Lessons Learned

people

When I left pharmacy school over 20 years ago, I thought I had attained all the knowledge I needed in order to care for patients.  The one thing that all those years of studying didn’t teach me was that my patients were going to become my greatest teachers.

Here are the five most important lessons I have learned from my patients.

 

  1. Listen first. In school we are often taught the importance of “telling” a patient what they need to know about a drug or a medical condition. We practice over and over imparting the top five or so points about a medication, from how to take it to the myriad of possible side effects.  How many times have I spit out the knowledge in my head, then after listening to the patient I realize that it was either too much information, not applicable to their daily life or they just didn’t understand.  Over the years I have become a much better listener.  My patients have taught me that each person and situation is unique and to truly care for them means to simply listen.

 

  1. Trust requires work. When a patient comes to me for advice, they are trusting my assessment of their current condition and medical history. They trust I am not simply giving them random advice; that what I advise is backed by science, is evidence based and supported by my education, training and experience. Upholding this trust requires work. As much as possible I need to keep up with recent guidelines, studies and lines of inquiry in evidence based medicine.

 

  1. Many patients over the years have demonstrated amazing perseverance throughout incredible pain, suffering and loss. They have taught me to keep finding the positive and most especially, to endeavor to live with a posture of gratitude.

 

  1. Look beyond the surface.  As health professionals we often don’t see beyond the immediate presentation of the person in front of us. A patient’s short temper, harsh words or impatience is often directed at us or our staff. Over the years I have learned that the root of behavior is far different from what I see. Patients have taught me that behind the behavior is often a myriad of other issues such as pain, inability to cope, grief, and other emotions or life circumstances that have nothing to do with me, so I don’t take it personally.

 

  1. Empathy goes a long way. Even if I cannot directly relate to being held captive by addiction or have unrelenting pain, I can still express empathy for the human suffering of my patients.  Even in tough situations such as a person going through narcotic withdrawal, the care I provide is much more effective and meaningful when patients feel that first, I am on their side, even when I have to say no or make a tough call.

 

Ultimately, the human side of patient care cannot be taught in school, it can only be taught to us by those we care for, and I look forward to my continued learning.

 

 

Flu shots? They make me sick!

other-shots-of-patient-care-1

Ever get tired of hearing people tell you they won’t get the flu shot because it made them sick?  Or people who say they’re really healthy so they don’t need it, or it doesn’t work anyway so why bother?

These are just a few of the many things pharmacists will hear from their patients over the coming few months.  Talking with patients who see myths regarding vaccines as fact is one of the most challenging aspects of vaccination.

It always surprises me when I see patients in my travel clinic, their willingness to get vaccines costing hundreds of dollars for rare diseases but will not accept the free vaccination for influenza.  Every one of these patients are more likely to encounter influenza than Japanese Encephalitis or even Hepatitis A.

A couple of years ago I started to change how I approach people regarding influenza vaccination.  Whether it be patients refusing the vaccine or those who come in for vaccination somewhat reluctantly, I realized that by providing a few pieces of scientific fact, in language they can relate to, vastly increased the uptake and acceptance of flu shots.

Here are my top 5 points to increase patient uptake of flu shots:

1-Explain what it is. Make a point of telling patients you are protecting them from a “serious lung infection”. This infection, influenza, gives you a high fever, likely a cough and makes you feel like you’ve been hit by a truck.  It comes on fast and you will likely be sick for at least a week.  The danger with influenza is it leaves your lungs vulnerable and pneumonia can set in, or it makes medical conditions critically worse.  This is what puts people in the hospital and causes death.

2-Explain what it is not.  It is essential to tell patients what the flu shot is NOT protecting them from.  My usual spiel goes something like, “This shot does not protect you from nausea, vomiting, diarrhea, “stomach flu”, colds or sinus infections.  Those are all caused by other viruses that spread person to person.  You can, and likely will, get some of those illnesses this winter.”  I give this information even as I am giving the shot to people who ask for it.  This helps to prevent the person who got the stomach flu a few days later from blaming it on the shot.

3-Take away the mystery. Vaccine are not easily understood by the general public.  Using imagery is a great way to help people understand what vaccines do.  “I am giving you a killed off version of the virus.  Your body recognizes it as an invader, even though it is dead, and makes antibodies to protect you against the virus.  Antibodies fit like puzzle pieces on the virus.  If you get sick with the real thing, those antibodies will fit on the virus and get rid of it before it makes you sick.” Simply put, vaccines cause a natural immune response in the body, making the immune system “stronger” against this particular virus.

This also helps to explain antigenic shift to a patient and why they need to get the vaccine every year.  The virus “changes its shape” and the antibody will not “fit any more”.

It also explains how sometimes the vaccine is not a good match.  I tell patients that science is not perfect.  Experts do their best at matching the circulating strains.  But whether it is a 20% match or an 80% match, 20% protection is better than no protection given the extremely low risk of vaccination and the high risk in getting influenza.  Which brings me to my next point.

4-Give a personal example if you have one. If it is suitable, share a personal story of someone you know who encountered influenza and suffered from its consequences.  My neighbor and good friend, a perfectly healthy 40-year old mom of two boys, was on life support for over a month and nearly lost her life from influenza.  She is lucky to be alive, though she lost her voice permanently from the prolonged intubation and her lungs are irreversibly damaged.  If you don’t have a story, feel free to share this one.  Her name is Jocelyn and she has given me permission to share with anyone who will listen. 

5-Express empathy and Roll with Resistance. I often say, “It’s my job to present to you the science and facts so that you can make an informed decision.”  In the end, it is the patient’s choice, but I want to ensure I’ve done my best to help them make an informed decision based on facts.

When a patient tells me they don’t get the flu shot, I always ask them why.  This helps me pinpoint what type of information to provide.  For example, if refusal is because it “made them sick”, I want to know “what kind of sick.”  Often I hear that they had the “stomach flu” or a winter full of bad colds.  Of course, those illnesses have nothing to do with influenza so I can address that gap in knowledge at that time.  If they say they don’t “believe in it” or they think they don’t need it, I use open ended questions to ascertain why they feel that way.

In expressing empathy, understanding and then providing facts in patient language, we can go a long way in increasing vaccination rates and ultimately the health of our patients and our community.

3 Tech Tips to Save Time 

time

Let’s face it, pharmacists are time crunched.  Not a day goes by in my practice where I don’t wish for more time to complete the ever growing pile of work in front of me.

Some of you from the “pre-computer” generation, such as myself, may remember that when we were in grade school, the promise of computers and “robots” on the horizon touted a future of an easier work life. Disappointingly, this has not been so.  While computers have made some things easier (eg. no more typewriters for prescription labels), it has also meant an overwhelming amount of information to sift through.  So how do we simplify things and make technology work for us in our clinical practice?

While pharmacy software has continued to evolve in terms of dispensing, pharmacists are moving away from technical skills to being more engaged with patients, and this means needing to access different types of tools quickly.  When I’m upfront assessing a patient’s drug therapy or creating a care plan or medication review, I need fast access to things like therapeutic guidelines, risk calculators and drug dosing tools.  I don’t have time to google and search for what I’m looking for.

Here’s my top three tips for using technology to create efficiency in clinical practice:

1- Clean up the desk top.  Nothing is more frustrating than having a desk top so full or cluttered that you cannot find the icons you need.  Use folders and a clean looking background to simplify each station.

2- Be consistent.  With multiple stations and multiple users in a pharmacy, each terminal can have different short cuts and book marks and icons.  To make things easier for my pharmacists, I strive to have all our terminals consistent.  That means being able to access the same short cuts, icons and tools in the same place no matter what station they are using.  It saves an immense amount of time if pharmacists can find, in mere seconds, the CDA chart for renal dosing or a Framingham calculation tool, or any other resource or reference they need.  We use Dropbox to achieve this, though it is by no means the only tool that can accomplish this task. All our references and short cuts are available in the one location and categorized according to therapeutic area.  Pharmacists and technicians can also easily add documents and references and have it appear on all terminals for all team members.

3- Use technology in patient care.  Pulling out the iPad or tablet to show a patient a quick video (for example, on a device technique or to reinforce education) can buy valuable time for things like documenting the patient encounter or completing the paperwork for a service. Make sure you watch any videos first to ensure they reinforce the message you want to get across and are reflective of best practice.

 

Intake: Where it’s at

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Typical day in our pharmacy.  Pharmacists are at intake engaging with patients.  Yes, we did not tidy up before I snapped this candid of my staff!

When I graduated from pharmacy over 20 years ago, the buzz and excitement at the time was “pharmaceutical care”.  I can remember carrying to my first job a copy of Hepler and Strand’s “Opportunities and Responsibilities in Pharmaceutical Care”(1990).  Such was my enthusiasm to provide this type of care to patients.

What ensued was 20 years of practice where the majority of my time was spent signing my name on the plethora of prescriptions presented to me.  Mixed in with some counselling on new prescriptions or a smattering of other tasks such as dealing with drug plans, inventory, orders and narcotics, what’s striking is that about 80% of my time was spent on technical tasks which did not require the university degree I had worked so hard to attain.

Pharmacy practice has largely remained unchanged over the past 20 years.  Pharmacists still perform technical tasks a large majority of their time, tasks more suited to registered technicians and assistants.  Often the only interaction pharmacists have with patients is to give verbal and written information about new drugs.

It is not surprising that real change has not occurred in pharmacy practice as the profitability in pharmacy has historically depended on the drug product going out the pharmacy door as quickly as possible. Pharmacists, as the final check, were the rate limiting step for profitability, thus honing our skills for fast, efficient dispensing was paramount.

Today however, with the convergence of expanded scope practice and the changing landscape of pharmacy reimbursement, billable and cash paying services, the time is ideal for pharmacists to step out front and fully embrace our role as pharmaceutical care providers.  Medication reviews, care plans, adapting therapy, chronic disease management are all about optimizing drug therapy and solving drug related problems (DRPs).

However.…we simply cannot do this on the back end of work flow when we’re checking prescriptions.

Pharmaceutical care requires that we work WITH the patient, engaging them in their own care and decision making, becoming involved in their therapy, taking responsibility for drug therapy decisions and collaborating with other care providers.  To do this we need to be out front.  We need to dialogue with patients when they present to allow for assessment of their medications, chief complaints and chronic disease therapy.   The “pharmacist at intake” model has yet to be widely adopted, but initial pharmacist assessment is absolutely critical to providing patient centered care.  Here’s my top 5 reasons why:

  1. It is nearly impossible to find and resolve DRPs with only a patient profile and a prescription hard copy in front of you (ie: the most common “pharmacist checking” scenario). The vast majority of problems are not discovered due to a lack of discussion with the patient. Assessment of the patient (not just the patient’s file) and shared decision making along with the patient are essential.
  2. Checking prescriptions can be done at a fraction of the cost by a registered technician. Pharmacists are no longer needed for back end checking. Therapeutic assessment of the prescription can be done on the front end of work flow along with the patient.
  3. If our only interaction with a patient is to provide information (ie: counselling), we will shortly be regarded as irrelevant. This is the information age and approximately 92% of adults aged 18-39 now carry a computer in their pocket.  Information is at our patients’ fingertips and pharmacists are no longer the only source of drug information.
  4. Profitability from drug product is shrinking (low fees/margin, PPNs, loss of rebates/pan-Canadian, cuts on short fills/blister packaging). Profitability from expanded services is increasing.  Identifying opportunities and providing expanded scope service requires assessment and engagement of the patient by the pharmacist.
  5. Pharmacist on the back end is highly in-efficient.  If a pharmacist does discover a DRP through back-end counselling, the prescription has already been entered, prepared, checked, and the patient has waited.  Now the team must go through the entire process again to fix the problem and the patient waits yet again.  This is a highly inefficient use of staff resources.

 

Pharmacists have an incredible opportunity to step into their true role. No other profession has the expertise to guide patients and engage in shared decision making to optimize drug therapy.  Pharmacists have unique knowledge of therapeutic guidelines, patients’ current drug therapy, alternative drug therapy options, drug benefit lists, drug administration solutions, and previous response to medications. We cannot afford to wait another 20 years.  We need to step out from behind the counter and engage our patients where they’re at.

The Hurdle of Uncertainty

Hurdles ccMelindaHuntley

“You should check with your doctor on that.”

“Let me just fax your doctor and I will get back to you.”

“This medication interacts with one of your other pills.  I will just call your doctor and see what he wants to do.”

“This dose isn’t quite right. Let me fax your dentist and check with her.”

Pharmacists face many challenges in their day, and solving drug related problems is one of the biggest.  Historically, without the power to enact change for our patients, we abdicated the responsibility for drug therapy problems back to our physician colleagues.   With the changing scope of practice sweeping across the country, many pharmacists are faced with having to use their skills to make clinical decisions which previously they would have deferred to another prescriber.

Pharmacists take patient safety as one of the pillars of practice.  We double and triple check everything, look into more than one reference when we’re unsure and refer when we don’t have a clear picture of the patient’s health.  This tendency towards “needing to be sure” is both an asset and a hurdle.

When I ask pharmacists what barriers they are experiencing that has them directing patients back to another prescriber for drug therapy problems they could easily solve within their scope of practice, I hear things like:  “I’m just not sure.”  “What if it’s something more serious?” “The references don’t agree.”  “I don’t want to take responsibility for that.”  “What if I make the wrong choice?”

While I always advocate for clinicians to care for patients within their scope of knowledge and skill, in many cases pharmacists have both the expertise and the ability and still choose to refer.  It is the hurdle of uncertainty.

Today I heard one of the most impressive explanations of the learning shift that one pharmacist has moved through on the road of practice change.

The most important thing I learned is that uncertainty is a natural part of our clinical decisions and that taking responsibility for our decisions and following up with patients can alleviate the burden of it.

Uncertainty will always be with us as medicine is both a science and an art.  Objective and subjective data collection, patient assessment, making clinical decisions, follow up…. all involve a combination of knowledge, experience and skill and the ability to make a decision that we take responsibility for.  The relationship with the patient and ability to follow up on the results of our decisions not only make us more effective at solving drug related problems, but provides a wealth of additional experience and knowledge to improve our practice and ultimately the care of our patients.

My Practice

PharmacyU recently came in and produced a short video on my practice at Meridian.  It is really well done and highlights how we use expanded scope in patient care.  Kudos to PharmacyU for their superb editing skills and to my staff for their efforts in this production.

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Video Link Here under “Innovators”

Magazine Feature Here

 

 

 

 

Beyond Renewal->Adapting

"No matter where you go, there you are." -Buckaroo Bonzai

cc licensed ( BY ) flickr photo by Stefan Andrej Shambora: http://flickr.com/photos/st_a_sh/493343628/

Many colleagues have asked for examples of where they can adapt in their practice.  While expanded scope of practice is in different stages in each province, most provinces already have, or will soon have, changes in pharmacy legistlation to allow for pharmacists to adapt prescriptions.  Before we get into practice examples, let’s define adapting a prescription as the following*:

  • Renewing a current prescription without having a refill authorized by a prescriber.
  • Changing a dose, formulation or regimen of a prescription
  • Substituting another drug that is expected to have a similar therapeutic effect.

*(this most closely matches the legislation in Alberta)

Most pharmacists have no trouble renewing existing therapy.  Usually, the perception being that there is little risk in renewing for the short term a medication the patient is already on.  Where pharmacists hesitate is when they are faced with therapy that they feel is either inappropriate or less than ideal for their patient and making the decision to change therapy.

Caring for patients is complex business.  It requires patient assessment, drawing up of a care plan, making clinical decisions, ensuring any necessary follow up is done and collaboration with other health professionals.  As the level of care and decision making rises, so does risk.  Pharmacists often ask me about how to protect themselves against risk when making decisions.  While there is no fail safe, and there will be at some point a decision you will second guess or perhaps realize was in error, it is important to know that all clinicians make errors.  The primary concern of course is patient safety, and keeping our clinical decisions within bounds of our own personal knowledge and skills is essential.

So where to start?  If you are a pharmacist who hasn’t moved beyond extending prescriptions and is feeling uncomfortable with moving forward in clinical decision making, what do you do?  It is undoubtedly the way of the future, so how do you move forward?

One way pharmacists have moved forward in adapting and even further into independent prescribing is to take on a specialty.  There are many out there, for example: Certified Diabetes Educator, Certified Respiratory Educator, Certificate in Travel Medicine, etc.  These certifications often give pharmacists the confidence to make clinical prescribing decisions.

However, not everyone wants to obtain certification or write an exam.  For those who are in community or hospital practice, the confidence and ability to move forward can be gained, and the way to start is to just jump in.  It can seem overwhelming to look at your entire practice and scope of knowledge and pick out where you need to brush up or improve your skills.  What I often tell pharmacists is to start with ONE area.  Choose a therapeutic area that you are interested in or used to be interested in and start with that.

If you happen to have an interest in cardiovascular meds then choose learning in that area and focus on it.  Become familiar with the CCS guidelines for atrial fibrillation, dyslipidemia, heart failure, etc.  Or start with the newest hypertension guidelines.  Then, the most important step is to start applying your knowledge to your patients.   If it’s hypertension you have chosen then make a point of talking with every patient on an antihypertensive to see if they know what their goal blood pressure is.  Ask if they home monitor and teach them what their goal should be.  Ask patients to bring in a history of their home blood pressure monitoring numbers so you can assess whether their therapy is working for them. Once you start engaging patients and are confidant in your knowledge of the current guidelines, it will flow naturally to be assessing whether their antihypertensive therapy is appropriate and keeping them at target.  From there you will find yourself making clinical recommendations for changes in therapy.  So many patients fall through the cracks in pretty much every therapeutic area that there will be no lack of opportunity to make drug therapy decisions.

If you don’t know what your passion is, I usually suggest you start with something like pediatric dosing of antibiotics.  This is an easy foray into adapting doses with fairly clear guidelines for therapy.  Start with every pediatric otitis case you see and check if the drug being prescribed is actually indicated for otitis and whether it is indeed being prescribed at the correct dose.  Make ‘Bugs’n Drugs’ your best friend and double check in a second or even third resource when you start out.  It won’t be long before you won’t have to look up when to use high dose amoxil and what the dose actually is.  In a busy practice you will find yourself seeing many prescriptions that require adapting and it will soon become second nature for you to adapt them.  The first few times you may struggle on the wording of your notification to the prescriber, but soon it becomes second nature.

“Dr._______  I adapted the dose of amoxiciliin to 90mg/kg/day x 5 days for this patient with otitis media; she had antibiotic exposure two months ago and attends daycare (as per Bugs & Drugs 2012).  I have advised the mother on possible adverse reactions and will follow up with her in 5 days to see if symptoms have resolved.   Patient weight= 15kg”

Amoxicillin 450mg tid x 5 days

Joe Pharmacist BscPharm

December 13, 2013

Of course, taking responsibility for the clinical decision and prescribing means you have assessed the patient adequately.  This doesn’t take as long as you might think and becomes quicker and seamlessly part of your work flow the more you do it.  After assessing and adapting the prescription, the part where most pharmacists groan is in documentation.  Yes, you have to notify the prescriber (example above) and document your decision in the patient record.  Again, the more you do it the easier it becomes and the less time it takes.   Pharmacists document in all sorts of ways: DAP, SOAP, narrative, etc.  Something as simple as:  “Patient seen today with chief complaint of otitis media.  Has had one course of cefixime two months ago, attends daycare.   Rx was written at 30mg/kg/day x 10 days.  I adapted dose to 90mg/kg/day x 5 days as per Bugs and Drugs.  Follow up scheduled for 5 days for efficacy and ADRs.”

Of course you must ensure you follow all the regulations and Standards of Practice for your particular province.  Make yourself familiar with them and figure out how to meet requirements in an efficient manner that puts the least amount of stress on your work flow.

Moving out of our comfort zones is scary…that’s why they’re comfort zones, because we’re nice and comfortable where we are.  But guaranteed, once you start expanding your practice, professional satisfaction grows incrementally along with great patient care.

Pocket Wisdom

I was rifling through a box of papers from the days of my first few years of practice in the small town of Chemainus (1994-1998).    The beginning of learning how to care for patients and fit into the medical system.   I came across a folded up piece of paper that I recognized as one I had carried in my lab coat pocket for many of those early years…

Ode to Patient Care

If we speak with the tongues of specialists and consultants,

and have not love, we will have nothing more than the noise

of our own voices and the clanging of pet ideas.

If we develop new methods, write new curriculum,

and learn new techniques,

and if we understand all about the five stages of dying

so that we are not surprised when a patient is angry or depressed:

and yet we have not love, we are useless.

If we give up our old anxieties about talking with patients

concerning their true feeling,

but we have not love, we gain nothing.

Love never ends.

As for tumour conferences,

they will pass away;

As for workshops,

they will cease;

As for inservice training,

it will change.

For our methods are always imperfect

and our plans often don’t work out.

When I first became a helper, I thought like an idealist

and talked like an expert.

As I began to mature, I realized that I too was afraid

and the patient often taught me.

For now we see only reflections of sickness and death,

but someday we will see them face to face.

And the time will come when we will know for sure what it is like,

and we will be sorry we ever judged.

So methods, techniques, case conferences, care plans,

seminars, small group experiences, counselling-

There is all this and much more we would suggest for

gaining insight and increasing effectiveness:

But greater than all of these is love.

Dan McEver

Now posted once again where I practice daily so I can be reminded of what really matters….

Navigating Change in Pharmacy Practice

Full ahead

cc licensed ( BY SA ) flickr photo by Maciej Lewandowski: http://flickr.com/photos/macieklew/336716711/

We all know change is upon us. The various pressure points prodding at pharmacy practice can seem overwhelming. Disappearing rebates and pharmacy profitability shifting to professional services means that filling prescriptions at top speed is no longer fueling profit and focus is shifting to billable professional services. Undoubtedly, much has to change in our practices to move forward into a new practice paradigm. What’s the path and how do we get there?

Conversations with colleagues and implementing change in my own practice has brought forward five main “change points”:

Work flow

Workflow as it currently is in most pharmacies is highly inefficient for the new era of pharmacy practice. We mostly see pharmacists at the back end of work flow checking and counseling patients. This is highly inefficient as problems are often not discovered until the prescription has been inputted, processed AND the patient has waited for “x” amount of time. If the pharmacist finds a problem at checking or counseling, the entire process starts over again. In addition, there is no assessment of the patient’s indication, possible drug related problems, or an efficient tagging of possible clinical services (ie: billing opportunities). The skill of being able to quickly pin point what clinical services we can bill for at each patient encounter is becoming more and more critical as profitability in product decreases and profitability in expanded services increases. (More on this in The Future of Pharmacy Practice.)

Responsibilities

We have been hearing for years that technicians need to take on more roles and responsibilities in the dispensary. In many provinces, technicians can check another technician’s work. For the new era of pharmacy practice, this is essential. Pharmacists will be more hands off in dispensing leaving the preparing and checking of prescriptions to their technicians. The availability of qualified pharmacy technicians and change in their scope of practice is paramount to change in pharmacy practice.

Software

Pharmacy software historically has fallen short in allowing clinical documentation. In saying that, most pharmacists haven’t been using or searching for this function. We need software developers to move forward in this area. (This may involve pressuring your software company for further change.) However, some software you can actually work with. It just may take some figuring on how to maximize your software functions for your documentation needs. Software incapabilities should not be used as a reason to not move forward with practice change. Move forward, work with what you have, and push for software updates to make documentation and collaboration requirements (ie: copious faxing) seamless in your practice.

Confidence

Pharmacists that I have worked with and/or mentored in practice change, often confess that they just don’t have the confidence to “make the call” when it comes to drug related problems. They’d rather put the ball back in the physician’s court to make decisions. Even when they are SURE that there is a better drug or regimen or dose for their patient, they send a fax so the physician can make the change. There are many reasons for this, better addressed in a separate post, but most pharmacists cite a lack of confidence, perceived or real lack of knowledge, and lack of time to feel comfortable assessing the patient and making the decision.

Most pharmacists are on the back end of dispensary workflow, being called forward by a technician for counseling or if they encounter what they determine to be a real problem. But there’s the problem. We are depending upon our technicians to identify problems or patient needs rather than assessing for ourselves whether the patient has a drug therapy problem. This workflow arrangement misses countless problems, and with the new billing framework, countless opportunities to bill for patient care services.

Tackling a lack of confidence and knowledge/skills can seem overwhelming but in fact it is not. It can be done in a step by step manner with each step building upon the previous one. Assessment and prescribing skills can be sharpened and confidence builds with the applying of new skills. The amount of time spent documenting, assessing and following up with patients also becomes shorter as comfort and skill level increases.

Expectations

Pharmacists’ relationship with physicians and patients is changing. Physicians are receiving more “notifications” of prescription changes and pharmacist prescribing rather than “requests” or recommendations. (And yes, this is causing some tension and confusion between the professions.) Patients, on the other hand, are experiencing a higher degree of care and assessment. While patients have to become accustomed to waiting longer to see a pharmacist, most will realize, through experience, that when they do see their pharmacist their drug therapy is ultimately improved.

Within each of these change points there are individual barriers unique to each pharmacists practice setting. How we address our barriers and move forward will ultimately determine the sustainability of pharmacy practice.

What’s In Store : The Future of Pharmacy Practice

Future Up ahead sign

cc licensed ( BY SA ) flickr photo by OTA Photos: http://flickr.com/photos/101332430@N03/9681096812/

 

During an interview last week I was asked what pharmacy practice would look like 5-10 years from now. Seems to be the burning question these days…..change is here (whether we want it or not!)

  • rebates are disappearing
  • financial pressures are increasing
  • alternative reimbursement structures are popping up in every province
  • expanded scope of practice is moving forward
  • new roles for technicians

When the dust settles, where will the practice of Pharmacy end up?

The various points of influence and pressure are propelling pharmacy practice towards the focal point of patient assessment.

Of course, assessment has always been a part of pharmacy, usually coming second to dispensing, but we’re at the cusp of seeing assessment become our driving focus.

What do I mean by that?

Historically, decisions on drug therapy have mostly been made by physicians, dentists and more recently, nurse practitioners. Pharmacists have assumed the prescription was appropriate and should be the best drug for the patient. Our role was to maximize the benefit and reduce the risk for the patient (by checking dosing, drug interactions, counseling and suggesting compliance strategies, etc.)

This jived well with profitability in community pharmacy which has historically been fueled by filling prescriptions as fast as possible. Most pharmacists, overwhelmed with the basic necessities of checking the processing and accuracy of the prescription, have not been given the time or workflow ability to assess the patient.

One of a pharmacist’s main responsibilities has always been to assess whether a drug is appropriate for the indication and is indeed the best choice for that patient. It’s a core standard of practice, but one that hasn’t reached it’s full potential. (A practice consultant at the College of Pharmacists in Alberta recently told me she “almost never” sees a notation on the prescription about the patient’s indication.)

As the pressure to change increases and pharmacy moves forward, what we will see is pharmacists taking on the role more and more of prescriber, and at the core of prescribing is patient assessment.

We are seeing this already in the ability to extend, adapt or change a prescription. This role is expanded in some jurisdictions with the ability to apply for full prescriber or initial prescribing status.

However, the uptake in adapting/prescribing has been slow in provinces where pharmacists have the ability to do so. Billing statistics show that pharmacists will more easily extend (renew) a prescription rather than change one. They will also more easily extend a prescription for one week than for three months. It seems the more assessment required (and the more risk), the less likely pharmacists are to prescribe.

Prescribing DOES involve more risk. It also requires time to assess a patient and do the proper documentation to go along with it. So in an already busy practice, why is this change in practice paradigm coming and why should we care?

Here’s why:

Good for PROFITABILITY

Let’s face it, we don’t have a job if our pharmacies are not profitable. It doesn’t matter if you are independent or corporate, staff or owner. Health care is a business and no business survives running in the red. Right across the country pharmacy sustainability is being shaken up. Profitability of pharmacy has always rested on script count. The more prescriptions we could pump out, the more profitable we were. This led to pharmacists coming out of school, being thrown into primarily a dispensing role, and over the years losing their clinical skills and confidence in patient assessment. Some pharmacists even found themselves being told by employers to “cut down on counseling” to get back to checking.

With rebates disappearing, the profitability of the prescription mill is going down. However, reimbursement for expanded clinical services is increasing. Being reimbursed to extend, adapt, assess, independently prescribe, do med reviews and follow ups, treat minor ailments, etc will put financial pressure on pharmacy practice to change. To provide these services efficiently, our assessment and documentation skills need to be dusted off and sharpened up.

Good for PATIENTS

Pharmacists as prescribers are in a very unique position. We have immense background knowledge of evidence based practice, clinical guidelines, drug availability, plan coverage and clinical experience with patient factors such as kidney function and weight. We can see the entire picture for that patient, for the third party payer and for our practice. Indeed, that puts us in the best position for deciding on drug therapy for our patients.

Pharmacists as prescribers also have the best arsenal to improve patient adherence. The ability to change a patient’s therapy and follow up in a timely manner provides efficient patient care which improves patient satisfaction with their therapy (which increases adherence). Providing short supplies of new medications, following up and then adjusting a patient’s dose, regimen, or switching to an entirely new medication results in a tailored drug regimen that fits with the patient’s lifestyle, expectations, drug coverage and overall medication regimen. This actually goes beyond adherence as you are partnering with the patient to provide shared care.

A quick example: Patients starting on gabapentin for neuropathy often stop therapy due to adverse effects or perceived ineffectiveness. It is time consuming and frustrating to book appointments over and over again with a physician until the dose is adjusted correctly. Patients will often give up due to adverse effects or thinking it just isn’t working for them. If that patient is followed up every week by their pharmacist, the pharmacist can work with the patient to fine tune therapy. (Experiencing too much drowsiness? Slow down on the taper up. Tolerating fine but pain relief not there? Taper up towards max dose.) We can fine tune a patient’s medication, improve adherence and bill for follow up services which makes the service profitable.

Good for THIRD PARTY PAYERS and GOVERNMENT

No shocker here, but government and third party payers want to save money. We’re constantly hearing that drugs are the leading driver of rising health costs. Pharmacists are in an ideal position to save payers HUGE dollars. (Your patient needs an ACEI. Should you choose Mavik or ramipril, both of which have the same therapeutic response?) When most pharmacists consider cost they are usually looking at what it is going to cost the patient. Not as much thought goes into what it is costing the third party payer. (If Mavik and ramipril are both covered, the cost difference to the patient is often minimal. The cost difference to a third party payer over time is immense.) Pharmacists have extensive background knowledge on drug cost and evidence based interchangeability (as opposed to just pharmacokinetic interchangeability). It’s the ability to save the patient and the payer huge dollars. There is a big role for pharmacists that third party payers are missing. The ability for pharmacists to save on drug costs is an emerging partnership that will have greater impact as pharmacist prescribing continues to increase.

We know change is upon us. In a nut shell, we are going from “How do I make someone else’s choice of medication work best for this patient” to “What IS the best choice of medication therapy for this patient” and taking an active role in assessment, prescribing and adjusting patients’ medication therapy.

Guaranteed that every pharmacist could name several barriers to this change in practice. Conversations with colleagues and implementing change in my own practice has uncovered many obvious and not so obvious ones. There is no doubt that much needs changing in the structure of our practices and the environment of health care to facilitate pharmacy moving forward. These will be looked at in “Navigating Change in Pharmacy Practice.”

Picture this: FUTURE PRACTICE

Pharmacist is sitting at an intake desk. Patient sits down and pharmacist proceeds with assessment. “What did you see your doctor for today?” Pharmacist assesses indication, history of chief complaint, and (if not already on file) any allergies, medical conditions and current meds. Pharmacist checks the provincial system for additional information (labs, kidney function, medications), decides the ciprofloxacin being prescribed is not a good choice given patient’s advanced age and medications. As well, the UTI ( without a urine screen) is better treated empirically with cefixime. Pharmacist can adapt the Rx, bill for the assessment and counsel at intake. The patient is handed the pharmacist’s business card and advised to call if any issues crop up with the therapy and the pharmacist enters a phone follow up reminder into the computer software to pop up in 7 days. The pharmacist writes up the adapted prescription and passes the Rx back to a technician and doesn’t see it again. The pharmacist then moves onto the next patient.

This may sound unreal in a busy pharmacy where patients are lined up. However, the current work flow set up with the pharmacist at the back end of dispensing is highly inefficient and unprofitable with the new framework. If a drug related problem (DRP) is uncovered when checking or counseling, or the patient requires additional therapy or it really should be a refusal to fill….. think of all the time wasted inputting, processing, preparing… perhaps for nothing! And all that time the patient waited; only to wait again after you assess their drug related problem and provide them what they REALLY need. The biggest problem with pharmacists at the back end of work flow is that the majority of DRPs are completely missed due to a lack of patient assessment….and so are the billing opportunities.

It requires a paradigm shift in the role of the pharmacist. A lot of time is wasted in pharmacy by the pharmacist only coming in at the end to check and counsel. That time can be put in at the front end. It requires a change in employer and patient expectations. Yes, it may take longer at intake, but that pharmacist may provide professional services billing that exceeds dispensing fees, gains a loyal patient and provides more billing opportunities by scheduling follow ups into the system during assessment. Once used to the change, patients are more than happy to wait when they know they will have a conversation with the pharmacist and be assured their therapy is appropriate.

Assessing a patient can also seem time consuming, especially when you are not accustomed to this type of work flow. However, like anything, the more you assess and document, the more comfortable it becomes and more efficient the process. Pharmacist initial assessment of the patient is necessary for the new framework to be profitable. It cannot be left up to the technician to decide if there is a problem or expanded service billing opportunity. At intake the pharmacist can immediately assess the appropriateness of the prescription in front of them, the needs of the patient, can pull up patient history and determine right then what is needed. Does the patient need an adapt? Do they need an additional drug prescribed? Do they need nothing at all today? Do they need a med review scheduled? Do your previous notes indicate they’re due for an A1C? Was there a missed follow up that can be completed and billed? When was their last blood pressure check?

A quick example: If you’re at intake, it’s easy to assess a patient who has high cardiovascular risk being prescribed diclofenac for acute pain as benefiting from a change to naproxen. Adapting that Rx is within every pharmacists’ scope of practice in Alberta (and most provinces, if not now, then in the future). So you’ve improved patient care, reduced risk, and billed for a professional service. (And that Rx was handed off to the tech, and given to the patient on the back end because you’ve already counseled them during your assessment.)

As pharmacists get more used to documenting and triage this takes less and less time. The pharmacist can then write up a prescription (and note which clinical service to bill), or if deemed the Rx is fine, send it back to the tech to prepare and have it checked by a registered technician. Technicians on the back end of pharmacy makes sense. Technicians can teach patient devices like inhalers, blood pressure and blood glucose meters, how to draw up liquid medications, etc. These are all technical functions. When fortunate enough to have pharmacist overlap, the second pharmacist can handle any unanswered questions. Most often, with this type of patient care, additional questions or problems that may come up can be answered in a phone or email follow up (and billed as a follow up service).

It can be comfortable being in the back of the dispensary, being called forward by a technician for counseling or if they encounter what they determine to be a problem. Assessing at intake can seem daunting if you feel out of practice or it’s out of your comfort zone. However, steps can be taken to develop skills, knowledge and confidence while pharmacists are still at the back end, to prepare for the shift to more focused patient assessment.

I would argue that pharmacists are returning to the role they were trained for. Pharmacy schools are preparing their grads for patient assessment and drug therapy decision making. Many of them are coming out ready to embrace that role. What they are finding is that the the majority of practices have not changed.

However, the financial pressures and changing reimbursement and scope of practice structures will force change. We MUST change for the profession to be viable. Technicians can dispense, check prescriptions, teach devices and manage inventory. More and more patients use mobile devices or the internet to learn about their drugs. Assessing drug therapy, tailoring a patient’s drug regimen, solving drug related problems and providing timely follow up is a pharmacist’s expertise, and an essential component of health care that cannot be replaced.