Pharmacy Forecast 2016-2020

The ASHP Foundation released a "Pharmacy Forecast: 2016-2020" Strategic Planning Advice back in December. My first thought is a pause thinking how long I have been out of pharmacy school. I start counting on my fingers from '99 and think, wait, what? SEVENTEEN years. I am officially the pharmacist I stood beside in one of my first pharmacy jobs. I considered him wiser. Maybe I am wiser, but I still sometimes feel like school was not too terribly long ago.

This is the fourth edition of this particular report, and I generally try to read every edition. This one somehow slipped by until this past week when I found it and read it rather quickly. There are some applicable topics for today's healthcare pharmacist that I want to dive into.

Strategic Planning versus Reactive Planning

I have not seen a lot of strategic planning within the hospital pharmacy model. We do a lot of reactive planning based on other departments mostly in line with cost management and saving money. We plan operations in how we staff our departments based solely on how many patients are in the hospital but do not use other metrics such how complicated medically is the patient? What if the patient comes in with a chronic infection versus the patient who comes in as a first-time infection? What if the patient has 20 or more home medications on board? Census is more than just number of patients. What if it is measured by a formula of disease states both acute and chronic along with number of hospital admissions in the past 5 years plus number of medications? A patient doesn't equal a patient. Maybe this applies in a surgical patient, but not in a patient with COPD, ARDS and decompensating on a ventilator due to a hospital-acquired infection.

Opening the report is a timely introduction:

"Since the start of the pay-for-performance movement1 and passage of the Patient Protection and Affordable Care Act (ACA), there has been intense pressure on healthcare organizations to improve quality while reducing costs. The stress created by this pressure has been exacerbated by proliferation of expensive specialty medications, egregious price increases for some sole-source drug products, and the escalation of generic drug prices. In response to this environment, many healthcare organizations are pursuing mergers and acquisitions in an attempt to create economies of scale without the cost of new construction. Another tactic is to partner with outside entities such as chain pharmacies."

Specifically what caught my eye this time was the section on work force. Change in practice models claim a shift from inpatient to ambulatory type practice.

"THE SHIFT TO AMBULATORY CARE As healthcare organizations respond to payment reforms that aim to lower costs and improve patient outcomes, health-system pharmacy practice leaders are challenged to optimize the role of the pharmacy work force in new models of care. One area of challenge is the shift in emphasis from inpatient to ambulatory care.1 Reflecting this change, three-fourths of Forecast Panelists (FPs) agreed that over the next five years, in at least 25% of health systems, patient care pharmacists will have umbrella responsibilities for both inpatients and outpatients (survey item 1). Further, 69% agreed that at least 25% of health systems will reallocate 10% or more of inpatient pharmacy positions to ambulatory-care positions (item 2). Consistent with anticipated growth in ambulatory care, 65% of FPs predicted a vacancy rate of greater than 10% for ambulatory-care pharmacy leadership positions over the next five years (item 5). Pharmacy staff development programs should ensure that there are adequate opportunities for education and training in management of ambulatory care pharmacy practice, transitions of care, and medication management of chronic illnesses. "

How do we lose money? Readmissions, using more inpatient days than necessary due to reasons in and out of our control, and not following certain standards that are attached to payment or removed when standards are not met while in-patient. 

Did you notice one thing? The salaries of newly hired entry-level pharmacists will decline by 10% while pharmacist technician salaries will increase?

You know I get excited about this one:

"PHARMACISTS AS PROVIDERS Nearly 80% of FPs predicted that at least 25% of health systems will have a formal plan for including pharmacists, along with nurse practitioners and physicians assistants, in advanced roles that allow primary-care physicians to care for more patients (item 4). Supporting the high level of agreement with this statement is the shortage of primary-care physicians, proposed federal legislation to grant provider status to pharmacists, and the large number of states that authorize pharmacists to establish collaborative practice agreements with physicians. 2 Recent changes in reimbursement rules related to complex chronic care and transitional care management3 support the addition of pharmacists to primary-care teams. Many health systems will be establishing a privileging process for pharmacists to ensure that those with expanded patient care roles have the necessary competence for those roles."

I suggest you read through the report. It is mostly put together through surveys, but has some very timely information for the next 4-5 years in pharmacy.

PHARMACY FORECAST 2016-2020

Sepsis and Septic Shock Guidelines

One of the main guidelines in sepsis is the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock from 2012 (updating the 2008 guidelines).

Pocket Guide

Key recommendations and suggestions:

• Early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C)
• Blood cultures before antibiotic therapy (1C)
• Imaging studies performed to confirm a potential source of infection (UG)
• Administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B)
• Infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C)
• Initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C)
• Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to acheive a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C)
• Fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG)
• Norepinephrine as the first-choice vasporessor to maintain mean arterial pressure >/= 65 mm Hg (1B)
• Epinephrine when an additional agent is needed to maintain adequate blood pressure (2B)
• Vasopression (0.03 U/min) can be added to NE to either raise MAP to target or to decrease NE dose but should not be used as the initial vasopressor (UG)
• Dopamine is not recommended except in highly selected circumstances (2C)
• Dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite acheiving adequate intravascular volume and adequate MAP (1C)
• Avoiding use of IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C)
• Hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B)
• Low tidal volume (1A) and limiation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS)
• Application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B)
• Higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C)
• Recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C)
• Prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of </= 100 mm Hg in facilities that have experience with such practicees (2C)
• Head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B)
• A conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C)
• Protocols for weaning and sedation (1A)
• Minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B)
• Avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C)
• A short course of neuromuscular blocker (no longer than 48 hours) for patients with early ARDS and a PaO2/FIO2 < 150 mm Hg (2C)
• A protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose </= 180 mg/dL (1A)
• Equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B)
• Prophylaxis for deep vein thrombosis (1B)
• Use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B)
• Oral or enteral (if necessary) feedings, as tolerated, rathern than either complete fasting or provision of only IV glucose with the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C)
• Addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hours of intesive care unit admission (2C). 

Osteoporosis: Topic of the Day

The National Osteoporosis Foundation released an update to its Clinician's Guide to the Prevention and Treatment of Osteoporosis last year (April 2014). 

The current version (2014) was released April 1, 2014. The 2014 version of the Clinician’s Guide stresses the importance of screening vertebral imaging to diagnose asymptomatic vertebral fractures; provides updated information on calcium, vitamin D and osteoporosis medications; addresses duration of treatment; and includes an expanded discussion on the utility of biochemical markers of bone turnover and an evaluation of secondary causes of osteoporosis.

Osteoporosis Guidelines

Postmenopausal women and men age 50 and older

National Osteoporosis Foundation (2014) U.S. Preventative Services Task Force among other organizations

Postmenopausal women

 American Association of Clinical Endocrinologists (2010) – North American Menopause Society (2010)

Men

Endocrine Society (2012)

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Review of the 2014 NOF Clinician's Guide

• Approach to the diagnosis and management of osteoporosis
• Universal Recommendations 
• Pharmacotherapy (Who) and FDA indications
• Sequential and combination therapy
• Duration of treatment

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Dual‐energy Absorptiometry (DXA) Bone Density Testing: Indications

• NOF guideline
  • Women > 65 years old and men > 70 years old
  • Younger postmenopausal women, women in the menopausal transition, and men age 50‐69 years old with clinical risk factors for fracture • e.g., current smoker, low body weight, history of osteoporosis, low trauma fracture in a first‐degree relative
  • Adults who have a fracture after age 50 years
  • Adults with specific conditions or medications associated with bone loss
• Other – Women 50‐ 64 years old with FRAX overall fracture risk > 9.3% (USPSTF) – 

WHO Definition of Osteoporosis Based on Bone Mineral Density testing results:

• Normal 
  • BMD within 1 SD of the mean level for a young-adult reference population
  • T-score at -1.0 and above
• Lone Bone Mass (Osteopenia)
  • BMD between 1.0 and 2.5 SD below that of the mean level for a young-adult reference population
  • T-score between -1.0 and -2.5
• Osteoporosis
  • BMD 2.5 SD or more below that of the mean level for a young adult reference population
  • T-score at or below -2.5
• Severe or Established Osteoporosis
  • BMD 2.5 SD or more below that of the mean level for a young adult reference population
  • T-score at or below -2.5 with one or more fractures

Imaging Recommendations

• Vertebral Imaging recommended for women age 70 and older and all men age 80 and older if BMD T-score at the spine, total hip or femoral neck is </= -1.0
• Women age 65-69 and men age 70-79 if BMD T-score at the spine, total hip or femoral neck is </= -1.5
• Postmenopausal women and men age 50 and older with specific risk factors: low trauma fracture during adulthood (age 50), historical height loss of 1.5 inches or more (4 cm), prospective height loss of 0.8 inches or more (2 cm), or recent or ongoing long-term glucocorticoid treatment.

FRAX was developed to calculate a 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture (defined as clinical vertebral, hip, forearm or proximal humerus fracture). FRAX algorithm available at www.nof.org as well as at www.shef.ac.uk/FRAX.

FRAX is for postmenopausal women and men age 50 and older. In patients being pharmacologically treated for osteoporosis, clinical judgment must be use in interpreting results. No treatment in 2 years could be interpreted as untreated. Femoral neck BMD is preferred in calculating FRAX.

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Diagnosis of Osteoporosis (WHO Criteria) (Postmenopausal women and men >/= 50 years of age)

• T‐score at ‐1.0 or above  (SD) Normal
• T‐score between ‐1.0  and ‐2.5 (SD) - Low bone mass (Osteopenia)
• T‐score at or below ‐2.5 (SD) - Osteoporosis
• T‐score at or below ‐2.5 (SD) with one or more fractures - Severe or established osteoporosis SD = standard deviation

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Diagnosis of Osteoporosis (International Society for Clinical Densitometry 2007 Guidelines)*

• Z‐score above ‐2.0 (SD) “Within the expected range for age”
• Z‐score at or below ‐2.0 (SD) “Low bone mineral density for chronological age” or “Below the expected range for age” SD = standard deviation Premenopausal Women, Men < 50 Years of Age, and Children * These criteria are never used alone to diagnose osteoporosis in these populations

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RECOMMENDATIONS IN ALL PATIENTS:

Several interventions to preserve bone strength can be recommended to the general population. These include an adequate intake of calcium and vitamin D, lifelong participation in regular weight-bearing and muscle-strengthening exercise, cessation of tobacco use, identification and treatment of alcoholism, and treatment of risk factors for falling. 

Bone‐Healthy Lifestyle:

• Calcium - Recommended elemental calcium intake should be obtained ideally through dietary sources + supplements
• Age Group Recommended Daily Intake Maximum Daily Intake
  • 19-50 years 1000 mg
  • 50-70 years 2000 mg Men = 1000 mg Women = 1200 mg
  • ≥ 71 years 1200 mg

According to the updated 2014 National Osteoporosis Foundation guideline, intakes of calcium in excess of 1200 to 1500 mg per day could place a patient at increased risk for kidney stones, cardiovascular disease (CVD), and stroke. (J Bone Metab 2014;29:531‐3; J Bone Metab 2014;21:21‐8; Am J Clin Nutr 2011;94:270‐277)

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Vitamin D: This is the amount needed to maintain the majority of healthy patients within the sufficient range

• Age Group Recommended Daily Intake
  • National Osteoporosis Foundation (2014)
    • <50 years 400-800 units (4000 units max daily intake) 
    • ≥ 50 years 800-1000 units (4000 units max daily intake)
• Institute of Medicine (2010)
  • ≥ 71 years 800 units (4000 units max daily intake)
  • 51-70 years 600 units (4000 units max daily intake)
  • 19-50 years 600 units (4000 units max daily intake)

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When to Consider Drug Treatment

• History of (low trauma) hip or vertebral fracture
• T‐score - ‐2.5 at femoral neck, hip, or spine by central DXA
• Postmenopausal women and men 50 years of age if T‐score between –1 and –2.5 and 10‐year hip fracture probability of 3% or a 10‐year all major osteoporosis‐related fracture probability of 20%

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Bisphosphonates:  inhibit osteoclastic bone resorption and reduce osteoclast activity and beneficial effect on osteoblasts.

• Drug holidays are being considered for bisphosphonates to prevent which serious long‐term adverse effects 
• Show residual effects after discontuation
• Evidence for efficacy beyond 5 years is limited, whereas rare safety concerns become more common beyond 5 years. 
• Reasonable to discontinue after 3-5 years in patients who have a modest risk of fracture after the initial treatment period, but in high risk, continued treatment or alternative treatment should be considered.

Non-Bisphosphonates: produce temporary effects that wane with discontinuation.

Duration of Treatment and Drug Holiday

• Alendronate: Duration of treatment 5 years. Assessment for reinitiation: 1-2 years
• Risedronate: Duration of treatment 5 years. Assessment for reinitiation: 1 year
• Zoledronic acid: Duration of treatment 3 years. Assessment for reinitiation: 2-3 years

Denosumab Role in Therapy

• FDA osteoporosis indications
  • Postmenopausal women and men with high fracture risk (Osteoporosis fracture, multiple risk factors, can’t use other meds)
  • Androgen deprivation therapy for nonmetastatic prostate cancer
  • Adjuvant aromatase inhibitor for breast cancer
• AACE guideline – first line
• Increases BMD for at least 8 years
• Vertebral, hip, & nonvertebral fracture prevention
• Quicker reversal with medication discontinuation
• Adverse effects: Common adverse reactions (> 5% and diff placebo)
  • Back, shoulder, leg, and musculoskeletal pain – Increased cholesterol – Cystitis
  • Cases of MRONJ and atypical fractures

Raloxifene Role in Therapy

• FDA indications
  • Osteoporosis prevention and treatment
  • Postmenopausal women with osteoporosis and/or at high risk for invasive breast cancer
• AACE guideline –Second‐ and third‐line therapy
• Dose ‐ 60 mg daily
• Contraindications ‐ active or past history venous thromboembolism
• Precaution – risk for stroke
• Adverse effects – Vasomotor symptoms (hot flushes) – Leg cramps – Breast tenderness – Spotting – Venous thromboembolism – Box warning – fatal stroke

Teriparatide Role in Therapy

• FDA indications
  • Postmenopausal women at high risk for fracture
  • Men with primary or hypogonadal osteoporosis at high risk for fracture
  • Glucocorticoid‐induced osteoporosis
  • High fracture risk
    • Previous fracture
    • Extremely low BMD (T‐score < ‐3.5)
    • Multiple risk factors for fracture
  • Teriparatide Dose, Selection, and Common Adverse Effects
    • 20 mcg subcutaneously daily for 24 months
    • Once weekly injection in trials – ? Start antiresorptive agent before end of therapy
    • Contraindications – Skeletal muscle radiation, bone cancer, hypercalcemia, Paget’s disease
    • Common adverse effects
      • Orthostasis – first doses
      • Nausea, arthralgia, leg cramps
      • Hypercalcemia (check calcium at baseline)
      • Box warning ‐ osteosarcoma (animal data)

Calcitonin: Role in Therapy, Efficacy, Dose, and Adverse Effects

• FDA indication – osteoporosis treatment for women   5 years post menopause with low bone mass
• AACE guideline – fourth‐line therapy
• Only vertebral fracture prevention
• Dosing –Intranasal ‐ 200 units daily alternating nares
• Adverse effects –Nasal – rhinitis, epistaxis, irritation –Subcutaneous – pain, redness –Other – nausea, allergic response, backache, headache –FDA post‐marketing analysis for cancer risk

References:

• National Osteoporosis Foundation (2014)

• U.S. Preventive Services Task Force – calcium vitamin D (2013)

• Ann Intern Med 2013;158:691‐696

• U.S. Preventive Services Task Force – screening (2011) – www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm

• International Society for Clinical Densitometry (2013) – www.iscd.org/documents/2013/07/2013‐iscd‐official‐ positions‐adult.pdf

• American Association of Clinical Endocrinologists(2010)

• Endocr Pract 2010;16(Suppl 3):1‐37

• North American Menopause Society (2010) – www.menopause.org/docs/default‐document‐ library/psosteo10.pdf?sfvrsn=2

• Endocrine Society (2012) – J Clin Endocrinol Metab 2012;97:1802‐1822

CPOE Implementation: A Status Report

Back in 1999, the Institute of Medicine (IOM) published the article "To Err is Human: Building a Safer Health System," which focused on preventing adverse drug events (ADEs).

Computerized Physician Order Entry (CPOE) was touted as a tool to reduce ADEs. Subsequent studies pointed out how it would help prevent medication errors and improve patient safety.

The US government has pushed computerization, as well.

"To improve the quality of our health care while lowering its cost," President Barack Obama said back in January 2009, "we will make the immediate investments necessary to ensure that, within 5 years, all of America's medical records are computerized."

It has now been 6 years, and medical records are still not 100% computerized.

Implementation of CPOE has been slow due to its complexity and huge cost. To further entice hospitals to jump on board with electronic health records (EHR), the US Centers for Medicare and Medicaid Services (CMS) sends money to facilities that meet set goals.

EHR systems are not something that can be rushed, but for dollars, workarounds happen. There is also the threat of penalties if systems are not implemented.

As the EHR market has matured, the once-crowded field of vendors has narrowed significantly.

At the end of 2013, just 10 vendors accounted for about 90% of the hospital EHR market: Epic, MEDITECH, CPSI, Cerner, McKesson, Healthland, Siemens, Healthcare Management Systems, Allscripts and NextGen Healthcare, according to Becker's Hospital Review.

No CPOE standardization

CPOE systems are all different, so how are they compared? A hospital may have implemented a CPOE, but does that equate to a sufficient system? Do groups like Leapfrog take into account CPOE errors or just the percentage of usage by prescribers? Do we rate CPOE systems like we rate hospitals?

Data show vendor CPOE market share, but there are no rating systems to evaluate the systems after implementation, or even a list of hospitals that decided to change systems due to issues.

Limited medication profiles

Another issue with CPOE is its lack of a coherent view of a patient’s profile while entering medications. It is also difficult to verify orders without a comprehensive view of the medications that the patient is taking.

This lack of a full picture causes the user, whether prescriber or verifier, to rely on the software alone, rather than a comprehensive approach. Seeing the whole picture while entering and verifying orders would probably decrease errors.

Alert fatigue

When CPOE systems are used for other tasks aside from entering and verifying orders, there is more alert fatigue.

On the pharmacist verification end, it is common to see alerts of different significance with nothing to differentiate high importance from low. For example, the same type of alert may be used to discuss inventory, prior authorization, and other messages that take away from the verification role, even though many of these alerts previously happened at order entry.

Pharmacists should not have to think pharmacologically and pharmacokinetically about how a medication works along with alerts dealing with inventory, cost, and formulary status that once occurred at the front end. There should be a way to differentiate these alerts and have them fire at appropriate times, rather than during actual medication review. 

Tailoring the CPOE to be more user-friendly for the prescriber often comes at the expense of more frustration on the back-end with verification. For example, a CPOE may allow a prescriber to free type directions for medications taken irregularly (3 days a week, different strengths on different days), choose non-formulary medications rather than built-in CPOE formularies, and remove alerts that need to be seen at order entry.

In this way, verification becomes more of an order entry “fix” role that pulls attention from clinical aspects of verification.

CPOE software is also designed under the assumption that prescribers and verifiers are working in a quiet environment, but both sides are working in noisy environments. When a phone is ringing, a patient is yelling, and a nurse is asking a question, quick pop-up alerts may not be enough of a warning. Even the most focused individual will make mistakes.

More duplicate orders

The Journal of the American Medical Informatics Association published a study pre and post-implementation of a CPOE in an ICU and found that duplicate medication ordering errors increased after implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001).

Sometimes, there is a lack of integration between laboratory values, both inpatient and home medications, and other data or different modules that do not communicate smoothly.
 
Last but not least, if the staff is not happy with the CPOE software that is implemented, they are not going to use it as designed. - See more at Pharmacy TImes.

Why Hospital Pharmacy Struggles

It is no surprise to hospital pharmacists that there is an internal battle going on. I cannot outline the struggle without first describing how hospitals get paid. Hospitals are a business and businesses cannot continue to function without money to pay its employees and generate profit.

Hospitals are paid by different methods depending on who is paying the bill.

Medicare: the federal program for the elderly usually pays the hospital a flat fee per case depending on the case. There are around 750 different diagnostic related cases (D.R.G.'s) that can be billed and each command a flat rate regardless of what happens in the hospital. These flat rates are changed due to lobbying and advice from commissions and other methods. Many times hospitals claim the payments received are below cost which causes the hospital to lose money.

Medicaid: the federal-state program for the poor, blind and disabled hospitals receive the same D.R.G's or a set amount of dollars per day (per-diem) or fee-for-service (F.F.S.) payments. These are set by state governments. Again, many times hospitals claim the payments received from Medicaid are below cost which causes profit loss.

Private insurers: purchased by consumers and pay hospitals on the basis of per-diems or fee-for-service. These usually exceed hospitals' costs and help override the losses from Medicare and Medicaid. Private insurers also help with net profits for the hospital and are negotiated yearly.

Breaking down the particular fees agreed upon, it's fairly evident that the pharmacist's role in billable services is on the distribution aspect: the medication provided and the rest is dollars saved but not billed. For example, if I dispense 2 bags of IV vancomycin, the hospital can bill $XX for the medication. If I recommend changing vancomycin to an oral antibiotic, the savings are due to medication and delivery costing less. I am not billing the other aspects of the IV to PO change. The patient has less chance of infection with an antibiotic given by mouth than IV and is easier to administer. Maybe even the cultures drawn show equal sensitivity and the choice of by mouth antibiotic is an ideal choice over choosing IV. There are cost savings for the drug (still distribution in nature) and costs in drug delivery, but the consult itself to change a medication has no billable service to the pharmacy department but indirect savings to the hospital as a whole. There are also cost savings with preventable adverse drug errors in regards to length of hospital stay billed, but nothing billed on catching anything amiss on a patient's profile, rounding with physicians, billing a "consult" or anything tied to a clinical pharmacist directly as a provider.

In other words, pharmacists command high salaries but do not have a way to bill for the same amount in return. Pharmacists and pharmacies cost the hospital a lot of money.

Hospitals are starting to learn that using pharmacists to cut medication errors cuts down on readmission (financial penalties with reimbursement). They are learning that there are costs tied to a patient experiencing an adverse drug reaction and other indirect cost savings, but the hospitals still need a return on their investment. Perhaps that is where provider status for pharmacists will fill in the gap?

Not only do we struggle with what we bill and what we cannot bill, we also struggle with being segmented within our own pharmacy departments. Distributive pharmacists (order entry pharmacists) are looked upon as aging dinosaurs out-of-touch with the clinical aspect of rounding with physicians and making real-time recommendations at bedside and new graduates state, "I don't want an order entry job. I want to be a clinical pharmacist." There is a division that seems to be encouraged with residency programs, fellowships, and board certification leading to "clinical" jobs and none required for order entry jobs. Maybe you are one of the lucky ones in a more progressive hospital that tries hard to incorporate both models into staffing with pharmacists decentralized on the hospital floors interacting "clinically" with nursing, physicians and patients. Maybe you are still stuck to a computer monitor in the basement of a hospital barely interacting with anyone directly. The models are all over the place because of the lack of being able to bill for what pharmacists provide besides a bag of medication.

Another struggle is that clinical pharmacists do not want to be bothered by pharmacy operational problems or regulatory issues. Operational problems affect patient care as well and translates into costs for the department and hospital. 

The last struggle that I have observed over the last fifteen years is the lack of excellence in leadership. I do not have many peers who strive for leadership roles in pharmacy but are fine to sit back and just work as a pharmacist rather than a manager. There are not a lot of strong leaders teaching and mentoring others on how to lead within the pharmacy and because of that pharmacists do not have a lot of power or clout to make change happen inside the pharmacy. This also translates into the lack of leadership and power where change happens on a government level.

What is the answer? I am hopeful that provider status will open the door to pharmacists becoming a return on investment for hospitals rather than a huge expense, but I also believe that there should be more meshing with understanding the business side of hospital pharmacy with clinical pharmacy because the two together would benefit what should be the ultimate goal of a hospital: patient care and minimizing costs.

Pharmacists in the ER Equals Better Patient Care

One of the biggest impacts a pharmacist can make in the hospital setting is in the emergency department (ER). There has been a growing interest and trend in placing pharmacists in the ER to review medications, both reconciliation of home medications and medications administered in the ER to ensure correctness and cut down on medication errors and drug interactions that contribute up to 7,000 yearly deaths in the US. A pharmacist in the ER can review real-time orders that are typically bypassed by staff pharmacists due to the urgency of an ER patient.

Pharmacists can also improve flow of patients through the ER, educate prescribers and staff development about medications and their costs and also utilize the ER as a place to precept and mentor students and residents. Pharmacists can participate in codes, help with admissions in home medications and help with discharge medication reconciliation. Pharmacists in the ER can also be involved with the ER department in providing presentations, publications and other activities to the department. Pharmacists can monitor the use of expensive medications to make sure use is consistent with approved criteria (Factor VII, alteplase, etc.) and conduct MUEs in the emergency room setting. These pharmacists could also be involved with microbial culture follow-up. The emergency department is usually a place of unpredictability in acute illnesses and patient volume. High risk medications are used more often and a greater chance of a medication error reaching the patient.

Currently in most hospital settings, hospitals use a clerk to fill out a home medication sheet which typically can include errors in drug name, drug strength and directions. Many times staff pharmacists are clarifying home medications days later than what is optimal. I have personally witnessed mistakes in high-risk medications like warfarin that are discovered days later. In short, when a patient is admitted, they are prescribing for themselves with no oversight from a pharmacist, and physicians do not want to take ownership of what the patient takes at home since they are presenting with something acute that may have nothing to do with the herbals they take on the side.

The American Society of Health-System Pharmacists (ASHP) believes every hospital pharmacy department should provide its emergency department with the pharmacy services that are necessary for safe and effective patient care. The Joint Commission also has compliance requirements that can be met with a pharmacist in the emergency department (MM.4.10. which requires that all medication orders be evaluated by a pharmacist prior to administration of the first dose and MM 7.10 which identifies high-risk or high-alert medications and all the processes involved from procuring to monitoring and medication reconciliation). One of the National Patient Safety Goals is to accurately and completely reconcile medications across the continuum of care which would include the first stop in the emergency department.

One of the most common reasons most hospitals do not employ emergency room pharmacists is due to cost. Small hospital pharmacies are staffed at a bare minimum. Most hospitals do not realize that pharmacists working in the emergency room can reduce readmissions, medication errors and drug interactions to save money but more importantly increase patient safety while being treated for an acute illness.

1.       Impact of a prescription review program on the accuracy and safety of discharge prescriptions in a pediatric hospital setting. J Pediatr Pharmacol Ther. 2008 Oct;13(4):226-32. doi: 10.5863/1551-6776-13.4.226.

2.       Levy DB. Documentation of clinical and cost saving pharmacy interventions in the emergency room. Hosp Pharm. 1993;28:624-627,630-634,653.

3.       American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in emergency preparedness. Am J Health Syst Pharm. 2003; 60:1993-5.

4.       Cohen V, et al. Effect of clinical pharmacists on care in the emergency department: a systematic review. – Am J Health-Syst Pharm. 2009;66;1353-1361

National Patient Safety Goals: The Joint Commission

Should Pharmacists Become Board Certified?

I enjoy brainstorming with other pharmacists on becoming board certified.

I remember back in 1998-1999, the assistant dean of my alma mater, the University of Tennessee at Memphis, stressed how important it was to consider residency and board certification. At the time, I was 25 years old and making decisions that would impact me for life.

I decided back then to decline that path. I only saw the dollars that were before me in retail pharmacy and the student loan debt approaching 6 figures. So, I quipped, "Why would I want to work for half pay or less for a whole year?" and "Why would I want to spend money and time to become board certified when there are no immediate financial rewards?"

Hindsight is 20/20. Fast forward to a 40-something in the profession for more than 14 years experiencing all sorts of different pharmacy experiences. After trying most, I have regrets regarding my earlier decisions. I regret not doing a rotation overseas. I regret not doing a residency. I regret that I dismissed it all for more money.

I know that not everyone feels like me, and that is understandable. Perhaps I am just a different sort who realized fairly quickly that I was falling behind. Whatever the reason, I decided to pursue a Board Certified Pharmacotherapy Specialist (BCPS) certification a couple of years ago. I work in a small community setting in a smaller city, and although it is nothing like Memphis in terms of clinical opportunities, such opportunities can be found with a little luck. Passing the test was probably up there with my other personal accomplishments.

Why should you become board certified?

1. According to the Board of Pharmacy Specialties (BPS) website, "From patient to provider, the value of the BPS-certified practitioner registers throughout the health care continuum. For pharmacy professionals, documentation of specialized experience and skills yields the additional benefits of personal satisfaction, financial rewards and career advancement." I definitely agree, but most BCPS-certified pharmacists I have spoken with did not receive a raise unless they changed jobs. While BCPS certification may have helped with landing a clinical job in the past, it might just be something to separate you from a PharmD without BCPS on any pharmacist job interview today.

2. If you have been out of school for more than 5 years, I bet you have already forgotten some of what you have learned. You can either depend on your local hospital's computer system to remind you of every little thing OR you can take charge of what you know and remain committed to being the best pharmacist you can be. Think of it like this: if you work in a hospital and are commanding larger salaries than new graduates with fresher knowledge, there comes a point at which you are replaceable. Remain competitive in your field, which means using continuing education to really learn something, rather than last-minute cramming to renew your state license.

3. A paper published in 2006 states that "Future Clinical Pharmacy Practitioners Should Be Board-Certified Specialists.” In the past, clinical pharmacists have not made board certification a priority, but this is changing rapidly in both clinical and staff positions. As pharmacists move in the direction of becoming reimbursed professionals for optimizing medications, there will be a trend toward licensing agencies requiring board certification in certain scenarios. Sure, that is not the case today, but if you would have told me in 2000 that the market would be in its current shape with oversaturation and residency demand, then I would have done things very differently in 1999-2002.

4. The PharmD curriculum is not enough to get you in sync with other health care professionals. Experience in dealing with physicians and their assistance along with board certification will take you to the next level in recommending appropriate treatment. Placing new graduates in clinical positions without experience and expecting them to build relationships with clinicians is not the best-case scenario for building pharmacist clinical teams. Requiring board certification ensures a higher level of expertise and is moving toward becoming a requirement in many hospitals. The benefits in just preparing and studying for the test are immense, in my experience.

5. Last, but not least, you should become board certified to give your patients the best care possible. This was my number 1 reason. I remember the day when I sat at my desk years ago and realized I had no idea about new practice guidelines and that order entry had essentially turned me into a robot dependent on the computer. I realized that it was time to make some personal changes that would cost me both dollar and time, yet result in amazing benefits for my patients.  

Most pharmacists are reluctant to pursue BCPS certification because no one wants to fail, much less fail twice. Although it is humbling to fail once, it is euphoric to pass, even the second time.

I hope to inspire more pharmacists to be their best in our profession. If you fail, realize that any amount of learning will significantly change how you practice pharmacy. 

A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition

Click on image to order A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition (no paid link on this, just for your information)

            As a pharmacist and a clinician at my local hospital, there have been times where I am starting a new PN (total parenteral nutrition) and needed help beyond the usual formula or write-up that we use. In the information age, we have a diverse amount of information online at our fingertips; however sometimes this information can be from sources that are not legitimate. I can google PN and a disease state and hope for something relevant, or I can seek out material that is tried, true and tested.

            The A.S.P.E.N. Parenteral Nutrition Handbook, 2nd Edition is a pocket-sized handbook or quick reference that covers many parenteral nutrition topics with students in dietetics, nursing, medicine and pharmacy in mind. There are 10 fully revised chapters from the 2009 1st edition including: 

1.  Chapter 1: Nutrition Screening, Assessment, and Plan of Care

2.   Chapter 2:  Overview of Parenteral Nutrition

3.   Chapter 3:  Parenteral Nutrition Access Devices

4.   Chapter 4:  Parenteral Nutrition Formulations and Managing Component Shortages

5.   Chapter 5:  How to Prescribe Parenteral Nutrition Therapy

6.   Chapter 6:  Review and Verification of Parenteral Nutrition Orders, Preparing Parenteral Formulations, and Ordering

7.   Chapter 7:  Parenteral Nutrition Administration and Monitoring

8.  Chapter 8:  Complications of Parenteral Nutrition

9.  Chapter 9:  Medication-Related Interactions

10.  Chapter 10:  Home Parenteral Nutrition Support

These chapters cover many of the relevant topics for the patient receiving parenteral nutrition (PN) including some newer topics on order review, compounding, and drug shortage management. Also this handbook contains evidence-based guidelines from the A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations (JPEN, March 2014) and A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing (JPEN, March 2014).

I have taken the time to utilize this handbook while dosing PNs in the past few weeks and have found this reference accurate while covering many of the topics I needed.  I especially enjoyed the chapter on parenteral nutrition complications.  I found the topics succinct and spot-on for finding quick information on a couple of questions I had on a patient’s PN.

If you are looking for a guide with a broad range of topics related to PN that will help your student, resident or even new pharmacist managing PN, this guide will help you tremendously.