TY - JOUR
AU1 - Vest, Tyler A
AU2 - Gazda, Nicholas P
AU3 - Eckel, Stephen F
AB - administration, dispensing, medication-use process, monitoring, pharmacy, prescribing The medication-use process (MUP) is the essential and foundational system that provides the framework for safe medication use within the healthcare environment, ensuring medications are utilized and patients are followed in the most appropriate manner across all settings.1 As stewards for appropriate medication use within healthcare organizations, health-system pharmacists have a leadership role in optimizing the MUP to increase the efficiency and safety of patient care.1 The US Pharmacopeia describes 8 major steps of the MUP: procurement, prescribing, transcribing, order entry, preparation, dispensing, administration, and monitoring.1 The MUP is represented in Figure 1. The authors have used the working terms of prescribing/transcribing, dispensing, administration, and monitoring for the 4 steps of the MUP because the broad use of computerized prescriber order entry (CPOE) has limited transcribing.2 The American Society of Health-System Pharmacists (ASHP) has been an advocate for the importance of the role of the pharmacist in the MUP through advocacy, policy statements, and publications.2-7 Figure 1. Open in new tabDownload slide The medication-use process. ADCs indicates automated dispensing cabinets; BCMA, barcode medication administration; CDSS, clinical decision support system; CPOE, computerized prescriber order entry; IV TAWF, intravenous technology-assisted workflow. Figure 1. Open in new tabDownload slide The medication-use process. ADCs indicates automated dispensing cabinets; BCMA, barcode medication administration; CDSS, clinical decision support system; CPOE, computerized prescriber order entry; IV TAWF, intravenous technology-assisted workflow. Although ASHP and the American Journal of Health-System Pharmacy (AJHP) have been active in publishing evidence and materials in different areas of pharmacy practice over the years, healthcare changes and new emerging technologies continue to transform the ideal MUP. Because of this, it is important for health-system pharmacy leaders to understand the fundamental concepts and literature supporting various improvements and exploration regarding the current and future state of the MUP. For pharmacy leaders to implement evidence-based best practices across the pharmacy enterprise, they must understand the literature that is being published on the MUP both in pharmacy and nonpharmacy journals. Publications that provide a review of the recent literature around the MUP can be an efficient aid to pharmacy leaders who do not have sufficient time to thoroughly review the wealth of pharmacy literature published yearly.8-10 The purpose of this commentary is to review professional and regulatory guidelines that demonstrate the need for and essential nature of pharmacy departments in prioritizing the MUP, share literature trends that the authors have observed regarding the MUP, and identify future considerations for the profession as pharmacy leaders take responsibility and accountability for the MUP within their organizations. Professional and regulatory guidelines The MUP is of particular interest to pharmacy leaders because of the potential impact it has on clinical outcomes, operational efficiency, and finance. However, the MUP also has a significant impact on patient safety. Medical errors due to medications cause upwards of 100,000 deaths annually, signifying the importance of the MUP.11 These safety implications are why the MUP is highly scrutinized by regulatory bodies and professional organizations. Due to the ever-increasing number of medications on the market and the unique coordination required to program them into various electronic systems, it is of the utmost importance that organizations have robust and sound medication-use systems to minimize medication errors. The Joint Commission, a main accrediting body for hospitals across the country, provides numerous standards addressing the MUP and best practices to follow. In the medication management section of the Joint Commission standards, specific standards have been developed around the main phases of the MUP (ie, prescribing/transcribing, dispensing, administration, and monitoring).12 These standards focus on practices that optimize safety for patients, including standards around labeling, storage, transportation, verifying the 5 R’s, responding to adverse events, and data-focused evaluation of errors.12 The Joint Commission gives institutions flexibility in the methods they use to meet these standards.12 That is why it is critical to lead an evidence-based department and stay up to date on literature and advances in the MUP to ensure organizations are is promoting best practices set forth in the various recommendations of regulatory bodies. The MUP is also recognized as a foundational tenet of pharmacy practice, which is emphasized by professional organizations through guideline documents developed by organizational membership. In the ASHP guidelines on preventing medication errors in hospitals, there is a call for pharmacist interdisciplinary participation on hospital and health-system committees to ensure there are checks and balances across all steps of the MUP.13 These guidelines call for technology and innovative practices to ensure safety and efficacy across the MUP.13 Other organizations, such as the Institute for Safe Medication Practices (ISMP), provide tools and self-assessments to improve the MUP at all organizations.14-16 This again emphasizes the importance institutions must place on meeting regulatory guidelines. There is a continued need for research on the MUP to ensure that guidelines developed are informed by high-quality evidence and that organizations use this evidence in their approach to providing patient care. This need for high-quality evidence is no different from that in clinical practice and pharmacotherapy recommendations.17 Literature trends In reviewing the accumulated evidence in published studies, the authors have identified certain trends. Whether these studies end up being highlighted in the annual review of practice-enhancing publications or not, it is critical to understand the type of evidence being evaluated. In the prescribing/transcribing step, a growing number of investigators are exploring the impact of clinical decision support systems and how they affect appropriate medication use.8-10 Of the 17 articles reviewed in the 2019 publication, 14 were directly related to CPOE and clinical decision support.10 This includes the impact alerts can have on medication errors and continued optimization of alert technology.10 Several studies have discussed the merits and pitfalls of alert technology and alert fatigue.8-10 Studies have also evaluated the impact of these tools on drug allergies and appropriate medication choice.8-10 This is a growing area of scholarship as CPOE systems have been described in the literature for many years and constitute a mature pharmacy management topic.8-10 However, implementation of CPOE can have unintended consequences and result in potential errors due to utilizing technology, creating a need to manage, maintain, and regularly update CPOE systems.8-10 There is a continued need in the literature to evaluate the optimal ways to manage these unintended consequences. The last 3 years of literature and research on the dispensing step have focused on technologies that improve the overall dispensing process and the development and advancement of pharmacy technicians to improve the dispensing process.8-10 Technologies that have been discussed include intravenous technology-assisted workflow systems and various devices such as closed-system drug transfer devices, automated dispensing cabinets, and robotics.8-10 The literature focuses on many implementation projects around these technologies, but there is a continued need for more robust long-term evaluation of the impact of these technologies on efficiency, safety, and cost savings.8-10 Pharmacy technicians have been utilized in several studies to improve dispensing, specifically in the context of product verification.8-10 However, most studies have focused on the merits of the technologies.8-10 There is an opportunity to focus future studies on how personnel resources can be best allocated to support new technologies. The dispensing step of the MUP continues to be an ongoing focus of research in the profession. With respect to the administration step of the MUP, the last 3 years of literature and research have focused heavily on emerging technology and optimization of existing technology.8-10 There has also been a look forward to proactively identify high-risk areas within the hospital and the risk factors associated with and leading to adverse drug events. One technology that has frequently been studied in the literature is barcode medication administration. Articles have focused on the emergence of this technology as well as the interdisciplinary interplay between pharmacists and their nursing colleagues.8-10 However, despite the identification of high-quality articles on administration in the last 3 annual review publications, the administration step is frequently the least researched step of the MUP, with fewer than 10 articles identified for ranking in each of the annual publications.8-10 There is an opportunity for sites to both focus on the administration step of the MUP and contribute to the literature on this topic. The monitoring step, in contrast to the administration step, has had the largest number of identified articles to rank in each of the 3 publication years, with 25 articles identified in the 2019 publication.8-10 This is likely due to a significant amount of innovation across the pharmacy enterprise with ongoing monitoring and optimization of clinical care once treatment decisions have been made. At the onset of our article series, antimicrobial stewardship was one of the most researched topics. However, articles in this area have tapered off, with studies transitioning to broader concepts such as medication reconciliation, technology around transitions of care, and clinical trigger tools. Transitions of care and the roles pharmacists play in both the acute and ambulatory care settings are emerging as areas of opportunity for continued research in the MUP.8-10 As was common among the other steps of the MUP, technology has played a significant role in publications in the monitoring section of the article series.8-10 Use of the electronic health record (EHR) and trigger tools to identify mistakes at discharge, provide ongoing monitoring, and minimize risk was frequently highlighted.8-10 The MUP remains a topic of research in the literature.8-10 However, as previously mentioned, many publications have focused on implementation projects at single sites. There have been very few randomized or prospective studies to evaluate the impact of technologies or new services on efficiency or patient outcomes.8-10 There is a great need for multisite evaluations of newer technologies in the MUP. Articles emerging in the transitions of care and ambulatory space have highlighted the importance of not only evaluating acute care medication use but also considering and studying the impact of the MUP across the care continuum.8-10 Future considerations The MUP is continually evolving as new healthcare technologies are introduced, literature is published that demonstrates new and better ways to care for patients, and health systems merge multiple individual hospitals into integrated delivery networks. One significant change relates to the transcribing stage. Over a decade ago, most hospitals relied on pen and paper for prescribing. Physicians, or other healthcare providers, would handwrite medication orders in physical medical charts while rounding. The charts would be flagged to indicate there was a new order in them and then placed at the central nursing station. Health unit coordinators (HUCs), or individuals in similar positions, would pull the orders from the charts and send a copy to the pharmacy. A pharmacy technician would enter the order into the pharmacy information system, and a pharmacist would verify it. The HUC would also transcribe the order to a paper medication administration record (MAR), to be later verified by nursing. This record would document medication administration until the next 24-hour period, when pharmacy would generate the MAR. Today, with CPOE commonplace in all institutions, this process is a relic of the past. Providers now use CPOE while on rounds. Orders are electronically sent to pharmacy for verification and also automatically updated to the electronic MAR. The roles that the HUC and pharmacy technician used to have are no longer needed, and, as a consequence, it is no longer necessary to distinguish the transcribing step as a separate step in the MUP. With CPOE, the MUP now essentially goes from prescribing to dispensing. There are other trends in healthcare that deserve attention for their potential to impact the MUP, just like CPOE has removed the transcribing step. In the following, we discuss these trends and the potential impacts they might have. Increasing role of health systems in ambulatory care. The MUP is traditionally thought of as relating to acute care. This is because the transcribing and administration steps are traditionally considered to be related to an HUC writing on the MAR and nurses giving the medication. When a patient is in the ambulatory care setting and taking their own medications at home, the MUP is not usually mentioned or considered. Also, participants are usually siloed and not connected with an EHR. However, as health systems continue to expand into the ambulatory care setting, aided by the increasing complexity of medication therapy regimens, the ideal steps in the MUP for this setting need to be better understood and research needs to be conducted that illustrates best practices and areas for improvement. It will also be necessary to place the pharmacy department leadership roles of the MUP in the context of the ambulatory care setting. Increased use of enterprise informatic systems spanning the health system. As organizations move from “best of breed” information systems (systems from multiple vendors that are connected through interfaces) to “enterprise” systems (all one vendor and system), efficiencies will increase. These systems will continue to have better clinical decision support and introduce artificial intelligence/machine learning into the processing of orders. However, as processes become more automated, how do the roles of providers, pharmacists, and nurses evolve to better care for patients with the freed-up time? This needs to be studied to understand current gaps in care and how these different health professionals can work to move toward zero patient harm. Increased virtual nature of care. The traditional MUP relies on healthcare professionals being located at the point of care. Providers prescribe in the patient’s room, pharmacists verify orders in the hospital, and nurses are on the ward. As technology improves and healthcare becomes more comfortable with virtual care, individual providers can be located in different places. These individuals might not even be in the vicinity of where healthcare is occurring. In addition, as patients desire to stay at home and it is more efficient to deliver care virtually, the MUP will look very different than it does today. Evolving role of pharmacy technicians. In the traditional MUP, pharmacy technicians were responsible for entering orders into the pharmacy information system. These individuals also filled automated dispensing machines and compounded sterile preparations. With the advent of CPOE with enterprise systems and ready-to-use intravenous medications, these activities are no longer needed. With the opportunity to utilize these individuals in unique roles such as meds-to-beds programs and taking of admission medication histories, care for patients should only improve. This will also lead to these individuals needing better training and hopefully higher salaries, as well as further professionalization of their roles. Placing these individuals in critical roles interfacing with patients could be a great opportunity for pharmacy technicians, and studies need to be completed to evaluate this. Understanding how the formulary and procurement impact the MUP. Although US Pharmacopeia has an 8-step process (Figure 1), many people think the MUP traditionally starts at prescribing. However, numerous steps must occur before the provider requests a certain medication. The pharmacy and therapeutics committee needs to determine the optimal medications that will be allowed for use in the organization. There is also a process for procurement that requires attention to the supply chain. This could include sourcing sterile products from appropriate compounding manufacturers or determining how to respond to a drug shortage. All these decisions can have a significant impact on the MUP. In addition to the intricacies of technology and patient care and the rapidly evolving healthcare landscape, the complexity of the MUP is further increased by federal regulations such as the Drug Supply Chain Security Act.18 Organizations will have to optimize their workflows to ensure that they are sourcing products that adhere to such laws. If we include these steps into the MUP, pharmacy departments will understand the critical link they are to patient care and the rest of the organization will appreciate their importance. Growing need for aggregation of data and utilization of analytical tools. Our automated pharmacy systems generate significant amounts of data. Many times, these disparate systems keep the data they generate separate. It is incumbent on pharmacy departments to strive to pull all these datastreams into one database. The pharmacy department can then utilize various analytical tools to evaluate the efficiency, safety, and cost-effectiveness of what they do. They can also use the data to identify optimal care delivery models and evaluate the return on investment for various technologies. However, to do this, the first step is to aggregate data and then sort it to assist with decision-making. The importance that the pharmacy department has in the MUP will only grow over time. Pharmacy leadership needs to understand that their department, more than anyone else, is responsible for stewardship of the MUP. They are accountable and responsible for it and should demonstrate their leadership of the MUP to their organization. When there are failures of the MUP, patient care becomes inefficient or unsafe. This means that a nonoptimized MUP could lead to medication errors or patient care that takes longer or is more expensive than it should be. Who else but pharmacy can optimally shepherd it? Conclusion The MUP will never go away, and continues to be a focused topic of research. As new technology is implemented in patient care, the MUP will become more complicated and less dependent on humans. However, it will still require an oversight group to ensure that it functions well and that patient care is safe. Professional guidelines, regulatory standards, and literature trends support the need for pharmacy to have ownership of the MUP. The future considerations discussed further expand on the need for pharmacy to take charge. Pharmacists have all the knowledge and training to do this well; however, it will require a better understanding of data and informatics. Monitoring the future MUP will require analysis of data and understanding of technology. Pharmacy is ideally positioned to lead the health system through the MUP into the future of patient care. To do this, it is important to routinely review the published literature and to incorporate significant findings into daily practice. Health-system pharmacists have an active role in improving the MUP at their institutions, and awareness of research in this area can assist in changing practice at the institutional level. The essential nature of the MUP is the basis of safe and effective medication use in the health system. This article is part of a special AJHP theme issue on the impact of pharmacy departments on the medication-use process. Contributions to this issue were coordinated by Stephen F. Eckel, PharmD, MHA, and Rita Jew, PharmD, MBA, BCPPS, FASHP. Disclosures The authors have declared no potential conflicts of interest. References 1. United States Pharmacopeia . USP-NF general chapter <1006> physical environments that promote safe medication use . Accessed September 6, 2018 . https://www.uspnf.com/sites/default/files/usp_pdf/EN/USPNF/c1066.pdf 2. Pedersen CA , Schneider PJ, Ganio MC, et al. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2019 . Am J Health-Syst Pharm. 2020 ; 77 ( 13 ): 1026 - 1050 . Google Scholar Crossref Search ADS PubMed WorldCat 3. American Society of Health-System Pharmacists . The consensus of the Pharmacy Practice Model Summit . Am J Health-Syst Pharm . 2011 ; 68 ( 12 ): 1148 - 1152 . Crossref Search ADS PubMed WorldCat 4. American Society of Health-System Pharmacists . ASHP Practice Advancement Initiative 2030: new recommendations for advancing pharmacy practice in health systems . Am J Health-Syst Pharm . 2020 ; 77 ( 2 ): 113 - 121 . Crossref Search ADS PubMed WorldCat 5. Pedersen CA , Schneider PJ, Ganio MC, et al. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2018 . Am J Health-Syst Pharm . 2019 ; 76 ( 14 ): 1038 - 1058 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Schneider PJ , Pedersen CA, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017 . Am J Health-Syst Pharm . 2018 ; 75 ( 16 ): 1203 - 1226 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Schneider PJ , Pedersen CA, Ganio MC, et al. ASHP national survey of pharmacy practice in hospital settings: workforce—2018 . Am J Health-Syst Pharm . 2019 ; 76 ( 15 ): 1127 - 1141 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Vest TA , Gazda NP, Schenkat DH, et al. Practice-enhancing publications about the medication use process in 2017 . Am J Health-Syst Pharm . 2019 ; 76 ( 10 ): 667 - 676 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Vest TA , Gazda NP, Schenkat DH, et al. Practice-enhancing publications about the medication-use process in 2018 . Am J Health-Syst Pharm . 2020 ; 77 ( 10 ): 759 - 770 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Vest TA , Gazda NP, Schenkat DH, et al. Practice-enhancing publications about the medication-use process in 2019 . Am J Health-Syst Pharm . 2021 ; 78 ( 2 ): 141 - 153 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Saljoughian M . Avoiding medication errors . US Pharmacist. 2020 ; 45 ( 6 ): 10 - 11 . Google Scholar OpenURL Placeholder Text WorldCat 12. Joint Commission . Standards . Accessed July 6, 2021 . https://www.jointcommission.org/standards/ 13. Billstein- Leber M , Carrillo CJ, Cassano AT, et al. ASHP guidelines on preventing medication errors in hospitals . Am J Health-Syst Pharm . 2018 ; 75 ( 19 ): 1493 - 1517 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Institute for Safe Medication Practices . Resource library . Accessed July 8, 2021 . https://www.ismp.org/resources?field_resource_type_target_id%5B12%5D=12#resources--resources_list 15. Institute for Safe Medication Practices . Self assessments . Accessed July 8, 2021 . https://www.ismp.org/self-assessments 16. Institute for Safe Medication Practices . Tools . Accessed July 6, 2021 . https://www.ismp.org/tools 17. Lesar T , Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes . Jt Comm J Qual Saf. 2003 ; 29 ( 5 ): 211 - 226 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 18. Food and Drug Administration . Drug Supply Chain Security Act (DSCSA) . Accessed July 12, 2021 . https://www.fda.gov/drugs/drug-supply-chain-integrity/drug-supply-chain-security-act-dscsa © American Society of Health-System Pharmacists 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - The essential nature of and continued need for health systems to prioritize the medication-use process
JF - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/zxab404
DA - 2021-10-27
UR - https://www.deepdyve.com/lp/oxford-university-press/the-essential-nature-of-and-continued-need-for-health-systems-to-l34ftWviTf
SP - 314
EP - 318
VL - 79
IS - 4
DP - DeepDyve
ER -