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.

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.

Care of the Patient

cc Flickr shared by By Pulpolux !!!

This post has stuck with me for weeks, and while I blogged about it on my personal site, I feel it has a lot to say to me as a health professional.  So often, as we concentrate on our patient’s heath issues, solving drug related problems and working to optimize their therapy, we can overlook the big picture.  We forget that what is simple to us can often be overwhelming or beyond understanding for our patient.

A Reason To Celebrate

–posted by Dodo on Jul 7, 2012

Numbly, I left my husband, Marty, at the hospital where I had been visiting two of my children and headed for the grocery store. Since it was eleven p.m., I drove to the only store I knew was open twenty-four hours a day. I turned my car motor off and rested my head against the seat.

What a day, I thought to myself. With two of my young children in the hospital, and a third waiting at Grandma’s, I was truly spread thin. Today I had actually passed the infant CPR exam required before I could take eight-week-old Joel home from the hospital. Would I remember how to perform CPR in a moment of crisis? A cold chill ran down my spine as I debated my answer.

Exhausted, I reached for my grocery list that resembled more of a scientific equation than the food for the week. For the past several days, I’d been learning the facts about juvenile diabetes and trying to accept Jenna, my six-year-old daughter’s, diagnosis.  In addition to the CPR exam I’d spent the day reviewing how to test Jenna’s blood and give her insulin shots. Now I was buying the needed food to balance the insulin that would sustain Jenna’s life.

“Let’s go, Janet,” I mumbled to myself while sliding out of the car. “Tomorrow is the big day! Both kids are coming home from the hospital. … It didn’t take long before my mumbling turned into a prayer.

“God, I am soooo scared! What if I make a mistake and give Jenna too much insulin, or what if I measure her food wrong, or what if she does the unmentionable—and sneaks a treat? And what about Joel’s apnea monitor? What if it goes off? What if he turns blue and I panic? What if? Oh, the consequences are certain to be great!”

With a shiver, my own thoughts startled me. Quickly, I tried to redirect my mind away from the what ifs.

Like a child doing an errand she wasn’t up for, I grabbed my purse, locked the car, and found my way inside the store. The layout of the store was different than what I was used to. Uncertain where to find what I needed, I decided to walk up and down each aisle.

Soon I was holding a box of cereal, reading the label, trying to figure out the carbohydrate count and sugar content. “Would three-fourths a cup of cereal fill Jenna up?” Not finding any “sugar free” cereal, I grabbed a box of Kellogg’s Corn Flakes and continued shopping. Pausing, I turned back. Do I still buy Fruit Loops for Jason? I hadn’t even thought how Jenna’s diagnosis might affect Jason, my typical four-year-old.  Is it okay if he has a box of Fruit Loops while Jenna eats Kellogg’s Corn Flakes?”

Eventually I walked down the canned fruit and juice aisle. Yes, I need apple juice, but, how much? Just how often will Jenna’s sugar “go low” so she will need this lifesaving can of juice? Will a six-year-old actually know when her blood sugar is dropping? What if…? I began to ask myself again.

I held the can of apple juice and began to read the label. Jenna will need fifteen carbohydrates of juice when her sugar drops. But this can has thirty-two.  Immediately I could see my hand begin to tremble. I tried to steady the can and reread the label when I felt tears leave my eyes and make their way down the sides of my face. Not knowing what to do, I grabbed a couple six-packs of apple juice and placed them in my cart. Frustrated by feelings of total inadequacy, I crumpled up my grocery list, covered my face in my hands and cried.

“Honey, are you all right?”  I heard a gentle voice ask.  I had been so engrossed in my own thoughts that I hadn’t even noticed the woman who was shopping along side of me. Suddenly I felt her hand as she reached towards me and rested it upon my shoulder. “Are you all right? Honey, are you a little short of cash? Why don’t you just let me…?”

I slowly dropped my hands from my face and looked into the eyes of the silvery haired woman who waited for my answer. “Oh, no, thank you ma’am.” I said while wiping my tears, trying to gather my composure. “I have enough money.”

“Well, Honey, what is it then?” she persisted.

“It’s just that I’m kind of overwhelmed. I’m here shopping for groceries so that I can bring my children home from the hospital tomorrow.”

“Home from the hospital! What a celebration that shall be. Why, you should have a party!”

Within minutes this stranger had befriended me. She took my crumpled up grocery list, smoothed it out, and became my personal shopper. She stayed by my side until each item on my list was checked off. She even walked me to my car helping me as I placed the groceries in my trunk. Then with a hug and a smile, she sent me on my way.

It was shortly after midnight, while lugging the groceries into my house, that I realized the lesson this woman had taught me. “My kids are coming home from the hospital!” I shouted with joy. “Joel is off life support and functioning on a monitor. Jenna and I can learn how to manage her diabetes and give her shots properly. What a reason to celebrate.” I giggled to myself. “I have a reason to celebrate!” I shouted to my empty house.

“Why you should have a party,” the woman had exclaimed.

And a party there will be!

The human side of patient care cannot be learned in school.  It can only be taught to us by those we care for… our patients.