One of the more interesting aspects of writing a blog for public consumption is the great conversations that can take place as a result. One such conversation took place this evening when two delightful gentlemen called me to discuss some of my observations in The Rewards of Performance. These gentlemen represented the plan that I discussed in the post and they wanted help clarify a few points I had made.
While some of their discussion centered around things that were corrected previously in some spots but not updated throughout the post (I am a pharmacist, not a copy editor), they had one very important clarification surrounding my logic on 90 day fills.
As it turns out, the plan in question (that was not named) does not, in fact, have a reduced dispensing fee for 90 day supplies. This invalidates the math done (since struck from the post) and changes one of my concussions. Based on this new information, the pharmacy would indeed benefit marginally from increasing their 90 day fill rate. The trade-off now is $150 for achieving a 25% rate for 90 day fills versus a loss of eight dispensing fees (down from 12 with monthly fills).
The logic behind incentives for 90 day refills, however, is still something that this author disagree with. While 90 day fills may be associated with better estimated compliance (based on claims data) with 90 day fills, this also creates a difficulty for pharmacists to spot actual adherence problems (see Claims Data is not Clinical Data). They also decrease the number of potential interactions the pharmacist can have with the patient to collect information that can improve outcomes beyond simple compliance. These interactions are where pharmacists can have the greatest impact on patient care and savings in healthcare expenditures.
I look forward to future conversations with these gentlemen, and other readers of this blog. One of the main reason this blog exists is to encourage a thoughtful conversation about many of the issues in pharmacy.
Every medication has the potential for unwanted effects, but some medications deserve a little more attention from the pharmacist. While pharmacists both understand and advise patients on potential and realized ADRs on a daily basis, few take the time to maximize their impact and, further, to document this important clinical work.
A Continuing Medication Monitoring (CMM) Workflow
Every pharmacy has a workflow. Many “traditional” pharmacies focus their workflow on the dispensing role of the pharmacist, and this does not put the proper emphasis on the potential of the pharmacist to make meaningful clinical interventions. In order for pharmacists to establish their relevance in a modern healthcare environment, pharmacies need to redesign their workflows to transition the pharmacist a dispensing focused role to a interventionist role.
Technicians play an important role in allowing the pharmacist the flexibility to engage with the patient as an interventionist. While the pharmacist is still required to complete the final verification step in most states, technicians can be leveraged to handle many of the non-clinical tasks the pharmacist traditionally has done. Some states even allow technicians to check other technicians for routine refills, further freeing the pharmacist to concentrate on clinical issues. It is the view of the authors of the Thriving Pharmacist, though, that the pharmacist should stay in the prescription workflow. This is because by being available on the counter, the pharmacist has best access to the patent, an attribute that will be leveraged heavily below.
We have also added pharmacists to our staff to achieve what we sometimes refer to as a “slack” pharmacist. This pharmacist is not tasked with working the counter (performing the final verification and CMM). Their job involves a working on a variety of other services in our pharmacy. This pharmacist also serves as a pressure-release valve for the pharmacist performing CMM. If a patient needs additional education, counseling, or one-on-one time with a pharmacist, the “slack” pharmacist can be used to hand-off duties during a busy time of the day. These also include completing documentation for more clinically involved interventions started during the final verification and CMM stages of the workflow.
Identifying Potential ADRs
The pharmacist acting as an interventionist needs to focus not only on the prescription(s) being filled at the present time, but also in the entire patient profile. For this reason, having access to a clinically-tuned profile is helpful (see the discussion “A Clinical Profile” in “Continuous Medication Management (CMM) and the Profile“). Armed with a easy-to-use profile, the pharmacist is almost ready to bring ADR screening into the workflow. One last preparatory step if helpful, though. As stated earlier, every drug has potential ADRs. It is often useful to start with a subset of drug classes on which to focus and to create a protocol to follow. Once this is decided, and the appropriate information is communicated to the appropriate pharmacy staff, the hunt is on.
Example Program
In working with a local Quality Improvement Organization (QIO), our pharmacy decided initiate a new, focused, ADR screening program centered on three classes of medications with significant ADR risk. These three classes were:
Diabetic Medications
Anticoagulants
Narcotic Pain Medications
These categories of medications were updated in our clinical documentation system to be flagged (color-coded) in order to alert our pharmacists to focus in on these medications with respect to ADRs. While the focus of our initial efforts could have included any number of different categories with significant potential ADRs, these categories have significant issues and are well represented in our practice.
ADRs were further divided into two categories
Potential ADRs – Things that the patient may experience but are not yet identified or confirmed
Confirmed ADRs
New intervention categories matching the above were added to our clinical documentation software (PharmClin) to document ADR related pharmacist activity.
During the final verification stage of the prescription workflow, our pharmacists review the complete clinical patient profile, including a screen for drugs in the selected class, looking for potential ADRs. With the color coding of these classes of drug classes, this is a quick step. The pharmacist can then create an intervention in the documentation system focused on the drug(s). This intervention can then be printed and added to the will call with the patient’s prescriptions for pick-up.
Example printed tag to include with patient will-call. Pharmacist can then document presence of ADRs with any specific notes.
It is at the point of sale where the pharmacist has the opportunity to have the greatest impact on patient care. The register clerk, seeing the note in the above patient’s order, calls the pharmacist over to the register. After a quick review of the printed note, the pharmacist can ask the necessary questions to quickly ascertain if the patient is experiencing unwanted effects from the medication. Based on what is discovered, the pharmacist can initiate a variety of possible outcomes:
If the results are negative, or not a serious issue, the pharmacist can then make notes on the printed intervention, and, when they have a few moments on the counter, complete the intervention with the gathered information.
If the patient needs additional counseling or education, the pharmacist can move them to a semi-private counseling area and hand-off care to the “slack” pharmacist.
If information needs to be forwarded to the prescriber, a detailed SOAP note addressing the issue along with specific recommendations for the prescriber can be created (again, the “slack” pharmacist may be called into duty).
Discussion
The process described is not unique, nor is it particularly innovative. Pharmacists in a variety of practice settings can and do uncover the existence of ADRs and work with the patient to enhance outcomes. The key point, however, that differentiate the discussion above from many more traditional workflows is the documentation of the actions taken in a clinical record. If it is not documented, then the value of the pharmacist is essentially lost.
Conclusion
Pharmacists are capable of impacting patient care every day. The profession is renowned as being one of the most accessible health care providers. It is not, however, until pharmacists start to document their interventions that they will be recognized as true interventionists. This step is critical to the advancement of the pharmacist to provider status. Having a clinical records system is becoming critical to make every encounter with the patient count.
