Stephen F. Eckel, PharmD, MHA, BCPS, FCCP, FASHP, FAPhA

As I travel around the country and talk to fellow health-system pharmacists, I observe many who are tired. The stress and pace of clinical and administrative positions are relentless, not allowing time for recovery, planning, learning, and organization. Many individuals feel like they go from one crisis to another.

Although pharmacists are medication experts and have unique insights into the medication-use process in their organizations, it doesn’t always feel like others think we know the most or that we have control of decisions for our departments. Instead, we sense that individuals external to the pharmacy department influence what we do and how we do it. If that’s how you feel, here are a few thoughts on how to eventually take control and win at your own game.

 A lot of data are being generated, but the information we need for success is either too hard to get or overwhelming to comprehend. Although accessing, formatting, and interpreting data can be difficult and time-consuming, it is difficult to argue against compelling data. All departments should be investing in and training individuals who can access various data streams and display them for decision-making purposes. The process of learning your organization’s data usually illuminates areas that either are not efficient or have opportunities for improvement. Being able to identify and resolve these issues before others tell you to do so will go a long way toward giving you control of departmental decisions.

Leadership positions are not for the faint of heart.

 Unfortunately, we have too many managers in leadership positions. These individuals work hard to sustain the status quo. Instead of working hard and desiring to grow the department to take on new responsibilities, these individuals are comfortable or feel stretched by their current breadth of activities. True leaders are attempting to do more, whether it is extending into new areas or performing current responsibilities better. There is risk associated with desiring to do more, and it requires more work. If a pharmacist is already feeling overwhelmed and exhausted, why would he or she want to do more? However, I would argue that there is as much risk in managing the status quo. By demonstrating leadership by proposing to your organization new opportunities and then delivering on them, you will gain additional confidence in your skills and show a desire to improve patient care. If choosing the status quo is the preferred path, the potential for individuals outside your department to give direction increases as the pharmacy landscape evolves.

 When things get busy, the first item that drops from our schedules is time for planning. It is hard to justify taking time to plan when meetings appear to consume your day or the top priority is responding to the day’s emergency. At the end of the week, the time that was lost for reflection was never regained. After repeating this cycle frequently, an individual loses the opportunity to reflect and plan, and act upon what comes from this time. Whether you are a clinician or have an administrative position, you cannot give your best to patient care over the long term without taking time for reflection and planning. Although it may be difficult to justify this time when you are on the clock, you cannot be the best pharmacist, change agent, and leader without consistent reflection and planning.

Health care will only get busier and more demanding in the future. Taking the steps outlined here can help us to win at our own game by enabling us to anticipate future pressure and issues, and to respond before outside forces make us act.

I would appreciate any insights and experiences you might have on this perspective. Let me know what you think by e-mail at seckel@unc.edu or follow me on Twitter at @stepheneckel.

Stephen F. Eckel, PharmD, MHA, BCPS, is associate director of pharmacy at the University of North Carolina (UNC) Medical Center and clinical associate professor at the UNC Eshelman School of Pharmacy.

Articles

Although pharmacists are medication experts and have unique insights into the medication-use process in their organizations, it doesn’t always feel like others think we know the most or that we have control of decisions for our departments.

Winning at Our Own Game

If you have ever attended a sales presentation by a software or technology vendor, you have probably heard the term “plug and play” or “a simple interface.” Either term usually refers to the standalone program the vendor is promoting for easily connecting to the information technology (IT) system of an organization. Unfortunately, connecting to the IT system never seems to be easy when the technology is installed. History shows that implementation takes more time and resources than originally planned, pharmacy’s specific needs might not be everyone else’s priority in an organization, and the vendor may say something like “We have never seen this before” when installation of the program doesn’t go as planned.

The pendulum has definitely shifted from a focus on “best-of-breed” IT systems to enterprisewide IT systems. However, we should not be dismayed by our past experiences or current perspectives in trying to garner support for standalone technologies. Although the benefits of having one system are noted, it’s hard for large technology companies and systems to create at the pace of innovation in health care and to have knowledge and expertise in all the various niches of pharmacy. Therefore, we cannot avoid selecting, installing, and building interfaces with standalone products.

It is important that we stress our need for integration of all systems, with free flow of data through robust interfaces (interoperability). Although it is sometimes easier to avoid working to generate support and resources for a technology, or not to interface it at all, this is a bad decision in the long term. Interoperability is the future of health care technology and the activities of pharmacy departments, and is essential for optimal patient care.

For pharmacy to take full advantage of the future interoperability of IT systems, the following needs to be considered:

We need to use real-time data for making patient care decisions.

 Health care has been slow to fully utilize data in robust decision making for managing patients and the efficiency of operations. Much of the reason for this is a lack of access to data or not having individuals who can present it for optimal utilization. If we are not intentional in demonstrating the need, or the opportunity, for how data can be used for decision making, we cannot obtain positions for individuals who have data analytic skills.

We need to have technology work for us, instead of us having to work for technology.

 I hear of many scenarios in which departmental operations have to work around limitations and capabilities of a technology. This is concerning because we are the customer and the technology should be customized to our needs. Although there might be times when a workaround is a safety issue and, therefore, should not be allowed, in many other situations, pharmacy is held back by the limitations of a technology and an organization’s lack of interest in being flexible. This is a travesty we should not tolerate.

We should not fear standalone technologies.

 I believe an enterprisewide system cannot meet all our professional needs. Therefore, we need to be willing to strategize and push for boutique systems that can make our operations more efficient. This requires boutique system providers to integrate into our operations and fit into legacy systems. Failure to do this will limit overall adoption success and create opportunities for technologies that can work.

Technology is not going away, as we continue to automate manual systems and push data and information to the point of decision making. We need to utilize this information to provide optimal services and ensure that our patients are getting access to the highest-quality care.

I would appreciate your insights and experiences regarding this topic. Let me know what you think by e-mail at seckel@unc.edu or follow me on Twitter at @stepheneckel.

The Opportunity of Interoperability

As the current president of the North Carolina Association of Pharmacists (NCAP), I have needed to learn about practices and aspects of pharmacy different from those included in my current work setting or for which I was trained. As a merged association, NCAP has the opportunity to represent all aspects of the profession. To be effective in my position, I need to understand what is happening in the breadth of pharmacy. Therefore, I frequently challenge myself to consider opportunities to continue advancing the role of the pharmacist in North Carolina. Although some individuals consider our state progressive in terms of pharmacy practice, there are still many opportunities for improving the care we provide our patients.

Unfortunately, these opportunities do not happen by themselves. They are the result of numerous coordinated steps. All of this is bundled in the term 

, which requires telling our stories to individuals who have the power to effect change.

Until now, I didn’t fully understand the importance of advocacy for legislative changes and never actively championed a cause. I’ve visited my representatives before, but did not participate much more than that. I now recognize I have not done my part.

The following are some lessons about advocacy that I have learned over the past year while leading NCAP. Although this list is not exhaustive, I think these points are all necessary for effecting positive change.

 Positive changes do not happen by themselves, but are the result of careful planning. Pharmacy needs to know where it wants to go and have the ability to communicate this vision to others. This is essential for building consensus from the broadest reaches of the profession. Ideally, everyone agrees with the vision and can see how patients benefit from the change.

 It is not enough to agree that a strategy is correct. A detailed plan for accomplishing a goal must be developed. This includes identifying the materials and information necessary for communicating the plan broadly, as well as the individuals who are essential for carrying out the steps.

 Nothing significant can be achieved without the support of others. Besides ensuring most pharmacists in your state agree, gaining allies from physician and nursing associations, among others, is critical.

 Although I am a person of action, I recognize that advocacy does not result in immediate success. It requires timing, communication, consistency of leadership, and patience. If there is unwillingness to persevere when it appears that a goal is not achievable, success will be difficult. Being present and consistently communicating your message goes a long way toward ensuring success.

 This is the area where I have personally grown the most in my position. Although I have tacitly supported many initiatives within our state over the years, I have not gone out of my way to assist. I recognize that if we do not have individuals willing to put in the time and effort, pharmacy practice will not keep pace with the changes occurring in the health care system. If I firmly believe that our patients deserve better than the current system, that unrest should motivate me to act until change happens. I think all of us recognize that the current health care system is not optimal and that pharmacists have knowledge and skills that can help to resolve these issues. We need to commit ourselves to help change our state and national policies that prohibit the broad use of pharmacists.

 We definitely do not do this enough in our profession and workplaces. We need to take time to thank everyone for their support and involvement in achievements. Seeing the result of our hard work can motivate future involvement when needs arise.

Although much more than the above goes into advocacy, these points are essential to the overall process. I am hopeful that all of our state and national pharmacy associations are working tirelessly to develop consensus and recommend changes that will enhance pharmacists’ ability to improve the care of our patients. They definitely deserve our best.

I would appreciate your insights and experiences regarding this topic. Let me know what you think by e-mail at seckel@unc.edu or follow me on Twitter at @stepheneckel. 

Stephen F. Eckel, PharmD, MHA, BCPS, is associate director of pharmacy at the University of North Carolina (UNC) Medical Center, and clinical associate professor at the UNC Eshelman School of Pharmacy.

As the current president of the North Carolina Association of Pharmacists, I have needed to learn about practices and aspects of pharmacy different from those included in my current work setting or for which I was trained.

The Importance of Advocacy

I wonder if health-system pharmacists who read and hear about the growing opioid epidemic react as if this is someone else’s issue. Because many of us work in the acute care setting and this is primarily an ambulatory issue, it is easy to be a passive observer. I think there are many opportunities for health-system pharmacists to be actively involved in reducing opioid overuse.

A few important points stress the need for vigilance:

		Eighty percent of all opioid use in the world occurs in the United States. This is an incredible statistic when you consider that Americans make up only 5% of the world’s population.

		During the time leading up to his nomination as FDA Commissioner, Rob Califf, along with the FDA, has called for policies and processes to assist in reversing the epidemic.

 This has become a major issue for the FDA.

		In March, President Obama announced additional actions to help reduce opioid abuse.

 The White House is actively becoming involved in addressing it.

When recognizing the sheer size of the problem and the importance that governmental officials have placed on this epidemic, healthsystem pharmacists need to actively join the fight to limit inappropriate opioid use. Because we spend so much time ensuring appropriate medication use, this seems appropriate, and we are well trained to do it. Here are some things we can do:

Ensure that the approach to ordering controlled substances at your institution is sound.

 The number of individuals who have ordering privileges and power of attorney should be minimal, and there need to be appropriate checks and balances. If 1 individual manages the entire ordering and inventory process, the opportunity for diversion increases.

Have a process for checking waste in procedural areas.

 A large opportunity for diversion occurs during procedures because syringes are pre-drawn and then wasted if not used. Every provider needs to be aware that the pharmacy will regularly check waste that is returned for disposal for diversion reasons.

 Frequently generating reports to identify outliers among individuals who administer controlled substances is essential. Unfortunately, departments do not routinely do this. Although it is not exciting to consistently generate these reports, and never enjoyable to identify a diverter, having the discipline to do this regularly and robustly is essential to all pharmacy departments.

Use the state’s controlled substances reporting system (CSRS) for patients at risk for misuse during each medication history.

 Pharmacy departments are getting active in taking a medication history upon admission, and few even review the CSRS as part of this process. Although this is an important step in the medication reconciliation process, it is also an opportunity to identify an abuser who is getting frequent prescriptions. Actively reviewing the CSRS for these suspected patients can provide information to the medical team in order to address issues during admission.

Ensure the formulary has limited controlled substance availability and appropriate restrictions on prescribing.

 Although pain management is very important in the acute care setting, a designated individual needs to ensure that needless or inappropriate medications are not stocked and that only individuals who should prescribe some of these medications are the ones doing so.

 Educating physicians and monitoring prescriptions to minimize the total amount of doses allowed and the number of refills can help to limit the potential for addiction to start. Although we want to be certain that pain is controlled and patients are comfortable, we also want to make sure patient access is limited beyond this.

Employ a pain management pharmacist in the ambulatory care setting.

 Patients can be referred to a pain management pharmacist at discharge if pain does not resolve or is not managed appropriately. Pain management pharmacists can also advise their department on appropriate formulary medications and processes for limiting abuse.

We all have a role in making sure we do not contribute to the growing opioid epidemic. Health-system pharmacists are integral to the process. We need to join our ambulatory care colleagues to make sure all medicines are used appropriately.

I would appreciate any insights and experiences you might have regarding this perspective. Let me know what you think by e-mail at seckel@unc.edu or follow me on Twitter at @stepheneckel.

Stephen F. Eckel, PharmD, MHA, BCPS, FCCP, FASHP, FAPhA, is associate director of pharmacy, University of North Carolina Hospitals, and clinical associate professor at the University of North Carolina Eshelman School of Pharmacy.

		US: 5% of world population; 80% of opioid consumption. Allgov.com website. allgov.com/news/controversies/us-5-percent-of-world-population-80-percent-of-opioid-consumption-141215?news=855100. Published December 15, 2014. Accessed April 11, 2016.

		Califf, FDA top officials call for sweeping review of agency opioids policies [news release; February 4, 2016]. FDA website. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm484765.htm. Accessed April 11, 2016.

		Fact Sheet: Obama administration announces additional actions to address the prescription opioid abuse and heroin epidemic [new release; March 29, 2016]. whitehouse.gov website. whitehouse.gov/the-press-office/2016/03/29/fact-sheet-obama-administration-announces-additional-actions-address. Accessed April 11, 2016.

I wonder if health-system pharmacists who read and hear about the growing opioid epidemic react as if this is someone else's issue.

The Opioid Epidemic: Can Health-System Pharmacists Help?

Many hospitals support pharmacy residency programs. Throughout the winter, pharmacists in those institutions are actively engaging with pharmacy students, giving them tours throughout their hospitals, sharing their departments’ educational and training philosophies, getting to know the students’ passions and career interests, and recruiting them to train in these institutions. It is a wonderful time for hospital staff to meet future graduates who are excited about becoming pharmacists.

Unfortunately, our profession continues to debate the role residencies play in our training spectrum. Many professional associations have adopted policies requiring graduates to complete a residency before going into direct patient care. The associations support their position by noting the lack of preparation by pharmacy schools for highly specialized positions in hospitals, and that hospitals require residencies as a prerequisite for these positions.

Other individuals are convinced that new pharmacy graduates are ready for these positions. This position is defended by noting that the accreditation standards for pharmacy schools are patient-focused, there are not enough residencies to accommodate all graduates, and many employers will hire pharmacy graduates without a residency.

Although many individuals continue to debate the definition of “direct patient care,” let us address the training needed for a pharmacist to have prescribing privileges under approved protocols. Implicit in this discussion is that provider status has been adopted and state pharmacy practice acts have been updated to allow for this practice. With collaborative practice arrangements already existing in many states, thinking about whether a new graduate is ready to practice in this setting is germane to today. We tend to use the term “direct patient care,” but I wonder if the discussion would change if we substituted it with “provider” (as in “provider status”) instead.

Here are a couple of thoughts on ensuring that our profession is ready for prescribing under protocol:

 It is hard for me to accept that a new pharmacy graduate is capable of fully assessing a patient, understanding all the lab results and medical history, and making a pharmacotherapy recommendation, while taking into account the published literature. My experience with pharmacy students is that they do not have the breadth of insight and experience needed to assimilate all of this information.

 After attending and lecturing for many continuing education programs over the years, I can tell you that a minority of attendees pay close attention. We attend mostly because we need to renew our license. We prioritize timing, cost, and venue over content. Relying on passive education to keep a pharmacist current on treatment advances worries me, based on my observations over the years and questions I have received regarding my presentations. If these points cause concern regarding provider status for pharmacists, then additional safeguards need to be introduced to ensure that patients have access to competent pharmacists who can be providers.

Additional training beyond a pharmacy degree is necessary.

 The best and easiest way to obtain this training is through a residency. Although options, such as certificate programs or traineeships, might need to be developed due to supply issues, the best training program will always be a residency.

Portfolios should be used for relicensure.

 We need a much more active process to demonstrate individual competency each year. Continuing professional development is often referenced in this regard. I have had experience leading this in North Carolina, and have found it to be much better than the traditional method in ensuring ongoing competency. Whichever method a state board uses for collecting and reviewing this information, learning goals and the subsequent plan needs to be documented, and then examples of patient care should be submitted. Board certification is another option, but changes might need to be introduced to allow this to happen.

I do not think the debate over pharmacist preparation will end anytime soon. However, our profession has desired provider status for so long that we need to ensure that we have a competent workforce to provide the care our patients need. I am concerned that a pharmacy degree with our current relicensure process is not enough for the difficult patient situations that provider status could present. I would appreciate your insight and experience regarding this issue. Let me know your thoughts via e-mail (seckel@unc. edu) or Twitter (@stepheneckel).

Our profession continues to debate the role residencies play in our training spectrum.

Preparing Individuals for Provider Status

At the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting, held in New Orleans, Louisiana (December 6-10, 2015), we celebrated 50 years of this event. It was special hearing from people who attended the first ASHP Midyear meeting, and it allowed me to reflect on how it has evolved:

		It is the largest gathering of pharmacists in the world. '

		It is focused on advancing clinical pharmacy. '

		Numerous vendors and companies demonstrate products and services that can be used to advance your practice. '

		The residency showcase allows students to learn about the next step in their career development. After attending various educational sessions and networking with many colleagues, I left the meeting with the following observations.

. These individuals face tremendous pressures, such as decreasing margins on inpatient admissions, shrinking drug product reimbursement, various regulations that require significant attention to detail to maintain compliance with them, meeting institutional quality initiatives, identifying capital to cover sterile product area remodels or new technology purchases, and finding new revenue in the ambulatory setting. All of these things have to be done while maintaining an engaged pharmacy workforce. Not many people are equipped to be successful at balancing all of these competing pressures.

There is tremendous optimism regarding the profession

. Although it is difficult to manage all the various activities, I remain optimistic about the profession'of pharmacy. If we are able to exert strong leadership during this season of change and capitalize on the opportunities,'pharmacy departments'can emerge stronger'than they currently are. I'believe this will result in'better patient care than'is currently offered, with'a focus on improving the'use of medications while'ensuring our limited'resources are used wisely.

. Based'on attending continuing education sessions that discussed future possibilities and evaluating recent technologies developed by different exhibitors, I was impressed by the proliferation and potential of new innovations. Many of these devices were not even contemplated a few years ago. For example, at the Spotlight in Science presentation, researchers described how 'they are creating a “Pharmacy on Demand.” This device, which can fit on a tabletop, will be able to create small molecules and biologic products. Although this device still requires further testing and development, the data presented were compelling, as are the possibilities for what this device could mean for drug manufacturing and pharmacy in the future.

You must be organized to take full advantage of this meeting

. Because of the breadth of activities at this meeting, attendees cannot attempt to do everything. Before coming, you should identify and schedule 2 or 3 priorities for each day. If you are like me, many things at this meeting can attract your attention, but without making a strategic schedule in advance, you could leave the meeting without accomplishing your primary objectives.

Although this meeting achieved the 50-year milestone, it still has'a promising future. I hope to be able to attend the 75th meeting. In thinking about the development presented at this meeting, I cannot fathom what health-system pharmacy practice will be like in the future and how the meeting will be organized to prepare individuals for practice. I would appreciate any insights and experiences you might have on these topics. Let me know what you think via e-mail (seckel@unc.edu) or Twitter (@stepheneckel).

Stephen F. Eckel, PharmD, MHA, BCPS, FCCP, FASHP, FAPhA, 

is associate director of pharmacy, University of North Carolina Hospitals, and clinical associate professor at the University of North Carolina Eshelman School of Pharmacy. 

At the American Society of Health-System Pharmacists Midyear Clinical Meeting, held in New Orleans, Louisiana, we celebrated 50 years of this event.