Oncology Pharmacists Play an Expanding, Integral Role in Patient-Centric Care

Pharmacy Times interviewed Kirollos Hanna, PharmD, BCPS, BCOP, FACC, director of pharmacy at Minnesota Oncology, assistant professor of pharmacy at the Mayo Clinic College of Medicine, and editorial advisory board member for Pharmacy Times Oncology Edition™, on the role of the oncology pharmacist on the patient care team. Hanna discussed the multifaceted involvement of oncology pharmacists in various aspects of patient care, the need for consistent engagement of oncology pharmacists across practice settings, oncology pharmacists’ critical role in treatment decision-making, and the potential for optimizing their workflow through technological advancements to allow oncology pharmacists to have more time for patient care.

Pharmacy Times: What is the focus of your work as an oncology pharmacist on the patient care team?

Kirollos Hanna, PharmD, BCPS, BCOP, FACC: I think when you look at the level of involvement of oncology pharmacists within the realm of hematology/oncology, it is quite a significant involvement across the board. Now, I think when you look at how oncology pharmacists are involved, it's really going to vary based on the type of practice and the practice model. But oncology pharmacists are not only serving in a clinical capacity where they're working right alongside the care team, oncology pharmacists serve in so many different roles within hematology/oncology. There are opportunities to serve from an informatics perspective, helping build out EMRs and treatment plans and protocols. There are opportunities to work on the administrative level, where you're making decisions around the system standards and pathways and formulary decisions and such.

From my experience over the past several years, I have sort of transitioned from working in a very large academic to now being in an administrative role within community oncology, and parts of these different hats or umbrellas that I served under included—when I was with Mayo Clinic, I worked right alongside the providers. We were directly involved in patient care. On a daily basis, we rounded on our patients. We were very involved in ordering of chemotherapy, dose modifications, patient education, care team education, and just really ensuring that the treatment selection for patients is very tailored and very patient-centric based on the presentation of that patient.

Oncology has become extremely complex, and things like cytogenetics or biomarkers and such are oftentimes areas where pharmacists can be pivotal in certain clinical interventions, tailoring therapy to each individual patient. I've also worked in capacities where I worked in outpatient infusion centers, where we were supporting patients through an oral chemotherapy program through infusion therapies. And that role also really had a lot of opportunity for the pharmacist to practice at the maximum capacity of their licensure—education, monitoring adherence and compliance, adverse event management, ensuring follow up for patients is clinically appropriate, whether it's a lab that's needed, an EKG that's needed, whatever it is really based on the therapeutics that patient may be on.

Even now on the administrative side, from an administrative perspective, I think it's very important though that to still have that clinical mindset because it's very hard to make administrative decisions, if the clinical part of it isn't tied to some of that decision making. So, when you look at things like formulary decisions, pathway placements and pathway preferencing, EMR integration and build outs, all of those are things that I'm involved in on a day to day level while still incorporating my clinical hat, and that allowed that experience that I've had in prior years as well.

Pharmacy Times: How consistent is your level of involvement on the patient care team, and does that involvement level vary based on any factors?

Hanna: So, for oncology pharmacists, really, regardless of the model that you find across practices, whether we're talking about a Sloan Kettering, MD Anderson, Mayo Clinic, or whether we're talking about small community oncology and rural settings, I really think that the need and the justification for pharmacist involvement is there across practice [settings], especially with the complexity within oncology. Again, oncology is no longer a handful of cytotoxic drugs. Everything now is very central to the patient—the patient's presentation, cytogenetics, biomarkers, treatment sequencing is an important consideration—and then you even start to look at operational things as simple as biosimilar adoption and, contracting and such.

Pharmacists really should be significantly involved in the care team, regardless of the type of model that you have. That does need to be consistent involvement because we continue to see oncology expand and grow. It's an area I think within health care that has the most growth that we see across the board. Thus, just kind of speaking to the importance of consistent involvement within pharmacy, in all the practices that I have been a part of over the years, pharmacy is an integral component of the care team. They're not siloed, and they are considered a part of that team. Regardless of if it's from an administrative perspective, a clinical perspective, whether it's academic, whether it's community, it has really been a role that is crucial to the success of a cancer center.

Pharmacy Times: What is the value of your consultation on treatment and care decisions on the patient care team for patients with cancer, and what does that look like?

Hanna: So, I think involvement in terms of treatment decision making, I have seen clinical models where a pharmacist actually serves in a role on behalf of the provider to really be the key person to prescribe chemotherapy. Obviously, a treatment decision and treatment plan are going to come from a multidisciplinary discussion between the provider, the pharmacist, the care team, and the patient and the patient's caregiver to really try to develop the most optimal approach for that patient. But I have seen pharmacists involved to that degree of autonomy.

Now, in the grand scheme of things across the board, pharmacists will be a little will be involved in different ways, shapes, and forms. But in terms of that patient centric, patient decision making aspect, pharmacists are generally well involved in that decision making process. And even after the fact, to ensure successful completion of therapy or successful time on therapy, you look at many practices and pharmacists serve in a clinical role on an oral chemotherapy team, for example—what does that entail? Phone calls made out to the patient, ensuring that they're taking their medication properly—instead of 2 tablets once a day, they're doing that once or twice a day, or whatever it may be in terms of adherence and compliance—and that their labs are evaluated. There are many patients that may come in, get a lab, and there are programs out there [in which] that lab may not even be evaluated by a provider. And actually the pharmacist is relied upon to ensure the labs meets certain thresholds where the pharmacist can allow that patient to continue on treatment as they are, or intervene with the oncologist to whether it's a dose reduction or dose hold, etc. So, really, the degree of involvement on the patient care side is a little bit different depending on the types of practices, but it also does tend to be pretty consistent in that the pharmacist is directly involved on various clinical initiatives that impact the patient directly.

Pharmacy Times:What is your involvement on decisions around drugs being included in the EMR?

Hanna: So, I think the incorporation of drugs and treatment plans and protocols within the EMR is really multifaceted because there's different components. Are we talking about incorporating a drug, just like a biosimilar change based on a contract? Or are we talking about building out a complete regimen, pathways, standards of care, etc? And I think, really, across practice and across how all these things are adopted, you'll see quite a bit of variability across the board. But again, in some areas, pharmacists may be the ones running the show, when it comes to a new drug is approved, we're going to include it in the EMR.

Now being included in the EMR doesn't always mean it's going to be a standard of care, it's not going to be always prescribed. That could be something as simple as building it out, making sure that the proper fluids, proper administration time, proper little nuances of the drug are part of the EMR. However, when it comes down to this treatment decision making from a pathways perspective, from a formulary perspective, from a protocol perspective, pharmacists are also heavily involved, and they're oftentimes the personnel or gatekeepers as to what gets built out in the EMR and verified within the EMR, that's accurate and aligns with the system practices. But it oftentimes stems from discussions within a pharmacy and therapeutics committee [P&T committee], so a P&T committee, and again, within the title of that committee is pharmacy. So, pharmacists are oftentimes heavily integrated within a P&T committee. Those discussions will revolve around clinical best practices, contracting, and then oftentimes from P&T committees, a decision may be made of something needing to be built out within the EMR and then the pharmacists oftentimes will take that and sort of take it to the next steps of actually building things out, integrating them, etc. So those are kind of the different ways of how pharmacists are touching our EMRs.

Pharmacy Times:In your view, what are some ways oncology pharmacists’ involvement could be better utilized on patient care teams?

Hanna: So, I think oncology pharmacists in many areas are not utilized to their absolute maximum potential. And a lot of it just stems from the normal workflows of pharmacy that we have been used to. And what do I mean by that? Product verification, the compounding and mixing component of verifying products, physical dispensing of products—a lot of these operational steps that are part of our day to day work take a lot of time. But we can leverage technology and AI to really automate a lot of this and really take off of the pharmacist a lot of the operational burden, where we can then implement different roles for the clinical pharmacists to really practice at the top of their license—prescribing capability, billing for education for patients, implementing key interventions, ordering labs for patients—just sort of integrating the pharmacists within that care team to the same capacity if not even additional capacity similar to an advanced practice provider, where there is this authority that they function and operate under that hematologist or oncologist.

So, I do think that there's a lot of opportunity for the role of the pharmacist to continue to expand—the value is absolutely there. But I do think that we can probably start to leverage various technologies and different things in the works to start shifting away. Now we definitely don't want that to go in the opposite direction where technology and automation and AI justify fewer FTEs within pharmacy, because that would sort of be the opposite of the intent of this message. But really, there are opportunities where you can take your pharmacists and implement them and integrate them in in ways where you take off the burden of your physicians and you take off various administrative and operational burdens that a pharmacist can help with. So, some opportunity there that I think, in the next several years, we're likely going to see some improvement and some different, both challenges as well as successes that we're going to see come out from technology.