In recent years, hospital pharmacists have begun to emerge from the proverbial and sometimes literal basement pharmacy and are serving at the patient's bedside as part of the clinical team. The 2010 Patient Protection and Affordable Care Act, along with federal payment and health information technology policies, is expected to accelerate the trend.

The old model in which physicians wrote prescriptions, nurses brought them to the pharmacy, and the pharmacist filled the order and sent it up to the floor "has completely changed for good reason," says Mark Donaldson, director of pharmacy services at Kalispell (Mont.) Regional Medical Center. "There has been a tremendous shift from being out of sight, out of mind to really being at the forefront of prescribing practices and making sure that the patient is getting the right drug at the right time at the right dose every time, rather than being more reactive."

Fifteen or 20 years ago, pharmacists typically only rounded with doctors at academic medical centers, says Ed Kent, pharmacy implementation manager, performance services at the hospital alliance VHA Inc. Now pharmacists are rounding at about 44 percent of hospitals, according to a new American Society of Health-System Pharmacists survey of more than 500 hospitals. The figure is virtually 100 percent at facilities with more than 400 beds.

Why the change? The 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System" shone a harsh spotlight on medication errors at hospitals, Donaldson says. As a result, hospitals, the government and quality organizations began to focus on ways to reduce adverse medication events.

Also, pharmacy began to shift to a more clinical profession, says Douglas Scheckelhoff, ASHP vice president of professional development. The growth of residency training programs got pharmacists into hospitals where they received hands-on experience with patients as part of a multidisciplinary team. Then, about a decade ago, pharmacy went from a baccalaureate- to a doctoral-level program.

Now pharmacists are not just dispensing drugs, but focusing on medication safety, working to get the best drugs for the lowest cost, trying to improve outcomes, easing the transition into the hospital by making sure patients' existing drug regimens are followed, managing drug therapy, striving to shorten patient stays when possible, and trying to prevent readmissions related to medications, Scheckelhoff says. "If you have pharmacists as part of the medical team or close to the patient's bedside, they're going to be in a much better position to help make these things happen. If you don't have them as part of the team, it's a void."

Technology has helped fuel the trend. Such advances as automated dispensing machines, computerized provider order entry and bedside bar-coding systems allow pharmacists to get out of their offices and onto patient floors. As pharmacists have become more involved in direct patient care, pharmacy technicians have begun to take on more of the traditional drug-dispensing role.

But the shift in hospital pharmacy practice to direct patient care is not uniform, as the ASHP figures show. The society is trying to facilitate change with its Pharmacy Practice Model Initiative, which aims to develop a practice model that supports the most effective use of pharmacists as direct patient care providers. A goal of the effort is to create a self-assessment tool so hospitals can determine what clinical services their pharmacists will provide and what technology is needed to support them. Another objective is to develop recommendations on a core set of services all hospital pharmacists should provide.

Starting Points

For hospitals interested in having their pharmacists become more involved in direct patient care, there are some logical places to start, says Marie A. Chisholm-Burns, head of the Department of Pharmacy Practice and Science at the University of Arizona College of Pharmacy, Tucson. These include: hospital units with high-risk patients, such as the ICU; units with high medication-error rates; and patients on high-risk medications or on drugs with narrow therapeutic windows.

As medications have become more complex and the population of patients with multiple chronic conditions increases, many physicians have come to realize they can't be experts at all things and now turn to hospital pharmacists as their medication experts. Because more new physicians are trained in an integrated fashion, not only are they expecting pharmacists to participate in the care team, "they're demanding it," says Chisholm-Burns, who specializes in transplant medications.

One area in which pharmacists have proven their value is anticoagulation-medication management. At hospitals without pharmacist-provided heparin management, death rates were 11.4 percent higher, length of stay was 10 percent higher, Medicare charges were 6.6 percent higher, bleeding complications were 3 percent higher, and the transfusion rate for bleeding complications was 5.4 percent higher, according to a study of more than 700,000 Medicare patients requiring anticoagulation therapy at 955 hospitals. The research, published in the August 2004 issue of Pharmacotherapy, found similar results with warfarin. The ASHP survey found that currently pharmacists routinely manage inpatient heparin and warfarin therapy at only about 37 percent of hospitals. Medication management at hospital outpatient anticoagulation clinics also can significantly reduce readmissions resulting from complications from these drugs, Kent says.

Today's hospital reimbursement picture is likely to intensify the need for pharmacist involvement in direct patient care, several experts say. For example, as Medicare continues to clamp down on hospital payment, pharmacists can help to maximize reimbursement because of their ability to select the right drug at the lowest cost and to reduce lengths of stay by preventing adverse events and improving outcomes through medication management, Chisholm-Burns says.

Meanwhile, the health reform law's push to further shift the basis of Medicare payment from quantity to quality is expected to reinforce the trend. Health care-associated conditions serve as an example. In 2007, the Centers for Medicare & Medicaid Services stopped paying for care related to certain HACs. The list now includes several medication-related events, such as blood clots, death or disability from medication errors, and certain types of infection. Under health reform, Medicare in 2015 also will decrease payment for hospitals performing the worst with regard to HACs. As a result, hospital pharmacists are getting more involved in such realms as anticoagulation management for patients at high risk of blood clots and antimicrobial stewardship, Kent says.

Readmissions are another area in which pharmacists can help hospitals prepare for health reform, several sources say. Beginning in October 2012, most types of hospitals will face Medicare payment penalties if they have higher-than-expected readmission rates for heart failure, pneumonia and heart attack. A significant number of readmissions occur because patients fail to follow their medication regimen or experience adverse drug interactions, Kent says.

Having pharmacists team with nurses in the discharge process and with patient follow-up can dramatically reduce readmissions related to medications, Scheckelhoff says. Such a coordinated effort can have the biggest impact with high-risk patients whose health is dependent on adhering to their medication regimens.

The Glue in the Care Continuum

The Affordable Care Act "is just another reason to get the pharmacists more engaged in the patient care team," says Mark Eastham, senior vice president of McKesson Pharmacy Optimization, a consulting arm of the McKesson Corp. "Pharmacy is really the only hospital department that provides clinical care to each and every hospital patient."

This makes having a comprehensive pharmacy strategy vital for hospitals interested in participating in the accountable care organization program created by the health reform law, several experts say. The purpose of ACOs is to manage the health of a patient population across care settings. "The glue of the health care team is the pharmacists because they're managing that patient's medications throughout the care continuum," Kent says.

While health reform intensifies the shift in hospital pharmacy practice to the point of care, the federal meaningful use regulations are expected to encourage adoption of the information technology that enables the trend. For hospitals to qualify for federal health information technology incentive payments, the final rule requires that more than 30 percent of patients with at least one medication recorded must have at least one medication ordered through computerized provider order entry systems. A future phase of the regulation is expected to include hospital use of bedside bar-code or radio-frequency medication verification.

So far, hospitals have been slow to invest in this type of technology. For example, about 19 percent of hospitals surveyed by ASHP used inpatient CPOE systems with decision support in 2010, although the percentage is higher among larger hospitals. About 35 percent of hospitals use bar code medication administration.

Kalispell's Experience

Technology not only allows pharmacists to concentrate on clinical care, it also helps them prevent errors and improve efficiency. At 155-bed Kalispell Regional Medical Center, prescriptions are scanned digitally so nurses no longer have to run the orders to the pharmacy. Pharmacy personnel verify that the prescription is appropriate and, through the computer system, approve the nurse's access to that drug via an automated dispensing machine. The machine scans the nurse's fingerprint before releasing the drug. These secure medicine cabinets are located in each ward on each floor and house about 90 percent of medications used in the facility.

Digital scanning and the use of ADMs have cut the turnaround time between when a prescription is written and when the patient receives the drug—from hours to an average of less than seven minutes, Donaldson says.

The ADMs play a huge role in preventing medication errors, he says. When a nurse goes to get a medication, she has to pull up the right patient's information; otherwise, she's not going to find the drug. The nurse has to pull the right drug; otherwise that drawer is not going to open. And when that drawer opens, it only gives the nurse access to that one particular dose of that one particular drug for that one particular patient.

To close the loop in medication safety, the medical center uses bedside bar-code medication verification. Before administering a drug retrieved from the ADM, the nurse must scan the drug, the patient's wristband and the physician's order. If all three do not match, the nurse cannot give the drug to that patient, Donaldson says.

Kalispell is now transitioning to CPOE.

The pharmacy department's expansion into such arenas as direct patient care, patient safety and quality improvement, and technology has led to calls for an elevation of the pharmacy director to a position within hospital administration. The last five years have seen the emergence at some facilities of a new title: chief pharmacy officer. This promotion gives pharmacy leaders greater influence on care quality because their reach now extends across silos, Kent says.

The new designation has not caught on everywhere. "We have won the hearts and confidence of the nurses, the physicians and the rest of the clinical team," Donaldson says. "Our next biggest challenge is being recognized by administration for what we bring to the table."

Geri Aston is a freelance writer in Chicago. Getting Results



Getting Results

Pharmacist involvement in direct patient care often has positive effects on various therapeutic and drug-safety outcomes, according to a systematic review and meta-analyses of 298 research studies. Eighty-eight of the studies were of the inpatient hospital setting. Here is a partial list of how many studies found that pharmacists' involvement in direct patient care had favorable, not favorable, mixed and no results.

•Blood pressure control
Number of studies 59
Favorable results 50 studies (84.7%)
Not favorable results 0 studies
Mixed results 2 studies (3.4%)
No effect 7 studies (11.9%)

Number of studies 35
Favorable results 18 studies (51.4%)
Not favorable results 1 study (2.9%)
Mixed results 1 study (2.9%)
No effect 15 studies (42.9%)

•Length of hospital stay
Number of studies 32
Favorable results 19 studies (59.4%)
Not favorable results 0 studies
Mixed results 3 studies (9.4%)
No effect 10 studies (31.3%)

•Anticoagulation therapy
Number of studies 20
Favorable results 17 studies (85%)
Not favorable results 0 studies
Mixed results 0 studies
No effect 3 studies (15%)

•Blood glucose control
Number of studies 11
Favorable results 9 studies (81.8%)
Not favorable results 0 studies
Mixed results 1 study (9.1%)
No effect 1 study (9.1%)

Source: "U.S. Pharmacists' Effect as Team Members on Patient Care: Systematic Review and Meta-Analyses"; Marie A. Chisholm-Burns, et al.; Medical Care, October 2010