Intake: Where it’s at

IMG_1233

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.

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.

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.

Disillusioned?

ccFlickr shared by MacQ

I remember the day I realized I was caught in the prescription mill and it seemed there was no way out. I was standing in the pharmacy, just a couple years out of university, with some of Linda Strand’s writing in my hand. I knew without a doubt that “Pharmaceutical Care” was what I should be doing. I also knew that I had no idea how to “do” medication management. I didn’t know any pharms who were doing it, was not really taught it in university, and I had ALL these prescriptions to deal with non-stop all day.

Okay, so that was 1996… but I know I’m not the only one who had a rude awakening once they started their professional practice. Wasn’t I supposed to help patients manage their medications and optimize their therapy? Make sure patients who needed drug therapy received it and those that were receiving unnecessary drugs were identified?

Yup, that’s really our job. The prescription mill? A trained tech can produce an accurate Rx from a hard copy. As a matter of fact there’s probably a computer out there that can read an Rx and spit out an accurate product. It’s not rocket science.

But looking at the over all picture of a patient from their labs, self reporting of chief complaint, previous response to meds and current drug therapy, etc. and deciding whether the Rx in front of you is really the BEST therapy for that patient…or if they really even need drug therapy at all? That’s the art and science of Pharmacy. Making the clinical decision to adapt (change) that prescription or prescribe for that patient, when you know therapy can be improved, then following up on that care…no machine can manage that. It takes knowledge, clinical experience, triage skills, sourcing of info, patient interview skills, ability to refer and knowledge of your own personal skill set and boundaries.

In considering all that, what I often hear from colleagues is that it isn’t possible. We have no time, not enough support staff, our software isn’t capable of what we need it to do, it takes too much paperwork, etc.

And really…when you’re stuck churning out hundreds of scripts a day it’s easy to slowly drift into apathy, or feel burnt out…tuck your head down and do a great job of at least searching out drug interactions (or assessing the clinical validity of the ones the computer caught), checking doses that look way out there, answer patient’s questions… Just be accurate, make no mistakes and go home.

Over the years as I worked at top speed in the mill, I lost a lot of my clinical skills. What you don’t use you lose, right?  I hadn’t looked up an A1C on a patient or applied the newest Otitis guidelines in so long I was afraid to start.

If I was given the perfect circumstances, all the time I needed, the ideal practice setting…would I be able to do the job I wanted to? Could I take responsibility for a patient’s medication management, make recommendations on drug therapy, solve complex drug related problems? Well…I wasn’t sure.

We know that care of the patient is our primary task.  Pharmacists have no problem putting patient’s first. I see it every day. We’ve never been paid to talk to patients or assess medical issues and make recommendations, but we do it.

Where we can be our own worst enemy is in lacking the confidence to make the shift into medication management:  to take responsibility for clinical decisions, make the call, sign our name to the decision.  And sometimes we know that our skills need to be sharpened and our knowledge refreshed but we don’t know where to start.

Mentorship and good learning opportunities are essential for practice change;  Assessing for yourself what you need in order to shift your practice and feel comfortable doing it, and finding the energy and passion to embrace change.

We now have the framework, have a start at being paid to manage patients’ medication therapy, not just handle prescriptions; and it’s up to us as a profession whether we take it up, change our mind set, our focus and move forward.

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.

Burn out

Flickr cc shared by alfromelkhorn

Burn out …. who hasn’t experienced it working in health care?  We are under the gun, trying to deliver health care to the maximum amount of patients in the least possible amount of time.

I recently read a great post written by Dike Drummond on “Compassion Fatigue”. I had never heard the term before, but it resonated with me as a truth. Compassion fatigue is a signal that burn out is approaching. What struck me was the way it was described. Not the typical symptoms of just being tired and unenthusiastic.

Compassion fatigue is when you find yourself challenged to care about your patients in the way you know is proper and expected in your position. One of the key components of quality healthcare is the ability for you to connect with your patients and for them to sense that connection….

Cynicism, sarcasm and feeling put upon are the first signs

If you find yourself being cynical or sarcastic about your patients you have compassion fatigue. It can come in the little voice in your head, or mumbling under your breath or “venting” to your colleagues or staff.

There have definitely been times in my professional life when I have felt this way. When an “interruption” by a patient was a bother while I was trying to complete other work.  There are times when I have definitely felt my empathy was out of reach.

Sometimes the signs are there, but I don’t recognize them. It’s easier to just keep going, be exhausted, unenthusiastic and get through the week.  Easier to stay in the place where you aren’t happy doing what you’re doing, can’t be in the moment, and wish you were anywhere and doing anything else.

At those moments I’ve lost the passion for my work, that spark, the reason I got into this gig in the first place.

And mix that with being physically exhausted and feeling like your work has no bigger purpose or meaning…that’s burn out.

Drummond has many suggestions for battling compassion fatigue including scheduled rest, exercise and personal time.  I would also add that as health professionals we need to feel our work is making a difference.  If we feel we are simply handing T3s to the next addict, managing drug shortages and talking to insurance companies… it is difficult to see the real difference we are making in the lives of our patients.  That can leave us unenthusiastic and just plain tired.

So, I would add to Drummond’s suggestion that as health professionals we need to find meaning in our work.  We need to see tangibly that we are making a difference for our patients.  The easiest way to do this is by being as involved as possible in patient care.  Get involved in improving patient  therapy, not just the solving of all the technical problems.  We need to rediscover our role as experts in medication management., carve out minutes in our days for those follow up phone calls, and keep on learning as we move forward in our practice.