1. Advancing the Role of Pharmacy Technicians
Radhika Pisupati, Pharm.D., BCPS
Lynette Richards, Pharm.D., BCPS
St. Joseph’s Healthcare System

2. Conflicts of Interest
We do not have a vested interest in or affiliation with any corporate organization offering financial support or granting monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias our presentation.
Radhika and I have nothing to disclose

3. Objectives
Describe the ASHP Pharmacy Practice Model Initiative recommendation on pharmacy technician practice
Identify reasons to expand role of pharmacy technicians within the healthcare system
Describe expanded roles of pharmacy technicians
Identify barriers to pharmacy technician role expansion
Today we would like to introduce to you some information that you may not be all that familiar with. We are going to describe some points published by ASHP in the Pharmacy Practice model initiative regarding technicians, discuss some of the reasons why optimizing the role of pharmacy technicians is not only beneficial to the employee but to the department, identify some of the barriers to expanding their roles and describe some of the expanded roles
So with that here is our first question

4. Question?
With the adoption of the latest healthcare reform, pharmacists and pharmacy technicians will be legislatively limited to dispensing roles.
True or False
True or false, the latest healthcare reform has restricted the pharmacy departments functions to dispensing only?

5. Question?
With the adoption of the latest healthcare reform, pharmacists and pharmacy technicians will be legislatively limited to dispensing roles.
True or False

6. ASHP Pharmacy Practice Model Initiative1
Group of healthcare leaders convened in 2010 to optimize the future of pharmacy practice
Goals
Advance the health and well-being of patients
Develop and disseminate optimal pharmacy practice models
Effectively use pharmacists as direct patient care providers by optimizing pharmacy technician roles and technology
Tools for implementation
Hospital self assessment
C-suite resources
Changes in health care reform began in 2010 with the Affordable care act. Our administration at that time wanted to increase patient access to acute and preventative care by expanding healthcare insurance coverage and changing insurance policies and regulations. Ultimately the end goal was to improve the quality of care. Regulations were put into place affecting reimbursement for the services provided , especially in the acute hospital setting, if a certain quality or level of care was not provided. This is measured in several ways including patient satisfaction and reportable core measures. In preparation for that change ASHP convened a group of pharmacy leaders across America to help optimize pharmacy practice. Their goals were to ensure advances in the health and well being of patients, and develop and disseminate a template for the optimal pharmacy practice model. This would involve finding out what services could be provided by the pharmacy, incorporating the latest technology, and giving hospital pharmacies across America the tool to help establish this in their individual facilities.
In the end, they outlined ways to effectively use the pharmacist and a direct patient care provider but optimizing the role of pharmacy technicians.
The tools for implementation included the self assessment and c-suite resource.

7. ASHP Pharmacy Practice Model Initiative2
Healthcare systems must consider
System accountability
Fiscal responsibility
Resource deployment
Increased demand
Performance improvement measures
Patient safety
Data collection
Call for restructuring patient care management
Barriers
Staff development and training
Technology
System culture
The tools just mentioned direct healthcare system pharmacies to consider collectively, resources must be utilized more wisely, restructuring of patient care must be done, and the barriers must be overcome. Basically the tools hel;p pharmacies prepare and develop models that would work best in their individual facilites and patient populations. So with that how many in the audieenc have seen or completed the Pharmacy Practice Model Initiative self-assessment tool?

8. Have you completed PPMI self-assessment tool?

9. Well in the tri state area connecticut is leading the way with 25-50% of hopsital pharmacies completing the self-assessment, while New York and New Jersey are within the country’s average at 10-25%. So there are still a lot of opportunities to be explored.
Figure 1. PPMI HAS Completion by State. ASHP 2015

10. ASHP PPMI Self-Assessment Tool
All distributive functions that do not require pharmacist judgment
Medication history (MH) collection
Medication allergy verification
“Tech-check-tech” (TCT)
Sterile compounding
Clinical monitoring compilation
Inventory management
Medication assistance program
Quality improvement programs
Information technology
Supervisory role/lead technicians
Board certification
One question on the self assessment tool that is very poignant for this presentation is “Are medication preparation and distribution tasks assigned to pharmacy technicians, to the extent possible, to allow redeployment of pharmacists’ time to drug therapy management activities at your hospital?” which means are we utilizing our technicians to their fullest potential? So are we robustly involving them in medication history collection, allergy verification, sterile compounding, supervisory roles. Are we requiring board certification to ensure they have a standard knowledge base.

11. Benefits of Advanced Roles
Increased pharmacist mobility and patient profile review
Increase employee satisfaction
Increased nursing satisfaction and multidisciplinary relationships
Improved turn around times
Decreased medication costs
Decreased medication errors
There are so many obvious benefits to exploring more roles for pharmacy technicians which include increased pharmacist mobility, which can lead to increased multidisciplanary satifaction, improved turn around times, decease in costs, and even medication errors.

12. Barriers Lack of standardized regulations and training
Diversity of requirements for entry into the workforce
Administration (C-Suite)
Incentive
There will also be some obvious barriers to expanding the role of technicians which include resistance from adminsitration, lack of incentive, and largely the lack of standardization.

13. Barriers Lack of standardized regulations and training
Diversity of requirements for entry into the workforce
Administration (C-Suite)
Incentive

14. Tri-State Area Pharmacy Technician Regulations
Regulated
Registration with the Board of Pharmacy
Documented continuing education/ training req.
National certification req.
Connecticut
Yes
New Jersey
No, unless certified (PTCB/ExCPT) No
New York
Pharmacy technician regulations vary widely from state to state. Just looking in the Tri-state area alone there is a lot of variation in requirements. Clearly, this is to the professions disadvantage. Charles e. Myers said “Achievement of significant gains in redeployment of health-system pharmacists to clinical activities will be feasible only if far more pharmacy technicians become adequately qualified to handle medication distribution” and “Pharmacy has yet to face its responsibility for ensuring the competence of pharmacy technicians, and this is holding the profession back from adequately addressing patients’ clinical medication-use needs” There however is a movement towards revising boards of pharmacy regulations for technicians. Which would allow for refining and broadening of their responsibilities. In 1993 on 12 states regulated technician, to date there are at least 45 states that regulate technicians via certification, licensure, or registration.

15. Best Practices in Advanced Technician Roles
So lets explore some of the opportunities mentioned in the self assessment question. We will briefly detail tech-check-tech, information technology, supervisory roles, and go more in depth with medication history collection.

16. Tech-Check-Tech 4,5 Several studies published on TCT
Comparable accuracy
Improved clinical outcomes
Memorial Hermann Southeast Hospital (TX)
Medication cart fill
Floor stock medication refill
Patient care area
Automated dispensing device
Patient specific orders previously reviewed and approved by a pharmacist
Tech-check-tech is a system in which a well trained and usually certified pharmacy technician can verify or double check another technician’s work. Currently this practice is only allowed in certain states and is most times restricted to certain medications and or circumstances. But there have been multiple studies proving that well trained technicians are just as good as if not more precise than pharmacist check. As a result of these implementations, pharmacists are more able to mobilize to the floor and directly interact with patients and other healthcare providers.
Memorial Hermann Southeast Hospital is a member of the largest non-profit healthcare system in Texas. They utilize the latest technologies including CPOE, pyxis medication profile system, Medication barcode scan during Pyxis refill/ at bedside, Alaris smart pump guardrails. They implemented this practice because they thought it could limit distractions during order entry, increase staff development, and optimize patient outcomes. So they developed an application, training, and quality assurance program or process. At the time they had 6 pharmacy technicians checking Pyxis refill and cardinal assist. Unit dose and IV admistureschecks were excluded. They are expanding the tech role to include crash cart check, clinical, and productivity monitoring.
Some may view tech check tech practice to be detrimental to the pharmacist’s position. This truly is not the case. We must view it as an opportunity to expand our role as a direct healthcare provider. There is also some legislation that prohibits using this practice as a tool to decrease pharmacist ftes

17. Information Technology6
Collaborate with pharmacist informaticist
Manage automation and technology systems
Develop and implement end-user education
Stay updated on newest technology
Ensure appropriate and accurate charges billing
Compile and analyze data reports
Pharmacy technicians involved in information technology are very hands on with the IT pharmacist. They work closely together to help manage medication dispensing devices and order entry systems, ensuring accurate data is entered for medication profiling and charging. They also provide education on the latest updates and help compile data for reports.

18. Supervisory Role/Lead Technician
Duke University Health System
Hiring
Orientation/training
Performance appraisals
Work distribution
Inventory ordering and management
Cost containment
Performance improvement and quality assurance
Clinical coordinator for affiliated programs and schools
Duke University Health system is utilizing their pharmacy technicians in the supervisory role. This role allows an experienced and certified technician to be a part of the hiring process, they also provide training, education, and ongoing quality assurance for employees. They complete evaluations, manage inventory, help find way to contain costs. The lead technician also helps to coordinate student rotations for affiliated tech programs and schools. Now we are going to delve most deeply into pharmacy technician medication history collection.

19. Compounding Preparation Training Sterile IV compounds Chemotherapy
Neonatal/Pediatric oral and IV syringes
Training
Aseptic technique
USP 797 compliance
Calculations
Additional institution specific requirement(s)
Certification

20. ASHP-APhA Medication Management in Care Transitions Best Practices (MMCT)7
Developed to ascertain best practices of transitions of care by pharmacists and Pharmacy Technicians
Winning programs
Einstein Healthcare Network
Froedtert Hospital
Hennepin County Medical Center
Johns Hopkins Medicine
Mission Hospitals
University of Pittsburgh School of Pharmacy
University of Utah Hospitals and Clinics
Cassano, A. ASHP-APhA Medication Management in Care Transitions Best Practices. Rep. American Society of Health-System Pharmacists and American Pharmacists Association, Feb

21. Programs with Pharmacy Technicians Involvement
Winning programs
Einstein Healthcare Network
Froedtert Hospital
Hennepin County Medical Center
Johns Hopkins Medicine
Mission Hospitals
University of Pittsburgh School of Pharmacy
University of Utah Hospitals and Clinics
Cassano, A. ASHP-APhA Medication Management in Care Transitions Best Practices. Rep. American Society of Health-System Pharmacists and American Pharmacists Association, Feb

22. Pharmacy Technician Role
Einstein
‘APPLE’ Role – Ambulatory Pharmacy Patient Liaison Empowerment
Attend discharge rounds, interview patients and assess medication needs
Facilitate discharge prescriptions
Triage and screen patients that require pharmacist intervention
Froedtert
Discharge prescription processing, insurance verification, adjudication, prior authorization, filling and delivery
Johns Hopkins
Discharge prescription processing, insurance verification and claim adjudication, referrals to patient assistance program
Mission
Make initial contact with patients at discharge.
Make follow up arrangements with providers.
Three follow up phone calls after discharge (72 h, 1 week of first refill, after 1st visit with PCP)
Alert pharmacist regarding medication discrepancies
University of Utah
Partner with pharmacists for discharge, thrombosis referrals, clinic services, transplantation care and MTM services

23. Einstein Healthcare Network
Cassano, A. ASHP-APhA Medication Management in Care Transitions Best Practices. Rep. American Society of Health-System Pharmacists and American Pharmacists Association, Feb

24. Rx Team Model: Results Pharmacy technicians role
Emergency department pharmacy technicians from several hospitals received praise at ASHP Midyear 2013 for 96% accuracy
The Hospital of Central Connecticut (THOCC) Pharmacy technician and pharmacist collaboration
25,000 ED medication reconciliations from late 2012 to late 2013 with documentation showing 96% accuracy
Other ED health care providers showed 66% accuracy

25. Cooper University Hospital
Camden, NJ; Monday-Friday from 7:00 am- 3:30 pm
Patient interviewed by pharmacy technician within 72 hours of admission
Information collected
List of all home medications
Outpatient pharmacy information
Healthcare provider information
Home medications verified by contacting
Outpatient pharmacy
Physician’s office
Long term care facility/skilled nursing facility
Pharmacists identified and resolved any noted medication reconciliation discrepancies
CUH is a 550-bed urban academic medical center located in Camden, New Jersey. Over 700 physicians in more than 75 specialties practice within the CUH health system. The pharmacy department is structured under a hybrid model using teams of centralized and decentralized pharmacists comprising staff, patient care, and clinical pharmacists. The department consists of over 90 pharmacy employees, including 32 pharmacist full-time equivalents (FTEs), 27 pharmacy technician FTEs, and management staff. Dispensing pharmacy service is provided 24 hours a day, seven days a week.
Pharmacy technician-centered medication reconciliation program with full pharmacist supervision
Using electronic health record to capture single medication list
Previous process: physicians and nurses collected admission medication history
Without verification/reconciliation utilizing retail pharmacy data
Patients discharged on inaccurate medication lists
Sen S, et al. Am J Health-Syst Pharm. 2014; 71(1):

26. Cooper University Hospital
Desired technician skills
Strong communication
Attention to detail
Self-motivation
Hospital work experience
Retail pharmacy experience contributed to strong communication skills and increased knowledge of commonly prescribed medications
Training process
One-on-one supervision by pharmacy technician mentor
Orientation to medication reconciliation process and EHR computer training
Instruction on patient interview techniques
Role observation
Desired technician skills were identified by pharmacist/administration
Sen S, et al. Am J Health-Syst Pharm. 2014; 71(1):

27. Cooper University Hospital
Perspectives
Technicians – improved job satisfaction
Pharmacists focused on the integration and connection between a hospital stay and patient’s care as an outpatient
Program bridged care between the inpatient and outpatient realms of pharmacy and physician services
Physicians were able to focus on patient care rather than time-consuming medication history process and appreciated the time saved
Program enhanced patients’ experiences by improving the quality of bedside care
Sen S, et al. Am J Health-Syst Pharm. 2014; 71(1):

28. Morton Plant Hospital Clearwater, FL
Patients > 18 years old admitted directly from ED between 1:00pm and 9:30 pm and taking at least 3 medications were included
Two certified pharmacy technicians hired for process
Previous process: ED nurses collected medication history
687-bed community owned facility with an average daily ED census of person with 60% of admissions from the ED
Anticipated that the interventional program could improve the accuracy of patient information and subsequently the ability of health care providers to make appropriate assessments and interventions would be enhanced and incidence of adverse drug events should decrease
Pre-post study comparing historical control group (RN conducted med history) prior to implementation of pharmacy technician program to prospective cohort group (Pharmacy technician conducted med history)
One month lapse between pre and post intervention data collection periods to allow for adequate training of pharmacy technicians and implementation of new program
Primary objective: determine any differences in percentage of patients with accurate medication histories prepared by nurses compared to pharmacy technicians
Secondary objectives: any differences in total number of medication errors, types of medication errors, documentation of patient allergies and reactions and documentation of the last administration date and time of high-risk anticoagulant and antiplatelet medications
Hart C, et al. P&T. 2015; 40(1):

29. Morton Plant Hospital Training process
On-site training by PGY1 pharmacy practice resident over 2 weeks
Medication history process: patient interview, checklist utilization, reviewing and updating old records, and contacting patient’s pharmacy
Trained to document allergy information and last dose taken of each medication
Trained on computer software
Educational lectures: patient communication, high-risk medications, medication reconciliation process
Taught the Medication history process: patient interview, checklist utilization, asking prompting questions, reviewing and updating old records, and contacting patient’s pharmacy
Hart C, et al. P&T. 2015; 40(1):

30. Morton Plant Hospital
Hart C, et al. P&T. 2015; 40(1):

31. Morton Plant Hospital
300 medications total (150 in each group pre and post)
Hart C, et al. P&T. 2015; 40(1):

32. Medication History
MH Collection and allergy verification pilot at SJRMC (emergency department)
Training
Discussed importance of initiative
Required to complete MH related continuing education
Verbally instructed on patient interview process
Technician observed pharmacist perform interview process
Technician assessed performing patient interview
Obtain translator certification
Implementation
MH collection in ED by technician
Medication list verified by technician and pharmacist
Pharmacy Technician Medication History Training Checklist
Technician Name:
Discuss with pharmacist/pharmacy resident the importance of medication history in Transitions of Care
Receive verbal instruction on how to conduct patient medication history interview
Receive verbal instruction on how to add medication list in Soarian and Medhost
Observe pharmacist/pharmacy resident complete 3 medication histories and enter medication list in Soarian and Medhost
Complete 5 medication histories and enter medication list in Soarian and Medhost while observed by pharmacist/pharmacy resident
Complete NJSHP Membership
Complete Medication History Module on
Waiting list for translator certification course

33. Medication History Completed
Results
Medication History Completed
n= 100
15 Med Histories
≥ 1 error
85 Med Histories
No errors 33 33

34. Results
p<0.001
RRR=77%
ARR=50%

35. Medication History at SJHS
MH Collection and allergy verification at SJRMC (emergency department)
Future direction
Implementation of pharmacy technician MH program in SJRMC-ED
Continuous quality assurance and improvement
Routine training and education
Optimize current software utilization

36. Technician Roles OR Technician Clinical Technician
Procedural compliance
Clinical Technician
Data collection for trials, MUEs
Unit inspections/off site inspections
Sample medications
Patient assistance program
Aseptic technique testing

37. Technician Roles Automated Dispensing Cabinet (ADC) Informatics
Optimize inventory in ADCs
Drug diversion surveillance
Troubleshoot failures/other problems with ADCs
Informatics
Inventory Management

38. ASHP PPMI Self-Assessment Tool: SJHS Experience
Most distributive functions that do not require pharmacist judgment
√ Medication history (MH) collection
Medication allergy verification
“Tech-check-tech” (TCT)
√ Sterile compounding
√ Clinical monitoring compilation
√ Inventory management
√ Medication assistance program
√ Quality improvement programs
√ Information technology
√ Supervisory role/lead technicians
√ Board certification
One question on the self assessment tool that is very poignant for this presentation is “Are medication preparation and distribution tasks assigned to pharmacy technicians, to the extent possible, to allow redeployment of pharmacists’ time to drug therapy management activities at your hospital?” which means are we utilizing our technicians to their fullest potential? So are we robustly involving them in medication history collection, allergy verification, sterile compounding, supervisory roles. Are we requiring board certification to ensure they have a standard knowledge base.

39. Question?
All of the following are avenues for pharmacy technician role advancement except?
Inventory management
Procedural compliance initiatives
Quality improvement initiatives
Medication order verification

40. Questions?

41. References
"Pharmacy Practice Model Summit: Executive Summary." AJHP 68 (2011): Web. Aug <
Wellikson, Larry. "Healthcare Imperative for Practice Model Change." PPMI. Aug PPMI: Pharmacy Practice Model Initiative. Web. Aug <
“PPMI Hospital Self-Assessment Worksheet.” PPMI. Aug PPMI: Pharmacy Practice Model Initiative. Web. Aug 2015 < >.
Samuel, Rachel. Liem, Aily. “Tech-Check-Tech Program Implementation and Operational Impact.” TSHP. March Web. Aug <
Page, Michael. “Tech-Check-Tech Programs: What Pharmacists Need to Know” Pharmacy Times: published online. June Web. Aug <
“ASHP Statement on the pharmacy technician’s role in pharmacy informatics.” Web. Sept <
Cassano, A. “ASHP-APhA Medication Management in Care Transitions Best Practices.” Feb Web. Aug < >.