In response to the call for greater health care quality, the Medicare Modernization Act of 2003 provided for medication therapy management (MTM) services for patients with the goals of providing education, improving adherence, and detecting adverse drug events and medication misuse. Pharmacists recognize the value of providing cognitive pharmaceutical services (CPS), such as MTM services (both financial and patient care oriented), but have long recognized significant barriers to adding CPS to their already hectic workflow. Perceived barriers have prevented pharmacists from either implementing and/or sustaining CPS. Not surprisingly, lack of time, trained personnel, and reimbursement have been cited as the reasons pharmacists are not providing CPS.1–7
Although studies provide some insight on potential barriers to pharmacists providing CPS, they do not address or expand on the underlying contributing factors for the lack of time and/or lack of trained personnel.2,3
Lack of time may be because of a combination of factors, including high prescription volume, poor acceptance and use of technology, limited or inexperienced staff, corporate or organizational conflicts, a workflow that has not been revised to accommodate changes in practice, such as increased patient counseling, prescription volume, or additional personnel or technology, or other factors. The manner in which factors contributing to a lack of time/personnel manifest themselves as barriers to providing CPS is unknown, and no known research has characterized these factors and explored possible solutions.
One approach to better understand barriers and facilitators to providing CPS is to adopt a work system approach. A work system approach includes both a view of a current system in operation and a dynamic view of how a system evolves over time through planned change and unplanned adaptations. The approach is prescriptive enough to be useful in describing the system being studied, identifying problems and opportunities, describing possible changes, and tracing how those changes might affect other parts of the work system.8,9
The Systems Engineering Initiative for Patient Safety (SEIPS) model was adopted to study pharmacy work systems ().10
The model served as a useful framework for studying work system change and design because it provides a holistic view of a work system rather than focusing on a single component. It is grounded in human factors engineering principles and offers a framework for examining different components of a work system, interactions between components, and how the components may impact care processes and outcomes. The model consists of 5 key components of the work system: people, organization, technology/tools, tasks, and environment. The model has been used to study how interrelationships between the structural components of the work system interact to influence various work system processes and ultimately the outcomes of the work system.11–13
The SEIPS model might offer an improvement over Donabedian’s Structure-Process-Outcome model,14
which tends to focus on characteristics of practitioners, whereas the SEIPS model focuses on how the practitioner is impacted by the specific components of the system in which they work.
Fig. 1 SEIPS model for work system and patient safety.7
A recent demonstration program provided an opportunity to study pharmacy work system factors that act as barriers or facilitators to pharmacists providing CPS. The Wisconsin Pharmacy Quality Collaborative (WPQC) is a consortium of private and public third-party payers, community pharmacies, and the Pharmacy Society of Wisconsin (PSW, the Wisconsin State Pharmacy Association) that created an incentive-aligned, quality-based CPS demonstration program. Payers pay pharmacists for CPS provided to patients covered by their insurance plans. Payments are made for intervention-based level I services related to drug product selection (eg, changing doses, tablet splitting, formulary interchange, adherence) and patient education such as device instruction. To be reimbursed for most of these CPS, the pharmacist must identify the opportunity and contact the prescriber to change the therapy. Pharmacists also are paid for appointment-based level II MTM services, which include comprehensive medication review (CMR) and medication reconciliation. A typical level II service includes identifying the patient (either from the pharmacy’s patient profile or provided by the payer), performing a CMR with a patient, creating and providing a plan for the patient and prescriber, and documenting and billing for the service. A national drug wholesaler developed a web-based software platform to facilitate pharmacist documentation and billing for CPS. A full description of the demonstration project can be found elsewhere.15
The goals of this study were to identify and describe community pharmacy work system characteristics as important barriers or facilitators to providing CPS in WPQC. Using the SEIPS model as a guiding framework, the investigation focused on (1) characteristics of people in the work system, (2) the tasks that are performed in the work system, (3) the environment of the work system, (4) the tools and technology used in the work system, and (5) the role of the pharmacy organization in the work system.