Pharmacy Practice Model for Academic Medical Centers

Transcription

1 Pharmacy Practice Model for Academic Medical Centers May 2010 THE POWER OF COLLABORATION

2 Purpose In 2007, the University HealthSystem Consortium formed a task force to determine the pharmacy services that should be available to all patients in academic medical centers and to examine the evolving role of pharmacists in providing those services. Summary The best way to deploy pharmacists, technicians, and technology in support of the ongoing transition from a product focus to a patient-centered care model ensuring the safe and effective use of medications in all practice settings has been a major topic of discussion for many years. The task force began by examining practice models to establish a consensus on a set of minimum standards that should be applicable to the delivery of pharmacy services. Four models were studied: the drug-distribution-centered model, the clinical-pharmacist-centered model, the patientcentered integrated model, and the comprehensive model. The goal of applying a model is to elevate the entire profession so that all pharmacists gravitate toward a higher level of clinical practice in their activities, emphasizing a greater use of pharmacy technicians and technologies to perform nonjudgmental tasks while still providing comprehensive services. Four case studies are used to illustrate the practice models that institutions with different resources and needs are using to meet the challenge of providing the best and most efficient pharmacy care for various types of patients. Conclusion The task force concluded that institutions need a practice model to support basic medication management services on a consistent basis for all patients and specialized services for specific patients depending on their clinical situations. Technology may help achieve this goal, but a well-trained workforce and an appropriate model design are critical for success. Not one but rather several dominant practice models are likely to evolve as organizations rise to meet the challenge. Contents I. Introduction II. Task Force III. IV. Contributions/Background Information Definition of the Practice Model V. Pharmacy Services That Should be Consistently Provided at AMCs VI. Considerations in Model Design VII. Practice Model Examples VIII. Deployment of the Practice Model Within the UHC Alliance of 107 AMCs University HealthSystem Consortium 2001 Spring Road, Suite 700 Oak Brook, IL (630) Fax: (630)

3 Introduction The pharmacist s role in health systems continues to evolve from a product focus to a patient-centered care model ensuring the safe and effective use of medications in all practice settings. The best way to deploy pharmacists, technicians, and technology in support of the transition has been a major topic of discussion for many years. The University HealthSystem Consortium (UHC) Pharmacy Council established a task force in August 2007 to develop a position paper describing the pharmacy services that should be available to all patients in academic medical centers (AMCs). The document was to include recommended practice models and a discussion of the pros and cons of each model. One of the key activities of this effort was a reiterative process moving toward a consensus on, and a commitment to, a set of minimum standards applicable to the delivery of pharmacy services. The members of the task force recommended the minimal services that should be included, but did not attempt to prescribe how to implement or provide these services. Goals of the Pharmacy Practice Model Task force members had 3 overarching goals in developing and disseminating this document: 1. To introduce a level of services that all academic hospital pharmacies should provide for patients and to foster the recognition that there are some patients who require more intensive services because of the complexity of their drug therapy 2. To provide a means by which pharmacy directors can secure the resources needed to reach that level 3. To provide examples of ongoing case studies of the development, implementation, outcomes, and continuing progress from pharmacy practice models at member AMCs striving for that level Introducing a targeted level of services. The first goal speaks to the desire to bring pharmacists to a common level of patient-centered services. Pharmacy directors understand that pharmacists provide different levels of service and intend to continue educating them to bring the profession to a more optimal level: 1. The basic level involves preparation, dispensing, and order processing. 2. The desired level involves clinical activities such as consulting, direct contact with and education of patients, and taking responsibility for the medication therapy management process and patient outcomes. 3 Complicating the matter of striving to bring pharmacists to this level is the reality that there is great variability among academic hospital pharmacists in terms of the kinds of services they are prepared to provide. Healthsystems use several pharmacy practice models. The 2008 national survey of pharmacy practice in hospital settings conducted by Pedersen et al. (2009) described 3 distinct practice models. 1 In addition, there is a fourth (comprehensive) model. 1. The drug-distribution-centered model. Pharmacists are engaged primarily in drug distribution and reactive order processing but have little proactive involvement with the health care team in developing therapeutic plans for patients. Pharmacists have little accountability for outcomes associated with or leadership responsibility for the medication-use process. 2. The clinical-pharmacist-centered model. Pharmacists are engaged exclusively in clinical activities with medical teams on the nursing units and accept little or no responsibility for issues related to the medication-use or delivery systems. There may be little or no collaboration between clinical and distributive pharmacists; these pharmacists have selective accountability for and ownership of the medication-use process. 3. The patient-centered integrated model. Pharmacists accept responsibility for both the clinical and the distributive activities of the pharmacy department. Their clinical role is enhanced because well-trained pharmacy technicians manage most of the drug distribution. Pharmacists are proactively engaged in medication selection and use with the interdisciplinary team and exhibit a high degree of ownership of and accountability for the medication-use process. 4. The comprehensive model. Pharmacists accept a range of responsibilities for both clinical and distributive activities and provide integrated care; clinical specialists are essential and engaged in activities that advance practice, education, and research. This model uses distributive, generalist, and specialist pharmacists. 2 Great heterogeneity in practice is found in AMCs. For example, some pharmacies, as seen in academic hospitals using an integrated model, provide distributive services and have a relatively consistent level of clinical service for all patients. Others provide distributive services, general clinical services for most patients, and a higher level of service with clinical specialist providers for patients who require complex drug therapy. Specialists are more pervasive in large AMCs, especially the 25% of them that are associated with a college of pharmacy, than in

4 smaller nonacademic hospitals. So while a certain similarity exists among many AMCs, there is also great divergence in the identification and utilization of specialists and generalists, and in the blend of generalists and specialists in handling everything from order processing to dispensing to clinical services. The goal of the model is to elevate the entire profession so that all pharmacists gravitate toward a higher level of clinical practice in their activities, emphasizing greater use of pharmacy technicians and technologies to perform nonjudgmental services while still providing comprehensive ones. In this regard, education and resident training should be increased over time as AMC pharmacies move toward hiring more postgraduate year 1 (PGY1)- and postgraduate year 2 (PGY2)-trained pharmacists. Providing a means of obtaining the resources necessary to advance the practice model. This goal recognizes that some member hospitals have been successful in acquiring the resources needed to reach a clinical level of care and others have been less so. The current (2009) economic recession is affecting academic hospital pharmacies in that some departments have been forced to reduce staff or delay program implementation. The later discussion of presenting financial justification to hospital administration is an attempt to provide some guidance to directors of pharmacy on resource acquisition and allocation. Providing current examples of various practice models. Ongoing case studies of the development, implementation, outcomes, and continuing progress of pharmacy practice models at member AMCs striving for clinical services are presented. Outcome of the Pharmacy Practice Model Ultimately, the true test of any pharmacy practice model lies in the challenging work of identifying and measuring true patient care outcomes that yield a safer, more effective medication-use system. A team-based approach to care is advocated to allow pharmacists to develop shared goals and shared accountability for patient outcomes. Task Force Purpose The task force was formed to develop a paper describing the pharmacy services that should be available to all patients in AMCs. Recommended models of practice and a discussion of the pros and cons of these models are included. Membership The following UHC members, who were nominated by the UHC Pharmacy Council Executive Committee, made up the task force: 1. Paul W. Bush, chairperson, chief pharmacy officer, Duke University Hospital (formerly at the Medical University of South Carolina Medical Center) 2. Daniel M. Ashby, senior director of pharmacy, The Johns Hopkins Hospital 3. Roy Guharoy, chief pharmacy officer, professor of medicine, University of Massachusetts Memorial Health Care (formerly at Upstate University Hospital) 4. Scott Knoer, director of pharmacy, University of Minnesota Medical Center, Fairview 5. Steve Rough, director of pharmacy, University of Wisconsin Hospital and Clinics 6. James G. Stevenson, director of pharmacy services, University of Michigan Hospitals and Health Centers 7. Michelle Wiest, director of clinical pharmacy programs, University Hospital, The Health Alliance of Cincinnati Process The task force began by compiling best practice reference documents and proceedings from conferences that addressed the advancement of practice and the establishment of clinical pharmacy services. Task force members then set about considering what minimum set of pharmacy services should be available at AMCs. This step was followed by a commenting process with multiple iterations until a consensus on definitions was reached. Next, task force members debated, reworked, edited, and voted in 5 sequential rounds to establish the level of support for each service the number of members agreeing that a service is essential (Appendix). This document was then drafted, reviewed, edited, and approved by the task force and the Pharmacy Council Executive Committee and released for publication. 4

5 Contributions/Background Information Health-system pharmacy has progressed dramatically over the past 50 years or so since the comprehensive audit of hospital pharmacy was conducted in 1955 and published in the Mirror to hospital pharmacy in The shift of the pharmacist s role from focusing on the product to centering on the patient accelerated in the late 1960s and 1970s. 4 Hilton Head Conference Transformational change occurred at the American Society of Health-System Pharmacists (ASHP) conference at Hilton Head Island in 1985, when a large group came together to discuss clinical pharmacy and the reasons for providing pharmacy services directly to patients. The 3-day meeting established, among other objectives, the goals of the clinical practice of pharmacy and the methods of advancing that practice. This conference also further defined the duties and responsibilities of the hospital pharmacy for its time. This seminal meeting ended with a strong consensus report. Survey results at that time verified this approach with strong agreement on the following statement: In order for pharmaceutical care to be provided, pharmacists must be genuinely interested in and committed to the well-being of the patients they serve. (Agreement reached 5.96 on a 6-point scale, where 1 meant not very important and 6 meant very important. ) The transformation could perhaps best be described as pharmacy practice moving from caring about patients to taking ownership and responsibility for drug therapy outcomes. Many members used this document in the late 1980s and early 1990s to identify what pharmacists should be doing. Perhaps relevant to today s paper was the lack of a widely agreed-on philosophy of pharmacy practice. 5 Changes in practice accelerated after the Hilton Head conference and the 1989 Pharmacy in the 21st Century Conference; the concept of pharmacists as professionals providing pharmaceutical care became commonly accepted as the best model for pharmacy practice. Clinical care and specialization became more evident in the 1990s. The idea evolved that generalists were needed to meet the medication care needs of the general patient population and specialists were needed for the care of patients with more complex, critical, or urgent medication needs. In the 1990s, a new practice philosophy advanced, with pharmacists described as caregivers focusing on all aspects of medication care for all patients. 4 San Antonio Conference In 1993, ASHP convened a national conference with the goal of accelerating the implementation of pharmaceutical care. This effort culminated at the 1993 San Antonio conference, Implementing Pharmaceutical Care, which continued the historic changes setting the direction for pharmacists implementing clinical practice. 6 Among the important and still relevant topics discussed at the San Antonio conference was overcoming barriers to pharmaceutical care: specifically, resource-related, systemic, educational, legal, and professional barriers. Many institutions have overcome some of these barriers, but still end up bogged down by other hurdles. One goal of this paper is to help establish pharmacy practice models that will overcome those remaining barriers. Also, the lack of consensus on the meaning of the term pharmaceutical care continues to indicate a lack of cohesive direction that could impede the progress of the profession. The 1993 San Antonio conference concluded with a number of recommendations for implementing a model of pharmaceutical care that could be perhaps summarized as Just do it. 6 The San Antonio conference made it clear that pharmacy departments, while willing and able, were still struggling to identify and implement optimal practice models. Directors of pharmacy need guidance on how to effectively lead change. These leaders face challenges in the form of staffing, pharmaceutical costs, clinical quality, regulatory and accreditation standards, and medication safety. 4 A primary challenge is achieving a common vision of practice for all pharmacists within a given practice setting, since the variable views of roles and responsibilities for pharmacists within health-system pharmacy practice models can be a barrier. More Current Challenges A later challenge, medication safety, became a central mandate in 1999, when the Institute of Medicine reported the large number of deaths caused each year by medication errors. As the population continues to age, the impact of medical errors in geriatric patients is a continuing and growing concern since such errors lead inexorably to increases in morbidity and mortality. 7 In response to this call for reducing medication errors, most of the changes in the care process since 1999 have focused on additions to informatics technology and 5

6 activity around pharmacist-managed clinics. Efficiencies gained through the effective use of integrated technologies may enable pharmacists to effectively provide more services with existing human resources and to target patients and drugs requiring specific follow-up. Unfortunately, other aspects of implementing new practice models, such as clinical care, staffing, and pharmaceutical cost controls, have lagged behind the pace of technological advancement. Possibly the most vexing problem is that as pharmacists have taken on more clinical care roles, their relative shortage in hospitals has led to overworked staff struggling to prioritize which services provide the most value to patients. Pharmacists know that optimizing medication therapy and increasing patient safety both lead to improved drug therapy outcomes, but given limited resources, pharmacists still need leadership and direction to identify processes that will best serve patients. 4 Model Design Pharmacy practice models can provide a structure to develop leadership and direction. According to Breland (2007), the design of pharmacy practice models must meet these 7 basic principles: 1. Each patient should have a pharmacist. 2. Patients should receive consistent care. 3. Drug therapy for all patients should be available at all hours. 4. Pharmacy work should be prioritized according to patient needs. 5. Pharmacy time management should not be driven by the tasks pharmacists enjoy. 6. Pharmacists should be scheduled to work in special areas to advance their skills to a higher level. 7. Pharmacists are responsible first to the patient. 4 ASHP Vision and Guidance Also in 2007, ASHP published its vision for building the workforce capacity of pharmacy departments in hospitals and health systems to meet the growing challenges related to optimizing the use of medicines. Part of that vision involves moving toward the creation of interdisciplinary teams that will rely on pharmacist leadership for the safe and effective use of medications. In line with Breland s opinions (2007), 4 ASHP also expects that the shortage of pharmacists will be chronic and will not be eliminated by technology. Long-range expectations are that increasing numbers of pharmacists will pursue residencies, obtain more specialty credentials, and continue their professional development in an environment of changing and improving credentials led by the National Association of Boards of Pharmacy. 7 ASHP also presented a very clear vision of pharmacy functions in hospitals in : 1. Reviewing individual patients medication orders for safety and effectiveness and taking corrective action as indicated. 2. Collaboratively managing medication therapy for individual patients. 3. Educating patients and caregivers about medications and their use. 4. Leading continuous improvements in the quality of medication-use process. 5. Leading the interdisciplinary and collaborative development of medication-use policies and procedures. 6. Acquiring quality drug products from trusted supply sources. 7. Preparing medications in the doses and dosage forms needed. 8. Distributing medications to inpatients and outpatients. 9. Ensuring the availability of quality drug information. 10. Influencing drug administration policies and procedures and the use of related devices. 11. Conducting quality reviews of medication utilization in the hospital s or health system s population of patients and seeking improvements where indicated. 12. Leading and influencing decisions about medicationrelated informatics, other technology (including drug administration devices), drug administration, and automated medication-use processes. Looking ahead, ASHP plans a Practice Model Initiative Summit in 2010 to discuss these issues and address practice standards to advance the process begun at the 1985 Hilton Head conference. With these aims in mind, this paper encourages academic hospital pharmacies to reassess their utilization of pharmacists, pharmacy technicians, and technology to develop new pharmacy practice models that will produce more optimal patient outcomes and will better realize the value that pharmacists can bring to patient care. 6

7 Further, ASHP targets the achievement of the following 6 goals by 2015 (ASHP 2015 Health-System Pharmacy Initiative, revised April 11, 2007): 1. Increase the extent to which pharmacists help individual hospital inpatients achieve the best use of medications 2. Increase the extent to which health-system pharmacists help individual nonhospitalized patients achieve the best use of medications 3. Increase the extent to which health-system pharmacists actively apply evidence-based methods to the improvement of medication therapy 4. Increase the extent to which pharmacy departments in health systems have a significant role in improving the safety of medication use 5. Increase the extent to which health systems apply technology effectively to improve the safety of medication use 6. Increase the extent to which pharmacy departments in health systems engage in public health initiatives on behalf of their communities The models described in this paper attempt to move the practice of pharmacy toward the 2015 ASHP goals and a higher level of clinical activity. Definition of the Hospital Pharmacy Practice Model The manner in which a pharmacy department s human resources are distributed to fulfill (a) the departmental mission of ensuring that patients achieve optimal outcomes from the use of medicines and (b) the departmental responsibility for leading improvements in the medication-use process. The model takes into account how pharmacists, pharmacy technicians, and other pharmacy staff spend their time and how they interface with patients, health professionals outside of pharmacy, hospital executives, information systems, devices, and vendors. Pharmacy Services That Should Be Consistently Provided at AMCs List of Categories Task force members developed a list of characteristics of the model AMC pharmacy department and assigned 8 categories and a number of services within each category. A detailed listing of the precise wording agreed on by the members is provided in the Appendix. The following is a summary of all 8 categories evaluated by task force members 9 : 1. Patient care services for all patients 2. Patient care services for specific patients based on need 3. Medication preparation and delivery 4. Medication safety 5. Medication-use policy 6. Information systems and technology 7. Quality outcomes and performance improvement 8. Education and research The voting support by task force members is detailed in the Appendix, and despite the fact that consensus 7 was reached for the vast majority of recommended minimum services, differences remained. There were even some differences for a few services where consensus was reached. Often differences centered on the question of whether a specific service should be provided by pharmacists for all patients or for special higher-risk populations, with other health professionals involved in providing the service for lower-risk patients or less complex cases. For those categories where consensus was reached, task force members wish to restate their strong commitment to services such as medication-use policy, medication safety, technology, quality, and education; however, the consensus categories and services are not the focus of this section. For services where a divergence in opinion for specific services remained even after 5 rounds of voting, a discussion of each of those contested services is still valuable in determining the services a hospital pharmacy department might want to consider when applying a practice model.

8 Patient Care Services for All Patients Perform medication histories for patients admitted as inpatients. Task force members split on whether this service is essential to the practice model. The issue at hand may come down to whether a given pharmacy has the human resources for pharmacists to perform a medication history for all patients. Votes for including this service in the model state essentially that pharmacists should perform this function, given that the literature shows them doing so with substantially greater accuracy than other caregivers. Votes against inclusion point out that this could be a workflow issue, with physicians performing histories that cannot wait for another discipline before a treatment plan is initiated. Finally, it was pointed out that the increased use of electronic medical records (EMRs) may eventually improve the quality and accuracy of medication histories, particularly if pharmacy staff take a leadership role in designing these systems throughout the continuum of care. Perhaps EMRs, which are rapidly and readily available, could allow a pharmacist to perform a medication history without disrupting treatment flow. There was consensus among the group that trained pharmacy technicians could do this work under the supervision of the pharmacy department. Perform medication histories for patients admitted as 23-hour admit patients. A strong majority of the task force voted against considering this service as essential in the context of the practice model. The single vote in favor mentioned that pharmacists should strive to perform this service only in procedural areas with the highest volume and risk, such as the catheterization laboratory, the radiology department, and the emergency department. Otherwise, the strong majority voting against considering the service as essential mention that pharmacy staff are limited and need to be focused on those services of most value to the patient; it was suggested that pharmacy technicians could perform this service. Given that some 23-hour admit patients may not have dedicated pharmacy services, a task force member suggested that pharmacists could perhaps act as intermediaries, flowing these patients into the same discharge process as other patients and providing prescriptions ahead of time or directing these patients to the outpatient pharmacy, where counseling could take place. Perform medication histories for patients admitted to procedural areas. A strong majority of the task force did not rank this service as essential in the context of the practice model. The negative votes were driven by many of the same factors that led to the same vote count for the 23-hour admit medication histories. Basically, most members did not think pharmacy departments would have the resources to deploy for this service. One explanation for this value judgment was that available resources should be focused instead on providing a quality medication reconciliation process. However, this explanation was challenged by the notion that a quality medication reconciliation coupled with an inaccurate medication history would only perpetuate medication errors throughout the continuum of care. Reconcile medications upon admission for patients admitted as inpatients. A solid majority of the task force voted in favor of this service as essential in the context of the practice model. A dissenting member voiced the opinion that this service should be provided and that the pharmacist should have a key role but the process need not be the sole responsibility of pharmacy staff. Reconcile medications upon admission for patients admitted to procedural areas. A solid majority of the task force voted against considering this service as essential in the context of the practice model because of many of the factors that led to the same vote count for the 23-hour admit medication histories. One task force member repeatedly pointed to the literature showing that pharmacists are more accurate than other caregivers in performing admission and discharge medication services. Those against considering the service as essential also stated that other caregivers can perform this function, perhaps under the direction of a pharmacist. Review all nonemergent orders prior to the first dose administered. While the task force voted in favor of including this service, there was some discussion around both the timing and the process of implementing it in the academic hospital setting. The perception of the members was that while there is a movement toward pharmacists getting involved in postanesthesia care units and reviewing emergency department orders, more time might pass before this service could be provided in procedural areas such as endoscopy. Some members even questioned the value of the service for endoscopy. One member mentioned the need for balancing patient access and safety, explaining that pharmacists can make patient care safer, but that requiring prior pharmacist review for all orders could significantly reduce efficiency. Members suggested that the use of electronic order systems with clinical decision support might actually provide a safe means of providing care while freeing some pharmacist time to provide other important activities in the ideal model. In fact, the current regulatory requirement for universal pharmacist order review implies that all orders require the same level of pharmacist input. If 8

9 clinical decision support systems could systematically, safely, and effectively screen low-complexity orders, this would permit increased pharmacist involvement in more complex cases and medications and better utilization of pharmacist time. Participate in patient care rounds. A majority of the members voted for this service as essential in the context of the practice model. Comments were positive but hedged with concern about limited resources. One member mentioned that rounding takes a great deal of time and that having pharmacists spend 3 hours on rounds each morning might not be realistic in practice. The reality is that resident trainees perform this service. Rounds were also viewed as a valuable component of the educational process, so preceptors need to be able to model practice for the students/residents, although it may not be an efficient use of time in the absence of students. Overall, task force members felt that this is a valuable service, but that an approach needs to facilitate efficient rounds. One member proposed that pharmacists participate in multidisciplinary patient care rounds focusing on education, intervention, and medicationprescribing patterns, but that these rounds be structured to effectively manage the utilization of pharmacists. Breland (2007) explains that pharmacists practice best when working directly with the patient at the bedside. 4 In this context, pharmacists most directly influence drug therapy planning, determining the total pharmaceutical care needs of patients they know fully. As a result, other caregivers, physicians, and nurses respect pharmacists most when sharing the responsibilities for assessment, planning, monitoring, and patient outcomes. 4 Task force members are in partial agreement with Breland (2007): Pharmacists need to practice as close to the patient as possible, with the caveat that an efficient system needs to be devised. Educate patients about new medications. A solid majority of the members voted for this service as essential in the context of the practice model. At a minimum, pharmacists should be directly involved in the education of select patients with complex medication regimens. The task force recognized that the pharmacy department needs to be accountable to make sure that education occurs, even if it does not happen at the moment of discharge. One member mentioned that medication reconciliation and counseling could perhaps take place either before or after discharge. The pragmatic reality is that education at discharge would take 20 minutes per patient, and it currently stands as an unfunded mandate. Any effort to accomplish this at discharge would have to be creative, such as providing prescriptions with 9 education at discharge. One member proposed that a pharmacy technician, under the supervision of a pharmacist, perform discharge services. Patient Care Services for Specific Patients Based on Need Task force members were in unanimous agreement that there are services that should be provided for all patients when a specific clinical situation exists. These services can be provided by a pharmacist assigned to selected patients or by all pharmacists. Services identified by the task force include the following: 1. Participate in anticoagulation management 2. Participate on resuscitation teams 3. Participate on nutrition teams 4. Participate in antimicrobial stewardship 5. Streamline medication orders (e.g., intravenous [IV]- to-oral medication conversions) 6. Provide pharmacokinetic evaluation, monitoring, and dosing 7. Provide parenteral nutrition assessment and order change 8. Provide dosing adjustments for medications that should be modified based on renal function 9. Manage medication therapy in collaboration with other members of the health care team (e.g., CDTM [collaborative drug therapy management] practice agreements) 10. Provide programs for patients that prevent disease and improve health Medication Preparation and Delivery Pharmacy oversight of the process of reconciling controlled substance waste. A solid majority of the members voted for this service as essential in the context of the practice model. The only issue was collaboration. Members felt that having 2 people, such as a pharmacist and another licensed caregiver, act as observers in any care area would meet their requirement for a collaborative effort. Integration of distribution and clinical services. The members split on whether this approach was essential to the practice model. This split can be characterized by a view of the generalist versus the specialist concept, which is once again at the heart of the issue and this pharmacy practice model. The question the profession asks itself is whether all pharmacists should be expected to

10 perform a similar level of distributive and clinical services. Pharmacists with specialized expertise in certain clinical areas may be less focused on distribution. It is important to understand that the model does not stipulate that all clinical pharmacists play identical roles by spending the exact same percentage of time on clinical and distribution activities, but rather that all have responsibility to support the medication-use system. Medication Safety Task force members are strongly committed to the concept that pharmacists should play the lead role in medication safety. In this regard, there was debate as to whether the EMR medication management functionality should be designed and overseen by pharmacists with a reporting relationship to the director of pharmacy services. A solid majority of members voted for this service as essential in the context of the practice model. The sole dissenter voiced concern over the method of reporting, stating that since EMRs might be managed by a health information technology/informatics department, there is the possibility that pharmacists would report through the information technology department, therefore making it unnecessary to report to the director of pharmacy. Clearly, the $20.2 billion in potential funding for health information technology included in the 2009 American Recovery and Reinvestment Act will have an impact on the technology side of pharmacy. Most members believe that EMR activity for medication management and ownership should be in the pharmacy department, but that is not the only model that works. Complete and interoperable EMRs, such as virtual video links to expand pharmacy services and stretch resources, need to be available in the future and would increase efficiency. This would constitute a good return on investment (ROI). Medication-Use Policy The long-range expectations are that pharmacists will continuously improve and collaboratively redesign medication-use processes to optimize safety and improve patients health-related quality of life. Pharmacists will ensure that medication-use processes incorporate interdependence, checks, and immediate safety feedback mechanisms. In addition to caring for individual patients, pharmacists will ensure that the outcomes of medication therapy are assessed and managed on both a systemwide and a patient population basis. 8 To achieve the best outcome for the patient, a pharmacy practice model must address all elements of the medication-use process: ordering, dispensing, administering, and monitoring. Only then will the ideal model provide all pharmacists with complete ownership of every piece of the medication-use process. Medication samples. A solid majority of the members voted for the premise that, for institutions that allow samples, a program to manage them is essential in the context of the practice model. There was concern about the lack of regulation and control in the use of samples, however. For example, a survey at the University of Utah found that samples were not understood or taken properly by 60% of the patients surveyed. Numerous studies have suggested that using samples can lead to inappropriate use of brand-name drugs, resulting in safety concerns and rising health care costs. 10,11 Contrary to the intent behind free drug samples, wealthy or insured patients are likely to receive them. 12 Because of members stated concerns, the Institute of Medicine has recently called for further investigation of sample use. 13 A system should be in place to ensure the appropriate use of samples throughout the health system via pharmacy-controlled dispensing limited to evidencebased prescribing for indigent patients. Practitioners fear losing patients to other practitioners if they do not provide samples. To alleviate this concern, the caveat was added that a system should be in place to ensure the appropriate use of medication samples throughout the health system. The concern is that samples are not managed and that the potential for security or documentation abuse exists. Some UHC institutions have eliminated the use of sample medications in their health systems altogether and replaced them with a prescription for samples from the doctor; pharmacists then fill the prescription. This process allows regulation and patient counseling to occur. In this case, the pharmacist in a clinic would meet with, screen, and counsel patients to ensure that they understand all instructions and that samples are appropriately labeled. Information Systems and Technology Task force members believe that pharmacy departments should use technology to enhance patient safety and the proper distribution of medications and information systems to ensure the proper use of medication. Members also agreed that the department should have a role in technology assessment, acquisition, and deployment. 10

11 Quality Outcomes and Performance Improvement Pharmacy departments should participate in quality, safety, and performance initiatives related to medication use at organization and department levels. Specifically noted was the importance of applying infection control principles to medication preparation, dispensing, and administration. Education and Research Task force members identified participation in the education and training of doctor of pharmacy students, pharmacy residents, and technicians as an important role for the department. The members also believe that pharmacy staff should lead or collaborate in clinical or operational system/process research activities, contribute to the practice literature, and participate in professional organizations. Specifically, UHC institutions should play a critical role in the education of future practitioners as well as future pharmacy educators. Considerations in Model Design Assessment To succeed, a new practice model must allow pharmacists the time, orientation, authority, and responsibility to provide clinical care to patients. 4 Questions whose answers may be critical in developing an optimal practice model include: 1. What is the role/value of pharmacist participation in teaching rounds? 2. With regard to generalists and specialists in various models, what are the outcomes produced by practitioners in these models? Are there certain settings where generalists are more effective and others where specialists are more effective? 3. In an integrated practice model, will new knowledge and systems develop? Who will produce the scholarship in clinical pharmacy if the specialists are deemphasized and what impact will that have on the future? 4. What is the optimal method of order verification? Should it be centralized or decentralized to the pharmacist primarily managing the patient (and what value can be achieved through better use of clinical decision support to reclaim pharmacist time so it can be reallocated to direct patient care)? 5. Which services (antimicrobial stewardship, nutritional support, anticoagulation, etc.) can be provided effectively by all generalists and which need a specialized team of pharmacists to provide this care? 6. What will the future role of residents be in this evolving practice model? Could pharmacists move to a model more like medicine in which much of the direct patient care is provided by residents under the supervision of a more senior pharmacist? For many pharmacy departments, the recent economic recession entails the directive to do more with less. Given current economic conditions, AMCs may consider employing more pharmacy residents in the care process. This may result in more and larger pharmacy residency training programs. Departments will need to consider the implications of this increase in resident numbers for the structure of residency programs and adequate supervision of residents. A major challenge that must be overcome in transforming the practice model is convincing hospital pharmacy personnel that they need to change. 4 Change management skills will be paramount in leading the transformation of pharmacy practice models, as many pharmacists are comfortable with their current roles. The transition may require strong leadership to make tough decisions, but also the patience and discipline to start small and implement changes in stages over time. Hospital and Facility Characteristics An integrated model is frequently favored by those who come from AMCs with tertiary/quaternary services. Naturally, these centers gravitate toward a model composed of pharmacists with PGY1 and PGY2 training. Although health systems have different levels of resources, prioritization of service value should be achieved. For example, even with limited resources, a director of pharmacy can prioritize those activities that are the most important: 1. Where is the best ROI? 2. What are the activities of greatest value? 3. Where is the best place to focus (i.e., areas that need attention)? 11

12 Smaller, less complex institutions may be best served when every pharmacist provides the same level of services. Perhaps the highest value the pharmacist can bring to environments where resources are limited is rounding in the intensive care unit (ICU) and focusing on patients at high risk or those receiving drugs that have the highest potential risk or are very expensive. One approach is to create a multiyear plan to implement the model that raises pharmacists to a higher level where they can ensure the delivery of the foundational clinical and distributive services that have been agreed on for all of their patients. In the SUNY Upstate University Hospital case study, the challenge was to implement a new pharmacy practice model that started with considering how to develop pharmacists. From pharmacy residency training programs to expanding the number of students brought in from pharmacy schools, from improved computer systems to augment training to monitoring patients with compromised renal function, systems and processes were put into place to manage the transition. For example, a new pharmacy note system allowing pharmacists on any shift to understand the patient from a pharmacology background was implemented. Also, the director of pharmacy moved some staff from 1 location to another as part of the restructuring and streamlining for clinical monitoring. The steps to success in implementing the new model were clinical monitoring to ensure excellent patient care, drug distribution, academic involvement, partnering with physicians, community education, and education of pharmacists to accomplish the mission. Pharmacy Personnel In the integrated pharmacy practice model, pharmacists simultaneously provide a broad range of clinical services as well as order review and perhaps some medication distribution oversight for the patients they serve, while at the same time they may specialize in the care of select patient populations. In this model, all pharmacists strive to practice at the highest clinical level, generalized enough to provide patients with advanced medication therapy management services but specialized enough to do particular clinical work. An important implication of this integrated model is that the traditional roles of not only the pharmacist, but also the pharmacy technician, change. Traditional roles of pharmacy technicians should be re-evaluated for opportunities to shift selected pharmacist responsibilities to these practitioners. 1 For example, in one case study, pharmacy technicians are decentralized. While technicians always delivered medications to patients, they were more like runners when they left the central pharmacy. In the new model, technicians are responsible for drug distribution for their patients, freeing up some of the pharmacists time to perform higher-level work while still managing distribution services. 5 Education and Training of the Pharmacist Workforce The issue of adequate training was raised at the 1985 Hilton Head conference, 5 and although this issue remains, it is not a focus of this paper. Education, training, experience, and awareness of practice standards and trends help create the practice model vision. 4 That is why some task force members believe that with proper education and training over time, all organizations should move toward the integrated model. For example, in The Johns Hopkins Hospital case study, a career ladder was established to allow someone to enter the hospital as a pharmacist, then advance to a clinical pharmacist I and finally to clinical pharmacist II. One of the barriers to creating a highly trained workforce resulted from the elimination of funding for second-year specialized pharmacy residency programs by the Centers for Medicare & Medicaid Services in A survey conducted by ASHP in July 2008 found that roughly 80% of hospitals that employ clinical pharmacists prefer or require the training for recruitment if the supply of specialty-trained pharmacists is adequate. Despite aggressive advocacy by ASHP membership, the restoration of funding for specialized training programs was not included in the health care reform legislation. This step is essential for developing a highly trained pharmacy workforce, and advocacy must continue until funding is restored. Whatever training methods are used to educate pharmacists, the resulting structure should move away from a tiered hierarchy to an integrated service approach. The education and training program should ensure that pharmacists are held accountable for tasks and responsibilities such as patient outcomes, safety, and drug costs. Finally, it is important to make sure that during the transition, pharmacists are treating patients and that no one falls through the cracks for the sake of education and training. 12

13 Roles Pharmacists. Practice roles have expanded over the past decade, and more pharmacists than ever are now working in advanced clinical practice roles, managing nutrition support, infectious disease, pharmacokinetic, anticoagulant, and pharmacotherapy consultation services; clinical research programs; and outpatient pharmacy clinics. The Joint Commission of Pharmacy Practitioners and ASHP agree that the roles and required credentials for the pharmacy workforce will be modified to ensure that medication use is safe, effective, and appropriate. 8 Deployment of staff within a given practice model remains a major challenge. Another challenge in transitioning toward direct patient care is that some physicians may not be familiar with the benefits and value of a pharmacist in patient care rounds. As part of the process of introducing the pharmacist into the patient environment, it is important to remember that most physicians have limited clinical pharmacology training. A physician who has had the chance to work with a pharmacist, however, quickly learns to consult him or her on medication decisions. A related issue is that some clinical pharmacists may identify more with physicians than with the pharmacy department and may not feel the need to achieve its goals. Part of the transition may require bringing these pharmacists back into alignment with their department to encourage them to meet its overall medication management goals. In the University of Minnesota, Fairview, case study, a linguistic method of making this transition eliminating old job descriptions and creating new ones was used. Positions such as clinical specialist and pharmacist were eliminated and replaced with clinical pharmacist and pharmacy clinical leader. The clinical specialist role was blended into the clinical pharmacist and pharmacy clinical leader roles. The latter is responsible for leading a team of clinical pharmacists and decentralized pharmacy technicians. In the SUNY Upstate University Hospital case study, job descriptions for pharmacy technicians were expanded to include management of automated dispensing cabinets (ADCs), compounding of IV admixtures, and participation in performance improvement initiatives. The responsibilities of decentralized pharmacists included processing medication orders, managing risk-stratified patients, and taking care of all medication management issues. The residents, along with an assigned pharmacy faculty member, managed patients on the weekends. As the SUNY Upstate University Hospital case study also demonstrates, roles can be transitioned into the new pharmacy practice model to show success over time. Creating a pharmacist presence in patient care areas resulted in a huge demand for additional pharmacy service, which in turn led to implementation of pharmacymanaged therapeutic drug monitoring, renal dosing, anticoagulation management, IV-to-oral switch, a teambased active infectious disease management program, and the development of a closed drug formulary. Daily pharmacology conferences provided by pharmacists and residents helped staff gain current knowledge of therapeutic modalities. Within a couple of years, the new practice model resulted in managing basic clinical services per protocol during all shifts. Affiliation with pharmacy colleges helped pharmacists gain additional resources in managing their daily tasks. Teaching involvement at both nursing and medical colleges resulted in high visibility for the department. Pharmacy executives in hospital administration. In 2009, ASHP released a statement explaining that the pharmacy executive must be best positioned within an organization to ensure the highest utilization of pharmacy expertise in decision making affecting the policies, procedures, and systems that support safe, effective, and efficient medication use. This ASHP statement suggests that when pharmacy leadership reports directly to the principal executive, rather than through multiple layers of management, the quality and timeliness of the information exchange improve significantly. Proximity to hospital administration allows the pharmacy executive to better explain the impact of the practice model on quality of care and ROI; moreover, pharmacy leaders who are thus positioned can more actively engage in critical decision making and will be more effective in helping the health system anticipate and address rapid change. 14 Recognizing the influential role that pharmacists play in ensuring the safety of medication-use systems in hospitals and health systems, the National Quality Forum recommended in 2009 that pharmacy leaders be included in an organization s leadership team and involved with integral system decisions. 15 The roles of the pharmacy executive include, but are not limited to, strategic planning; medication-use management; quality outcomes and performance improvement; drug utilization management; informatics and technology; supply chain, financial, and human resources management; regulatory and accreditation compliance; research and education missions; and institutional representation and leadership. 14 One strategic approach for empowering 13

14 the role of the pharmacy executive in improving the medication-use process is a high-performance pharmacy practice framework that sets priorities based on feasibility, the potential for financial return, and the effect on quality and safety. 16 The pharmacy executive needs to learn to tell the ROI story more effectively to educate hospital leadership. Most hospitals lump pharmacy in with other ancillary services, an approach that is not in harmony with real revenue and expenses for the department. Hospital administrators are savvy executives who can observe staff costs and pharmaceutical spend rates, but need guidance from the pharmacy department to understand the totality of the relationship between medication and staffing costs. Pharmacy executives need to learn to take the risk of divulging costs and cost-saving measures such as a list of entrepreneurial requests that show an ROI bottomline impact to hospital leadership. Pharmacy departments are unique because personnel are only 17% to 20% of the budget, while drugs represent 80% to 83%. One ROI argument that a pharmacy executive can make to control spending is to show that having the right pharmacy staff in the patient environment reduces pharmaceutical costs. Evidence for this relationship abounds in the form of metrics on drug spending per admission and per discharge. For example, UHC hospitals where spending on clinical pharmacists is in the top quartile also experience pharmaceutical costs that are in the bottom quartile. The literature shows clear evidence that rates for pharmacist medication history and reconciliation accuracy are higher than they are for other providers, resulting in more clinical interventions and fewer medication errors reaching the patient 17 : 1. Pharmacists intervene in a higher percentage of cases than nurses (34% versus 16%, P < 0.001), and pharmacists have a higher number of interventions per patient than nurses (0.6 versus 0.22, P = 0.027). 2. Pharmacists document more medications per admission history than physicians (5.6 versus 2.4), and pharmacists document more medication interactions, drug-related admissions, and previous drug failures than physicians. The value of pharmacist medication histories is that they are estimated to reduce mortality rates by 128 deaths per hospital per year and to reduce costs by $7 million per hospital per year, as well as save nursing and physician time, improve relationships with physicians, and increase job satisfaction for pharmacists. 17 It is possible to develop a management plan for investing in pharmacist resources for expanded medication reconciliation. This plan would include quality and safety impact to project annual error avoidance, ROI with literaturebased and institution-specific statistics to show savings associated with avoiding harmful errors, and other benefits such as time savings for other providers and improved pharmacist job satisfaction and retention. As pharmacist relations with physicians develop, it is easier to implement services that dramatically reduce drug costs. Once such a management plan is approved, it is important to get started quickly by developing a protocol or procedures, using forms from other organizations, involving pharmacy clerkship students/residents, and considering pharmacy technicians if pharmacists are unavailable. If new full-time-equivalent positions (FTEs) are not approved, then a pharmacist should be put in the emergency department where physicians can see a large impact immediately. Pharmacy departments should be encouraged to develop forms and procedures for other disciplines, to provide training, and to be persistent in measuring and reporting outcomes. 17 Finally, although a business case can be made for obtaining pharmacist resources for medication reconciliation, multidisciplinary collaboration is necessary. Pharmacists who perform medication reconciliation improve patient safety in a collaborative fashion, reduce transcription errors by improving the accuracy and completeness of medication lists and orders, maintain continuity of care, promote physician collaboration, improve job satisfaction, decrease the workload for nurses and house staff, and finally, increase the time available for other activities. 17 Three arguments show that the new model increases ROI: 1. Involving pharmacists avoids and reduces medical errors. 2. Getting pharmacists involved with those activities helps physicians see their value, establishes a higher level of credibility, and makes physicians more likely to trust pharmacists and take their recommendations, which are more accurate and save lives Pharmaceutical costs are best managed when drug distribution, automation, and information systems are fully developed and allow pharmacists to be reallocated to direct patient care. 14

15 Practice Model Examples Four members of the task force wrote case studies to provide examples of the practice model in use at their respective academic hospital pharmacy departments. The Johns Hopkins Hospital case illustrates the pointof-care pharmacy role, while the University of Michigan Hospitals and Health Centers case emphasizes the team-based approach to pharmacy. The University of Minnesota Medical Center, Fairview case elaborates further on the integrated team model. Finally, the SUNY Upstate University Hospital case is an excellent example of how an academic hospital pharmacy department with limited resources relative to larger health systems can attain the new practice model over a decade. Background Information/Overview: The Johns Hopkins Hospital Hospital/health system. Johns Hopkins Medicine is a $5.0 billion organization established in 1997 as the virtual integration of the Johns Hopkins University School of Medicine (JHUSOM) and the Johns Hopkins Health System. JHUSOM and The Johns Hopkins Hospital, a 950-bed AMC, are the major components of the Johns Hopkins Health System, a vertically integrated, multiinstitutional system for medical services delivery. Mission. The department of pharmacy places a priority on patient care, teaching, and research. Academic programs, affiliations, and student rotations. The department has affiliation agreements with more than 20 schools of pharmacy and provides pharmacy residency training for an average of 18 residents per year across 10 different ASHP-accredited PGY1 and PGY2 programs. Average statistics and daily census. Over the past fiscal year, the hospital had approximately 47,000 inpatient discharges, 55,000 operating room cases, 86,000 emergency visits, and an average inpatient census of 752 patients. Services. The department is responsible for providing acute-care pharmacy services for a diverse population of medical, surgical, pediatric, and oncology patients, with additional services provided within the Johns Hopkins Outpatient Center and affiliated clinics. In addition, the Pharmacy Investigational Drug Service provides support for the distribution of approximately 350 Institutional Review Board approved studies annually. Pharmacy services. The organizational structure includes 4 decentralized divisions supported by a central pharmacy. Facility. The decentralized divisions closely mirror the organizational structure for the hospital. The Weinberg Division supports the Sidney Kimmel Comprehensive Cancer Center. The Pediatrics Division provides services for the Johns Hopkins Children s Center. The Carnegie- 6 Division is responsible for service to adult surgical and critical care patients. The Osler-2 Division services a diverse adult population that includes psychiatry, general medicine, obstetrics and gynecology, ophthalmology, and emergency medicine. The Central Pharmacy Division provides sterile compounding, distribution of controlled substances, 24-hour unit-dose-cart fill, ADC supply, and replenishment and inventory control and management. Pharmacy Administration and Pharmacy Information Systems support and complement the divisional structure. Four ambulatory pharmacies provide outpatient prescription services. Technology. The prescribing function of the medicationuse system is facilitated by the Eclipsys Sunrise Clinical Manager computerized prescriber order entry (CPOE) system. The CPOE system is integrated with the GE Centricity pharmacy information management system via a customized 2-way electronic interface. Nursing documentation of medication administration is completed electronically. Medication distribution and storage are facilitated by ADCs for selected critical or emergency use drugs. The central pharmacy employs technology extensively. Robotic technology is used for unit-dose-cart fill, preparation of infusion syringes, and high-speed packaging. A McKesson MedCarousel device facilitates picking and restocking of unit-dose medications by technicians. Intravenous admixture preparation is supported by a Baxa solution compounder. Pyxis C II Safe technology is employed to facilitate the storage and distribution of controlled substances from the central pharmacy. Bar-code technology to support knowledge base drug administration is the focus of current evaluation. Composition of pharmacy staff. The department has 100 budgeted FTEs for pharmacists and 115 budgeted FTEs for technicians. There are 27 clinical specialist pharmacists. Educational backgrounds and credentials vary among practitioners. Pharmacy technicians are required to become certified through the Pharmacy Technician Certification Board (PTCB) and must be 15

16 registered with the state Board of Pharmacy. Most of the staff pharmacists have completed the doctor of pharmacy degree. A minority have completed PGY1 pharmacy practice residency training. Nearly all clinical pharmacy specialists have completed both PGY1 pharmacy practice and PGY2 specialized practice residencies. Most are certified by the Board of Pharmaceutical Specialties. Residencies. Specialized pharmacy practice residency programs are offered in the following areas: critical care, infectious diseases, health-system pharmacy administration, pharmacotherapy, medication safety, oncology, pain and palliative care, pediatrics, and primary care. In addition to the traditional 1-year PGY1 pharmacy practice program, a nontraditional 2-year program is offered for continued professional development of existing staff. Services. Decentralized pharmacy divisions operate 24 hours a day, 7 days a week. Services provided on a continuous basis include medication order review and verification, medication distribution, drug information, and code team participation. Replenishment of ADCs, distribution of controlled substances, and investigational drug service support are provided primarily as first-shift functions. Additional support is provided throughout the rest of the day through a resident-on-call program and around-the-clock pager access to clinical pharmacy specialists and pharmacy managers. Pharmacy technicians are used primarily to support medication acquisition, preparation, and distribution. Selected technical personnel also serve in supervisory roles supporting key processes or personnel management. Practice Model Philosophy/vision. The philosophy directing the department is that pharmacists are the health care professionals best prepared and positioned to oversee the entirety of the medication-use system to ensure that it is safe and effective and provides optimal patient outcomes. To achieve this ideal, most pharmacists should be positioned to allow ready access to their services and visibility by patients and other members of the health care team. Pharmacists must be supported by a capable and competent technical work-force that increasingly accepts responsibility for the order-fulfillment functions of the process. Moreover, technology must be leveraged to add greater efficiency and safety to existing processes, resulting in improved quality and reduced costs. Patient care related services. These services are provided through pharmacists practicing in diverse roles. Pharmacy generalists provide direct patient care by acting as pointof-care pharmacists. In this integrated role, they influence medication prescribing by physicians or other authorized prescribers, support medication distribution, help nurses as needed with drug administration, and are available to help monitor responses to drug therapy. Specific services that may be provided include comprehensive medication order review, pharmacokinetic drug dosing and monitoring, clearing organ function assessment and drug dosing, participation in patient care team rounds and code teams, patient and in-service education, drug information, and drug policy and formulary management. In addition to providing many of the services described in the generalist model, pharmacy specialists support restricted drug programs and the management of complex and high-risk medications. Selected practitioners may also be involved in consultative services for patients with specialized pharmacotherapeutic needs. Specialist practitioners have significant responsibility for the development and implementation of order sets, guidelines, and protocols that govern care delivery and medication use by other practitioners beyond the hours for direct patient care services. Specialists also conduct or support drug-related research and other scholarly activities. Enabling technologies. A major expansion of technology is planned with the goal of having more than 90% of medication doses stored and accessible through ADCs. The deployment of this Pyxis complete model will result in benefits such as significantly fewer missing doses and reduced time from drug prescription to administration. Increased involvement of pharmacy technicians to support medication distribution represents a significant opportunity for the redeployment of valuable pharmacist resources. Deployment of staff. Staff members are deployed to provide access to basic pharmacy services 24 hours a day, 7 days a week. Most resources are deployed to support first-shift coverage of the more extensive services that are offered Monday through Friday. This is justifiable in many cases, as in the matching of pharmacist resources for participation in patient care rounds or in the service to patients at outpatient clinics and infusion services that operate predominantly during these hours. Such disproportionate coverage may result in some patients being disadvantaged by reduced access to important core pharmacy services at other times. These disparities are the focus of current analysis by the department. 16

17 Outcomes. Many different outcomes might be measured to gauge the success of this practice model. Process measures can serve as surrogates for pragmatic reasons, but the true test lies in identifying and measuring patient care outcomes to verify that the model yields a safer, more effective medication-use system. Future direction. The Pharmacy Clinical Practice Standards Council was established in 2008 to define the desired scope and quality of clinical pharmacy programs and services provided to Johns Hopkins Hospital patients. The council has defined core clinical pharmacy services as those that any hospitalized patient or other health care practitioner should expect to receive from a pharmacist when needed. Specialized services should also continue to be provided to meet complex pharmacotherapeutic needs in high-risk patient populations. The pharmacist practice model that best supports the optimal provision of these services has become a matter of analysis and discussion in organizing and planning for newly defined services. A team-based approach to care is advocated to allow pharmacists to develop shared goals and shared accountability for patient outcomes. Future service areas may diverge from historically decentralized pharmacist coverage and may necessitate modification of coverage for both point-of-care and clinical specialist pharmacists. Teams should be designed to combine complementary and overlapping skill sets that provide planned redundancies for service provision. In this model, team members will also share responsibility for the education of their fellow team members. Methods to ensure competencies must be developed and maintained. Lesser value-added functions will be evaluated for opportunities to revise or eliminate them. The traditional roles of pharmacy technicians will be evaluated for opportunities to shift selected pharmacist responsibilities to these practitioners. Background Information/Overview: University of Michigan Health System (UMHS) Hospital/health system. The University of Michigan opened the first university-owned medical facility in the United States in Mission. The mission of the UMHS is to provide excellence in patient care/service, research, and education. The goal is to have UMHS be the first place people want to come when they need health care, the leader in education and advancing medical and health science, and the place where people prefer to work. Academic programs and affiliations. UMHS is fully integrated with the University of Michigan and its health care schools and colleges, including the medical school, the school of nursing, and the college of pharmacy. The department provides extensive support to the college of pharmacy in both introductory pharmacy practice experience and advanced experience. Average statistics and daily census. The average daily census in inpatient facilities in 2009 is approximately 775. There are some 43,000 inpatient admissions annually and 1.6 million ambulatory care visits in UMHS facilities. Services. UMHS comprises 4 inpatient hospitals: University Hospital, C.S. Mott Children s Hospital, Women s Hospital, and the Cardiovascular Center. Pharmacy services. UMHS operates a central pharmacy and several satellite pharmacies. Facility. Pharmacy services are provided from a central pharmacy in University Hospital, as well as from satellite inpatient pharmacy locations on 3 floors within University Hospital, an operating room pharmacy, and an emergency department pharmacy. A pharmacy located in C.S. Mott Children s Hospital provides service to both Children s Hospital and Women s Hospital. In addition, there is an operating room pharmacy located in Children s Hospital. A pharmacy is available in the Cardiovascular Center to provide services to inpatient acute care and critical care beds, procedural areas, and the operating and recovery rooms of the facility. Outpatient infusion pharmacies are provided in the University of Michigan Comprehensive Cancer Center and in 1 offsite health center. Ambulatory care pharmacies are located in University Hospital, in the University of Michigan Comprehensive Cancer Center, and at one of the large off-site health centers. Technology. The hospital uses Eclipsys Sunrise Clinical Manager CPOE for all inpatient beds, as well as an electronic medication administration record (emar). The Mediware WORx system is used for inpatient pharmacy information. A McKesson Robot-Rx provides 24-hour unit-dose-cart fill for adult inpatients. McKesson s PACMED system is used to repackage medications, with an internally developed program called LabelSafe for bar-code-labeled products. Omnicell WorkflowRx with vertical carousels is used for inventory management and bar-code-assisted distribution of drug products to pharmacy work areas, Omnicell unit-based dispensing cabinets, and outpatient clinic locations. The ordering of drug products is fully integrated into the carousel system. The 17

18 Cardiovascular Center uses an ADC cartless dispensing model. For Children s Hospital and selected batched medications in the adult population, ValiMed is used to test high-risk parenteral medications to ensure the correct medication and concentration. Composition of pharmacy staff. Inpatient pharmacy services are staffed by 50 pharmacist generalists, 37 pharmacist specialists, and 103 technicians. Residencies. The department has 10 pharmacy residents, with PGY2 programs in critical care, infectious diseases, hematology/oncology, pediatrics, cardiology, and informatics. Services. All inpatient orders are transmitted by the Eclipsys CPOE system, verified in Mediware WORx through an interface, and transmitted to the emar. Order verification by pharmacists is done in both satellite pharmacies and patient care units. Comprehensive drug distribution services (primarily first doses) are provided from satellite pharmacies, central pharmacy distribution (Robot-Rx, Omnicell Pharmacy Central, clinic requisitions), and ADCs. Due to space constraints in other patient care areas, a cartless drug distribution system is in place only in the Cardiovascular Center. Comprehensive clinical pharmacy services are provided by clinical pharmacist specialists and pharmacist generalists. Clinical pharmacist specialists are deployed by medical service in some cases (hematology/oncology, solid organ transplant, etc.) and geographically in others (medical, surgical, and pediatric ICUs). Practice Model Philosophy/vision. The evolution of the pharmacy practice model is a primary goal of the department. This effort is aimed at optimizing the application of the clinical expertise of pharmacists and other personnel in the medication-use process, to include evaluating and implementing the use of enabling technology and extending the use of pharmacy technicians. In an AMC, there is an important role for pharmacist specialists, particularly with highly specialized patient populations, as well as in providing doctor of pharmacy and residency education and in advancing the research and scholarship mission of the health system and university. One of the fundamental challenges is to create a practice model that integrates pharmacist specialists and generalists into a cohesive team. A critical but subtler change is to shift the focus of pharmacists clinical activities from a predominantly medical team customer focus to one that has more emphasis on the patient as a primary customer. Specifically, activities such as ensuring compliance with medication-related quality measures, providing patient education, and coordinating care activities related to drug therapy are receiving greater emphasis as the practice model evolves. Patient care related services. The scope of patient care related services is broad and similar to those described elsewhere in this paper. However, service delivery is uneven, with some services provided for certain patients and not for others. One of the key activities of practice model efforts at UMHS is to gain consensus on and a commitment to a set of minimum standards on the delivery of pharmacy services for all patients. Clearly, the needs of patients vary depending on the complexity of their medication therapy and disease states. This variation logically results in the requirement for more intensive pharmacist services in some patients. However, UMHS feels that certain core services should be provided for all patients, independent of the day of the week that the admission takes place. The practice model will be structured to ensure that these minimum services are provided, without reducing the more intensive services required by more complex cases. Enabling technologies. In addition to the CPOE system, which allows pharmacists to wirelessly verify and adjust medication therapy from virtually anywhere in the institution, a comprehensive clinical workstation called PharmDoc has been developed. PharmDoc organizes patient information, including laboratory and pharmacy data, from the EMR (called CareWeb and available wirelessly throughout the institution) and organizes it in a logical format for pharmacists. It also incorporates decision support tools to help identify patients who meet specific criteria that require follow-up by a pharmacist. Finally, PharmDoc serves as a vehicle for communication between pharmacists and allows the incorporation of notes and documentation within the system. In addition, CareWeb provides electronic access to drug information, policies, and other reference materials. Deployment of staff. One of the major challenges has been the deployment of staff within the practice model. Several pilot units have been implemented in which pharmacist generalists have been relocated from the satellite pharmacy to the patient care area, where they conduct order verification and problem solving, integrate a variety of clinical pharmacy services, and participate in interdisciplinary care with physicians, nurses, and other professionals. Some of the specific roles the generalists have include IV-to-oral switching; renal dosing adjustments; order perfection; dose rounding for selected agents; responses to questions on IV compatibilities and medication-related 18

19 questions from patients, physicians, and nurses; participation on the rapid response and code teams; pharmacokinetic dosing of selected agents; formulary management; discharge counseling on selected agents such as warfarin and enoxaparin; provision of nursing in-services; and medication reconciliation. Strong communication between generalist pharmacists and pharmacist specialists who may have patients on the specific patient care units is critical. In addition, UMHS believes that pharmacist specialists have a responsibility to serve as a resource to support and develop the clinical skills of the generalists. Redeployment of pharmacist resources to patient care units has resulted in a re-examination of the drug distribution system model, with increased emphasis on ways to make it more efficient and require fewer pharmacist resources. Outcomes. Data collection on the impact of these practice model changes is just beginning. Initially, satisfaction data on the impact of the pharmacist in the patient care area were gathered from physicians and nurses. Patients will be included in the future, although this must be coordinated with other patient satisfaction data being collected institutionally. PharmDoc creates a record of the clinical interventions and consultation provided by pharmacists. These process measures will be used to estimate their impact on a variety of medication safety, quality, and cost measures. Future direction. Key departmental priorities are to continue to focus on developing a team-based approach to the pharmacy practice model, integrating clinical specialists and generalists, developing core services that will be provided for all inpatients, increasing the emphasis on becoming more focused on patients and their unmet medication-related needs (particularly in the context of transitions in care), and continuing to advance the role of pharmacists at UMHS on the basis of overarching goals of excellence in patient care, teaching, and research. Background Information/Overview: University of Minnesota Medical Center, Fairview, University Campus Hospital/health system. Fairview Health Services (FHS) provides a full continuum of health and medical services with 8 hospital-based care systems, 91 clinics, 6 urgent care centers, 30 retail pharmacies, and 39 orthopedic and rehabilitation centers. The University Campus of the University of Minnesota Medical Center, Fairview, is 1 of 8 Fairview Hospitals in Minnesota. Mission. The mission of the University Campus is to improve the health of the communities it serves. Skills and resources are committed to the benefit of the whole person by providing the finest in health care while addressing the physical, emotional, and spiritual needs of people and their families. Supporting the research and education efforts of the University of Minnesota and its tradition of excellence is also part of the mission. Academic programs, affiliations, and student rotations. The University Campus is affiliated with the University of Minnesota Academic Health Center and is the primary teaching site for the colleges of pharmacy, medicine, nursing, and allied health. Approximately 160 five-week Advanced Pharmacy Practice Experience student rotations are precepted annually. The organization has recently begun precepting students on Introductory Pharmacy Practice Experiences as well. Average daily census. The University Campus runs an average daily census of approximately 300 high-acuity patients. Included in this number are 70 pediatric patients. Services. Major services include solid organ transplants, bone marrow/stem cell transplants, hematology/oncology, and cardiovascular services. Pharmacy services. Fairview Pharmacy Services LLC (FPS), a subsidiary of FHS, provides progressive and integrated pharmacy services covering the entire spectrum of customer needs. In addition to retail and hospital pharmacies, FPS operates a central compounding pharmacy, a specialty pharmacy, investigational drug services, a mail-order pharmacy, a medication therapy management pharmacy, a warfarin clinic, a home care pharmacy, and a pharmacy benefits management service. One major accomplishment of FPS has been the implementation of a system medication formulary. In 2008, FPS posted $300 million in revenue. Facility. In addition to a large central pharmacy, satellites are located in the ICU and operating room. Clinical pharmacists have designated work areas on patient care units. Technology. CPOE has been implemented across FHS. The EMR system is Eclipsys, although conversion to Epic is planned to take place in approximately 2 years. There is a cartless distribution model with ADCs. Wireless computers on wheels and CPOE allow pharmacists to be more efficient during patient care rounds. 19

20 Composition of pharmacy staff. Pharmacy staff is composed of 115 FTEs 56 pharmacists and 59 technicians/others. The vast majority of professional staff, especially those hired in the past 8 years, are doctors of pharmacy who have also completed a PGY1 residency. Decentralized pharmacy technicians are responsible for managing missing doses, and they also do rounds on the patient care units. Technicians have performed techcheck-tech since the 1980s for cart fill and more recently (since 2002) have expanded to checking ADC refills. Residencies. The institution is committed to training pharmacy residents. There are 6 PGY1 residents, 2 PGY2 health system pharmacy administration/master of science residents, and 1 PGY2 oncology specialty resident. Services. Pharmacy provides clinical services, drug distribution, medication safety, regulatory compliance, process improvement initiatives, protocol development, and professional development of staff/students/residents. Practice Model Philosophy/vision. The passion for excellence for patients drives the University Campus, in partnership with the University of Minnesota, to be the best health care delivery system for the United States. The goal of the department is to use well-trained technicians and automation to run the drug distribution process, allowing pharmacists to practice at the top of their license and focus on patient care. Pharmacists are deeply involved in the hospital s quality and safety agenda. Patient care related services. In addition to order verification and drug distribution, clinical pharmacists are directly involved with many patient care activities. Pharmacists participate in daily rounds with physicians and other members of the interdisciplinary health care team. Policies are in place for pharmacist monitoring and adjustment of renally dosed medications, aminoglycosides, vancomycin, parenteral nutrition, warfarin, antiemetic dosing on adult oncology units, IV-to-oral interchanges, and therapeutic interchange. Further, a pharmacist-led discharge medication teaching pilot has also recently begun on the general pediatric units, with an eye to expanding the program to the entire hospital. Enabling technologies. CPOE and wireless computers on wheels have been crucial to the success of practice model changes. To provide continuity of care, pharmacists create electronic patient monitoring forms and update weekly medication monitoring worksheets. Deployment of staff. Three years ago, the University Campus transitioned from a clinical specialist to an integrated team model. The historical (early 1980s to 2005) clinical specialist model consisted of decentralized, trained pharmacists who had bachelor s degrees and completed order entry and other operational duties, while approximately 10 full-time clinical specialists with doctorates, the majority residency trained, provided clinical pharmacy services to most of the acute areas of the hospital. While the decentralized pharmacists staffed both day and evening shifts, clinical specialists provided services during the day Monday through Friday. This model had remained largely unchanged since the 1980s and was necessary because there was a large gap in skill levels between the 2 groups of pharmacists at that time. As the residency program flourished, extremely competent, clinically focused pharmacists graduated. During residency, these pharmacists rounded with the medical team, taught students, and practiced at a very high level. Once hired into staff/decentralized positions, their role became primarily distributive, and a disproportionately large portion of their job consisted of entering medication orders. Meanwhile, clinical specialists had no order entry component to their jobs and performed all the clinical monitoring. The system continued with 2 tiers of pharmacists on the patient care units, although the formal training of both groups had become basically the same. Over the next decade, the residency-trained, doctoratelevel pharmacists assumed the majority of the professional staff positions, resulting in an increasing desire for more advanced roles for decentralized pharmacists. In 2003, a group of staff members convened to evaluate current pharmacy practice and recommend the best staffing model for the organization. A comprehensive group then met to examine all distributive and clinical work performed within the department. This group of pharmacy technicians, managers, central and decentralized pharmacists, and clinical specialists met for approximately 6 months. The recommendation of the group was to move to a new integrated model in which a team is responsible for taking care of all of the pharmacy needs for particular patients. Previously, 2 pharmacists could be serving the same group of patients. One pharmacist was responsible only for dispensing medications, while the other performed only clinical monitoring. Now, every team member is accountable for the entire patient. 20

21 Old job descriptions (clinical specialist and pharmacist) were eliminated, and new ones (clinical pharmacist and pharmacy clinical leader) were created. The role of the clinical specialist was blended into the clinical pharmacist and pharmacy clinical leader roles, allowing the department to shift 5 FTEs back into direct patient care and to increase evening pharmacist coverage on patient care units (to 16 hours a day, 7 days a week). In the new model, the pharmacy clinical leader is responsible for heading a team of clinical pharmacists and decentralized pharmacy technicians. Current teams include oncology/bone marrow and stem cell transplants, critical care, pediatrics, cardiovascular care, and solid organ transplants. Teams provide oversight and coordination for all pharmaceutical care activities on their units, including clinical services, drug distribution, medication safety, regulatory compliance, process improvement initiatives, protocol development, and professional development of staff/students/residents. Clinical pharmacists in the new model are responsible for all of the daily pharmaceutical care of their patients and perform medication order review and verification, identify and solve drug therapy problems, provide clinical pharmacy services, round with physicians and other members of the health care team, provide drug information, supervise decentralized technicians, and teach students and residents. These pharmacists also participate in longitudinal projects and initiatives, as assigned by the clinical pharmacy leader and pharmacy managers. Technicians have been decentralized. While they have always delivered medications to patients, they were more like runners when they left the central pharmacy. In the new model, they are responsible for drug distribution for their patients. They carry missing dose pagers, fill and repair their Pyxis machines, do handoffs at the end of their shifts, help with patient transfers, conduct drip rounds in the ICUs, check for weights and allergies, and act as the triage person for distribution issues. Outcomes. This integrated system of care has allowed staff to be more efficient and more effective. Clinical pharmacists leverage wireless workstations to be more productive on rounds. Workflow is less compartmentalized and now provides pharmacists with an understanding of the entire patient, leading to high-quality care. Further, the practice model change has allowed several new clinical services to be implemented. Work on departmental quality and safety projects has also increased. Overall, the change has resulted in a much more engaged pharmacy staff. By leveraging well-trained technicians and automation, staff members can practice more at the top of their licenses. Future direction. Integrating pharmacy services into the medication reconciliation process is an area of future focus. To effectively utilize resources, the institution would like to have pharmacy students and student interns help pharmacists in this task. Continuing to leverage technology and automation to improve patient safety is a goal. Using advanced technology also allows pharmacists to continue to focus on patient care and clinical services. Current projects involve beta-testing an IV robot and pursuing the use of bedside bar-coding. The department continues to strive for greater pharmacy integration into patient care and excellent patient outcomes in order to become the best health care delivery system in the United States. Background Information/Overview: SUNY Upstate University Hospital Hospital/health system. This 378-bed campus, a level-1 trauma center and the only AMC in the area, runs an average 80% occupancy with high-acuity patients and serves 2 million people in a 15-county region. Mission. The mission of the department of pharmacy, consistent with the organization s mission, is to provide excellence in patient care, education, research, and community service. Academic programs, affiliations, and rotations. The hospital is part of the SUNY Upstate Medical University, which includes the colleges of medicine, nursing, graduate studies, and health professions. It serves as a primary training site for Wilkes-Barre University and the Albany College of Pharmacy, offering both introductory pharmacy and advance practice experiences to approximately 40 students. Pharmacy faculty members teach at the colleges of medicine and nursing, and a 4-week elective on clinical pharmacology is offered to fourth-year medical students. In addition, a formal clinical pharmacology consult service is offered for patients receiving complex drug therapy. Average statistics and daily census. The average daily census is 302, with approximately 108,000 patient days and 50,000 emergency room visits annually. Services. Specialty services include the area s only pediatric emergency center, ICU, burn center, regional oncology center, and renal and pancreatic transplant programs. Pharmacy services. There are central and inpatient locations, as well as a retail pharmacy. Facility. The hospital has around-the-clock comprehensive pharmacy services from a central pharmacy, as well as decentralized services from 6 inpatient locations 21

22 during day shifts on weekdays. Also, a private retail pharmacy is located on the campus. Technology. Technologies rolled out between 2000 and 2005 include profile-based ADCs in all inpatient areas (Pyxis); ADCs in surgery suites, clinics, and the emergency department; vertical carousels for inventory management (Omnicell); scanners for accurate loading of ADCs (Pyxis PARx ); CPOE (Siemens); pharmacygenerated e-mar (Siemens); and a wireless communication system (Vocera). Approximately 95% of medication doses are available in the ADCs. Loading and refills are managed by technicians. Composition of pharmacy staff. There are 62 FTEs: the director, 2 associate directors, 25 pharmacists, 33 technicians, and a secretary. The vast majority of professional staff, especially those hired in the past 10 years, have doctor of pharmacy degrees. Approximately 65% of the technicians are certified through the PTCB. Residencies. Three PGY1 pharmacy practice residents are accepted every year. Services. Central pharmacy provides drug distribution and sterile compounding. Decentralized services include order verification via CPOE, risk-stratified management of all patients, pharmacy-managed protocols (aminoglycosides, vancomycin, renal dosing, and anticoagulation), team rounds, patient education, drug information, compliance with core measure activities, and education for residents and nursing staff. Clinical services are provided by pharmacists 24 hours a day, 7 days a week, and an on-call pharmacy faculty serves as a back-up for complex clinical service-related queries during evenings and nights. Because of limited staffing over the weekend, the on-call pharmacist, together with an assigned resident, provides follow-up clinical services. Outpatient infusion pharmacy services are provided in the regional oncology center. Clinic drug distribution is managed through the use of ADCs. On weekdays, a full-time pharmacist provides formal anticoagulation services in the ambulatory care area. Practice Model Philosophy/vision. The goal of the department is to meet the mission of the organization by delivering optimum pharmaceutical care via integration of clinical and distribution services. Patient care related services. After the restructuring that took place in 1998, the increased pharmacist presence in patient care areas resulted in a huge demand for additional pharmacy services, which in turn led to the implementation of pharmacy-managed therapeutic drug monitoring, renal dosing, anticoagulation management, IV-to-oral switch, a team-based active infectious disease management program, and the development of a closed drug formulary. Daily pharmacology conferences provided by pharmacists and residents helped staff gain current knowledge of therapeutic modalities. Within a few years, the integrated practice model resulted in managing basic clinical services per protocol during all shifts. Affiliation with colleges of pharmacy helped pharmacists gain additional resources in managing daily tasks. Teaching involvement at both nursing and medical colleges resulted in high visibility for the department. Enabling technologies. A CPOE system interfaced with pharmacy was implemented in 2005 and changed the pharmacy practice paradigm. It allowed pharmacists to verify orders without leaving rounds so they can do numerous interventions even before orders are entered into the CPOE system. Programming changes in the pharmacy computer system with utilization of rules-based clinical decision support allowed the generation of realtime alerts for patients on high-risk drugs or antimicrobial agents; those requiring therapeutic drug monitoring, renal dosage adjustment, or anticoagulation management; and those with pending orders requiring clarification. Clinical pharmacy notes documented in chronological order allow any pharmacist to review and identify patient needs. A Vocera wireless communication system allows staff at different locations to communicate instantly to meet patient needs, resulting in fewer telephone calls from nursing and the availability of medications for emergency use. Deployment of staff. Before 1998, the practice model was based largely on manual distribution activities with only very limited clinical services offered in the ICU and the pediatric area. Most IV admixtures were prepared by nursing staff. The manual drug distribution system forced pharmacists to spend most of their time filling medication carts or addressing missing medications. Staff morale was low, and the chaos resulted in an unsafe medication management process and high staff turnover. However, the department had qualified pharmacists and technicians who were looking for an opportunity to participate in medication management activities. In 1998, leadership included the director, an associate director of operations, and 5 pharmacists who had the title of senior manager and who had staffing responsibilities 90% of the time. The challenge was to create a practice model that allowed the optimal utilization of human resources to significantly improve patient care outcomes. 22

23 In 1998, the first annual retreat took place; the entire staff reviewed various options for reorganizing to meet patient care needs. The retreat was followed by numerous weekly meetings to formulate a model for delivering optimal distribution and clinical services for all patients. Recommended were leveraging of automation, expansion of the technician role, academic programs, and an integrated pharmacy practice model allowing pharmacists to get actively involved in medication management. Departmental restructuring was immediately initiated and included the implementation of a pharmacy practice residency program, the recruitment of an additional 5 pharmacists, the installation of ADCs in all inpatient areas, and the creation of 2 new positions: associate director of clinical services and manager of automation services. Pharmacist job descriptions were changed to incorporate both distribution and clinical tasks. Technician job descriptions were expanded to include management of ADCs, compounding of IV admixtures, and participation in performance improvement initiatives. Decentralized pharmacists responsibilities included processing medication orders, managing risk-stratified patients, and handling all medication management issues in the area. The residents, along with an assigned pharmacy faculty member, managed patients on the weekends. When turnover occurred, vacancies were filled with qualified pharmacists. The new model became successful within a short time. The staff-driven performance improvement initiatives implemented in 1998 have resulted in a great change in staff accountability and ownership. All staff members attend annual retreats where the agenda includes review of financial/operational/clinical accomplishments and performance improvement initiatives for the next fiscal year. The retreats are followed by voluntary staff meetings held every 2 weeks to implement the initiatives. Technicians play an active role in designing and implementing drug distribution related initiatives. Pharmacy also led the establishment of a nonpunitive adverse event reporting system. The task was not easy since it involved a culture change. Support from the Institute for Safe Medicine Practices, senior management, and key nursing and physician leaders resulted in a 20-fold increase in the reporting of events and numerous performance improvement initiatives. The department s culture was transformed into a robust lesson-learned environment. Pharmacy-led continuing medical education and continuing education programs for the community and hospital-sponsored monthly community lectures on medication management were also initiated and take place regularly. Outcomes. The department has successfully fulfilled Joint Commission surveys through 2007 and received a best medication management system award from UHC in The comprehensive interdisciplinary infectious disease management program has resulted in lower costs for antimicrobials and less antimicrobial resistance. Research activities have been published in numerous professional journals and presented at meetings of national organizations. A physician satisfaction survey conducted in September 2007 reported 95% satisfaction with pharmacist-provided services, and 60% of the respondents suggested expanding clinical services. Factors such as the leveraging of automation, the maximizing of technician productivity, an integrated practice model, the enhancement of staff competence, a strong presence in academia and patient care areas, and a pharmacist-led clinical pharmacology consult service have allowed the department to position itself in the forefront of delivering patient care. Restructuring, along with establishment of accountability and effective use of automation, has resulted in improved patient care services. Furthermore, a robust drug distribution system, around-the-clock clinical monitoring of patients, and participation in academic and community education programs have been implemented to meet mission goals. The department moved to a new state-of-the-art facility on the third floor in The facility includes United States Pharmacopeial Convention Chapter 797 compliant clean rooms, a conference room, a pantry, a locker room, automated drug storage, a security system, and, most important, the well-designed strategic placement of personnel for close supervision of all staff. The new location has resulted in easy access by physicians, nurses, and other providers, leading to engagement and enhanced communications. Future direction. Tremendous progress has been made in fulfilling the organizational mission. However, as is the case with other AMCs, the acuity of the hospital s patients is escalating, and limited resources continue to present a challenge. A bedside bar-coded medication administration project is in progress. 23

24 Deployment of the Practice Model Within the UHC Alliance of 107 AMCs The models deployed at UHC hospitals vary significantly. However, it is clear that pharmacy leaders at these institutions are committed to models that position pharmacists to provide the best care for patients. The goal is a practice model that supports basic medication management services on a consistent basis for all patients and specialized services for specific patients depending on their clinical situations. Technology may help achieve this goal, but a well-trained workforce and an appropriate model design are critical for success. Not one but several dominant practice models will evolve. As they are designed, members should consider the task force s recommendation for services provided for all patients: 1. Reconcile medications upon admission for patients admitted as inpatients 2. Reconcile medications during all changes in level of care, including transfers and postoperatively 3. Reconcile medications for patients based on criteria and patient needs prior to discharge to ensure continuity of care 4. Develop individualized treatment and monitoring plans for patients 5. Review all nonemergent orders prior to first dose administered 6. Monitor patient medication profiles daily 7. Participate in patient care rounds 8. Educate patients about new medications 9. Counsel patients who are prescribed high-risk medications or complex medication regimens on their discharge medications during inpatient hospitalization 10. Communicate a patient s discharge information to the patient s pharmacy and, if applicable, to the referring physician 11. Participate as a member of the emergency department s patient care team 12. Participate as a member of the operating room s patient care team The task force has also provided recommendations for care services for specific patients based on need, medication preparation and delivery, medication safety, medication-use policy, information systems and technology, quality outcomes and performance improvement, and education and research (Appendix). The work of the task force is intended to provide guidance to UHC pharmacy leaders as they continue to refine practice models within their AMCs and to help UHC Pharmacy Council committees as they develop projects and initiatives in support of the membership. The UHC Pharmacy Council will support continued practice model development by sharing best practice methods, fostering research, collecting data, analyzing outcomes, and influencing professional and executive leaders to support and provide resources to carry out the activities of the pharmacy practice model. 24

25 References 1. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration Am J Health-Syst Pharm. 2009;66: Armistead J. A fourth option in practice models. American System of Health-System Pharmacists Connect Discussion Board. Accessed October 18, Francke DE. Mirror to hospital pharmacy: a report of the audit of pharmaceutical service in hospitals. Washington, DC: American Society of Hospital Pharmacists; Breland B. Believing what we know: pharmacy provides value. Am J Health-Syst Pharm. 2007;64: Directions for clinical practice in pharmacy. Proceedings of an invitational conference conducted by the ASHP Research and Education Foundation and the American Society of Hospital Pharmacists. February 10-13, Am J Hosp Pharm. 1985;42: Implementing pharmaceutical care. Proceedings of an invitational conference conducted by the American Society of Hospital Pharmacists and the ASHP Research and Education Foundation. San Antonio, TX, March 12-15, Am J Hosp Pharm. 1993;50: Bonk ME, Krown H, Matuszewski K, Oinonen M. Potentially inappropriate medications in hospitalized senior patients. Am J Health-Syst Pharm. 2006; 63: ASHP long-range vision for the pharmacy work force in hospitals and health systems: ensuring the best use of medicines in hospitals and health systems. Am J Health-Syst Pharm. 2007;64: McKesson Solutions. High performance pharmacy. Accessed May 22, Cutrona SL, Woolhandler S, Lasser KE, et al. Characteristics of recipients of free prescription drug samples: a nationally representative analysis. Am J Public Health. 2008;98: Cutrona SL, Woolhandler S, Lasser KE, et al. Free drug samples in the United States: characteristics of pediatric recipients and safety concerns. Pediatrics. 2008;122: Chew LD, O Young TS, Hazlet TK, et al. A physician survey of the effect of drug sample availability on physicians behavior. J Gen Intern Med. 2000;15: Institute of Medicine of the National Academies. Preventing medication errors: quality chasm series. Washington, DC: National Academies Press; ASHP statement on the roles and responsibilities of the pharmacy executive. Am J Health-Syst Pharm. 2009;66: National Quality Forum. Safe practices for better healthcare 2009 update: a consensus report. Washington DC: National Quality Forum; Vermeulen L, Rough SS, Thielke TS, et al. Strategic approach for improving the medication-use process in health systems: the high-performance pharmacy practice framework. Am J Health-Syst Pharm. 2007;64: Joyce MC, Rough S. Applying MTM to the inpatient setting: medication reconciliation and continuity of care. Presented at: American Pharmacists Association Annual Meeting and Exposition; April 4, 2009; San Antonio, TX. Contributors Paul Abramowitz, PharmD Assoc. Hospital Director for Professional Services Chief Pharmacy Officer University of Iowa Hospitals and Clinics Paul W. Bush, PharmD, MBA Chief Pharmacy Officer Duke University Hospital James Jorgenson, MS, RPh Executive Director Clarian Health Partners, Inc. Steven Rough, MS, RPh Director of Pharmacy University of Wisconsin Hospital and Clinics Michelle (Shelly) Wiest, PharmD, BCPS Director Clinical Pharmacy Programs University Hospital The Health Alliance of Greater Cincinnati Daniel M. Ashby, MS, FASHP Senior Director of Pharmacy The Johns Hopkins Hospital Roy Guharoy, PharmD, MBA, FCP, FCCP, FASHP Chief Pharmacy Officer Professor of Medicine University of Massachusetts Memorial Health Care Scott Knoer, MS, PharmD Director of Pharmacy University of Minnesota Medical Center, Fairview James G. Stevenson, PharmD Director of Pharmacy Services University of Michigan Hospitals & Health Centers John S. Clark, PharmD, MS, BCPS Associate Director of Pharmacy University of Michigan Hospitals & Health Centers Todd W. Nesbit, PharmD, BCPS, Associate Director Decentralized and Clinical Services The Johns Hopkins Hospital 25

26 Appendix: Opinions of the Task Force on Minimum Pharmacy Services That Should Be Consistently Provided at AMCs The task force voted on whether each of the services listed below should be considered a responsibility of the pharmacy department; no consideration was given to how the department should fulfill that responsibility. Not all task force members voted on each service. No. Yes Votes/ No. Task Force Members Voting Service Category Patient Care Services for All Patients 4/8 Perform medication histories for patients admitted as inpatients 1/6 Perform medication histories for patients admitted as 23-hour admit patients 1/6 Perform medication histories for patients admitted to procedural areas 7/8 Reconcile medications upon admission for patients admitted as inpatients 0/5 Reconcile medications upon admission for 23-hour admit patients 2/6 Reconcile medications upon admission for patients admitted to procedural areas 8/8 Review all nonemergent orders prior to the first dose administered 7/8 Develop individualized treatment and monitoring plans for patients 8/9 Educate patients about new medications 8/8 Monitor patient medication profiles daily 5/8 Participate in patient care rounds 7/8 Reconcile medications during all changes in level of care, including transfers and postoperatively 6/9 Reconcile medications for targeted patients prior to discharge to ensure continuity of care 7/9 Counsel patients who are prescribed high-risk medications or complex medication regimens on their discharge medications during inpatient hospitalization 5/7 Communicate the patient s discharge information to the patient s pharmacy and, if applicble, to the referring physician 5/5 Participate as a member of the emergency department s patient care team 5/5 Participate as a member of the operating room s patient care team Patient Care Services for Specific Patients Based on Need 8/8 Participate in anticoagulation management 7/7 Participate on resuscitation teams 8/8 Participate on nutrition support teams 8/8 Participate in antimicrobial stewardship 8/8 Streamline medication orders (e.g, IV-to-oral medication conversions) 8/8 Provide pharmacokinetic evaluation, monitoring, and dosing 8/8 Provide parenteral nutrition assessment and order change 8/8 Provide dosing adjustments for medications that should be modified based on renal function 8/8 Manage medication therapy in collaboration with other members of the health care team (e.g., CDTM practice agreements) 7/7 Provide programs for patients that prevent disease and improve health Medication Preparation and Delivery 8/8 Unit-dose drug distribution system: all doses 7/7 Unit-dose drug distribution system: all scheduled and as-needed doses to the greatest extent possible 7/7 Dispense medication labeled with machine-readable coding (bar codes) 8/8 Pharmacy oversight of medications in all care locations 7/8 Pharmacy management of all investigational medications 8/8 Pharmacy preparation of injectable chemotherapy 8/8 Pharmacy management of medication waste 8/8 Pharmacy management of medication returns 8/8 Pharmacy management of medication recalls 26

27 7/9 Pharmacy oversight of the process of reconciling controlled substance waste 8/8 Standardize medication doses to improve safety and efficacy 8/8 Compounding formulations and protocols 8/8 Pharmacy management of ADCs 8/8 Ensure appropriate medication label components and label quality 8/8 Safe medication storage 7/8 Pharmacy control of medication transport to the point of dispensing 4/8 Integration of distribution and clinical services 8/8 Use pharmacy technicians in traditional and advanced roles Medication Safety 7/7 Bar-code medication administration (BCMA) 8/8 Use clinical decision support-based infusion pump technology (smart pumps) 8/8 Adhere to a high-alert medication policy 8/8 Use drug nomenclature that enhances safety 8/8 Use order sets 8/8 CPOE 8/8 Incorporate computer decision support in CPOE and pharmacy software systems 8/8 Availability of patient information 8/8 Pharmacy-maintained medication administration record 8/8 Medication event prevention, monitoring, and reporting 8/8 Education of allied health professionals on medication safety issues 3/4 EMR medication management functionality designed and overseen by pharmacists and reported to the director of pharmacy Medication-use Policy 8/8 Effective formulary system 8/8 Active pharmacy and therapeutics committee 8/8 Provide an effective drug shortage management program 8/8 Effective industry representative policies 8/8 Drug monographs for formulary evaluation 8/8 Nonformulary medication review 8/8 Manage resource utilization through a pharmacy-coordinated program 8/8 Forecasting of financial performance 8/8 Medication policy development 8/8 Medication use evaluation 8/8 Drug information services 8/8 Communication systems (newsletters, bulletins, etc.) 8/8 Dietary supplement policy 7/8 Coordinate a medication sample program Information Systems and Technology 8/8 Ensure that technology provides patient safety 8/8 Use technology to ensure the proper distribution of medications 8/8 Use information systems to ensure the proper use of medications 8/8 Participate in the assessment of technology Quality Outcomes and Performance Improvement 8/8 Participate in quality, safety, and performance initiatives related to medication use at organization and department levels 8/8 Ensure that infection control principles are applied to medication dispensing and administration Education and Research 7/7 Participate in the education and training of doctor of pharmacy students 8/8 Participate in the education and training of pharmacy technicians 8/8 Participate in the training of pharmacy residents 8/8 Lead or collaborate in clinical or operational system/process research activities 7/7 Contribute to the practice literature 5/5 Participate in professional organizations 27

28 University HealthSystem Consortium 2001 Spring Road, Suite 700 Oak Brook, IL (630) Fax: (630) University HealthSystem Consortium. All rights reserved. The reproduction or use of this document in any form or in any information storage and retrieval system is forbidden without the express, written permission of UHC. 4/ SC0110