James C. McAllister III, MS, FASHPPharmacy Times Editor, Health-Systems Pharmacy Section

Mr. McAllister is a health-systemsconsultant based in Chapel Hill,North Carolina.

Several excellent educationalsessions related to intravenous(IV) therapy were featured atthe American Society of Health-SystemPharmacists (ASHP) Midyear ClinicalMeeting in December, prompting me toreflect upon how much more diverse,sophisticated, and complicated IV therapyhas become during my career.

The IV route is used much more frequentlynow than it was 20 years ago,with virtually every hospitalized patientreceiving IV therapy at some point duringhis or her admission. Similarly, theIV route is increasingly used in theambulatory care environment and indiagnostic and procedure labs. I amtroubled, however, that pharmacy departmentsconsider IV solutions thathave not been compounded in theirpharmacy to be products for whichthey are not responsible.

Medical and technological advances,as well as market forces, havecontributed to the evolution of IV therapy.IV chemotherapy, which hasbecome much more sophisticated, isroutinely administered in ambulatorycare environments. New IV packagingextends well beyond a limited numberof intermittently administered antibioticsto include a broad array of basesolutions with electrolytes and otheradditives.

Certain intravenously administereddrugs are available exclusively throughspecialty pharmacy distributors overwhich pharmacy departments have littleor no control. Intelligentinfusion devices, which havebeen shown to reduce dosingerrors associated withIV infusions, include druglibraries with minimum/maximum dose-checkingfunctionality and monitoringcapabilities using wirelesstechnology. Hospitalsand their departments ofpharmacy have investedheavily in technologies thatare intended to improvevarious facets of the medicationuse process. Giventhese advancements, it isunderstandable that pharmacydepartments have prioritizedtheir resources tomaximize quality, efficiency, and cost-effectiveness.Distribution of IV basesolutions is often relegated to materialsmanagement or a similar department,and routine monitoring of use isreserved only for those patients whohave fluid and electrolyte challenges.

As a result, we largely ignore IV solutionswithout additives as a commodityfor which we have little responsibility.In some hospitals, pharmacy departmentshave allowed IV solutions withpremixed electrolytes to be issued byother departments or purchased onstanding purchase requisitions by procedurelabs and other departments;administration is at their discretion, withoutoversight.

All IV drugs and solutions are deemedlegend drugs for good reason, not onlyby the FDA but also by the Joint Commissionon the Accreditation of HealthcareOrganizations and ASHP in theirstandards and guidelines. The IV routeof administration is implicated in fartoo many serious medication errors. Isuspect that the underreporting phenomenonis prevalent with this groupof drugs and the diverse environmentsin which they are used.

It is time for pharmacy to assumeresponsibility for all IV therapy in allenvironments. This does not mean that

 IV fluids must be dispensed by thepharmacy department.We must designand implement system safeguards,however, to ensure that these drugs areadministered safely and appropriately.IV solutions are medicines; they are notcommodities. We must not let thetrend of seeing them as such continueor proliferate. What do you think?

Articles

With the widespread use of the intravenous route in many settings, safeguards are needed.

Editor's Note: Are Intravenous Fluids Becoming a Commodity?

Mr. McAllister is a health-systems consultant based in Chapel Hill, NC. 

Last month I wrote a commentary on pharmacy's focus on quality and described study results revealing the great opportunities now available for us to help lead quality improvement efforts in the ambulatory care environment. I recently attended a conference of the North Carolina Association of Pharmacists and listened to a presentation by Laura Cranston, executive director of the Pharmacy Quality Alliance (PQA). The PQA is a coalition of many organizations, including most of our profession's membership organizations. Its mission is to promote standardized performance indicators to measure the quality of services provided to outpatients, primarily in ambulatory and community settings. 

Cranston presented a compelling argument for PQA's mission, including a quote from Mark McClellan, MD, PhD, former Centers for Medicare & Medicaid Services administrator. He appropriately recognized that if pharmacy wants to be compensated for its medication therapy management (MTM) services, a systemized way to deliver MTM services&#8212;and clearly demonstrate the results&#8212;is essential. 

Performance measures in retail settings (and earlier, in hospital settings) traditionally have focused on statistics, such as prescriptions filled per pharmacist shift, generic conversion rates, and customer satisfaction, which is convenience-oriented. Instead, we should consider measuring patient medication adherence, as well as the value patients receive from counseling services. We also need to assess whether patients are achieving pharmacotherapeutic goals as defined and supported by evidencebased medicine. 

This expectation for documenting the quality of pharmacy services presents an opportunity for the entire profession to elevate its societal mission and publicly demonstrate its value in new and meaningful ways. Meeting this challenge, however, requires a widespread commitment on the part of all of us, regardless of our practice setting. Health-system pharmacists have been compelled to document and demonstrate quality improvement initiatives, not only by their organizations, but by accreditation agencies, and, more recently, by public and private payers. We have plenty of room to improve, but we also should offer assistance locally to our ambulatory pharmacy colleagues, as they develop strategies to demonstrate and document the quality of the services they provide. We can be helpful in reassuring them of the positive aspects of quality measurement, as well. 

The PQA represents a collaboration of 60-plus stakeholders who have embarked on a deliberate, methodical, and consensus-based process to develop reliable quality measures&#8212;an effort that should reflect positively on our capabilities and value. As part of this process, beginning in 2008, the alliance intends to launch demonstration projects designed to validate its efforts to develop effective and meaningful measurement tools. PQA is guided by a steering committee representing 15 organizations. In her role as executive director, Cranston, a committed pharmacist herself, is coordinating these efforts, which can have a very positive impact on our profession. 

The effort may meet with resistance from within the profession, and it will require work with boards of pharmacy, professional associations, payers, and others. Finally, and most importantly, we must be diligent to ensure that this important initiative is understood and valued by the patients we serve. I encourage you to visit the PQA Web site (

) and monitor its progress, if not volunteer to help. Will you?

Documenting the quality of pharmacy services presents an opportunity for the entire profession to demonstrate its value in new and meaningful ways.

Editor's Note: Efforts Under Way to Document Quality of MTM Services

In his April 2007 Editor’s Note, Fred Eckel urges payers to restructure financial incentives for pharmacies. He suggests that a shift from the traditional dispensing-based approach would enable pharmacists to focus their energies on activities that result in drug misadventures and optimizing therapeutic outcomes. I suspect that overall health care costs would be reduced as well, as evidenced by initiatives such as the Asheville Project. Mr. Eckel refers to the emerging medication management programs as a glimpse into our possible future and concludes that such activities should lead to a more secure professional future, thus increasing our value to the people we serve.

The majority of our readers are aware of the National Provider Identifier (NPI) number issue. The NPI concept was part of the Health Insurance Portability and Accountability Act legislation enacted in 1996 and is intended to establish electronic data exchange, establish unique identifiers for individuals and corporate providers, and protect security and privacy of patient information. The mostexciting dimension of the NPI legislation is that pharmacists are specifically identified as potential providers who are authorized to apply for an NPI number.

NPI numbers are, or will be, essential for any pharmacist who is eligible to submit a bill for cognitive services. It will be essential for all pharmacy practitioners who perform medication therapy management services, as well as related activities in medication management, but it does not broaden the scope for what pharmacists can bill. For pharmacists who practice in health systems, only those who practice in ambulatory care settings will need an NPI number initially.

So, why should you apply for an NPI number? I believe that, if a large number of pharmacists apply for a number, a signal will be sent that we as a profession believe we have more to offer than traditional roles recognized by the lay public. It also prepares us for the possibility that, like our colleagues who practice in an ambulatory setting, health system pharmacists have the skills and interests to provide valuable (and time-consuming) services that improve drug therapy outcomes. Many practitioners already have practices that are more patient-focused and only loosely affiliated with the dispensing activities for which hospitals bill. We must continue to be able to bill for the essential and equally important drug distribution and control functions on which our profession is based. Hospitals are being held accountable by the Centers for Medicare & Medicaid Services for certain core measures such as smoking-cessation initiatives, vaccination programs, post—myocardial infarction therapy, and much more. Such activities are a perfect fit for our training and interests. It seems inevitable that we will be compensated for acute care drug therapy management activities. If such an opportunity knocks, those of us who have NPI numbers can begin billing without looking for a vehicle to do so.

As I have told my staff, application is easy and free, and you receive your number in a timely fashion. To learn more about the NPI issue, I suggest that you visit the Web site of the National Plan and Provider Enumeration System, 

. If you want to apply for your own NPI number, go to 

https://nppes.cms.hhs.gov/NPPES/Static Forward.do?forward=static.npistart

. It could be a part of an exciting journey. (P)T

Mr. McAllister is director of pharmacy at University of North Carolina (UNC) Hospitals and Clinics and associate dean for clinical affairs at UNC School of Pharmacy, Chapel Hill.