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Dr. Ronnie Strickland, Remote Pharmacy Services at Cardinal discusses how outsourcing pharmacy fills gives floor pharmacists time for patient communication and focus on safety. He discusses what can be done from a remote virtual standpoint and how this can help protect patients. In rural, smaller hospitals, along with night shifts, often a nurse is required to be a nurse and a pharmacist. Outsourcing tools protect and intervene in errors, many of which are medication safety-related.
Hi, thank you so much for joining us. Again, my name is Julie Sukup with the medical memory and I'm excited to have another episode of take one patient. It's a great resource now that we're starting to look at virtual and recording and all of the things to talk about patient communication and communication excellence. I'm very excited to have Dr. Ronnie Strickland join me today, as far as working with Cardinal Health. Hi, Dr. Strickland, how are you?
I'm doing well, how about yourself?
Great. So I think what would be most useful to start is actually for us to talk a little bit kind of about your background, starting as a pharmacist, and starting in that capacity, and kind of how you got into more of an operational role with Cardinal and what you're doing now.
Sure. I'm a 1992, graduate of Campbell University School of Pharmacy, I do have a pharmacy degree, worked the first part of my career in a retail setting and moved up into operations management there. And, you know, things just got to the point where, you know, the the retail grind kindly got to me. So I went back into a hospital, which was my original love, actually worked my entire pharmacy career or the during the time that I was in pharmacy school in a hospital pharmacy. So I moved back, worked my way up through operations, and I was actually a pharmacy director of a small rural hospital licensed 100 bed, we had a 50 bed nursing home that was owned by the hospital, we also had 12 Physician Clinics that we owned. And this was back in the early 2000s. So that was kind of a, a novel approach at the time. So there's a lot more of that that goes on now. But you know, back in the early 2000s, it was not very common for health systems to own Physician Clinics. So, you know, as we as we move to advance our pharmacy practice there in the hospital and increase the offerings. One of the things with us being a small rural facility, we closed at 9pm at night. So I started investigating some type overnight order entry, company, or contract that we could get into, so that our patients would be covered by pharmacist review of medications 24 hours a day, at the time, that was just beginning that we were just starting to get into, you know, the full electronic health record. And so, you know, in order to have a true electronic health record, you need a true 24 hour electronic medication administration record. So, in order to do that, and do it correctly, you need a pharmacist verify in order. So we went through the different companies that were out there, Cardinal Health being one, I actually had several friends that worked for Cardinal at the time, two of which worked in the remote pharmacy services business. So I felt like, you know, I had a pretty good connection, you know, into into that operation. The interesting thing was that we were managed by a larger facility, about 35 hospitals across the Carolinas and also down into Georgia at the time. And so they kind of like forced me to utilize their in house service and utilize one of the 24 hour hospitals over at the in, in one of the larger cities. I'm not going to call any names, but it was certainly one of the larger cities. And yeah, we did that for a little while, didn't really work out all that well. You know, obviously the pharmacist on site at the hospital, you know, their main focus was the hot the large number of patients that they had in their facility. So we ended up switching back and go into cardinal and, you know, through through the chain of events that occurred and, you know, I ended up with Cardinal actually started working as a staff pharmacist with the remote pharmacy services team based in North Carolina, worked my way up through team director, Regional Director for the East Coast. And then my current role when I've been in this role for almost three years now is National Operations Director for Cardinal Health's remote pharmacy services business. So it's a little bit of background about me.
So one thing that is interesting that I didn't really realize is just what you started talking about and in case you know, other people don't really understand is, is talking a little bit about the verification with a pharmacist when there isn't a pharmacy open or right there. And so it talks a little bit more about, like what that need is, and, and how that kind of calm was based on the pressures that were pretty good nurses at that time. And the challenges that, that why there is a need for a remote type of service that that allows for
that. Yeah, totally, you hit the nail on the head, it's very important. Most of your regulatory agencies or your accreditation agencies for hospitals that require the same level of care, you know, 24 hours a day, seven days a week. So what would happen when our pharmacy would close that night, our automated dispensing machines are and you may hear me refer to those as ATMs moving forward throughout the conversation, you know, they're placed on an override, and the nurses actually would just, you know, the, the requirement, if they had something that needed to be administered during the night, they would go in, override the medication, and you know, they're putting their license at risk on verifying that, hey, there's no drug interactions, there's no allergy interaction, there's, you know, all all of this is fine, I can do this. And I can administer this to this patient safely. So what having an overnight order entry service does, it takes that burden and that onus off of the nursing staff, and it puts it on a true pharmacist and the nurses are able to, you know, pick up the phone call, if they have a drug information, question. Physicians are able to call if they have a an interaction question or any question about a medication for a patient. So it's really, you know, putting that putting that responsibility back where it should be. And that's on a pharmacist. So you have that pharmacists, 24 hours a day, seven days a week, 365 days a year. So
well, and that's what's interesting is when, you know, when we first spoke about it, it was just that you said, I mean, now you have a nurse that's doing a nice night shift, you know, is already a little shorter staffs is maybe a little bit tired, or, or whatever that is, now all of a sudden, needing to have, you know, a pharmacy, you know, there needs to be a pharmacist also. And just the small little pieces that that can evolve from that. It wishes you know, not even losing your license or his license, but also like the impact on a patient because if the provider is saying, hey, you need to administer this, well, they're gonna administer it, you know, and so, it's definitely kind of, like, brings out like a wow, there's, there's a challenge in this in this system, especially in more rural, or, you know, hospitals that don't have as much staff, you know, issue that you guys are really, truly, truly solving in that complexity, or in that in that piece, you know?
Absolutely. Yeah, I mean, and the thing that we need to keep in mind, in society today, we have more and more and more healthcare professionals, I'm not just gonna say nurses, it's also pharmacist, it's also physicians, that are being you know, criminally charged for medication errors, you know, and way follow one of the things that I am big on as I follow a just culture, and when you have a system, where, you know, a nurse is having to make a decision on is this medication safe for this patient, then you have, you have a system that is set up for error. So it you know, by by not having some type, you know, pharmacy service 24 hours a day, whether that be remote or whether that be on site, you know, you're really, you have a system that is setting people up for failure.
Right? Well, and that's one of the things we had talked about too, is you know, COVID shifted a lot of things in a really positive way where now you know, the resources, the resources are there, as far as tech wise, even functionally wise, to be able to better educate patients also, you know, medical memory we do a lot with educating patients even sometimes, you know, sending videos on behalf of the pharmacist on behalf of the pharmacy on behalf of the provider just on the education side of it, but also the ability to get this like virtual support like virtual support for nurses that may not understand it or need to like have that, you know, stop put in place. Virtually, you know, so how is even that ideation that you have really shifted to that virtually since COVID?
Well, one of the things that we've seen you know, and years ago our our bread and butter customer was that small rural hospital 5075 beds that really can afford to have 24 a 24 hour pharmacy on site. So, you know, one of the and we really went after and marketed to that customer, well COVID really changed the insight or the thought process of people, you know, not only I mean, you know, prior to COVID, how many how many patients that, you know, that had gone through a telehealth visit with their, with their physician, you know, very few, it was out there, the technology's available, and, you know, some places were using it, but it was not widespread. Well, COVID actually, really drove home the point that this is a successful model. And actually, it's probably a little bit more safe, because you can take a 10 minute conversation with a physician, and you're not having to go through the physician office, you're not having to go through all of that. And it's it's driven home, the fact that, hey, we can practice medicine safely from a remote standpoint, you know, and we've started to see that more and more State Boards of Pharmacy, are addressing remote pharmacy services, they're addressing work at home versus work from a licensed pharmacy. You know, they're addressing, you know, the the entire model that we practice. Yeah, one of the good things regarding, you know, the company that I work for, we actually started this this business concept back in 2003. My previous boss actually worked with ASHP and co authored ASC HPs guidelines on remote Pharmacy Order Processing. So,
and that's what we're even seeing, you know, a lot on our side, too, is also is, you know, of course, using video to educate patients, or any of those things is providing that that medium in one of two ways, either we are seeing some of our hospitals where they're just really busy during the busy during the middle of the day, they're wanting to have these bed to bed conversations or these batsmen explanations of medications, but to pull away from all the other things, it's just not as doable. So being able to even you know, send a one way video, you know, a video message that they can watch again and again, and be able to understand their discharge medications, what they're supposed to do, all of those things can have an incredible impact without having to take the time to go and go to the hospital and go to each one of those things, which all those pieces of time really add up. Even if it's just having a hi, how are you and walking to the floor, you know, is how can we start to maximize? You know, you talked about the, the you always want them to be at the top of their top of their clinical skills, how can we maximize, you know, those conversations are those educational pieces, to provide patients that have that information, really understand it, but also to, like, ensure that they're, they're being safe, you know, in, in that piece is what you're talking about with a lot of these places where, where it's closed, where they can have, alright, I need to talk to an ER doctor, I need that flag video sent to me that says, hey, there's a problem, you know, too. And I think that was interesting. I used to that of you want them at the top of their list the top of their clinical skills, you know, how can we cut down the times of the non muted things by providing that their ability to do that virtually, you know,
one of the things that we're doing currently and we actually have a customer actually here in North Carolina, and and we've done some Becker's webinar presentations with that, with that pharmacy director there but they saw a need and hospitals, CEOs that they deal with decreased CMS reimbursement due to their readmission rates. Well, this particular hospital had, you know, their CHF readmission rate was pretty high and they were getting substantial penalties on their their CMS reimbursement. So when they reached out to us in one of the things that we did, you know, were during the day we're processing or verifying, you know, probably 50% of their orders that come in, and what they've done is they have decentralized a pharmacist, and that pharmacist is actually doing good discharge counseling for patients that are leaving the hospital and covering their medications and, and making sure that, you know, the patient knows exactly what medication that they need to continue or they need to discontinue or do things that they need to start. And it's not just that process, but they've also done some other things with nursing, but they saw a 65% reduction in their CHF, patient readmission rate. So, you know, they've been able to cut down on that CMS penalty, and, you know, increase their reimbursement, while also, you know, providing another patient safety mechanism, you know, to patients that are being discharged. The most confusing thing for patients going home is what medications do I start? What medications do us continue? But more importantly, what medications did we stop? Yeah, one of the things that we've seen a good bit and most hospitals do these where you do their unit substitutions. You know, there may be six drugs in one class, and I'll give you the appropriate proton pump inhibitors. Most hospitals use one. Well, when the physician is doing the discharge list or the discharge med list, you know, they they may not indicate on there for the patient to stop. Let's say it's protonix now. Yeah. Okay. So the patient goes home. And they're taking protonix, but they're also taking the other proton pump inhibitor than they were before they came in. So that really gives the pharmacist at the opportunity. And you know, and we all know the pharmacist or the medication specialist, ya know, it gives them the opportunity to spend the time with that patient and really make sure that their medication list for patients going home is accurate, and the patient understands what they need to do.
Yeah, absolutely. Well, and we're seeing that with quite a few of the hospitals that medical memory is working with too, because you know, that conversation is so vital and so important. Because after you're discharged, you're not really sure what you were doing. And a lot of times, the patient isn't really the one that's like caretaking this so even if you know they're getting home and sisters helping or brothers helping the other day or wife isn't there, you know, that's where they started even recording a lot of that information, because they're like, hey, just so you know, check this recheck this share it, you know, and leveraging, you know, the tools that are available for that patient education, because to prevent that, because I think you I remember you saying that it was like 70 75% of patient safety issues or challenges with that are medication related with, like taking the wrong thing or not taking whatever it might be, which is, which is crazy to think about, especially as it relates to preventing those readmissions back in.
Right. Yeah, and, you know, and we, we have a breadth of data that is available out there. And we typically, we processed north of eight, well over 8 million medication orders last year, and you know, about 3% of those are actual things that we had to intervene on. Well, that 3% worked out to be and I've got that number right here. 255,000 clinical interventions that were performed by pharmacist. Yeah, and of those, what we found, and our data supports that half of that number is, you know, a patient safety concern on those interventions that we did. So that's, that's, you know, over 125,000 potential medication errors, or medication events that could have taken place, just in the past year with the with the hospitals that we cover. Wow. So well.
Yeah, that onus off of the nurse or any checkpoint even if it's a pharmacy, as you were talking about of saying, let us do this work of it so you can get out to patients and educate and communicate or, or also you have this failsafe, you know umbrella in case you know, it's 2am and you're not reading it right nurse that's not a specialist here. Wow, that's a lot that's a lot of people and I know I mean as best I can think about two to 5000 people you know if you know something, but you know,
it's significant Yeah, it's very significant. Yeah. And and having you know, some type of whether it be remote or whether it be on site but yeah, we what we do is really weekend free the pharmacist up in a side by side situation where you know, we might be working during the day and that pharmacist is able to go up and do clinical rounds, they are able to go up and have that pay should interview at discharge or even have that patient interview on admission as what? Yeah, so yeah, for med reconciliation, and, you know, med reconciliation, and it's something and it's a program that we're working on right now as well, you know, really being able to do patient intervention via video, at the admission to the hospital or even while the patient still in the emergency room. We all know that if we're not getting accurate medication list when they come into the hospital, then everything's going to be inaccurate throughout their entire hospital stay. So very important to to address the situation, or to address, you know, that patient medication history at the start, or at the onset of their hospital stay. So very,
no, absolutely. Well, awesome. I mean, I really appreciate kind of what you know, what you guys are doing, and that extra support. I know, even a lot of my nursing friends, you know, to think I know that that whole case that came up at Vanderbilt really scared every one of mysid mentors or something, and I think you already you know, we're working on solving that challenge even before it hits so that, you know, we're already asking our nurses do so much, you know, or more with less, or even our pharmacist to do more with less, that, you know, providing some of these services to take that onus off to go into where they went into, which is patient care, patient communication. You're really supportive, you know,
right. Patient safety is a is a huge, it's, it's a passion of mine, I actually had to deal with a medication error that resulted in a patient death. It was It happened at a location that I was working at, and I was the pharmacy manager, and, you know, having to sit down and have that conversation with that patient's family that, hey, you know, a medication error resulted in this death. Yeah. So it's it's very important in you know, patient safety. I remember reading To err is human, the ihr report that came out back in the 90s. And it's absolutely amazing, the the number of mistakes and yeah, I mean, you some of the things that you don't realize that are medication errors, yeah, let's, let's say a patient is supposed to get a drop in their ride, I get it into left I technically, that is a medication error. It's administered at the wrong site. Yeah. So anything that we can do to improve patient safety in a hospital setting because patients or patients are at our mercerie mercy in an acute care or long term acute care setting. So it's very important for us to put all the mechanisms in place that we can to protect those patients and make their their stay as absolutely safe as possible. Remote pharmacy services can certainly do that, you know, we can work with expanded beyond just overnight. You know, I have pharmacist, I have about 175 pharmacists that work for me, part of them work during the day, you know, not all of them work overnight, and I worked side by side with some of the pharmacies and hospitals that we work.
Awesome. Awesome. Well, thank you so much for joining me and kind of educating especially me about some of these places and how how, um, you know, the virtual aspect is really, really available now. In a lot of fastest stuff that people don't think of so patient safety and medication so I appreciate your time and thank you so much.
And I have certainly enjoyed it and I appreciate you giving
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