Maggie McKay (Host): Whether you're in the hospital
or an outpatient, you know how crucial getting your medication is. But did you
ever think about all the people behind the scenes making sure you get the
accurate medicine on time and the right dose? Today, our guests are Dr. Shirley
Guan and Dr. Keegan Bachelor. They're going to tell us about medication safety
and pharmacy advancements at Community Memorial Healthcare.

Host: This is Wise and Well, presented by Community
Memorial Healthcare. I'm your host, Maggie McKay. Welcome, Dr. Guan and Dr.
Bachelor. Thank you so much for making the time to be here today.

Keegan Bachelor, Pharm.D: Thank you for having us.

Shirley Guan, Pharm.D: Yes, likewise.

Host: Absolutely. Dr. Guan, you are the Medication
Safety Coordinator at Community Memorial and Dr. Bachelor, you're the Manager
of Outpatient Pharmacy Operations. Can you both tell us what those titles mean
and what it takes in terms of education and training to become a pharmacist?

Shirley Guan, Pharm.D: Yeah. I could tell you, since
I started Medication Safety Coordinator, which was last year, previously I was
a retail pharmacist and also worked in hospital pharmacy for the last seven
years. It takes a lot of knowledge to know how the system operates in order to
serve as a medication safety coordinator. I feel like I am the liaison to work
with a multidisciplinary team that consists of physicians, nurses and
leadership members, working to improve medication quality and safety, as well
as addressing any potential improvements in our system on medication use.

Host: And what does it take in terms of education and
training? How long does it take to become a pharmacist?

Shirley Guan, Pharm.D: For me, it took four years of
undergrad. I had a bachelor of science degree and then another four years for
doctor of pharmacy.

Host: Okay. And Dr. Bachelor?

Keegan Bachelor, Pharm.D: Yeah. I have a similar
history in that matter. I went to a traditional four-year undergrad and
received my bachelor's in science and then pursued a doctorate in pharmacy
school, which is an additional four years. You'll hear there are other options.
They have accelerated programs like University of Pacific, for instance, does
have an accelerated program. You can get your doctorate in three years after
your undergrad. They even have an even more accelerated program that allows
them to get full doctorate within, I believe, it's four years or five years.
And they go by the speed of the students. So that if the student would like to
go faster or slower, they kind of adjust it. So, that's a unique situation, but
they do have those opportunities out there for pharmacists.

Shirley Guan, Pharm.D: Yeah. And it doesn't just end
right there after your four years of doctoral degree. Once you come out, you
could specialize in inpatient pharmacy. They have residencies out there for
pharmacists to train you whether you want to specialize in acute care settings
or outpatient settings. They also have ambulatory care services, more related
to medication management therapy. There's a variety of things you can do, and
it goes all the way from one to three years and includes fellowships as well.

Host: And Dr. Bachelor, what does your title mean,
Manager of Outpatient Pharmacy Operations?

Keegan Bachelor, Pharm.D: Essentially, I'm the
pharmacist that overlooks all the staffing here at our outpatient pharmacy at
CMH. It could be as simple as ordering paper. It could be interpersonal
situations that I have to discuss with my staff. And oftentimes, it's just kind
of fixing things. So, we're at the hospital, but we're actually separate. So,
we're a building, not located in the hospital like a traditional pharmacy that
you'll find in the basement, but we're actually a building on the other side of
the parking lot, but we do work within the hospital itself. So if there's an
instance where I need to reach out to a nurse or a doctor, and there was a
situation where we need to fix, you know, I'm the guy who kind of helps bridge
that gap, helps with communication between our staff here at the hospital and
outpatient because we're all on the same team, which is kind of unusual
compared to most retail pharmacies such as Walgreen, CVS, Rite Aid. They're
complete separate entities. They call the hospital if they have questions about
prescriptions, but they don't have the same resources that we do here at CMH.

Host: And Dr. Guan, what is medication safety? How
important is that?

Shirley Guan, Pharm.D: To start off with, I feel like
most people associate medication safety with adverse effects of certain
prescriptions they see on television. They might also hear horror stories on
the news of mistakes coming from nurses administering a wrongful medication to
a patient or maybe even a pharmacy filling an incorrect medication, thus
leading to patient harm.

So while this is not unheard of, medication safety really
varies in risk and is a lot more complex than what the public kind of
interprets it to be. So, the overall goal of medication safety is to reduce the
number of unsafe medication practices and errors that occur throughout the
medication use process. And when I'm talking about medication use process, this
can include anything from prescribing the medication, dispensing, preparing the
drug, administration of the drug, as well as the storage of the medication.

So in general, medications are not harmful when they're
prescribed for its intended use. However, it should be conveyed that medication
use is not without risks. Whenever there is a gap in medication use process,
this has a potential to lead to medication errors and possibly even lead to
patient harm. So, for instance, when patients state that they feel good and
they're currently on an antidepressant and they assume it's safe to stop their
medication without consulting their physician, their healthcare practitioner,
or maybe even their pharmacist patients may not know that they can end up
experiencing severe withdrawal symptoms if they cold turkey stop the
medication. And this could stem from a lack of education being provided to
patients from both the physician's office and also at the end of the pharmacy
consultation process. It's reported that up to 25% of all medication-related
injuries are actually preventable.

So, my role as the medication safety coordinator is to
optimize and improve our practices as well as improving our system to prevent
and mitigate any patient harm. But I believe it's crucial to start at the level
of patients and ensuring that they're well educated on what they take and why
they're taking it. So, we should always encourage patients to be an advocate
for themselves and ask questions in order to be well informed of their own
care.

Patients don't realize the risk associated with using
multiple pharmacies. This is a term called polypharmacy. When they do doctor
shopping or pharmacy shopping, maybe it's to get better pricing or have certain
prescribers, you know, prescribe what they want versus what's best for the
patient themselves. There's a risk associated with that because not every
pharmacy communicates to each other, and doctors don't know this information
too if the patients are seeing multiple physicians. And then so, what happens
is the patients are on multiple medications. Some of them can interact with
each other, but nothing gets communicated.

When we have our outpatient pharmacy, where the patients can
come back, not only after they use it for Meds-to-Bed services, they can come
back to the same pharmacy, they can come back to our hospital and just the
information follows the patients throughout. Nothing is lost. It serves as a
benefit for the patient because we're sometimes able to deduce the fact that
patient was on a medication, this is why they've been hospitalized. And if we
get rid of that medication, that would resolve their hospitalization.

Host: How is your pharmacy medication management set
up? Does it differ from other healthcare organizations?

Shirley Guan, Pharm.D: So, our medication management
system is mainly driven by our electronic health system and automation. Having
a system that interoperates can reduce medication errors, reduce repetitive
work, and improve patient safety and care. So when our patients are initially
admitted, their most updated medication list gets inputted into our electronic
health record. This record then follows the patient for lifetime. It's
important that patients provide the most accurate medication list because this
can help physicians manage their care better. We also have a highly qualified
and educated staff of pharmacists who review patient's medication list, their
labs, their disease state and then provide recommendations to adjust and modify
therapy.

For instance, we utilize a clinical decision support system
that helps us track patients who have been on antibiotics for more than 48
hours, but have really no real indicative source of infection. So, we're able
to quickly communicate this with our physicians after we identify this. And
physicians can ultimately make the decision to stop unnecessary use of
antibiotics sooner. This overall can help prevent patients from developing
adverse effects from their current use of antibiotics, such as common things
like diarrhea and, in the long run, prevent things like antibiotic resistance
from occurring. So recently, we've also expanded our clinical roles and
supplemented our knowledge with further board certification.

So when it comes to managing pharmacy inventory and storage,
we utilize an automated system called Pharmogistics and Pyxis. This ensures
that we have a sufficient level of medication at all times and helps us avoid
any waste. Any medication that we purchase, we have individualized barcodes
associated to that specific medication, which gets scanned and logged into our
system. This essentially allows us to track what we carry. And for any drug
recalls that we receive, we're able to quickly identify and pull out the
effective medications. We also store medications on patient floors, so that
it's readily accessible to nurses and physicians. And then when the nurse is
preparing to administer a medication, they're able to sign onto these Pyxis or
medication-dispensing machines. They pull up the patient's name and then they
pick whatever medication is due so that the machine will actually popped out a
drawer and a bin with a correct medication. Because these medications are
individually barcoded, before administration, the nurses will use a barcode
scanning process to ensure the correct medication is given to the right patient
and at the right time.

And then lastly, to kind of circle into our discharge
process, our physicians work closely with our case managers and social workers
to ensure that it's a smooth transition to home or another care facility.
Again, our discharge medications are reviewed by our pharmacists, and any final
recommendations to adjust the dose or therapy are communicated to our physicians.

And then lastly, once the discharge medication list has been
completed, an electronic prescription is sent out to any outpatient pharmacy
that's preferred by our patients. Nurses will also review these discharge
medications with patients and include a medication card, which serves as an
educational tool for our patients to take home. For example, the medication
card will list commonly prescribed blood thinners along with the most common
side effects associated with that class of medication. And again, this is to
enhance patient knowledge and understanding of their own care.

Host: Wow. It sounds like you've got it down,
especially those drawers that pop open. That's so Jetsons.

Shirley Guan, Pharm.D: Automation.

Host: Futuristic.

Shirley Guan, Pharm.D: Yes.

Host: Dr. Bachelor, you mentioned earlier that, a lot
of pharmacies in hospitals are in the basement, but you guys are on the same
campus, but not in the hospital, but you're right there. That must be so
convenient. What does this offer to patients? Like what unique advantages when
they leave the hospital to have this? You know, they don't have to go into the
hospital maybe to get their prescriptions or whatever.

Keegan Bachelor, Pharm.D: Yeah, it's a very unique
situation that we're in. And the patients, for instance, they could go to the
ER or one of our clinics nearby. And once they get diagnosed and the prescriber
prescribes them an antibiotic, for instance, they can literally walk to our
pharmacy, it's here on campus. They can wait. Our wait time's typically within
five to 15 minutes after receiving the prescription. It's all done
electronically nowadays, compared to a typical hard copy prescription that the
doctor would hand the patient and they would have to bring it to the pharmacy
and drop it off.

So typically, we start working on the prescription before
the patients even get here. They can come to the hospital, get their
prescription. They don't have to wait hours, they don't have to drive around.
It's a very unique situation. We've had a lot of praise. The patients that come
here, they often say, you know, "Why doesn't every hospital have
this?" And so, we love hearing that and we love giving that service to our
patients. And we don't have long wait times, like a lot of our competitors and
our phones aren't constantly ringing. So, it's a huge advantage, and it's not
well known. We're fairly new. We've only been open since November 5th of 2021.
So, we're really a new pharmacy and it's been going really well.

Shirley Guan, Pharm.D: I think a real advantage of
actually this hospital-based pharmacy is we have a streamlined communication
process with our physicians. We have access to patient labs. So, on the
outpatient side, we don't have to guess what their renal function is like or
assume, you know, they're still on a medication that could have drug
interactions with. These are all things that we have easy access to and we can
address any of these issues with our physicians fairly quickly. So, the
turnaround time for clarification on medication issues is very fast as well.
Maybe that's why patients are able to get their prescriptions faster and they
could potentially avoid these long delays in, you know, any of their
prescription clarification.

Host: Yeah. That's wonderful. Dr. Bachelor, I
understand that you have a very unique program called Meds-to-Beds. Can you
explain why Community Memorial started this program and how patients benefit
from it?

Keegan Bachelor, Pharm.D: Yeah. So, we first started
this program, Meds-to-Beds, which is essentially bringing the prescription to
the patient's bedside upon discharge. And the reason why we started this
program was we were hoping to increase our patients' adherence, which is
something most pharmacies tend to see, you know, adherence, which means
hopefully the patient's taking the medication as directed when they're supposed
to take it and continuing to take that medication. It's not unusual for
patients to not be adherent.

So while focusing on that, we also wanted to decrease our
hospital's 30-day readmission rates, which means, let's say, a patient comes in
to the hospital or the ER, they come for treatment, but then they come back a
few days later because if it's diabetes, for instance, it's not being treated
at home properly. So, those rates directly affect our contracts here at the
hospital. We don't want to lose those contracts. We're scored by insurance
companies. When patients are readmitted, that negatively affects our hospital
and our scores. And most importantly, it affects the patient. We want to make
sure that the patients are being treated correctly and that's our number one
concern, right? And then thirdly, we want to make sure to improve our patient
satisfaction scores, right? So, we want to make sure they feel confident in
their medications, what it's for, how to use it. We started Meds-to-Beds to
kind of focus on all of these, compared to a traditional hospital that sends a
prescriptions to another pharmacy, and maybe the patient isn't feeling well and
they have their family member or friend go to the pharmacy and pick up their
medication. And, from my past experience at Walgreens, we'd have the family
member come pick it up and I'm giving the consult to an individual that's not
the patient, and hoping that they say the exact same words I'm telling them.
And if you've ever played, you know, the game Telephone, I mean, oftentimes
things are changed and left out, and it kind of breaks any barriers such as
that we try to resolve here at the hospital.

Another thing that we've noticed is that there's a lot of
barriers with patients in general, like the one we just discussed.
Transportation issues, for instance, we have patients that leave the hospital.
Maybe they don't have a car or maybe they can't drive, but they need to go pick
up their medication for their blood pressure, their cholesterol, but they don't
have a ride to the pharmacy, right? Or their family member's not available,
they're at work. So by us delivering directly to the patient, we're able to cut
out that barrier. We give a consult to the patient directly when they're in bed
or maybe if they have a caretaker, at least we're talking to them specifically
rather than a third party. And then also, high copays, that's something that we
constantly are trying to resolve here at the hospital. We're able to cut down
all these barriers compared to a traditional retail pharmacy that may not have
all these resources that we do here at the hospital. For instance, oftentimes
insurance isn't covered, the medication's not on formulary, so we're able to
reach out to the prescriber or the nurse through an app that we use called
Mobile Heartbeats. We have direct access to the physicians and say, "Hey,
you know, this antibiotic isn't covered by their insurance. Do you mind if we
change it to the alternative, so that the copay is $5 rather than $500?"
We just want to make sure we break down all these berries before they even go
home and hopefully take care of the patient.

Host: It is very clear that the Community Memorial is
committed to going beyond the basics of just hospital pharmacy operations, and
you're so innovative in this area, the hospital. So for example, I understand
you're working on receiving an accreditation for being a specialty pharmacy.
What additional benefits and services will this accreditation offer your
patients, physicians and staff, Dr. Bachelor?

Keegan Bachelor, Pharm.D: Yeah. So, a specialty
pharmacy is a little bit different than a traditional retail pharmacy. It's
even different than compounding. So oftentimes compounding pharmacies are
considered specialty. But specialty pharmacy, you're required to jump through a
lot more hurdles. You have to have a lot more hands-on. You have to hire
specific staff that's highly, highly trained in specialty diseases such as HIV
oncology, if it's rheumatology or whatever it might be. So, you have to choose
what disease state are you going to focus on, you're not going to do all of
them. And then, you're going to have pharmacists that are specially trained in
these disease states. So for instance, I've worked at two specialty pharmacies.
One located in downtown Nashville to specialty Walgreens. It's a closed door
pharmacy, that's the traditional route, which will also set us apart if we do
become accredited. We will be different or unique compared to our competitors.
We will be an open door pharmacy, meaning if you want to get your HIV or
oncology medication filled with us, you can simply walk in and talk to a
pharmacist live as opposed to calling a pharmacy that's in a different state,
which is often the case. And then, they mail order your prescriptions to you.
It's all done over the phone, which is fine, but some patients do prefer the
in-person route or, you know, face-to-face, they want to meet their pharmacist.
So, we do have that advantage.

And the reason why the specialty is different than typical
medications that we fill here at our pharmacy is that oftentimes these
medications are $3,000, $5,000, $12,000 for a one-month supply. So, you have to
realize the insurance wants more hands on, more logging of information with
these medications, so they don't want to just send it to a pharmacy and pay for
$12,000 medication for a patient, and then they take it home and they don't put
in the refrigerator or they don't know how to use it. So, we're required to
contact the patients, not only give a consult like we typically do, but it has
to be a more thorough consult. We have to go into much more details. We have to
spend more time with the patients to make sure they know what it's being used
for, what are the side effects, which we do in a day-to-day basis, but there's
a lot more requirements. There's a 24/7 phone number that the patient, if they
wake up in the middle of night and they say, you know, "I'm having a side
effect," or "I have a question about this medication," they can
call us and speak to us and say, "Hey, you know, I need help," if
it's something that's preventing them from taking their medication and being
adherent, which we discussed. So, that's kind of the difference. There a lot
more training, a lot more documenting.

Host: So, that's really good for the patients. And
just briefly, how does it help the physicians and the staff to be accredited as
a specialty pharmacy?

Keegan Bachelor, Pharm.D: It's going to help our
patients and our staff and colleagues here at the hospital tremendously.
Because typically what we're doing is a doctor here will prescribe Cimzia, for
instance, and we receive the prescriptions, but oftentimes we have to call a
specialty pharmacy, such as OptumRx Specialty, or one of the other ones like
Walgreen Specialty, CVS Specialty, and it's located in a different state. So,
we get on the phone, we transfer it out to another pharmacy, which delivers to
our patients by mail. And, again, it's just very distant compared to what we
are striving for here at CMH. Again, we're striving for a more personal
experience. You can call us, walk down here.

Shirley Guan, Pharm.D: I feel like the specialty
pharmacy itself, a lot of these medication are high risk medications to be
dispensed. And if we could provide that service right after discharge or, like
Keegan mentioned, at the point of sales, you know, these are things that we
could communicate to the patient right away, consult them. We're able to chart
everything into our system, so that if they do get readmitted back to the
facility or their hospital, we're able to know what happened to the patient.
So, this is kind of like a continuum of care for patients, so we're not out of
the loop if something does happen to them.

Keegan Bachelor, Pharm.D: Yeah. And also, specialties
for chronic illnesses that do require more detail, there's also a treatment
plan, which is different than our current pharmacy. When you're in specialty,
you have to discuss treatment plan with the providers and the patients and make
sure you're all on the same team, which is different. I don't go through
treatment plans with my current patients, with the providers. I may have
questions that need to be answered, but I'm not going through looking at labs
and making sure everything's accurate to the same extent that specialty does
require.

Host: Thank you both so much for being here. We
really appreciate your time. And you have taught us so much today. I did not
know so many of those things and what to consider when you're in outpatient or
in the hospital and medications and how important they are. So, we really
appreciate all your knowledge and sharing it with us.

Again, that's Dr. Shirley Guan and Dr. Keegan Bachelor. If
you'd like to find out more, please visit mycmh.org, that's my cmh.org. If you
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This is Wise and Well, presented by Community Memorial
Healthcare. Thank you for listening.