Category: Clinical Pearls

Clinical pharmacy pearls for the thriving pharmacist

Do We Need Pharmacists?

If the title of this article makes you uncomfortable, it should. This is the exact question my business partner, Randy McDonough posed to our pharmacists at a recent clinical meeting. The profession of pharmacy is literally at a precipice. The future of pharmacy depends on how every pharmacist answer this question.

The issue facing the profession is one of initiative, or the lack thereof. For years, thought leaders in pharmacy have been pushing pharmacists to perform at the top of their licenses. We have been asking our staff to do more than simply count, pour, and label drug product. We need our pharmacists to leverage their relationship with the patient to help them active their drug therapy goals. We need pharmacists to monitor outcomes. We must have pharmacists that take the initiative to act as health care providers, not simply drug dispensers.

Yes, there are pharmacists that are doing some or even all of this. The problem for the profession is that these outstanding individuals are in the minority. Today, many pharmacies are struggling to keep their doors open. I am not just talking about independent pharmacies. Even the larger players are having difficulty maintaining enough profitability to continue to provider pharmacy services.

The key to the next generation of pharmacy is getting paid for clinical services that pharmacists can, and in some places, are already providing. The problem is one of timing. Pharmacy owners and pharmacists desperately went to be paid for their services. But many, even most, are not providing the services, nor are they even ready to start. This is a classic chicken / egg problem. Pharmacies have to prove themselves in order to be paid for the services, but many pharmacy owners won’t make changes until they are already getting paid.

Additionally, even if a pharmacy owner is committed to making these changes in order to be ready for future of clinical revenue, finding pharmacists that are willing to put forth the effort required is unbelievably difficult. Far too many pharmacists have become complacent. They are being paid very well to do very little outside of dispensing functions and they are far too comfortable with their limited responsibility. The thought of putting their clinical skills to work is both scary and daunting.

The answer to the question posed at the beginning is actually easy. Yes! Hell yes! Pharmacists are definitely needed. But the pharmacists that are needed are not those that are simply dispensing. Dispensing will eventually become extinct. Healthcare is evolving, and these skills don’t require highly paid professionals. Where we are headed, like it or not, is going to make a lot of pharmacists and pharmacy owners uncomfortable. Change is hard. Change is inevitable.

So if you are a pharmacist, ask yourself this tough question: Am I ready to take on the new challenges of healthcare? Am I going to evolve to become a clinical interventionist? If the answer is yes, and I hope that it is, then you need to start now. Be ready to prove your importance in healthcare. Learn new skills. Advance your practice site. And above all else, Make Every Encounter Count.

Clinical Mayhem​?


Today, there are many forces encouraging patients to use more than one pharmacy. Physicians are directing patients to chain pharmacies with $4 prescription options. Grocery store chains are offering discounts on gasoline for each prescription transfer. Some patients that simply shop around for convenience, price or both. When a patient elects to use multiple pharmacies, commonly referred to as polypharmacy, there are several significant implications, including a few less obvious possibilities, to be considered. Today’s edition of Tales from the Counter describes a few of these gotcha’s.

Like many of our Tales From the Counter, our adventure begins with a clinical intervention. In our case, our workflow identified a patient that was a candidate for an additional drug therapy. Current guidelines suggest patient would benefit from initiation of a statin to lower cardiovascular risks. Our pharmacist took the time to initiate a discussion with the patient about the possibility of adding a statin during their next encounter.

Like a lot of our recommendations, we always make sure that the patient is aware of any possible suggestions we would like to make to the prescriber. This helps the patient maintain a modicum of control over their own healthcare. The success of any therapy change is inherently dependent on the patient’s willingness to participate.

In this case, the patient wanted to discuss the recommendation with their doctor at their next appointment. Our pharmacist indicated that she would send a note to the patient’s physician outlining the discussion that they shared, the recommendation, and the patient’s desire to discuss the possible new therapy with the physician.

The physician reviewed the note our pharmacist sent and their response included a notation indicating that they were sending a new prescription. Because our pharmacist knew that the patient wanted to speak with the doctor about this before initiating any change in therapy, our pharmacist put a hard-stop on the filling of any new prescription for a statin on the patient.  She also took time to call the patient to alert that a prescription was expected and to let her know that we would not fill it until she spoke with her doctor and gave us the green light.

This is where polypharmacy unexpectedly creeps into our story. We did not receive a new prescription for a statin on the patient. Another pharmacy, the one the patient chooses to use for one of their medications based on out of pocket costs, received, filled and called the patient to pick up their new prescription.

The unexpected call about a new medication upset the patient. Our attempt to leave the patient in control of their healthcare failed. We did not anticipate that the prescriber would write the prescription. Nor did we anticipate, or even consider, that the prescription being sent would go elsewhere. We failed our patient on multiple levels despite our best efforts.

The TV commercial character Mayhem, played by Dean Winters, is associated with unexpected and sometimes even catastrophic events. This portrayal also works well for the healthcare clinician. It behooves us to always be on the lookout for the unexpected. Recognize that often we will miss something that later will seem obvious. Our job is to mitigate these challenges. Remember that everything we do should be in the best interest of the patient, but also with their knowledge and permission as well. Our miscommunication could have been prevented. And even our attempt to intervene was thwarted by an unexpected twist.

As you work to make Every Encounter Count, be sure you also stay on the lookout for mayhem lurking around the corner.

Sometimes There Isn’t a “Right” Answer

In a modern pharmacy, specialized systems and software assist the pharmacist in identifying potentially important issues important to patients. It is important to recognize that while these aids are invaluable, they also require sound clinical judgement and an underlying knowledge of the disease states and pharmacotherapy involved. I would like to share an example in this edition of Tales from the Counter.

Our patient was just released from a hospital and the History of Present Illness (HPI) was remarkable for:

  • ischemic stroke treated with Tissue Plasminogen Activator (TPA)
  • hemorrhagic complications from the TPA and
  • glaucoma (unspecified) being treated with dorzalamide, timolol and lantanoprost.

The discharge orders included a prescription for methylphenidate 5 mg daily without any diagnosis information provided. After reviewing the HPI, it was determined that the methylphenidate was being used off-label to treat post-stroke depression.

Because we put diagnosis information in our pharmacy management system, automated screening performed by our system includes drug-disease interactions. In this specific case the following warning appeared:

This medication is contraindicated in patients with glaucoma.

Other drug-disease interaction sources list the same contraindication. Facts and Comparisons Interactions, for example, labels this issue with a severity level of Not Recommended.

Whenever any type of automatic screening alert presents, the pharmacist needs to pay attention. The reason, however, is not necessarily what many might expect. A health care provider can be sued for negligence for ignoring a warning, but they can also be held negligent for heeding the warning and withholding or delaying treatment.  The pharmacist needs to pay attention to the provided information and document what they did with the information and why they decided on their course of action.

The first step is understanding exactly what the computer generated warning actually means. A quick search of the literature revealed that this contraindication is poorly documented. The use of methylphenidate in patients with glaucoma has the potential to increase intra-ocular pressure. The increase appears to be dose dependent: most of the reports in the literature cite doses more than 30 mg of methylphenidate

If one wanted to avoid this interaction, they would consider another treatment option for the depression. However, alternate drugs that could be used to treat depression also have their potential issues in this patient. Tricyclics like nortriptyline must be used with caution as they also interact with glaucoma (severity is listed as Extreme Caution by Facts and Comparisons). Drugs like escitalopram are associated with an increase the risk of bleeding events; a drug-disease interaction with the hemorrhagic stroke recently treated. This interaction’s severity level—Extreme Caution.

The alternatives to treating the depression are therefore somewhat limited by the patient’s HPI. The alternatives really boil down two options:

  1. Do not treat the post-stroke depression
  2. Treat the depression and manage any associated risk

There is no right or wrong answer here. We elected to dispense the methylphenidate along with documentation to the prescribing physician that included a recommendation to monitor the response of the patient’s intra-ocular pressures. The rationale was that the low dose methylphenidate was less likely to create problems with the glaucoma and would not further increase the risk of hemorrhagic stroke. There are certainly other possible answers, but the others also involve some level of associated risk. The important part is the act of documenting.

Major Interactions

Recently, pharmacies failing to address significant drug interactions has made national headlines. But while the pharmacists that failed to address these interaction are certainly at fault, to some degree we all share in the fault. Today’s healthcare world is regularly pushing providers to do more for less. The payor and the patient both want low cost, and with respect to pharmaceuticals, they often getting what they want.

The public’s frenzy for low cost pharmaceuticals has fueled the fire. Pharmacy reimbursement is almost exclusively based on the drug product dispensed, and reimbursement today often barely covers drug cost. Pharmacists are generally not paid for their clinical expertise.  In order to stay competitive, pharmacies have to increase prescription volumes while using fewer pharmacists. Instead of using a pharmacist to perform continuous medication monitoring or drug utilization review, pharmacies are increasingly relying on computers to help the pharmacist identify problems with drug regiments.

Today, pharmacies almost exclusively use a type of software generically referred to as pharmacy management system. Besides handling the record keeping for dispensing prescriptions, the package also includes screening for drug interactions, therapeutic duplication, drug allergies, and drug / disease issues. The problems identified by a software package like this will range from trivial issues with no clinical relevance to life-threatening problems. Because of the enormous volume of alerts generated by these systems, alert fatigue is a real concern.

But while computers can generally find problems, at this point they still lack the clinical expertise to make the important judgements required. A pharmacist still needs adequate time to evaluate the implications of the sometimes lengthy list of potential problems. Given the time, pharmacists can help ensure a patient will have positive therapeutic outcomes while minimizing the associated risks. To emphasize this, let us look at a brief tale from the counter.

We start out with a patient taking Oxybutynin and Nortriptyline. They have been taking this combination for some time now. Looking at the most recent refills, the only item noted by the computer based screening is a late refill on one of the medications. No drug interactions were flagged by the computer, but as it turns out this is not necessarily accurate. If the pharmacist looks at these two medications in a dedicated drug interaction reference, they find that there actually is an interaction:

Pharmacologic effects and plasma concentrations of Nortriptyline HCl Oral may be decreased by Oxybutynin Chloride ER Oral

The interaction is considered a MODERATE risk, with a delayed onset. The reference also notes that there is not a lot of documentation to support this interaction. In this case, the pharmacist recognized the interaction without the aid of the computer screening. The interaction poses minimal risk as the nortriptyline dose is generally titrated to the desired effect. The intervention might involve a brief discussion with the patient explaining the issue.

But the plot thickens: more recently, the oxybutynin was discontinued and a newer medication started. Myrbetric does flag as a drug interaction in the pharmacy management system, but again the system did not display an alert because it was set to only display moderate and severe interactions. The reference used by the software classified the interaction as minor.

But when using a dedicated interaction reference, the story is quite different: the interaction significance is classified as major.

Pharmacologic effects of Nortriptyline HCl Oral may be increased by Myrbetriq Oral. Elevated plasma concentrations with toxicity (e.g. QT prolongation/Torsades de Pointes) may occur.

Note that the effect on the nortriptyline is opposite that of the other drug. The overall risk is much higher for this type of interaction, and one of the listed consequences is Torsades de Pointes, a rare but very significant heart arrhythmia that can be fatal. Fortunately, the pharmacist was given adequate time to consider the new therapy, spotted the interaction, and addressed it with the patient and prescriber.

So the national headlines decrying pharmacists missing important interactions also serves to highlight how important having a pharmacist exercise their clinical judgment is to patient care. Perhaps the there is another interaction that needs to be addressed:

Interaction: poor reimbursement decreases pharmacist staffing.
Significance: Major
Onset: Delayed
Documentation: Strongly suspected

Effect: Ability of pharmacists to perform clinical activities is negatively impacted by current pharmacy reimbursement model focused on inexpensive drug product.

Be sure you make every encounter count!

Shall we play a game?

The title above comes from the 1983 movie WarGames. The plot of this movie centers around a young computer hacker that manages to access a Department of Defense computer. That computer asks the hacker, Shall we play a game? That game just happens to be Global Thermonuclear War, and as it turned out, the game was actually very real.

Sometimes, an apparently innocuous event can quickly become very dangerous, not unlike the game our hacker was playing. There are few tasks in the pharmacy world more potentially dangerous than filling controlled substance prescriptions. The risks exists on both sides of the prescription counter. Improper use by the patient can lead to significant morbidity and even death. Pharmacists face significant regulatory challenges trying to balance federal laws and DEA rules, all while assessing appropriate prescribing habits and patient outcomes.

Pharmacies and pharmacists are generally well-versed in complying with federal and laws and DEA regulations surrounding the ordering and managing of controlled substance inventory. A bigger challenge is ensuring prescriptions being filled meet all of the rules and regulations to ensure that it is valid. It is not enough to simply ensure that the prescription is not forged. To be valid, a prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice.  The pharmacy has a corresponding responsibility to ensure proper prescribing of controlled substances.

Recently, the DEA has started conducting audits of pharmacies, and they are not just looking at record-keeping for inventory and ordering. Failure to fulfill the pharmacy’s corresponding responsibility to verify the prescription is valid can result in fines of up to $10,000 per violation. Let’s look at some ways to ensure your pharmacy is not subject to this type of thermonuclear attack. Below are what I consider to be best practice principles for controlled substance dispensing.

Check the PMP (Prescription Monitoring Program) and Document Findings

This should go without saying, but every controlled substance prescription you fill should be checked every time. Even if you think you know your patient, and they have only ever used your pharmacy before, be sure they have not changed their habits. Be sure to document both your search and the results.

Determine and document the indication for the medication

If the pharmacist doesn’t know what the medication is being used for, they cannot assess the appropriateness of the therapy. While a pharmacist may be able to guess the probable indication, it is important to verify and document this information every time you fill a controlled substance. Included in this is the expected duration of therapy. All of this information does not necessarily have to come from the prescription or the prescriber, it may be possible to determine parts of this simply by speaking with the patient.

Understand the accepted guidelines for treatment

In order to be able to assess the validity of a prescription, you need to be sure you understand what the standard of care is for the condition being treated. For pain medications, especially, there is a accepted progression that should be followed. Once this is in the back of your mind…

Document previous treatments used and their outcomes

Did the prescriber jump right to an controlled substance (e.g. an opioid), or did they other medications first (e.g non-steroidal medications)? Is the etiology of the condition treatable with non-pharmacologic vectors, and if so, have they been tried? What were the outcomes? In the case of pain treatments, if the pain is chronic, is the patient being followed by a pain specialist? Do they have a pain contract? Each patient is a story, and without knowing and documenting the story, assessing validity of the therapy is more difficult.

Watch Trends

Every course of treatment will have a natural progression. An acute treatment may flare and wane with time and end. Chronic treatments may slowly escalate. All of these may be normal, but it is the pharmacists job to look for potential diversion of controlled substances. By watching trends and speaking with the patient about them as they occur, you can more easily spot diversion and take appropriate actions.

The reoccurring theme in these practices is documentation. While we use a clinical documentation platform (PharmClin) to document these types of activities, the documentation can be done in a variety of other ways. Having this documentation goes a long way toward satisfying corresponding responsibility.  Be sure to take the time to protect yourself, and make every controlled substance prescription a complete story. Make every encounter count!

Don’t Treat the Number, Treat the Patient…

During my senior year in pharmacy school, one of the most important lessons drilled into me was to look at the bigger picture. As a young professional, I naturally tended to look at individual data points like lab values and then make recommendations. Generally speaking, this is a not seeing the forest for the trees type problem. With time, practice, and maturity, I have become much better at evaluating the patient as a whole and not just seeing them as a group of numbers.

This skill is applicable to many different arenas in life, and a gentle reminder is sometimes needed to refocus our priorities. I was participating in conference call discussing the implementation of a new high performing network that launched in Iowa. The discussion was centered on the various metrics being used to assess the performance of pharmacies when the Vice President of Pharmacy Operations for the sponsoring payor made an astute observation to the group of pharmacists. He noted:

[custom_blockquote style=”red”] I am concerned that the pharmacies here are focusing too much on the metrics and not enough on transforming their practices.  [/custom_blockquote]

He could not have been be more succinct. Today, pharmacists and pharmacies are being pushed to perform, and are being evaluated using arbitrary metrics like the EQuIPP measures. But actual performance in the context of healthcare is not easily measured using simple metrics. Too often pharmacists are looking for ways to move a number in the desired direction. Doing this risks losing sight of the ultimate goal, optimizing each patient’s drug regimen. But by simply moving a measure does not equate to a patient receiving better care.

So it is time for pharmacists to take a step back. Take in the vastness of the forest around us. Focus on transforming your pharmacy practice. Instead of simply filling prescriptions, work to understand your patients’ disease states, their therapeutic outcomes, and goals, and the issues they are having. Working with together with your patients in this way will result in both a more satisfying practice and improved outcomes. Take care of the patient, and the numbers will follow. Make every encounter count starting today.

The Fragmentation of Patient Care

The other day, I wrote about a case involving a medication for which the plan required to be filled at a specialty pharmacy. This was an example of fragmentation of care. In Pharmacy, fragmentation is often either financial, or the result of contractual requirements imposed by benefit managers or plans. Examples include:

  • maintenance medications that are required be filled by a mail order pharmacy
  • requiring specific, specialty pharmacies to fill certain medications
  • doctors sending patients to multiple pharmacies to help the patient save money on select medications
  • pharmacies offering incentives to transfer mediations, creating transient patients using numerous pharmacies.
  • drug companies directing patients to specific pharmacies for special pricing of their products.

The list could go on, but each example has the same consequence: the complete patient record resides across multiple pharmacies. The record is fragmented. This makes it much more difficult for any one pharmacist or practitioner to have a complete understanding of the patient’s medication therapy, making assessing and monitoring the patient’s therapy much more difficult.

The implications of care fragmentation are significant. If the pharmacist cannot accurately determine if the prescription they are filling is appropriate, inappropriate or even dangerous, problems will arise. Problems, in the context of prescription medications are, at a minimum, undesired. They can be a lot more significant, too; the worst case scenario might death. While the PBMs do pass pharmacies some information about medications filled by other pharmacies, the data is mostly designed to prevent duplicate fills of a given medication. It is paramount, therefore, that pharmacists work combat both fragmentation and its consequences.

Combatting Fragmentation

There is no way to completely eliminate fragmentation as long as our system puts its emphasis on reducing cost, and not on patient outcomes. While an outcomes based system may be something that will eventually become prominent in our country, we cannot afford to wait. We need to combat this problem, and the weapon of choice is communication.

The first problem for the pharmacist is identifying fragmentation. Patients don’t just walk in and announce that they use four different pharmacies. Using tools like electronic claim notifications and rejects can alert you to the existence of some forms of fragmentation. Communicating with the patient, however, is the best way. Regularly ask the patient what other medications they are taking that your pharmacy doesn’t provide. Any time you discover the potential for multiple pharmacy use, it is important to document your findings in the patient’s pharmacy record. More to the point, communications need to be initiated to ensure that all pharmacies involved have a good understanding of the patient’s therapies and outcomes. Once the problem is identified and information exchanged, the immediate crisis is over. It is now time to address the root cause of the fragmentation.

I always start the discussion with the patient. It is important to understand exactly why they are using more than one pharmacy provider. I always emphasize the importance of having a single pharmacy home, but I am always watchful for circumstances that will prevent this from occurring. Once I understand the reasoning, I look for solutions.

  • Whenever possible, I try to consolidate the pharmacies a patient uses. Ultimately, I would prefer to get them to use one pharmacy, their pharmacy home. Obviously, I would prefer that they use my pharmacy, but that is a decision for the patient. Even if I lose a them, they will be better off in the long run with a single pharmacy home.
  • In cases where the patient must use more than one pharmacy, I try to have the patient minimize the total number of pharmacies involved.
  • Finally, I educate the patient. If they must use, or they insist on using, multiple pharmacies, I emphasize that they as the patient, are responsible for making sure that all parties involved are kept up to date on all medications. They must be their own advocate. While some inter-pharmacy communication does occur, it may not be enough to prevent real problems from occurring.

Mis-information is also a problem, and education is a part of the this solution, as well. I have personally observed prescribers sending patients to multiple pharmacies for a variety of reasons. Mostly, though, they are simply trying to help the patient get the best value for their healthcare dollar. Prescribers understand that the medication doesn’t do any good for their patent if they cannot afford it or fail to take it regularly. This is a great place to educate the physician on the value of the pharmacist in the equation. Spend some time visiting with prescribers. Let them know what a good pharmacist does to ensure good compliance. Talk about medication synchronization and compliance packaging. Make sure they understand that a single pharmacy home may have a larger impact on outcomes than price alone. If they have an open mind, you may change their habit.  What is more, you might actually receive additional referrals for your efforts.

Ultimately, fragmentation comes down to choices. Our job is to be sure that people making choices do so with the best information possible. If we do our job well, everyone benefits. Make your encounters count.

 

Why Generic Dispensing Rates are not “Clinical” Measures

Some time back I wrote about “The Rewards of Performance“. In that piece, I discussed the existence of Generic Dispensing Rates (GPR) as one of the measures used by a plan to “reward” a pharmacy for clinical performance. Since that time, several additional plans have announced their 2016 Prescription Drug Plans, and several have a form of reward or penalty based on the pharmacy’s GPR.

Economics 101

In every pharmacy I have ever worked, a generic drug was always offered to the patient if it was or is available. Generic drugs have always benefitted the health system by reducing overall drug spending by health plans. Back several years ago, pharmacies even made a better margin on generic drugs, so the pharmacy was rewarded for the helping increase the adoption of genetic drug options.

Today, pharmacy is facing a plague of Maximum Allowable Cost (MAC) prices for generics that are essentially pricing most generic drugs at or just above the pharmacy’s acquisition cost. Given this drastic reduction in pharmacy reimbursement over the last 5 years, one would expect that overall drug costs would actually be way down, just like pharmacy profits. In fact, this does not appear to be the case. See “Examining Medicare Part D Transparency” for a quick analysis.

Clinical Measures

Clinically, we are interested in many different types of outcomes. These might be specific to the disease being treated, or they could be global, like total health spend for the patient. Consider the cholesterol lowering “statin” drugs as an example. Typical outcomes might include:

  1. Degree of lowered LDL (Bad Cholesterol)
  2. Possible increased HDL (Good Cholesterol)
  3. The existence of Adverse Drug Effects (ADRs), especially muscle weakness / rhabodomyolosis.
  4. Overall cost the the health system.

From a clinical standpoint, atorvastatin is a great product to lower cholesterol compared to some of the older products like simvastatin. It is also now generically available and very inexpensive.  At lower doses, it has a low incidence of ADRs. If a patient does not achieve their LDL / HDL goals, the dose can be increased, but with an increased likelihood of ADRs. If ADRs do appear, a choice has to be made to balance the overall reduction in LDL with the existence of ADRs. This can be handled two different ways. First, choose a different generic drug like pravastatin, which has a lower incidence of ADRs, but also is not as effective at reducing LDL. Second, choose to use a lower dose of the brand name drug like Crestor, which may lower LDL more than atorvastatin at a lower dose and without any ADRs.

Based solely on drug cost, Crestor is much more expensive to the patient and the plan. What is unknown, however, is the long term cost associated with the choice of this medication. Any decrease in morbidity that results in fewer doctor visits, fewer hospitalizations, or fewer emergency room visits could easily outweigh the marginally higher cost of the brand name drug. Other examples of brand name medications that can save the health system money include the new anticoagulants. Overall reductions in required monitoring, unplanned ER visits and other costs may actually save the system money over time. A one-size-fits all approach to generic drugs like a GDR incentive does not address patient care.

The existence of GDR is therefore entirely an economic measure. If PBMs want to encourage generic drug use, this is one way. The goal GDR needs to be accessible in order to actually encourage pharmacies to buy in to the concept, and not all PDMs are realistic in their expectations. Consider one 2016 Medicare Part D plan that includes a Direct and Indirect Renumeration (DIR) fee with a GDR based incentive to reduce a pharmacy’s DIR fee. The required GDR for this incentive to apply is 95%. For a point of reference, our pharmacy typically has a GDR at or slightly above 90%. All of the stores in our franchise (thousands of stores) average closer to 80%. A 95% GDR is virtually impossible to achieve unless the pharmacy works tirelessly to switch all brand-only drugs to generic drugs without respect to clinical outcomes.

Treat the Patient, Not the Numbers

Back in pharmacy school, I was told to treat the patient, not the numbers. Unfortunately, the current attempt to quantify quality in pharmacy benefit portion of Medicare (Medicare Part ) is currently limited to numbers. EQuIPP scores curtently measure the compliance, measured as the Percentage of Days Covered (PDC) for several categories of drugs along with the prevalence of high risk drugs and the pharmacy’s ability to perform assigned comprehensive medication reviews. These numbers are arguably more closely related to clinical outcomes than GDR, but they still fall short of actually measuring the impact a pharmacy can have on patient care and total health spend.

I have faith that the measures used by Medicare and others will expand to include more direct measures of care. Until then, however, I believe that if GDR is going to be used as a basis for “reward” on any plan, it should be reasonable, and not lumped into “clinical” performance. The GDR “goal” for the incentive outlined in “The Rewards of Performance” was 86%. Based on the thousands of pharmacies represent by my PSAO, this level encourages those on the lower end to improve, and offers them a reachable goal.

Do not forget, though, that the focus of pharmacy is the patient and their outcomes. Pharmacists can impact these outcomes in many ways, including not dispensing medications. Be sure you answer three questions with each patient you care for:

  1. What can you do to ensure the patient achieves their therapeutics outcome(s).
  2. Is the patient’s therapy is safe, without unnecessary ADRs
  3. How can you help the patient maximize the effectiveness of their therapy

In other words, make every encounter count.

Being Proactive

Previously, I discussed complacency as it relates to pharmacy practice. But this is not the only challenge a dedicated pharmacist faces. Even a great interventionist struggles with being reactive from time to time.

Reactive |rēˈaktiv|
adjective: acting in response to a situation rather than creating or controlling it: 

To be fair, there is no way that anyone can avoid being reactive all of the time. Pharmacy is littered with opportunities for situations to arise that the pharmacist cannot reasonably predict and properly prepare. A common example might be receiving prescription electronically for a patient you have never seen before moments before (or even as) the patient walks through your door.

Strive for Proactive

Our pharmacy regularly struggles with this exact type of situation. In one regard, it is nice to be the place many providers refer patients. But a poorly handled referral  (because you were not prepared) does nothing to help you grow your business. You only get one chance to make a first impression with a new patient. But a proactive approach will do wonders for your business image and your first impression.

A large part of being proactive is simple common sense, and most of it distills down to one thing: excellent patient and provider communication. The trick is to create a workflow that allows any unexpected order or issue to be initially addressed in an efficient manner. Note that I wrote addressed, not completed. Being proactive really means letting the patient know where you are with the issue, what is needed, and what to expect will happen next.

A Reactive Case Study

Recently, we received an unsolicited order for wound supplies from a local prescriber’s office for a patient we had never seen. The order was received by fax at 4:30 pm, and the office regularly closes at that point and no patient information (phone number, address etc) was included on the faxed order.

Because nothing was known about the patient or the order, and because the office was already closed, the pharmacist or technician places this order on the counter for the next day’s staff to address. The pharmacist’s shift ends at 5:00 pm and the pharmacist fails to let the others working know about the new order.

About 45 minutes after receiving the order, the patient presented to the pharmacy for the wound supplies that they are expecting to be ready.

When the patient arrives, the staff are confused and do not know about the order. They search around, and eventually find the order. At this point, the pharmacy staff is completely out of control of the situation and is entirely reactive to the problem. To make matters worse, the items that the patient needs are not ones stocked by the pharmacy, and the patient needs them now. The situation spirals from bad to worse, and the image of the pharmacy and pharmacist is tarnished in the eyes of the patient, who fully expected this to be done and ready.

Proactive Case (Version).

Being proactive in the case above is going to be difficult. Our first order of business would be to contact either the prescriber or the patient to assess the urgency of the order and to gain insight in to what their expectations were for our pharmacy. With the prescriber’s office being closed, the pharmacist could have the prescriber paged to gather additional information. The only other option would be to use a local phone directory to try to establish contact with the patient to determine their needs and expectations. Note that SOMETHING needs to be done shortly after the order is received, and whatever is done needs to be documented in a manner that the next person to deal with the situation will be able pick-up and immediately know what the situation is.

The pharmacist asked the technician to call the office and finds the office closed (as expected). Rather than page the prescriber, the technician attempts to look-up and contact the patient using the phone directory. They call what they believe to be the patient’s home number and get no answer, so they leave a general message for the patient indicating that they wish to speak with the patient about a new order received. Both of these calls are documented and placed into a pending queue for the pharmacy, and an action item is created and added to initiate a call to the office in the morning.

The pharmacy has done very little at this point, but they have been reasonably proactive. While do not have any additional information needed to proceed with the order, it is officially “pended” awaiting a call back from the patient and a call is scheduled for the morning to call the prescriber. The pharmacy now has documentation that they can share with the patient that will demonstrate a proactive approach.

This patient arriving shortly after the unexpected order is received is possibly the worst possible scenario, and the fact that the patient has an expectation that things will be ready aggravates the situation considerably. Two things, however, make this situation more manageable:

  1. The readily retrievable pended issue that can be matched to the new patient’s requests and
  2. The documentation of what was already done by the technician.

The above items demonstrate to the patient that the pharmacy is vested in solutions. Little time needed to be spent by the pharmacist or technician to get up to speed on the situation. Despite now being in a reactive position with this patient, the pharmacy handled the situation in the best possible way.

Being proactive applies to anything that could reasonably be anticipated. An common example might be counseling the patient on potential adverse drug reactions (ADRs) when they first receive the medication. Recently, a patient came into the pharmacy and received a shingles vaccination. The pharmacist that gave the immunization failed to proactively mention the possibility of a local rash (ADR) at the injection site that takes several days to appear and then disappear. The patient did have this local reaction and came into the pharmacy concerned. Proactively counseling would not have prevented the patient from coming to the pharmacy (when I counsel Zostavax, I ask them to come in if they have a reaction so I can assess the rash and further counsel on signs and symptoms of cellulitis for them to watch for), but it does prevent the patient from a moment of panic.

Conclusion

In business, image is everything. Being proactive can make a huge difference in all aspects of a pharmacy practice, and it is not limited to simple transactions. A proactive pharmacist will look for possible issues that are not currently issues. Things like the price of a medication might not be a problem for a 64 year old patient with excellent commercial insurance now, but thinking proactively, addressing the possibility of a less expensive medication now, before cost becomes an issue, is something that will make your pharmacy stand out. Think Proactive. Be Proactive. It can help you make every encounter count!

Letting the Patient Update your Records

Recently I spent several weeks navigating a small health issue that involved outpatient surgery. When checking in at the clinic, the receptionist handed me a tablet and asked me to complete a History of Present Illness (HPI). I did not think too much about this until a week later, when one of my colleagues asked me what our I considered to be the most common intervention our pharmacists made when working with patients. The answer, for us, is a general form of medication reconciliation. We do it every day, though the form the intervention takes varies from case to case.

In our practice, and I am sure many others are not any different, we deal with a significant number of patients that are taking their medications according to the instructions provided by the prescriber. The problem is that these directions don’t necessarily match what was written on the most current prescription. We are routinely the last to know about changes that are made in our patient’s therapies. What starts out looking like an issue with compliance really becomes an exercise in medication reconciliation.

The thought that occurred to me was this: what if we could have the patient review their own medications from time to time and alert us to any changes that have occurred? Using a tablet type device that the pharmacy staff could configure to perform this query would be an excellent use of this type of technology, but even using a simple paper copy of the patient’s profile would be a step forward.

During the time that the patient reviews the accuracy of their profile, they could also be queried about other information related to their drug therapy. Example might include recent lab values (e.g. INR or A1C) or possible Adverse Drug Reactions (ADRs). The possibilities are almost limitless!

The Implementation

Using PharmClin (our clinical software package), a medication snap-shot of the patient’s profile can quicky be printed. By attaching this to a clip board, the patient can review the list while they wait. During the process of generating the medication list, the pharmacist can also review other desired data they wish to collect, and print these for inclusion with the profile. Many common items we use are pre-populated within PharmClin (for many important drug classes) to allow quick data entry by the pharmacist.

The goal is to provide a quick review and data collection period during the patient waiting period. When the medications are ready, the pharmacist can quickly review the information for additional questions and the patient can be on their way.

This workflow would not necessarily work in all situations. If a patient calls ahead, for example, they may be in a hurry to leave (not expecting to review their profile or answer additional questions). The workflow for medication synchronization patients, likewise might need some adaptation. For this reason, any implementation needs to be fluid, and the records to be presented to the patient should be able to be generated quickly and on demand. In cases where the patient is not currently available to perform a review, simply asking them if they might have time for a quick review at a later date (maybe the next time they pick up) could plant the seed and encourage them to make time at their next visit.

Conclusion

Taking the initiative to perform medication reconciliation is a valuable service, and this can be facilitated by leveraging the pharmacists access to the patient. Invariably, discrepancies will be discovered, leading to new interventions with both the patient and the prescriber. An implementation like this one is yet another example of making every encounter with the patient count!