Advancing the Role of the Pharmacy Technician: a Systematic Review

SCIENCE AND PRACTICE

Journal of the American Pharmacists Association 58 (2018) 94e108

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Journal of the American Pharmacists Association

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REVIEW Advancing the role of the pharmacy technician: A systematic review

* Ashlee N. Mattingly , T. Joseph Mattingly II article info abstract

Article history: Objectives: To summarize the findings of a literature search on advancing the role of pharmacy Received 26 June 2017 technicians, including the types of training identified and the potential costs and benefits to Accepted 29 October 2017 both the technician and the pharmacy. Data sources: A literature search of Scopus, Embase, and Medline was conducted on January 11, 2017. Study selection: Original research, research reports, case studies, or association reports were included for review. Articles were considered to be relevant based on identification of an advanced pharmacy technician role or addressing additional training/education for technician functions. Data extraction: A standard data extraction form was used to collect study authors, article title, year published, journal title, study design, brief description of methods, primary outcome measures, advanced technician roles identified, additional education or training addressed, and additional costs and benefits identified in each article. Results: A total of 33 articles were included for full review and data extraction. Study design varied, with 17 (52%) quantitative, 1 (3%) qualitative, 5 (15%) mixed-method, and 10 (30%) case study designs. Seventeen (52%) of the studies included were published after 2006. The mechanism of training was primarily through supervised on-the-job training, allowing technicians to assume administrative-based positions that facilitated a pharmacist-led clinical service, with either the pharmacist or the pharmacy receiving the greatest benefits. Conclusion: Although the literature supports technicians performing advanced roles in the pharmacy, resulting in either improved patient outcomes or opportunities for pharmacists to engage in additional clinical services, the benefits to the technician were primarily indirect, such as an increase in job satisfaction or a more desirable work schedule. If a technician is to take on additional roles that require completion of a formalized training or educational program, benefits that are more tangible may help to inspire technicians to pursue these roles. © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Both the American Society of Health-System Pharmacists Technician Certification Board (PTCB).1,2 The ASHP statement (ASHP) and the American Pharmacists Association (APhA) further delineates among the competencies of an entry-level have supported the standardization of education, training, and technician and acknowledges that with additional training, certification requirements for entry-level pharmacy techni- technicians can take on advanced roles.1 These advanced roles cians, including completion of a training program accredited include “tech-check-tech,” purchasing or fiscal management, by ASHP and the Accreditation Council for Pharmacy Educa- supervisory positions, assistance with medication history, tion and national certification through the Pharmacy medication therapy management, immunizations, quality improvement, hazardous drug handling, patient assistance programs, education and training, community outreach, drug Disclosure: The authors declare no conflicts of interests or financial interests in any product or service mentioned in the article. This includes grants use evaluation, adverse drug event monitoring, industry, and 1 (pending or received), employment, gifts, stock holdings or options, hono- informatics. ASHP states that there may be additional raria, consultancies, expert testimony, patents, and royalties for all authors opportunities for advanced roles not included in this list. and members of their immediate families. However, training components to prepare technicians for * Correspondence: Ashlee N. Mattingly, PharmD, BCPS, University of these roles is yet to be defined. Maryland School of Pharmacy, 20 North Pine Street, Room S449, Baltimore, MD 21201. In 2010, ASHP held the Pharmacy Practice Model Initiative E-mail address: [email protected] (A.N. Mattingly). (PPMI) with the goal to “advance the health and well-being of

Advancing the role of the pharmacy technician

Objective Key Points The objective of this literature search was to summarize the Background: findings of advancing the role of pharmacy technicians, including the types of training identified and the potential After completing an advanced training program, few costs and benefits to both the technician and the pharmacy. national pharmacy organizations have clear and supportive policies on the use of pharmacy techni- Methods cians in novel positions both inside and outside of the pharmacy. Search strategy The costs and benefits of advancing the pharmacy technician are not defined. A literature search was conducted using Scopus, Embase, and Medline, including any date through January 11, 2017. The Findings: search included a combination of “pharmacy technician” OR “pharmacy technologist” AND “education” OR “training.” The Thirty-three articles were included that evaluated the search was limited to peer-reviewed articles and reviews use of pharmacy technicians in an advanced role and published in English. Search results from each database were identified the training required and subsequent costs exported to Microsoft Excel, merged, and sorted for removal of and benefits obtained from using technicians in this duplicate citations. role. The mechanism of training was primarily through Study selection supervised on-the-job training, allowing technicians to assume administrative-based positions that facil- Original research, research reports, case studies, and asso- itated a pharmacist-led clinical service, with either ciation reports were included for review. Viewpoints or com- the pharmacist or the pharmacy receiving the great- mentary papers were excluded. Articles were considered to be est benefits. relevant based on identification of an advanced pharmacy technician role or addressing additional training/education for technician functions. Initial screening of all abstracts and titles patients by developing and disseminating a futuristic practice was conducted independently by both authors to determine model that supports the most effective use of pharmacists as whether to include or exclude based on selection criteria. direct patient care providers.”3 Participants in the PPMI agreed During the abstract and title screening phase, an a priori level that “pharmacy technicians could be used more extensively to of agreement on inclusion/exclusion was set at 80%. All free pharmacists from drug distribution activities.”3 To suc- screening disagreements were reconciled through discussion cessfully implement and maintain these new services, atten- before moving to full-text review. Full-text articles were tion has been focused on the advancement of technicians and assessed for inclusion, and reasons were documented for all how they can offset the dispensing responsibilities of phar- excluded papers. macists and assist in the facilitation of these services. As a result of the PPMI, in 2013 the PTCB set new requirements to be implemented in 2020 that would require all technicians Data extraction wishing to obtain certification to complete a training program accredited by the Pharmacy Technician Accreditation Com- A standard data extraction form was used to collect study mission before being eligible for the examination.4 The authors, article title, year published, journal title, study design, implementation of this requirement was suspended in 2017, brief description of methods, primary outcome measures, fi citing the need for additional research and deliberation.5 advanced technician roles identi ed, additional education or fi fi Although there is support from national organizations for training addressed, and additional cost and bene ts identi ed the advancement of technicians, the primary focus remains in each article regardless of economic perspective used. Study on creating an environment that allows pharmacists to design was operationalized as a categoric variable, and each practice at the top of their licenses. The realization that the article was determined to be either a quantitative, qualitative, role of the technician must evolve for this to happen appears mixed-methods, or case study. to be an afterthought. The ASHP and APhA statements define the role of the technician in terms of an “aid to the phar- Results macist in providing optimal patient care”1 or “assisting the pharmacist with the delivery of patient care.”2 With techni- A total of 785 records were identified through database cians defined as support staff and the advocacy for their searches, resulting in a total of 549 unique articles after du- advancement merely to facilitate the progression of the role plicates were removed (Figure 1). Agreement was reached of the pharmacist, the question remains as to who is the independently for 507 out of 549 articles (92%) concerning beneficiary from the advancement of technicians. If addi- inclusion/exclusion based on abstract and title screening. tional training is needed to prepare technicians for advanced Disagreements were discussed until full agreement was roles, the scope and cost of this training as well as the ben- reached, resulting in 27 (55%) of the 42 articles added to full- efits gained from advancing the role of the technician must be text review. During abstract screening, 347 (63%) of the arti- defined. cles were excluded owing to lack of relevance to pharmacy

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Figure 1. Summary of literature screening and selection (PRISMA 2009 ﬂow diagram).

technicians, being commentary only, or failure to identify an and 10 (30%) required previous training. The remaining 3 advanced role or added education/training for technicians. training mechanisms included informal on-the-job training Of the 202 articles remaining, an additional 169 (84%) were led by the pharmacists or other technicians, formal technician excluded during full-text review owing to lack of relevance to training programs by and apart from the employer, and test- advanced pharmacy technicians or technician education/ based certification to demonstrate competency after educa- training (86/167) or being commentary only (83/169). A total tion. Twenty (61%) required a formal training program, 19 of 33 articles were included for full review and data extraction. (58%) required an informal on-the-job training program, and Study design varied, with 17 (52%) quantitative, 1 (3%) quali- 12 (36%) required test-based certification. The majority of the tative, 5 (15%) mixed-method, and 10 (30%) case study de- articles, 21 (64%), required a combination of training signs.6-38 Seventeen (52%) of the studies included were mechanisms. published after 2006. Thirty-two (97%) of the articles included Both direct and indirect costs and benefits were identified were published in journals with a primary audience of phar- in 27 articles (82%). Direct and indirect costs included the time macy practitioners, with the only nonpharmacy journal being for both the technician and the educator to complete the the British Journal of Cancer. training (2 [7%]), supplies included in the training (4 [15%]), Various advanced roles for pharmacy technicians identified and the cost to cover routine operations in the pharmacy through the review include increased administrative, clinical, during the training when appropriate (2 [7%]). Indirect bene- dispensing, or leadership responsibilities. Nineteen articles fits to the organization of advancing technician roles and re- (58%) identified administrative roles, 15 (45%) identified clin- sponsibilities were identified as cost savings through potential ical roles, 12 (36%) identified dispensing roles, and 3 (9%) elimination of pharmacist positions (4 [15%]), increase in po- identified leadership roles. Sixteen articles (48%) identified tential revenue through expanded clinical services (9 [33%]) more than 1 advanced role, with 4 (25%) identifying admin- and improved efficiency (9 [33%]), improved patient adher- istrative, clinical, and dispensing roles, 7 (44%) identifying ence (3 [11%]), and improved satisfaction from other de- administrative and clinical roles, 2 (13%) identifying adminis- partments (2 [7%]) and patients (7 [26%]) in pharmacy services. trative and dispensing roles, 2 (13%) identifying administrative Direct and indirect benefits to the pharmacist and technician and leadership roles, and 1 (6%) identifying administrative, were identified throughout, such as increases in technician dispensing, and leadership roles. wages (7 [26%]), improved job satisfaction for technicians (6 Six training mechanisms were identified. Of these, 3 were [22%]) and pharmacists (2 [7%]), a stronger career ladder for baseline qualifications that a technician must have to be technicians (3 [11%]), and an increase in confidence of the considered for the role. Nine articles (27%) required certifica- technician in their knowledge and ability to perform a tion, 8 (24%) required a minimum amount of work experience, particular skill (4 [15%]; Table 1).

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Advancing the role of the pharmacy technician

Table 1 Qualitative data extracted from all included studies

Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/benefits identified outcome(s) Schafheutle EI, Jee SD, 2017 Mixed methods Fitness for purpose of Pharmacy technician in 2 years' work Higher salary for Willis SC tech education and Great Britain experience in either technicians after training in U.K. community or hospital; training; higher salary knowledge-based and for technicians in competency-based hospital compared with qualifications community Bailey JE, Surbhi S, Bell 2016 Case study Describe the design, Assist in medication Certified; health systeme Allow techs to perform PC, Jones AM, et al. implementation, and review and obtaining specific training: health at the top of their experience using accurate admission med system personnel; license; positive trends technicians to improve list in hospital; reinforce program-specific in all key process transitions of care medication-related training (didactic and measures over time; education; identify interactive): faculty and positive trend in home potential social barriers staff and program visit completion rate to discharge; develop pharmacists; patient after discharge; high specific plans for communication and home visit completion patients to obtain motivational rate; positive trend in discharge meds interviewing; phone follow-up within 24 hours of medication history completion rate; discharge; schedule training; appropriate identify potential DTPs home visits and make drug disposal practices; at home visits for 84.9% reminder calls; perform basic disease of patients; coordinated medication management (signs/ targeted MTM by reconciliation and symptoms of adverse pharmacists for 104 identify potential DTPs; drug events and patients; positive trend provide follow-up worsening condition); in number of targeted documentation to safety planning training MTM contacts; pharmacist; contact for home visits; formal coordinated outpatient pharmacist for online assessments; CMRs for 33% of emergencies; conduct follow-up discussion patients; positive trend 2nd home visit; make and role playing to in number of outpatient support session assess knowledge, CMRs conducted by reminder calls and help understanding, and pharmacist; positive arrange transportation; skills; on-the-job trend in number of attend support sessions training: program participants scheduled and encourage patient pharmacists for support sessions participation; schedule CMR visits and reminder calls; assist Medicaid patients in maximizing drug plan coverage; assist physicians in obtaining prior authorization; help patients identify and use least expensive pharmacy Evans JL, Gladd EM, 2016 Case study Describe the creation of Manage pharmacists' 4 months (on-the-job Improved efficiency Gonzalez AC, Tranam a clinical pharmacy schedule (appointment supervision, interactive and productivity of S, et al. technician template, scheduling, mock patient scenarios, pharmacist and managing and written exams); increase in volume of cancellations); manage certified; orientation to patient care provided consultations (review clinical pharmacy by pharmacy team; referral, determining services; creation of initial 3 months (only 1 priority, scheduling clinical pharmacist tech): pharmacist could appointment); gather schedules; appropriate devote an additional10e metric data and consultation review 15 hours each month generate reports; and appointment to clinical services, communicate clinical scheduling; method for increase in number of pharmacy prioritizing patient pharmacist-completed announcements; care; triage or transfer encounters (240e290) coordinate clinical of care (pharmacist or per month, completed pharmacist peer review provider issue); basic an average of 90 phone process; contact familiarity with disease encounters each month patients via phone to states managed by to provide education to provide education pharmacist; review of patients; with addition about proper high-risk meds; of 2nd tech: offset 104.3 medication appropriate patient hours of pharmacist administration, storage communication skills; time, patients were

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Table 1 (continued )

Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/beneﬁts identiﬁed outcome(s)

and disposal, and chart EHR documentation; contacted within 48 review of Rx dispensing data collection and hours of receiving history and reporting; competency referral to schedule documentation in assessment appointment, increase medical record; from 41% of referrals communicate with resulting in completed other health care patient encounter to providers to coordinate 56%, decrease from 22.6 pharmacy care and days average to notify of completed complete encounter to consults; assist with 10.3 days, completed an drug information average of 193 phone inquiries; prepare encounters each month educational materials to provide education for patients and health care providers; assist with data collection Gilbert EM, 2016 Case study Describe the services Developed the role of Certified; on-the-job In 18 months, patient Gerzenshtein L offered and the roles “patient care advocate” training for navigating care advocates of the pharmacist, for pharmacy the patient's health obtained >$700,000 in students, and technicians; help to record; filling out and patient assistance; technicians overcome insurance providing clinical provide “seamless flow and payment barriers; information on prior of medication “own” a disease state; authorization forms; management services” monthly refill calls; collaborating with adherence reminder specialty pharmacists calls on insurance appeal submissions; find disease-specific patient copay assistance; “become familiar with therapies associated with treating these specific disease states” Justis L, Crain J, 2016 Quantitative Effect of pharmacy Role in cognitive Classroom training for 56% of sites improved in Marchetti ML, technicians on industry pharmaceutical the 3 MTM platforms diabetes PDC (originally Hohmeier KC standard adherence services, including used; web-based only 7/16 had a 4-star performance measures MTM and adherence training activities for score); 100% of sites (Star ratings) coaching; support tasks these platforms; hands- achieved a 5-star score on in-store training for cholesterol (originally 14/16 were 5-star, other 2 were 4- star); 100% of sites had a 5-star score for RASA measure (originally 16/ 16 were 5-star); 56% of sites improved in score Shireman TI, 2016 Quantitative Effectiveness and Calling and reminding 8 hours of training (1 h 30 minutes of tech time Svarstad BL sustainability of a patients; printing Rx self-study, 7 h joint per completed visit at protocol using profiles; setting up workshop); assist the $13.01/h; 95.4 minutes pharmacists, table and chairs; using pharmacists in making per patient of tech time technicians, and novel an automatic monitor and confirming over 6 months; $104.80 tools for adherence and to measure BPs; appointments; setting per patient for BP control in administering patient up a semiprivate BP pharmacist, tech, and uncontrolled self-report tools counseling station; tools used; $22.2 ± 16.3 hypertensive patients measuring BPs; per 1 mm Hg decrease collecting previsit tools in SBP; $60 ± 228.4 per completed by patients 1 mm Hg decrease in DBP; $665.2 ± 265.2 to help 1 more patient achieve BP control; $463.3 ± 110.7 to help 1 more patient achieve good refill adherence; decrease in SBP and DBP compared with control; increase in percentage of patients achieving BP control; increase in percentage

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Table 1 (continued )

Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/beneﬁts identiﬁed outcome(s)

of patients achieving good refill adherence; decrease in time of pharmacist-patient encounter compared with previous studies Houle SKD, Rosenthal 2014 Case study Description of 2 Admin duties: Regulated pharmacy Greater professional MM, Tsuyuki RT successful appointment technician; selected satisfaction; greater implementations of scheduling; due to experience, pharmacy efficiency progressive technician transcribing care notes conscientiousness, and with reduced facilitation of into reports for willingness to expand duplication of effort; pharmacist’s patient communication to role; mutual trust pharmacist could focus care activities in the other health between pharmacist more time on activities community professionals; drawing and tech led to requiring clinical up injections for flu expansion of roles expertise; greater clinics or travel capacity for billable medicine services consultations; completing a medication history; identifying patients for pharmacist consultation; collating dispensing records and lab results before rounds; checking Rx prepared by other techs; in-store marketing of vaccine services; phone high- risk patients to book vaccine appointments; coordinate onsite clinics with retirement homes; inventory, billing, and documentation Svarstad BL, Kotchen 2013 Quantitative Refill adherence rates Calling and reminding 8 hours of training (1 h Increase in refill JM, Shireman TI, and changes in systolic patients; printing Rx self-study, 7 h joint adherence rate during Brown RL, et al. and diastolic BP and profiles; setting up workshop); assist the intervention; decrease proportion of patients table and chairs; using pharmacists in making in SBP and DBP, and achieving BP <140/90 an automatic monitor and confirming increase in BP control mm Hg to measure BPs; appointments; setting during intervention; administering patient up a semiprivate BP increase in refill self-report tools counseling station; adherence rate after measuring BPs; intervention; lower SBP collecting previsit tools and greater SBP completed by patients reduction after intervention; patients had higher level of adherence monitoring and support by their pharmacists Reed M, Thomley S, 2011 Case study Describe a tech-check- A technician role called 6 months' experience Pharmacist still Ludwig B, Rough S tech program created a “Validated Pharmacist or PTCB; in-house self- performs a final check and implemented at an Assistant” to perform learning packet (must on 10% of doses; 90% of academic medical checking functions, score 90% on a written pharmacists agreed center commonly “tech- exam covering that they had more check-tech” material); practical time for patient care training with activities and reduced pharmacist oversight drug distribution (must complete 24 workload; 82% of hours of practical pharmacists agreed training); validation: that the program must attain 99.8% improved their overall accuracy rate for 2500 job satisfaction; consecutive doses reduction in time spent checked during 5 checking cart fill from 6 separate audits over 5 hours 5 minutes per

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Table 1 (continued )

Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/beneﬁts identiﬁed outcome(s)

separate days; errors day to 20 minutes per introduced at <0.2% (<5 day out of every 2500 doses) Pattin AJ, Powers MF, 2011 Quantitative Describe a training Nonclinical role in MTM 2-hour live session: Increase in number of Lengel AJ program for pharmacy process; identify Powerpoint techs who thought they technicians about their eligible patients; presentations; review could perform MTM role in the MTM process schedule appointments of an MTM manual services after (instructions on how to completing the training log into different program (statistically software systems); significant); increase in schedule patient number of techs who appointments; perform thought that MTM other functions; pre- services are important and post-survey for customers (not statistically significant); increase in number of techs who strongly agreed that technicians can help pharmacists perform MTM services (statistically significant); techs excused from work and paid hourly rate to attend training McKee J, Zimmerman M 2011 Quantitative Development and Advanced Practice Certified with 1 year's Pharmacist time saved, implementation of Pharmacy Technician to equivalent experience allowing for more tech-check-tech check unit doses in unit dose filling; clinical services to be prepared by other didactic training (self- implemented; technicians (“tech- learning packet); elimination of a 0.5 FTE check-tech”) competency pharmacist position; assessment (100% savings of $83,576 of accuracy rate for each pharmacist salary; annual audit; audit: increase in 500 line items in the compensation for cart fill and 100 line technician (5%); items in the automation increased job refill process) satisfaction; peer recognition; taking ownership of expanded roles Friesner DL, Scott DM 2010 Quantitative Identify aspects of Compounding oral Certified; 1-year Certified techs more technicians' medications; training program likely to compound experience, training, compounding topical (technical degree); 2- topical medications; practice setting, and medications; preparing year training program certified techs more location that influence 3rd-party billing; refill (associate degree); likely to request refill roles requests; obtaining Pharmacist-Assisted authorizations medication history; Technician Self- ordering stock; taking Instruction Module new prescriptions over the phone; counseling patients on OTC medications van den Bemt PMLA, 2009 Quantitative Frequency of Medication history; Communication skills; Decrease in patients van den Broek S, van medication and allergy medication definitions of allergic with 1 medication Nunen AK, Harbers discrepancies before reconciliation; allergy reactions; general discrepancies JBM, et al. and after history; prepare a pharmacotherapy; implementation of recommendation on pharmacotherapy of medication antithrombotic for anticoagulants reconciliation anesthesiologist; delivery of reconciled medication list, allergies, and advice on antithrombotic to anesthesiologist Mark SM, Saenz R, 2008 Qualitative Overview of how the Order entry; clinical Certified; training in 4 Decrease in turn- Yourich BE, Weber RJ role of a technician can data collection; profile of the 6 existing around time; increased be incorporated into reviews; medication pharmacy department nursing satisfaction reconciliation; deliver areas; acceptable scores with pharmacy

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Table 1 (continued )

Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/beneﬁts identiﬁed outcome(s)

the pharmaceutical meds to nurse; customer service care process establish relationships ratings on previous with nurses; answer evaluations; order phone calls from entry; 2 weeks of unit- patient care providers; based training: 1 week resolve missing with technician medication doses; (customer service discharge medication training program; counseling observational preparation; component of medication drip technician interaction rounds; emergency/ with nurses); 1 week code support; follow- with pharmacist up on charting omissions; narcotic surveillance and use of dispensing cabinets; drug use and compliance reporting; adverse drug reaction and error surveillance Scott DM, Halvorson D 2007 Quantitative Evaluation of the Pharmacy technician in Certified; 1-year Grandfathered wages, benefits, and North Dakota training program technicians had the responsibilities of (technical degree); 2- highest hourly rate pharmacy technicians year training program followed by 1-year (associate degree); graduates, 2-year Pharmacist-Assisted graduates, and PATSIM Technician Self- graduates; Instruction Module grandfathered (PATSIM) technicians had the highest gross salary followed by 1-year, PATSIM, and 2-year graduates; higher hourly rate for certified technicians Read H, Ladds S, Rhodes 2007 Quantitative Assessment of patient Drug history; drug Accredited medicines Decrease in patients B, Brown D, understanding of interactions; whether management course with chemotherapy Portlock J support medications: supplies of support (private study; study delays; decrease in baseline and second medications were days; competence in patients experiencing measurement required work-based activities in chemotherapy dose a written portfolio; reductions; decrease in OSCE); directed study support medications on patient counseling, required; decrease in chemotherapy pharmacy time to regimens for breast dispense; decrease in cancer, support mean cost of items medications, supplied to patients; identification of side decrease in technician effects, drug time; cost of training interactions, written program; decrease in examination, pharmacy time per assessment of patient resolving Rx counseling skills issues; patients rated through in-practice their level of observation understanding of support medications higher Rose D, Evans SW, 2005 Case study Describe the Technician responsible 3 years' post- Save doctor hours; Williams R implementation of a for transcribing qualification decrease in turn- technician discharge discharge prescriptions experience; MTO2 around time; fewer transcribing service grade or above; errors than when qualified accredited doctors wrote the checking technician; orders qualified medicines management technician; academic tutorial (read 2 standard operation

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Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/beneﬁts identiﬁed outcome(s)

procedures; sign indicating they understand process; read and understand the Trust’s safe prescribing procedure); supervised transcribing (transcribe 100 items and assessed: can make 1 minor but no major errors); audited regularly Hilaire ML, Powers MF, 2004 Quantitative Develop a structured Providing technical 3-hour live training Techs were paid for Kit MJ training module for assistance with BG session (technical time in training; technicians to enhance meters aspects of BG meters; confident they could training for technical information help with technical aspects of BG meters component; hands-on questions; improved experience); pre- knowledge regarding training survey; post- meters training survey; provided a manual as a reference Zillich AJ, Aquilino ML, 2004 Quantitative Knowledge and Promotion of smoking 2-hour course (tobacco- Improved knowledge Farris KB attitudes of technicians cessation interventions related health statistics; regarding smoking before and after nicotine dependence; cessation; increased attending a smoking stages of behavioral confidence to discuss cessation program change model; smoking cessation; available smoking increased perception of cessation how smoking cessation pharmacotherapies; counseling would affect clinical practice abstinence guidelines); pre- training survey; post- training survey Burnett D, Dooley MJ, 2003 Case study Develop technician Qualified cell- Aseptic chemotherapy Increased workload for Wall D involvement in the processing preparation pharmacists and manufacture of cell- technologists experience; didactic technicians while techs based therapies for the education; formal attended training; treatment of cancer training (production of expansion of service to antibody-primed allow hiring of autologous additional tech; macrophage-activated advanced knowledge killer cells; didactic and skills; development sessions (5 days); of a 6-tier pay supervised activities; structure; additional recognizing specific salary cells; washing and culturing cells; addition of stimulating drugs to activate cells); validation: demonstrate competence in compliance to standard operating procedures (gowning, washing, gloving, aseptic technique) Hobson J 2003 Case study Describe the Anticoagulant service In-house teaching Job satisfaction; implementation of an technician: accurately packs, 6 hours/pack patients have anticoagulant service interpret INR results; (hemostasis; additional time with technician calculate dose pulmonary embolism; pharmacy staff; saved adjustments; counsel pharmacology and drug ~25 hours of patients about their interactions; cardiac pharmacist time per anticoagulant; answer conditions; deep week patient queries; assist venous thrombosis; in the recall of patients thrombophilia); who fail to attend; reading list; list of tasks assist in service audits and activities; 2-hour tutorial after each pack;

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Table 1 (continued )

Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/beneﬁts identiﬁed outcome(s)

formal assessment: role-playing test, shadow staff in clinic setting, competence (had to dose 50 consecutive patients) Ambrose PJ, Saya FG, 2002 Quantitative Accuracy of trained Trained technicians to 6 months' experience Save pharmacist time; Lovett LT, Tan S, et al. technicians checking check unit dose filling unit dose pharmacists report unit dose medication medication cassettes medication cassettes; increase in job cassettes filled by other didactic training satisfaction technicians (“tech- (lectures on unit dose check-tech”) process, proper packaging and repackaging techniques, medication safety, basic pharmaceutical calculations, written exam [had to achieve 80%]); practical training (observing a pharmacist checking cassettes; hands-on experience); audited for 3500 doses: had to have 99.8% accuracy rate, monthly audits of 500 doses Leversha A, Ahlgren KL, 2001 Mixed methods Impact on patient care Identify patients Training session to Address admission Gray MJ and pharmacy staff admitted in past 24 identify issues related medication issues hours; obtain a to their encounter with promptly; ensure that photocopy of drug patients and tech referrals were therapy chart; information to provide followed up on day of interview patient about to patient about request; increase in medication supplies; hospital pharmacy’s number of patients inform patient of role seen by pharmacy staff pharmacy discharge within 24 hours of procedure; take drug admission; decrease in therapy chart and medications that are patient’s medications to needed to be supplied pharmacy for on discharge; cost verification; record on savings of $1.22 per pharmacy computer patient on discharge that patient's medications; medication is stored in pharmacists able to pharmacy; ensure address clinical issues supply of medications quicker; discharge required in ward; medications processed complete referral forms more efficiently; for patients with increase in technician questions for job satisfaction pharmacist Koch KE, Weeks A 1998 Case study Justification for and Clinical technician: Hospital technician Improved work impact of 2 clinical collect lab data, screen training program (6 schedule; expanded technicians patients, track months); basic training responsibilities; salary outcomes; clinical in pharmacy math, increase: 9%; save administrative pharmacology, overall pharmacist time: extra assistant: secretarial explanation of each 8 hours of clinical time services, manage clinical program and each day, 1e2 hours of administrative portions tech’s role; reading documentation; of clinical pharmacy materials; made rounds improved tracking projects with pharmacists; enhancing the competence measurement of the assessment pharmacists' time and impact Ness JE, Sullivan SD, 1994 Quantitative Error rates and types of Trained technicians to Certification þ 1 year Implied costs of Stergachis A errors check unit dose inpatient experience, additional training; medication drawers completion of a training benefits of replacing filled by other program (general skills

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Table 1 (continued )

Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/beneﬁts identiﬁed outcome(s)

technicians (“tech- exam, introductory verification check-tech”) session on study, pharmacists with techs comprehensive session supported by a training manual, general introdution to unit dose distribution systems, exam covering material, minimum accuracy in checking) Raehl CL, Pitterle ME, 1992 Mixed methods Clinical pharmacy Filling unit dose carts; 6 states required some Increased use of Bond CA services' relationship to filling orders for floor in-service training; 5 pharmacy technicians the use of technicians stock; managing states required high was associated with control drug inventory school graduation; 4 increased involvement were listed as higher states required 3 by pharmacists in function roles months of on-the-job patient-specific clinical training; 3 states pharmacy services; required techs to meet association between institutional higher technician use requirements and higher technician salaries Spooner SH, Britton ME, 1991 Mixed methods Evaluation of support Expanded dispensing; Technicians train Reassigning technical Erskine LM, and process for checking unit-dose technicians; entry-level tasks (savings of Verschoor BA, et al. expanding tech roles carts; front counter training tied to core $237.60/day if switch scheduling; total competencies; certain tasks from pharmacists parenteral nutrition technician jobs would to technicians; savings order entry; expanded require a higher level of of 23.76 h/day if switch decentralized roles: competency with tasks from pharmacists filling prescriptions, training; job rotation to technicians); cost of compounding, technician turnover of dispensing and $1500/technician inventorying narcotics, (savings of $1166.67 of front counter training costs/mo); scheduling, addition of 712.8 h/mo manufacturing of of pharmacist time; central venous improved job nutrition, peripheral satisfaction; cost of venous nutrition, large- implementing would volume sterile be 4.16 additional solutions, analgesic technician FTEs; cost to syringes; scheduling train, supervise, and manufacture of large- coordinate tech volume sterile functions solutions; packaging and dispensing dyes for radiology; management roles Phillips CS, Ryan MR, 1988 Quantitative Current roles, future Supportive activities Self-study Implied delegation of Roberts KB roles, preference of more frequently correspondence additional activities to training and tech delegated than program; community technicians to save recognition dispensing college based; formal pharmacist time; prefer in-house training; formal in-house college of pharmacye training programs 1st based program; formal followed by programs training at another at colleges of pharmacy pharmacy; informal on-the-job training Fillmore AD, Schneider 1986 Quantitative Cost to train Drug administration 9-week training $12,277 for phase 1 PJ, Bourret JA, program: 4 phases training; $16,903 for Caswell RJ phase 2 training; $20,382 for phase 3 training; $33,900 for phase 4 training; $1783 cost for personal acquisition; $5683 cost per trainee Mahoney CD, Gallina 1982 Case study Descriptive Liaison between 600 hours' on-the-job Creation of a career JN, Jeffrey LP pharmacy supervisor training; classroom ladder; recognition of and supportive instruction in all performance; increased personnel; determining aspects of pharmacy salary; increased

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Advancing the role of the pharmacy technician

Table 1 (continued )

Author(s) Year Design Objective(s) and Advanced roles Additional education Costs/beneﬁts identiﬁed outcome(s)

priorities for clinical services; stability in position; established production advanced training increased job procedures; training program for specialized satisfaction and continuing and more sophisticated education programs for assignments; trainees and continuing education technicians programs Hoffmann RP 1982 Quantitative Tech utilization, Different “levels of Different job Highest salary for chief training, roles, job technicians” qualification technician, lowest for requirements, salaries requirements; different data entry levels of on-the-job training; typing ability and high school graduation most common qualification; high preference for proper phone etiquette; passage of a math quiz; knowledge of medication terms; background in math; hospital pharmacy experience Jeffrey LP, Mahoney CD 1975 Quantitative Descriptive Supervision of other Formal on-the-job Career ladder; supportive personnel; training program (15 increased salary; coordinate work 40-hour weeks) recognition assignments for other technicians; training of staff Miller DE, Kendall RW, 1972 Mixed methods Interest in expanded Maintenance and repair Mostly 1-on-1 training Indirect benefits of Hynniman CE, et al. role and job satisfaction of patient care personalized based on career advancement or equipment; individual support staff upward mobility maintaining operating and scope of the new room's supply; role to support the “purchase, preparation, pharmacy operation; and distribution of authors recommend implants” the individualized training over formal training Abbreviations used: BG, blood glucose; BP, blood pressure; CMR, comprehensive medical review; DBP, diastolic blood pressure; DTP, drug therapy problem; FTE, full-time equivalence; MTM, medication therapy management; MTO2, medical technical officer grade 2; OSCE, observed structured clinical examination; OTC, over-the-counter; PDC, patient-delivered care; PTCB, Pharmacy Technician Certification Board; RASA, renin angiotensin system antagonists; SBP, systolic blood pressure.

Discussion of pharmacy service is to provide patient care and optimize medication delivery, organizations should consider whether Roles they are underutilizing technicians who are capable of performing more patient care activities. The role of the pharmacy technician was typically limited to Three articles identified roles in positions that require pro- one that does not require professional judgment, and this is fessional judgment. Read et al. discussed the use of a pharmacy supported by the ASHP statement identifying that advanced technicianeled outpatient breast cancer clinic,21 and Hobson technicians are able to assist in the delivery of clinical services. used technicians to dose warfarin in an outpatient anti- The roles identified in the literature are consistent with tech- coagulation clinic26; both studies were performed in the United nicians performing administrative positions, such as managing Kingdom and reported favorable patient outcomes. The third patient appointments7,8,11-13,15,26 and pharmacy consulta- study, conducted in a preoperative screening clinic in the tions,8,29 administering patient self-report tools,11,13 and Netherlands, used technicians to perform medication recon- billing and documentation of vaccine administration.12 There ciliation and to prepare a recommendation for the anesthesi- is also support for using technicians to collect a comprehensive ologist regarding discontinuance of any antithrombotic before medication history7,12,17,18,21,28 and to collect clinical data surgery.18 These studies support using technicians in clinical needed to appropriately dose and monitor medica- positions beyond data collection and may help to conceptualize tions,8,12,19,29 but this information is reported to the pharma- additional advancement opportunities in the United States. cist who then evaluates and makes a clinical recommendation The literature also identified roles in which technicians to the health care team. Although this may be seen as used their experience to perform positions outside of the advancement from the traditional dispensing roles, if the aim pharmacy. For example, Burnett et al. identified the use of

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A.N. Mattingly, T.J. Mattingly II / Journal of the American Pharmacists Association 58 (2018) 94e108 pharmacy technicians with experience in chemotherapy organization. Training provided by employers may focus on preparation as cell-processing technologists in the manufac- the needs of the organization and are potentially less likely to ture of cell-based therapies for the treatment of cancer,25 and consider career enhancement as a primary outcome for the Fillmore et al. evaluated their use as drug-administration technician. In addition, practitioners providing the training technicians.34 Technicians can also serve a role in assisting may lack skills as educators, limiting the effectiveness of patients with insurance and cost barriers.7,9 Navigating the knowledge transfer. health care system can be an overwhelming and confusing task for patients. Technicians engaging in the navigation of fi these complexities can assist patients in obtaining medica- Cost/bene t tions that they otherwise would not have been able to receive. Gilbert and Gerzenshtein found that by integrating pharmacy Several costs to either the pharmacy department or the technicians in an outpatient infectious disease clinic, they individual technician must be weighed against the potential fi were able to assist patients in obtaining more than $700,000 bene ts of advancing the role of the technician. One such cost 21,30,32,34 from patient assistance programs.9 is the training program. Depending on the complexity One area that appeared to be lacking in the literature was of the new role, the training required and the subsequent cost fi the use of pharmacy technicians in managerial or supervisory will vary. Fillmore et al. identi ed in 1986 that the cost to the roles. The ASHP position statement supports the use of tech- pharmacy department to train 1 pharmacy technician to 34 nicians in this capacity, but only 3 articles reviewed identified perform a drug administration role would be $5683, and £ using technicians in a management role,32,35,37 all of which Read et al. in 2007 reported a training cost of 1955 to prepare were published before 2000. Those articles primarily used a technician to lead an outpatient clinic for breast cancer pa- 21 technicians to supervise other support staff35,37 and to train tients. Few articles evaluated the full costs of advanced new technicians32,27; none of the articles reviewed used technician training or whether the technician should be technicians in formalized managerial or decision-making po- responsible for a proportion of the costs. sitions. The 2016 Law Review released by the National Asso- Scott and Halverson in 2007 evaluated the salaries of ciation of Boards of Pharmacy identified that only 8 states pharmacy technicians in North Dakota and compared the level require that at least 1 pharmacy technician serve as a member of training with the reported salary. They found that grand- of the board of pharmacy,39 limiting the impact they can have fathered technicians with no formal training reported the on the evolution of their role or the practice of pharmacy. highest salaries at $13.11/hour compared with technicians who completed either a 1-year certificate program or a 2-year Associate in Applied Science degree. Marginal increases ($0.10 Training to $0.30/hour) were associated with each level of training if the technician became certified. These results imply that work Several articles identified that adequately trained phar- experience and tenure with an employer have the greatest macy technicians can be used in a more extensive capacity, but impact on salary, not the level of formalized training what constitutes adequate training is still undecided. In completed.20 contrast to the training requirements outlined by ASHP1 and The APhA statement encourages the development of APhA,2 common prerequisites for consideration for a position compensation models that promote sustainable career oppor- included certification7-9,14,16,17,19,20,30 and a minimum amount tunities.2 However, the trend appeared to focus on benefits of previous work experience.12,14,16,17,20,22,27,30 Five of the resulting from an increase in pharmacist time8,12,14,16,19,26-30,32,33 articles12,21,22,26,30 required technicians to have completed a resulting in an expansion of services,25,29 greater pharmacy formal educational program; however, 3 of those efficiency,7,8,11,12,19,21,22,28,29 andimprovedpatientout- articles21,22,26 were based in the United Kingdom, and comes.7,11,13,18,22,28 An increase in salary was identified in only 1 article12 involved technicians in Alberta and British 7 of the articles reviewed,6,16,25,29,35-37 and only 2 articles Columbia, Canada. Only 1 article30 published in the United monetized the increase, 1 with a 5%16 and the other a 9%29 States required technicians to have completed a board of increase. Nonmonetary benefits were identified, such as an pharmacyeapproved training program to be considered for increase in job satisfaction,12,16,26,28,32,35 a more desirable work the advanced role. None of the articles required technicians to schedule,29 and increasing the knowledge base of techni- complete an accredited technician training program. cians.15,23,29 These incentives may offer additional motivation for In 1988, Phillips et al. surveyed pharmacists-in-charge in current technicians to learn and grow but may not be a strong both community and institutional pharmacies in Tennessee incentive to recruit the best employees into the field or to and found that formal on-the-job training programs were the support a longer career plan with a stable financial trajectory. preferred method of training.33 Although the content of each Consideration for technician advancement could follow the program differed according to the varying knowledge path of other allied health technologists and technicians. For and skills required to perform the specialized roles, the results example, dietetic technicians must either complete an of that research were consistent with the results of several accredited program or obtain a bachelor degree and pass a other studies, in which technicians were trained via an national credentialing examination.40 Technicians are then in-house didactic component,7,10,11,13-16,18,21-27,29,30,34,35,37 able to obtain additional certifications to allow them to supervised on-the-job training,6-10,14,18,19,21,22,25-27,29,33-37 and advance their career. Another example is dental hygienists. a competency-based examination.6-8,14,16,21,22,25-27,29,30 According to the American Dental Association, dental hy- Although on-the-job training may be adequate in some gienists are required to obtain an associate degree from an cases, it is difficult to replicate and reproduce to ensure that accredited program, pass a licensing examination, and receive knowledge and skills are transferable outside of the a license from their individual state board. Hygienists then

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Advancing the role of the pharmacy technician have the opportunity to further their education by obtaining the beneﬁts to the technician were primarily indirect, such as bachelor and master degrees,41 and in 2005 the American an increase in job satisfaction or a more desirable work Dental Hygienists' Association recommended the creation of a schedule. If a technician is to take on additional roles that doctorate in dental hygiene to further advance the profes- require completion of a formalized training or educational sion.42 These and other allied health professions provide a program, beneﬁts that are more tangible may help to inspire potential outline for a path forward to advance the role of the more technicians to pursue these roles. pharmacy technician.

Limitations References

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