Original ResearchA qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach
Introduction
In response to the call for greater health care quality, the Medicare Modernization Act of 2003 provided for medication therapy management (MTM) services for patients with the goals of providing education, improving adherence, and detecting adverse drug events and medication misuse. Pharmacists recognize the value of providing cognitive pharmaceutical services (CPS), such as MTM services (both financial and patient care oriented), but have long recognized significant barriers to adding CPS to their already hectic workflow. Perceived barriers have prevented pharmacists from either implementing and/or sustaining CPS. Not surprisingly, lack of time, trained personnel, and reimbursement have been cited as the reasons pharmacists are not providing CPS.1, 2, 3, 4, 5, 6, 7
Although studies provide some insight on potential barriers to pharmacists providing CPS, they do not address or expand on the underlying contributing factors for the lack of time and/or lack of trained personnel.2, 3 Lack of time may be because of a combination of factors, including high prescription volume, poor acceptance and use of technology, limited or inexperienced staff, corporate or organizational conflicts, a workflow that has not been revised to accommodate changes in practice, such as increased patient counseling, prescription volume, or additional personnel or technology, or other factors. The manner in which factors contributing to a lack of time/personnel manifest themselves as barriers to providing CPS is unknown, and no known research has characterized these factors and explored possible solutions.
One approach to better understand barriers and facilitators to providing CPS is to adopt a work system approach. A work system approach includes both a view of a current system in operation and a dynamic view of how a system evolves over time through planned change and unplanned adaptations. The approach is prescriptive enough to be useful in describing the system being studied, identifying problems and opportunities, describing possible changes, and tracing how those changes might affect other parts of the work system.8, 9
The Systems Engineering Initiative for Patient Safety (SEIPS) model was adopted to study pharmacy work systems (Fig. 1).10 The model served as a useful framework for studying work system change and design because it provides a holistic view of a work system rather than focusing on a single component. It is grounded in human factors engineering principles and offers a framework for examining different components of a work system, interactions between components, and how the components may impact care processes and outcomes. The model consists of 5 key components of the work system: people, organization, technology/tools, tasks, and environment. The model has been used to study how interrelationships between the structural components of the work system interact to influence various work system processes and ultimately the outcomes of the work system.11, 12, 13 The SEIPS model might offer an improvement over Donabedian's Structure-Process-Outcome model,14 which tends to focus on characteristics of practitioners, whereas the SEIPS model focuses on how the practitioner is impacted by the specific components of the system in which they work.
A recent demonstration program provided an opportunity to study pharmacy work system factors that act as barriers or facilitators to pharmacists providing CPS. The Wisconsin Pharmacy Quality Collaborative (WPQC) is a consortium of private and public third-party payers, community pharmacies, and the Pharmacy Society of Wisconsin (PSW, the Wisconsin State Pharmacy Association) that created an incentive-aligned, quality-based CPS demonstration program. Payers pay pharmacists for CPS provided to patients covered by their insurance plans. Payments are made for intervention-based level I services related to drug product selection (eg, changing doses, tablet splitting, formulary interchange, adherence) and patient education such as device instruction. To be reimbursed for most of these CPS, the pharmacist must identify the opportunity and contact the prescriber to change the therapy. Pharmacists also are paid for appointment-based level II MTM services, which include comprehensive medication review (CMR) and medication reconciliation. A typical level II service includes identifying the patient (either from the pharmacy's patient profile or provided by the payer), performing a CMR with a patient, creating and providing a plan for the patient and prescriber, and documenting and billing for the service. A national drug wholesaler developed a web-based software platform to facilitate pharmacist documentation and billing for CPS. A full description of the demonstration project can be found elsewhere.15
The goals of this study were to identify and describe community pharmacy work system characteristics as important barriers or facilitators to providing CPS in WPQC. Using the SEIPS model as a guiding framework, the investigation focused on (1) characteristics of people in the work system, (2) the tasks that are performed in the work system, (3) the environment of the work system, (4) the tools and technology used in the work system, and (5) the role of the pharmacy organization in the work system.
Section snippets
Methods
A qualitative approach to describing community pharmacy work system characteristics was used. Semistructured interviews were used for data collection. Semistructured interviews are useful when researchers are guided by a specific framework, and flexibility is needed to more completely explore topics and concepts mentioned by an interviewee.
A purposive sample of 6 pharmacy key informants at 6 community pharmacies was selected to interview. The 6 pharmacies were among 24 pharmacies that were
Results
Six interviews with 8 pharmacists (6 key informants and 2 staff pharmacists) were completed. Overall, the SEIPS model was useful in capturing themes related to important factors within the work system related to providing CPS in WPQC. Importantly, the interview process was able to capture not only changes that were made and facilitators to providing CPS but also how pharmacists problem solved through barriers, personnel issues, and physical work design constraints. Pharmacists also discussed
Discussion
The purpose of this study was to use a work system approach to uncover and describe work system characteristics that pharmacists mentioned as important barriers or facilitators to providing CPS.
The SEIPS model appeared to be a useful framework to use in structuring the interviews with pharmacists about work system factors. The 5 components of the SEIPS model allowed the interviews to explore a comprehensive list of factors that turned out to be important in work system change. Importantly,
Limitations
This study has several limitations. Pharmacists volunteered for this study and may be more knowledgeable than nonparticipants. Furthermore, pharmacists may have more favorable attitudes toward and be more facile with providing CPS. However, qualitative methods emphasize selecting participants who are conversant with a particular phenomenon, so this may not necessarily be a bias.18
There may have been some interviewer bias during the thematic analysis because of experience and training, but a
Conclusions
Numerous factors within a pharmacy work system appear important in enabling pharmacists to provide CPS. To be successful in providing CPS, pharmacists, as well as organizational decision-makers, leaders, and policymakers, must be cognizant of the multidimensional nature of how providing CPS is influenced by different components of the pharmacy work system. Characteristics of the pharmacy organization and increasing the use of technical staff within a pharmacy work system appear to be the most
Acknowledgments
The authors thank Dr Kari Trapskin from the PSW as well as Drs David Kreling and Beth Martin for their support of this study.
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