Clinical Services Result in Staffing Evolutions

Everything a pharmacist does has consequences. Especially moving toward increased clinical services. As the pharmacist moves closer to the top of their scope of practice, the entire pharmacy support staff must amp up their own practice. Technicians, clerks, even front-end cashiers take on new responsibilities to support the pharmacist’s increasing clinical role.

Technicians aren’t just running dispensing robots; they are managing the entire dispensing process. In some states, techs are checking other technology, administering vaccines, running telepharmacies, and filling in other duties once considered the pharmacist’s responsibility.

Clerks are moving up to fill dispensing-related tasks once reserved for techs, often becoming techs themselves. Cashiers aren’t just running registers, they are becoming living, breathing, smiling information resources who direct patients to the latest product and service offerings throughout the pharmacy.

Increasing support staff involvement in the provision of clinical pharmacy care does more than shift repetitive pieces of dispensing, inventory management, medication history, and other mechanical tasks away from pharmacists. 

“It is a paradigm shift in the use of technicians or other pharmacist extenders,” says Eric M. Maroyka, PharmD, BCPS, director of the Center on Pharmacy Practice Advancement for the ASHP. “Most states have recognized pharmacy technicians and have changed scope of practice to empower technicians to take medication histories and perform other tasks that used to require pharmacists. Staff can be repurposed to perform higher level tasks that can close quality and safety gaps. That frees up the pharmacist to pivot to a more service-based model working with the interprofessional care team or as an independent practitioner.”

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Carlie Traylor, PharmD, associate director of strategic initiatives for the NCPA, has worked with the new paradigm firsthand. She moved to NCPA after serving as Clinical Director of Chancy Drugs, a group of independent pharmacies in Georgia. 

“A generation ago, the pharmacist’s role was to input the prescription,” Traylor says. “Now it has evolved into a technician role. We are seeing this happening in the clinical field as well-medication therapy management, immunization, patient education, medication adherence, med synchronization. Technicians can be your foot soldiers to effectively triage patients and facilitate pharmacists to have more effective and efficient clinical interactions with more patients.” 

Empowering support staff can be a major boost for pharmacists working in comprehensive medication management in almost any setting. Jill Borchert, PharmD, professor and vice chair of pharmacy practice at Midwestern University Chicago College of Pharmacy was lead author on a 2018 American College of Clinical Pharmacy white paper on incorporating pharmacy techs and other support personnel into patient care processes. 

Best practices focus on matching the right support staffer with the right task to help the pharmacist focus on the tasks that best match their training.

Borchert works in ambulatory care, rooming patients, preforming point-of-care testing, documenting care. Does it really take a PharmD to test for strep infection? Or take a medication history?

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“Much of what we do may not require advanced training,” she says. “There’s good evidence that trained technicians can be truly effective in collecting patient information, performing some of those initial portions of medication reconciliation, documenting care, supporting the pharmacist. If we could be more efficient using support staff, we could potentially expand the reach of the pharmacist, see more patients, even potentially lower the overall cost of care.” 

Travis Wolff, PharmD, BCACP, thinks of support staff in terms of return on time investment (ROTI). Wolff, and his wife, Sunni Wolff, PharmD, own Med-World Pharmacy in Sapulpa, OK and Apothecary Pharmacy in nearby Mounds.  

They also run PharmFurther, a coaching business that helps community pharmacists work smarter instead of harder. “Working smarter,” according to the Wolffs, includes delegating every possible task to support staff. Running a pharmacy efficiently and effectively means managing resources efficiently and effectively. A pharmacist’s most valuable, most limited resource is time.

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“We’ve learned the hard way to ask every time if this is a clinically relevant task that requires a pharmacist’s clinical decision-making or to meet a regulatory requirement. If it doesn’t come down to one of those two things, you probably shouldn’t be doing it yourself,” says Wolff.

“We delegate and filter that ROTI concept through everyone’s workflow and systems. If you don’t delegate tasks that your support staff should be doing, you become the bottleneck in the pharmacy workflow and patient care. The rest of the staff can’t do their jobs properly because you are getting in the way and slowing them down.”

Evolution Across Settings

What to call those non-pharmacist staffers is unclear because staff roles, like pharmacist roles, are governed by state law. 

A task that might require a tech in one state might be done by a clerk in another state and not specified in another jurisdiction. Where some states require little more than a registration for techs, a growing number of states require accredited training and third-party certification to work as a tech. 

“It ends up being that collective group of pharmacy personnel, namely pharmacy technicians, that are a great group to step into these changing roles,” notes David R. Bright, PharmD, associate professor of pharmaceutical sciences at Ferris State University College of Pharmacy. 

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“We may end up seeing more of a differentiation between more advanced technicians and entry level technicians. The Pharmacy Technician Certification Board is creating an advanced technician designation and credentialing to support the profession moving in that direction.”

Bright likens the growing importance of pharmacy technicians to similar changes in medical practice.

Medical practices have evolved from a physician-nurse-receptionist to include the physician, physician’s assistants, nurse practitioners, medical assistants, billing clerks, insurance and patient assistance program specialists, and more. Just as the physician remains responsible for the entire practice and depends on a growing variety of mid-level practitioners and support staff, pharmacy is developing its own cadre of support staff. 

The composition of the pharmacy team, and the tasks each member performs, depends on state law, the needs of the practice and its patients, and the pharmacists’ own preferences.

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“We have pharmacies with four or five pharmacists and the demands on the technicians are very different than in stores with a single pharmacist,” says Brian Hille, BSPharm, vice president of specialty and wellness services for Albertsons Companies. 

“The direction of travel has been to allow greater technician assistance to the pharmacist. Every pharmacy operates a little differently and you have needs and demands according to the type of pharmacy, the patient population, the volume, the needs of the pharmacist. In our Idaho stores, technicians are administering vaccinations. Just as vaccinations opened the door for a lot of clinical services by pharmacists, doors are opening for technicians.”

A Professional Career Ladder

It wasn’t long ago that techs did little more than fill pill vials. In 2019, techs are taking on a growing variety of duties in pharmacy administration and management, quality control and assurance, sterile and nonsterile compounding, and a growing list of patient-facing clinical tasks, starting with point of care testing and immunizations.

“It’s still early, we’ve only seen two states go down that immunization path,” says Bill Schimmel, PTCB executive director and chief executive officer. “And we are seeing this same conversation at other boards of pharmacy. These conversations around hiring, training, and delegation by pharmacists are happening in every board of pharmacy as well as state and national pharmacy associations. And almost every employer out there is having the same discussion, from large chains to independent pharmacies.”

Maroyka likened the shift to radiology. Radiology techs once did little more than adjust radiation shields and position film sheets for x-rays. The radiologist did everything else. Today, radiology techs do everything except read and interpret the image. 

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“[Radiology technicians] have created a very structured set of credentials and have carved a path to a recognized career,” Mayorka says. “That is what we are doing as we look to professionalize the pharmacy technician workforce.”

ASHP and the Accreditation Council for Pharmacy Education revised accreditation standards for tech education and training following a consensus conference in 2017. Effective at the start of 2019, nine standards were added to the previous six, and emulate the elements of pharmacist training and education programs while emphasizing collaboration with pharmacists and other members of the healthcare team.

PTCB built on those new standards to roll out its own Advanced Certified Pharmacy Technician (CPhT-Adv) credential. The new credential is supported by new assessment-based certificate programs that will launch in late 2019 and 2020. 

The first five programs include Technician Product Verification (TPV), Medication History, Controlled Substance Diversion Prevention, Billing and Reimbursement, and Hazardous Drug Management.

To earn the CPhT-Adv certification, CPhT level techs need three years of work experience plus four of the first five assessment-based certificates. 

No One Left Behind

The new accreditation standards and certificates continue to recognize the value of on-the-job training, says Lisa Lifshin, BSPharm, ASHP’s director of Pharmacy Technician Program Accreditation & Residency Services. The ultimate goal is for all pharmacy technicians to complete a formalized, standardized training program. 

“Similar to pharmacists who have gone through pharmacy school, we want every prospective employer, every state board of pharmacy, to know what each level of technician has been through and can be expected to know,” Lifshin says. “That is the point at which we can all go back and say let’s have another look at technician ratios to help pharmacists meet their full potential in patient care.”

Standardizing support staff training and certification is no easier than standardizing anything else in pharmacy across 50 state practice acts and pharmacy boards. The process starts with one or two states willing to trial an innovative practice such as allowing pharmacists to prescribe specific medications or allowing technicians to administer vaccination.

“The question is making those a practice standard nationally,” says Elizabeth Cardello, RPh, senior director of corporate alliances for the APhA. “[APhA] is working collaboratively with other pharmacy associations, the practice community, and regulatory entities to make sure best practices become standard and consistent. We did it with immunization protocols across all 50 states and we will do it in these other areas as well.”

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The next changes to standard practice could be in TPV, which allows technicians to take on a larger portion of the dispensing process, Schimmel predicts. Expect to see more technicians taking charge of inventory management, purchasing, scheduling, billing and reimbursement, serving on pharmacy boards, and taking patient information. 

One thing techs are unlikely to be doing anytime soon is counseling patients. 

”Pharmacists have extensive training, knowledge, and expertise,” Schimmel says. “If I have a question about my prescription, I really do want to talk with the pharmacist.”