve mentioned before an idea to recognize tablets without a pharmacist’s eyes on the product. In addition, the increased use of bar coding and RFID makes this more of a reality than ever before. When used appropriately, bar coding and RFID technology can provide safe and effective dispensing without the need for a pharmacist’s direct oversight. In addition, these same technologies can be used to track medications throughout the facility; just one more benefit. As an example, take a look at some of the technologies being used in long term care to provide remote dispensing without the necessity for a pharmacist on site.

    I agree with much of what the ASHP statement had to say, but am painfully aware of the barriers to implementing the alternative model they describe. Some of the more obvious barriers mentioned in the article include regulatory issues, economic realities and pharmacist’s lack of training in many of the advanced roles. In addition I believe that pharmacists are often reluctant to embrace technologies that will benefit them in their practice setting. I frequently see this in the role I play now. It’s hard to say if the reluctance is from general lack of interest or fear, but it is a definite hurdle to implementing many of these systems.

    Turning these ideas into reality will be challenging. As a group, pharmacy has been unable to make significant changes to their practice setting for more then 30 years. I have no idea why, but it is a serious problem. Without forceful leadership pharmacy will be using the same practice model for another 30 years and nobody wants that.

    Technology-enabled practice: A vision statement by the ASHP Section of Pharmacy Informatics and Technology Am J Health Syst Pharm 2009 66: 1573-1577

    3 thoughts on “View on technology-enabled practice from ASHP”

    1. Jerry,

      I VERY much agree with you here. Paragraph three rings so true. I, as you, am in a different practice environment now, but my 15 years in clinical care felt very much like this.

      The practice model makes all the difference. I hope you had a chance to watch the webinar Pharmacy OneSource put on yesterday. (If you missed it, you can find links to a recorded version at as well as slides) Steve Pickette, Systems Clinical Manager for Providence outlined how he has implemented a standard clinical practice model in 27 hospital on the west coast. It is a practice model that ensures pharmacists are fully engaged in clinical activities. Bottom line: in the early sites where the practice model has been fully integrated they have witnessed reductions in overall drug budget expenses – without exception. This in the face of overall inflation in drug costs around the country.

      Pharmacy is unique in that the more focus and human resource time put into clinical work, the more lives and dollars are saved. Clinical Decision Support tools facilitate this by taking the routine “If on Drug A and Lab value Y is greater than X, intervene” analysis and streamlining it. Leaves the human brain open to do the more complex clinical work it was designed to do.

      Kudos on a great article.


    2. Charles,

      I haven’t had a chance to watch the webinar your mentioned, but I will definitely take a look at it tonight.

      The longer I work in hospital pharmacy, the more surprised I am that more directors chose not to engage pharmacists at the highest clinical level. It’s a real problem. You analysis about pharmacists clinical work equating to saved lives and money is right on. The only problem is convincing high level executives that the numbers are accurate. We need groups like ASHP, ACCP, etc. to push, and I mean hard. It certainly won’t be easy to change the culture in which pharmacy is viewed.

      Thanks for stopping by and for the information.


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