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Lakeview Internal Medicine Pharmacy Service: A Pharmacist's Perspective

Written by Carrie Koenigsfeld

In January 2005, I was contacted by the Dean of our College regarding an exciting new opportunity. She had been contacted by an area physician with an Internal Medicine Clinic regarding the possibility of having rotation students and/or a pharmacist faculty member at their site. The physician was primarily interested in starting up a pharmacist run Point of Care Anticoagulation clinic. At this point, I had been working in the area of community pharmaceutical care since the start of my residency in 1998. However, ambulatory clinical pharmacy was something I had often entertained. When deciding upon residencies, I debated between completing a Family Practice residency or a Community Pharmaceutical Care residency. As a faculty member, I had often entertained other opportunities, but had never taken the leap out of the pond of community care. I had worked for 7 years to develop and implement disease state management services in the community setting. I was at the point where things were becoming routine, almost like riding a bike where you don’t need any hands. The challenge was no longer there. Thus, the contact from the Dean in January caused me to look at the crossroads I had arrived at. I had two choices: continue to push community pharmacy forward in the “land of familiar” or journey into a land I had not yet traveled in an ambulatory clinic setting. This was a difficult choice. When one has invested an immense amount of time and effort into something, leaving it is difficult. However, I looked at this as a sign. This was an opportunity to better myself clinically and to develop services from the ground up in a physician clinic setting. I believe if I ever go back to community pharmacy, this experience will only make me stronger.

The transition to the Internal Medicine Clinic took quite a bit of time, which was often frustrating. Numerous meetings were held to determine the desires of the clinic and opportunities available for pharmacist involvement. The clinic was truly excited about having a pharmacist involved, but there were grey areas on what a pharmacist in this setting could do. Logistics had to be worked out regarding the requirements of having a Drake faculty member on-site and the responsibilities of the clinic, Drake, and the faculty member. It was difficult at first to determine the appropriate contact persons at the clinic as initial contact was made by one of the physicians. The office manager had to be informed from both the college and physician side on what the desired outcomes would be. Sometimes with numerous people involved the communication network became muddled.

To assist in my journey into the realm of Coumadin monitoring, I attended in May 2005 an Anticoagulation Preceptorship training in New Mexico with the Lovelace Foundation. This program provided a general overview of anticoagulation. I found that it primarily focused on anticoagulation most relevant to the hospital setting. However, there were a couple site visits where we visited locations that had pharmacist run Coumadin clinics. I found this very helpful to visit with these pharmacists, especially because these clinics are very busy with a total patient count over 2000 patients. I also worked over the summer on collecting forms for use in Coumadin monitoring, putting together a rotation handout and rotation article binder, and brainstorming on future programs/services.

Simple obstacles have been faced along the way. The initial intent was that the Point of Care (POC) Coumadin finger stick testing would be done in the clinic by the pharmacist. However, a trial run was done prior to my arrival with nursing staff. It was found that there was difficulty getting a good sample of blood and concern that the device was not correlating well with a venous blood draw. The laboratory in the same building as the clinic now handles the finger stick testing and then sends the patient up to the clinic to be assessed. This actually has worked out better than our initial plan since it eliminates the POC testing aspect and allows us to focus on the clinical aspects of monitoring the patient. Other simple difficulties were obtaining office space. With the assumption that this would be my clinical practice site, I would need an office. A new internist and a nurse practitioner were joining the clinic, plus additional nursing staff and myself, making space very limited. After numerous discussions, a space was identified, but would not be available until the end of the summer. This limited my ability to start working with the clinic until my office was available. A phone line with voicemail, internet access, passwords for patient databases, and building key cards were also other items that had to be arranged. I had to remind myself that although things seemed to be taking months to get going, that the ultimate result would be worth waiting for.

On August 26, 2005, my office was finally ready at the clinic. I moved my office things from Drake to the clinic that Friday afternoon. On Monday, I had my first rotation student. Although I found it difficult initially to have a student on rotation when I was completely new myself, it has proved to be extremely helpful to have a student involved in this development process. Over the last month, we have begun to see the patients of one physician for Coumadin monitoring. We have had to “tweak” the forms initially developed to better fit the process that was in place prior to my arrival. We have worked on developing a form for performing annual medication assessments that is based on identification of drug therapy problems. We have developed a process of new medication follow-ups and are utilizing a preprinted sticker to document our encounters to be placed in the charts. A counter-detailing service has been developed where we allow pharmaceutical representatives to schedule appointments to discuss medication updates. We then provide the physicians with summaries of these interactions on a monthly basis. A smoking cessation clinic is being developed in conjunction with a faculty member at another local clinic. In October 2005, we will begin to expand our services to one additional physician in the clinic.

Overall, I find myself very fortunate to have had this opportunity placed before me. Although starting something new is not stress free, it has given me an opportunity to be innovative in developing services in a clinic setting from the ground up. It has challenged me clinically to refresh on areas I have not reviewed in awhile. Most importantly, it is allowing me to be entrepreneurial and to push the practice of pharmacy forward.