The ever expanding role of pharmacists

Lately I’ve found myself thinking about how pharmacists are involved in healthcare. Despite popular belief pharmacists do more than simply work in the pharmacy.

Throughout my career I’ve become accustomed to people viewing pharmacists as the stereotypically person behind the counter at the drug store “counting pills”. While that’s not all pharmacists do, I’ve learned to live with the general publics simplistic view. I don’t think most people realize that pharmacists are involved in every aspect of a patient’s care. If you’ve ever been in a hospital, received a prescription medication, had a loved one in a long term care facility, received intravenous medications at home like total parenteral nutrition (TPN) or antibiotics, received an albumin or intravenous immunoglobulin (IVIG) infusion in an outpatient infusion center or met with a pharmacist in a clinic setting for a medication therapy management (MTM) session, then you’ve been touched by a pharmacist.
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Another opportunity for pharmacist$

Reuters: “During the current study, 21 percent of the 1506 participants said they had previously not taken medications because of money concerns. Another 5 percent said they were worried they might not be able to pay for drugs.

The researchers, who published their results in the journal Academic Emergency Medicine, considered both groups to be “at risk” of nonadherence with future prescriptions.

Looking at the responses to other questions on the survey, Rhodes and her team found that people were more likely to be at risk of nonadherence if they had money issues – for instance, they worried about money, didn’t have enough food, reported housing problems, and had inadequate health insurance. But they were also more likely to be at risk of nonadherence if they smoked, used illegal drugs, or experienced domestic violence, as either the victim or perpetrator.”
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Pharmacists and medication adherence

WSJ: “”Retail pharmacists appear to be able to play a really substantial role in encouraging patients to use their medications better,” says William Shrank, an assistant professor of medicine in the division of pharmacoepidemiology at Brigham and Women’s Hospital in Boston. “They are an underutilized resource.”

A study by researchers at the Walter Reed Army Medical Center in Washington, D.C., published in the Journal of the American Medical Association, found that a pharmacy-care program for 200 people age 65 and older who were taking at least four medications for chronic conditions boosted adherence to 97% from 61% after six months. Patients were educated about their medications, including usage instructions; medications were dispensed in blister packs that made it easier to keep track of whether they had taken their pills for the day; and pharmacists followed up with patients every two months.

After 12 months, those who continued to get the pharmacy care kept their adherence at about 96%, while adherence among those for whom the program was discontinued dropped to 69%.”

This ties back in to what I was talking about on Saturday, i.e. that better use of pharmacists in the community practice setting might be a good thing. And one way to get community pharmacists to spend more time with patients is to get them out from behind the counter and away from the phones using better automation and technology. The inability of a patient to adhere to their medication regimen costs the healthcare system in the United States millions of dollars each and every year, but for some reason we continue to sit idle and allow it to continue.

Where will automation and technology make the biggest impact in pharmacy?

I was planning on writing a rant this morning about lack of motivation, leadership and dumbasses – hey, I was in a fould mood when I got up – but then I opened an email from a friend. He asked me “How can retail pharmacists get involved in this [pharmacy informatics] industry?”. My first thought was to say that retail pharmacy would be the death of our profession and that they have no business getting involved in pharmacy informatics. Harsh I know, but I told you I was in a foul mood.

Then I did something I rarely do, I thought about the question a bit more before answering. After some time I came to the conclusion that retail, or more generally outpatient, pharmacy is exactly where more automation and technology is needed. I follow a few retail pharmacists on Twitter and one generalization I can make from reading their Tweets is that they all pretty much hate their jobs. Why? Because they spend precious little time working as pharmacists, instead spending most of their time physically filling prescriptions, chasing insurance claims, etc.

What retail pharmacy needs is a super-sized dose of pharmacy automation, technology and greater pharmacy technician involvement. Nowhere in pharmacy is there a greater need for automation and technology than outpatient services. Much of what’s done in the outpatient pharmacy setting does not require a pharmacist. This echoes the words by Chad Hardy last week on the RxInformatics website. Chad states “The longer we rely on pharmacists to run the entire supply chain, the higher our risk of obsolescence.” He’s absolutely right, although the article he references insinuates that pharmacists will become obsolete secondary to technology. Nay, I say. Technology in the outpatient arena can offer pharmacists the opportunity to break away from the mundane and do a little more hands on patient care. In addition, the drive to implement automation and technology in the retail setting creates the perfect job opportunity for pharmacists interested in informatics.

Of course we’ll have to prove to the retail boys upstairs that they can save money by using pharmacists in a more clinical role, but that’s what business cases are for. Unfortunately I couldn’t write a business case to save my life. In fact, a colleague of mine told me that pharmacists are terrible at creating business cases. I suppose that’s true as most of us didn’t become pharmacists to practice business. Instead we became pharmacists to provide patient care. Go figure.

Hey, don’t forget about the technology in the central pharmacy

The February 1, 2011 issue of the American Journal of Health-System Pharmacy (AJHP) has an interesting article on page 202 in a section called Management Consultation. The article is titled “Redesigning the workflow of central pharmacy operations”1. I’d like to have everyone read this article, but unfortunately access requires a ASHP membership or an AHJP subscription.

The article discusses the process involved in redesigning the workflow within an acute care central pharmacy, but fails to mention the use of technology.

So let’s break it down a bit, shall we?
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Why not a computerized pharmacist?

So IBW’s Watson recently competed and won ‘Jeopardy!”. Well, ‘Jeopardy!’ is a lot harder than verifying many medication orders routinely seen by pharmacists in the acute care setting.

According to a recent article at Network World: “Watson’s ability to analyze the meaning and context of human language, and quickly process information to find precise answers, can assist decision makers such as physicians and nurses, unlock important knowledge and facts buried within huge volumes of information, and offer answers they may not have considered to help validate their own ideas or hypotheses, IBM stated.

From IBM: “… a doctor considering a patient’s diagnosis could use Watson’s analytics technology, in conjunction with Nuance’s voice and clinical language understanding solutions, to rapidly consider all the related texts, reference materials, prior cases, and latest knowledge in journals and medical literature to gain evidence from many more potential sources than previously possible. This could help medical professionals confidently determine the most likely diagnosis and treatment options.””
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Time to accept pharmacy robotics as our friend and ally

As the word “robot” passes its 90th birthday1 – introduced by Karel Capek in his play R.U.R. (Tossums’s Universal Robots) in January 1921 – it’s become obvious that robotics has not only captured the imagination of geeks everywhere, but has become a point of interest in many industries including healthcare.

Late last year ASHP began pushing the idea of a new pharmacy practice model, PPMI. The movement was a hot topic for a while, but seems to have lost a lot of steam recently – “Hence the name: movement. It moves a certain distance, then it stops, you see? A revolution gets its name by always coming back around in your face” (Tommy Lee Jones in Under Siege 1992) – Anyway, when the PPMI movement was still going strong many important people in the pharmacy world struggled with the best way to approach a new pharmacy practice model. Many believe, and rightly so, that the best way for pharmacists to reinvent themselves is to become the cornerstone of a more robust patient care model. After careful consideration I believe the best hope for developing such as model will be to rely heavily on pharmacy robotics to handle much of the repetitive dispensing duties now handled by pharmacist on a day to day bases. You know, free up the pharmacists. It’s not a new concept, but one that seems to escape us.

Obviously it will take some time to develop robotics to the point where it will be effective in such a system, and it certainly won’t be cheap, and pharmacists will have to fight with state boards of  pharmacy to accept it, and pharmacy administrators will have to work closely with their hospitals to develop such a systems, and someone’s going to have to be brave enough to step up to the plate and get stated, and so on and so forth. In other words it’s going to be hard and it won’t happen overnight.

Who’s up for a little project? For now let’s just take a quick look at some of the things that lead me to believe robotics is worth another look as a potential solution.

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The next big thing in pharmacy informatics? Hint: IDK

RxInformatics: “The following was a list serv question from Monica Puebla, PharmD, MBA, BCPS for a HIS course. Here is my response to the Question. I would add State Boards of Pharmacy to the list of those to present this as well.

“If you were given the opportunity to present to your DOP, VP and CFO a project that you deem would have the greatest impact on the pharmacy department as well as the health-system in general from any point of view, clinical, financial, operational, without regards to costs, what would it be?””

John’s response was to “Study under what circumstances pharmacist order review (perfection) could be taken over by automated clinical decision support while increasing quality and safety” in addition to including a nice list of references related to ‘perfection’ (listed at the bottom of this post). I highly recommend looking at the references John provides because they’re informative and enlightening. You can also read more about the ‘perfection’ idea at one of John’s older posts here. It’s amazing that this discussion has been going on for well over a year and to the best of my knowledge has yet to make much headway.
Continue reading The next big thing in pharmacy informatics? Hint: IDK

Going cartless

I spent some time recently speaking with the director of pharmacy (DOP) from a large acute care facility about operations and various dispensing models. In this particular instance, the hospital utilizes a cartfill model, decentralized pharmacists in satellites to handle first doses, batched IV’s and automated dispensing cabinets for pain meds and other “PRN” medications.

At one point the conversation drifted toward a discussion of using a cartless dispensing model. The DOP wasn’t a fan. The reason cited was a fear that utilizing automated dispensing cabinets in a cartless model would create a workflow logjam in the pharmacy as the entire day would be dedicated to “massive ADC [automated dispensing cabinet] fills”. I understand the thought process, but have found through experience that this simply isn’t true. In a well-constructed workflow a cartless model is quite efficient.
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UA College of Pharmacy professor promotes pharmacists in direct patient care

I received my normal ASHP NewsLink via email today and found this interesting little tid-bit: “Public Television Station Features Research on Value of Pharmacists - Watch pharmacist researcher Marie Chisholm-Burns on Arizona Public Television discussing ASHP Foundation-funded research about the value of pharmacists.”

Dr. Chisholm-Burns spends a little time on Arizona Public Media discussing some of the research she’s done using pharmacists in direct patient care. It’s really good stuff. The video can be found at the Arizona Public Media website.  The AJHP article that Dr. Chisholm-Burns refers to in the video can be found here.