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

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

Could a Robot Do Your Job?

Could Artificial Intelligence Replace Pharmacists?

The question that pharmacists need to ask themselves is, “Could my job function be replaced by artificial intelligence?” Many would respond confidently with a no. According to Geoff Colvin of Fortune magazine, author of Talent is Overrated and Humans are Underrated, if your job does not have human behavior in its function, you would be quite surprised to hear you are replaceable. Computers and robots cannot show empathy, compassion, sympathy or collaboration. Artificial intelligence (AI) can check drug-drug interactions, drug-disease state interactions and make recommendations and much more.  AI can check medication compounding and final product with better accuracy than human accuracy. To survive long-term, pharmacists need to provide more than just a final verification with order entry and final product.

Pharmacists’ jobs are a big target for more automation especially since medication errors are a big issue in public health safety. According to the Institute of Medicine, an estimated 7,000 deaths in the U.S. each year are due to preventable medication errors. Medication errors also cost about $16.4 billion annually. Pharmacists are slowly being replaced at the University of California San Francisco Medical Center and are responsible for receiving prescriptions, packaging, and dispensing.

Pharmacists need to collaborate with other healthcare professionals

Pharmacists need working relationships with physicians and other healthcare professionals in the hospital or in the ambulatory care setting. We need to be a valid member of the healthcare team offering real-time advice and recommendations on patients during rounds. We also need improved communication. If we merely sit in a seat in the same room of a hospital entering orders and checking the final product, we could easily be replaced by artificial intelligence.

It becomes even more vital for the Pharmacist Provider Status bill to pass simply to help add billable functions to our role instead of just billing for product. I have no doubt with the right system and hospitals willing to pay for the technology, pharmacists could lose their role in order entry and checking. We make mistakes because we are human and checking is not a complicated process. We already have the potential to allow computer systems to do the allergy checking and drug interaction checking for us without much of a thought. We now have prescribers entering orders directly into the computer. It is not unfathomable for a computer to check what the prescriber entered with much more accuracy than a pharmacist for less money.

Pharmacists need to be involved with direct patient care.

Medication reconciliation is a place where pharmacists could have patient contact and ensure that medications are entered correctly into the electronic medical record. Pharmacists could be more involved in warfarin and diabetic education collaborating with other professionals. Pharmacists could also be involved with educating patients about their medications before they leave the hospital. All of these things do cost money for the hospital since they are mostly not billable, but the pharmacist would be able to do more than what a computer could do alone.

A computer is unable to replace human interaction. Pharmacists need to bring more value to the healthcare table than functions that can be done by artificial intelligence.

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.

Pharmacists Wanting a Career Change?

If you could go back to the day you decided to become a pharmacist, would you do it again?

I will pause and give you time to think though if you are like me, you may not need that much time to say yes or no.

Someone in my family who I respect told me recently that pharmacists generally are a group of whiners with the inability to manage or lead very well. You cannot generalize the whole lot of us in one broad statement, but...

Why are pharmacists so unhappy?

Well for starters, pharmacists are not in the position to be power players of knowledge and expertise. Yes, we are players of knowledge but we cannot really bill for it, so all of the advice we give to those at the counter and prescribers at the hospital is free, thus we have no power. Consults are free. Telling someone how to take their medication is free and in fact is taking away from the 150 prescriptions per hour that the district managers and corporate leaders are needing to make a profit. We are no different in our billing structure than when I worked in a seed factory working a quota for money on the line and if I hit the magical 101% production, I could make a little more money.

Pharmacists don't make businesses a lot of money but are highly paid. In other words poor return on investment.

The best article I have read on the matter is written by Jerry Fahrni "Why Pharmacy Continues to Fail." I highly recommend it. It sheds light into all things pharmacy and how the profession continues to stagnate from business to leadership.

So, what to do. Stay or find a new career?

That is the question. Do we wait around for law to change, which it will eventually, or do we go ahead and research and find another way to make a difference in patients' lives? I still believe nursing would have been a better choice with expanded provider status, working hand-in-hand as part of the healthcare team with direct patient care and learning directly from physicians. Nurses can operate walk-in clinics with retail pharmacies and bring business while we are still getting paid for dispensing.

Pharmacist Provider Status Gains Traction

The Top Searched Medications of 2014

The Top Searched Medications of 2014

Interested in the top searches in medications in 2014? This year’s list includes:

1. Antibiotics: No, this is not a drug but a drug category; however I suppose capturing the whole category is OK. We have issues with antibiotic resistance, drives for antimicrobial stewardship, and drug-drug interactions. 

2. Adderall: Increased from #6 search last year though it’s been around for years. Adderall has spent the past 10 years in the top 10 of medication google searches.

3. Alprazolam: Same as Adderall has been searched enough to be in the top 10 for 11 years.

4. Ibuprofen: Who knew but I bet all the parents of kids are constantly looking up doses.

5. Steroid: This could capture creams, tablets, and parenteral.

6. Tramadol

7. Tylenol

8. Paracetamol: Another term for APAP 

9. Naproxen

10. Aspirin

11. Sildenafil: I wonder if online pharmacies are the reason? Privacy in purchasing.

12. Sertraline

13. Amoxicillin

14. Gabapentin

15. Cyclobenzaprine

16. Analgesic: Again a class of drugs that contain many specific ones on this list.

17. Fluoxetine

18. Bupropion

19. Omeprazole

20. Escitalopram

With mostly medications for pain, depression/anxiety, and infection the list captures usage as well. Cite top prescribed drugs in same year?

Pharmacy Distractions

Yesterday, I decided to record the number of distractions I faced on a regular work day. This proved to be a distraction in itself considering the pharmacy where I worked is in an open plan where technicians, phones, cubicles and door to the hospital hallway are all within ten feet of where I sit. There are four or five telephone lines which ring regularly. There are usually one to two other pharmacists sitting within five feet and two to three technicians in the same vicinity.

Yesterday I recorded over 150 interruptions. I even faulted myself for starting personal conversations which distracted others. 

What are some things we can do to make the pharmacy workplace have less distractions? Interruptions contribute to medication errors and having a dedicated space where interruptions are not allowed should be implemented. Chemotherapy entry, preparation and checking definitely falls into this category. The Institute for Safe Medication Practices found that each interruption is associated with a 12.7% increase in errors. I have personally attempted to enter new chemotherapy on a patient in the noisiest place where phones are ringing consistently, technicians are interrupting the workflow with issues on the phone that they cannot handle and other staff are just walking by to chat, all while the TV is reporting the news and a radio in the back is piping out 80s music. It is enough to cause me to go into panic mode. Ask for a dedicated space with less distractions or a no-interruption zone. You may not get it but it is on the record that you asked. In the meantime, one tip I have tried is headphones with something soothing to completely block out all noise when concentration is key. Bose makes great noise-canceling headphones that work! Though I would love to work in silence, blocking out everything but one sound is better than ten sounds all interrupting and distracting what you are trying to do safely. 

Another source of interruptions is when a medication is out-of-stock. This issue can completely lead a pharmacist into a rabbit hole of issues. First I have to ask if we have the medication which leads to comments of inventory failure and what process is to blame. Second we have to call other hospitals and ask to borrow a medication which interrupts them as well. We also have to call a courier service to deliver the medication which leads to delay in delivery of treatment to the patient. If we could reduce missing medications, we could reduce distractions and phone calls. This type of interruption falls under system distractions along with medication timing and other issues that causes distractions on how we handle system failures or deficits.

Alert fatigue is another source of distraction. It is common for me to receive five or more alerts per order when entering a medication with the majority being unnecessary. For example, when entering a sodium chloride IV fluid, I will routinely be alerted that the chloride in the IV fluid will be a duplication with the potassium chloride (chloride duplication). I will also receive an alert that sodium chloride is on national backorder. Most of the times medication alerts include what is formulary, nonformulary, to notify IT staff when medication is depleted, duplication of class that isn't clinically significant, insignificant labs that can include a time period longer than current hospitalization and even how to enter medications differently for a new process that can change quite often. It is used more times than not as an email to communicate inventory issues that should be saved for another time and not when entering a medication where the most important issues are drug, strength, indication, directions and allergies. All of the important stuff can be diluted quickly by things that are nowhere near as important than the task at hand.

Educating the staff is very important in handling distractions and improving patient safety. Educating the staff to know when to interrupt with something important that cannot wait a second and when to write a note for the pharmacist to handle a few minutes later is important. Placing phones with multiple lines in a separate area to lower distractions while the pharmacist is entering orders or checking orders and/or having a designated technician to answer phones and not filling is an idea to consider. Also educating a technician on how to answer the phone and troubleshoot is invaluable!

The Institute for Safe Medication Practices has looked at this issue and has an invaluable write-up about things that can be done to help pharmacists and technicians focus on what matters most... patient safety.

The Patient that Made the Difference

Her initials were the same as mine, and we greeted one another after a few phone conversations with "Hi, BB, it's BB." 

We had this connection. Two grown women. Both single and young. The big difference was that I was her home health pharmacist in charge of her pain pump and she had terminal cancer.

When you are halfway through your life (and maybe your career) there comes a time when you look back and remember the patients that change your life and maybe even validate the half-ass "I want to be a pharmacist" decision made by a young twenty-something with no idea how profound the decision would have on every aspect of your life. 

B wanted to go to Florida and be in the ocean one more time.  Her boyfriend was in Florida and since she knew her time was short, the ocean was on her bucket list... with the dilemma of a pain pump. That's where I fit into the story, finding a creative way to make it happen along with a couple home health nurses and some supplies. She was a nurse, too, and was a big part of her own end-of-life care.

It has been eleven years ago. B was 33 years old. I had been a pharmacist for only four years; a baby in the working world with little idea of how that year would change my life.

I had these biweekly chats with her concerning supplies she might need, including the intravenous pain medication itself but we often left the rigid discussion of how we were connected through pharmacist and patient to human conversation of "please do monthly self breast exams," to "live a full life and travel Beth!" to "who cares what people think about you, you certainly won't care when you are at the end of your life" and "I wish I could have been a mother." It was almost as if I had been granted insight into the world of a life ending way too soon and maybe learning my own lesson along the way. I sure did.

I finally went to meet her the last few days of her life. I waited much too long to meet my friend and that is my only regret. There is a professional line you have to keep in place with your patients, but sometimes that looks a little different patient to patient.  She squeezed my hand and had a picture of her vibrant former self before cancer ravaged her body sitting on her nightstand. "You are beautiful," I had said although wishing I had arrived months before.

Pharmacists and nurses along with other healthcare providers can make a difference. 

I witnessed the same thing with my father-in-law's nurse at the VA in Nashville caring for a man that had no family at bedside because of a lack of a relationship with his family. His nurse was amazing and was not only his nurse but his friend.  

I saw it again in Memphis on a hospice rotation where I saw different patients in different stages of terminal illness along with their families in different stages of grief. 

My life changed with each of these moments and patients who touched my life and maybe that young twenty-something college student knew more than I thought about selecting a career?

Cholesterol Guideline Changes

A whopping 13 million more Americans will now be taking statins due to the recent changes in the guidelines formulated by the American Heart Association and the American College of Cardiology (source:  NEJM).  The new guidelines released by the American Heart Association were released back last November.  

The new guidelines are taking a very different approach.  Rather than focusing on specific end targets for cholesterol, the guidelines focus more on risk and prevention of strokes and heart attacks.  They disregard the guideline that doctors should prescribe cholesterol-lowering drugs when a patient's LDL, or bad cholesterol, reaches a certain threshold — in recent years, above 130.  The guidelines also say everyone with known heart disease should be taking statins.

The guideline recommends statin therapy for the following groups:

• People without cardiovascular disease who are 40 to 75 years old and have a 7.5 percent or higher risk for having a heart attack or stroke within 10 years.  (According to a new risk calculator).
• People with a history of a cardiovascular event (heart attack, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack, or coronary or other arterial revascularization).
• People 21 and older who have a very high level of bad cholesterol (190 mg/dL or higher).
• People with Type 1 or Type 2 diabetes who are 40 to 75 years old.  The drugs are also recommended for younger adults if their LDL cholesterol is over 190.

(Just for reference the old guidelines, using a different calculator, prescribed statin use at a 10-year risk above 20 percent, along with an LDL-cholesterol reading above 130).

As far as side effects go:

• FDA's Guidelines

10 Rules of Email Etiquette at Work

One of the most frustrating things about pharmacy jobs today, for me at least, is the lack of email etiquette at work.  I know it sounds crazy to even bring this up, but I have been pondering this post for years.  You see, I have been guilty of not being the best at email, but over the years it is becoming crystal clear the errors people make every single day that not only make the sender look badly, but can actually fracture a team.  Without further ado, the email changes I would like to see in the pharmacy and hospital world with a disclaimer that since I have been practicing for almost 15 years, these examples go way back in time. 1.  REFRAIN FROM REACTIVE EMOTIONAL EMAILS.  If you find yourself getting worked up over what you are reading, do your best to avoid pressing reply and firing off a response.  Avoid sending emails when you’re feeling any type of negative emotion. These types of emails will ALWAYS make you look unprofessional and maybe even unstable.  Before you send off that email rant or reply to an email that angers you, try cooling off overnight.  Or, write an uncensored draft that you never actually send. Remember that all emails are forwardable.  If you don't want your whole department to read it, do not send it.

2.  RESIST THE REPLY ALL BUTTON.  This is the one that literally will make my entire head explode at work.  I have seen coworker after coworker make this mistake and it is not pretty.  This can make you look totally clueless all the way up the chain.  Coworkers don't let coworkers reply all.  In fact, I would love to see the day when reply all is no longer an option in Outlook, Gmail, or any other email client.  Why?  Because it creates mindless replies when all of the discussion could be tabled and then ONE single email sent out to a team.  Time after time in all of my jobs have seen emails go out - an official type declaration of what we are going to be doing - and someone else will reply all and jump in with something else essentially calling out critically all the things wrong with the initial.  Take the time to call the person that sent the email and give them the professional courtesy to make any corrections.  Don't shoot the messenger!

3.  UNDERSTAND WHAT CC AND BCC MEAN.  The recipients listed in the To field are the direct addressees of your email. These are the people to whom you are writing directly.  CC, which stands for “carbon copy” or even “courtesy copy,” is for anyone you want to keep in the loop but are not addressing directly in the email. The person(s) in the CC field is being sent a copy of your email as an FYI. Commonly, people CC their supervisors to let them know an email has been sent/an action has been taken or to provide a record of communications. The general rule of thumb is that recipients in the To field are expected to reply or follow up to the email, while those in the CC field do not.  So many times I see the ones in the CC field adding in their two-cents and then the whole thing becomes a reply-all festival.

4. IF YOU ADD SOMEONE IN THE CC OR TO FIELD, LET THE OTHERS KNOW.  Guess what?  There are times when people are added willy-nilly for no good reason and you look back and notice it a couple of emails later.  Let people know.  Professional courtesy and politeness go a long way.

5.  BCC IS GOOD FOR ONE THING ONLY.  Let's say that only half in your department contributed to the annual walk fund.  Rather than sending out an email to all those that contribute in the TO field where each of them can see who did contribute and who did not, put your own name in the TO and the rest in the BCC.  That way, gossip about who gives and doesn't is stopped before it can even begin.  Don't use the BCC field to add someone random to eavesdrop on the email.

6.  PICK UP THE PHONE.  If you notice that you are going back and forth on an email and getting nowhere, the phone still works.  Guess what?  Voices can convey so much more than words and rarely are misinterpreted as much as typed words.  I remember an email I saw that was sent for the third time.  The second time it was heavily highlighted with quotes from the manager's email weeks before.  The third send apologized for resending the email yet again but someone was not doing it correctly.  Because of the sender's frustration, more time was wasted from the entire department reading about some small piece in the whole operation, and worse, half of the department had nothing to do with the infraction.

7.  DON'T PUT A QUOTE IN YOUR SIGNATURE.  There is no reason for it.  From The Wordsmith:

******Avoid quotes, witty sayings and colors in the signature.

8.  DON'T ASSUME EVERYONE READS THEIR EMAIL IMMEDIATELY.  If something is important and needs to be communicated quickly, pick up the phone.

9.  DO NOT FORWARD AN EMAIL UNTIL YOU ASK PERMISSION.  This is just plain common professional sense.

10.  DO NOT USE UNPROFESSIONAL FONTS OR BACKGROUND PAPERS.  They only distract.  This means NO comic sans.

Hope that helps.  And, by the way, I do mess up on some of these myself.