Pharmacy Technicians: Roles, Responsibilities and Contributions to the Provision of Pharmacy

Transcription

1 Pharmacy Technicians: Roles, Responsibilities and Contributions to the Provision of Pharmacy Services in Health-System Settings 1 White paper drafted by the Organizational Affairs Committee of the Michigan Society of Health- System Pharmacists

2 2 AUTHOR INFORMATION: Stephen M. Stout, Pharm.D., MS (corresponding author) Pharmacotherapy Specialist, Wolters Kluwer Clinical Drug Information 2242 Georgetown Blvd, Ann Arbor, MI Ph: (517) ; Ryan Bickel, Pharm.D., MHA, BCPS Pharmacy Manager, Borgess Pipp Hospital 411 Naomi St., Plainwell, MI Ph: (269) ; Ryan Foster, Pharm.D., MBA Director, Pharmacy Services, Spectrum Health Hospital Group 100 Michigan Street NE, Grand Rapids, MI Ph: ;

3 3 Mark Isopi, Pharm.D., MBA, FASHP Senior Regional Medical Liaison, Amgen Inc Pembroke Ave, Livonia, MI Ph: ; All authors: Nothing to disclose.

4 4 ABSTRACT Pharmacy technician roles, responsibilities and contributions to care were not formally established in the state of Michigan until Public Act 285 (formerly Senate Bill 92) was signed into law in September This Act, which is scheduled to go into effect on Oct. 1, 2015, establishes licensure requirements for technicians and defines practice in a way that allows for expanded technician contributions. While pharmacy leaders in the state generally view expansion of technician roles favorably, the lack of any formal definition and regulation of technician practice was previously seen as a primary barrier to progress in this area. Accordingly, Michigan pharmacy technicians have been under-utilized in some roles relative to national trends. The Organizational Affairs Committee urges continued advancement and specialization of the pharmacy technician workforce, with the expectation that this will: 1) save pharmacist hours and/or free pharmacists for other activities, without compromising patient care; 2) increase diversity, specialization and job satisfaction among pharmacy technicians; and 3) advance the standing and image of the field as a long-term career option for prospective candidates.

5 5 INTRODUCTION In early 2003, the Council on Credentialing in Pharmacy (CCP) published its White Paper on Pharmacy Technicians 2002: Needed Changes Can No Longer Wait, a declaration endorsed by 12 member organizations of CCP, including the American Pharmacists Association, American Society of Health-System Pharmacists (ASHP) and the American College of Clinical Pharmacy. 1 The white paper s stated purpose was To set forth the issues that must be resolved to promote the development of a strong and competent pharmacy technician work force. The CCP recommended that action be pursued in five areas with respect to pharmacy technicians and/or other support personnel, with the aim of formalizing roles and expectations for these individuals and maximizing their contributions to pharmacy services: 1) Defining and communicating a vision, with specific goals and plans for pursuit of that vision; 2) Defining roles, responsibilities and competencies; 3) Establishing education and training standards, and maintenance requirements for these; 4) Establishing credentialing and accreditation standards; and 5) Establishing and promoting adoption of regulatory standards consistent with the above. In Michigan, a milestone in progress toward this vision was reached in September 2014 when Public Act 285 (PA 285, formerly Senate Bill 92) was signed into law by Gov. Rick Snyder. Previously, Michigan was one of only six states that did not regulate pharmacy technicians. 2 PA 285 amends the Michigan Public Health Code to establish education, licensure and maintenance requirements for pharmacy technicians, as a subfield of pharmacy, and is

6 6 scheduled to be enacted on Oct. 1, The Act broadly defines pharmacy technician practice as including the following activities: Assisting in the dispensing process Handling transfer of prescriptions, except controlled substances prescriptions Compounding drugs Preparing or mixing intravenous drugs for injection into a human or veterinary patient Contacting prescribers concerning prescription drug order clarification, which does not include drug regimen review or clinical or therapeutic interpretation Receiving verbal orders for prescription drugs, except orders for controlled substances Any other specifically authorized functions The Organizational Affairs Committee (OAC) of the Michigan Society of Health-System Pharmacists (MSHP) created this document to attempt to more specifically define pharmacy technician roles, responsibilities and contributions to the provision of pharmacy services in health-system settings in Michigan, as a contribution to the ongoing professional dialogue concerning regulation and advancement of this field. LITERATURE REVIEW Scope of Practice Based on searches of recent scientific and trade literature, three major national publications have attempted to characterize the scope of pharmacy technician practice in the United States: ASHP s 2007 ASHP Long-Range Vision for the Pharmacy Work Force in Hospitals and Health

7 7 Systems: Ensuring the Best Use of Medicines in Hospitals and Health Systems; 4 CCP s 2009 Scope of Contemporary Pharmacy Practice: Roles, Responsibilities, and Functions of Pharmacists and Pharmacy Technicians; 5 and the National Association of Boards of Pharmacy (NABP) s 2012 Model State Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy. 6 Pharmacy technician practice as outlined in all of these documents occurs under the supervision of a pharmacist, and the practice roles are a sub-set of pharmacy practice roles (i.e., there are no functions unique to pharmacy technicians). The vision outlined by ASHP in 2007 describes a scope of pharmacy technician practice in health-system settings as including the following: 4 Drug product: o Acquisition o Preparation o Dispensing o Distribution Management and supervision of: o Drug acquisition and supply logistics o Use of technology and aspects of informatics o Quality assurance activities o Other pharmacy technicians Assisting in data collection and screening for therapeutic drug monitoring The CCP publication borrows its definition of pharmacy technician practice from NABP, defining technician practice as including the following: 5

8 8 Assisting in dispensing Medical claims processing Medication stocking Cashiering Not including: o Drug utilization review o Clinical conflict resolution o Prescriber contact for order clarification or therapy modification o Patient counseling o Dispensing process validation o Prescription transfer o Receipt of new prescription drug orders In addition to the above, NABP also includes a section describing somewhat expanded practice roles of certified pharmacy technicians (certification as determined by the state board of pharmacy) as including: 6 Receiving new medication orders Prescription transfer Compounding Assisting in dispensing Performing all functions allowed to be performed by technicians, but specifically excluding: o Drug utilization review

9 9 o Clinical conflict resolution o Prescriber contact for order clarification or therapy modification o Patient counseling o Dispensing process validation The definition of technician practice in PA 285 (see INTRODUCTION), while not identical to any of the above, is most consistent with the final and broadest definition put forward by NABP and with a trend toward advancement of practice roles for qualified technicians as described below. Trends and Emerging Practice Roles Beyond the basic definition of pharmacy technician practice, the CCP publication goes on to describe a pharmacy technician practice analysis, completed in 2005, evaluating the professional activities of certified pharmacy technicians (CPhTs, in this sense reflecting certification specifically by the Pharmacy Technician Certification Board [PTCB]). 5,7 In this analysis, a survey of pharmacists, CPhTs, technician educators, regulators and state pharmacy board representatives indicated that, while health-system CPhTs were primarily responsible for assisting inpatient dispensing, preparing intravenous admixtures and pre/repackaging medications, compared to previous surveys they were increasingly involved in activities such as: 7 Compounding Communicating changes in product availability Coordinating different forms of communication throughout the practice setting

10 10 Performing and documenting equipment sanitation, maintenance and calibration Quality assurance activities (pharmacy technicians in general; not specific to health systems): o Multiple-point checking o Assisting monitoring of patient outcomes o Inventory control o Coordinating medication error communication o Education, training and certification o Reviewing billing discrepancies / fraud issues Tech-check-tech (TCT), a practice model in which pharmacy technicians rather than pharmacists check the accuracy of order filling by other technicians, was the subject of a recent literature review. 8 Across 11 published studies describing the practice in different institutions, the accuracy of TCT protocols was comparable to pharmacist checking for prescription order accuracy. Other literature in the past 10 years has described pharmacy technician involvement in other novel or advanced practice roles in the U.S., including: Taking medication histories 9-11 Medication reconciliation 12,13 Maintaining patient records 14 Screening patient profiles to identify candidates for clinical interventions 14 Requesting prescription refill authorizations from prescribers 11 Counseling on nonprescription medications 11

11 11 Scripted patient education 14 CURRENT STATE OF PRACTICE IN MICHIGAN In 2011, MSHP initiated the Pharmacy Practice Model Initiative of Michigan (PPMI 2 ) as a means to refine and implement recommendations from ASHP s Pharmacy Practice Model Initiative. One of the first actions taken by MSHP was to survey the directors of pharmacy at Michigan hospitals. MSHP utilized an early version of ASHP s Hospital Self-assessment Tool, 15 which contained 15 questions relating to pharmacy technician practice. Most of the questions focused on specific tasks or activities performed by technicians; however, a couple addressed technician certification status and opportunities for advancement. Approximately one-third (n=35) of the hospital pharmacy directors in the state completed the survey by the end of June In June 2013, the MSHP Organizational Affairs Committee contacted ASHP and requested the current results of the Hospital Self-assessment Tool for Michigan hospitals. Fifty-two hospitals had completed the assessment. A review of the survey responses (Table 1) shows that pharmacy technician practice in Michigan has made little advancement since the original survey.

12 12 Table 1. ASHP Hospital Self-Assessment Tool: Michigan Hospital Responses Relating to Pharmacy Technician Practice Question 1. Are medication distribution tasks assigned to pharmacy technicians to allow redeployment of pharmacists time to drug therapy management activities at your hospital/health system? Answer Choice Tasks fully assigned throughout all areas Tasks fully assigned for some areas Tasks partially assigned in some or all areas Tasks not assigned MI 2011 (N=35) 31.4% 11.4% 57.1% MI 2013 (N=52) 26.9% 21.2% 5 1.9% US 2013 (N=1,079) 38.9% 25.0% 31.0% 4.2% Not applicable 2. Is initiation of medication reconciliation, including obtaining and documenting patient medication information for pharmacist review, assigned to pharmacy technicians who have appropriate education and training at your hospital/health system? Tasks fully assigned throughout all areas Tasks fully assigned for some areas Tasks partially assigned in some or all areas Tasks not assigned 5.7% 8.6% 85.7% 5.8% 5.8% 88.5% 3.0% 6.9% 7.2% 77.5% Not permitted by law 5.7% 3. Is review of patient charts to identify medication allergies that require pharmacist follow up assigned to pharmacy technicians who have appropriate education and training at your hospital/health system (e.g., identify allergies not documented in the pharmacy information system)? Exists in all areas/situations (100%) Exists in most areas/situations (50 99%) Exists only in some areas/situations (1-49%) Does not exist (0%) 5.7% 8.6% 85.7% 1.9% 3.9% 5.8% 88.5% 2.5% 2.7% 6.5% 88.3% 4. If permitted by law, is the accuracy of medication dispensing by pharmacy technicians checked by other technicians (i.e., "tech-check-tech") who have appropriate education and training at your hospital/health system? Exists in all areas/situations (100%) Exists in most areas/situations (50 99%) Exists only in some areas/situations (1-49%) Does not exist (0%) 11.4% % 3.9% 15.4% 44.2% 5.2% 6.9% 9.9% 43.8% Not permitted by law 25.7% 36.5% 34.2% 5. Is the compounding of routine sterile preparations in conformance with welldocumented procedures performed by pharmacy technicians who have appropriate education and training at your hospital/health system? Exists in all areas/situations (100%) Exists in most areas/situations (50 99%) Exists only in some areas/situations (1-49%) Does not exist (0%) 57.1% 25.7% 2.9% 14.3% 57.7% 25.0% 3.9% 13.5% 64.6% 22.6% 4.1% 5.8% Not applicable 2.9%

13 13 6. Is the compilation of clinical monitoring information (e.g., International Normalized Ratios) for pharmacist review assigned to pharmacy technicians who have appropriate education and training at your hospital/health system? Tasks fully assigned throughout all areas Tasks fully assigned for some areas Tasks partially assigned in some or all areas Tasks not assigned 2.9% 82.9% 3.9% 82.7% 1.3% 1.8% 3.0% 78.9% Tasks performed by hospital information system 14.3% 13.5% 15.1% 7. Is the inspection and replenishment of medication storage devices assigned to pharmacy technicians who have appropriate education and training at your hospital/health system? Yes No 97.1% 2.9% 98.1% 1.9% 96.7% 3.3% 8. Is the management of controlled substance systems assigned to pharmacy technicians who have appropriate education and training at your hospital/health system? Yes No 74.3% 25.7% 76.9% 23.1% 72.3% 27.7% 9. Is the management of medication assistance programs assigned to pharmacy technicians who have appropriate education and training at your hospital/health systems? Yes No Not applicable 8.6% 48.6% 42.9% 5.8% 46.2% 48.1% 18.8% 30.6% 50.6% 10. Are components of quality improvement programs conducted by pharmacy technicians who have appropriate education and training at your hospital/health system? Exists in all areas/situations (100%) Exists in most areas/situations (50 99%) Exists only in some areas/situations (1-49%) 2.9% 14.3% 6 1.9% 13.5% 55.8% 7.5% 14.4% 42.8% Does not exist (0%) 22.9% 28.9% 31.8% Not applicable 3.5% 11. Is the management of pharmacy department information technology systems, including routine database management and billing systems, assigned to pharmacy technicians who have appropriate education and training at your hospital/health system? Exists in all areas/situations (100%) Exists in most areas/situations (50 99%) Exists only in some areas/situations (1-49%) Does not exist (0%) 22.9% 28.6% 37.1% 11.4% 17.3% 30.8% 36.5% 13.5% 17.0% 25.1% 32.3% 20.6% Not applicable 1.9% 5.0% 12. Is the supervision of other pharmacy technicians assigned to technicians who have appropriate education and training at your hospital/health system? Exists in all areas/situations (100%) Exists in most areas/situations (50 99%) Exists only in some areas/situations (1-49%) 8.6% 17.1% 8.6% 7.7% 17.3% 17.3% 17.8% 13.9% 13.6% Does not exist (0%) % Not applicable 5.7% 7.7% 8.4%

14 Are pharmacy technicians at your hospital/health system certified by the Pharmacy Technician Certification Board (PTCB)? All pharmacy technicians are PTCB-certified (100%) Most pharmacy technicians are PTCB-certified (50%-99%) 57.1% 25.7% 11.4% 48.1% 28.9% 19.2% 42.7% 32.4% 19.4% Some pharmacy technicians are PTCB-certified (1%-49%) 5.7% 3.9% 5.6% No pharmacy technicians are PTCB-certified (0%) 14. Are all distributive functions that do not require a pharmacist's clinical judgment assigned to pharmacy technicians at your hospital/health system? Yes No % 44.2% 65.8% 34.2% 15. Are opportunities for advanced, specialized pharmacy technician roles available at your hospital/health system (examples of advanced pharmacy technician roles include: dispensing medications with remote video supervision, managing medication assistance programs, initiation of medication reconciliation [obtaining list], order entry for pharmacist's verification, and technician supervising other technicians)? Yes No % 61.5% 40.4% 59.7% When compared to the national results, it appears that Michigan hospitals lag behind other states in optimizing the use of pharmacy technicians. In general, Michigan hospitals are less comfortable delegating distributive functions, which do not require pharmacist judgment, to technicians. Fewer Michigan hospitals use technicians to manage medication assistance programs or assist with quality improvement programs. The ASHP assessment tool provided a glimpse of pharmacy technician practice in Michigan, but MSHP desired to know more. In 2011, MSHP created a second survey, which was distributed to the 50 participants of the PPMI 2 Conference. The participants consisted of pharmacy leaders from across the state representing various aspects of health-system pharmacy practice,

15 15 including acute care, ambulatory care and academia. This survey assessed the participants vision of technician practice and barriers to achieving this vision. Forty-two pharmacists (84 percent) completed the PPMI 2 survey. Approximately two-thirds of participants strongly agreed that pharmacy technicians, with appropriate education and training, should be used much more extensively in Michigan hospitals to free up pharmacists to perform clinical activities. The respondents generally agreed that the future vision of pharmacy practice in Michigan has pharmacy technicians taking increased ownership of drug preparation and distribution. A level of uncertainty existed about liberalizing the practice of tech-check-tech. Table 2 summarizes the survey results regarding the preferred future for pharmacy technicians. The PPMI 2 survey also attempted to identify barriers that must be addressed before pharmacy technicians can achieve an optimal practice in Michigan. The top five barriers included: 1. Lack of recognition and legal accountability by the state of Michigan. 2. Lack of standardized education and training. 3. Large variability in the roles of pharmacy technicians among various hospitals. 4. Lack of career ladders for technicians. 5. Too few technicians are interested in pursuing the occupation as a long-term career.

16 16 Table 2. PPMI 2 Conference Participants Level of Agreement Regarding the Preferred Future for Pharmacy Technicians. Agree Neutral Disagree All distributive tasks that do not require clinical judgment are assigned to technicians. Technicians are responsible for drug product preparation and distribution work within a well-documented, quality assurance environment designed to ensure patient safety. Each technician has documented competency for the tasks within his job description. Tech-check-tech when appropriate information technology and other safeguards are in place to ensure accuracy and safety. 90% 7% 3% 92% 2% 5% 91% 2% 7% 71% 26% 3% WHY TO PURSUE ADVANCED ROLES, TRAINING AND FURTHER DEVELOPMENT Health care organizations are facing a veritable health care tsunami: ICD 10, value-based purchasing, Medicaid expansion, and the unknown potential impact of the Affordable Care Act, just to name a few. These initiatives are placing a renewed focus on improving clinical outcomes, improving safety and quality, and controlling costs. With an effective pharmacy practice model, pharmacists and pharmacy technicians will be able to effectively support each of these initiatives. The effectiveness of a pharmacy practice model will, in large part, be determined by the ability of pharmacies to leverage the unique skills and expertise of certified pharmacy technicians. Historically, pharmacists have been reluctant to delegate many routine responsibilities to pharmacy technicians. However, as pharmacist roles evolve and the scope of pharmacy practice changes, the delegation of basic dispensing functions and other technical

17 17 tasks becomes imperative. Pharmacists are shifting focus to spend more time on medication therapy management and utilization and less time on dispensing functions. Advancing the roles of pharmacy technicians should be an important focus for all pharmacy departments. However, before technicians can begin to practice in these advanced roles, an effective training program and evaluation methodology is needed. In many organizations, technician training is inconsistent and not well defined. This often leads to high turnover and staff dissatisfaction. Effective training programs have been shown to reduce turnover and improve employee satisfaction. 16,17 With standardized, reproducible training programs, pharmacy technicians can begin to operate at higher levels within the health care system. Advanced roles for pharmacy technicians extend pharmacy services and allow pharmacists to focus on the aspects of the medication use system that require clinical decision making. Pharmacy technicians fill drug orders, compound complex sterile products and maintain medication stocks. In addition, they may: interact with patients to obtain accurate medication histories for medication reconciliation; review medication profiles and lab results with defined guidelines to support pharmacists; and evaluate, implement and maintain pharmacy automation. Utilizing unit-based pharmacy technicians to coordinate and communicate medication needs has been shown to reduce calls to pharmacy and reduce the number of late or missed medication administration events. 18 Pharmacy technicians have also been shown to positively impact the accuracy of medication histories taken for medication reconciliation. 13,19 Although the need to advance pharmacy technician roles is clear, the environment to foster this advancement is lacking. Barriers to broader, systematic advancement include inconsistent state requirements for pharmacy technicians and the lack of advanced or specialty technician

18 18 certification. According to Everett McAllister, chief executive officer and executive director of PTCB, the next step in advancing the role of the pharmacy technician is to develop an enhanced credentialing system. 20 Many organizations have transformed their pharmacy practice models to be more nimble and more responsive to the changing needs of the health care landscape. Doing so has allowed pharmacists to move beyond traditional dispensing roles and assume more responsibility for clinical outcomes. In order to sustain the gains and further develop the role of pharmacists and pharmacy technicians, organizations must develop new ways of thinking around the deployment of pharmacy resources. Providing challenging, rewarding opportunities promises to improve retention, satisfaction and, ultimately, patient outcomes. The Michigan Society of Health-System Pharmacists Board of Directors approved the content of this white paper on Jan. 15, Ed.

19 19 REFERENCES 1 Council on Credentialing in Pharmacy white paper on pharmacy technicians: Needed changes can no longer wait. J Manag Care Pharm. 2003; 9: National Association of Boards of Pharmacy. Survey of pharmacy law. 3 Michigan Senate Bill bject&objectname=2013-sb American Society of Health-System Pharmacists. ASHP long-range vision for the pharmacy work force in hospitals and health systems: Ensuring the best use of medicines in hospitals and health systems. Am J Health Syst Pharm. 2007; 64: Council on Credentialing in Pharmacy, Albanese NP, Rouse MJ. Scope of contemporary pharmacy practice: Roles, responsibilities, and functions of pharmacists and pharmacy technicians. J Am Pharm Assoc (2003). 2010; 50: e National Association of Boards of Pharmacy. Model state pharmacy act and model rules of the National Association of Boards of Pharmacy. 7 Muenzen PM, Corrigan MM, Smith MA et al. Updating the pharmacy technician certification examination: A practice analysis study. Am J Health Syst Pharm. 2005; 62: Adams AJ, Martin SJ, Stolpe SF. "Tech-check-tech": A review of the evidence on its safety and benefits. Am J Health Syst Pharm. 2011; 68:

20 20 9 Michels RD, Meisel SB. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm. 2003; 60: Knight H, Edgerton L, Foster R. Pharmacy technicians obtaining medication histories within the emergency department. Am J Health Syst Pharm. 2010; 67: Friesner DL, Scott DM. Identifying characteristics that allow pharmacy technicians to assume unconventional roles in the pharmacy. J Am Pharm Assoc (2003). 2010; 50: Thompson CA. Legality of technicians' involvement in medication reconciliation not clear. Am J Health Syst Pharm. 2009; 66: Siemianowski LA, Sen S, George JM. Impact of pharmacy technician-centered medication reconciliation on optimization of antiretroviral therapy and opportunistic infection prophylaxis in hospitalized patients with HIV/AIDS. J Pharm Pract. 2013; 26: Weber E, Hepfinger C, Koontz R et al. Pharmacy technicians supporting clinical functions. Am J Health Syst Pharm. 2005; 62: American Society of Health-System Pharmacists. PPMI hospital self-assessment Fox KC. Mentor program boosts new nurses' satisfaction and lowers turnover rate. J Contin Educ Nurs. 2010; 41: Gebhart F. Trained technicians cut pharmacist turnover at CVS. Drug Topics 2001; 145: 58.

21 21 18 Conroy C, Cattell R, Nicholls M. Contribution of a ward-based technician service to delivering effective patient health care and reducing dispensary workload. International Journal of Pharmacy Practice 2011; 10: van den Bemt PM, van den Broek S, van Nunen AK et al. Medication reconciliation performed by pharmacy technicians at the time of preoperative screening. Ann Pharmacother. 2009; 43: Traynor K. New PTCB chief seeks to advance technician practice. Am J Health Syst Pharm. 2012; 69: 820, 22.