- Email: [email protected]
Impact of Community Pharmacy Automation on Workflow, Workload, and Patient Interaction
RESEARCH
Impact of Community Pharmacy Automation on Workflow, Workload, and Patient Interaction Lauren B. Angelo, Dale B. Christensen, and Stefanie P. Ferreri
ABSTRACT Objective: To compare workload productivity, workflow efficiency, and pharmacist–patient interaction in automated and nonautomated community pharmacies. Design: Observational study. Setting: Four community pharmacy sites within a regional pharmacy chain. Study Participants: 173 patients and 11 pharmacists. Interventions: Patient surveys, pharmacist surveys, and direct observation. Main Outcome Measures: Patient satisfaction, frequency of pharmacist–patient interactions, and prescription dispensing productivity and efficiency. Results: Results from the three nonautomated pharmacies were averaged and compared with results from the automated pharmacy. Patient satisfaction was generally favorable for both automated and nonautomated pharmacies, but scores for the automated site were significantly better on items measuring one domain, technical competence of pharmacy staff. No association was found between patient counseling and prescription workload in automated or nonautomated sites. Personnel at the automated site made significantly more offers to counsel patients, but the number of patients who received counseling did not differ significantly. Automation was associated with a higher number of prescriptions dispensed per full-time equivalent pharmacist and fewer technical dispensing tasks performed by pharmacists. Conclusion: Patient satisfaction was not related to the presence of an automated dispensing system. Automation was associated with higher prescription productivity, but actual counseling rates were no different from those observed in nonautomated pharmacies. The likelihood that a patient would receive counseling was not related to staffing levels, automation, or workload. Whether counseling occurred appeared to depend on factors other than automation. Keywords: Community pharmacy, automation, patient interaction, workflow, workload. J Am Pharm Assoc. 2005;45:138–144.
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Received November 9, 2003, and in revised form March 25, 2004. Accepted for publication April 30, 2004. Lauren B. Angelo, PharmD, MBA, is Assistant Professor, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Butler University, and Coordinator, Kroger Pharmacy Patient Care Center, Indianapolis, Ind. At the time this research was conducted, she was a Community Pharmacy Practice Resident with Kerr Drug and the University of North Carolina, Chapel Hill. Dale B. Christensen, PhD, is Professor, Division of Pharmaceutical Policy and Evaluative Sciences, School of Pharmacy, University of North Carolina, Chapel Hill. Stefanie P. Ferreri, PharmD, CDE, is Clinical Assistant Professor, Division of Pharmacotherapy and Experimental Therapeutics, School of Pharmacy, University of North Carolina, Chapel Hill. Correspondence: Lauren B. Angelo, PharmD, MBA, College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Avenue, Indianapolis, IN 46208-3485. Fax: 317-940-8520. E-mail: langelo@ butler.edu See related article on page 145 of this issue. Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Funding: American Pharmacists Association Foundation Incentive Grant for Practitioner Innovation in Pharmaceutical Care and Merck & Co. research grant. Previously presented at the American Pharmaceutical Association Annual Meeting, March 15–19, 2002, Philadelphia, Pa. Brief preliminary findings from this study were published in the September/October 2002 issue of ComputerTalk.
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I
ncreases in pharmacist productivity have occurred largely through the use of technicians and technology in today’s pharmacies. Computer systems handle tasks such as maintenance and screening of patient drug profiles and third-party billing much more efficiently than in years past. Furthermore, with the advent of national certification standards, pharmacy technicians are more equipped to assume dispensing tasks formerly done by pharmacists. Automated dispensing systems represent the latest in technology to be introduced in the community pharmacy setting. Nevertheless, according to one recent survey, pharmacists still spend more than 60% of their time involved with dispensing activities that could be performed by technicians and automation.1
AT A GLANCE Synopsis: Automation contributed to an increase in the productivity of pharmacists but not to any measurable difference in patient counseling rates in this assessment of the effects of automation on patient satisfaction, frequency of pharmacist counseling, and dispensing productivity and efficiency. In an automated pharmacy, productivity increased and pharmacists consequently performed fewer technical tasks. While offers to counsel patients about their medications were made more frequently in the automated pharmacy, actual patient counseling rates did not differ from those in nonautomated pharmacies, and pharmacists remained engaged largely in the dispensing process. Patient satisfaction was higher for the pharmacy with the automated dispensing system, but differences were significant for one domain (technical competence of pharmacy staff), nearly so for another domain (consideration of patient needs), and not statistically different for a third domain (explanation of information). Analysis: Community pharmacist productivity can increase through use of automation and technicians. With the demanding workloads that community pharmacists face, automation could be expected to free pharmacists from technical tasks and allow them to engage in patient care services. In line with recent studies of pharmacists’ activities—showing that counseling occupies little of their time—patient counseling rates in this study were low and not affected by the availability of automated dispensing equipment or by pharmacists’ workloads. Task reallocation among pharmacy personnel could enable pharmacists to provide patient care services without affecting dispensing productivity. In a companion article on page 145 of this issue, two of these authors examine the effect of workflow redesign on pharmacist–patient interaction and dispensing responsibilities in one of the nonautomated pharmacies studied here.
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RESEARCH
In fact, automation is one of the primary factors contributing to a shift in pharmacy practice from predominantly technical dispensing activities to patient care services.1 Automation aids the dispensing process by replacing the tedious labor-intensive tasks common to pharmacy operations.2 Automated technology thereby offers the potential to enable pharmacists to perform patient-related activities at more optimal levels. The incremental time saved could potentially amount to an hour throughout the day.3 With this available time, pharmacists could, for example, increase their interactions with patients and become more involved with clinical services. While greater use of automation and technicians offer the promise of increased delivery of patient care services, little evidence indicates that this has occurred in practice. Assessment of the effect of automated dispensing technology is, therefore, a critical and timely issue.
Objectives The primary objective of this study was to compare an automated dispensing pharmacy with three nonautomated pharmacies in terms of workload productivity, workflow efficiency, and pharmacist–patient interaction in a chain pharmacy environment. The specific objectives were to: 1. Assess the effect of automation on: a. Patient satisfaction with the level of care provided and the pharmacy services received. b. Patient interaction with pharmacists and pharmacy staff. c. Prescription dispensing productivity and efficiency. 2. Describe the workflow processes in both automated and nonautomated pharmacies, particularly from the perspective of counseling services received by patients.
Methods This observational study assessed workload, workflow, and the extent of patient interaction in four community pharmacy sites affiliated with a regional pharmacy chain. One of the four sites used a ScriptPro (ScriptPro LLC, Mission, Kans.) automated dispensing system, which was compared with three nonautomated sites. The ScriptPro system had been in place for 17 months before the study. The automated site and two of the nonautomated sites had drive-through pharmacy services. All four sites had interactive voice response telephone systems to filter refill requests. The data sources for this study consisted of patient satisfaction surveys, practicing pharmacist surveys, direct observation of workload and workflow, records of prescription dispensing volume, and direct observation of patient interaction with pharmacists. Approval of this study and the survey instruments used was granted by the University of North Carolina Institutional Review Board (IRB) via an exempt review process. The IRB likewise waived the necessity for signed informed consent from study participants. Journal of the American Pharmacists Association
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Patient Surveys Two patient surveys were developed. The General Patient Survey included three subscales extracted from a validated survey developed by MacKeigan and Larson.4,5 The questionnaire was designed to assess the following domains: consideration of patient needs, explanation of information patients received with the dispensed prescription, and technical competence of the pharmacy staff. The consideration domain used eight statements to assess the pharmacy staff’s respect for the patient, responsiveness to the patient, and time spent with the patient. The explanation domain used six statements to assess the extent of explanation of the medication and adverse effects and degree of patient understanding. The technical competence domain used four statements to assess the patients’ perceptions of the pharmacists’ abilities in the dispensing process. A 5-point Likert scale was used to determine the extent to which patients agreed or disagreed with survey statements. The questionnaire was randomly distributed to patients at the time prescriptions were dispensed. Respondents were instructed to complete the questionnaire anonymously and return it in a stamped, addressed envelope that was provided with the survey. As an incentive for survey completion, respondents received a discount coupon that could be used in the pharmacy. A Survey of Pharmacy Services was designed to assess wait times, prescription status (new versus refill), interaction with pharmacists, and the nature of drug information delivered orally at the time prescriptions were dispensed. The survey instrument was reviewed by three pharmacists providing services at one of the pharmacy sites before use. Randomly selected patients completed surveys onsite after they received their prescriptions from the pharmacy. The surveys were collected in a sealed box to preserve confidentiality.
Pharmacist Survey The Pharmacist Opinion Survey was given to each of the pharmacists practicing at the respective study sites. It requested pharmacists’ opinions of workflow in their pharmacies and the activities that interfere with time spent counseling or interacting with patients. Time and privacy issues when counseling patients were also evaluated. Completed surveys were returned through the mail with prestamped, addressed envelopes.
Direct Observations Workflow and patient interaction measurements were conducted by direct observation of the dispensing and counseling activities during 8 selected hours at each of the four sites. The days of the week and times of the observations were held constant for all four sites. All observation sets were performed by the study investigators and a research assistant on Monday and Friday mornings in 2-hour intervals. The pharmacists and pharmacy staff at each of 140
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the sites were not informed about the intent of the study and observations. Because the primary investigator was a pharmacy practice resident at the time of the study, the pharmacists and pharmacy staff were told that the observations were part of her research project and that the data would be shared with them upon completion of the research. Two separate observation sets were established. During the first set, the observer used the Operations Checklist to record pharmacy operations and dispensing activities such as volume, staff member (i.e., pharmacist, technician, cashier, or student) performing each specified task, prescription processing steps, placement of equipment, and design of the pharmacy. The Patient-Interaction Checklist was used to record prescription volume, number of counseling events, staff members providing counseling, and length of time spent counseling. The patient-interaction observations were made concurrently with the distribution of the Survey of Pharmacy Services.
Data Analysis The survey results and observation data for the three nonautomated pharmacy sites were combined and averaged for comparison with the automated site. Statistical tests, including chi-square, Fisher exact probabilities, Student t tests, and correlation coefficients, were employed depending on the type of variable measurement used. A comparison of patient satisfaction based on the General Patient Survey subscales was determined by using simple unweighted average responses to the statements within each domain in the manner outlined by MacKeigan and Larson.4,5 These averages were determined based on responses ranging from 1 to 5, with negatively worded statements inversely adjusted. Responses of 1 or 2 were scored as “favorable” or “satisfied.” Mean scores for each domain were then calculated. P values (a priori alpha levels of .05) based on Student t tests were used to compare the mean responses. Dispensing workloads at each of the pharmacy sites were determined from standard daily accounting records, as well as by direct observation. The relationship between the percentage of patients counseled and prescription workload was explored using simple linear regression analysis. For each hour of observation, pharmacist and technician staffing levels were noted, as well as the number of new and refill prescriptions processed. Workload was expressed as prescription volume per hour per full-time equivalent (FTE) pharmacist and prescription volume per hour per FTE technician. The number of patients who were counseled about their prescriptions during the time of the workload assessments was also recorded. These data were extracted from the Survey of Pharmacy Services and averaged for each observation period.
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Results
RESEARCH
Table 1. Patients’ Satisfaction with Aspects of Pharmacy Services (n = 91)
Patient Satisfaction Surveys A total of 100 General Patient Surveys were distributed at the time of prescription dispensing at each of the four sites. Response rates across the sites were 18%, 22%, and 24% from the three nonautomated sites and 27% from the automated sites (Table 1). For each of the three satisfaction domains represented in the survey instrument, patients at the automated site expressed slightly greater satisfaction than did those whose prescriptions were obtained at the three nonautomated sites, but only for technical competence did the difference reach significance.
Counseling Activities The frequency of counseling activities and differences between automated and nonautomated sites using survey responses from pharmacists and patients and direct observation are shown in Table 2. As in Table 1, responses from the nonautomated sites were averaged into a single value for each measure. Pharmacy staff at the automated site made significantly more oral offers to counsel patients (P = .001). No significant differences were found for the other measured parameters. In the 43 instances when counseling was provided by pharmacy staff, pharmacists counseled patients in 12 of 26 sessions at nonautomated sites and in 7 of 17 sessions at the automated site. This means that counseling was performed by someone other than a pharmacist more than one half of the time. Because of the nature of the study, the extent of information provided to patients during the observed counseling periods was not assessed. For those patients who received counseling, each respondent indicated that the oral information provided was helpful. The length of time of each counseling event observed was recorded using a stopwatch, but too few timed counseling activities were observed to report reliable results.
Nonautomated Sites (n = 64) Mean ± SD
Domain Consideration of patient needs
Automated Site (n = 27) Mean ± SD
P valuea
2.09 ± 0.300
1.76 ± 0.33
.060
Explanation of information patients received with dispensed prescription
2.01 ± 0.310
1.82 ± 0.21
.236
Technical competence of pharmacy staff
2.10 ± 0.023
1.76 ± 0.16
.007b
Abbreviation used: SD, standard deviation. aBased
on t test results using a Likert scale: 1, strongly agree; 2, agree; 3, not sure; 4, disagree; 5, strongly disagree.
bStatistically
significant at P < .05.
Pharmacy Workload A mean (± SD) of 24 ± 16.28 prescriptions were dispensed per hour in the nonautomated sites during the observation periods. The automated site had higher prescription volumes, averaging 59 ± 7.26 prescriptions dispensed per hour. The relationship between the mean percentage of patients counseled, and the pharmacist workload during each observed hour varied widely, with no apparent pattern. Correlation coefficients were 0.379 and 0.298 for the nonautomated and automated sites, respectively, indicating only weak associations with pharmacist workload. The relationship between the average percent of patients counseled and the technician workload for each hour also revealed no observable pattern (for the nonautomated pharmacies: r = –0.154 and automated pharmacies: r = –0.117).
Discussion Dispensing Activities The technical dispensing activities performed in each site were examined through direct observation with a particular emphasis on determining the type of personnel who performed each task (Table 3). A technical activity was defined as one that could have been performed by a nonpharmacist under supervision of a pharmacist. Reported are actual counts of each activity performed by a pharmacist; tasks not completed by a pharmacist were performed by either a technician or cashier. Entering prescriptions into the computer was the technical activity most frequently performed by pharmacists across sites and observation periods. All of the technical activities, except for counting or reconstituting prescriptions, were performed significantly more often by pharmacists than technicians or cashiers in the nonautomated sites compared with the automated site.
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Patient counseling was not a frequent activity in the observed automated and nonautomated pharmacies. With the exception of one counseling period, 50% or fewer of all patients observed receiving prescriptions were counseled. The overall modal counseling rate was less than 20%. However, based on survey responses, patients were generally satisfied with services despite relatively infrequent counseling. Patient satisfaction with pharmacy services was generally quite high across the three satisfaction domains and across pharmacy sites. The scores were relatively similar across the three domains for both the nonautomated and automated data sets. The automated site consistently scored higher than the combined scores from the three nonautomated sites. Thus, counseling was apparently not a factor affecting patient satisfaction, but this may be too simple an explanation. North Carolina regulations require that pharmacists provide an “offer to counsel” with every new prescription dispensed. Perhaps patients Journal of the American Pharmacists Association
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were satisfied with other aspects of pharmacy services, or perhaps they were satisfied merely with the offer to counsel. Another explanation is that patients may not have had high levels of awareness or expectations regarding pharmacist counseling opportunities or obligations. As required by state law, counseling must be provided by a pharmacist or pharmacy student under the direct supervision of the pharmacist. In the study sites, however, counseling was oftentimes performed by someone other than a pharmacist or pharmacy student (Table 2). This level of counseling may be insufficient to foster optimal levels of patient knowledge and adherence. The pharmacy policy at the study sites has taken the state’s counseling criteria a step further by requiring that every patient picking up a prescription, regardless of new or refill status, receive an offer to be counseled. This policy was facilitated using an automated signature log implemented several years before the study period. This automated device prompted the patient to answer whether he or she had questions for the pharmacist. All patients receiving a prescription must sign the log. As shown in Table 2, an oral offer to counsel on new prescriptions was extended only 28% of the time, on average, in the nonautomated sites, and 78% of the time in the automated site. Increasing the rate of offers to counsel to 100% as required by state pharmacy regulations and study sites would mean more counseling opportunities for pharmacists. Based on the data generated in this study, pharmacists should have the time to take advantage of these opportunities as more pharmacies become automated, given the existing availability of technicians at all sites and the finding that pharmacists were performing technical activities associated with dispensing a prescription. As illustrated in Table 3, technicians’ skills were better used in the automated site than the nonautomated sites. Automated dispensing systems are thought to improve workflow, increase accuracy, eliminate the need to hire additional staff to accommodate increasing prescription volume, and allow for more patient counseling.6,7 The addition of automation in the respective study site may have contributed to the enhanced workflow efficiency as
compared with the nonautomated sites. Defined work stations were evident and technician functions were better used but have not been optimized. The pharmacists in the nonautomated sites expressed concern about lack of time to counsel patients (Table 2), yet they performed technical functions more frequently than did the pharmacists at the automated site. In particular, computer data entry was commonly performed by the pharmacists across all sites, and was strikingly high for the nonautomated sites (77%). This finding parallels that of an Arthur Anderson study, which demonstrated a great deal of pharmacist involvement with dispensing functions.1 Encouraging the pharmacist instead of the cashier or technician to deliver the prescription to the patient and having the technician answer the telephone or enter data into the computer would facilitate counseling by the pharmacist, seemingly at no extra labor cost to the pharmacy. Given the benefits and purpose of automation, pharmacists working with such technology should focus on the opportunity it provides to become more involved with pharmaceutical care.1 Using any incremental time saved and increasing technician responsibilities will support this effort. A relationship between the patient counseling rates and pharmacy workload could not be established. Even with additional pharmacists or pharmacy staff available at the automated pharmacy, the frequency of counseling events was not greater than the nonautomated sites. The primary difference was that the automated site operated at a higher workload volume than the nonautomated sites. This would be expected and was likely the justification for implementing the automated system at this location. Even among the pharmacies with low workload for both pharmacists and technicians, the frequency of counseling was minimal. The counseling events that took place seemed closely linked with the practice habits of the pharmacists and pharmacy staff working in the pharmacies at the times the observations were made. As shown in Tables 2 and 3, technicians and cashiers were more likely than pharmacists to interact with patients upon receipt of the prescription and at the point of prescription delivery to patients. Thus, the involvement and support of the technicians and cashiers with
Table 2. Frequency of and Perceptions About Counseling Events in Four Pharmacy Sites
Activity (data collection method)
Nonautomated Sites No. Occurrences/ Opportunities (%)
Automated Site No. Occurrences/ Opportunities (%)
P valuea < .001
Oral counseling offers made (direct observation)
24/86 (28)
38/49 (78)
Patients counseled about new prescriptions (patient survey)
6/13 (46)
3/11 (27)
.300
Counseling events performed by pharmacist (direct observation)
12/26 (46)
7/17 (42)
.498
Pharmacists who believed they had adequate time to counsel
3/8 (38)
2/3 (67)
.424
5/8 (63)
1/3 (33)
.424
(pharmacist survey) Pharmacists who believed they had adequate privacy when counseling (pharmacist survey)
aFisher
142
exact probability test.
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Table 3. Pharmacists’ Technical Dispensing Activities in Four Pharmacy Sites
Pharmacists’ Technical Dispensing Activitiesa
Nonautomated Sites No. Occurrences/ Opportunities (%)
Automated Site No. Occurrences/ Opportunities (%)
Receive prescriptions from patients
21/57 (37)
3/33 (9)
Enter prescription data into computer
76/96 (79)
32/73 (44)
< .001b
Retrieve stock bottles for dispensing
58/104 (56)
5/33 (15)
< .001b
Count or reconstitute prescriptions
29/116 (25)
3/38 (8)
Label prescription bottles
20/105 (19)
1/33 (3)
< .05c
File completed prescriptions for pickup
10/31 (32)
0/14 (0)
< .05c
Deliver prescriptions to patients
3/75 (4)
7/54 (13)
< .05c
Answer telephone
22/71 (31)
22/59 (37)
aActual
.004b
.034b
.484b
numbers of discrete activities by all pharmacy personnel during observation periods.
bResults cFisher
P value
of 2 × 2 chi-square analysis.
exact probability test.
respect to pharmacist–patient interaction will likely have an effect on patient counseling rates.
Limitations Because of geographic constraints, only one automated site was studied, whereas three nonautomated sites were studied. Including more automated sites with similar volume and staffing characteristics would increase the power of this study. In addition, having more than 8 hours of observation at each site would have resulted in larger sample sizes for both activity assessment and survey collection. The automated site and two of the nonautomated sites had drive-through windows in the pharmacies. Physical barriers and privacy concerns prevented any observations of counseling events and distribution of surveys to patients using the drive-through windows to pick up their prescriptions. Observations of such events and survey responses from these patients would have helped to increase the sample sizes of the data collected. An alternative study design would have been to analyze a single pharmacy site before and after implementation of an automated dispensing system. Because the site could have then served as its own control, a more clear assessment of the effect of this technology could be made. On the other hand, generalizability of study results would become an issue, as all data would have been collected from a single site. By examining four sites, the study observed general practice patterns of pharmacists, at least in this pharmacy chain. No pharmacy students or interns were staffing the pharmacies at the times the observations were made. The effect of the presence of students on the dynamics of the pharmacy operations would have been instructive, as these individuals are able to counsel patients under the guidance of a pharmacist and would perhaps Vol. 45, No. 2
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contribute to higher counseling rates. The investigators of the study served as the observers, and observer bias may have been present. A Hawthorne effect with both pharmacists and patients may have been an issue as well given the presence and proximity of the observers. However, use of standardized forms minimized observer bias. Since pharmacy personnel were not aware of the purpose of the study, this was not believed to be a significant issue. At times, patients seemed to have difficulty differentiating the pharmacist from other pharmacy staff because of similar uniform attire and lack of name badges. The lack of pharmacist identity could have contributed to inappropriate patient responses to survey questions about counseling. Other misunderstandings or false interpretations of survey questions by both pharmacists and patients are also possible.
Conclusion Automation was associated with a higher number of prescriptions dispensed per pharmacist FTE and with proportionately fewer technical tasks associated with dispensing performed by pharmacists. However, pharmacists remained engaged in technical aspects of dispensing, and counseling rates were not different from those observed in nonautomated pharmacies. Likewise, higher prescription workloads were not associated with fewer patient counseling activities at any of the sites investigated. Staffing levels were not related to the likelihood that a patient received counseling. Whether counseling occurred appeared to depend on factors other than use of automation and technology. Given this era of high dispensing workloads for pharmacists, many pharmacies appear to lack adequate organization in terms of pharmacist performance of technical dispensing tasks. Even in the presence of automation, pharmacists in this study continued to perJournal of the American Pharmacists Association
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form traditional technical dispensing tasks that could be performed by technicians. A reallocation of tasks could enable pharmacists to redirect their focus from the dispensing process to patient counseling and education. Further research is needed to investigate ways in which pharmacists can provide patient counseling in a manner that is efficient but also consistent with the letter and the intent of prescription drug counseling regulations.
References 1. Arthur Andersen LLP. Pharmacy activity cost and productivity study. November 1999. Accessed at www.nacds.org/user-assets/PDF_files/ arthur_andersen.PDF, December 20, 2002. 2. Barker KN, Felkey BG, Flynn EA, Carper JL. White paper on automation in pharmacy. Consult Pharm. 1998;13:261–93. 3. Parks L. Pharmacy aide could improve workflow and pharmacist productivity. Drug Store News. 2001;23(5):25. 4. MacKeigan LD, Larson LN. Development and validation of an instrument to measure patient satisfaction with pharmacy services. Med Care. 1989;27:522–36. 5. Larson LN, MacKeigan LD. Further validation of an instrument to measure patient satisfaction with pharmacy services. J Pharm Market Manage. 1994;8:125–40. 6. Parks L. Robotic pharmacy system helps independent cut costs. Drug Store News. 2001;23(3):68. 7. Parks L. Pharmacies look to technology to ease prescription boom. Drug Store News. 2000;22(18):19.
PHARMACY THROUGH THE AGES
Powder Divider Powders, usually of a single substance reduced to fineness, were once an important dose form for the compounding pharmacist. Powders were most often dispensed in paper packets that contained a single dose. Compounding the correct dose and folding each paper into uniform envelopes was a skill developed only through increasing manual dexterity gained by repetition. A number of techniques were used to prepare the individual dose. One method was to divide the bulk powder in half, and then to continue dividing each half by half again, until the proper number of doses were separated. Allen’s Powder Divider, shown here, was an attempt to produce exact doses quickly. The bulk powder was placed in the V-shaped trough and leveled; a series of knives could be placed to evenly divide the powder into as many as 24 doses. When the individual doses were separated, the pharmacist would push the back end of the divider forward and a dose would drop into a waiting powder paper. Only a few powders remain available commercially; the best known is probably BC Powder (GlaxoSmithKline), which originated in a North Carolina pharmacy in 1906. SOURCE: PROCEEDINGS OF THE AMERICAN PHARMACEUTICAL ASSOCIATION. 1895;43:596.
Dennis B. Worthen, PhD, is Lloyd Scholar, Lloyd Library and Museum, Cincinnati, Ohio, and JAPhA Contributing Editor, Heroes of Pharmacy.
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Impact of Community Pharmacy Automation on Workflow, Workload, and Patient Interaction Lauren B. Angelo, Dale B. Christensen, and Stefanie P. Ferreri
ABSTRACT Objective: To compare workload productivity, workflow efficiency, and pharmacist–patient interaction in automated and nonautomated community pharmacies. Design: Observational study. Setting: Four community pharmacy sites within a regional pharmacy chain. Study Participants: 173 patients and 11 pharmacists. Interventions: Patient surveys, pharmacist surveys, and direct observation. Main Outcome Measures: Patient satisfaction, frequency of pharmacist–patient interactions, and prescription dispensing productivity and efficiency. Results: Results from the three nonautomated pharmacies were averaged and compared with results from the automated pharmacy. Patient satisfaction was generally favorable for both automated and nonautomated pharmacies, but scores for the automated site were significantly better on items measuring one domain, technical competence of pharmacy staff. No association was found between patient counseling and prescription workload in automated or nonautomated sites. Personnel at the automated site made significantly more offers to counsel patients, but the number of patients who received counseling did not differ significantly. Automation was associated with a higher number of prescriptions dispensed per full-time equivalent pharmacist and fewer technical dispensing tasks performed by pharmacists. Conclusion: Patient satisfaction was not related to the presence of an automated dispensing system. Automation was associated with higher prescription productivity, but actual counseling rates were no different from those observed in nonautomated pharmacies. The likelihood that a patient would receive counseling was not related to staffing levels, automation, or workload. Whether counseling occurred appeared to depend on factors other than automation. Keywords: Community pharmacy, automation, patient interaction, workflow, workload. J Am Pharm Assoc. 2005;45:138–144.
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Received November 9, 2003, and in revised form March 25, 2004. Accepted for publication April 30, 2004. Lauren B. Angelo, PharmD, MBA, is Assistant Professor, Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Butler University, and Coordinator, Kroger Pharmacy Patient Care Center, Indianapolis, Ind. At the time this research was conducted, she was a Community Pharmacy Practice Resident with Kerr Drug and the University of North Carolina, Chapel Hill. Dale B. Christensen, PhD, is Professor, Division of Pharmaceutical Policy and Evaluative Sciences, School of Pharmacy, University of North Carolina, Chapel Hill. Stefanie P. Ferreri, PharmD, CDE, is Clinical Assistant Professor, Division of Pharmacotherapy and Experimental Therapeutics, School of Pharmacy, University of North Carolina, Chapel Hill. Correspondence: Lauren B. Angelo, PharmD, MBA, College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Avenue, Indianapolis, IN 46208-3485. Fax: 317-940-8520. E-mail: langelo@ butler.edu See related article on page 145 of this issue. Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Funding: American Pharmacists Association Foundation Incentive Grant for Practitioner Innovation in Pharmaceutical Care and Merck & Co. research grant. Previously presented at the American Pharmaceutical Association Annual Meeting, March 15–19, 2002, Philadelphia, Pa. Brief preliminary findings from this study were published in the September/October 2002 issue of ComputerTalk.
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ncreases in pharmacist productivity have occurred largely through the use of technicians and technology in today’s pharmacies. Computer systems handle tasks such as maintenance and screening of patient drug profiles and third-party billing much more efficiently than in years past. Furthermore, with the advent of national certification standards, pharmacy technicians are more equipped to assume dispensing tasks formerly done by pharmacists. Automated dispensing systems represent the latest in technology to be introduced in the community pharmacy setting. Nevertheless, according to one recent survey, pharmacists still spend more than 60% of their time involved with dispensing activities that could be performed by technicians and automation.1
AT A GLANCE Synopsis: Automation contributed to an increase in the productivity of pharmacists but not to any measurable difference in patient counseling rates in this assessment of the effects of automation on patient satisfaction, frequency of pharmacist counseling, and dispensing productivity and efficiency. In an automated pharmacy, productivity increased and pharmacists consequently performed fewer technical tasks. While offers to counsel patients about their medications were made more frequently in the automated pharmacy, actual patient counseling rates did not differ from those in nonautomated pharmacies, and pharmacists remained engaged largely in the dispensing process. Patient satisfaction was higher for the pharmacy with the automated dispensing system, but differences were significant for one domain (technical competence of pharmacy staff), nearly so for another domain (consideration of patient needs), and not statistically different for a third domain (explanation of information). Analysis: Community pharmacist productivity can increase through use of automation and technicians. With the demanding workloads that community pharmacists face, automation could be expected to free pharmacists from technical tasks and allow them to engage in patient care services. In line with recent studies of pharmacists’ activities—showing that counseling occupies little of their time—patient counseling rates in this study were low and not affected by the availability of automated dispensing equipment or by pharmacists’ workloads. Task reallocation among pharmacy personnel could enable pharmacists to provide patient care services without affecting dispensing productivity. In a companion article on page 145 of this issue, two of these authors examine the effect of workflow redesign on pharmacist–patient interaction and dispensing responsibilities in one of the nonautomated pharmacies studied here.
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In fact, automation is one of the primary factors contributing to a shift in pharmacy practice from predominantly technical dispensing activities to patient care services.1 Automation aids the dispensing process by replacing the tedious labor-intensive tasks common to pharmacy operations.2 Automated technology thereby offers the potential to enable pharmacists to perform patient-related activities at more optimal levels. The incremental time saved could potentially amount to an hour throughout the day.3 With this available time, pharmacists could, for example, increase their interactions with patients and become more involved with clinical services. While greater use of automation and technicians offer the promise of increased delivery of patient care services, little evidence indicates that this has occurred in practice. Assessment of the effect of automated dispensing technology is, therefore, a critical and timely issue.
Objectives The primary objective of this study was to compare an automated dispensing pharmacy with three nonautomated pharmacies in terms of workload productivity, workflow efficiency, and pharmacist–patient interaction in a chain pharmacy environment. The specific objectives were to: 1. Assess the effect of automation on: a. Patient satisfaction with the level of care provided and the pharmacy services received. b. Patient interaction with pharmacists and pharmacy staff. c. Prescription dispensing productivity and efficiency. 2. Describe the workflow processes in both automated and nonautomated pharmacies, particularly from the perspective of counseling services received by patients.
Methods This observational study assessed workload, workflow, and the extent of patient interaction in four community pharmacy sites affiliated with a regional pharmacy chain. One of the four sites used a ScriptPro (ScriptPro LLC, Mission, Kans.) automated dispensing system, which was compared with three nonautomated sites. The ScriptPro system had been in place for 17 months before the study. The automated site and two of the nonautomated sites had drive-through pharmacy services. All four sites had interactive voice response telephone systems to filter refill requests. The data sources for this study consisted of patient satisfaction surveys, practicing pharmacist surveys, direct observation of workload and workflow, records of prescription dispensing volume, and direct observation of patient interaction with pharmacists. Approval of this study and the survey instruments used was granted by the University of North Carolina Institutional Review Board (IRB) via an exempt review process. The IRB likewise waived the necessity for signed informed consent from study participants. Journal of the American Pharmacists Association
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Patient Surveys Two patient surveys were developed. The General Patient Survey included three subscales extracted from a validated survey developed by MacKeigan and Larson.4,5 The questionnaire was designed to assess the following domains: consideration of patient needs, explanation of information patients received with the dispensed prescription, and technical competence of the pharmacy staff. The consideration domain used eight statements to assess the pharmacy staff’s respect for the patient, responsiveness to the patient, and time spent with the patient. The explanation domain used six statements to assess the extent of explanation of the medication and adverse effects and degree of patient understanding. The technical competence domain used four statements to assess the patients’ perceptions of the pharmacists’ abilities in the dispensing process. A 5-point Likert scale was used to determine the extent to which patients agreed or disagreed with survey statements. The questionnaire was randomly distributed to patients at the time prescriptions were dispensed. Respondents were instructed to complete the questionnaire anonymously and return it in a stamped, addressed envelope that was provided with the survey. As an incentive for survey completion, respondents received a discount coupon that could be used in the pharmacy. A Survey of Pharmacy Services was designed to assess wait times, prescription status (new versus refill), interaction with pharmacists, and the nature of drug information delivered orally at the time prescriptions were dispensed. The survey instrument was reviewed by three pharmacists providing services at one of the pharmacy sites before use. Randomly selected patients completed surveys onsite after they received their prescriptions from the pharmacy. The surveys were collected in a sealed box to preserve confidentiality.
Pharmacist Survey The Pharmacist Opinion Survey was given to each of the pharmacists practicing at the respective study sites. It requested pharmacists’ opinions of workflow in their pharmacies and the activities that interfere with time spent counseling or interacting with patients. Time and privacy issues when counseling patients were also evaluated. Completed surveys were returned through the mail with prestamped, addressed envelopes.
Direct Observations Workflow and patient interaction measurements were conducted by direct observation of the dispensing and counseling activities during 8 selected hours at each of the four sites. The days of the week and times of the observations were held constant for all four sites. All observation sets were performed by the study investigators and a research assistant on Monday and Friday mornings in 2-hour intervals. The pharmacists and pharmacy staff at each of 140
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the sites were not informed about the intent of the study and observations. Because the primary investigator was a pharmacy practice resident at the time of the study, the pharmacists and pharmacy staff were told that the observations were part of her research project and that the data would be shared with them upon completion of the research. Two separate observation sets were established. During the first set, the observer used the Operations Checklist to record pharmacy operations and dispensing activities such as volume, staff member (i.e., pharmacist, technician, cashier, or student) performing each specified task, prescription processing steps, placement of equipment, and design of the pharmacy. The Patient-Interaction Checklist was used to record prescription volume, number of counseling events, staff members providing counseling, and length of time spent counseling. The patient-interaction observations were made concurrently with the distribution of the Survey of Pharmacy Services.
Data Analysis The survey results and observation data for the three nonautomated pharmacy sites were combined and averaged for comparison with the automated site. Statistical tests, including chi-square, Fisher exact probabilities, Student t tests, and correlation coefficients, were employed depending on the type of variable measurement used. A comparison of patient satisfaction based on the General Patient Survey subscales was determined by using simple unweighted average responses to the statements within each domain in the manner outlined by MacKeigan and Larson.4,5 These averages were determined based on responses ranging from 1 to 5, with negatively worded statements inversely adjusted. Responses of 1 or 2 were scored as “favorable” or “satisfied.” Mean scores for each domain were then calculated. P values (a priori alpha levels of .05) based on Student t tests were used to compare the mean responses. Dispensing workloads at each of the pharmacy sites were determined from standard daily accounting records, as well as by direct observation. The relationship between the percentage of patients counseled and prescription workload was explored using simple linear regression analysis. For each hour of observation, pharmacist and technician staffing levels were noted, as well as the number of new and refill prescriptions processed. Workload was expressed as prescription volume per hour per full-time equivalent (FTE) pharmacist and prescription volume per hour per FTE technician. The number of patients who were counseled about their prescriptions during the time of the workload assessments was also recorded. These data were extracted from the Survey of Pharmacy Services and averaged for each observation period.
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Results
RESEARCH
Table 1. Patients’ Satisfaction with Aspects of Pharmacy Services (n = 91)
Patient Satisfaction Surveys A total of 100 General Patient Surveys were distributed at the time of prescription dispensing at each of the four sites. Response rates across the sites were 18%, 22%, and 24% from the three nonautomated sites and 27% from the automated sites (Table 1). For each of the three satisfaction domains represented in the survey instrument, patients at the automated site expressed slightly greater satisfaction than did those whose prescriptions were obtained at the three nonautomated sites, but only for technical competence did the difference reach significance.
Counseling Activities The frequency of counseling activities and differences between automated and nonautomated sites using survey responses from pharmacists and patients and direct observation are shown in Table 2. As in Table 1, responses from the nonautomated sites were averaged into a single value for each measure. Pharmacy staff at the automated site made significantly more oral offers to counsel patients (P = .001). No significant differences were found for the other measured parameters. In the 43 instances when counseling was provided by pharmacy staff, pharmacists counseled patients in 12 of 26 sessions at nonautomated sites and in 7 of 17 sessions at the automated site. This means that counseling was performed by someone other than a pharmacist more than one half of the time. Because of the nature of the study, the extent of information provided to patients during the observed counseling periods was not assessed. For those patients who received counseling, each respondent indicated that the oral information provided was helpful. The length of time of each counseling event observed was recorded using a stopwatch, but too few timed counseling activities were observed to report reliable results.
Nonautomated Sites (n = 64) Mean ± SD
Domain Consideration of patient needs
Automated Site (n = 27) Mean ± SD
P valuea
2.09 ± 0.300
1.76 ± 0.33
.060
Explanation of information patients received with dispensed prescription
2.01 ± 0.310
1.82 ± 0.21
.236
Technical competence of pharmacy staff
2.10 ± 0.023
1.76 ± 0.16
.007b
Abbreviation used: SD, standard deviation. aBased
on t test results using a Likert scale: 1, strongly agree; 2, agree; 3, not sure; 4, disagree; 5, strongly disagree.
bStatistically
significant at P < .05.
Pharmacy Workload A mean (± SD) of 24 ± 16.28 prescriptions were dispensed per hour in the nonautomated sites during the observation periods. The automated site had higher prescription volumes, averaging 59 ± 7.26 prescriptions dispensed per hour. The relationship between the mean percentage of patients counseled, and the pharmacist workload during each observed hour varied widely, with no apparent pattern. Correlation coefficients were 0.379 and 0.298 for the nonautomated and automated sites, respectively, indicating only weak associations with pharmacist workload. The relationship between the average percent of patients counseled and the technician workload for each hour also revealed no observable pattern (for the nonautomated pharmacies: r = –0.154 and automated pharmacies: r = –0.117).
Discussion Dispensing Activities The technical dispensing activities performed in each site were examined through direct observation with a particular emphasis on determining the type of personnel who performed each task (Table 3). A technical activity was defined as one that could have been performed by a nonpharmacist under supervision of a pharmacist. Reported are actual counts of each activity performed by a pharmacist; tasks not completed by a pharmacist were performed by either a technician or cashier. Entering prescriptions into the computer was the technical activity most frequently performed by pharmacists across sites and observation periods. All of the technical activities, except for counting or reconstituting prescriptions, were performed significantly more often by pharmacists than technicians or cashiers in the nonautomated sites compared with the automated site.
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Patient counseling was not a frequent activity in the observed automated and nonautomated pharmacies. With the exception of one counseling period, 50% or fewer of all patients observed receiving prescriptions were counseled. The overall modal counseling rate was less than 20%. However, based on survey responses, patients were generally satisfied with services despite relatively infrequent counseling. Patient satisfaction with pharmacy services was generally quite high across the three satisfaction domains and across pharmacy sites. The scores were relatively similar across the three domains for both the nonautomated and automated data sets. The automated site consistently scored higher than the combined scores from the three nonautomated sites. Thus, counseling was apparently not a factor affecting patient satisfaction, but this may be too simple an explanation. North Carolina regulations require that pharmacists provide an “offer to counsel” with every new prescription dispensed. Perhaps patients Journal of the American Pharmacists Association
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were satisfied with other aspects of pharmacy services, or perhaps they were satisfied merely with the offer to counsel. Another explanation is that patients may not have had high levels of awareness or expectations regarding pharmacist counseling opportunities or obligations. As required by state law, counseling must be provided by a pharmacist or pharmacy student under the direct supervision of the pharmacist. In the study sites, however, counseling was oftentimes performed by someone other than a pharmacist or pharmacy student (Table 2). This level of counseling may be insufficient to foster optimal levels of patient knowledge and adherence. The pharmacy policy at the study sites has taken the state’s counseling criteria a step further by requiring that every patient picking up a prescription, regardless of new or refill status, receive an offer to be counseled. This policy was facilitated using an automated signature log implemented several years before the study period. This automated device prompted the patient to answer whether he or she had questions for the pharmacist. All patients receiving a prescription must sign the log. As shown in Table 2, an oral offer to counsel on new prescriptions was extended only 28% of the time, on average, in the nonautomated sites, and 78% of the time in the automated site. Increasing the rate of offers to counsel to 100% as required by state pharmacy regulations and study sites would mean more counseling opportunities for pharmacists. Based on the data generated in this study, pharmacists should have the time to take advantage of these opportunities as more pharmacies become automated, given the existing availability of technicians at all sites and the finding that pharmacists were performing technical activities associated with dispensing a prescription. As illustrated in Table 3, technicians’ skills were better used in the automated site than the nonautomated sites. Automated dispensing systems are thought to improve workflow, increase accuracy, eliminate the need to hire additional staff to accommodate increasing prescription volume, and allow for more patient counseling.6,7 The addition of automation in the respective study site may have contributed to the enhanced workflow efficiency as
compared with the nonautomated sites. Defined work stations were evident and technician functions were better used but have not been optimized. The pharmacists in the nonautomated sites expressed concern about lack of time to counsel patients (Table 2), yet they performed technical functions more frequently than did the pharmacists at the automated site. In particular, computer data entry was commonly performed by the pharmacists across all sites, and was strikingly high for the nonautomated sites (77%). This finding parallels that of an Arthur Anderson study, which demonstrated a great deal of pharmacist involvement with dispensing functions.1 Encouraging the pharmacist instead of the cashier or technician to deliver the prescription to the patient and having the technician answer the telephone or enter data into the computer would facilitate counseling by the pharmacist, seemingly at no extra labor cost to the pharmacy. Given the benefits and purpose of automation, pharmacists working with such technology should focus on the opportunity it provides to become more involved with pharmaceutical care.1 Using any incremental time saved and increasing technician responsibilities will support this effort. A relationship between the patient counseling rates and pharmacy workload could not be established. Even with additional pharmacists or pharmacy staff available at the automated pharmacy, the frequency of counseling events was not greater than the nonautomated sites. The primary difference was that the automated site operated at a higher workload volume than the nonautomated sites. This would be expected and was likely the justification for implementing the automated system at this location. Even among the pharmacies with low workload for both pharmacists and technicians, the frequency of counseling was minimal. The counseling events that took place seemed closely linked with the practice habits of the pharmacists and pharmacy staff working in the pharmacies at the times the observations were made. As shown in Tables 2 and 3, technicians and cashiers were more likely than pharmacists to interact with patients upon receipt of the prescription and at the point of prescription delivery to patients. Thus, the involvement and support of the technicians and cashiers with
Table 2. Frequency of and Perceptions About Counseling Events in Four Pharmacy Sites
Activity (data collection method)
Nonautomated Sites No. Occurrences/ Opportunities (%)
Automated Site No. Occurrences/ Opportunities (%)
P valuea < .001
Oral counseling offers made (direct observation)
24/86 (28)
38/49 (78)
Patients counseled about new prescriptions (patient survey)
6/13 (46)
3/11 (27)
.300
Counseling events performed by pharmacist (direct observation)
12/26 (46)
7/17 (42)
.498
Pharmacists who believed they had adequate time to counsel
3/8 (38)
2/3 (67)
.424
5/8 (63)
1/3 (33)
.424
(pharmacist survey) Pharmacists who believed they had adequate privacy when counseling (pharmacist survey)
aFisher
142
exact probability test.
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RESEARCH
Table 3. Pharmacists’ Technical Dispensing Activities in Four Pharmacy Sites
Pharmacists’ Technical Dispensing Activitiesa
Nonautomated Sites No. Occurrences/ Opportunities (%)
Automated Site No. Occurrences/ Opportunities (%)
Receive prescriptions from patients
21/57 (37)
3/33 (9)
Enter prescription data into computer
76/96 (79)
32/73 (44)
< .001b
Retrieve stock bottles for dispensing
58/104 (56)
5/33 (15)
< .001b
Count or reconstitute prescriptions
29/116 (25)
3/38 (8)
Label prescription bottles
20/105 (19)
1/33 (3)
< .05c
File completed prescriptions for pickup
10/31 (32)
0/14 (0)
< .05c
Deliver prescriptions to patients
3/75 (4)
7/54 (13)
< .05c
Answer telephone
22/71 (31)
22/59 (37)
aActual
.004b
.034b
.484b
numbers of discrete activities by all pharmacy personnel during observation periods.
bResults cFisher
P value
of 2 × 2 chi-square analysis.
exact probability test.
respect to pharmacist–patient interaction will likely have an effect on patient counseling rates.
Limitations Because of geographic constraints, only one automated site was studied, whereas three nonautomated sites were studied. Including more automated sites with similar volume and staffing characteristics would increase the power of this study. In addition, having more than 8 hours of observation at each site would have resulted in larger sample sizes for both activity assessment and survey collection. The automated site and two of the nonautomated sites had drive-through windows in the pharmacies. Physical barriers and privacy concerns prevented any observations of counseling events and distribution of surveys to patients using the drive-through windows to pick up their prescriptions. Observations of such events and survey responses from these patients would have helped to increase the sample sizes of the data collected. An alternative study design would have been to analyze a single pharmacy site before and after implementation of an automated dispensing system. Because the site could have then served as its own control, a more clear assessment of the effect of this technology could be made. On the other hand, generalizability of study results would become an issue, as all data would have been collected from a single site. By examining four sites, the study observed general practice patterns of pharmacists, at least in this pharmacy chain. No pharmacy students or interns were staffing the pharmacies at the times the observations were made. The effect of the presence of students on the dynamics of the pharmacy operations would have been instructive, as these individuals are able to counsel patients under the guidance of a pharmacist and would perhaps Vol. 45, No. 2
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contribute to higher counseling rates. The investigators of the study served as the observers, and observer bias may have been present. A Hawthorne effect with both pharmacists and patients may have been an issue as well given the presence and proximity of the observers. However, use of standardized forms minimized observer bias. Since pharmacy personnel were not aware of the purpose of the study, this was not believed to be a significant issue. At times, patients seemed to have difficulty differentiating the pharmacist from other pharmacy staff because of similar uniform attire and lack of name badges. The lack of pharmacist identity could have contributed to inappropriate patient responses to survey questions about counseling. Other misunderstandings or false interpretations of survey questions by both pharmacists and patients are also possible.
Conclusion Automation was associated with a higher number of prescriptions dispensed per pharmacist FTE and with proportionately fewer technical tasks associated with dispensing performed by pharmacists. However, pharmacists remained engaged in technical aspects of dispensing, and counseling rates were not different from those observed in nonautomated pharmacies. Likewise, higher prescription workloads were not associated with fewer patient counseling activities at any of the sites investigated. Staffing levels were not related to the likelihood that a patient received counseling. Whether counseling occurred appeared to depend on factors other than use of automation and technology. Given this era of high dispensing workloads for pharmacists, many pharmacies appear to lack adequate organization in terms of pharmacist performance of technical dispensing tasks. Even in the presence of automation, pharmacists in this study continued to perJournal of the American Pharmacists Association
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form traditional technical dispensing tasks that could be performed by technicians. A reallocation of tasks could enable pharmacists to redirect their focus from the dispensing process to patient counseling and education. Further research is needed to investigate ways in which pharmacists can provide patient counseling in a manner that is efficient but also consistent with the letter and the intent of prescription drug counseling regulations.
References 1. Arthur Andersen LLP. Pharmacy activity cost and productivity study. November 1999. Accessed at www.nacds.org/user-assets/PDF_files/ arthur_andersen.PDF, December 20, 2002. 2. Barker KN, Felkey BG, Flynn EA, Carper JL. White paper on automation in pharmacy. Consult Pharm. 1998;13:261–93. 3. Parks L. Pharmacy aide could improve workflow and pharmacist productivity. Drug Store News. 2001;23(5):25. 4. MacKeigan LD, Larson LN. Development and validation of an instrument to measure patient satisfaction with pharmacy services. Med Care. 1989;27:522–36. 5. Larson LN, MacKeigan LD. Further validation of an instrument to measure patient satisfaction with pharmacy services. J Pharm Market Manage. 1994;8:125–40. 6. Parks L. Robotic pharmacy system helps independent cut costs. Drug Store News. 2001;23(3):68. 7. Parks L. Pharmacies look to technology to ease prescription boom. Drug Store News. 2000;22(18):19.
PHARMACY THROUGH THE AGES
Powder Divider Powders, usually of a single substance reduced to fineness, were once an important dose form for the compounding pharmacist. Powders were most often dispensed in paper packets that contained a single dose. Compounding the correct dose and folding each paper into uniform envelopes was a skill developed only through increasing manual dexterity gained by repetition. A number of techniques were used to prepare the individual dose. One method was to divide the bulk powder in half, and then to continue dividing each half by half again, until the proper number of doses were separated. Allen’s Powder Divider, shown here, was an attempt to produce exact doses quickly. The bulk powder was placed in the V-shaped trough and leveled; a series of knives could be placed to evenly divide the powder into as many as 24 doses. When the individual doses were separated, the pharmacist would push the back end of the divider forward and a dose would drop into a waiting powder paper. Only a few powders remain available commercially; the best known is probably BC Powder (GlaxoSmithKline), which originated in a North Carolina pharmacy in 1906. SOURCE: PROCEEDINGS OF THE AMERICAN PHARMACEUTICAL ASSOCIATION. 1895;43:596.
Dennis B. Worthen, PhD, is Lloyd Scholar, Lloyd Library and Museum, Cincinnati, Ohio, and JAPhA Contributing Editor, Heroes of Pharmacy.
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