Structural Overview of Supply Maintenance

Doctors provide an overview of the interdisciplinary structural system of supply maintenance, which prevents and manages drug shortages.

Troy Trygstad, PharmD, MBA, PhD: So because you’re experts in this space, give us a sense of what this looks like structurally. You’ve got some FTEs [full-time equivalents] that are working on drug information—what can we substitute, what can’t we substitute? You’ve got folks working on how we load the order sets within the EMR [electronic medical record]. You’ve got folks on the phone with procurement. But then out from there, you’ve also got P&T [pharmacy and therapeutics] committees. What’s the big picture of all the moving parts that you’re interacting with when the bat phone rings and you say, 'OK, we’ve got mission critical drug shortage now—go activate these groups'?

Richard Montgomery, RPh, MBA: I think you pretty much touched on most of them going through. You’ve got to get through to the chief medical officer to let him know or the service line administrator and then just run what you said. How much do we have? How much time do we have? How much is that going to last us? Get IT [information technology] on the phone. You’ve got nursing leadership involved. Your cabinets—how are we going to restock this? Do we have to pull meds medicines back? Are we going to reallocate it to this space? Are we going to take it from here? We’ve got to let these nurses know it’s no longer here, and then how much are we going to keep in central so we can submit outpatient specifics. So there are a lot of moving parts.

Troy Trygstad, PharmD, MBA, PhD: Who are the most important people you work with outside of the pharmacy group?

Richard Montgomery, RPh, MBA: We’re a Cerner shop, so PharmNet is our pharmacy IT system.

Troy Trygstad, PharmD, MBA, PhD: So your engineers with your IT.

Richard Montgomery, RPh, MBA: We’ve got our IT folks and then the medical staff.

Troy Trygstad, PharmD, MBA, PhD: So you’ve got somebody that’s representing their voice within the medical director or something like that. OK.

Richard Montgomery, RPh, MBA: Right. And then the nursing administration, so we can push it down.

Troy Trygstad, PharmD, MBA, PhD: You’ve got essentially nursing ops operations.

Richard Montgomery, RPh, MBA: For me it is the directors of pharmacy at the campuses and then buyers, because we have a separate buyer’s call. Because sometimes it doesn’t always filter down to the buyers from when you talk to the directors and just tell them, “Hey, this is a problem.” We push e-mails. We call them stat alerts, push them out and stuff.

Troy Trygstad, PharmD, MBA, PhD: What does the interaction look like at a conference between manufacturers, wholesalers, representatives, and whoever else is involved?

Richard Montgomery, RPh, MBA: I don’t know, Erin, they might not shake her hand. Yeah, it’s a good interaction.

Erin Fox, PharmD, BCPS, FASHP: People are cordial.

Richard Montgomery, RPh, MBA: It’s cordial.

Erin Fox, PharmD, BCPS, FASHP: People are cordial.

Richard Montgomery, RPh, MBA: We need to have those lines of communication. It’s always been my opinion that it’s a two-way street. They need to know what we’re doing; we need to know what they’re doing, because if a new procedure comes out and these drugs are coming out, they want to know: Am I going to go from here to here in what I need to produce, or if there is some clinical initiative that comes out, what happens then? Hopefully, they’re on top of it already. But, yeah, it’s cordial for the most part.

Erin Fox, PharmD, BCPS, FASHP: Even being able to talk with some suppliers like I did during the small volume saline shortage, many of them did not make the link that that was why they were short of sterile water. So trying to educate them a little bit about how people are going to need the sterile water, and they’re going to need a lot more of it, and they’re going to need vials and syringes. That information is very helpful to them. Also explaining why we want to know. It’s not because I’m trying to dig into their finances—it’s telling them we need to make a plan for our patients. And I talk with suppliers a lot about patients. Our patients are impacted by this. We need to decide if we’re going to restrict it or if we’re going to stop procedures. This is why I need to know today, and they’re usually, depending on the company, responsive.

Troy Trygstad, PharmD, MBA, PhD: The fascinating analogy would be endangered species and biodiversity. In some ways, you’re sort of monitoring to see if we have these species out there and you start to think about—and what you just described was if we lose this species—that there are effects that go beyond that species, right?

Erin Fox, PharmD, BCPS, FASHP: Sure.

Troy Trygstad, PharmD, MBA, PhD: And so it’s this, again, interconnected ecosystem that you’re monitoring and then responding to, it sounds like. Is that a fair analogy?

Richard Montgomery, RPh, MBA: Yeah. And the sterile water example was perfect because we couldn’t get bags; therefore, we went to a push, but you need the sterile water to make the syringes that you’re using for the push. So it all kind of is interconnected, and it’s a cascading effect, and then it’s a closed loop. Sometimes manufacturers don’t think about this because they’re focused on making that saline. We had to reach out to some 503Bs outsourcing facilities to get sterile water, and then I think I did the calculation. We were paying $1400 for a gallon of sterile water if you broke it down into increments. Think about that one.

Troy Trygstad, PharmD, MBA, PhD: Interesting. How has the role of that pharmacy group changed? Has the relationship with the physician staff changed at all over time with the work that you do, or is it basically the same it’s been for 30 years?

Richard Montgomery, RPh, MBA: In my opinion, I think it’s pretty status quo. I think some of the younger ones especially understand a little bit more of what’s involved, especially within the IT side and why it doesn’t work. But, as we’ve talked about, the background stuff that we do—they don’t see a lot of it. They may hear about it, but as long as they have the product or an alternative in their hand, they’re OK with it.