Jerry Fahrni

Category: Pharmacy Practice

  • Who should drive the selection of pharmacy automation and technology?

    Who should be the driving force behind the selection of new automation and technology in a hospital pharmacy? It’s a simple question really, and in my mind there’s only one clear answer: pharmacy should drive the selection of their own automation and technology. That makes sense, right? Well it certainly does to me.

    However, lately I’ve seen a disturbing trend when talking with hospital pharmacies about their selection process. It appears that the IT department – you know, those guys that configure computers and keep your network and hospital servers humming along – has been given a lot of authority in the selection process. Call me crazy, but that seems a little strange to me.

    I’ve always thought of IT as a service department, someone to help you accomplish your goal when it involves technology. As an IT pharmacist it was my job to look at pharmacy automation and technology, evaluate it, weigh the pros and cons, and make a decision based on what was best for the goals of the pharmacy. Once that was done I would get IT involved in the process to make sure we had everything we needed from not only the vendor, but our own hospital IT department as well. If there were gaps we would work together to flesh them out.

    What happens if the IT department is given the leeway to make a decision for the pharmacy on which automation and/or technology they should use? They might make the “right decision”, but if they did it would be the result of sheer dumb luck. The selection process should be one that looks to find the best fit for the pharmacy, one that fits into the pharmacy’s distribution model, one that lines up with existing technology, one that takes future pharmacy plans into consideration, one that will help drive pharmacists out of the pharmacy toward more clinical activities,  one that acknowledges the strengths and weaknesses of the vendor in terms of functionality, usability and support,  and so on. The decision should not be based on who uses the best security protocol, or who prefers Dell Servers over HP Severs, or whether or not the vendor needs network access for support or not, and so on and so forth.

    I truly feel sorry for healthcare systems that ignore their pharmacy personnel when thinking about purchasing new automation and technology for pharmacy operations. In my opinion it’s a recipe for disaster. I certainly wouldn’t want to work in a pharmacy where the tools I used were selected by someone who didn’t even know what I was working on. The next time you have the oil changed in your car, ask the mechanic if he would let the person that installed their computers pick out his tools. I bet you’ll get a similar response to mine, although the language may be a bit more colorful. Better yet, ask a software engineer if he’d let a pharmacist pick out the hardware and software necessary to do his job. It’s a safe bet that he’d look at you like you’d lost your mind.

  • Adding Pharmacists to Primary Care Teams Increases Guideline-Concordant Antiplatelet Use in Patients with Type 2 Diabetes [article]

    Here’s an interesting little tid-bit in the January issue of The Annals of Pharmacotherapy. According to the article “adding pharmacists to primary care teams significantly and substantially increased the proportion of type 2 diabetic patients using guideline-concordant antiplatelet therapy“. Good stuff to be sure. Unfortunately the study only looked at the proportion of patients using antiplatelet therapy at 1-year after engaging the pharmacist. It would be interesting to see data around decreased morbidity, hospital readmission rates, etc to go along with the improved guideline-concordance.

    Abstract

    BACKGROUND: Antiplatelet therapy is recommended as part of a strategy to reduce the risk of cardiovascular events in patients with type 2 diabetes. However, compliance with these guideline-recommended therapies appears to be less than ideal.

    OBJECTIVE: To assess the effect of adding pharmacists to primary care teams on initiation of guideline-concordant antiplatelet therapy in type 2 diabetic patients.

    METHODS: Prespecified secondary analysis of randomized trial data. In the main study, the pharmacist intervention included a complete medication history, limited physical examination, provision of guideline-concordant recommendations to the physician to optimize drug therapy, and 1-year follow-up. Controls received usual care without pharmacist interactions. Patients with an indication for antiplatelet therapy, but not using an antiplatelet drug at randomization were included in this substudy. The primary outcome was the proportion of patients using an antiplatelet drug at 1 year.

    RESULTS: At randomization, 257 of 260 study patients had guideline-concordant indications for antiplatelet therapy, but less than half (121; 47%) were using an antiplatelet drug. Overall, 136 patients met inclusion criteria for the substudy (71 intervention and 65 controls): 60% were women, with mean (SD) age 58.0 (11.9) years, diabetes duration 5.3 (6.0) years, and hemoglobin A1c 7.6% (1.5). Sixteen (12%) had established cardiovascular disease at enrollment. At 1 year, 43 (61%) intervention patients and 15 (23%) controls were using an antiplatelet drug (38% absolute difference; number needed to treat, 3; relative increase, 2.6; 95% CI 1.5-4.7; p < 0.001). Of these 58 patients, 52 (90%) were using aspirin 81 mg daily.

    CONCLUSIONS: Adding pharmacists to primary care teams significantly and substantially increased the proportion of type 2 diabetic patients using guideline-concordant antiplatelet therapy.

  • Pharmacy tabletop unit-dose packager comparison [table]

    Tabletop unit-dose packagers don’t get much respect, but have you ever been in a hospital pharmacy servicing more than 100 beds that doesn’t have one? I haven’t. Not to say that every pharmacy out there has one, but they’re certainly prevalent.

    The Cadet by Euclid is pretty much synonymous for “tabletop unit-dose packager” in the pharmacy world. It’s akin to how people use the term Xerox to refer to any copy machine, or iPod for any mp3 player. So don’t be surprised if someone refers to your tabletop unit as a “Euclid” regardless of which one you have.

    Anyway, I was doing a little research on the subject and thought I’d share my findings with you (table below). The one piece of data I don’t have is price; companies aren’t exactly transparent with that type of thing.
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  • The impact of prescription time guarantees on patient safety

    I came across an interesting article at the ISMP website this morning. The article details the results of a community pharmacy survey looking at what impact policies and procedures related to guaranteed prescription fill times have on medication errors. The results are predictable and scary.

    “Eighty-three percent of pharmacists working at pharmacies with advertised time guarantees reported that the time guarantee was a contributing factor to dispensing errors; almost half of them (49%) felt this contributing factor was significant. In fact, 44% of pharmacists working in pharmacies with time guarantees reported a dispensing error they were personally involved in, which was directly attributed to rushing to fulfill the time guarantee.”

    That right there is reason enough to not allow time guarantees when it come to filling a scripts.

    Read the rest of the article, especially the table of pharmacists’ perspective on time guarantees. It’s worth a few minutes of your time.

    Afterthought: Why do pharmacists continue to work in this environment? Do they like the work most of the time, and only hate it some of the time? I used to know a few pharmacists that worked in the retail sector of pharmacy, but they’ve all moved on. A couple went to work for PBM’s and two abandoned the profession altogether: one left pharmacy to become an accountant – he’s much happier these days – and another one just quit. I don’t know what she’s up to these days, but the last time we spoke she was dabbling in interior design.

  • IV room workflow management system comparison [table]

    There are basically four IV room workflow management systems that I’m aware of: DoseEdge by Baxa, Pharm-Q In The Hood by Envision Telepharmacy, SP Central Telepharmacy System by ScriptPro and Phocus Rx by Grifols. Here’s a little table I’ve put together comparing them based on what I know.

    Product

    DoseEdge

    Pharm-Q In The Hood

    SP Central Telepharmacy

    Phocus Rx System
    Popularity

    High

    Medium

    Low

    Low
    Hardware Stationary camera stand, remote workstation Stationary camera mounted on i.v. bar in hood, remote workstation Stationary camera stand, remote workstation Two compact 5 MP cameras mounted outside hood**New hood with integrated cameras and workstation
    Software SaaS model “IV Workload Management Solution”; photo capture; pharmacist work queue; barcode verification “Web-based”; photo capture; pharmacist work queue; video messaging Photo capture;  web-based pharmacist check queue Photo capture; bi-directional com; image capture; pharmacist check queue
    Acute Care Focus

    High

    Medium

    Low

    High
    Interesting features SaaS model; per-dose pricing;  barcode scanning; telepharmacy remote checking; SAS70 compliant hosting/storage site; automated volume calculations; kitting Telepharmacy remote checking;  video messaging between tech and pharmacist; patented camera for use in hood; multiple configurations Telepharmacy remote checking; integration with central pharmacy workflow system; “call button” for pharmacist interaction Camera mounted outside hood;  barcode scanning; pharmacist queue can be accessed via mobile device; configurable stage verification**New hood design with camera and workstation built into hood.
    Advantage(s) Head start in the market; market penetration; name recognition; Baxa backing (resources); photo capture; iv room specialty; Use of telepharmacy technology (have been doing telepharmacy for a while); camera design; photo capture Use of telepharmacy technology; name recognition (although not in AC) Unique camera feature; acute care focus; i.v. room specialists; only product with camera and workstation built directly into the hood**Integrated camera and monitor in hood
    Biggest Weakness Cost; no new features in a while Small; no market penetration Relative unknown in AC; poor online information and marketing Relative unknown product

  • What the NECC fiasco means for automation in pharmacy IV rooms

    According to the CDC website, the fungal meningitis outbreak linked to a tainted batch of steroid injections made by the New England Compounding Center in Framingham, Massachusetts has resulted in more than 500 case reports and 36 deaths (as of November 28, 2012).

    A lot of things happen when something like this occurs. People become fearful, regulatory agencies begin to scrutinize processes and practices, organizations like ASHP begin to formulate statements and create plans to deal with questions and backlash, healthcare systems begin to reconsider how they do things, and people begin to change the way they think. It’s a natural progression. I’ve seen it happen more than once during my career; never to this extent, but I’ve seen it before. It typically leads to practice changes and an entirely new market for consultants.

    The NECC case has caused quite a stir in the pharmacy community. I’ve seen a wild swing in topics of discussion among pharmacists in the acute care setting, i.e. hospitals. Two things in particular have caught my attention: 1) all of a sudden everyone is worried about compounding safety in the IV room, and 2) everyone is talking about robotics. I’ve talked to a couple of friends that are still practicing pharmacy and they are “in the process of looking at IV robots”. Both cited NECC as the reason for their new interest in robotics.
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  • Transforming pharmacy technicians for the future

    I support the use of pharmacy technicians in many roles inside acute care pharmacies. I believe that they are a valuable tool and, when properly utilized, pharmacy technicians can not only improve pharmacy operations and patient safety, but can also give pharmacists freedom to focus on clinical duties and patient care.

    This is why I found a recent article in Pharmacy Practice News so interesting. The article describes a program at Inova Alexandria Hospital in Alexandria, Virginia where the department of pharmacy has developed a system to educate their technicians for expanded roles.

    The program outlined in the article is quite extensive and involved. Why would Inova Alexandria Hospital undertake such a task? It’s simple really. As stated in the article: “The implementation of automation means expanded roles for technicians. Automation promotes safety and accuracy, and when used properly, it can save valuable time, freeing up technicians to work in other areas of patient care and enabling pharmacists to act as direct care providers. The American Society of Health-System Pharmacists’ (ASHP) Pharmacy Practice Model Initiative cites technicians as a cornerstone of the future of pharmacy practice and recommends increased educational requirements for technicians in the future.” I couldn’t agree more.

    The program consists of monthly sessions targeted at educating technicians about medications and disease states. It is designed to promote interactive discussion and teamwork, and appears to have paid off in spades for Inova. According to the article, “The benefits of the technician education forum are numerous. Technicians have become more engaged and accountable for their work and have reported an increased job satisfaction. Furthermore, teaching technicians about correct dosing and safety allows them to become a second set of eyes for pharmacists. Technicians present concerns or questions during daily activities based on topics and concepts previously presented.”

    The article presents examples of how to present clinical information to technicians, and even includes a chart for tips on starting a technician education program of your own. It’s a great article and I encourage everyone involved in pharmacy to take a few minutes to read it.

    The future of pharmacy remains uncertain, but it is clear that technicians are an underutilized commodity in acute care pharmacy. Expanding the role of pharmacy technicians can only improve pharmacy practice and serve as a springboard to launch pharmacist into more patient centric activities.

    cross-posted at Talyst.com

  • Improving medication safety with accurate medication lists and education [article]

    Here’s an interesting article in the October 2012 issue of Joint Commission Journal on Quality and Safety. The article looks at the impact of pharmacy involvement in the medication reconciliation process. In this “study” pharmacy was involved in ensuring an accurate medication list as well as following up with patients after discharge to “enhance patient safety”.

    Overall the results appear positive: improved accuracy of pre-admission medication lists, reduction in medication errors, reduction in 30- and 60-day readmission, and reduction in ADEs associated with readmission and ED visits.

    I only have two minor complaints about the article. First, the data is old. It’s good information, but the impact is diluted by the fact that it was collected nearly 2 years ago. And second, you have to have a subscription to read the entire article, or be willing to shell out $20 to download the full text. Information like this should be open access.

  • Pharmacists’ Recommendations to Improve Care Transitions [article]

    No big surprise here. An study that used pharmacists to “[provide] perspectives on admission and discharge medication reconciliation, in-hospital patient counseling, provision of simple medication adherence aids (eg, pill box, illustrated daily medication schedule), and telephone follow-up” found that “pharmacists are well positioned to participate in hospital-based medication reconciliation, identify patients with poor medication understanding or adherence, and provide tailored patient counseling to improve transitions of care“. Makes sense, don’t you think? After all, that’s what pharmacist do. They deal with medications. All things to do with medications, which includes medication reconciliation.

    When I was in pharmacy school at UCSF fourth year pharmacy students were responsible for medication reconciliation. Each “general medicine” team had a fourth year pharmacy student on it, and when there was a new admission the student would interview the patient and reconcile their medication lists. Then we’d simply place the reconciled list in the chart for the attending. When it was time for discharge we’d do it all over again. Often times we’d go as far as to get the discharge prescriptions filled at the outpatient pharmacy and deliver them to the patient bedside where we would provide consultation and education before the patient went home. Pretty cool stuff. This is how it should be done at every hospital. Just sayin’.

  • 4 technologies every hospital pharmacy should be using right now

    There are lots of useful technologies out there for pharmacies, but I see precious few being put to good use. Why? Oh, who the heck knows. It’s a mystery to me. People whine all the time about how bad pharmacy operations are, but they never do anything to fix it. Human nature I suppose. If I were a DOP or CPO I’d be using anything and everything I could get my hands on to improve operations and make life easier for my pharmacists, and in turn easier for “pharmacy” and nursing, which in theory leads to better patient care. It’s the great circle of life. Sort of.

    Here are four things I think every hospital pharmacy should be using, in no particular order:
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