January 20-22, 2012 Des Moines Marrio, 700 Grand Avenue, Des Moines, IA

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1 January 20-22, 2012 Des Moines Marrio, 700 Grand Avenue, Des Moines, IA Session 1: Clinical Transi ons and Preven on of Hospital Readmissions D: Technician: U lizing Pharmacy Technicians to Support the Medica on Reconcilia on Process 11:15am - 12:15pm ACPE UAN L01-T Ac vity Type: Knowledge-Based 0.1 CEU/1.0 Hr Program Objec ves for Pharmacy Technicians: Upon comple on of this CPE ac vity par cipants should be able to: 1. Iden fy how inaccurate medica on reconcilia on records can effect pa ents nega vely 2. Apply processes discussed to assist the pharmacist in reviewing medica on records for reconcilia on 3. Compare hospital versus community roles of technicians in the medica on reconcilia on process Speaker: Gary Clark, RPh, PharmD, is the Clinical Pharmacy Manager for Iowa Health Des Moines which includes Iowa Methodist Medical Center, Iowa Lutheran Hospital, Blank Children s Hospital, and Methodist West Hospital. He is also an Adjunct Assistant Professor for Drake University s College of Pharmacy and is a preceptor for the IH-DM hospitals rota on students. Gary is a graduate of Iowa State University, Ames, Iowa, receiving a Bachelor s degree in Psychology in 1981, and a graduate of Drake University, Des Moines, Iowa, receiving a Bachelor s degree in Pharmacy in 1990, and a Doctor of Pharmacy in Speaker Disclosure: Gary Clark does not report any actual or poten al conflicts of interest in rela on to this CPE ac vity. Off-label use of medica ons will not be discussed during this presenta on.

2 Faculty Disclosure Utilizing Pharmacy Technicians to Support the Medication Reconciliation Process Gary Clark reports he has no actual or potential conflicts of interest associated with this presentation. Gary Clark, RPh., PharmD Clinical Pharmacy Manager Iowa Health Des Moines Learning Objectives Upon completion of this activity pharmacy technicians will be able to: 1. Identify how inaccurate medication reconciliation records can affect patients negatively 2. Apply processes discussed to assist the pharmacist in reviewing medication records for reconciliation 3. Compare hospital versus community roles of technicians in the medication reconciliation process Pre-Assessment Questions What percentage of patients will upon admission to a hospital have problems with their medication record? 5% 10% 25% 50% The most common med rec problem would likely be? drug omission dose of drug frequency of drug incorrect drug For accurate medication lists, which group is more effective? pharmacist Rx Technician Both What percent of medication discrepancies could lead to moderate or severe harm? Medication Reconciliation Definition from the Joint Commission: Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. This process comprises five steps: 1) develop a list of current medications; 2) develop a list of medications to be prescribed; 3) compare the medications on the two lists; 4) make clinical decisions based on the comparison; and 5) communicate the new list to appropriate caregivers and to the patient. Synopsis of The Joint Commission s National Patient Safety Goal NPSG Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. 1

3 Why is Med Rec a Problem? What are Causes of Med Rec? A study in the Archives of Internal Medicine noted that the most common causes of unintended medication inconsistencies were: 1 Omission of a drug (46%) 2 Dose of the drug (25%) 3 Frequency of the drug (14%) 4 Drug was incorrect (4%) The study concluded that over 53.6% of older medical patients taking at least 4 medications have unintended medication discrepancies at the time of hospital admission. In addition, more than a third of these had potential to cause moderate or severe harm. Source: Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165: Cornish PL, Knowles SR, Marchesano R, et al. Unintended Medication Discrepancies at the Time of Hospital Admission. Arch Intern Med. 2005;165: Could this also be a reason? What About This Concern? Experience in Michigan of Using Rx Techs for Medication Reconciliation As reported in the Michigan Pharmacist Association, the experience at a hospital, Spectrum Health, was that the medication reconciliation process once consisted of the prescriber documenting their history, taken by a nurse, without assigning additional follow up when information was incomplete. The process for the medication list is now physician order-driven with the prescriber taking the med history and is then followed by clarification when needed, by the Med Rec Techs. Experience in Michigan of Using Rx Techs for Medication Reconciliation Unplanned admissions begin with prescribers recording a medication history on a medication reconciliation order form. This completed form initiates the process for the Med Rec Techs to enter the information in the home medication section of the EMAR. For incomplete information, Med Rec Techs will clarify by contacting the patient or family, outpatient pharmacy or primary care physician. New information is written on a reconciliation form and shared with the pharmacist to contact the prescriber for orders or to place in the chart to be reviewed by a prescriber. The Med Rec Techs work is driven by admission orders and a list of unplanned admissions. A time study revealed each patient requires about 10 minutes of Med Rec Tech time to input the medication history. If follow up is required, the average time spent is 20 minutes per patient. Approximately one-third of all home medication lists require follow up. Lindsey K. Medication Reconciliation: Physician-driven and Pharmacy-managed by Med Rec Techs, Michigan Pharmacists Association, 5/14/ Lindsey K. Medication Reconciliation: Physician-driven and Pharmacy-managed by Med Rec Techs, Michigan Pharmacists Association, 5/14/

4 Utilization of Rx Techs for the Best Possible Med History in Canada The Canadian Journal of Hospital Pharmacy has published several studies on using pharmacy technicians to obtain medication histories upon patient admission. The goal of obtaining an accurate med history is to: Prevent adverse drug events Reduce new drug-related problems The reason for including technicians in the process is because they are familiar with drug dose forms, strengths and schedules of Rx and OTC medications. Best Possible Med History Study Synopsis of a study of utilizing Rx technicians in obtaining the Best Possible Med History (BPMH) in a 440 bed tertiary hospital in Canada: Rx Techs were selected with good interpersonal and communication skills and underwent a 7 day training program with independent study. Once proficiency was documented they would observe RPh s conducting patient interviews followed by conducting supervised interviews, then independent interviews. Interviews were preformed Monday through Friday on all patients admitted within the previous 24 hours and had medications ordered. The study was over a 39 day period. Technicians used a form to document patient information (including allergy info & body weight) and pertinent drug information which was compared with the inpatient medication list for discrepancies. Remtulla S. Best Possible Medication History by a Pharmacy Technician at a Tertiary Care Hospital. Can J Hosp Pharm Sep-Oct; 62(5): Best Possible Med History Study Technicians used a form to document patient information (including allergy info & body weight) and pertinent drug information which was compared with the inpatient medication list for discrepancies. A total of 415 patients were reviewed (average of 11/day) but 89 were unable to be completed due to language barrier, problems with alertness or cooperation, or other reasons for a net of 326 patients. The average time per interview was 11 minutes (2-48 minutes) which included the time to research each patient record. A total of 1345 meds were reviewed (4 meds per patient). The technicians identified 775 discrepancies which averaged 1 out of every 4 patients. Best Possible Med History Study Remtulla S. Best Possible Medication History by a Pharmacy Technician at a Tertiary Care Hospital. Can J Hosp Pharm Sep-Oct; 62(5): Best Possible Med History Study Example of the Med History Form Used in the Trial The Authors concluded that: the results of this study support the concept of pharmacy technicians obtaining the BPMH. Incorporating technicians into the medication reconciliation process could help to make this service available to more hospital inpatients. Another BPMH Canadian Study Synopsis of a study of comparing RPh and Rx Technicians in an ER obtaining Best Possible Med History (BPMH) in a 400 bed community hospital in Canada: The ED is a level II trauma center with adult and pediatric patients. During a one month period (weekdays during daytime hours) patients presenting to the ED were enrolled to be interviewed twice, once by a pharmacist and once by a technician. Patients were eligible if they were being admitted or were requested to have a med history done. Patients were excluded if they came from a nursing home or other hospital or if a med history had been initiated by a health care professional other than a pharmacist. Three pharmacists & 2 technicians participated in the study. Remtulla S. Best Possible Medication History by a Pharmacy Technician at a Tertiary Care Hospital. Can J Hosp Pharm Sep-Oct; 62(5): Johnston R; Saulnier L, Gould, O. Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists. Can J Hosp Pharm 2010;63(5):

5 Another BPMH Canadian Study A total of 120 patients were initially identified, with a total of 59 actually having a med history done. Pharmacy Technicians received additional training from a 4 step process: an interactive learning and education session was provided, during which background information was reviewed and tips for success when obtaining a BPMH were outlined. background readings were supplied, to be completed before initiation of the study. each technician participated in several practice interviews, during which he or she interviewed a patient after a pharmacist had done so; the histories obtained by pharmacist and technician were compared, and discrepancies were reviewed and discussed. each technician underwent a competency assessment, during which he or she interviewed a standardized patient and received detailed feedback from the assessor. Another BPMH Canadian Study Johnston R; Saulnier L, Gould, O. Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists. Can J Hosp Pharm 2010;63(5): Johnston R; Saulnier L, Gould, O. Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists. Can J Hosp Pharm 2010;63(5): Results from 2 nd Canadian Study Results from 2 nd Canadian Study Johnston R; Saulnier L, Gould, O. Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists. Can J Hosp Pharm 2010;63(5): Johnston R; Saulnier L, Gould, O. Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists. Can J Hosp Pharm 2010;63(5): Another BPMH Canadian Study The Authors concluded that: There were no statistically significant differences between pharmacists and trained pharmacy technicians in terms of the presence of discrepancies for prescription or over-the-counter drugs or the mean number of discrepancies for each type of medication. What Will Boards of Rx Allow? The Iowa Board of Pharmacy Examiners will allow pharmacy technicians to record medication histories for further review by a licensed pharmacist. This can include obtaining medication histories from the patients. In Minnesota, the state board of pharmacy allows pharmacy technicians to obtain and document a complete list of a patient s medications on admission to the health care organization. In addition, the Board noted that hospital s pharmacy technicians may obtain and record the medication histories of patients who are being admitted for surgery. The Arizona State Board of Pharmacy, said pharmacy technicians in the state may obtain and record a medication history if that activity is limited to writing down exactly what the patient says. The director of the Indiana State Board of Pharmacy, said he did not know of anything in the state s rules and regulations that would prohibit pharmacy technicians from obtaining and recording medication histories. Johnston R; Saulnier L, Gould, O. Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists. Can J Hosp Pharm 2010;63(5): Thompson CA. Legality of Technicians Involvement in Medication Reconciliation Not Clear. March 1, 2009, AJHP News 4

6 Potential Role of Rx Tech in Med Rec How can pharmacy technicians be involved in the process? Review and document patient s medication (prescription and OTC) assuring appropriate dose, route, frequency and duration of therapy Assist with medication order entry Are there jobs available? Potentially, any pharmacy, retail or hospital, would benefit from have pharmacy technicians assist with medication reconciliation. In reality there aren t may jobs specifically for med rec. There are some hospitals that are specifically hiring for Medication Reconciliation Pharmacy Technicians. The next couple of slides show examples of positions available (as of Dec 1, 2011) Are there jobs? Examples: Are there jobs? Examples: MEDICATION RECONCILIATION TECHNICIAN Department: Emergency Department Schedule: Part-time Shift: Day/Evening shifts, weekend & holiday rotation Hours: flexible schedule Job Details: Associate Degree or a technical certification in a health care related program or the equivalent knowledge and experience is required. Medical Terminology required. A minimum of three (3) years related work experience plus demonstrated medication management is required. Pharmacy Technician certification is preferred. Certified Pharmacy Technician - Medication Reconciliation Technician Description Working under the direct supervision of the Staff Pharmacists and Pharmacy Technician Supervisor: (1) responsible for entering all home medication orders into the Pharmacy Software System (PSS); (2) upon notification of patient discharge, responsible for updating home medication record in PSS to match ordered discharge medications; (3) will work with pharmacists and nurses, as necessary, to resolve any discrepancies/errors in home medication orders (4) Will also assist Technician Supervisor as needed in departmental operations, ordering medications and supplies, etc. Qualifications Education: High School diploma (or equivalency) required. College degree preferred. Licensure/Certifications: National Pharmacy Technician Certification (CPhT); SC Pharmacy Technician Certification. Experience: Two years recent retail/outpatient pharmacy experience preferred, with emphasis on entering prescriptions into a pharmacy software system. Medication Reconciliation Assistant The Pharmacy Technician is responsible for ensuring accurate picking, reparation and dispensing of medications. In addition, the employee will uphold and demonstrate the Prince Williams Hospital values, Integrity, Commitment, Accountability, Responsiveness and Expertise, through the use of our Standards of Behavior in their day to day actions. The employee may also be responsible for other duties as assigned to meet the needs of the department. High school graduate or equivalent. One to 2 years experience. VA Pharmacy Tech licensed required within 9 months of hire with documentation of enrollment in a Pharmacy Tech Program. CPhT preferred. Work Schedule Part time; 30 hours week 1st shift, position is benefit eligible Medication Reconciliation Specialist Two years experience as a certified pharmacy technician. Certified by the Pharmacy Technician Certification Board required and renewed every two years as a Certified Pharmacy Technician (CPhT). Registered with the Florida Board of Pharmacy as a Registered Pharmacy Technician (RPhT). High School Diploma or equivalent required. Coordinate efforts with the pharmacist to ensure that all medication histories are collected and reviewed in a timely manner. Communicate effectively with all patient populations to gather accurate medication histories. Communicate effectively with pharmacists, nurses, family members and others outside the hospital to gather further medication history information. Demonstrate professionalism and excellent interpersonal skills in all... Example of Rx Tech Qualifications for Medication Reconciliation Qualifications CPht Retail Pharmacy Experience Prescription Receiver Refill Experience Formal interview process 1-2 days shadowing a Pharmacist Good communication skills Experience in pharmacy Good problem solving skills Able to withstand the environment Example of a Training Process for Technicians Developed formal training program Training sessions Med Rec process overview & technician role Obtaining medication histories Created comprehensive training manual Provides multiple handouts for reference Mock patient interview scenarios Shadow pharmacists in ER Shadow Med Rec technicians Lead technician is essential 5

7 Another Example of a Training Process for Technicians Background reading 3 page competency checklist Observe pharmacist x 10 interviews Perform supervised interviews x 10 patients Pharmacist signs off competency Advantages of Rx Techs with Med Rec Pharmacists couldn t do their job without them Review of orders Code participation C&S review MD Consults Tech career ladder, increased job satisfaction Positive feedback from MDs/RNs Minimized workload for admitting RN Assist with retrieval of stats Potential Roadblocks with Rx Techs Involved in Med Rec Process Hiring and retaining quality technicians Retraining RPhs to work with techs in clinical setting Keeping up with continued changes in responsibilities, new processes, etc. Training/Competencies Limited Scope of Practice Staffing Level Nursing Perception Conclusion Based on the information provided, involving pharmacy technicians in the medication reconciliation process has several advantages: Increases pharmacist satisfaction Pharmacists feel process is more efficient Decreases average pharmacist time spent per admission and discharge Allows for expanded pharmacy involvement in MR on a greater number of patients Medication Reconciliation Post-Assessment Questions What percentage of patients will upon admission to a hospital have problems with their medication record? 5% 10% 25% 50% The most common med rec problem would likely be? drug omission dose of drug frequency of drug incorrect drug For accurate medication lists, which group is more effective? pharmacist Rx Technician Both, equally What percent of medication discrepancies could lead to moderate or severe harm?

8 References Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165: Johnston R; Saulnier L, Gould, O. Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists. Can J Hosp Pharm 2010;63(5): Lindsey K. Medication Reconciliation: Physician-driven and Pharmacy-managed by Med Rec Techs, Michigan Pharmacists Association, 5/14/ Remtulla S. Best Possible Medication History by a Pharmacy Technician at a Tertiary Care Hospital. Can J Hosp Pharm Sep-Oct; 62(5): Thompson CA. Legality of Technicians Involvement in Medication Reconciliation Not Clear. March 1, 2009, AJHP News 3 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 May;43(5): Continuing Pharmacy Education Go to click on My Portfolio Scroll down to Take Exam Enter Access Code: (case sensitive) Pharmacists - Technicians - 7

9 2012 Educational Expo Utilizing Pharmacy Technicians to Support the Medication Reconciliation Process Gary Clark, RPh., PharmD Post Assessment Questions 1. What percentage of patients will upon admission to a hospital have problems with their medication record? A. 5% B. 10% C. 25% D. 50% 2. The most common med rec problem would likely be? A. drug omission B. dose of drug C. frequency of drug D. incorrect drug 3. For accurate medication lists, which group is more effective? A. Pharmacists B. Rx Technician C. both, equally 4. What percent of medication discrepancies could lead to moderate or severe harm? A. 5 B. 10 C. 40 D On average, the amount of time spent doing a medication reconciliation for pharmacy technicians during the studies presented was: A. 5 minutes B. 10 minutes C. 30 minutes D. 60 minutes 6. The Iowa Board of Pharmacy Examiners will allow pharmacy technicians to record medication histories for further review by a licensed pharmacist A. True B. False 7. To be successful at medication reconciliation, the most important trait for a pharmacy technician is to: A. have no real experience in pharmacy B. have good communication skills C. be able to stand for hours at a time D. be multi lingual

10 8. In the Canadian Study, the most common type of discrepancy was: A. Type 0 no discrepancy B. Type 1 documented intentional discrepancy C. Type 2 undocumented intentional discrepancy D. Type 3 unintentional discrepancy 9. A major role of a pharmacy technician in medication reconciliation is to review and document patient s medication (prescription and OTC) assuring appropriate dose, route, frequency and duration of therapy. A. True B. False 10. The advantages to having pharmacy technicians involved in the medication reconciliation process include: A. Pharmacists benefit from assistance B. Tech career ladder, increased job satisfaction C. Minimized workload for admitting RN D. All of the above