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Pharmacy Practice in Focus: Oncology
There are no clearly defined, widely accepted clinical pharmacist metrics.
Capturing meaningful clinical pharmacy metrics has proven challenging and is not a new endeavor. Literature published on metrics typically describes designs used to distribute pharmacist workload and guide pharmacists toward prioritizing high-value activities; however, data specifically addressing how to maximize pharmacist value in an outpatient oncology setting are sparse.1
In 1974, Bergman et al published an article on clinical pharmacy interventions in an inpatient Veterans Affairs (VA) ward. Pharmacists documented types of interventions and the number of interventions made, which were then collected and analyzed similarly to how interventions are documented electronically today.2 In 1986, Hatoum et al published a review that included more than 50 papers demonstrating the value of inpatient clinical pharmacists to cost savings and quality of care.3 In 1988, Vinson reported on the experiences of developing clinical metrics tied to cost savings to justify supporting full-time equivalent pharmacists (FTEs) for the clinical pharmacy role.4 This article described many of the advanced clinical pharmacy roles utilized today, such as chemotherapy education, rounding with physicians, and drug monitoring.4 This early research demonstrated the value of pharmacists in inpatient settings by documenting interventions and linking their contributions to cost savings and quality of care, as well as by showing the value of FTEs in modern health care.
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In 1996, Schumock et al published a review of more than 100 articles from 1988 to 1995 on the economic evaluation of clinical pharmacy and described the positive economic impact of clinical pharmacists.5 This group then published a subsequent review of 59 more articles from 1996 to 2000, which also demonstrated the positive overall economic benefit of clinical pharmacy.6 Services evaluated in the latter article encompassed much of what we consider modern clinical pharmacy, such as multidisciplinary rounds, pharmacist-led disease management, pharmacokinetic monitoring, and targeted drug programs.6
In 2010, Chisholm-Burns et al published a systematic review on the economic benefits of clinical pharmacy that included 126 papers focused on the outpatient ambulatory care practice setting. These papers collectively demonstrated the economic benefit of clinical pharmacist services when interventions were focused on disease state management, recommendations of therapeutic alternatives, and multidrug regimens.7
In 2017, Jokanovic et al published an overview of 31 systematic reviews of the value of pharmacy-led medication review in the community setting; none of the systematic reviews focused on oncology management.8 The most cited areas of focus were cardiovascular effects and diabetes. The authors suggested that these disease states utilize medications frequently associated with hospital-related adverse drug events (ADEs) and further suggested that patient groups with high potential for medication-related problems may benefit the most from pharmacist medication review.8 In 2024, a systematic review and meta-analysis of pharmacist interventions in improving oncology care, primarily in the outpatient setting, was performed. There was a benefit in treatment adherence, a reduction in grade 3 ADEs, and fewer medication-related problems.9 In this systematic review, most of the studies included were published within the past 15 years, highlighting the recent growth in this field.9 Due to the complex nature of patients with cancer, including greater likelihood of medication-related issues, there is an abundance of opportunities for benefit from clinical pharmacy services.
Despite a massive cache of literature describing the benefits of clinical pharmacy, there are no clearly defined, widely accepted clinical pharmacist metrics. In 2021, Acquisto et al published comprehensive and detailed inpatient clinical pharmacist quality measures; however, these have not been widely adopted.10 Acquisto et al identified various organizational stakeholder groups such as The Leapfrog Group, the Institute for Safe Medication Practices, and the Institute for Healthcare Improvement, along with relevant literature, using a modified Delphi approach to reach a consensus on the most significant pharmacist quality measures.10 American Society of Health-System Pharmacists (ASHP) released a recommended approach to ambulatory pharmacy metrics written by Smith et al; however, it remains unclear how many institutions utilize this resource.10,11
Griffin et al surveyed pharmacists in oncology centers in 2021 and 2022 and found that one of the challenges in oncology pharmacy is the lack of a well-defined description of a clinical pharmacist’s role.12 They emphasized that heterogenicity of practice sites and work responsibilities, combined with lack of data, creates challenges in developing national benchmarks and metrics.11,12 Some metric experiences make the point that interventions should be captured automatically to not burden the pharmacist team with “double documentation.”13,14 Kandaswamy emphasized quantifying pharmacist activity by dispensing units or occupied beds is antiquated and does not capture a modern pharmacist’s role.15
One approach to capturing pharmacist workload without merely counting patients is to weigh patients based on drug regimen complexity and severity of illness using tools such as the Medication Regimen Complexity-Intensive Care Unit Scoring Tool.11,15 Another method of capturing pharmacist workload by Casset et al described the creation of an inpatient metric dashboard based on literature review and input of staff pharmacists within the Saint Luke’s Health System and quality teams.16 Given the lack of a single, standardized approach to quantify clinical pharmacist workload, further exploration of ways to quantify workload should be evaluated.
At the University of New Mexico Comprehensive Cancer Center (UNMCCC), we have 4 clinical ambulatory oncology pharmacists (all with BCOP certification and 3 of whom have completed a PGY-2 in oncology) who review patients with specifically assigned providers. These pharmacists have high autonomy as they can craft their jobs where they see the most patient need. They do not verify orders, and pharmacist entry of verbal orders is discouraged. Our institution is one of the few nationwide that uses Mosaiq for physician chemotherapy order entry and oncology scheduling and Cerner for patient charting records. This gives us the added challenge of pulling metric data from 2 different sources. We have an electronic “thank you” system for colleagues to recognize one another, which can be filtered by pharmacist and date. Our primary goal was to provide meaningful feedback to the clinical pharmacists, align practices, and evaluate workload distribution without additional documentation from the clinical pharmacist.
We pulled reports detailing provider visits, pharmacist PowerChart visits, and pharmacist charting. We used ChatGPT to write Python code that processes large data sets and combines them into specific metrics comparable between pharmacists and from month to month. We created the following metrics: pharmacist note count, oral oncology educations, chart visits, percentages of provider visits that also had a chart visit by a clinical pharmacist, and percentage of infusion patients who also had a chart visit by a clinical pharmacist. Our hospital policy discourages pharmacists from ordering labs and entering orders on behalf of providers; therefore, these metrics are not captured. These results are shared with individual clinical pharmacists each month, and each staff member is compared with the sum of their peers.
We created an annual, in-house, clinical pharmacist provider and clinic staff satisfaction survey using Microsoft Forms. To encourage provider feedback, the survey was anonymous, very brief (3 questions), and multiple choice. In addition, questions were based on specific past concerns brought up by providers/staff members and designed in collaboration with the clinic pharmacists. Providers were also allowed space to enter comments and add their names if they wished not to remain anonymous. Table 1 outlines the specific questions used and the aggregate results.
The scoring scale ranges from 1.0 (lowest) to 10.0 (highest). The pharmacist numbers do not necessarily correspond to those in Figure 3 to maintain anonymity. Questions start with 1- or 2-word headings—“accessibility,” “clinical knowledge,” and “respect”—to reduce required provider attention and maximize participation.
A dashboard was developed to include metrics tracked, progress on annual goals, recently received recognition, and monthly rounding questions to allow for personal reflection and growth. This is updated and reviewed monthly with each clinical pharmacist (Figure 1).
Reviewing pharmacist metrics monthly on an individual basis allows clinical pharmacists to understand their practice and how they compare with their peers. For instance, a pharmacist following a low percentage of patients in relation to their physician counterpart can consult with a pharmacist with a higher provider-visit alignment and adjust their methods. In this sense, the metrics aided pharmacists in reprioritizing their time toward patient care, especially among those likely to need more interventions in anticipation of provider visits.
Following are the monthly rounding questions that are used to guide supportive conversation between the manager and clinic pharmacist:
BMT, bone marrow transplant; CAR, chimeric antigen receptor; GI, gastrointestinal; ID, infectious disease; P&T, pharmacy and therapeutics; T&H, transplant and hematology.
A successful dashboard provides the dual utility of driving pharmacist alignment and providing a mechanism for communicating workload to institutional leadership. Patient chart visits are easy to interpret, and patient-centered data track pharmacist-patient workload and allow a straightforward comparison for prioritization of departmental planning. Using these data, we were able to defend a new clinic pharmacist position to pharmacy and hospital leadership. Interestingly, although our group was small and had regular conversations, we saw the pattern of “what gets measured gets done.” For example, in Figure 2 there is clear improvement of alignment of pharmacist chart visits after the dashboard was rolled out in February 2024. This alignment was achieved through supportive communication with pharmacist 3 about goals and expectations with the aid of our dashboard.
Provider champions are crucial to building an oncology clinic pharmacist service, so formal provider feedback should be sought and reviewed with the pharmacy team. The provider results from Figure 1 were shared with the clinic pharmacists individually and used to provide feedback and growth from those who work most closely with the pharmacists. There was a slight qualitative relationship between survey results and pharmacist workload. Provider feedback was very positive, which is useful in reinforcing helpful behaviors; however, there were several opportunities for improvement in the comments.
The dashboard was created in February 2024. Pharmacist 2 started leave in July 2023 and returned in September 2023. Note the alignment of pharmacist 3 from rollout date forward. In July 2024, pharmacist 4 entered PowerChart for every medication review completed in Mosaiq. In September, pharmacist 3 retired, and the other pharmacists needed to increase their workloads while we searched for a replacement.
Clinic pharmacist satisfaction is an added benefit of a dashboard because metrics are seen as important feedback and a good way to increase team accountability. We found that building a metric-based dashboard serves as a source of the regular feedback pharmacists may desire. They can see some of their hard work reflected in measurable and quantitative data sets. Giving feedback to these high-performing, clinically adept pharmacists can be challenging as a manager is often unable to maintain knowledge of the evolution of oncology treatment, nor can the manager regularly be present at all clinical touchpoints, monitoring pharmacist behavior and clinical decisions.
Our metrics incorporate some of the specific productivity metrics presented in the ASHP paper by Melanie R. Smith, PharmD, BCACP, DPLA, such as the number of notes entered in the electronic health record, medication education, colleague recognition, and physician satisfaction.11 We also incorporated the philosophies from the ASHP paper that explain that the metrics used should be understood by nonpharmacy staff, not require pharmacist “double documentation,” and be meaningful and actionable. For instance, when a new provider or service is added to our cancer center, we have a clear gauge of the workload distribution and, in case we are not approved for a new FTE to support the additional service, we know which pharmacist may have the most bandwidth to absorb the additional patient load.11
Our metrics are limited by our reluctance to require clinical pharmacists to record their interventions for the sake of metric counting and the limitation of the electronic medication administration record and our messenger system in pulling free-text documentation via reporting. For instance, approximately 30% of the patient charts our pharmacists consult month to month do not coincide with a provider visit, which is likely the result of “curbside consults.” Many interventions happen verbally between the pharmacist and provider or via a messenger app, and those interventions are never recorded. We capture pharmacist notes, often containing information regarding correcting drug-drug interactions or addressing adverse effects. Still, our staff has generally felt that adding checkboxes is more burdensome than just briefly describing their findings via free text in their notes.
Nick Crozier, PharmD, MBA, BCPS, BCOP, is the pharmacy director at the University of New Mexico Comprehensive Cancer Center in Albuquerque.
Jessica M. Lewis-Gonzalez, PharmD, BCOP, is a clinical hematology-oncology and cell therapy pharmacist at the University of New Mexico Comprehensive Cancer Center in Albuquerque.
Creating a metrics dashboard for oncology clinical pharmacists is rewarding for staff, helps align patient care, distributes workload, and can be used to communicate the value of oncology clinical pharmacists. Utilizing a metrics dashboard also provides clinical pharmacists a tool to monitor and track their productivity in more meaningful ways, such as percentage charts visited for scheduled patient visits, which in turn helps to refocus the priorities toward patient care. Further studies should continue to establish where clinical oncology pharmacists provide the most value and refine how to best capture clinical oncology pharmacist interventions directly without requiring double documentation. Metrics should be created based on evidence-based literature and staff and provider opinion and shared with the pharmacists regularly to provide timely feedback.
