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.

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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.

Starting Out

cc licensed flickr photo shared by stevendepolo

Lately I’ve had several colleagues ask me about practice change.  How do we boldly move forward in a new era where we are taking responsibility for drug therapy decisions and prescribing for our patients?  How do we brush up on our clinical skills and learning if we feel unprepared or not knowledgeable enough to take on this role?

I don’t know about you, but for many years I would do the basic CEUs, get them done for credit, and move on.  Need 15?  Got ’em.  I may have picked up the odd lesson in something I’m interested in or read a monograph for a new drug out of necessity because I was dispensing it more, but the learning often didn’t translate into my practice.  After the credit, much of the learning is forgotten.

What I have discovered in the course of changing my practice is that learning has to be relevant and integrated into my daily work for it to be useful.  For example, I don’t know how many CEUs I’ve done over the years on Diabetes…but I never could remember the incretin system.  DPP4 Inhibitor verses incretin mimetic?  Nada… Until I had a patient I was managing who was started on one.  Then when I re-read the guidelines, the monographs, re-learned the incretin system, etc.  I never forgot it again.  I had probably looked up the product monographs of each of the gliptins and liraglutide a dozen times when needing to counsel a patient, but it stuck with me now because it mattered.  Because I wasn’t simply counselling on side effects, I was making decisions regarding drug therapy for the patient.  I had chosen to take on the responsibility of medication management  which involved making changes in therapy. ie/ the buck stopped with me.  It created a learning curve that I had to dive into.  But now I make those type of recommendations on a regular basis.  And when I follow-up with those patients, find out how my therapy changes have affected them both for outcome and ADRs, my learning is multiplied.

What I am saying is that it has to start somewhere.

In the course of talking with colleagues I always ask them what their passion is within pharmacy.  If they don’t know, I ask them what medical condition or drug class is most interesting to you.  Did you love microbiology? (I hated it!)  But if you do, then start there.  Find out what the indication is for the antibiotic prescriptions you are dispensing (a convo with the patient will usually do) and create a learning curve for yourself.  The first few times you may need to look up the empiric therapy for a pediatric bladder infection.  But after a few, it will be automatic to adapt an Rx from Amoxil to Suprax for a child who had no urinalysis done.  After engaging that parent and making the choice to take that responsibility, you’ll never forget what you’ve learned and will apply it to other patients.

That’s the beginning of practice change.  Will you make some mistakes & occasionally feel foolish or incompetent?  Sure you will.  Think of all the mistakes from other prescribers you make calls on every day.  Our entire career we keep learning and improving, but the end result is better health care and knowing that you are making a huge difference in the lives of your patients.