Primary Care Providers’ Perspectives on Communication with Community
Pharmacists
By Christine Ko
Honors Thesis
UNC Eshelman School of Pharmacy University of North Carolina at Chapel Hill
February 7th, 2020
Approved:
Christine Ko, PharmD Candidate, is a student at UNC Eshelman School of Pharmacy,
University of North Carolina at Chapel Hill, Chapel Hill, NC. ORCID 0000-0003-3671-063X. Email: [email protected]
Jessica M. Robinson, PharmD, is an Assistant Professor, Department of Pharmacy Practice,
Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN. At the time of this study she was a Community Pharmacy Practice Research Fellow, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, and IPE Geriatric Fellow, Center for Aging and Health, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC. ORCID 0000-0002-1276-7570. Email:
Stefanie P. Ferreri, PharmD, BCACP, FAPhA is a Professor, Chair and Co-Director,
Independent Pharmacy Ownership Residency Program, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC. ORCID 0000-0002-1819-9631. Email: [email protected].
Acknowledgements:
The authors acknowledge Paul Mihas and the UNC Odum Institute for Research in Social
Science for their assistance in the creation of the qualitative semi-structured interview guide. The authors also acknowledge Chelsea P. Renfro, PharmD; Susan J. Blalock, MPH, PhD; Emma Feder, Kelly Jamieson, Hannah Thornton, Sunni Duffey, and Natalie Klein for their
contributions to coding and analysis of the quantitative data.
Conflicts of interest statement:
The authors report no conflicts of interest related to this research. This work was supported by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention
[Cooperative Agreement Number 1 U01 CE002769-01]. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
Previous presentations of work:
Research findings were presented (1) March 23-24, 2019 at the APhA Contributed Papers Program of APhA Annual Meeting in Seattle, WA and (2) November 22, 2019 at the Cone Health Research, Evidence-Based Practice and Quality Symposium in Greensboro, NC.
Corresponding author: Stefanie P. Ferreri, PharmD, BCACP, FAPhA, UNC Eshelman School
of Pharmacy, University of North Carolina at Chapel Hill, CB: 7574, Beard Hall 115B, Chapel Hill, NC 27599. Email: [email protected].
Abstract Word Count: 249/250 Text Word Count: 2325
Abstract:
Objectives: The objective of this study is to identify what information is considered useful by primary care providers (PCPs) and what communication methods are preferred when information is shared by community pharmacists. Methods: A mixed methods approach was used to collect data from PCPs interacting with North Carolina community pharmacies participating in a prior study. In that study, community pharmacists shared 873 medication therapy problems (MTPs) with PCPs by fax. PCP responses were collected to identify whether the MTP information shared was considered “useful.” A cohort of 173 PCPs found the information “useful” and were
recruited for participation in semi-structured interviews. The quantitative data were analyzed using chi-square and the qualitative interviews were analyzed using MAXQDA coding software. Results: A total of 873 MTPs were communicated to PCPs and 26% (n=230) were deemed to be useful by PCPs. Of the MTPs that were identified and deemed to be useful by PCPs, 37% (n=86) were accompanied with recommendations while 63% (n=144) were not (P=0.0316). Two PCPs completed interviews. PCPs value information about insurance coverage and medication cost; they prefer sharing information via electronic methods or fax. Variation exists among PCPs in their desire to build relationships with pharmacists. PCPs do not always consider community pharmacists as members of the interdisciplinary team but do believe successful communication must occur before a working relationship can be established. Conclusion: Community
pharmacists should take into consideration specific PCP preference of communication methods and usefulness of information shared when establishing a collaborative relationship with PCPs.
Keywords: Community pharmacy services; Attitude of health personnel; Interdisciplinary
BACKGROUND
Interdisciplinary care is defined as a process in which healthcare professionals from different fields of study work together to share their expertise and skill to impact patient care outcomes.1 This type of collaboration has been shown to improve health outcomes and reduce costs. Interdisciplinary care led to a reduction of 30-day hospital readmission rates in patients with high-risk medical conditions, and in another example led to a positive economic impact in an outpatient pain clinic, saving the hospital and insurance companies $36,228 and $11,482 per patient per year, respectively.2-3 While there are successful examples of interdisciplinary care in
both the inpatient and outpatient setting, a variety of existing barriers limit the scope of outpatient interdisciplinary care between pharmacists and primary care providers (PCPs). Examples of these barriers include lack of communication, lack of information sharing between healthcare providers, and differing opinions of what interdisciplinary care means.4-5 Due to these barriers, identification of collaborative opportunities and effective communication strategies for outpatient care are needed.
The driving force behind interdisciplinary care in the outpatient setting includes an increase in the number of complex patient cases and a surge in healthcare costs over the last 20 years, with approximately 90% of older adults in the United States taking ≥ one prescription medication in the past month and 40% taking ≥ five medications per month.6 In order to combat
increasing costs and poor patient outcomes, health plans are moving away from a volume-driven, fee-for-service payment structure towards value-driven, pay-for-performance models.6 The shift
in payment structure has afforded opportunities for pharmacists to provide a variety of
medication management services. In addition, PCPs are encouraged to integrate pharmacists into their patient care team, regardless of proximity of practice, to reduce costs and improve patient
outcomes. As pharmacists join these teams, however, best practices for communication between members of the interdisciplinary team have not yet been established.
Several collaboration models have been developed to better understand
prescriber-community pharmacist communication.7 Trust, interdependence, role definition, and high-quality communication are described as drivers of the collaboration between PCPs and pharmacists by all four models of collaboration. 7-11
In addition to identifying best practices for communication between pharmacists and PCPs, it is also important to identify what type of information should be shared between
settings.12 There is very little literature on what information shared by pharmacists is considered valuable to PCPs. A qualitative study in New Zealand examined general practitioners’ perception of new clinical services provided by pharmacists and concluded that in order to continue these new services, effective communication must be increased for services to be integrated into medical practices.13It was suggested that general practitioners’ acceptance of pharmacist-led
clinical services are correlated to the general practitioners’ understanding of the
recommendations communicated by pharmacists.13 Low-quality communication can negatively
influence the collaborative relationship between these professionals.13 The results of the New Zealand study suggest a need for more in-depth evaluation on what type of information is considered valuable by PCPs.
OBJECTIVES
The objective of this study is to identify (1) what information is considered useful by primary care providers (PCPs) and (2) what communication methods are preferred when information is shared by community pharmacists.
METHODS
Study Design & Setting
A mixed methods approach was used to collect data from PCPs interacting with North Carolina community pharmacists. In a previous study, community pharmacists assessed older adults for presence of fall-related risk factors, conducted medication reviews to identify potentially inappropriate use of medications linked to falls, and shared medication therapy problems (MTPs) and recommendations with PCPs.14,15 Information was shared with PCPs by fax using a form that included space for the pharmacists to both describe the MTP, as well as space to make a recommendation. PCPs were asked to respond to these communications using an included prescriber response form. The quantitative portion of this study focused on prescriber-reported usefulness when a MTP was identified and accompanied by a recommendation. It was hypothesized that MTPs where any type of recommendation was made were more likely to be useful to PCPs compared to MTPs where a recommendation was not made. The qualitative portion of this study focused on communication between PCPs and pharmacists. Semi-structured interviews were conducted with PCPs who responded that MTP communications were useful. These PCPs were recruited via fax.
Participants
Participants of the quantitative portion of the study included PCPs for whom a single MTP had been identified and shared with a PCP. For the qualitative portion of the study, participants for the semi-structured interviews were PCPs who received MTP communications from pharmacists and responded that the information shared was “useful.” PCPs were recruited for interviews by fax.
Data Collection
Quantitative data were collected and coded in the prior study. Medication
recommendations made by community pharmacists were coded as no recommendation made, incomplete recommendation made, and complete recommendation made. PCP responses to MTP usefulness were coded as not useful, useful, unsure of usefulness, and no response to usefulness. These data were used to test our hypothesis.
Qualitative interviews were conducted by phone, using a semi-structured interview guide. The guide was developed with assistance from the UNC Odum Institute for Research in Social Science (https://odum.unc.edu/). The guide was developed around two common themes extracted from the four collaboration models. Communication directionality and reciprocity are identified as important factors in achieving successful interdisciplinary practice.7 These two themes were used to guide the development of questions regarding information sharing and relationships between PCPs and pharmacists.
Data Analysis
The quantitative data were analyzed using a chi-square test. For qualitative interviews, a codebook was developed, and data were coded and analyzed using MAXQDA software.16 IRB & Protection of Human Subjects
The Office of Human Research Ethics, Institutional Review Board (IRB) at the University of North Carolina (UNC) Chapel Hill deemed this study (#18-1849) exempt from further review.
RESULTS
Participants
A total of 2020 medication therapy problems (MTPs) were communicated to PCPs. Of these, 873 MTPs met inclusion criteria and were included for analysis in the quantitative portion of the study. For the qualitative portion of the study, 385 MTPs met inclusion criteria for
qualitative analysis, and 173 unique PCPs were identified for participation in the semi-structured interviews. Two PCPs participated in the qualitative portion of the study and completed
interviews, with an average length of 22 minutes. Figure 1 represents the breakdown of participants.
Quantitative Results
Of the 873 MTPs included in the study, 26% (n=230) MTPs were indicated by PCPs as “Useful.” Of the MTPs that were identified as “useful” by PCPs, 37% (n=86) were accompanied with recommendations while 63% (n=144) were not accompanied with recommendations (Chi-square = 4.6208, P=0.0316).
Qualitative Results
Communication Directionality. PCPs value information from community pharmacists regarding insurance coverage and medication costs. In addition, PCPs do not share various patient information with pharmacists because they are unaware that pharmacists do not have universal electronic health record (EHR) access. One prescriber said, “I was under the impression that community pharmacists had [access to] patient demographics when I sent a prescription. I did not realize they did not have that.” Communication methods currently utilized by PCPs to communicate with pharmacists include phone and fax. PCPs state that fax is the easiest method of communication, but electronic methods are preferred over other methods.
Communication Reciprocity. Variation exists among PCPs in their desire to build relationships with pharmacists. Factors that influence PCP willingness to collaborate with pharmacists include patient socioeconomic status, geographic locations, and drug complexity. Another prescriber stated that healthcare professionals are “trying to save money for the patient and provide better health care.” PCPs prefer working with local, community-minded pharmacists and believe that successful communication must occur before a working relationship can be established between the two professionals. Specifically, one prescriber said, “I think it’s the communication first. If you take the time to call somebody, it’s amazing how helpful pharmacists want to be and how helpful they are.”
DISCUSSION
Although there are an increasing number of pharmacists collaborating with or wishing to collaborate with PCPs, the best method and information for pharmacists to communicate with PCPs is still unknown.17 This study offers to fill a gap in knowledge and practice of
interdisciplinary work between pharmacists and PCPs. It used the overarching themes of communication directionality and communication reciprocity from the four existing models of collaboration to determine what communication methods PCPs prefer and what information PCPs find useful when communicating with pharmacists. The results identified can help pharmacists overcome common communication barriers between practice settings.
Communication between pharmacists and PCPs is complex due to a lack of proximity of practice and the fact that community pharmacists are not generally co-located in the same facility as PCPs. The results of this study emphasize communication, information, and relationship gaps that currently exist. For example, pharmacists typically have limited access to crucial patient information such as lab results, medical diagnoses, and social history that can impact the level of
care that patients receive in the community setting.12 In this study, PCPs were unaware that
pharmacists lack access to this information. This may explain why some PCPs do not proactively share patient information with pharmacists, thereby limiting pharmacists’ abilities to make informed patient care assessments. The findings suggest that pharmacists wishing to establish a collaborative relationship with PCPs should communicate this limitation and request access to and sharing of any essential patient information in order to overcome this barrier. Several studies reveal successful collaboration strategies among community pharmacists and physicians.19-23 Another way community pharmacists can overcome the challenge of limited communication is to establish EHR access. For example, one community pharmacy was able to work with a local PCP to gain access to information and establish read-only EHR access for the community
pharmacy at no extra cost.18 By implementing this communication strategy, both pharmacists and PCPs were able to share information that the other provider may not initially have access to.24 The implementation of a communication strategy that works best for both the pharmacy and PCP workflow will create mutual awareness and respect between the two professionals and allow access to currently-limited patient information in order for both professionals to provide better care to patients.4
PCPs may also benefit from access to information only available from within the pharmacy. A challenge, however, is identifying what information is most useful to share with PCPs. Though a New Zealand study suggested that pharmacists should conduct medication reviews and communicate their findings to PCPs, 13 Pharmacists may find that this information
alone is not always useful for PCPs. The findings of our study suggest that in addition to sharing medication therapy problems, pharmacists should include a solution for any problems identified. However, simply sharing a solution or recommendation may not be sufficient. The quality of
pharmacists’ communication impacts prescriber acceptance and response.13 One way to ensure
that recommendations are of appropriate quality is to use a standardized framework such as the Situation, Background, Assessment, and Recommendation (SBAR) method.25-26 This
communication method has been shown to enhance communication quality and patient safety outcomes in interdisciplinary healthcare settings. One study found that by standardizing communication methods across all departments using SBAR, phone and in-person communication between healthcare professionals had greatly improved and significant improvement can be made in the satisfaction and collaboration of healthcare professionals.25
Pharmacists have the opportunity to share solutions to MTPs in addition to other information that may be useful to PCPs, and not otherwise accessible to them, are suggestions for cost-effective drug treatments and patient third party formulary information. By ensuring that communications to PCPs are clear, concise, and complete, pharmacists contribute a valuable role as part of the interdisciplinary care team.
Another communication challenge addressed by this study is the identification of preferred methods for communication between pharmacists and PCPs. Previous studies have reported that telephonic communication is the most common method used between PCPs and pharmacists.17 However, this study showed that PCPs preferred electronic communication, including email or EHR messaging. If electronic communication was unavailable, fax was preferred. This is likely because it allows PCPs to review and respond to messages within their own workflow. These preferences may vary by PCP, and pharmacists should determine what methods are preferred by individual practices when establishing a collaborative relationship.
Finally, it is evidenced through existing literature and the results of this study that PCPs do not always consider pharmacists as a member of the interdisciplinary care team.4-5
Pharmacists should initiate communication and determine best communication practices with PCPs when seeking to establish a collaborative relationship with PCPs. Through this initiation, PCPs will be able to acknowledge pharmacists willingness and desire to work with their office and build off their communication to create a lasting interdisciplinary healthcare team.
A limitation of this study includes the small sample size of PCPs interviewed for the qualitative arm. This may lead to a decreased generalizability of the qualitative results as they do not necessarily represent the perspectives of PCPs as a whole. Another limitation to this study was that the forms used by PCPs to respond to MTP communications was not developed to appropriately capture prescriber usefulness for communications with multiple MTPs. The forms used allowed pharmacists to make multiple recommendations. However, it limited the PCPs to provide only one response in the usefulness of these recommendations, not allowing PCPs to differentiate usefulness between multiple recommendations. This may limit the validity of the study results as PCP responses may not truly reflect the usefulness of the MTP communication. Finally, MTPs with no response were included for analysis as a “Not Useful” response. While lack of response does not necessarily mean that the PCP did not find the information useful, we hypothesize that lack of communication may indicate a lack of usefulness for the PCP. Further research is needed to validate this hypothesis.
CONCLUSION
Improving communication practices needs to be addressed in order for successful interdisciplinary collaboration between PCPs and community pharmacists to exist. Pharmacists should consider specific PCP preference of communication methods and usefulness of
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Appendices
Semi-Structured Interview Guide Icebreaker
1. Can you tell me about a specific time when you spoke with a community pharmacist other than for new prescriptions or refills?
Process – Directionality
2. What kind of information do community pharmacists typically share with you?
a. [PROBE: if Q2 not answered directly] What patient information do community pharmacists share with you?
b. [PROBE] What information do you think pharmacists have that would be of value to you?
3. What kind of information do you typically share with community pharmacists? a. [PROBE: If Q3 not answered directly] What patient information do you share
with community pharmacists?
b. [PROBE] What information do you have that would be valuable to community pharmacists?
4. When your practice receives patient care information from community pharmacists, what happens to that information?
a. [PROBE] How do you like to receive this information?
b. [PROBE] Who in your office is responsible for documenting information received from community pharmacists?
d. [PROBE] What are the support staff involved with when sharing information with community pharmacists?
e. [PROBE] What, if anything, would you like to be different?
5. Walk me through how information is shared from your office to community pharmacists? a. [PROBE] How do you go about sharing information with community
pharmacists?
b. [PROBE] What, if anything, would you like to be different?
6. Is there something about sharing information that you’d like to talk about that I haven’t asked?
Relationships - Reciprocity
7. Do you have a relationship with a community pharmacist that goes beyond sending prescriptions?
a. Yes Æ [PROBE] Tell me more about that?
b. No Æ [PROBE] What, if anything, would you like to change about your interaction with them?
8. How do you feel about your [If no to Q7: lack of] relationship with community pharmacists?
a. [PROBE] How important is it to you?
9. How do you think [If no to Q7: not] having a relationship impacts what is shared between you and community pharmacists?
10. How willing are community pharmacists to share information in their conversations with your staff?
a. [PROBE] How open do you think your staff are in their conversations with community pharmacists?
b. [PROBE] What, if anything, would you like to be different?
11. What kinds of things influence your willingness to work with community pharmacists? a. [PROBE] How does your relationship with community pharmacists affect your
desire to work with them?
12. Do you think an established relationship leads to successful communication or does successful communication leads to an established relationship?
Appendices – cont. Qualitative Codebook
Parent Code Child Code Definition
Interaction Example Code when participant describes an example of their
interaction with community pharmacists
Communication Directionality: Information Sharing Direction/Process Community Pharmacist Information (shared)
Code when participant describes the type of
information that community pharmacists share with PCPs
PCP Information (shared) Code when participant describe the type of
information that they usually share with community pharmacists
PCP Information (not shared)
Code when participant describes types of information they do not usually share with community pharmacists Process for receiving
information
Code when participant describes the PCP process for receiving information from community pharmacists Process for sharing
information
Code when participant describes the PCP process for sharing information with community pharmacists Information sharing
recommendations
Code when participant describes recommendations or experience related to information sharing
Communication Reciprocity: Relational Factors
Relationship Example Code when participant describes their relationship with community pharmacists
PCP sentiment about relationships
Code when participant describes how they feel about their relationship with community pharmacists
Relationship impacts information sharing
Code when participant describes how relationships impact sharing of information between community pharmacists and PCPs
Community pharmacy practice willingness to communicate
Code when participant describes their experience with community pharmacy practice willingness to
communicate or share information with PCP PCP practice willingness to
communicate
Code when participant describes their experience with PCP practice willingness to communicate or share information with community pharmacist
Influencing factors Code when participant describes factors that influence their willingness to work with community pharmacists Correlation between
relationship and communication
Code when participant describes impact of
relationship on communication or vice versa (which comes first?)
Recommendations Code when participant describes any additional recommendations or thoughts related to these topics