CLINICAL PHARMACY TECHNICIANS: A VALUABLE RESOURCE FOR CLINICAL PHARMACISTS

Eric W. Weber, PharmD, BCPS, Lezlie Cohn-Oswald, CPhT, Charley Hepfinger, PharmD, BCPS, Greg Kidd, PharmD, and Randy Koontz, RPh, MBA, MHA

Time spent on nonclinical activities can significantly hinder the efforts of pharmacists to enhance their clinical role. Here’s how clinical pharmacy technicians can help.

he past two decades have nomic, and political barriers often into the ambulatory care pharmacy been marked by tremen- have negated the utilization of qual- team—a move that enhanced the dous advancement in the ified pharmacists in these roles. clinical role of the pharmacist, im- T pharmacist’s role as a These barriers have included pa- proved patient care, and increased member of the health care team. tient and provider acceptance; physician satisfaction with clinical These advancements include the pharmacists’ reluctance to change; pharmacy services. integration of pharmacists into di- pharmacist shortages; employee In this article, we’ll discuss how rect medication therapy monitoring bargaining unit oversight; person- we developed the clinical phar- with patient assessment, adherence nel budgetary limitations; regula- macy technician program at the monitoring, medication therapy tory limitations; and nonclinical, Carl T. Hayden VA Medical Center, evaluation, and limited prescribing operationally based job duties. the various roles these technicians under defined scopes of practice. Historically, clinical pharmacists have played within our medical Although the value of pharmacists at the Carl T. Hayden VA Medical center, and the impact it has had on in expanded clinical roles has been Center in Phoenix, AZ have been the activities of clinical pharma- well documented,1–4 social, eco- well accepted as members of the cists. We’ll also describe how we ambulatory health care team. Nev- maintain and document the compe- ertheless, excessive time spent on tency of pharmacy technicians and Dr. Weber is a clinical pharmacy specialist, Ms. nonclinical activities significantly the potential we see for expanding Cohn-Oswald is a clinical pharmacy technician, and Dr. Hepfinger is a clinical pharmacist, all in impeded the efforts of these phar- their role in the future. ambulatory care services at the Carl T. Hayden VA macists to further enhance their Medical Center, Phoenix, AZ. Dr. Kidd is a clinical clinical role. This barrier was suc- DEVELOPING THE PROGRAM pharmacist in the anticoagulation clinic and Mr. Koontz is the clinical pharmacy program manager cessfully addressed when special- Carl T. Hayden VA Medical Center at the Carl T. Hayden VA Medical Center ized technicians were integrated has a large ambulatory care ser-

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Continued from page 22 vices (ACS) program that serves pharmacy technician program. As a and ambulatory care, with one full- four campuses and represents basic template for our initial pro- time equivalency assigned to each more than 500,000 provider visits gram, we used the program that service. annually. In fiscal year 2003, the had been implemented at the North ACS filled more than 1.75 million Mississippi Medical Center, Tupelo TECHNICIANS IN outpatient, 30-day equivalent and described in pharmaceutical ANTICOAGULATION MANAGEMENT prescriptions. The clinical phar- literature.5 When our first clinical technicians macy team within the ACS primary The development of our clinical were hired, our anticoagulation care department consists of 26 technician program did not occur service was being centralized. A professionals, including clinical overnight. There were many stake- single pharmacist managed over pharmacy specialists, clinical holders that needed to be involved 800 cases. The clinical technicians pharmacists, clinical support phar- in the development and implemen- were instructed on the use of war- macists, and clinical technicians. tation process—including ambu- farin and its adverse effects and Major team activities include latory care clinical pharmacists, on the clerical tasks involved with disease state management, medi- clinic physicians, clinic and phar- an anticoagulation clinic. Once cation counseling, patient assess- macy administration staff, the em- trained, the technicians were given ment, medication use guideline ployee bargaining unit, the human responsibility for nearly all of the development, medication profile resource department, and the operational activities of the central- and polypharmacy reviews, resi- technicians themselves. Program ized anticoagulation clinic under dent and student training, and implementation became easier the oversight of the clinical phar- participation in several multidisci- as the majority of stakeholders macist. As hoped, reducing the op- plinary patient care committees. recognized the potential clinical erational activities of the clinical In 1998, the clinical pharmacy and economic benefits of this new pharmacist allowed him to focus team’s goals focused on optimiz- program and welcomed its develop- on direct patient care decisions and ing cost-effective care and patient ment. on communication with providers. safety by increasing opportuni- Although barriers were minimal, On a daily basis, the clinical tech- ties for pharmacists to manage med- the team faced several significant nicians maintained patient records ication, particularly in the areas hurdles related to technicians’ and generated international normal- of providing drug information to knowledge and skills and institu- ized ratio (INR) reports for review patients and providers, assisting tional regulations. While all the by the clinical pharmacist. After the providers with disease state man- technicians selected for the new clinical pharmacist performed the agement, maximizing patient coun- positions had years of experience review and made recommenda- seling, and training students and and good communication skills, tions, the technicians telephoned residents. Unfortunately, the team’s specialized training was necessary patients who required a dose mod- staffing limitations and technical for them to function optimally in ification and documented each job assignments, combined with their assigned areas. In addition, a interaction with an electronic budgetary constraints and a rapidly position description had to be de- progress note. During each patient increasing patient enrollment, veloped, approved, and graded. Fi- contact, the technicians inquired made it difficult to achieve these nally, the initial job assignments about potential adverse effects, as- goals. had to be structured in such a way sessed patient adherence, and pro- At the time, it was estimated that as to ensure continued pharmacist vided secondary patient education more than 50% of clinical pharma- oversight, while circumventing the through the use of standardized cists’ time was dedicated to med- potential for professional territori- questions. The technicians also sent ication order entry and other alism. letters to patients who missed clinic technical functions. Knowing that The hurdles and barriers were appointments or were delinquent in we could not expand the clinical overcome and the clinical techni- their laboratory monitoring. To en- role of the pharmacists without cian program was implemented sure complete and accurate docu- curtailing the assigned nonclinical successfully. Our first two clinical mentation, all technician notes responsibilities, we began to con- pharmacy technicians were hired were reviewed and cosigned by the ceptualize and develop our clinical in 1998 to work in anticoagulation clinical pharmacist (Figure 1).

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Technicians use standardized questions and the flow sheets Technicians generate with recommendations during Prescription refills, an INR* report phone interviews with patients. clinic appointments, twice daily. and follow-up education are provided during phone interviews when requested by the provider or patient. Flow sheets are Patient care issues identified updated with new during the phone interview are laboratory results referred back to the pharmacist. and prioritized as critical (INR > 4.5) versus noncritical. Patients who are unavailable by telephone are mailed form letters to provide the following: INR The pharmacist results, lab or clinic appointment dates, reviews each If no concerns are identified during educational informa- flow sheet and the phone interview, the technician tion, and reminders makes dose informs the patient of the to have laboratory recommendations. pharmacist’s recommendations and work completed. places a note in the patient record.

Figure 1. Anticoagulation clinic workflow diagram. *INR = international normalized ratio.

Due to the successful perfor- safe use of warfarin therapy. The same bottle. The patient was ad- mance of the clinical technician following two cases highlight ways vised against mixing tablets. One and the growth in patient volume, in which clinical technicians can week later, a repeat INR was thera- a second clinical technician was intervene successfully to avoid peutic. No adverse outcome re- assigned to the clinic in 2001 and potentially negative patient out- sulted from this patient’s error. an additional clinical pharmacist comes. In the second case, an increased was added in 2002. (The number of In the first case, a patient with a INR in a previously stable patient patients presently enrolled in the previously stable INR presented taking warfarin prompted the clini- clinic exceeds 2,300.) with a considerably subtherapeutic cal pharmacist to recommend a Despite a high clinic workload, INR of 1. The patient reported no dose reduction. The technician’s in- positive patient outcomes have missed doses and no changes in terview with the patient revealed been maintained and provider sat- diet or alcohol consumption. In the that the patient’s community phy- isfaction has increased. A compara- absence of other likely causes for sician recently had prescribed tive evaluation conducted in 2002 rapid INR reduction, the patient trimethoprim/sulfamethoxazole. found that INR results for clinic was asked to read the imprint on The clinical pharmacist was noti- patients actually improved slightly the tablets in the warfarin vial. The fied and the technician advised the with the use of technicians—from technician identified the tablet as patient to contact his physician im- being within the therapeutic range levothyroxine rather than warfarin. mediately to discuss alternate an- 61% of the time to being there 63% Further discussion revealed that tibiotic options. Ultimately, the of the time (Figure 2). these tablets appeared similar in antibiotic was changed and the INR Clinical pharmacy technicians size and color and that the patient returned to the target level at the have been integral in optimizing the had placed both medications in the next evaluation.

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with the prescriber confirmed that there had been an ordering error. 65 63% The prescription was rewritten and processed. 61% OTHER ROLES FOR 60 THE TECHNICIAN Some pharmacy staff members at our institution initiated a pilot project to determine the cost- 55 effectiveness of using a clinical % of time within therapeutic range pharmacist/clinical pharmacy technician team in the primary care setting.6 Various interventions 50 performed by the clinical phar- Prior to use After use of macy team (such as discontinuing of technicians technicians unnecessary medications, changing medications, changing medication doses, adding medications, and Figure 2. Comparison of results before and after the integration of clinical phar- assessing patients for potential macy technicians within the anticoagulation clinic. adverse drug events or drug inter- actions) were documented, along with the estimated cost savings and PROVIDING SUPPORT The following two cases show the time required. During an eight- IN AMBULATORY CARE how our clinical pharmacy techni- week period, the clinical pharmacy In ambulatory care, as in anticoag- cians have intervened to prevent technician was responsible for 62 ulation management, the support possible adverse drug reactions interventions involving 44 patients. provided by clinical technicians is (ADRs) in the ambulatory care Overall results indicated that the vital to team success. Clinical tech- clinic. interventions resulted in an an- nicians assist the pharmacist in In the first case, a prescription nualized, medication-related cost medication profile reviews and for trimethoprim/sulfamethoxazole savings in excess of $33,000 and help assess patients for medication was written for a patient with a improved patient care (Figure 3). adherence and allergies. When a documented sulfa allergy. (The Clinical technicians serve as the nonformulary medication is pre- drug would produce a severe rash.) first line of triage for patients with scribed, the technician has been The clinical technician verified the pharmacy requests. Whether con- trained to review the prescription allergy with the patient and dis- tacted in the clinic or through our for compliance with published cussed the situation with the telephone-linked care program, guidelines and criteria for use. provider, who was unaware of the technicians assist patients with When needed, technicians commu- sulfa component in that particular logistic and operational pharmacy nicate with the particular pre- combined drug formulation. questions, while forwarding clin- scriber or the clinical pharmacist to In the second case, a prescrip- ical questions to the appropriate clarify the appropriateness of a tion for neutral protamine Hage- clinical pharmacist. given order. While clinical techni- dorn (NPH) insulin 120 U twice When the manufacturer of our cians frequently assist in collecting daily was written for a patient who formulary nasal steroid abruptly data related to a given medication was new to the VA. When the tech- discontinued medication produc- request, the clinical pharmacist de- nician sought to verify this dose, tion, one of our clinical technicians, termines whether to approve or the patient revealed that he had under the auspices of the associate deny the medication order and been taking NPH insulin 12 U twice chief of staff of ambulatory care, communicates clinical recommen- daily prior to this visit. The clinical coordinated a therapeutic substitu- dations to the prescribing provider. technician’s subsequent discussion tion that had been authorized by

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clinical questions at the weekly fol- 16,000 Total = $33,525 low-up visits are referred to clinical $13,817 pharmacists. 14,000 Clinical technicians are also re- 12,000 sponsible for monthly clinic inspec- 10,000 tions. They evaluate current stock, identifying any mislabeled, out- 8,000 $6,842 $6,093* dated, or inappropriate medica- 6,000 $5,532 tions in medication rooms and crash carts. When indicated, the Cost savings ($) 4,000 technicians remove or replace 2,000 $1,245 medications. Technicians docu- ment all findings and activities 0 Drug Drug Dose Prevent Fill cost monthly. Inspection compliance discontinued changed changed ADE/DI† avoidance rates have improved dramatically since the clinical technician team Category of intervention assumed this responsibility. Figure 3. Annual estimated cost savings for interventions. *Cost of added medications Our institution also has created (not shown, $457/year) deducted from initial cost savings on drugs discontinued ($6,550 criteria for guidelines regarding the – $457 = $6,093). †ADE = adverse drug event; DI = drug interaction. use of cholinesterase inhibitors in the treatment of Alzheimer’s de- mentia. These guidelines mandate the pharmacy and therapeutics tients who are unable to fill their baseline and interval Mini-Mental committee. With each refill request own box despite instruction are State Examination (MMSE) and ac- for the unavailable product, the scheduled for monthly appoint- tivities of daily living (ADL) testing. clinical technician entered a new ments with the technician. After training by a representative of prescription for the alternative Historically, clinical pharmacists the neurology department, clinical product as a verbal order from the or registered nurses were charged technicians administer follow-up prescribing provider. A computer- with filling medication boxes MMSE/ADL tests and document ized progress note was then en- monthly. Clinical technicians now the results in the electronic med- tered to document the conversion, provide this service at a fraction of ical record, which is cosigned by and the provider and patient were the salary cost. Further plans are the appropriate prescriber. contacted and advised of the med- underway for technician-led in- ication change. This process structional classes to help patients HOW DO WE ENSURE proved highly efficient and suc- or caregivers to fill boxes accu- ONGOING COMPETENCY? cessful, while minimizing pharma- rately without the need for a unique To maintain and document clinical cist and provider workload. clinic encounter or home visit. technician competency, clinical In early 2002, at the request of a In the smoking cessation clinic, pharmacists give bimonthly presen- primary care physician director at the pharmacy department is re- tations on topics selected by the our facility, a clinical technician sponsible for assessing each pa- technician team. In the past, topics opened a clinic to educate patients tient, selecting appropriate drug have included diabetes, laboratory on the correct usage of a weekly therapy, providing counseling on values and interpretation, osteo- medication box (an adherence aid drug therapy, and acquiring and dis- porosis, hypertension, anticoagula- with slots labeled for morning, pensing the pharmaceutical. While tion, reflux disease, and pharmacy noon, dinner, and bedtime each the pharmacist is responsible for law. Competency is assessed day). At their scheduled appoint- the clinical activities (counseling through written examination fol- ment, patients who demonstrate and drug selection during the first lowing each lecture. Continuing ed- the ability to fill the box accurately week’s class), technicians oversee ucation credits toward institutional and independently are discontin- the weekly acquisition and distribu- and Certified Pharmacy Technician ued from further follow-up. Pa- tion of the medication. Specific recertification are provided based

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Continued from previous page on successful completion. In addi- Patients with chronic hyperten- clinical outcomes, guideline com- tion, clinical technicians are evalu- sion, hyperlipidemia, diabetes, pliance evaluations). ated routinely by their supervising pain, and other conditions are re- Clinical technicians have been pharmacists, and are encouraged ferred to clinical pharmacists regu- instrumental in allowing our clini- to participate in all clinical phar- larly for medication management. cal pharmacy department to ex- macy educational and competency We provide pharmaceutical care to pand its role in disease state programs. our more remote patients through management and provision of cost- the use of telemedicine videocon- effective care without compromis- IMPACT ON CLINICAL ferencing equipment. Patients at ing any of our prior responsibilities. PHARMACIST ACTIVITIES our clinic in Show Low, AZ are able Technician involvement has en- The overriding goal of the integra- to discuss their medications with hanced the coordination of antico- tion of clinical pharmacy techni- clinical pharmacists in Phoenix on agulation management, smoking cians into our ambulatory care a daily basis. In 2002, clinical phar- cessation, and clinic inspections. pharmacy department was to cre- macists at our facility came to- Because of these improvements, ate a stronger team in which each gether to form Veterans Affairs clinical technicians and clinical member could use his or her re- Pharmacists Organized for Re- pharmacists have reported in- spective skills to the fullest to search (VAPOR), a clinical phar- creased job satisfaction. ● achieve the best pharmaceutical macy-driven research group that care for our patients. We feel that seeks to help pharmacists and The opinions expressed herein are we have been successful in ap- technicians develop ideas, com- those of the authors and do not proaching this goal. Advances in plete research projects, and dis- necessarily reflect those of Federal the activities of our technician staff seminate information about local Practitioner, Quadrant HealthCom have been discussed at length. The research and activities. Inc., the U.S. government, or any enhanced clinical pharmacist effec- of its agencies. This article may tiveness resulting from this role WHERE DO WE GO FROM HERE? discuss unlabeled or investiga- shifting is the other side of our We hope to continue to expand and tional use of certain drugs. Please team’s success story. modify the roles and duties of the review complete prescribing infor- In the past two years, clinical clinical technician in the future as mation for specific drugs or drug pharmacists have sharpened their situations dictate. Recently, staff combinations—including indica- focus on optimizing cost-effective shortages led us to assign clinical tions, contraindications, warn- medication use through committee pharmacy technicians temporarily ings, and adverse effects—before involvement and through medica- to the inpatient pharmacy sec- administering pharmacologic tion use guideline development and tion—and with good results. Poten- therapy to patients. enforcement. Recent budgetary tial opportunities for future use of shortfalls were quelled and reduc- these technicians include: expan- REFERENCES 1. Bond CA, Raehl CL, Franke T. Clinical pharmacy tions in force avoided through the ded order entry, patient education services and hospital mortality rates. Pharma- successes of a multidisciplinary (provision of written medica- cotherapy. 1999;19:556–564. 2. Sterne SC, Gundersen BP, Shrivastava D. Devel- cost-effectiveness committee. Our tion information, blood glucose opment and evaluation of a pharmacist-managed institution’s medication costs per meter training, diabetic foot asthma education clinic. Hosp Pharm. 1999;34:699–706. enrolled patient are among the low- checks, metered dose inhaler train- 3. Mutnick AH, Sterba KJ, Peroutka JA, Sloan NE, est in the VHA. ing), prescriber education (comput- Beltz EA, Sorenson MK. Cost savings and avoid- ance from clinical interventions. Am J Health Clinical pharmacy has imple- erized documentation of allergies, Syst Pharm. 1997;54:392–396. mented and coordinated a struc- adverse drug reactions and over- 4. Joseph AM, Neal D. Managing cold and flu: A protocol for the nurse and pharmacist. Fed tured polypharmacy program. the-counter and alternative medica- Pract. 1999; 16(11):23,27,28,51. Pharmacists have been able to ex- tions), assistance with research 5. Koch KE, Weeks A. Clinically oriented pharmacy technicians to augment clinical services. Am J pand their influence in disease and investigational drugs (inven- Health Syst Pharm. 1998; 55:1375–1381. state management, telepharmacy, tory, data entry, file maintenance), 6. Hepfinger CA, Cohn-Oswald LA. Clinical phar- macy interventions in an ambulatory care set- and research and to expand dis- and pharmacoeconomic assign- ting: Implications for improved patient care and ease state management programs ments (database support manage- medication cost savings. Poster presented at: ASHP Clinical Midyear Meeting; December 11, in primary care. ment, data pulls on costs and 2002; Atlanta, GA.

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