Download Pharmacy Technicians: Roles, Responsibilities

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Pharmacy Technicians: Roles, Responsibilities and Contributions to the Provision of Pharmacy
Services in Health-System Settings
White paper drafted by the Organizational Affairs Committee of the Michigan Society of HealthSystem Pharmacists
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AUTHOR INFORMATION:
Stephen M. Stout, Pharm.D., MS (corresponding author)
Pharmacotherapy Specialist, Wolters Kluwer Clinical Drug Information
2242 Georgetown Blvd, Ann Arbor, MI 48105
Ph: (517) 449-9286; [email protected]
Ryan Bickel, Pharm.D., MHA, BCPS
Pharmacy Manager, Borgess Pipp Hospital
411 Naomi St., Plainwell, MI 49080
Ph: (269) 685-0754; [email protected]
Ryan Foster, Pharm.D., MBA
Director, Pharmacy Services, Spectrum Health Hospital Group
100 Michigan Street NE, Grand Rapids, MI 49503
Ph: 616.391.3028; [email protected]
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Mark Isopi, Pharm.D., MBA, FASHP
Senior Regional Medical Liaison, Amgen Inc.
34922 Pembroke Ave, Livonia, MI 48152
Ph: 248-893-7509; [email protected]
All authors: Nothing to disclose.
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ABSTRACT
Pharmacy technician roles, responsibilities and contributions to care were not formally
established in the state of Michigan until Public Act 285 (formerly Senate Bill 92) was signed
into law in September 2014. This Act, which is scheduled to go into effect on Oct. 1, 2015,
establishes licensure requirements for technicians and defines practice in a way that allows for
expanded technician contributions. While pharmacy leaders in the state generally view
expansion of technician roles favorably, the lack of any formal definition and regulation of
technician practice was previously seen as a primary barrier to progress in this area.
Accordingly, Michigan pharmacy technicians have been under-utilized in some roles relative to
national trends. The Organizational Affairs Committee urges continued advancement and
specialization of the pharmacy technician workforce, with the expectation that this will: 1) save
pharmacist hours and/or free pharmacists for other activities, without compromising patient
care; 2) increase diversity, specialization and job satisfaction among pharmacy technicians; and
3) advance the standing and image of the field as a long-term career option for prospective
candidates.
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INTRODUCTION
In early 2003, the Council on Credentialing in Pharmacy (CCP) published its “White Paper on
Pharmacy Technicians 2002: Needed Changes Can No Longer Wait,” a declaration endorsed by
12 member organizations of CCP, including the American Pharmacists Association, American
Society of Health-System Pharmacists (ASHP) and the American College of Clinical Pharmacy. 1
The white paper’s stated purpose was “To set forth the issues that must be resolved to
promote the development of a strong and competent pharmacy technician work force.” The
CCP recommended that action be pursued in five areas with respect to pharmacy technicians
and/or other support personnel, with the aim of formalizing roles and expectations for these
individuals and maximizing their contributions to pharmacy services:
1) Defining and communicating a vision, with specific goals and plans for pursuit of that
vision;
2) Defining roles, responsibilities and competencies;
3) Establishing education and training standards, and maintenance requirements for these;
4) Establishing credentialing and accreditation standards; and
5) Establishing and promoting adoption of regulatory standards consistent with the above.
In Michigan, a milestone in progress toward this vision was reached in September 2014 when
Public Act 285 (PA 285, formerly Senate Bill 92) was signed into law by Gov. Rick Snyder.
Previously, Michigan was one of only six states that did not regulate pharmacy technicians. 2 PA
285 amends the Michigan Public Health Code to establish education, licensure and
maintenance requirements for pharmacy technicians, as a subfield of pharmacy, and is
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scheduled to be enacted on Oct. 1, 2015.3 The Act broadly defines pharmacy technician
practice as including the following activities:

Assisting in the dispensing process

Handling transfer of prescriptions, except controlled substances prescriptions

Compounding drugs

Preparing or mixing intravenous drugs for injection into a human or veterinary patient

Contacting prescribers concerning prescription drug order clarification, which does not
include drug regimen review or clinical or therapeutic interpretation

Receiving verbal orders for prescription drugs, except orders for controlled substances

Any other specifically authorized functions
The Organizational Affairs Committee (OAC) of the Michigan Society of Health-System
Pharmacists (MSHP) created this document to attempt to more specifically define pharmacy
technician roles, responsibilities and contributions to the provision of pharmacy services in
health-system settings in Michigan, as a contribution to the ongoing professional dialogue
concerning regulation and advancement of this field.
LITERATURE REVIEW
Scope of Practice
Based on searches of recent scientific and trade literature, three major national publications
have attempted to characterize the scope of pharmacy technician practice in the United States:
ASHP’s 2007 “ASHP Long-Range Vision for the Pharmacy Work Force in Hospitals and Health
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Systems: Ensuring the Best Use of Medicines in Hospitals and Health Systems;” 4 CCP’s 2009
“Scope of Contemporary Pharmacy Practice: Roles, Responsibilities, and Functions of
Pharmacists and Pharmacy Technicians;”5 and the National Association of Boards of Pharmacy
(NABP)’s 2012 “Model State Pharmacy Act and Model Rules of the National Association of
Boards of Pharmacy.”6 Pharmacy technician practice as outlined in all of these documents
occurs under the supervision of a pharmacist, and the practice roles are a sub-set of pharmacy
practice roles (i.e., there are no functions unique to pharmacy technicians).
The vision outlined by ASHP in 2007 describes a scope of pharmacy technician practice in
health-system settings as including the following:4

Drug product:
o Acquisition
o Preparation
o Dispensing
o Distribution

Management and supervision of:
o Drug acquisition and supply logistics
o Use of technology and aspects of informatics
o Quality assurance activities
o Other pharmacy technicians

Assisting in data collection and screening for therapeutic drug monitoring
The CCP publication borrows its definition of pharmacy technician practice from NABP, defining
technician practice as including the following:5
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
Assisting in dispensing

Medical claims processing

Medication stocking

Cashiering

Not including:
o Drug utilization review
o Clinical conflict resolution
o Prescriber contact for order clarification or therapy modification
o Patient counseling
o Dispensing process validation
o Prescription transfer
o Receipt of new prescription drug orders
In addition to the above, NABP also includes a section describing somewhat expanded practice
roles of certified pharmacy technicians (certification as determined by the state board of
pharmacy) as including:6

Receiving new medication orders

Prescription transfer

Compounding

Assisting in dispensing

Performing all functions allowed to be performed by technicians, but specifically
excluding:
o Drug utilization review
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o Clinical conflict resolution
o Prescriber contact for order clarification or therapy modification
o Patient counseling
o Dispensing process validation
The definition of technician practice in PA 285 (see INTRODUCTION), while not identical to any
of the above, is most consistent with the final and broadest definition put forward by NABP and
with a trend toward advancement of practice roles for qualified technicians as described below.
Trends and Emerging Practice Roles
Beyond the basic definition of pharmacy technician practice, the CCP publication goes on to
describe a pharmacy technician practice analysis, completed in 2005, evaluating the
professional activities of certified pharmacy technicians (CPhTs, in this sense reflecting
certification specifically by the Pharmacy Technician Certification Board [PTCB]).5,7 In this
analysis, a survey of pharmacists, CPhTs, technician educators, regulators and state pharmacy
board representatives indicated that, while health-system CPhTs were primarily responsible for
assisting inpatient dispensing, preparing intravenous admixtures and pre/repackaging
medications, compared to previous surveys they were increasingly involved in activities such
as:7

Compounding

Communicating changes in product availability

Coordinating different forms of communication throughout the practice setting
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
Performing and documenting equipment sanitation, maintenance and calibration

Quality assurance activities (pharmacy technicians in general; not specific to health
systems):
o Multiple-point checking
o Assisting monitoring of patient outcomes
o Inventory control
o Coordinating medication error communication
o Education, training and certification
o Reviewing billing discrepancies / fraud issues
“Tech-check-tech” (TCT), a practice model in which pharmacy technicians rather than
pharmacists check the accuracy of order filling by other technicians, was the subject of a recent
literature review.8 Across 11 published studies describing the practice in different institutions,
the accuracy of TCT protocols was comparable to pharmacist checking for prescription order
accuracy.
Other literature in the past 10 years has described pharmacy technician involvement in other
novel or advanced practice roles in the U.S., including:

Taking medication histories9-11

Medication reconciliation12,13

Maintaining patient records14

Screening patient profiles to identify candidates for clinical interventions 14

Requesting prescription refill authorizations from prescribers 11

Counseling on nonprescription medications11
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
Scripted patient education14
CURRENT STATE OF PRACTICE IN MICHIGAN
In 2011, MSHP initiated the Pharmacy Practice Model Initiative of Michigan (PPMI 2) as a means
to refine and implement recommendations from ASHP’s Pharmacy Practice Model Initiative.
One of the first actions taken by MSHP was to survey the directors of pharmacy at Michigan
hospitals. MSHP utilized an early version of ASHP’s Hospital Self-assessment Tool,15 which
contained 15 questions relating to pharmacy technician practice. Most of the questions
focused on specific tasks or activities performed by technicians; however, a couple addressed
technician certification status and opportunities for advancement. Approximately one-third
(n=35) of the hospital pharmacy directors in the state completed the survey by the end of June
2011. In June 2013, the MSHP Organizational Affairs Committee contacted ASHP and requested
the current results of the Hospital Self-assessment Tool for Michigan hospitals. Fifty-two
hospitals had completed the assessment. A review of the survey responses (Table 1) shows
that pharmacy technician practice in Michigan has made little advancement since the original
survey.
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Table 1. ASHP Hospital Self-Assessment Tool: Michigan Hospital Responses Relating to Pharmacy
Technician Practice
Tasks fully assigned throughout all areas
MI 2011
(N=35)
31.4%
MI 2013
(N=52)
26.9%
US 2013
(N=1,079)
38.9%
Tasks fully assigned for some areas
11.4%
21.2%
25.0%
Tasks partially assigned in some or all areas
57.1%
50.0%
31.0%
Tasks not assigned
0.0%
1.9%
4.2%
Not applicable
0.0%
0.0%
0.0%
Tasks fully assigned throughout all areas
0.0%
0.0%
3.0%
Tasks fully assigned for some areas
5.7%
5.8%
6.9%
Tasks partially assigned in some or all areas
8.6%
5.8%
7.2%
Tasks not assigned
85.7%
88.5%
77.5%
Not permitted by law
0.0%
0.0%
5.7%
3. Is review of patient charts to identify
medication allergies that require
pharmacist follow up assigned to
pharmacy technicians who have
appropriate education and training at
your hospital/health system (e.g.,
identify allergies not documented in the
pharmacy information system)?
Exists in all areas/situations (100%)
0.0%
1.9%
2.5%
Exists in most areas/situations (50–99%)
5.7%
3.9%
2.7%
Exists only in some areas/situations (1-49%)
8.6%
5.8%
6.5%
Does not exist (0%)
85.7%
88.5%
88.3%
4. If permitted by law, is the accuracy of
medication dispensing by pharmacy
technicians checked by other
technicians (i.e., "tech-check-tech") who
have appropriate education and training
at your hospital/health system?
Exists in all areas/situations (100%)
0.0%
0.0%
5.2%
Exists in most areas/situations (50–99%)
11.4%
3.9%
6.9%
Exists only in some areas/situations (1-49%)
20.0%
15.4%
9.9%
Does not exist (0%)
42.9%
44.2%
43.8%
Not permitted by law
25.7%
36.5%
34.2%
Exists in all areas/situations (100%)
57.1%
57.7%
64.6%
Exists in most areas/situations (50–99%)
25.7%
25.0%
22.6%
Exists only in some areas/situations (1-49%)
2.9%
3.9%
4.1%
Does not exist (0%)
14.3%
13.5%
5.8%
Not applicable
0.0%
0.0%
2.9%
Question
1. Are medication distribution tasks
assigned to pharmacy technicians to
allow redeployment of pharmacists’
time to drug therapy management
activities at your hospital/health
system?
2. Is initiation of medication
reconciliation, including obtaining and
documenting patient medication
information for pharmacist review,
assigned to pharmacy technicians who
have appropriate education and training
at your hospital/health system?
5. Is the compounding of routine sterile
preparations in conformance with welldocumented procedures performed by
pharmacy technicians who have
appropriate education and training at
your hospital/health system?
Answer Choice
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6. Is the compilation of clinical
monitoring information (e.g.,
International Normalized Ratios) for
pharmacist review assigned to
pharmacy technicians who have
appropriate education and training at
your hospital/health system?
Tasks fully assigned throughout all areas
0.0%
0.0%
1.3%
Tasks fully assigned for some areas
2.9%
3.9%
1.8%
Tasks partially assigned in some or all areas
0.0%
0.0%
3.0%
Tasks not assigned
82.9%
82.7%
78.9%
Tasks performed by hospital information system
14.3%
13.5%
15.1%
7. Is the inspection and replenishment
of medication storage devices assigned
to pharmacy technicians who have
appropriate education and training at
your hospital/health system?
Yes
97.1%
98.1%
96.7%
No
2.9%
1.9%
3.3%
8. Is the management of controlled
substance systems assigned to
pharmacy technicians who have
appropriate education and training at
your hospital/health system?
Yes
74.3%
76.9%
72.3%
No
25.7%
23.1%
27.7%
9. Is the management of medication
assistance programs assigned to
pharmacy technicians who have
appropriate education and training at
your hospital/health systems?
Yes
8.6%
5.8%
18.8%
No
48.6%
46.2%
30.6%
Not applicable
42.9%
48.1%
50.6%
10. Are components of quality
improvement programs conducted by
pharmacy technicians who have
appropriate education and training at
your hospital/health system?
Exists in all areas/situations (100%)
2.9%
1.9%
7.5%
Exists in most areas/situations (50–99%)
14.3%
13.5%
14.4%
Exists only in some areas/situations (1-49%)
60.0%
55.8%
42.8%
Does not exist (0%)
22.9%
28.9%
31.8%
Not applicable
0.0%
0.0%
3.5%
Exists in all areas/situations (100%)
22.9%
17.3%
17.0%
Exists in most areas/situations (50–99%)
28.6%
30.8%
25.1%
Exists only in some areas/situations (1-49%)
37.1%
36.5%
32.3%
Does not exist (0%)
11.4%
13.5%
20.6%
Not applicable
0.0%
1.9%
5.0%
Exists in all areas/situations (100%)
8.6%
7.7%
17.8%
Exists in most areas/situations (50–99%)
17.1%
17.3%
13.9%
Exists only in some areas/situations (1-49%)
8.6%
17.3%
13.6%
Does not exist (0%)
60.0%
50.0%
46.2%
Not applicable
5.7%
7.7%
8.4%
11. Is the management of pharmacy
department information technology
systems, including routine database
management and billing systems,
assigned to pharmacy technicians who
have appropriate education and training
at your hospital/health system?
12. Is the supervision of other pharmacy
technicians assigned to technicians who
have appropriate education and training
at your hospital/health system?
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13. Are pharmacy technicians at your
hospital/health system certified by the
Pharmacy Technician Certification Board
(PTCB)?
All pharmacy technicians are PTCB-certified
(100%)
Most pharmacy technicians are PTCB-certified
(50%-99%)
Some pharmacy technicians are PTCB-certified
(1%-49%)
57.1%
48.1%
42.7%
25.7%
28.9%
32.4%
11.4%
19.2%
19.4%
5.7%
3.9%
5.6%
No pharmacy technicians are PTCB-certified (0%)
14. Are all distributive functions that do
not require a pharmacist's clinical
judgment assigned to pharmacy
technicians at your hospital/health
system?
Yes
60.0%
55.8%
65.8%
No
40.0%
44.2%
34.2%
15. Are opportunities for advanced,
specialized pharmacy technician roles
available at your hospital/health system
(examples of advanced pharmacy
technician roles include: dispensing
medications with remote video
supervision, managing medication
assistance programs, initiation of
medication reconciliation [obtaining
list], order entry for pharmacist's
verification, and technician supervising
other technicians)?
Yes
40.0%
38.5%
40.4%
No
60.0%
61.5%
59.7%
When compared to the national results, it appears that Michigan hospitals lag behind other
states in optimizing the use of pharmacy technicians. In general, Michigan hospitals are less
comfortable delegating distributive functions, which do not require pharmacist judgment, to
technicians. Fewer Michigan hospitals use technicians to manage medication assistance
programs or assist with quality improvement programs.
The ASHP assessment tool provided a glimpse of pharmacy technician practice in Michigan, but
MSHP desired to know more. In 2011, MSHP created a second survey, which was distributed to
the 50 participants of the PPMI2 Conference. The participants consisted of pharmacy leaders
from across the state representing various aspects of health-system pharmacy practice,
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including acute care, ambulatory care and academia. This survey assessed the participants’
vision of technician practice and barriers to achieving this vision. Forty-two pharmacists (84
percent) completed the PPMI2 survey. Approximately two-thirds of participants strongly agreed
that pharmacy technicians, with appropriate education and training, should be used much more
extensively in Michigan hospitals to free up pharmacists to perform clinical activities. The
respondents generally agreed that the future vision of pharmacy practice in Michigan has
pharmacy technicians taking increased ownership of drug preparation and distribution. A level
of uncertainty existed about liberalizing the practice of tech-check-tech. Table 2 summarizes
the survey results regarding the preferred future for pharmacy technicians.
The PPMI2 survey also attempted to identify barriers that must be addressed before pharmacy
technicians can achieve an optimal practice in Michigan. The top five barriers included:
1. Lack of recognition and legal accountability by the state of Michigan.
2. Lack of standardized education and training.
3. Large variability in the roles of pharmacy technicians among various hospitals.
4. Lack of career ladders for technicians.
5. Too few technicians are interested in pursuing the occupation as a long-term career.
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Table 2. PPMI2 Conference Participants’ Level of Agreement Regarding the Preferred Future
for Pharmacy Technicians.
Agree
Neutral
Disagree
All distributive tasks that do not require clinical judgment are assigned to
technicians.
90%
7%
3%
Technicians are responsible for drug product preparation and distribution work
within a well-documented, quality assurance environment designed to ensure
patient safety.
92%
2%
5%
Each technician has documented competency for the tasks within his job
description.
91%
2%
7%
Tech-check-tech when appropriate information technology and other
safeguards are in place to ensure accuracy and safety.
71%
26%
3%
WHY TO PURSUE ADVANCED ROLES, TRAINING AND FURTHER DEVELOPMENT
Health care organizations are facing a veritable health care tsunami: ICD 10, value-based
purchasing, Medicaid expansion, and the unknown potential impact of the Affordable Care Act,
just to name a few. These initiatives are placing a renewed focus on improving clinical
outcomes, improving safety and quality, and controlling costs. With an effective pharmacy
practice model, pharmacists and pharmacy technicians will be able to effectively support each
of these initiatives. The effectiveness of a pharmacy practice model will, in large part, be
determined by the ability of pharmacies to leverage the unique skills and expertise of certified
pharmacy technicians. Historically, pharmacists have been reluctant to delegate many routine
responsibilities to pharmacy technicians. However, as pharmacist roles evolve and the scope of
pharmacy practice changes, the delegation of basic dispensing functions and other technical
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tasks becomes imperative. Pharmacists are shifting focus to spend more time on medication
therapy management and utilization and less time on dispensing functions.
Advancing the roles of pharmacy technicians should be an important focus for all pharmacy
departments. However, before technicians can begin to practice in these advanced roles, an
effective training program and evaluation methodology is needed. In many organizations,
technician training is inconsistent and not well defined. This often leads to high turnover and
staff dissatisfaction. Effective training programs have been shown to reduce turnover and
improve employee satisfaction.16,17 With standardized, reproducible training programs,
pharmacy technicians can begin to operate at higher levels within the health care system.
Advanced roles for pharmacy technicians extend pharmacy services and allow pharmacists to
focus on the aspects of the medication use system that require clinical decision making.
Pharmacy technicians fill drug orders, compound complex sterile products and maintain
medication stocks. In addition, they may: interact with patients to obtain accurate medication
histories for medication reconciliation; review medication profiles and lab results with defined
guidelines to support pharmacists; and evaluate, implement and maintain pharmacy
automation. Utilizing unit-based pharmacy technicians to coordinate and communicate
medication needs has been shown to reduce calls to pharmacy and reduce the number of late
or missed medication administration events.18 Pharmacy technicians have also been shown to
positively impact the accuracy of medication histories taken for medication reconciliation. 13,19
Although the need to advance pharmacy technician roles is clear, the environment to foster this
advancement is lacking. Barriers to broader, systematic advancement include inconsistent
state requirements for pharmacy technicians and the lack of advanced or specialty technician
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certification. According to Everett McAllister, chief executive officer and executive director of
PTCB, the next step in advancing the role of the pharmacy technician is to “develop an
enhanced credentialing system.”20 Many organizations have transformed their pharmacy
practice models to be more nimble and more responsive to the changing needs of the health
care landscape. Doing so has allowed pharmacists to move beyond traditional dispensing roles
and assume more responsibility for clinical outcomes. In order to sustain the gains and further
develop the role of pharmacists and pharmacy technicians, organizations must develop new
ways of thinking around the deployment of pharmacy resources. Providing challenging,
rewarding opportunities promises to improve retention, satisfaction and, ultimately, patient
outcomes.
The Michigan Society of Health-System Pharmacists Board of Directors approved the content of
this white paper on Jan. 15, 2015. Ed.
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2
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3
Michigan Senate Bill 0092.
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4
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van den Bemt PM, van den Broek S, van Nunen AK et al. Medication reconciliation
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