Implementation of the Pharmacy Practice Model Initiative within ...

PRACTICE REPORT Pharmacy Practice Model Initiative

PRACTICE REPORT

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Implementation of the Pharmacy Practice Model Initiative within comprehensive cancer centers Morgan B. Smith, Karl F. Gumpper, Grazyna Riebandt, and Evelyn M. Handel

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n recent years, progress has been made in transitioning the practice of pharmacy from a profession focused on product preparation and dispensing to one that centers on the provision of patient care services. This transformation has contributed to pharmacists becoming more valued members of interprofessional healthcare teams in a variety of practice settings. Now that healthcare reform has become a priority within the United States, it is imperative that the pharmacy profession responds by shaping its members into forward-thinking healthcare providers capable of providing optimal

Purpose. The progress made by cancer centers across the United States adopting the goals and measures of the Pharmacy Practice Model Initiative (PPMI) was studied. Methods. In collaboration with ASHP, the official PPMI hospital self-assessment (HSA) questionnaire and a 10-item supplemental survey specific to oncology pharmacy services were disseminated via e-mail to all 41 National Cancer Institute designated comprehensive cancer centers in the United States. Results. The HSA results of 26 (63%) of the 41 institutions surveyed were included in the analysis. Of the 26 participating institutions, 15 (58%) also completed the supplemental survey. Advanced pharmacist roles are highly prevalent among comprehensive cancer centers, with all institutions giving pharmacists discharge counseling responsibilities and deploying pharmacists to patient care units. Twentyfive institutions (96%) provide some level of pharmacist-driven drug therapy management services in at least some areas or

Morgan B. Smith, Pharm.D., is Outpatient Hematology/ Oncology Specialist, Novant Health Presbyterian Medical Center, Charlotte, NC; at the time of writing she was Resident Pharmacist, Roswell Park Cancer Institute, Buffalo, NY. Karl F. Gumpper, B.S.Pharm., BCPS, CPHIMS, FASHP, is Team Leader, Pharmacy Informatics, Boston Children’s Hospital, Boston, MA; at the time of writing he was Director of Pharmacy Informatics and Technology, American Society of Health-System Pharmacists, Bethesda, MD. Grazyna Riebandt, Pharm.D., BCOP, is Clinical Pharmacy Services Director; and Evelyn M. Handel, Pharm.D., BCOP, is Clinical Pharmacist Specialist, Roswell Park Cancer Institute. Address correspondence to Dr. Handel (evelyn.handel@ roswellpark.org). The following participating institutions completed both the hospital self-assessment and the 10-item supplemental survey: Abramson Cancer Center at Hospital of the University of Pennsylvania, Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Barbara Ann

situations and most often in the inpatient setting. Implementation of automation and technology in the areas of dispensing and order entry has occurred in over 80% of institutions. Advancement of pharmacy technician roles has received the least attention, with only 13 centers (50%) giving technicians sole responsibility for traditional dispensing functions, and 11 (42%) allowing technicians three or more advanced responsibilities. Only 12 institutions (46%) have established mechanisms to hold their pharmacists accountable for medication-related outcomes. Conclusion. Based on the survey results, suggested areas of improvement include the provision of drug therapy management in the outpatient setting, advancement in technician roles, utilization of automation and technology particularly at the point of administration, and implementation of mechanisms to hold pharmacists accountable for medication-related outcomes of their patients. Am J Health-Syst Pharm. 2014; 71:164760

Karmanos Cancer Institute, Georgetown Lombardi Comprehensive Cancer Center at Georgetown Medical Center, H. Lee Moffitt Cancer Center and Research Institute, Holden Comprehensive Cancer Center at the University of Iowa Hospitals and Clinics, Masonic Cancer Center at the University of Minnesota Medical Center, Mayo Clinic Cancer Center and Mayo Clinic St. Mary’s Hospital, Robert H. Lurie Comprehensive Cancer Center at Northwestern Memorial Hospital, Roswell Park Cancer Institute, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Smilow Cancer Center at Yale-New Haven Hospital, University of Michigan Comprehensive Cancer Center at University of Michigan Hospitals, VanderbiltIngram Cancer Center at Vanderbilt University Hospital, and Wake Forest Comprehensive Cancer Center at Wake Forest Baptist Health. The authors have declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/1001-1647. DOI 10.2146/ajhp140137

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

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pharmaceutical care within current and future health systems.1-3 The Pharmacy Practice Model Initiative (PPMI) is a progressive movement intended to further mold the practice of pharmacy and benefit patient care by encouraging the growth of pharmacists into effective direct patient care providers. Oncology pharmacy is a specialty area that has become increasingly prominent in recent years. Given the anticipated 48% increase in the cancer rate and 81% increase in patients living with or surviving cancer by 2020, the demand for providers of oncology services is expected to dramatically increase.4 As a result, the incorporation of pharmacists into clinical, administrative, and direct patient care positions that improve healthcare efficiency and outcomes has become of vital importance. Although large academic medical centers and pediatric hospitals across the United States are making progress in adopting the elements of the PPMI,5 the implementation of the PPMI specifically within comprehensive cancer centers has yet to be analyzed. The primary objective of this study was to evaluate the overall progress of comprehensive cancer centers across the country in adopting the components of the PPMI. This progress was measured through analysis of the hospital self-assessment (HSA) survey results. Background Sponsored by ASHP and the ASHP Research and Education Foundation, the PPMI was developed as a result of the 2010 Pharmacy Practice Model Summit held in Dallas, Texas. During this conference, 150 hospital and health-system pharmacist leaders met and came to a consensus regarding the optimal model of pharmaceutical care with a focus on direct patient care.6 Five goals reflecting various aspects of pharmaceutical care over the past five decades were formulated with a total 1648

of 26 measures of their achievement.5 These goals were created with the intent to shape pharmacy practice models within healthcare facilities across the country to provide novel and innovative patient-centered services necessary for the future of healthcare in the United States. The five goals of the PPMI listed on the National Dashboard are as follows5: 1. Pharmacist roles, practices, and activities will improve medication use and optimize medication-related outcomes. 2. Pharmacy technicians will prepare and distribute medications and perform other functions that do not require a pharmacist’s professional judgment. 3. Pharmacists and pharmacy technicians will have appropriate training and credentials for the activities performed within their scope of practice. 4. Pharmacy departments will utilize available automation and technology to improve patient safety and improve efficiency. 5. Pharmacists will demonstrate leadership in exercising their responsibility for medication-use systems and will be accountable for medication-related patient outcomes.

The National Dashboard displays the cumulative progress health systems have made in implementing the goals and measures of the PPMI. The lengthy survey tool used by ASHP to assess this progress is the ASHP National Survey of Pharmacy Practice in Hospital Settings, which is given to a random sample of academic medical centers and pediatric hospitals every year.5 Standalone cancer centers and specialty hospitals are not included in this population. A more readily available tool is the HSA, which allows pharmacists to determine how their hospital or health system aligns with the goals of the PPMI and is recommended to be taken as frequently as desired, especially after changes involving the pharmacy department are


made. 7 The HSA is administered through the PPMI website, and responses are tracked by ASHP. Only one submission from each facility annually can be considered “official” for data-reporting purposes. Within each state, participation in the HSA, on average, was relatively low in 2013, with only five states having over 50% of institutions completing the assessment (Maine, New Hampshire, Rhode Island, Washington, and Wisconsin). Most states have completion rates of 5–25%; in seven states, only 1–5% of hospitals and health systems have taken the survey.8 Contrary to the population primarily assessed to determine implementation of the goals and measures displayed on the National Dashboard, HSA responses have been primarily from smaller community hospitals (62%). Large academic medical centers comprise only 10% of HSA respondents. Methods A panel of all 41 National Cancer Institute (NCI)-designated comprehensive cancer centers was invited to participate in the survey. Panel participants included the director or chief of pharmacy for each institution and postgraduate year 2 (PGY2) oncology residency program directors for institutions with such programs. In November 2013, a 10-item survey (appendix) was distributed to the panel participants (n = 76) via e-mail with a request to also complete the PPMI HSA. Institutions were given four weeks to complete both surveys and were informed of the anonymity of their responses. Reminder e-mails were sent weekly by the research team in efforts to increase response rates. All e-mails also described incentives for full participation (completion of both surveys), which included publication acknowledgement and the receipt of a cumulative data report via e-mail containing a summary of the data collected from all responders for both the HSA and the supplemental survey questions.


Each institution that was identified as an NCI-designated cancer center was flagged in the HSA database, so summary reports could be generated for completion and data analysis. In January 2014, final data reports containing the results from each participating institution for both the 10-item questionnaire and the most recent HSA on file with ASHP were transmitted to the research team for analysis. The aggregate results of these data were then compiled and used to determine overall progress in achieving specific PPMI goals and measures by participating comprehensive cancer centers. The HSA, a 106-item questionnaire used primarily for institutions to assess and monitor changes to their own pharmacy practice model, has not been validated in any large studies to definitively determine adoption of PPMI goals and specific measures. Thus, the research team correlated each measure of the PPMI with specific HSA questions that were determined to be most appropriate for assessing the implementation of that measure. In addition to the HSA, the supplementary 10-item survey was utilized to determine the advanced pharmacy practices specific to oncology services at surveyed institutions. The HSA is designed to evaluate pharmacy practice model change across an entire facility, without regard to specialty, and thus contains no questions specific to oncology pharmacy practice. The 10-item questionnaire was developed by the research team and used to further understand how NCI-designated comprehensive cancer centers are expanding pharmacy services as they relate to advanced pharmacist roles and chemotherapy dispensing. All composite responses to reported items from the HSA are shown as the number (n) of institutions with percentages. Due to the small sample size, composite responses to reported items from the 10-item questionnaire utilizing continuous numerical values

are reported as medians with interquartile ranges (IQRs). Since there was no comparator group, confidence intervals and p values were not used. Results Of the 41 NCI-designated comprehensive cancer centers, 26 institutions (63%)completed the HSA since the release of the tool by ASHP in 2011, and 10 completed the survey in 2013, representing 20 states. Twentyone (81%) of the 26 institutions were classified as large academic medical centers with a median bed size

of 451.5 (IQR, 365.5–785.5) (Table 1). Pharmacy practice model types varied, with more than two thirds of centers claiming to have a comprehensive model consisting of pharmacists practicing in distributive, generalist, and specialist roles. Of the 26 participating institutions that completed the HSA, 15 (58%) also submitted responses to the supplemental 10-item questionnaire during the four-week survey period. Additional information for these institutions based on supplemental survey responses is

Table 1.

Characteristics of Institutions Having Completed the Hospital Self-Assessment Characteristic Region West Midwest South Northeast Hospital type Academic medical center/university hospital Community hospital Critical access hospital Long-term acute care hospital Pediatric hospital Rehabilitation hospital Specialty hospital (standalone cancer center) Veterans Affairs hospital Bed size 100–299 300–499 500–699 ≥700 Hospital Self-Assessment completion year 2011 2012 2013 Practice model type Mostly distributive pharmacists with limited clinical services Clinical generalist (integrated) model with limited differentiation of roles (nearly all pharmacists have distributive and clinical responsibilities) Separate clinical specialist and distributive roles Comprehensive model including pharmacists in distributive, generalist/integrated, and specialist roles

No. (%) Respondents (n = 26) 4 (15) 10 (39) 5 (19) 7 (27) 21 (81) 1 (4) 0 0 1 (4) 0 3 (12) 0 5 (19) 9 (35) 3 (12) 9 (35) 4 (15) 12 (46) 10 (39) 0

4 (15) 4 (15)

18 (69)


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presented in Table 2. Of the 10 items within the survey, results of 2 questions were excluded from this report for two reasons: (1) ambiguity in interpretation of item 1 among institutions caused some institutions to rank answers 1 to 5, not using any number more than once, while other institutions used the same numerical answer more than once, interpreting in such a way that more than one PPMI goal could be a top priority, and (2) differences in rankings and titles of pharmacists among institutions made item 4 very ambiguous, with some institutions not able to provide an answer.

Adoption rates of the five PPMI goals per HSA results are outlined below. Results from the supplemental survey specific to oncology pharmacy services (n = 15) are also presented below under the appropriate goal for each item. PPMI goal 1. Results for goal 1 are shown in Table 3. As a group, NCIdesignated comprehensive cancer centers have demonstrated pharmacist leadership in the provision of drug therapy management services. Twenty-five institutions (96%) reported pharmacist-driven drug therapy management at least in some areas regardless of medication com-

plexity (measures 1.6 and 1.7). This occurs more often in the inpatient than in the outpatient setting, with 16 institutions (62%) providing this service in “most to all” situations in the inpatient setting (measure 1.7), compared with 6 institutions (23%) in the outpatient setting (measure 1.6). A medication complexity index reportedly does not exist in 2 institutions providing these services to outpatients and 1 institution providing these services to inpatients. In addition to the above findings, 24 of these 25 institutions also reported that their pharmacists routinely document their recommendations in

Table 2.

Oncology Pharmacy-Specific Information Gathered From 10-Item Supplemental Survey (n = 15)a Characteristic Hospital type, no. (%) Standalone cancer center Cancer center integrated into a larger healthcare facility that also provides non-oncology-related patient care Median no. inpatient beds dedicated to providing cancer-related care to patients (IQR) Median no. oncology outpatient clinic visits (IQR) Median no. chemotherapy administration orders written daily (IQR) Median no. clinical pharmacist generalist (decentralized) FTEs assigned (IQR) Oncology inpatient care units Oncology outpatient clinics Median no. clinical pharmacist specialist FTEs assigned (IQR) Oncology inpatient care units Oncology outpatient clinics Institutions with pharmaicsts practicing in the following patient care settings, no. (%) Outpatient hematology clinic(s) Inpatient hematology Outpatient oncology clinic(s) Inpatient oncology Outpatient bone marrow transplantation Inpatient bone marrow transplantation Infectious diseases Anticoagulation management Pain/palliative care Nutrition Investigational drug service Institutions with an outpatient retail pharmacy capable of filling oral chemotherapy prescriptions, no. (%) Has such a pharmacy Onsite and owned by the institution Onsite and owned by an outside company Does not have such a pharmacy Affiliated with an offsite retail/specialty pharmacy Not affiliated with an offsite retail/specialty pharmacy IQR = interquartile range, FTE = full-time equivalent.

a

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Value

3 (20)

12 (80) 122 (89–145) 190 (65–350) 128 (68–200)

2 (1–6) 0 (0–8)

4 (2–7) 1 (0–2)

6 (40) 10 (67) 10 (67) 13 (87) 8 (53) 14 (93) 13 (87) 11 (73) 9 (60) 7 (47) 13 (87)

7 (47) 1 (7)

3 (20) 4 (27)


patients’ permanent medical records (measure 1.2). However, more participants reported that pharmacists

are authorized to write medication orders or prescriptions in the inpatient versus outpatient setting (85%

versus 73%; measure 1.3), and pharmacist authority to order serum medication concentrations was reported

Table 3.

Goal 1: Pharmacist Roles, Practices, and Activities Will Improve Medication Use and Optimize Medication-Related Outcomes No. (%) Respondents (n = 26)

Measure 1.1 Percentage of hospitals/health systems that have pharmacist review of all medication orders before the first dose is administered (either onsite or via telepharmacy except for procedure areas and emergency situations) Do pharmacists review medication orders before initial dose is administered? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) 1.2 Percentage of hospitals/health systems that require that pharmacists document their recommendations and follow‐up notes in the patients’ permanent medical records Are pharmacists in your hospital allowed to document recommendations and make follow‐up notes in patients’ permanent medical records? (expressed as no. [%] of “yes” answers) Do pharmacists routinely document recommendations and assess progress and achievement of therapeutic goals in patients’ medical records? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) 1.3 Percentage of hospitals/health systems where pharmacists have privileges to write medication orders (modify or initiate therapy) in the health care setting Are inpatient pharmacists authorized by policy or protocol to write medication orders as part of the pharmacists’ scope of practice? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) Are outpatient pharmacists authorized by policy or protocol to write medication orders and/ or prescriptions as part of the pharmacists’ scope of practice? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) Not applicable 1.4 Percentage of hospitals/health systems where pharmacists have the authority to order serum medication concentrations and other clinically important laboratory tests Do pharmacists have independent authority in your hospital to order serum concentrations and other clinically important laboratory analyses? (expressed as no. [%] of “yes” answers) 1.5 Percentage of hospitals/health systems that have pharmacists routinely assigned to patient care units/specialty services to provide drug therapy management at least 8 hr per day, 5 days a week for a majority of patients Are pharmacists assigned/deployed to patient‐care units at your hospital? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%)

2 (8) 24 (92) 0 0

24 (92)

5 (19) 7 (27) 13 (50) 1 (4)

7 (27) 3 (12) 12 (46) 4 (15)

2 (8) 0 17 (65) 6 (23) 1 (4)

14 (53)

6 (23) 16 (62) 4 (15) 0

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in only 14 centers (53%) (measure 1.4). Although 6 institutions reported having a pharmacist assigned to all patient care units at least 40 hours per week (measure 1.5), only 3 institutions (12%) reported that discharge education is provided to all patients (measure 1.8). All 26 institutions reported having pharmacists assigned to and providing discharge counseling for at least some of their inpatient population, which may or may not include oncology patients. Among comprehensive cancer centers, assignment of pharmacy resources to the oncology subspecialty is substantial. Deployment rates of pharmacists to both inpatient and outpatient oncology care units according to the supplemental survey (n = 15) are presented in Table 2. Patient care units with the highest rate of pharmacist allocation within participating institutions include in-

patient bone marrow transplantation (93%), inpatient oncology (87%), and infectious diseases (87%). Overall, allocation of pharmacists to inpatient hematology, oncology, and bone marrow transplantation care units exceeds that of outpatient care units in those settings. Within outpatient clinics, 8 of 15 centers (53%) reported the implementation of a pharmacist-run oral chemotherapy program in which pharmacists review oral chemotherapy prescriptions (n = 5, 63%), counsel patients on medications (n = 7, 88%), and follow up with patients and make recommendations regarding adverse reactions from therapy (n = 6, 75%). Of 7 institutions reporting to not have an oral chemotherapy program, 3 (20%) reported a pharmacist-run program being in development, and another 3 (20%) reported that these services are provided by another

practitioner (registered nurse, nurse practitioner, or physician assistant). PPMI goal 2. Advancement of the role of pharmacy technicians in participating institutions is outlined in Table 4. Half of surveyed institutions reported that all distributive functions that do not require a pharmacist’s clinical judgment are assigned to pharmacy technicians (measure 2.1). Of these traditional functions, participating institutions reported that their pharmacy technicians are used in the inspection and replenishment of medication storage devices, management of controlled substance systems, and the compounding of sterile preparations. However, only 39% of institutions reported that preparation and distribution tasks are being assigned to the extent possible to allow redeployment of pharmacists’ time to drug therapy management activities.

Table 3 (continued) Measure 1.6 Percentage of hospitals/health systems where pharmacists provide drug therapy management to all outpatients who exceed the threshold value on the patient medication complexity index Are drug therapy management services prioritized for outpatients based on patient medication complexity? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist Not applicable 1.7 Percentage of hospitals/health systems where pharmacists provide drug therapy management to all inpatients who exceed the threshold value on the patient medication complexity index Are drug therapy management services prioritized for inpatients based on patient medication complexity? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist Not applicable 1.8 Percentage of hospitals/health systems with pharmacists who routinely provide discharge counseling and/or conduct follow-up with at-risk patients or their pharmacies after discharge Do pharmacists provide discharge education to patients at your hospital? Discharge education is provided to all patients Discharge education is provided to some patient care units Discharge education is provided to high-risk patients Discharge education is available upon request

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No. (%) Respondents (n = 26)

2 (8) 4 (15) 17 (65) 2 (8) 1 (4)

6 (23) 10 (39) 8 (31) 1 (4) 1 (4)

3 (12) 10 (39) 8 (31) 5 (19)


Of all institutions, 42% reported pharmacy technician assignment to three or more nontraditional or advanced responsibilities (measure

2.2). Initiation of medication reconciliation was the least frequently adopted. Furthermore, of those institutions not assigning technicians to

medication reconciliation functions (n = 16), only 3 institutions reported this task to be “not permitted by law.” Checking of medication dispensing

Table 4.

Goal 2: Pharmacy Technicians Will Prepare and Distribute Medications and Perform Other Functions That Do Not Require A Pharmacist’s Professional Judgment No. (%) Respondents (n = 26)

Measure 2.1 Percentage of hospitals/health systems where pharmacy technicians exclusively perform all traditional preparation and distribution activities (specifically restocking of floor stock and/or automated dispensing cabinets, compounding sterile preparations, preparation of first doses, and controlled substance system management) Are all distributive functions that do not require a pharmacist’s clinical judgment assigned to pharmacy technicians at your hospital? (expressed as no. [%] of “yes” answers) 2.2 Percentage of hospitals/health systems utilizing pharmacy technicians in three or more nontraditional/advanced responsibilities/activities (specifically 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) 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? Tasks fully assigned throughout all areas Tasks fully assigned for some areas Tasks partially assigned in some or all areas Tasks not assigned Not permitted by law 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? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) Not permitted by law Is the management of medication assistance programs assigned to pharmacy technicians who have appropriate education and training at your hospital? Yes No Not applicable Is the supervision of other pharmacy technicians assigned to technicians who have appropriate education and training at your hospital? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) Not applicable Is telepharmacy technology to enable remote supervision used by the pharmacy department at your hospital when appropriate pharmacy staff is not available onsite?a Yes No Not applicable ( pharmacy open 24-7)

13 (50)

11 (42)

1 (4) 4 (15) 5 (19) 13 (50) 3 (12)

2 (8) 4 (15) 5 (19) 4 (15) 11 (42)

13 (50) 6 (23) 7 (27)

7 (27) 10 (39) 4 (15) 5 (19) 0

2 (11) 3 (16) 14 (74)

n = 19.

a


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accuracy of technicians by technicians (“tech-check-tech”) is reportedly used in 11 (42%) of the surveyed centers, with 2 institutions reporting to use it “in all areas/situations.” Of institutions not incorporating techcheck-tech into their daily workflow (n = 15), almost three quarters reported this function to be “not permitted by law.” Technician order entry for pharmacist verification was not evaluated by the HSA. Other advanced pharmacy technician roles implemented within institutions in “at least some areas” but not used to evaluate measure 2.2 included identification of medication allergies for pharmacist review (n = 1, 4%), gathering of clinical monitoring information (n = 5, 19%), conduction of quality-improvement programs (n = 16, 62%), and management of pharmacy department information technology systems (n = 16, 62%). PPMI goal 3. Comprehensive cancer centers have been working to incorporate well-trained professionals into their practice settings (Table 5). All participating institutions reported that at least some of their pharmacists are board certified or residency trained, with the latter being more common than the former (measures 3.1 and 3.2). Eighteen institutions (69%) reported that most to all of their pharmacists are residency trained (postgraduate year 1 with or without PGY2 training), whereas only 9 institutions (35%) reported that most of their pharmacists are board certified. No institutions reported that all of their pharmacists are board certified. In this study, board certification refers to having obtained a passing score on an examination administered for certification in any one of the six specialty areas designated by the Board of Pharmacy Specialties. Pharmacy technician certification is more common among comprehensive cancer centers, with most to all of pharmacy technicians being certified at 19 institutions (73%) (measure 3.5). Beyond 1654

certification and licensing, 7 centers (27%) reported having a credentialing and privileging process that outlines pharmacist prescribing and scope of practice (measure 3.3). PPMI goal 4. Automation and technology at the point of dispensing were highly prevalent among surveyed centers, with barcode technology and automated dispensing cabinets being utilized by 24 and 22 institutions, respectively (measures 4.2 and 4.3) (Table 6). In addition, 89% of institutions reported having computerized prescriber order-entry (CPOE) integrated with clinical decision-support systems in at least “some areas/situations” (measure 4.1). Utilization of technology at the point of administration is less prevalent, with 18 centers (69.6%) claiming to use barcode-assisted medication administration (BCMA) systems to verify patient identity and the accuracy of administration (measure 4.5). Only 4 institutions (15%) reported using smart infusion pumps integrated into a closed-loop medication-use process (measure 4.4). The supplemental survey responses revealed additional information about the use of automation and technology within the oncology subspecialty. Although 89% of institutions reported utilizing CPOE for order entry in at least “some areas/ situations” throughout the entire facility on the HSA, 11 institutions reported the use of CPOE specifically for chemotherapy order entry in the inpatient or outpatient setting or both. In addition, some cancer centers are now beginning to incorporate automation in the preparation of intravenous chemotherapy, with 3 institutions completing the supplemental survey reporting to use automated chemotherapy mixing systems. PPMI goal 5. Pharmacy leadership within hospital systems is highly prevalent among surveyed cancer centers, with 23 participants (89%) reporting that their pharmacy executives are in a position that has


frequent and direct contact with hospital administration on matters of medication use (measure 5.2) (Table 7). Twenty-three participants (89%) have considerable pharmacy involvement in organizational programs aiming to achieve annual documented improvement of medication-use systems. Furthermore, 19 (73%) claimed to have established proactive and ongoing risk assessments of their medication-use systems within the past 12 months (measure 5.5). In addition to medication safety self-assessments, strategic plans to implement automation and technology as well as to reallocate resources to devote more pharmacist time to drug therapy management have been developed in 24 and 15 institutions, respectively, both of which may improve the safety and efficiency of medication use (measure 5.3). Barriers to PPMI implementation. Institutions completing the supplemental survey (n = 15) were asked to select what they considered as barriers to implementation of PPMI components at their institutions. The most commonly reported barrier to adoption was a lack of funding or financial resources (73%), followed by an inadequate number of pharmacy personnel (53%) and inadequate implementation of automation and technology (33%). Few institutions reported resistance from hospital leadership (27%), pharmacists (13%), and pharmacy technicians (7%), among others. Four institutions (27%) reported that state pharmacy practice laws were impeding their ability to implement PPMI components, indicating that more legislative efforts may need to be undertaken to allow for progression of the pharmacy profession. One center reported that, at this time, the PPMI is not a priority at its institution. Discussion Since 2011, health systems around the country have been working to implement components of the PPMI


into their pharmacy department workflows. The results of this study indicate that NCI-designated comprehensive cancer centers have made headway in the adoption of PPMI goals and measures. This is the first report of documented progress made by comprehensive cancer centers since the initiation of the movement. Restructuring of pharmacy practice models within health systems from those in which pharmacists perform primarily distributive functions to models where pharmacists take on clinical and direct patient care responsibilities has occurred in all surveyed institutions. As a result,

comprehensive cancer centers have exhibited much success in the overall adoption of goal 1, where pharmacists practicing in these institutions are able to perform functions that have a positive impact on medication use and medication-related outcomes. In nearly all surveyed comprehensive cancer centers, pharmacists are deployed to patient care units, providing medication therapy management services (more often in the inpatient setting), documenting their interventions, and reviewing all medication orders before administration of the first dose. The HSA finding that drug therapy manage-

ment is performed more often in the inpatient setting is confirmed by the supplemental survey finding that pharmacists in participating institutions are more often deployed to inpatient hematology/oncology care units. Although surveyed institutions have made much progress in enhancing pharmacist roles, this study revealed that the authority of pharmacists to order medications, though present in many institutions, does not exist in all locations and tends to occur more often in the inpatient setting. Only half of centers give their pharmacists the ability to order

Table 5.

Goal 3: Pharmacists and Pharmacy Technicians Will Have Appropriate Training and Credentials for the Activities Performed Within Their Scope of Practice No. (%) Respondents (n = 26)

Measure 3.1 Percentage of hospital pharmacists who are board certified by the Board of Pharmacy Specialties (BPS) Are all pharmacists providing drug therapy management board certified by BPS? All pharmacists providing drug therapy management are board certified by BPS (100%) Most pharmacists providing drug therapy management are board certified by BPS (50–99%) Some pharmacists providing drug therapy management are board certified by BPS (1–49%) No pharmacists providing drug therapy management are board certified by BPS (0%) 3.2 Percentage of pharmacists who have completed ASHP‐accredited residency training Have pharmacists providing drug therapy management completed an ASHP‐accredited residency or achieved equivalent experience? All pharmacists are residency‐trained or have achieved equivalent experience (100%) Most pharmacists are residency‐trained or have achieved equivalent experience (50–99%) Some pharmacists are residency‐trained or have achieved equivalent experience (1–49%) No pharmacists are residency‐trained or have achieved equivalent experience (0%) 3.3 Percentage of hospitals/health systems that have a credentialing and privileging process beyond licensure that defines and authorizes pharmacists’ scope of practice Does your hospital’s credentialing and privileging process include pharmacist prescribing and define their scope of practice? (expressed as no. [%] of “yes” answers) 3.4 Percentage of pharmacy technicians working in hospitals/health systems who have completed ASHP-accredited training 3.5 Percentage of pharmacy technicians working in hospitals/health systems who are Pharmacy Technician Certification Board (PTCB) certified Are pharmacy technicians at your hospital certified by PTCB? All pharmacy technicians are PTCB certified (100%) Most pharmacy technicians are PTCB certified (50–99%) Some pharmacy technicians are PTCB certified (1–49%) No pharmacy technicians are PTCB certified (0%)

0 9 (35) 17 (65) 0

3 (12) 15 (58) 8 (31) 0

7 (27) Not assessed

12 (46) 7 (27) 7 (27) 0


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serum drug concentrations. In the provision of care for cancer patients, drug therapy monitoring includes chemotherapy agents (e.g., busulfan, methotrexate) and immunosuppres-

sants (e.g., tacrolimus, sirolimus, cyclosporine). Monitoring of these medications and their serum drug levels by a pharmacist can help to ensure drug efficacy while minimiz-

ing toxicity and freeing up more time for providers to spend with patients. Over half of participating institutions reported having a plan in place to reallocate resources for more

Table 6.

Goal 4: Pharmacy Departments Will Utilize Available Automation and Technology to Improve Patient Safety and Improve Efficiency Measure 4.1 Percentage of hospitals/health systems using a computerized prescriber order-entry (CPOE) system with clinical decision support for inpatient medication orders (e.g., rules that integrate order information, patient information, and clinical practice guidelines into computer system logic that provide feedback to prescribers). Have clinical decision-support systems been integrated with CPOE systems at your hospital? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) 4.2 Percentage of hospitals/health systems that routinely use machine-readable coding (e.g., barcoding technology with or without a robot) in the inpatient pharmacy to verify doses during dispensing. Is barcode technology used during the dispensing process at your hospital (with or without robotics)? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) Not applicable 4.3 Percentage of hospitals/health systems that use automated dispensing technologies (e.g., automated dispensing cabinets, robotics). Is automated dispensing or robotics used at your hospital for the routine dispensing of maintenance doses? (expressed as no. [%] of “yes” answers) 4.4 Percentage of hospitals/health systems that have smart infusion pumps that are integrated into a closed-loop medication-use process (i.e., where CPOE/pharmacy information system is integrated with pumps, and administration is documented on electronic medication administration record [eMAR]). Are smart infusion pumps integrated into a closed‐loop medication‐use process at your hospital (i.e., where CPOE/pharmacy information system is integrated with pumps, and administration is documented on eMAR)? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) Not applicable 4.5 Percentage of hospitals/health systems that use machine-readable coding (e.g., barcode-assisted medication administration system) to verify the identity of the patient and the accuracy of medication administration at the point-of-care. Is barcode point‐of‐care technology used during medication administration at your hospital? Exists in all areas/situations (100%) Exists in most areas/situations (50–99%) Exists only in some areas/situations (1–49%) Does not exist (0%) Not applicable

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No. (%) Respondents (n = 26)

7 (27) 5 (19) 11 (42) 3 (12)

2 (8) 11 (42) 11 (42) 1 (4) 1 (4)

22 (85)

1 (4) 3 (12) 0 21 (81) 1 (4)

1 (4) 13 (50) 4 (15) 8 (31) 0


pharmacists to provide drug therapy management services, suggesting continued refinement of oncology pharmacist roles in the future. The results of this study suggest that more emphasis should be placed on the advancement of pharmacist functions in the outpatient setting within NCI-designated comprehensive cancer centers. The progressive

use of oncology pharmacists at the Duke and University of North Carolina Lineberger/North Carolina Cancer Hospitals has proven the value of pharmacists in optimizing healthcare efficiency in the outpatient setting.9-12 In these facilities, pharmacists have developed over 200 chemotherapy order sets and initiated outpatient supportive care services focusing on

patient education and cancer symptom management. These services have effectively reduced the time physicians spend writing medication orders. In addition, employing a qualified pharmacist led to the development of a rapid infusion rituximab protocol that was shown to save over 600 hours of infusion time annually after its implementation.

Table 7.

Goal 5: Pharmacists Will Demonstrate Leadership in Exercising Their Responsibility for Medication-Use Systems and Will Be Accountable for Medication-Related Patient Outcomes No. (%) Respondents (n = 26)

Measure 5.1 Percentage of hospitals/health systems whose pharmacists with drug therapy management responsibilities are held accountable through formal evaluation for clinical outcomes of patients under their care. Has a mechanism been established to hold pharmacists accountable for patients’ medicationrelated outcomes at your hospital? (expressed as no. [%] of “yes” answers) 5.2 Percentage of hospitals/health systems whose pharmacy executive is recognized and positioned in the organization to influence decisions on strategic issues affecting medication use (e.g., pharmacy department reports to the chief executive officer or chief operating officer). Do pharmacy leaders engage in regular, direct communications with hospital administration and the board of directors about medication management systems performance (e.g., through the use of safety and quality measures and beyond routine pharmacy and therapeutics committee reporting)? (expressed as no. [%] of “yes” answers) 5.3 Percentage of hospitals/health systems that regularly conduct strategic planning to determine their optimal scope and level of pharmacy services, use of automation and technology, assignment of technicians, and readiness of staff to serve their patient population. Have you developed a strategic plan for implementing automation and technology designed to improve the safety and efficiency of medication use (procurement, prescribing, preparation, dispensing, administration, and monitoring)? (expressed as no. [%] of “yes” answers) Has the pharmacy department at your hospital developed a plan to reallocate its resources to devote significantly more pharmacist time to drug therapy management services? (expressed as no. [%] of “yes” answers) 5.4 Percentage of hospitals/health systems that have used the Pharmacy Practice Model Initiative Hospital Self-Assessment tool at least annually. 5.5 Percentage of hospitals/health systems that conduct proactive and ongoing assessments and mitigate risk of medication-use systems (e.g., Institute for Safe Medication Practices Medication Safety Self-Assessment). Does your hospital have an organizational program, with appropriate pharmacy involvement, to achieve significant annual, documented improvement in the safety of all steps in medication use? (expressed as no. [%] of “yes” answers) Has your pharmacy department performed a proactive and ongoing risk assessment of medication‐use systems within the past 12 months? (expressed as no. [%] of “yes” answers) 5.6 Percentage of hospitals/health systems that routinely provide training to pharmacy students and/or residents Is there a pharmacy residency program at your hospital/health system? (expressed as no. [%] of “yes” answers) Do you take 6 or more pharmacy students on rotations each year? (expressed as no. [%] of “yes” answers)

12 (46)

23 (89)

24 (92)

15 (58) Not assessed

23 (89) 19 (73)

26 (100) 26 (100)


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An evaluation of a pharmacist-run anticoagulation management service within a breast cancer clinic at the University of Texas M. D. Anderson Cancer Center showed that pharmacy services resulted in a reduced frequency of recurrent venous thromboembolisms and increased time spent in therapeutic International Normalized Ratios when compared with other population studies conducted among cancer patients receiving usual medical care.13 An explanation for the hindered pharmacist authority to perform progressive patient care functions stems from a current lack of fully qualified professionals. A majority of comprehensive cancer centers do not have a credentialing and privileging program defining pharmacists’ prescribing rights and scope of practice. Furthermore, with board certification and residency training being relatively new qualifications for pharmacists, especially in the oncology subspecialty, a large portion of pharmacists do not yet have the credentials to provide this level of care. The number of residency programs has increased over the past few decades. However, there are fewer residency positions than candidates in the United States (3,156 versus 4,480, respectively, in 2013).14 Information is not available regarding the number of applicants or match candidates for oncology specialty residencies in 2013 to determine if this pattern also applies specifically to oncology pharmacy training. Currently there are 74 ASHP-accredited oncology PGY2 residencies with 109 positions available across the country. However, this study has shown that NCI-designated comprehensive cancer centers recognize the value of residency training, as all of them reported training residents within their institution. Board certification through the Board of Pharmacy Specialties is an even newer credential that identifies those individuals most qualified to contribute at advanced 1658

practice levels. In 2012, 3,213 pharmacists became board certified in one of six specialty areas, making the total number 15,862, an ~20% increase from the total number of individuals board certified at the end of 2011. Specific to the management of cancer patients, at the end of 2012, there were 1,421 board-certified oncology pharmacists compared with 1,247 in 2011, with an examination passing rate of 46%.15 These numbers are promising and show that the percentage of pharmacists qualified for advanced practice is anticipated to grow. Many institutions have successfully implemented automation and technology including BCMA, barcode technologies at the point of dispensing, and CPOE. The apparent low implementation rate of smart infusion pumps within participating institutions may simply reflect the lack of interoperability between currently used technological systems. Institutions may be using smart infusion pumps but are unable to integrate them with an electronic medical record to provide a closed-loop system. With over 90% of centers currently having a plan in place to implement automation and technology that improve the safety and efficacy of the medication-use system, it can be expected that comprehensive cancer centers will show continued improvement in the near future pertaining to this component of the PPMI. Pharmacy has exhibited a leadership role over medication-use systems within comprehensive cancer centers, with a majority of institutions having pharmacy involvement in committees organized to document improvements in the medication-use system and ongoing proactive risk assessments. However, many participants reported not having a mechanism established to hold pharmacists accountable for patients’ medication-related outcomes. Pharmacy department leaders may find it difficult to achieve and implement such a system, especially with phar-


macists now having different roles and levels of training. By setting a framework through well-defined policies and procedures that outline a pharmacist’s role and responsibility during different care transitions and settings, periodically reevaluating these roles, and providing an incentive or reward system combined with formal evaluations, this system may help to align accountability with actions and motivate pharmacists to take ownership of the outcomes of their patients. Across comprehensive cancer centers, the optimization of pharmacy technician roles has received the least attention of all PPMI components. Providing pharmacy technicians with advanced roles, as permitted by state law, has many benefits, with the most apparent being to allow pharmacists more time to provide direct patient care functions such as drug therapy monitoring and management and medication discharge counseling. With nearly half of all study participants indicating that all of their pharmacy technicians are certified through the Pharmacy Technician Certification Board, this implies that many technicians are maximally qualified per today’s standards to take on advanced roles. The newly formed Pharmacy Technician Accreditation Commission, which ASHP formed in collaboration with the Accreditation Council for Pharmacy Education is anticipated to begin officially accrediting pharmacy technician programs in late 2014.16 There are currently 258 programs undergoing this process, according to a report released in August 2013. One of the goals of the ASHP 2015 Health-System Pharmacy Initiative is for at least 50% of new pharmacy technicians entering practice in health systems to complete ASHPaccredited training programs.17 Assessing the overall implementation of the PPMI is a difficult task, and there were several limitations to this study. Only a third of participat-


ing institutions had completed the HSA during 2013. Although the most recent documented results were included from each surveyed institution, implementation rates of PPMI measures may have been higher had institutions submitted more current response.5 Furthermore, only about half of the institutions with HSA results on file with ASHP also completed the supplemental 10-item survey specific to oncology pharmacy services during the one-month survey period. Completion of both surveys was recommended for institutions without an HSA for 2013 on file with ASHP. However, the two surveys were not linked, and, despite the use of multiple reminders, full participation could not have been further enforced. Another study limitation is that the HSA has not been validated in large studies to determine adoption of the PPMI goals and measures. Although a correlation of HSA questions to specific PPMI measures was completed by the research team, the original purpose of the HSA was to serve as an ongoing self-assessment tool to estimate the progress being made by institutions in advancing their pharmacy practice model. The possibility that subjectivity in interpretation of survey items may have affected responses must be noted. It is important to keep in mind when interpreting this study’s results that the HSA contains items applicable to all pharmacy specialties and services within any institution and is not meant to solely evaluate oncology pharmacy services. Although a comparison between participating NCI-designated comprehensive cancer centers and other institutions having completed the HSA would be optimal, there are several reasons for which a comparison could not be made. The difference in percentage of hospital types participating in this survey (80% large academic medical centers) compared with all institutions having taken the

HSA (10% large academic medical centers) makes comparing the implementation of PPMI components difficult. The majority of institutions around the United States completing the HSA have been small community hospitals. Such facilities have different levels of resources and funding compared with large academic medical centers, allowing for differences in the rate of PPMI implementation. Due to logistic reasons, the data from participating NCI-designated comprehensive cancer centers could not have been feasibly removed from the cumulative HSA data of all institutions. A comparison between NCIdesignated comprehensive cancer centers and another group of health systems of similar hospital type would be a useful future direction of oncology pharmacy practice research. The results of this study indicate that comprehensive cancer centers have demonstrated success in implementing a variety of goals and measures of the PPMI. The PPMI goals are interrelated, wherein the advancement in any one area of pharmacy practice is dependent on the ability to grow and improve in another. Overall adoption of the PPMI is multifaceted and requires flexibility in many aspects of the pharmacy department workflow and organization to reallocate resources and individuals into progressive practice models. With many pharmacy personnel seeking advanced credentials, the presence of fully qualified technicians and pharmacists will be on the rise and may help to increase the proportion of pharmacists providing direct patient care services in the future. It is our hope that this study serves to increase awareness of the PPMI and improve adoption rates within cancer centers across the country. Conclusion Based on the survey results, suggested areas of improvement include the provision of drug therapy management in the outpatient setting,

advancement in technician roles, utilization of automation and technology particularly at the point of administration, and implementation of mechanisms to hold pharmacists accountable for medication-related outcomes of their patients. References 1. Franchino DC. Redefining the pharmacist’s role. Am J Health-Syst Pharm. 2010; 67:178-9. 2. Abramowitz PW. The evolution and metamorphosis of the pharmacy practice model. Am J Health-Syst Pharm. 2009; 66:1437-46. 3. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice. A report to the US Surgeon General [December 2011]. www.usphs.gov/corps links/pharmacy/sc_comms_sg_report. aspx (accessed 2014 Jun 26). 4. Levis L, Smith AP, Benz EJ et al. Ensuring quality cancer care through the oncology workforce. J Oncol Pract. 2010; 6:7-11. 5. American Society of Health-System Pharmacists. Pharmacy Practice Model Initiative (PPMI): National Dashboard. www.ashpmedia.org/ppmi/nationaldashboard.html (accessed 2013 Dec 10). 6. American Society of Health-System Pharmacists. Pharmacy Practice Model Initiative (PPMI): PPMI Summit. www. ashpmedia.org/ppmi/ppmi-summit.html (accessed 2013 Sep 6). 7. American Society of Health-System Pharmacists. Pharmacy Practice Model Initiative (PPMI): hospital selfassessment worksheet. www.ppmi assessment.org/docs/assessment_ questions.pdf (accessed 2013 Sep 6). 8. American Society of Health-System Pharmacists. PPMI hospital selfassessment: PPMI HSA completion by state. www.ppmiassessment.org (accessed 2013 Sep 6). 9. Sessions JK, Valgus J, Barbour SY et al. Role of oncology clinical pharmacists in light of the Oncology Workforce Study. J Oncol Pract. 2010; 6:270-2. 10. Valgus J, Jarr S, Schwartz R et al. Pharmacistled, interdisciplinary model for delivery of supportive care in the ambulatory cancer clinic setting. J Oncol Pract. 2010; 6:e1-4. 11. Valgus J, Faso A, Gregory K et al. Integration of a clinical pharmacist into the hematology–oncology clinics at an academic medical center. Am J Health-Syst Pharm. 2011; 68:613-9. 12. Valgus J. Collaborative practice agreements in oncology: the future is bright. HOPA News. 2012; 9(2):1-20. 13. Jones KL, Barnett C, Gauthier M et al. Clinical outcomes of a pharmacistmanaged anticoagulation service for breast cancer patients. J Oncol Pharm Pract. 2011; 18:122-7.


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14. National Matching Services. ASHP Resident Matching Program: Match statistics. https://natmatch.com/ashprmp/about stats.html (accessed 2014 Jan 29). 15. Board of Pharmacy Specialties. News: Board of Pharmacy Specialties announces results of 2012 certification and recertification exams. http://bpsweb.org/news/ pr_021913.cfm (accessed 2014 Jan 29). 16. American Society of Health-System Pharmacists. New pharmacy accreditation commission launched. www. ashp.org/menu/AboutUs/ForPress/Press Releases/PressRelease.aspx?id=768 (accessed 2014 Aug 7). 17. American Society of Health-System Pharmacists. 2015 ASHP Health-System Pharmacy Initiative goals and objectives. www.ashp.org/s_ashp/docs/files/2015_ Goals_Objectives_0508.pdf (accessed 2014 Aug 7).

Appendix—Ten-item supplemental surveya 1. Please rank the following five goals of the PPMI by priority in regards to order of implementation at your institution, with 1 = top priority and 5 = lowest priority a. ____ Pharmacist roles, practices, and activities will improve medication use and optimize medication-related outcomes. b. ____ Pharmacy technicians will prepare and distribute medications and perform other functions that do not require a pharmacist’s professional judgment. c. ____ Pharmacists and pharmacy technicians will have appropriate training and credentials for the activities performed within their scope of practice. d. ____ Pharmacy departments will utilize available automation and technology to improve patient safety and improve efficiency. e. ____ Pharmacists will demonstrate leadership in exercising their responsibility for medication-use systems and will be accountable for medicationrelated patient outcomes. 2. What are some of the barriers that your institution currently faces in implementing the components of the PPMI? Please check all that apply a. Laws and regulations of pharmacy practice in your state b. Resistance from pharmacists c. Resistance from pharmacy technicians d. Inadequate number of pharmacy personnel e. Resistance from hospital leadership f. Inadequate implementation and utilization of automation and technology g. Lack of necessary funding h. Lower patient census i. Other (please specify): 3. Please indicate whether you are a: a. Standalone cancer center b. A cancer center integrated into a larger health care facility that also provides non-oncology related patient care

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4. If your pharmacy practice model includes the following types of pharmacists, please indicate the current qualifications required for hiring (please select all required for each position): a. Clinical pharmacist specialists: i. Board certification ii. PGY2 Oncology or other PGY2 Specialty Residency iii. PGY1 Pharmacy Practice Residency iv. Pharm.D. v. B.S. vi. Other: b. Clinical pharmacist generalists— decentralized (hybrid clinical and dispensing activities): i. Board certification ii. PGY2 Oncology or other PGY2 Specialty Residency iii. PGY1 Pharmacy Practice Residency iv. Pharm.D. v. B.S. vi. Other: c. Clinical pharmacist generalists—staff (primarily dispensing activities): i. Board certification ii. PGY 2 Oncology or other PGY2 Specialty Residency iii. PGY1 Pharmacy Practice Residency iv. Pharm.D. v. B.S. vi. Other: 5. Please indicate the total number of the following: a. ____ Number of inpatient beds dedicated to providing cancer-related care to patients b. ____ Number of clinical pharmacist specialist FTEs assigned to oncology inpatient-care units c. ____ Number of clinical pharmacist generalist (decentralized) FTEs assigned to oncology inpatient care units d. ____ Number of clinical pharmacist generalist (staff) FTEs assigned to perform inpatient chemotherapy dispensingrelated activities e. ____ Approximate number of daily outpatient oncology clinic visits f. ____ Approximate number of chemotherapy administration orders written daily g. ____ Number of clinical pharmacist specialist FTEs assigned to outpatient oncology clinics in which the pharmacist is based in the clinic (rather than in a dispensing role) h. ____ Number of clinical pharmacist generalist FTEs assigned to outpatient oncology clinics in which the pharmacist is based in the clinic (rather than in a dispensing role) i. ____ Number of clinical pharmacist generalist FTEs assigned to perform outpatient chemotherapy dispensingrelated activities


6. At your facility, are automated mixing systems currently being used to prepare intravenous chemotherapy dispensed to patients at your facility? a. Yes b. No 7. My facility currently uses CPOE for entry of chemotherapy orders in the following settings: a. Inpatient b. Outpatient c. Both d. Neither 8. Please indicate which settings you currently have clinical pharmacists practicing in: a. Outpatient hematology clinic(s) b. Inpatient hematology c. Outpatient oncology clinic(s) d. Inpatient oncology e. Outpatient bone marrow transplant f. Inpatient bone marrow transplant g. Infectious disease h. Anticoagulation management i. Pain/palliative care j. Nutrition k. Investigational drug service 9. Has your institution developed a program or specific practices for managing oral chemotherapy medications? Please check all that apply a. Yes, pharmacists provide patient counseling for oral chemotherapy b. Yes, pharmacists are actively involved in following up with patients regarding side effects and making recommendations for their management c. Yes, pharmacists review prescriptions written for oral chemotherapy for safety/accuracy d. No, but pharmacist-managed oral chemotherapy management program is currently in development e. No, but another practitioner (i.e., RN, NP) provides some or all of these services f. The institution does not currently have an oral chemotherapy program 10. Does your institution have an outpatient retail/ specialty pharmacy at which oncology patients can fill oral chemotherapy prescriptions? a. Yes, onsite and owned by the institution b. Yes, onsite and owned by an outside company c. No, but affiliated with an off-site retail/ specialty pharmacy d. No, and not affiliated with an off-site retail/specialty pharmacy a PPMI = Pharmacy Practice Model Initiative, PGY2 = postgraduate year 2, PGY1 = postgraduate year 1, Pharm.D. = doctor of pharmacy degree, B.S. = bachelor of science degree, FTE = full-time equivalent, CPOE = computerized prescriber order entry, RN = registered nurse, NP = nurse practitioner.