Technician Tutorial: The Ins and Outs of Pharmacy Inventory

Transcription

1 (Page 1 of 6) Technician Tutorial: The Ins and Outs of Pharmacy Inventory A patient s most basic expectation for service at a pharmacy is that prescribed medications are in stock. This is one reason it s so important to ensure your pharmacy has the medications your patients need, when they need them. Inventory is one of the most frequently performed tasks in a pharmacy, whether in a community or hospital setting. In fact, after dispensing, managing and maintaining inventory is the pharmacy technician s biggest role. This can offer great rewards for a job well done. On the other hand, ignoring inventory poses great risks. Just a glance can reveal pharmacies that have well-managed inventories and those that have neglected this vital job. This PL Technician Tutorial reviews the ins and outs of pharmacy inventory. You re working on a refill: a 90-day supply of metoprolol extended-release 100 mg tabs for Mary Bingham. Mrs. Bingham called in for this and said she ll be in tomorrow afternoon to pick it up. You are surprised when the computer alerts you there are only 80 tablets remaining in stock. You check the shelf, and the computer is correct. You re glad to have caught this issue, because the pharmacy dispenses a lot of this medication. Fortunately, Mrs. Bingham isn t in the pharmacy waiting for her prescription. Besides having meds available, for what other reasons are managing and maintaining pharmacy inventory important? Pharmacy inventory itself is costly. While keeping adequate inventory in stock is a necessary requirement to serve patients, keeping too much in stock can be financially detrimental. Both too little inventory (below the pre-determined reorder point or par level ) and too much inventory ( reorder quantities that cause you to exceed desired stock-on-hand ) are directly related to poor inventory practices. In addition, there is an actual dollar cost associated with the space for storing inventory in the pharmacy. Plus, space in a pharmacy is a valuable resource for other reasons. Good work takes place in an orderly environment. A disorderly environment can lead to mistakes and a breakdown in efficiency. When vital space such as countertops and shelving are used for long-term storage of inventory, workflow can be impeded. You wonder if there was somehow a mix-up with the reorder point for the metoprolol tabs, or the reorder quantity needed to maintain the appropriate amount of stock-on-hand. Normally, you keep up to 500 tabs of these tabs on the shelf, and reorder when you drop below 300 tabs. As you are thinking about this short supply of metoprolol in your pharmacy, you notice there are several unopened bottles of tranexamic acid tablets sitting on the counter. You know this med is not frequently dispensed and it s very expensive, so you make a mental note to mention this to the pharmacist. Copyright 2015 by Therapeutic Research Center

2 (Page 2 of 6) How is a pharmacy s inventory measured? Most pharmacies count their inventory and its value annually, semiannually, or quarterly. Many operations also have the ability to maintain a floating or perpetual inventory with automated inventory systems. These systems account for inventory and its value as it is received and as it sells. This method gives the pharmacy constant inventory information in real time. However, physical inventory adjustments are still needed periodically. This physical measurement of inventory requires the actual hands-on counting of bottles, tablets, etc. Inventory measurement can be contracted or done in-house. There are several companies that specialize in inventory measurement. Some pharmacies choose to use their own crew to do inventory. The method and frequency of inventory measurement is not as important as having a policy that governs how it is done. Following the policy gives the pharmacy a dependable method of knowing its inventory value. Inventory levels and ratios such as the inventory value as a percentage of annual sales may be somewhat similar in most pharmacies. However, differences in business approaches, work methods, and types of patients will affect these numbers for your pharmacy specifically. Where do pharmacies buy their inventory? Most pharmacies purchase the majority of their inventory from a supplier such as a wholesaler. Wholesalers are essentially a single source through which pharmacies can purchase drugs and supplies from various manufacturers. A large number of pharmacies in the U.S. are supplied by a few national wholesalers including McKesson, Amerisource/Bergen, and Cardinal. In Canada, major wholesalers include McKesson and Kohl & Frisch. Pharmacies usually have multiple suppliers, at least a primary and a back-up source. Big pharmacy chains may own their own wholesaler. Some pharmacies use a combination of external wholesalers and their own warehouse. Drugs can also be purchased directly from manufacturers. This is less convenient for pharmacies, but necessary for some drugs that have special requirements such as limited distribution or special storage. Business agreements govern discount rates, payment agreements, and return privileges between the pharmacy and its supplier. The wholesaler or warehouse offers an array of services other than supplying merchandise. The most important of these is to take inventory back. The agreement between the supplier and the pharmacy contains a set of rules governing all aspects of returning goods. Pharmacies need a way to sell goods back to the wholesaler when too much stock is delivered, the wrong item is received, medications go out of date, merchandise has stopped selling, etc. This inventory becomes unusable as it begins to expire in the store. (Remember that if only a month and year are designated for the expiration date, the drug expires on the last day of the month.) The downside of too much inventory is not only financial. Issues with clutter or not moving stock appropriately are also important considerations. The warehouse or wholesale operation can shift merchandise from a location where it is not being used to one where it will be used, but only if the pharmacy returns the product to the warehouse. Some pharmacy companies choose to use a returned goods company in addition to their principal wholesaler. These companies specialize in returns of out of date or close date merchandise that the main wholesaler doesn t accept. The payment from these companies is lower than the usual wholesale value, but they offer an easy way to dispose of product that is no longer saleable. These one box return companies also handle Schedule II controlled substances including the required DEA 222 transfer forms (in U.S.). Copyright 2015 by Therapeutic Research Center

3 (Page 3 of 6) What are some tools and strategies for ordering and maintaining inventory? While community pharmacies will order medications based on what is purchased in the store, hospital pharmacies will order what is needed from a list of drugs known as the hospital s formulary. The formulary is usually determined by a group of health care professionals and administrators (the Pharmacy and Therapeutics or P and T committee), balancing effectiveness of the medications with factors such as cost and safety. All staff should know their assignments and work to keep appropriate levels of useful inventory in stock. Fortunately, pharmacies also have good tools to help with this, such as shelf labeling, automated reordering, and automatic substitution. Shelf labeling is a manual technique of inventory management. Labels are used to mark a shelf place for each product. The label provides the name/strength/size of the medication, NDC (U.S.) or DIN (Canada), reorder number, bar code, size, etc. These labels help when it s time to reorder stock manually, such as when a med drops below its predetermined par level or reorder point. Generating a reorder in a welllabeled pharmacy can be done easily using a portable data terminal device to scan labels and adjust order quantities. By placing a label on the shelf for all products in the pharmacy, shortages can also be quickly identified. Creating new labels can also be very helpful. If the store has to wait for the warehouse or wholesaler to send labels, much of the impact of labeling is lost. Diligence and patience are required to keep a store well-labeled, but the benefit to inventory levels, and ultimately to patients, is well worth the effort. Automatic reordering is a feature most pharmacies already have, though many may not use it. Most computer systems allow reorder points and stock-on-hand values to be set for each medication, which is referred to as a point of sale inventory system. Prior to generating an order, the system can list all products that need to be replenished. A purchase order is then created and sent to the supplier. In more advanced systems, the software determines inventory level through usage, then orders the merchandise without any interaction from the pharmacy staff. Even with these automated systems, though, it is a good idea to review each order to make sure the items and quantities are appropriate. If unusually high or low amounts in the order catch your attention, take a look at your target inventory and actual inventory to see if everything makes sense. Most suppliers offer the option of automatic substitution to minimize out of stocks. This feature gives the warehouse permission to send another size or brand if they are out of stock, or if a more economical preparation becomes available. Chain pharmacies often have suppliers provide drugs from the same manufacturer to all stores in the area. This way, patients will receive a familiar-looking medication regardless of the location where they had it filled. Here is a list of other tasks to help with maintaining and managing inventory: Perform inventory tasks each day. Make sure you know the deadline by which an order must be placed in order to be received in the pharmacy by the next delivery day. Don t wait until products are out of stock to maintain your inventory. Pay extra attention to fast movers, meds that are very commonly dispensed such as atorvastatin, furosemide, and metoprolol. It can lead to patient dissatisfaction if these are out of stock, and also have significant financial impact for the pharmacy. In the community setting, avoid ordering new and expensive meds until a patient brings in a prescription. Verify the cost with the patient beforehand, and don t open the container or label it until the patient has paid. This way the drug can be returned to the supplier if necessary. In the hospital setting, the need to stock new meds will be determined by the formulary. However, circumstances may arise where a patient needs a new and expensive med that is not on formulary. If this is the case, a Copyright 2015 by Therapeutic Research Center

4 (Page 4 of 6) pharmacist or administrator will typically be able to advise about how much of the drug to order, and at what point any excess should be returned. Keep reasonable but not excessive amounts of non-income products such as bags, labels, and vials in stock. Like excess inventory of drug products, these can tie up cash flow and space. Mark products that are set to expire soon with a colored sticker or some other identifier so they can be used first and removed from the shelves for return to the supplier at the appropriate time. In some situations, such as for medication trays for code carts in the hospital setting, you will want to avoid stocking medications that will expire soon (e.g., within the next three months). The reason is that the carts will be stocked throughout the hospital, and monitoring and exchanging them within a short period of time due to expired meds is not an efficient use of time. Make sure you are aware of these types of rules in your pharmacy. Fortunately, you are able to manually add metoprolol extended-release 100 mg tabs to your order that will be delivered to your pharmacy tomorrow. The order is usually delivered early and gets checked in right away. What should be done when an order is received in the pharmacy? When an order is received in the pharmacy, make sure the number of cartons received matches up with the number of cartons shipped. Point out any noticeable damage to the shipment before the delivery person leaves. Check the order in as soon as possible after it arrives to make sure all ordered items have been received. Use the packing slip or invoice and mark off items as they are removed from the shipping containers and placed on pharmacy shelves, etc. Contact the wholesaler or supplier immediately for any damaged or shorted items. If the cause of a shorted item is a drug shortage, the pharmacist may need to work with prescribers to find alternatives for patients. Keep in mind that controlled substances may be delivered in a separate order from noncontrolled substances. These may need to be checked in by the pharmacist and the paperwork must be filed separately from other pharmacy invoices. Make sure drug products are placed in the appropriate area for storage: shelves, locked cabinet, refrigerator, or freezer. If you are unsure of proper storage, check with the pharmacist or look at the package or product labeling, under the How Supplied or Storage and Stability section. Make sure refrigerators and freezers are working properly to avoid wasting supplies of drugs that require refrigeration or freezing, such as vaccines. When stocking new meds in the pharmacy, pay attention to the potential for mix-ups to be caused by look-alike, sound-alike drug names. Use shelf tags, bins, etc to separate these products to prevent dispensing errors. Be sure to rotate stock when unpacking new orders so packages with shortest expiration get used up first. Place new product behind, not in front of, what s already on the shelf. Also, mark open stock bottles to avoid having multiple open bottles of the same product on the shelf. What should be done with regard to returning inventory to the supplier? Merchandise to be sent back to the warehouse should be kept in a designated area for returns. Usually drugs that expire within one to three months will be removed from shelves and placed here. A recall is another reason a drug may need to be removed from shelves and placed in a designated area. The return process should take place at regular intervals. This will ensure there are not huge stacks of unprocessed returns or multiple piles of return goods cluttering up the pharmacy. It is important to process returns on a consistent basis. This ensures the most credit for returns while freeing up inventory dollars to order the most needed items for your patients. Copyright 2015 by Therapeutic Research Center

5 (Page 5 of 6) You find out from the pharmacist that the bottles of unopened tranexamic acid tablets sitting on the counter were pulled from the shelves for return to the wholesaler. You place these in the designated area, knowing that returns will be processed within the next couple of days. How is the inventory of controlled substances different from inventory for nonscheduled drugs? In the U.S., inventory of controlled substances has specific requirements mandated by the Drug Enforcement Agency (DEA). The DEA requires that a controlled substance inventory (Schedule II-V) be done when a pharmacy first opens, then once every two years. This record needs to be kept in an easily accessible place for at least two years, in case of inspection. The record must contain the pharmacy s name, address, and DEA number and must be signed by the person who does the inventory. State boards of pharmacy also have requirements for inventory of controlled substances. An example of this would be perpetual inventory of Schedule II-V substances reported to the board of pharmacy twice a month. Both state boards of pharmacy and pharmacy policy may dictate other procedures involving controlled substances, such as the method for filing paperwork associated with the ordering of controlled substances, storage of controlled substances, etc. In the U.S., remember that the ordering of Schedule II controlled substances requires a special order form (DEA form 222) that is available as either a paper triplicate or electronically. When C-IIs have passed their expiration date, DEA Form 41 must be completed and destruction of the expired drugs must be witnessed. Rules regarding inventory of controlled substances are similar in Canada. For example, controlled substances may need to be counted quarterly to make sure there are no major discrepancies. Discrepancies may need to be reported to Health Canada, depending on the drug involved. Can medications that patients don t use be returned to stock? In most states and provinces, medications cannot be returned to stock once they have left a retail pharmacy. It s impossible to know how the medication was stored or if it s been altered in some way that might make it dangerous. In the U.S., some states do allow the return of medications if they are in their original container and unopened with the factory seal in place. If a medication is not picked up by a patient and has not left the pharmacy, it may be returned to stock. The drug should not be added back to the stock container unless it s the same lot number. If not, just keep it in the prescription container and remove patient-specific information. It can then be recounted into a new bottle and labeled for another patient. These rules also apply to pharmacies that deliver medications to patients. If the medication is never delivered and does not leave the possession of the driver, it may be returned to stock. Most states and provinces have specific regulations on what may be returned and what cannot. In the U.S., check with your state board of pharmacy for information on regulations specific to your state. In Canada, check with your provincial or territorial pharmacy regulatory authorities. In the hospital setting, unused unit doses can usually be returned to stock. However, storage conditions on patient care units may determine whether or not injectables can be returned to stock. For example, if a vaccine that requires refrigeration is found on a countertop in a med room or unused and in a med return bin, you should check with the pharmacist about what to do with the dose. It may need to be discarded, or if room temperature storage for a period of time is allowable per the manufacturer or other guidance, it may be able to be redispensed to another patient. The same is true for IV piggybacks such as antibiotics and for IV infusions or fluids such as heparin drips, insulin drips, and maintenance fluids (e.g., normal saline 1000 ml with potassium chloride 20 meq). Copyright 2015 by Therapeutic Research Center

6 (Page 6 of 6) One way to reduce unused medications in the hospital setting is to avoid delivering duplicate supplies. For example, if a nurse reorders a medication, you can look into the reason for the reorder. Many reorders are appropriate, such as when a medication ordered as a continuous infusion runs out (e.g., amiodarone, heparin, insulin) or when a bulk med is empty (e.g., inhalers, insulin vials, ointments). However, if a reorder seems too soon, it s a good idea to cover your bases and make sure the nurse is looking in the correct location for the med, such as for meds that are refrigerated. Also, make sure the patient wasn t transferred and his or her meds were delivered to the old location. If you do redispense a med in response to a reorder and find that the patient already has an adequate supply on the patient care unit, simply return the redispensed med to stock. When Ms. Bingham comes in to pick up her metoprolol the next day, she brings with her an unused Z-Pak that was prescribed for her husband about two weeks ago. She asks if it can be returned. You tell her there is a chance, since it is in the original package and has not been used. However, you ask the pharmacist to speak with her and confirm whether or not a return can be made. Project Leader in preparation of this PL Technician Tutorial: Stacy A. Hester, R.Ph., BCPS, Assistant Editor Cite this document as follows: PL Technician Tutorial, The Ins and Outs of Pharmacy Inventory. Pharmacist s Letter/Pharmacy Technician s Letter. August Copyright 2015 by Therapeutic Research Center

7 (Page 1 of 4) Technician Training Tutorial: Optimizing Pharmacy Workflow Optimizing workflow in the pharmacy is important for both efficiency and patient safety. Your pharmacy should ideally function like a well-oiled machine or a Swiss watch, as they say. This involves both the pharmacy environment itself and how the work is performed within the pharmacy environment. Think about it like cooking a meal. Isn t it much more efficient to keep the dishes clean, remove garbage, and return ingredients to their proper storage locations as you cook, as opposed to generating a bigger and bigger mess as you work? Doesn t following recipes give you a better chance of producing a delicious dish instead of something you never intended to create? Because work in the pharmacy involves more people and more functions, this scenario is amplified when we apply it to dispensing meds efficiently and safely for patients. Keep in mind that efficiency is not the same thing as rushing. Working efficiently means that effective work is done in a minimum amount of time. In contrast, rushing or using shortcuts could lead to more problems, such as errors, that will end up costing time in the long run. A good example of a shortcut that is quick but does not improve efficiency is the use of unsafe medical abbreviations. They may be faster to write out than the words they represent, but they are also known to cause very serious, even fatal, errors. This PL Technician Training Tutorial covers practices you can use to improve pharmacy workflow. Chuck Upton is a 57-year-old male who comes in to your pharmacy with a new prescription for dexlansoprazole 30 mg capsules, take one by mouth once daily. He is a new patient, so you hand him your standard form for new patients to fill out, which will include information about his allergies, medical history, and insurance coverage. Meanwhile, you notice three other people have come to the drop-off window, and things seem to be getting busy. The next patient has a list of ten refills she needs, so you ask her if she will be waiting to pick them up. She says, oh no, I know this will take some time, so I ll be back tomorrow afternoon. You go ahead and put Mr. Upton s Rx before hers. Mr. Upton has taken a seat and will be waiting for his Rx to be filled today. He s okay with the 20 minute wait time. What are some general practices I can use to improve the environment in my pharmacy? As a rule, the pharmacy should always be kept both clean and organized. This may be easier said than done, especially when the workload in the pharmacy is at its peak. Still, as they say, an ounce of prevention is worth a pound of cure. Always take the time to place medications and other pharmacy supplies in their proper storage locations. This helps ensure that correct medications will be chosen from pharmacy shelves for filling prescriptions. It also helps keep the dispensing process efficient, so you don t have to spend time searching for the correct supplies (e.g., bags, labels, lids, vials) when you need them. In addition, placing meds and supplies in their proper storage locations ensures that items stored in their proper places aren t hidden by other items that are inappropriately stacked or stored in places they don t belong. Copyright 2013 by Therapeutic Research Center

8 (Page 2 of 4) Be consistent about removing unnecessary items from the different locations in the pharmacy. For example, cleaning out discontinued or unclaimed meds from the will-call area (or removing discontinued meds from a patient care unit in the hospital) and returning them to stock on a regular basis will help keep the will-call area organized, improving efficiency and patient safety. Errors that can be avoided by keeping the will-call area neat and up-to-date include giving meds to the wrong patient. Another example is placing meds that are soon to expire in a designated area to be returned. This can help prevent dispensing of meds that are expired or too close to expiration to be dispensed. Keep in mind regulatory agencies in the U.S., such as state boards of pharmacy, mandate standards of cleanliness, such as keeping food and beverages out of refrigerators and freezers meant for medication storage. Place your food and beverages only in areas designated for food and beverages. Also, be sure to keep personal items such as purses and backpacks off of pharmacy floors and counters and in designated areas such as cubbies, lockers, or break rooms. How can the pharmacy be organized? Just as a house has designated areas for certain activities such as eating, showering, and sleeping, a pharmacy should have designated areas where certain activities are performed. Define areas of activity and what functions should be performed in each area. Some of the areas of activity might include prescription drop-off, computer order entry, compounding, and prescription pick-up. Technicians can be assigned responsibility for the specific areas. Then technicians can be cross-trained to work in different areas. Defining areas of activity in the pharmacy can reduce chaos, and allow technicians to focus on one task from start to finish instead of bouncing from one task to another. Note that if you work in a hospital setting, the different areas within the pharmacy may be far more different from each other than those within a community pharmacy. Special competencies may be required for technicians to work in areas of the hospital pharmacy such as the IV room. Assigning technicians to different areas can also help prevent bottlenecking in the pharmacy. For example, if only two technicians are working and both are at prescription drop-off, with no one assigned to the area for filling prescriptions, the queue at the pick-up window will be out of control with patients waiting for their filled prescriptions! Monitor areas of activity to make sure work is not backing up anywhere and that problems are getting handled in a timely manner. For example, if you see that a technician in an area other than yours is very busy and you are having a lag in your work, you might ask if you can step in and cover for a few minutes so that tech can troubleshoot on whatever is holding him or her up. You start entering Mr. Upton s information into the computer. He has an allergy to sulfa drugs (rash), and he has been taking acetaminophen for headaches and OTC omeprazole for upset stomach. He doesn t list any other medical conditions or Rx meds that he has been using. You look over his prescription to make sure all the necessary info is included: drug, dosage form, strength, route, directions, number of refills, etc. The information is all there, so you are ready to enter it in to the computer. What practices can be used to optimize workflow? There are a number of ways technicians can help optimize workflow in the pharmacy. It s best when all pharmacy staff work toward this common goal. Be on time for work. When folks come late to work, this can really throw a wrench in the workflow. No one likes to start out the day being behind. Besides, tardiness is unprofessional, a poor example for Copyright 2013 by Therapeutic Research Center

9 (Page 3 of 4) coworkers, and a possible stimulus for disciplinary action. Make sure your breaks are scheduled at appropriate times of day (those that aren t the busiest), coordinated appropriately with your coworkers, and that you return from your breaks on time. Once your pharmacy is clean and organized and areas of activity are established, it is important that the work patterns in each area are defined and followed. Work patterns mean that each technician is trained to perform the same work similarly, so the work is both efficient and safety checks are incorporated consistently. Work patterns can be defined for functions such as gathering patient information, selecting medications from pharmacy shelves, returning medications to stock, and so on. For example, the work pattern for choosing meds from pharmacy shelves may involve a number of double checks as well as the use of shelf tags for information about alternate storage locations for look-alike, sound-alike meds. Work patterns may also incorporate customer service as a priority. Some examples include acknowledging patients as they approach the pharmacy counter, promptly answering the telephone, and informing patients ASAP about any problems regarding the filling of their prescriptions. Here is a very basic example of a work pattern for incoming prescriptions: Acknowledge the patient Gather patient information including date-of-birth, medication history, diseases/conditions, allergies, insurance coverage Screen the patient s prescription for omissions Prioritize work, such as incoming prescriptions. Not all prescriptions much be filled ASAP, nor do all prescriptions need to be filled at once. Try to find out when each prescription needs to be ready and make a note on the prescription to inform other pharmacy staff. Then work on in-store prescriptions (or stat orders in the hospital pharmacy) first. Fill in the gaps and lulls in your workload with prescriptions that aren t as pressing such as those that you know won t be picked up for a day or two (or in the hospital, those that will go out on a scheduled delivery). Some work may be saved or scheduled for a time of day when you know you will be less busy. Have a system in place to handle problem prescriptions such as insurance rejects, out-of-stocks, refill requests, etc. These can be separated from normal workflow with the use of a special system such as colorcoded baskets. A technician can be assigned to work on these problems and follow up on them as necessary, rather than multiple technicians dealing with them individually and interrupting their assigned workflows. This technician will also need to notify patients of any issues with their prescriptions, whether they are instore or planning to pick up the prescription at a later date. Keep the lines of communication open. For example, communicate with your coworkers as soon as possible about any problems that you anticipate will affect workflow. Some examples of these types of problems include meds that are out of stock, special order meds, a large incoming order, a malfunctioning automatic dispensing machine, and a third-party payor computer that s down. When you communicate about these problems in a timely fashion, others may be able to help mitigate the problem, such as by providing an extra set of hands, notifying patients of delays, etc. Remember that work is all business and all about the patients. Don t let any kind of personal friction with coworkers impede professional communication. Also communicate with patients about any problems having to do with their prescriptions. This type of customer service is very important and can help prevent unwanted outcomes such as frustration or inconvenience for patients as well as delays or interruptions in their drug therapy. In the hospital setting, nurses will appreciate being kept abreast of problems with their patients orders that might lead to delays. Copyright 2013 by Therapeutic Research Center

10 (Page 4 of 4) An example of this might be a med that is especially labor intensive to prepare or the need for an order to be clarified by the pharmacist with a prescriber prior to dispensing. Be sure to minimize distractions when you are on duty in the pharmacy. Avoid excessive chatter about personal business, personal phone calls, text messaging, internet surfing, etc. Stay focused and on-task when you re working to help reduce the chance of errors and disturbances to workflow. Use your break times to attend to personal matters and socialize. Mr. Upton s Rx is rejected by his insurance because it will require prior authorization. Mr. Upton needs to try a generic form of this type of stomach medicine before his insurance will pay for dexlansoprazole, which is not available as a generic and is more expensive. Mr. Upton s Rx goes to another tech assigned to work on third-party rejections. You hear the technician tell Mr. Upton that his Rx is going to take longer than expected because there are issues with his insurance. Mr. Upton says he would be glad to come pick up his Rx first thing in the morning. Your coworker thanks him for his patience and assures him that his med will be waiting for him when he arrives tomorrow. Cite this document as follows: PL Technician Training Tutorial, Optimizing Pharmacy Workflow. Pharmacist s Letter/Pharmacy Technician s Letter. October Copyright 2013 by Therapeutic Research Center

11 (Page 1 of 4) Technician Training Tutorial: Patient Profiles 101 An important part of being able to provide the best drug therapy possible for patients is having all the necessary information about them and maintaining their patient profiles. Good patient profiles can help the pharmacist identify which drugs should be avoided, which drugs will be appropriate, the appropriate dose of a drug, and so on. In fact, about one in five serious, preventable adverse drug events happens because health care providers DON T have enough information about patients. This Technician Training Tutorial reviews the basics of gathering patient information. Casey Sanchez is a 25-year-old female patient who comes into your pharmacy with an Rx for doxycycline 100 mg PO BID x 21 days. She tells you she just moved into town and is a graduate student in English literature at the local university. You suspect she has never had a prescription filled at your place before. You double check this on the computer, and you do not find Casey Sanchez. What is my role, as a technician, in gathering patient information? In the community pharmacy setting, technicians are likely to have the most face time with patients. This opens up opportunities for asking patients questions and gathering info that is needed for making patient profiles and keeping them current. Name, address, and date of birth are three pieces of information that you likely gather for all patients, for identification. But beyond these basics, you can gather and maintain patient information that will help prevent problems with drug therapies. In the hospital setting, nursing staff will usually be responsible for entering most patient information into the computer. However, pharmacy technicians may play a role, such as with entering medication lists through medication reconciliation programs. What information should I ask for and maintain on patient profiles? Keep in mind that you need to gather information from new patients, but that you should also maintain current information on existing patients. There are a number of things that can change. Some examples are allergies, medical conditions, and weight. Making sure that a patient s info is up-to-date when refilling meds or dispensing a new Rx will help avoid any problems. When communicating with patients, be clear in your questions and statements. Always use simple terms and avoid the use of medical jargon. Request info from patients by using open-ended questions, as opposed to questions that can be answered with a simple yes or no. This can help avoid mix-ups and miscommunication. If your pharmacy has a policy on collecting patient info or a form you can use, make sure and use it consistently. Patient identifiers. Continue to ask for patient name, address, date of birth, and gender. This helps ensure the right patient gets the right med. It seems very simple, but mix-ups with patients are not unusual. And they can lead to significant harm. Names can be tricky. Always verify spelling of names, both first and last. Think about names such as Ann or Anne; Brian or Bryan; Erin or Aaron; Carrie, Cari, or Kerry; Smith or Smyth; Green or Greene; and so Copyright 2013 by Therapeutic Research Center

12 (Page 2 of 4) on. Plus, folks seem to be getting more and more creative with the spelling of names. They aren t always spelled like they sound. Make sure you have the correct middle initial, as well as suffix such as Jr, Sr, II, III, or IV. This can help prevent mix-ups between patients who have the exact same first and last names. Keep phone numbers and insurance information up to date as well. Some computer systems allow you to look patients up by phone number. And having current insurance info will prevent issues with billing. You ask Casey Sanchez to verify the correct spelling of her name, as well as her address, phone number, and date of birth. She spells her name with a K instead of a C (Kasey instead of Casey). You enter the name correctly into the computer, and you make a note on the Rx of the correct spelling. You also note in the computer that Kasey is a female. Allergies. Medication should not be dispensed (except in very rare circumstances such as emergencies) until a patient s allergies are documented. Don t just ask for medication allergies. Other allergies that you should document include vaccines, supplements, food, dyes, and other substances such as latex. In addition, ask for the specific reaction the patient had to the substance to which he or she is allergic, as well as when the reaction took place. This info can help the pharmacist make decisions (sometimes along with the prescriber) about whether or not a drug therapy is appropriate. Consider a situation where a patient who reports an allergy to the antibiotic penicillin is prescribed the antibiotic cephalexin for an infection. In general, patients who are allergic to penicillin can also have reactions with cephalosporin antibiotics such as cephalexin. If the patient reports a reaction such as stomach ache with penicillin, the pharmacist is likely to go ahead and dispense the cephalexin. Stomach ache is not generally a true allergic reaction. On the other hand, if the patient reports shortness of breath with penicillin, which is a serious allergic reaction, the pharmacist is likely to take additional steps to decide whether or not cephalexin will be safe for the patient. Here are a few more examples of why good allergy info is important: Patients with certain allergic reactions to eggs should in most cases only receive flu vaccine from allergy specialists. People with severe latex allergy might have trouble if medications in vials with natural rubber stoppers are dispensed. Patients with gluten sensitivity (celiac disease) can become very sick if they take medications that contain gluten. If a patient has had a serious allergic reaction to a vaccine in the past, he or she should not receive that vaccine again. You ask Kasey if she has any allergies. She responds that she is allergic to codeine, peanuts, and strawberries. When you ask for specific reactions and when they happened, she tells you that she has nausea with codeine, which happened about one year ago, and breathing problems and hives with both strawberries and peanuts, which happened when she was a kid. Medication lists. A comprehensive medication list is also important. This can help prevent any issues such as duplicate therapy, incorrect dosing intervals or schedules, use of medications that are no longer needed, and drug-drug interactions. A medication list should not be limited to Rx meds only. Meds such as overthe-counter products, and supplements such as vitamins and herbals should also be included. Also include meds that are used on an as-needed basis and meds that are used topically such as creams, patches, eye drops, and inhalers. These can be easy to forget. Copyright 2013 by Therapeutic Research Center

13 (Page 3 of 4) Vaccines that a patient has received should be included on a med list. This can help pharmacists recommend appropriate vaccines for patients who have missed them or who are due for another dose. You ask Kasey if she takes any medications. She says that she does not take any other Rx medications, but that she does occasionally take acetaminophen, ibuprofen, and OTC omeprazole. Medical conditions or disease states. Adding conditions or disease states to patient profiles can be key for helping the pharmacist really fine tune drug therapy. For example, kidney disease or renal failure is a factor for dosing many drugs. Doses will often need to be reduced because the body doesn t get rid of certain drugs as quickly when the kidneys aren t working well. An example of a drug that s cleared by the kidneys is the antibiotic trimethoprim-sulfamethoxazole. Clearance by the liver is another way the body gets rid of drugs. Doses of some drugs may need to be reduced for patients with liver disease or failure. This can be true for products with acetaminophen, opioids, and a handful of others. Pregnancy may not be thought of as a condition, per se, but it s important to include on a patient profile. Some drugs, such as ACE inhibitors (e.g., enalapril, lisinopril) should never be used in pregnancy. Some antibiotics such as quinolones (e.g., ciprofloxacin, levofloxacin) and trimethoprim-sulfamethoxazole should be avoided at certain times during pregnancy. It s also good for the pharmacist to know if a patient is pregnant when helping with selection of an appropriate OTC product. Likewise, if a patient is breastfeeding, this can be included in the patient profile. Drugs can pass to the baby through breast milk, so knowledge that a patient is breastfeeding can affect drug selection. You might be surprised to know that conditions such as glaucoma (high pressure in the eye) and myasthenia gravis (chronic muscle weakness) can affect drug selection. Certain drugs can worsen these conditions, so it s important for the pharmacist to be aware of them. For example, the antibiotic telithromycin should not be used by patients who have myasthenia gravis. Other common disease states that should be included on patient profiles include diabetes (specify type 1 or type 2), hypertension (high blood pressure), hypercholesterolemia (high cholesterol), asthma, heart failure, any type of cancer, etc. You ask Kasey if she currently has any medical conditions and she tells you that she has acid reflux and tension headaches but she doesn t take any Rx meds for either condition, just the OTC meds that she already mentioned. Height and weight. Having a patient s current weight is key, especially for children. Children s bodies and organs are still developing and don t yet function just like adults. Drug dosing for babies and kids is usually based on weight, such as milligrams per kilogram per dose (mg/kg/dose) or milligrams per kilogram per day (mg/kg/day). Since these patients weights change over time, be sure to always ask for the current weight. Note that 1 kilogram (kg) is equal to 2.2 pounds (lbs). These units are easy to mix up. Here are some example conversions: Mrs. Simm s baby son Carlisle weighs 14 lbs. How many kg does he weigh? 14 lbs 2.2 lbs/kg = 6.36 kg Mr. Brown s baby daughter Samantha weighs 6.7 kg. How many lbs does she weigh? 6.7 kg x 2.2 lbs/kg = 14.7 lbs Copyright 2013 by Therapeutic Research Center

14 (Page 4 of 4) How many kg do you weigh? How many lbs do you weigh? Keep this in mind if you need a quick comparison to help you remember the conversion. Always double check your calculations and computer entries. It doesn t hurt to glance at the patient either, just to make sure the weight makes sense. For example, if you mistakenly enter the value of 10.5 into a field with a unit of kg instead of lbs, the corresponding field with a unit of lbs might automatically populate with Just looking at the child might help you realize the mistake. A patient s height is necessary for calculating doses of some drugs such as some intravenous antibiotics and chemotherapy. This is most applicable in the hospital setting. Keep in mind that 1 inch is equal to 2.54 cm. Lifestyle. Having some information about a patient s lifestyle is important for drug therapy and also for helping the pharmacist encourage improvements and healthy behaviors. Lifestyle info that you can include on a patient profile includes: Consumption of certain foods and beverages. For example, alcohol can interact with meds that cause sedation (such as some pain killers) or with metronidazole (which can increase side effects). Grapefruit can interact with some meds and cause their blood levels to increase. Cigarette smoking, which can affect how drugs are broken down by the body Marijuana use, now legal in some states and in Canada, which may interact with some medications Of all the patient information you collect, lifestyle information might be the most sensitive for patients. Stay matter of fact and nonjudgmental in your tone. If you re uncomfortable, ask your pharmacist for guidance. Kasey tells you she is 5 4 and weighs about 140 lbs. You enter these values into the correct fields in the computer so that the units match up. Kasey is an occasional smoker and drinks alcohol occasionally as well. You thank her for her patience and for the information she has provided, and tell her it will be about 30 minutes before her Rx is ready. Kasey thanks you, and says she appreciates you asking for her information. She has never had anyone collect this info from her before in a pharmacy, and it helps her feel confident that she will be well taken care of now and when she needs other medications in the future. What else should I consider about gathering patient info and maintaining patient profiles? Make sure you are familiar with your computer system so you know where to enter and how to access patient information. Also, it s important to know where to enter and how to access additional info such as unusual allergies, notes regarding correspondence, and so on, that cannot be entered in any other field. Remember that patient information of any kind must never be shared with individuals who are not involved in a patient s care and that patient information should never be accessed unless it s necessary for the patient s care. Never share patient info with friends, family, or even coworkers unless it s directly related to pharmacy business. Keep in mind that patients are likely to appreciate privacy and discretion when they are sharing very personal information. You can help optimize this. Be conscious of the volume of your voice and use a more private consultation area in the pharmacy when possible. Cite this document as follows: PL Technician Training Tutorial, Patient Profiles 101. Pharmacist s Letter/Pharmacy Technician s Letter. March Copyright 2013 by Therapeutic Research Center

15 (Page 1 of 7) PL Technician Tutorial: Certification and CE Requirements Education, training, and certification help technicians demonstrate knowledge and skills, and their ability to meet pharmacy practice standards. New state requirements are bringing up questions about registration, certification, and licensure of pharmacy technicians. For example, the death of a toddler in Ohio resulting from a hospital pharmacy technician s error not caught by the pharmacist led to the passage of Emily s Law. Although the pharmacist was also held responsible, new requirements were put in place for Ohio pharmacy technicians to maximize patient safety and ensure appropriate pharmacy technician training. This tutorial explains what technician certification means, how to become certified, and how to maintain certification. It also reviews technician continuing education (CE) requirements and other professional development opportunities for technicians. Each state will have different requirements for its technicians. Use the Technician s CE & Training Organizer to find out requirements in your state and keep track of your completion of required courses. What are differences between registration, certification, and licensure for technicians? States may require technicians to be registered, certified, or licensed. Some states don t require anything of pharmacy technicians no registration, no licensure, and no certification. Other states use different terms to describe technician requirements. For example, in Oklahoma, technicians are not considered registered, but are given a permit. In Ohio, those who meet state requirements are termed qualified technicians, not registered or licensed. There is no standard definition of registration, certification, or licensure used by all states. However, there are accepted, professionally recognized definitions of these terms. Registration is defined simply as making a list. Registration is usually done to keep track of who is a technician, where they work or live, and in some states, do background checks. Registration is the only requirement in some states. In most states, registration does not address the educational and training background of pharmacy technicians. Some states require technicians to complete additional requirements to maintain their registration, such as completing a set number of CE hours. Nearly one-half of states include certification in their regulations. Certification is defined as the process by which a nongovernmental organization recognizes an individual who meets predetermined qualifications specified by that organization. Technicians can become certified by taking a national certification exam, or by meeting state certification requirements. National certification by exam through the Pharmacy Technician Certification Board (PTCB) or the National HealthCareer Association (NHA) recognizes technicians who have the education, knowledge, and training to efficiently assist pharmacists in the safe and accurate preparation and dispensing of medications and the provision of quality patient care and service. Some states require that technicians take one of the national certification examinations to get state certification, registration, or licensure. However, other states grant state certification by recognizing on-the-job training or a diploma, certificate, or associate s degree program from a community college or technical school. State certification may also be granted through completion of training approved by the state pharmacy board or pharmacy accreditor (e.g., the American Society of Health-System Pharmacists and Accreditation Council for Pharmacy Education [ASHP-ACPE]) as an alternative to taking a national examination. The number of states requiring either national or state certification is expected to increase due to patient safety concerns. There is even a push for a federal law requiring certification in all states. Check the Technician s CE & Training Organizer for certification requirements in your state. Copyright 2016 by Therapeutic Research Center

16 Copyright 2016 by Therapeutic Research Center (Page 2 of 7) Licensure is required for technicians in some states, including Arizona, California, and Utah. Licensure is defined as the process by which permission is granted to an individual to practice their occupation after it is determined that the individual has the minimum level of competency to practice safely. Licensure may require registration plus certification by exam and/or completion of education and training. Keep in mind some states use the terms licensure and registration interchangeably. Check the Technician s CE & Training Organizer to see if licensure is an option in your state. Which national organizations offer a certification exam? Certification exams are offered by the Pharmacy Technician Certification Board (Pharmacy Technician Certification Exam [PTCE] at and the National HealthCareer Association (ExCPT exam at PTCB is a non-profit organization governed by five pharmacy organizations, including the American Pharmacists Association (APhA), American Society of Health-System Pharmacists (ASHP), Illinois Council of Health-System Pharmacists (ICHP), Michigan Pharmacists Association (MPA), and the National Association of Boards of Pharmacy (NABP). The PTCB exam is vetted by NABP, which performed a psychometric audit of the PTCB exam in 2001 and determined that the PTCE is psychometrically sound, defensible, and valid. Since its inception in 1995, PTCB has certified over 555,000 pharmacy technicians through the examination. The ExCPT exam is administered by NHA and is endorsed by the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA). The NHA is one of the largest national health certification providers in the U.S. Established in 1989, the NHA provides national credentials and an information support network to allied health care professionals, educators, and the health care industry. What is the NCCA? What does this mean for a certification exam? The National Commission for Certifying Agencies (NCCA) reviews and accredits certification programs that assess professional competency. Meeting NCCA criteria means, among other things, that the certification program uses fair and valid tests, defines the professional s level of responsibility, and requires continued proficiency. The PTCB s certification program and the NHA certification process are accredited by NCCA. Which exam does my state require? The answer depends on your state. About a one-half of states currently include national certification through a specific exam in their regulations. Several states plan to add a national certification requirement in the near future. In some states, certification is voluntary, but a certain exam may be recognized by boards of pharmacy if technicians wish to get certified. Other states do not specify ANY certification requirements or recognize any specific exams for technicians. If your state requires national certification, you will need to complete an exam recognized by your state s board of pharmacy. Currently, all states that require national certification recognize the PTCE as board-approved; many of these states also recognize the ExCPT exam. If certification is voluntary in your state and a specific exam IS recognized by the board of pharmacy, it s a good idea to pursue national certification through the board-recognized exam(s), even though this certification is voluntary. For example, a state board may recognize the PTCE and/or ExCPT exam as being board-approved for technicians to use in a voluntary national certification process. If certification is voluntary in your state and a specific exam is NOT recognized by your state board of pharmacy, you can still pursue this step in your professional development through the PTCE or ExCPT exam. Some employers are also setting up internal certification standards that may apply in

17 (Page 3 of 7) states with no board-approved national certification exam requirements. Alternatively, in some states, there are other avenues for pursuing state certification, such as on-the-job training or completing an educational program. Before pursuing national certification in any state, check with your employer or pharmacist supervisor about specific requirements or certifications that may be recognized within your organization. Use the Technician s CE & Training Organizer to check your state s requirements, see which exams are board-recognized in your state, and watch for future changes in your state. Where do I take the exam? The PTCB exam is taken on a computer at one of over 220 Pearson VUE Professional Centers throughout the U.S. Overseas military personnel can be tested at DANTES sites. See for testing locations. The ExCPT exam is taken on a computer at a PSI Testing Center. There are over 600 test sites nationwide. See or call for testing locations. When and how do I sign up to take the exam? The PTCB exam is offered continuously. You can apply online year-round at After submitting your application, you ll receive a confirmation within 24 hours and an Authorization to Test (ATT) letter via (if you provided an address) or regular mail. Once you receive the letter, you can schedule an appointment with Pearson VUE to take the exam. The Authorization to Test letter gives you 90 days of eligibility to schedule an appointment to take the exam. The ExCPT exam can be taken continuously. You can apply at After submitting your application, you ll receive your confirmation to test. You ll have 24 hours to schedule your exam. Call to register to take the exam at a PSI location of your choice. Or go to to locate a nearby test center. How much does it cost to take the exam? It costs $129 to take the PTCB exam. The ExCPT exam costs $105. What are the pre-requisites for taking a certification exam? To take the PTCB exam, you must have a high school diploma or equivalent (e.g., GED), full disclosure of all criminal and State Board of Pharmacy registration or licensure actions. Coming soon in 2020, PTCB will require you to have completed an ASHP-ACPE accredited program in order to sit for the exam. To take the ExCPT, you must be within 30 days of obtaining a high school diploma or equivalent, and have successfully completed a training program offered by an accredited or state-recognized institution or an employer-based training program, or have a minimum of 1200 hours of supervised pharmacy-related work experience within any one year in the last 3 years. What do the tests cover? The PTCE questions test knowledge and skills related to the activities performed by pharmacy technicians. Most of the ninety multiple-choice questions relate to helping the pharmacist serve patients. The exam is broken down into nine knowledge domains, with medication order entry and fill process being the largest. The exam applies to both community and hospital settings. There are ten additional pre-test questions that do not count towards your final score. Copyright 2016 by Therapeutic Research Center

18 (Page 4 of 7) The ExCPT consists of 120 questions, including 20 pre-test questions. A quarter of the exam covers regulations and technician duties. About another quarter covers medications and drug therapy (e.g., drug classes, dosage forms, common side effects, interactions, and indications). The remaining questions cover the dispensing process, including calculations and IV preparation. How do I prepare for the exam? Pharmacy technician training texts, academic study programs, and on-the-job experience can be helpful in preparing for the exam. Completing an employer training program or technician training program offered through a technical or vocational school or community college may be helpful. Check with your pharmacist and other technicians who have successfully passed a certification exam about help developing a study strategy. Our Pharmacy Technicians University program is an online, interactive educational course designed to prepare enrollees to pass any pharmacy technician certification exam. It also helps enrollees learn what it takes to become a safe, efficient, and overall great pharmacy technician. The course allows users to go through the content at their own pace. Plus, there are pacing questions, case studies, educational games, and more to help cement the concepts to memory, as well as keep the experience fresh and enjoyable. You can get additional information and enroll by going to the Pharmacy Technicians University website. Other resources may be available through the testing organizations: The PTCB web site ( offers a sample exam to help in preparing for certification, available at: The NHA web site ( also offers sample exams and study guides to help with preparing for the ExCPT certification exam. These materials are available for purchase at: What are my legal liabilities once I become nationally certified? Whether you are certified or not, you can face criminal charges if you divert or steal medication, intentionally give a patient more or less medication than prescribed, or put false medical information in the patient s profile for billing or insurance fraud. If you fill a prescription incorrectly and harm a patient, you could face a lawsuit. This could happen if you enter incorrect information into the computer, prepare an intravenous medication incorrectly, or put the wrong medication in a prescription bottle and the pharmacist doesn t catch the mistake. Your employer may have a liability insurance policy that covers you. Talk to your employer to see if you should carry additional liability insurance. Make sure you understand what actions technicians are allowed to do in your state and the renewal requirements in your state. If you perform an action that is considered outside the scope of practice for technicians in your state, or fail to renew your registration, certification, or licensure as your state requires, you could be fined or lose your ability to practice. How long does national certification last? Certification is good for two years for PTCB and NHA. Also keep in mind that your state might require you to regularly (e.g., annually or every two years) renew your registration, certification, or licensure with the board of pharmacy. Some states require CE in addition to maintaining national certification. Do I need to maintain my national certification? Some states require certification for initial licensure or registration, but thereafter the technician does not have to maintain certification. Other states require that you maintain your national certification. Copyright 2016 by Therapeutic Research Center

19 Copyright 2016 by Therapeutic Research Center (Page 5 of 7) Even if it is not required by your state, it is a good idea to maintain your certification because you may move to a state that requires it, or your state law may change. If your ExCPT or PTCB certification lapses for more than 12 months, you will need to sit for the exam again to be certified. Check the Technician s CE & Training Organizer for information on your state or certifying board s renewal period and renewal requirements. What are the CE requirements for nationally certified technicians? To maintain certification, technicians certified by PTCB need to obtain 20 hours of pharmacy technician-specific CE every two-year renewal period. Pharmacist-specific CE is not accepted. At least one hour must be in pharmacy law and one hour must be in medication errors/patient safety. The CE programs do not have to be accredited by the American Council for Pharmacy Education (ACPE). Five of the hours can be completed by in-service projects assigned by your pharmacist, but by 2018 these hours won t be allowed due to inconsistencies in training. Examples include watching a training video, reading a journal article, or computer-based training (CBT). Your pharmacist will record these activities on a special form. A college life science (e.g., biology, chemistry) or math course, with grade C or better, counts as 10 hours. However, only a max of 10 of your 20 hours of CE credit can be earned from these college courses. Your transcript or grade report will serve as proof. (Contact PTCB to make sure your life science or math course will qualify.) All of the proof of your completed CE must be submitted to PTCB in time for your recertification (renewal). The online procedure for recertification can be accessed here: Technicians certified by ExCPT need to obtain 20 hours of CE every two years. At least one hour must be in pharmacy law. Similar to PTCB, the NHA also allows special projects and college courses to count toward your certification hours. All of the proof of your completed CE must be submitted to NHA in time for your recertification (renewal). The online form can be accessed here: Bear in mind states can have their own continuing education requirements that may be different from those required to maintain certification. For example, a state may require a certain number of live CE hours (e.g., CE delivered by live lecture or teleconference). They might also require that a certain number of hours cover designated topics such as pharmacy law or medication errors. For example, in South Carolina technicians need four hours of live CE annually. See our Technician s CE & Training Organizer for answers about exactly what, if any, CE is required in your state. You can also find the appropriate Pharmacy Technician s Letter CE course to meet any state requirement, including live CE requirements. In some states, the CE must be approved by the board or by ACPE. Consider doing only ACPEapproved CE programs to ensure the programs are acceptable in your state(s). For example, Louisiana specifies that ten hours must be ACPE approved. Your state might require tech-specific CE. Some CE is specifically designed for technicians. These programs have an ACPE code number with the letter T (as opposed to P for pharmacists) at the end of the code. Regardless of your state s requirements, try to choose tech-specific programs because their breadth, scope, and subject matter are geared specifically to technicians. Technicians can rest assured that Pharmacy Technician s Letter CE meets ACPE requirements, is specifically designed for technicians, and will meet PTCB, NHA, and state CE requirements. How does the board or certifying organization keep track of my CEs? You may not need to send in your CE certificates unless the state board or certifying organization audits them. Therefore, you will need to keep proof that you have completed and passed the required number and types of CEs for a period of time designated by your board and/or certifying organization

20 (Page 6 of 7) in the event of an audit. For example, for purposes of recertification, PTCB recommends keeping documentation of CE credits for at least one year past your certification expiration date. NHA requires that you upload credits online, or mail/fax copies of your completed CE for recertification. Some states require that documentation be kept up to five years. Technicians should print and keep their Pharmacy Technician s Letter CE statements of credit as proof of completed CEs. You also need to report CE credits through a national system, called CPE Monitor, if you want to earn any of your CE from an ACPE-accredited provider. CPE Monitor is a national, collaborative effort by National Association of Boards of Pharmacy (NABP) and the Accreditation Council for Pharmacy Education (ACPE) to provide an electronic system for pharmacists and pharmacy technicians to track their completed continuing pharmacy education (CPE) credits. To enroll, go to your Technician s CE & Training Organizer. I have been a technician for some time. Am I exempt from certification? Depending on your state and when you started working, you may be exempt from taking a national certification exam. You might have the option of working as a technician trainee for one or two years pending state certification, again depending on your state. Check with your state board for more information. What additional career development opportunities are possible if I become certified? Many options exist for technicians wishing to pursue career development or training once national or state certification is achieved. Talk to your pharmacist or employer about growth or specialization opportunities within your organization. Many technicians have advanced within their organization to be a Lead Technician, with resulting supervisory, scheduling, or other responsibilities. A Pharmacy Technician Trainer may have responsibilities for educating other techs on new technology, insurance billing, or other professional service initiatives. Some pharmacies may also offer opportunities for technicians to take on new roles to assist the pharmacist with patient care, disease state management, or medication therapy management programs. For example, some chain pharmacies allow technicians to complete a Certified Technician Screener or other training to participate in pharmacy glucose, cholesterol, and other screenings; immunizations; or disease state management programs as allowed in their state. Obtaining additional training may be helpful in expanding your responsibilities. For example, the National Pharmacy Technician Association offers certificate programs in Sterile Products or Compounding that combine home study and experience-based learning to help technicians further specialize. See for more information on these certificate programs. Who do I contact if I have additional questions? The Technician s CE & Training Organizer gives all the information on state CE and national certification requirements and renewal, state-recognized certification processes, and requirements and renewal periods for state registration, licensure, and permits. If you have national certification, use the Technician s CE & Training Organizer for information on recertification periods, renewal requirements, and what types of CE you need. Call Pharmacy Technician s Letter at or us at [email protected] if you need additional information on your requirements. You can also contact the national certification organizations or your state board of pharmacy if you have additional questions about certification or state requirements. Ask your employer or pharmacist supervisor questions about technician requirements in your organization. Copyright 2016 by Therapeutic Research Center

21 (Page 7 of 7) Contact and Website Information Pharmacy Technician s Letter / Pharmacy Technicians University Address: 3120 W. March Lane Stockton, CA Phone: [email protected] Pharmacy Technician Certification Board Address: 2200 C Street, NW Suite 101 Washington, DC Send Recertification Applications to: Pharmacy Technician Certification Board P.O. Box Baltimore, MD Recertification Application can be accessed here: Phone: Fax: [email protected] National Healthcareer Association 7500 West 160 th St Stillwell, KS Phone: Fax: [email protected] State Board of Pharmacy See for contact information for each state board Cite this document as follows: PL Technician Tutorial, Certification and CE Requirements. Pharmacist s Letter/Pharmacy Technician s Letter. March Copyright 2016 by Therapeutic Research Center

22 PL Detail-Document # This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER August 2014 Medication Therapy Management Hundreds of billions of dollars are wasted every year because of the misuse of medications. Pharmacistprovided medication therapy management (MTM) improves patient outcomes and reduces overall health care costs. MTM can describe a broad range of patient-centered services that optimize therapeutic outcomes for patients such as medication therapy reviews, anticoagulation management, and immunizations. The Medicare Modernization Act of 2003 created more opportunities for pharmacists to provide MTM by requiring all Medicare Part D prescription drug plans to offer an MTM program. A comprehensive medication review (CMR) with standardized written summaries must be offered annually to all Medicare Part D beneficiaries enrolled in an MTM program. This includes enrollees in long-term care settings. A targeted medication review (TMR) is also required at least quarterly for these patients to evaluate and manage specific or possible drug-related problems. For 2014 and 2015, there is a display (i.e., test ) measure for Part D plans that looks at the percentage of MTM-eligible Part D patients who have received a CMR. This display measure is expected to be counted as a quality measure for Part D Star Ratings in 2016 (based on 2014 data), so the number of CMRs provided today is important. But only about 10% of Part D patients eligible for a CMR get one. There are plenty of inspiring success stories of how pharmacists have expanded their services to include MTM, but there are also many considerations for pharmacists when getting started with MTM, which may vary depending on practice setting. Here is a toolbox to help you get started or enhance your MTM services, with helpful tips and links to some great resources from Pharmacist s Letter. Topic Program Development Tips and Resources Consider Your Resources and Strengths Network with other pharmacists who provide MTM and look for best practices. Recognize what you already do such as calling prescribers about drug-drug interactions, suggesting less expensive alternatives, or finding ways to improve adherence. Consider how to expand your patient care services from there. Start with disease states you know best. Consider low hanging fruit where you can have a lot of impact, such as cardiovascular conditions, diabetes, COPD, etc. Consider opportunities to engage patients about the use of devices such as inhalers, nebulizers, peak flow meters, insulin pens, needles, syringes, blood glucose meters, testing supplies, etc. Perform a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis for your practice. Use this to identify where changes need to be made to address internal deficiencies and be prepared to handle external challenges. Build Your Clientele Identify patients most likely to benefit from MTM (e.g., those who struggle to afford meds, those who get early or late refills, those who get multiple meds or who have multiple conditions or prescribers, those who need immunizations, those recently discharged from the hospital). Consider using computer-generated reports; recommendations from technicians, pharmacy students, or cashiers; and referrals from other health care providers. Also consider unique opportunities, such as in long-term care settings, when looking to expand services. Copyright 2014 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA ~ ~ ~ More...

23 Topic Program Development continued (PL Detail-Document #300801: Page 2 of 9) Tips and Resources Consider contracting with online MTM platforms, third party plans, or employers to identify patients who are eligible for reimbursable MTM services. Flag eligible patients in your pharmacy system and watch for computer eligibility alerts. Take action on suggested interventions and schedule CMRs for eligible patients. Look at the Logistics Determine the amount of time required for individual MTM appointments (e.g., usually at least 20 to 30 minutes for a CMR) and staffing required to schedule appointments. Identify a private or semiprivate area from which to conduct MTM sessions. Consider use of a privacy screen if necessary. Assess what equipment you will need, such as a computer and printer, secure filing area for paper records, sphygmomanometer and stethoscope, clipboard, etc. Get Buy-In from Staff, Providers, and Patients Educate staff about the importance of MTM (e.g., improved quality of patient care, improved outcomes, avoided adverse effects, reduced overall health care costs, enhanced patient satisfaction). Build relationships with key local providers and market your service to them. Consider setting up face-to-face appointments with providers to introduce yourself and explain your service, or notifying prescribers about scheduled CMRs. Consider marketing tools, such as a mass mailing to educate patients about the opportunity to make appointments for MTM, professional flyers stuffed in prescription bags, or posters that promote the service. Find out what patients or caregivers expect or desire from MTM. Engage patients and explain the individualized benefit that they will receive from a CMR, so they understand the value. For example, getting all health care providers on the same page, answering all medication-related questions, being able to stay healthier and save money, etc. Explain how MTM will help address the patient s top concerns. Develop a 30-second pitch for your entire pharmacy team to quickly and clearly explain the benefits of MTM and what the patient can expect. Here is an example script: Did you know your pharmacist can provide a medication check-up to look at all the medicines you take, including prescriptions, over-thecounter products, vitamins, herbal products, and supplements? We ll work as a partner with you and your prescriber to make sure you re getting the most benefit from your medicines. We ll also look at whether there are any less expensive alternatives that might help save you money, make sure you re taking the right meds in the right way and at the right doses, and answer any questions you may have about your medicines. You ll get a complete medication list after the visit. Would you like to schedule an appointment? Don t become discouraged by small setbacks such as recommendations that are not accepted by a prescriber. Roles Find ways techs can help prompt pharmacists to speak to patients about for MTM throughout the dispensing process, such as identifying eligible patients at Pharmacy Staff drop-off or flagging completed prescriptions. Encourage techs and other pharmacy staff to use the 30-second pitch and other More... Copyright 2014 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA ~ ~ ~

24 Topic Roles for Pharmacy Staff continued Billing and Reimbursement (PL Detail-Document #300801: Page 3 of 9) Tips and Resources marketing tools to recruit patients. Train techs to perform tasks such as getting intake forms from patients, filling out medication history forms, obtaining vital signs (if appropriate), etc. Delegate administrative tasks to pharmacy staff, such as scheduling appointments, prepping paperwork, making reminder calls, faxing info to providers, billing, and documenting, as appropriate. Incorporate pharmacy students into the process where possible. Share success stories with pharmacy staff to ensure they see the value of MTM and to keep them engaged and motivated. Apply for a National Provider Identifier (NPI) number in order to bill for MTM services covered under Medicare Part D ( Determine your fees. These may be negotiable with some payers and you will need to establish pricing for self-paying patients. Check with third party payers about how to bill for pharmacists services, such as what services are covered, what billing codes must be used (e.g., CPT, ICD), and where to submit the claims. If you are contracted with an online MTM platform, make sure all staff complete any necessary training and understand all documentation and billing requirements. Delegate billing to pharmacy staff when possible. MTM Workflow Setting It Up Develop a systematic process for providing MTM. For targeted interventions, build steps into your existing workflow if possible (i.e., identification of a problem, discussion with the patient, contacting the prescriber if necessary for interventions and/or to let him/her know that a medication review has been completed, and following up with the patient). Map it out with a flow chart. Consider having a point person who can lead the implementation of patient care services. Find out the capabilities of your available technology such as collecting data, identifying eligible patients, guiding the pharmacist through the MTM interaction, and generating patient education materials. Schedule appointments for CMRs during pharmacist overlap or off-peak times if possible. Consider whether telephone-based services are an option. Create a system for timely follow-up with patients and/or providers, such as with computer reminders or a binder divided by day of the month. Involve your entire pharmacy staff in follow-up to ensure that patient and provider recommendations are accepted and effective, to evaluate med changes and ensure problems are resolved, and identify new concerns. For Each CMR Appointment When scheduling the appointment and making reminder calls, ask patients to bring the meds they take (e.g., inhalers, samples, OTC products, vitamins, herbals, supplements, etc), an updated med list, any recent lab results, and a list of questions or concerns. Encourage the patient to bring a friend or family member if that person helps with the patient s care or with managing his or her meds. Have techs gather needed paperwork, equipment, and lab results (e.g., A1C, More... Copyright 2014 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA ~ ~ ~

25 (PL Detail-Document #300801: Page 4 of 9) Topic MTM Workflow continued Tips and Resources lipids, serum creatinine) in advance of patient appointments. Once the patient arrives, have a tech get the patient started with paperwork; gather all medications; document allergies, vaccines, medical and social history, labs and vital signs if available; help create the personal medication list; etc. Review available patient information from the patient profile or claims data provided by third parties. Rely on the patient to give you additional details. Find out how the patient uses his or her meds. Ask open-ended questions about why, how, and when the patient takes each med to find problems as you create the personal medication list in patient-friendly language. Use probing questions to get more info if needed. Ask about the patient s beliefs regarding their medications, including cultural or religious beliefs, whether they believe the medications are helpful, etc. Consider the patient s health literacy and address potential barriers. Evaluate the patient s medication-related concerns. Prioritize and focus on those that impact the patient most (e.g., high costs, complicated regimen, etc), and use this information to help guide the medication action plan. Find and prioritize medication-related problems. For example, match up medications with conditions to find unneeded meds or undertreated conditions. Consider whether other medications may be more effective, safer, or less expensive, or if the patient s regimen can be simplified. Use our helpful tool, Worksheet for Med Review, to get started with the above steps. Develop a plan based on the high-priority problems. Ensure patients understand your recommendations, and what information you ll be sharing with prescribers. Collaborate with the patient s health care provider(s) and communicate visit findings and documentation (including medication action plan and personal medication list), even if medication changes are not being recommended. Use a standardized format, such as a SOAP note, for documentation. Keep notes clear and concise. (See Resources from the Web section for more information.) Use templates for med lists, action plans, and communication with providers. (Note that beginning on January 1, 2013, Medicare Part D requires use of the CMS Standardized Format, which includes a cover letter, Medication Action Plan [MAP], and Personal Medication List for the Comprehensive Medication Review [CMR]. These documents must be provided to the patient within 14 calendar days of the visit.) o The above templates can be downloaded at Coverage/PrescriptionDrugCovContra/MTM.html. o Other sources for med list templates include: Making a Medicine List Makes You Medicine Smart ( List.pdf) My Medication Record ( How to Create a Pill Card ( More... Copyright 2014 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA ~ ~ ~

26 Topic MTM Workflow continued (PL Detail-Document #300801: Page 5 of 9) Tips and Resources My Medicine List ( My Medicine Record ( Empower patients with information about self-care, medical conditions, and medications. Use patient handouts to help educate patients. Liability Remember that documentation serves as a risk prevention tool. Document information that s correct and necessary and be consistent in your documentation. Be aware of local, state, and federal regulations that may apply with MTM services, such as HIPAA, CLIA, and OSHA certifications if they apply. Maintain records as required by payers and your employer. Credentialing and Education Determine if third party payers require special training or credentialing for pharmacists who provide MTM Consider training such as the certificate course for MTM that is available through the American Pharmacists Association (APhA). Stay up-to-date with evidence-based recommendations and guidelines Consider mechanisms for quality assurance like staff training, peer-review of clinical notes, etc. Resources from Pharmacist s Letter Communication, Development, and Education PL Patient Education Handouts Precepting in the Community Pharmacy Part 3: Incorporating Students into the Development and Implementation of Pharmacy Services (focuses on involving students in the establishment of an MTM program) Enhancing Patient Counseling with Effective Communication Skills Using Motivational Interviewing to Create Change Guide for Helping Patients Afford Their Medications Medication Adherence Toolbox Collaborative Drug Therapy Management (CDTM) Technician Training Tutorial: Helping Patients with Medication Lists (includes a medication list template) PL Colleagues Interact (to network with others who provide MTM) Quality Measures for Pharmacists Quality Measures: What Pharmacy Teams Need to Know Drug Therapy Formulary/Drug Comparison (includes dosage comparison charts, drug class comparison charts, device comparison charts, and a template letter for sending to prescribers to request drug switches) Potentially Harmful Drugs in the Elderly: Beers List STARTing and STOPPing Medications in the Elderly Clinical Guidelines: Selection, Use, and Implications for Healthcare Lab Monitoring for Common Medications Liver Function Test Scheduling Improving Patient Safety: Medication Reconciliation Basics Appropriate Use of Oral Anticoagulants More... Copyright 2014 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA ~ ~ ~

27 (PL Detail-Document #300801: Page 6 of 9) Topic Resources from Pharmacist s Letter continued Tips and Resources Disease States Improving Outcomes After Myocardial Infarction Improving Diabetes Outcomes Improving COPD Care Preventing and Treating Community-Acquired Pneumonia Improving Heart Failure Care The Current Cholesterol Controversy Treatment of Hypertension: JNC 8 and More Resources from the Web Medication Therapy Management: Utilizing the Pharmacists to Control Our Health Care Costs, a short video, is available at Information about APhA s MTM certificate program is available at Some currently available systems that can help with documentation and/or billing for MTM services: o Mirixa, founded by the National Community Pharmacists Association ( o OutcomesMTM ( o PharmMD ( o ConXus MTM, from Protocol Driven Healthcare, Inc. ( o Medication Management Systems/Assurance Pharmaceutical Care Documentation Software, from the University of Minnesota Peters Institute of Pharmaceutical Care ( o Medication Pathfinder, from Clinical Support Software ( More information on billing in non-hospital based settings at Physician-Based-Clinic-FAQ.pdf APhA MTM Central, with comprehensive info on MTM and resources for everything from clinical to business, is available at Integrating Comprehensive Medication Management to Optimize Patient Outcomes Resource Guide (from the Patient-Centered Primary Care Collaborative) Medicare Part D MTM info, including required forms, is available at Coverage/PrescriptionDrugCovContra/MTM.html MTM toolkit from Agency for Healthcare Research and Quality (AHRQ) is available at pdf Information about writing SOAP notes is available at cumentation.pdf More... Copyright 2014 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA ~ ~ ~

28 (PL Detail-Document #300801: Page 7 of 9) Topic Resources from the Web continued Tips and Resources Patient Assessment Tools Mini-Mental State Exam (MMSE) is available at Pain scales including Wong-Baker FACES and multiple language scales are available at Patient Health Questionnaire (PHQ-9) for depression is available at Definitions Comprehensive medication review (CMR): According to the Centers for Medicare and Medicaid Services (CMS), MTM includes an interactive person-to-person or telehealth consultation performed by a pharmacist or other qualified provider and an individualized, written summary in CMS standardized format. The summary includes a personalized medication action plan and medication list. CMR involves the systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them with the patient, caregiver, and/or prescriber. Some examples of recommendations that might result from CMR include a need for additional drug therapy, identification of an unnecessary drug therapy, identification of a drug dose that is too high or too low, availability of a more effective drug, identification of an adverse drug reaction, and identification of medication adherence issues. Also referred to as a comprehensive medication therapy review (MTR). The American Pharmacists Association (APhA) defines comprehensive MTR as a process where the pharmacist collects patient-specific information including all current medications including prescription and nonprescription products, herbals, and other dietary supplements. The pharmacist assesses the regimen to identify any medication-related problems, prioritizes problems, and then works with the patient and/or prescriber to create a plan to resolve any problems. Medication action plan (MAP): This is a document the patient receives at the end of an MTM visit. It should be a simple guide, written in patient-friendly language, for patients to keep track of their meds and health concerns, what they need to do to address those concerns, and associated actions that already have been taken. Medication therapy management (MTM): In addition to being described as a broad range of patientcentered services provided by pharmacists, MTM is also described more specifically by a framework consisting of five core elements: a medication therapy review (MTR), a personal medication record (PMR), a medication-related action plan (MAP), intervention and/or referral, and documentation and follow-up. This model is based on a set of standards adopted by APhA/NACDS (National Association of Chain Drug Stores), which can be found at Personal medication record or list (PMR or PML): Another document the patient receives at the end of an MTM visit. The PMR includes patient information (e.g., allergies, medication-related problems, demographic information) and a comprehensive list of all meds (Rx, OTC, herbals, dietary supplements) along with doses, reason for use, instructions for use, start/stop date, and prescriber, in patient-friendly language. Patients should be encouraged to keep this list updated and share it with all other health care providers, and pharmacists may do so as well, to promote continuity of care. continued on next page More... Copyright 2014 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA ~ ~ ~

29 (PL Detail-Document #300801: Page 8 of 9) Targeted medication review (TMR): A follow-up intervention to address specific or potential medication-related problems, assess medication use, monitor whether unresolved issues need attention, determine if new drug therapy problems have arisen, and assess if the patient has experienced a transition in care. These are also referred to as targeted MTRs. Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication. More... Copyright 2014 by Therapeutic Research Center 3120 W. March Lane, Stockton, CA ~ ~ ~

30 (PL Detail-Document #300801: Page 9 of 9) Project Leader in preparation of this PL Detail- Document: Stacy A. Hester, R.Ph., BCPS, Assistant Editor Cite this document as follows: PL Detail-Document, Medication Therapy Management. Pharmacist s Letter/Prescriber s Letter. August Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA ~ TEL (209) ~ FAX (209) Copyright 2014 by Therapeutic Research Center Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to or