PHA6129 LAB: Prescriptions in Hospital Pharmacy Practice and Drug Pricing

HOSPITAL PHARMACY

• Oversee the different steps in medication management and use system from the:

  • drug procurement

  • drug storage and inventory control

  • medication preparation and distribution

HOSPITAL PHARMACY

oversees the aforementioned steps until monitoring of the drug therapy outcome to optimize patient safety and improve patients' health related quality of life

Selecting and Procuring

PORTRAYED BY

• Clinicians

• Administrators

• Pharmacists

Storing

PORTRAYED BY

• Pharmacist

Prescribing

PORTRAYED BY

Physician/

Prescriber

Review Preparing and Dispensing

PORTRAYED BY

Pharmacist

Administering

PORTRAYED BY

Nurse/ Other health professionals

Monitoring

PORTRAYED BY

All practitioners, patient, and/or family

Storing

Storage of medication

Prescribing

• Assess patient;

• Determine need for drug therapy

• Select and order drug

Review Preparing and Dispensing

• Review and confirm order

• Prepare meds

• Distribute to patient location

Administering

Review dispensed drug order;

Assess patient and administer

Monitoring

Assess patient response to drug

Report reactions and errors

HOSPITAL PHARMACY SERVICES

Depends on the individual standards set specifically by the hospitals based on patient requirements and professional resources.

HOSPITAL PHARMACY SERVICES

A	Dispensing Service
B	Compounding Service
C	Clinical Service

DISPENSING

considered to be the main function of the pharmacy

DISPENSING SERVICE

Utilization of the technical abilities of hospital pharmacists

DISPENSING SERVICE

Requires expertise in pharmacology, pathophysiology, therapeutics, patient care, and basic communication skills

DISPENSING SERVICE

Comprised of:

Procurement and storage

Labeling

Patient counseling

Inventory management

Proper pharmaceutical waste disposal

DISPENSING

Act of the pharmacist in supplying one or more drug products to a patient,usually in response to an order from a prescriber through a prescription

DISPENSING

Pharmacists must plan, develop, control and monitor the maintenance and delivery of medicines, along with the information needed for proper storage and administration.

CLINICAL SERVICE

Specialized pharmacist function that promotes individualized patient care through therapeutic monitoring

CLINICAL SERVICE

Promotes integration of the pharmacist in the healthcare team as someone who interacts with other medical professionals for holistic patient management

CLINICAL SERVICE

• Includes functions such as:

  • Provision of drug information

  • Building of patient medication database

  • Therapeutic education/counseling

  •  Drug Utilization Review

  • ADR detection, reporting and monitoring

COMPOUNDING SERVICE

Preparation of medications, special dosage forms, and formulations not readily available.

COMPOUNDING SERVICE

• Requires understanding of pharmacologic principles involved in medication preparation in special dosage forms, such as:

  • bioavailability/bioequivalence

  • Stability

  • microbiology

  • manufacturing techniques

Non-sterile compounding

Ex: paper tabs

Sterile compounding

Ex: Cancer drugs, IV drugs

Dispensing of pharmaceutical items

Verification of medication request (i.e. completeness and appropriateness review)

Dispensing of pharmaceutical items

Preparation and labeling of medications for patients

Dispensing of pharmaceutical items

• Compounding

  • Sterile (Total Parenteral Nutrition, IV Admixtures)

  • Non-sterile (Extemporaneous compounding – paper tabs, dermatologicals, eye wash, etc.)

Dispensing of pharmaceutical items

• Charging of pharmaceutical items

• Coordinates with the healthcare team members

Handling of Dangerous Drugs, antidotes, and emergency drugs

Selection, procurement, dispensing, monitoring, recording

Inventory Management

Maintains proper storage of pharmaceutical items

Inventory Management

Adequate control over requisition and dispensing of medicines

Inventory Management

Recording and filled  of documents

Organization, administrative and management duties

Financial (preparation of budget, analysis of financial statement, price management)

Organization, administrative and management duties

Human Resource (staff scheduling, performance evaluation, preparation of training plan)

Organization, administrative and management duties

• Selection and procurement

• Representation to meetings and hospital committees (PTC, AMS, ICC, CNS, Waste Management, etc.)

PRESCRIPTION

A written order and instruction from a licensed prescriber to the pharmacist for the use of drug product/s for a specific patient.

PRESCRIPTION

All medication orders must be documented and signed by a physician affiliated with and authorized by the hospital.

TYPES OF HOSPITAL PRESCRIPTIONS USED

1	Regular Prescription
2	Physician’s Order Sheet (POS)
3	Computerized Physician Order Entry (CPOE)

REGULAR PRESCRIPTION

containing medication orders used by doctors for admitted patients

PHYSICIAN’S ORDER SHEET (POS)

Document with prescriber’s notes regarding patient’s progress, therapeutic orders (diagnostics, medication, diet, etc.), and management plan

PHYSICIAN’S ORDER SHEET (POS)

Serves as the basis of order transcription

Date and Time

PARTS OF THE POS

documents the time frame in which the doctor wrote in the POS to ensure good turnaround time for transcribing orders

Doctor’s Notes

PARTS OF THE POS

where physicians document pertinent therapeutic details (vital signs, diagnoses, management plans, etc.) which are not necessarily orders to be carried out

Orders

PARTS OF THE POS

where physicians write orders to be carried out (medications, laboratory/ancillary tests, diet changes, etc.)

physicians

Except for verbal or telephone order transcription, only _ involved in patient care can write in the POS. A separate documentation sheet is used by other members of the healthcare team for their notes.

COMPUTERIZED PHYSICIAN ORDER ENTRY

• A variety of computer-based systems that share the common features of automating the medication ordering process and that ensure standardized, legible, and complete orders (Kaushal et. al., 2003)

COMPUTERIZED PHYSICIAN ORDER ENTRY

Used by physicians to directly enter orders into hospital systems through a computer software in a digital interface.

Computerized provider entry (CPOE)

a system that allows direct, electronic entry of orders into an electronic record by licensed independent practitioners or other staff with prescribing privileges.

CPOE has several benefits

1	Reduce errors and improve patient safety (incudes built-in clinical decision support tools)
2	Improve efficiency
3	Improve reimbursements (when integrated with insurance system can flag orders that require pre-approval, helping you reduced denied insurance claims)

The use of CPOE has been associated with

1	Reduction in error due to assurance of standardized and complete orders before being processed/dispensed
2	Improvement in patient safety as clinical decision tools (drug allergy checker, drug interactions analysis, etc.) can be programmed into the software It is already high-tech, unlike in the past wherein you need to study all of it.
3	Enhanced efficiency as the manual process of transcription by a separate medical professional is eliminated

ELECTRONIC MEDICATION ADMINISTRATION RECORD (EMAR)

Application within an integrated electronic health record, or nursing documentation system that allows nurses and other providers administering medications to document medication administered to patient.

ELECTRONIC MEDICATION ADMINISTRATION RECORD (EMAR)

May be utilized with or without bedside barcoded medication administration (BCMA) functionality.

Benefits of using EMAR

1	Accuracy
2	Efficiency (if combined with CPOE, no need to transcribe a paper MAR)
3	Safety (can provide clinical decision support before and administration)

ELECTRONIC MEDICAL RECORDS

digital method of ordering and documenting inpatient stay and care that removes the manual use of paper. This system is usually used with CPOE in moving towards digitizing patient records.

MEDICATION ORDERS

These initiate the beginning of patient therapeutic management.

MEDICATION ORDERS

Part of a patient’s medical records that documents sequence of events during inpatient stay

MEDICATION ORDERS

Serve as main communication tool among healthcare providers

MEDICATION ORDERS

1.	Correct patient information
2.	Complete medication information
3.	Prescriber name and signature
4.	Other details, such as date and time
5.	Approved symbols and abbreviations only

OTHER TYPES OF MEDICATION ORDERS

1	Verbal/Telephone Orders
2	Non-Formulary Orders

3	Off-Label Orders
4	Compassionate Drug Use Orders

Verbal/Telephone Orders

In emergency cases in which a delay in carrying out an order can compromise patient care, orders may be given by the physician to authorized personnel (e.g., nurses, pharmacists) via telephone or verbally in person.

Verbal/Telephone Orders

The physician must verify the transcribed order through readback method, in which the personnel who received the order relays their transcription. Once approved, the order may be carried out immediately.

Verbal/Telephone Orders

The physician must acknowledge the order given by signing on the POS as soon as possible.

Non-Formulary (NF) Orders

Medications ordered by physicians which are not part of the official list of medications/formulary approved for use in the hospital.

Non-Formulary (NF) Orders

The pharmacist must inform the prescriber of the NF status of the order and may suggest alternative medications from the hospital formulary.

Non-Formulary (NF) Orders

These orders must be reviewed on a case-to-case basis before the order is approved and the medication is dispensed.

Non-Formulary (NF) Orders

Non-formulary medications are not usually stocked in the pharmacy, and delays in medication administration may be expected.

Off-Label Orders

The action of prescribing current available medications for an indication that is not yet approved, or the use of a medication in a patient population, dosage, or dosage form with no official approval.

Off-Label Orders

These orders need sufficient reason/indication for prescribing prior to approval, usually from the Pharmacy and Therapeutics Committee.

REASONS FOR OFF-LABEL USE

No approved drug as treatment for the condition

Conventional treatment had no therapeutic effect

Patient is unable to take approved treatment (allergy, contraindicated with other comorbidities, intolerance to side effects, etc.)

Conventional treatment is inaccessible

Clinical trials of already-marketed drugs for new indications may show effectiveness

Compassionate Drug Use Orders

The use of new and unapproved medications to treat or manage a patient’s life-threatening condition with no other alternative treatment available.

Compassionate Drug Use Orders

These fall under Off-Label Use, as well.

PROCESSING A PRESCRIPTION

1	Prescription Validation
2	Prescription Interpretation
3	Preparation
4	Dispensing and Education

Prescription Validation

Checking for completeness and correctness of information, including the date, patient identifiers, prescriber information (name, signature, license number, S2 license for Dangerous Drugs), etc.

Prescription Interpretation

Pharmacist assesses the medication order for completeness of information, patient and disease appropriateness, and medication availability based on the formulary and hospital inventory.

Prescription Interpretation

Pharmacist may use several sources as references, such as hospital formulary and other in-hospital documents, primary and tertiary references, online sources, etc.

Clinical decision support (CDS)

is a system that provides health providers with knowledge and person-specific information to enhance health and health care.

Clinical decision support (CDS)

1	Computerized alerts and reminders
2	Clinical guidelines
3	Condition-specific order sets

4	Diagnostic support
5	Contextually relevant reference information

Preparation

Filling of the prescription ordered appropriately by comparing the medication with the medication order and preparing the necessary labels.

Preparation

Prior to dispensing, the correctness of the picked medications and label must be validated by a separate individual.

Preparation

Charging/billing is usually done at this step before proceeding to the next

Dispensing and Education

Dispensing the medication must always include education about the drug or therapy, including indication, possible side effects, optimal dosing time/schedule, etc.

Hospital Pharmacy

provides pharmaceutical care to every patient and is considered as one of the revenue centers of a hospital.

financial sustainability

For the pharmacists to deliver quality service, _ is very important. Thus, Pricing method should be established to ensure profitable operation.

PRICE

the amount required as payment for something offered for sale

PRICE

the value that is put to a product or service and is the result of a complex set of calculations, research and understanding and risk-taking ability.

HOSPITAL PRICING COMMITTEE

Also known as Hospital Costing and Rate Setting Committee / Price Adjustment and Rate

HOSPITAL PRICING COMMITTEE

Function: to oversee the implementation of the cost determination and rate setting (including pricing) activities in the hospital.

Chief Finance Officer (CFO)

Manages the budget, develops financial strategies, and controls cost to ensure that the hospital is earning since they have to pay healthcare staff

Chief Administrative Officer (CAO)

Manages daily operations

Chief Operating Officer (COO) /Chief of Hospital

Also manages day-to-day operations such as strategic planning to deliver high quality patient care

Chief Accountant

Entire accounting process, reporting, compliance to government, taxes, financial health including PhilHealth compliance

Chief Medical Professional Staff or duly authorized representative

Person in-charge is a doctor

Procurement Officer

Purchasing department, handles necessary equipments, supplies, medicines

Business Development and Planning Officer

Build partnership with clients and other healthcare institutions like HMOs (e.g. Maxicare), and identify opportunities

Provisional Members

1	Cost and Revenue Center representative
2	Department/Unit/Section Head concerned
3	End-user representative/s

The Duties of the Committee shall be as follows:

1	be the primary oversight over the hospital rates/prices
2	determine their appropriate hospital rates/prices for approval
3	review current rates/prices and initiate updating of rates/prices if there are new modalities introduced in the market or new government regulations
4	monitor and evaluate the effectiveness of the costing and rate setting or pricing activities