Here's how one hospital prepared for decentralized pharmacy change
Technology ushered in first changes
In some ways, recent technological changes and breakthroughs have laid the foundation for a decentralized hospital pharmacy.
When the Oregon Health & Sciences University hospital and clinic of Portland, OR, moved to an electronic health record (EHR) and implemented provider order entry forms in the majority of its units, the groundwork was laid to move pharmacists out of the central pharmacy and into hospital units, says Jennifer E. Tryon, PharmD, MS, an assistant director of pharmacy.
"Before that we'd wait for orders to be faxed to us, and then we'd review them," Tryon says. "Now we can review them from anywhere in the hospital by using laptop computers."
One of the reasons why hospital leaders want to move pharmacists to the unit is so they'll transition from being reactive, waiting for orders to be written, to being on teams where they can be proactive and have more influence over how prescriptions are written, she says.
"Pharmacists can help physicians pick the best medication dose for patients," she adds.
"This change is much more time-efficient, and it's better for patients," Tryon says.
"My dream is that when a patient is admitted to the hospital and asks, 'Where's my nurse?' He'll also ask where his pharmacist is," she says. "If patients have questions, they can meet with a pharmacist, and the pharmacist will review their new medications with them and tell them what to expect."
Pharmacists also will go on rounds and participate in patient education.
"We talk a lot in hospitals about evidence-based medications," Tryon says. "We can help educate pharmacists, residents, nurses, and other providers about medications and serve as a resource for not only the patient, but for the rest of the health care team."
The transition to a decentralized pharmacy model has been taking place over the past few years, during a time when there has been a critical pharmacist shortage, she notes.
"When I first came here three years ago, there were an exorbitant number of shifts that we had difficulty filling," Tryon says. "We were in more of a reactive mode and waiting for orders to be faxed to us, and we couldn't recover from our order volume."
There had been satellite pharmacies that the hospital decided to close and centralize because of the pharmacy manpower shortage, she adds.
"Then in April, 2008, we went live with a new computer system, an electronic health record," she explains. "Then in June, 2008, we implemented provider-ordered entry for all areas except oncology and a few others."
Now a year later the hospital is training staff as part of a goal to decentralize the pharmacy and move pharmacists to units where they'll participate in clinical care.
"It's moving fairly fast, incorporating change in clinical practice," Tryon says.
Here's how the hospital has handled the transition process:
• Hospital leaders provide communication and support for jobs that are changing. "You need to have trust in your team and leadership," Tryon says. "Your teammates need to feel that we're going to work through this, and they won't be hung out without any information."
Everyone who is impacted by the transition to a decentralized pharmacy will need to know how the change will impact them personally.
For instance, the Oregon Health & Science University hospital's transition changed the way pharmacy technicians did their jobs, Tryon notes.
"We used to have technicians input the order," she says. "They'd enter the order the physician wrote, and then the pharmacist would be the third one to check it and make the final verification that the order makes sense after reviewing the patient's profile."
When the hospital switched to medication provider-ordered entry, there was no longer a need for technicians to be part of the medication entry process. The orders went directly to pharmacists, she explains.
"So we transitioned our technician roles into other areas and functions, including a technology-optimization piece with controlled substance monitoring," Tryon says.
"A lot of hospitals are looking at creating a clinical role for technicians, including having them help locate missing medications," she adds.
Technicians also could go through intensive care units (ICUs) and make certain patients have their next IV drip ordered, and they could work in a customer service center, answering routine phone inquiries, Tryon says.
"Any medical question could be relayed to a pharmacist, but by having a technician answer many of the calls we can decrease interruptions of pharmacists," she adds.
Some hospitals when decentralizing their pharmacies might choose to reduce their pharmacy technician workforce. But for others, it works better to reallocate technician resources, Tryon says.
• Provide adequate training. The key is to train staff in all of the processes and technology necessary for the transition.
Each pharmacist at Oregon Health & Science University hospital will shadow an experienced clinical pharmacist, following a training list, Tryon says.
"Then at the end of two days they review that list with their manager to make sure they're comfortable with it," she says.
For pharmacists who will be moving to oncology, critical care, and some areas of pediatric medicine, there will be more specialized training, she adds.
"After pharmacists pass their competencies, there is a two-week training period where they essentially work as though they are residents, side-by-side with a pharmacist," Tryon says. "Then directly following that two-week period there's another two-week period where they serve as a main pharmacist, with a second pharmacist to back them up."
The training was designed to be a condensed version of the pharmacy residency model, Tryon says.
The hospital's central pharmacy pharmacists have a wealth of experience and great understanding of medications, but they need to become comfortable with what clinical practice is, Tryon says.
"We've put a lot of energy into what the system is and what the change will be," she says. "We tried to put the actual system change in writing, and we do diagrams of our current state versus our future state and have come up with a list of how it is different."
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