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Interdisciplinary team work to make pharmacist clinics work

After you do the needs assessment, and decide what is the focus for your pharmacist clinics,
then we have go to the step 2: Clinic set-up. It is almost impossible for you to set up a pharmacist clinic by your own. We need lots of support from the local institution. It will include support from physician and nurse, support from laboratory, support from information technology, and support from clerical, and business support. Then there is no therapeutic way to have the physicians and nurses support. You know, you cannot do it rationally. So, I will show you the case in Taipei Veterans General Hospital. When we try to set up anticoagulation clinics, we have our patient target, which is in 3 departments. One is the cardiology department. We are focusing on patients with atrial fibrillation.
It need to take anticoagulant for lifelong. And the second target is cardiovascular surgery department. We are focusing on patients with valve replacement, especially for mechanical valve replacement. It also need to take the anticoagulant for lifelong. And the third focus is on stroke and neurovascular center. We are focusing on patients with cardioembolic stroke. It also need to take the anticoagulant for lifelong. So, once we know our target and we know which department we are interesting…… Then, we have to earn the trust from those departments. So, we join the inpatient care team and have team rounds with the physician and nurse every day.
And once you have the team work every day, then you also spend your time take care of the patient, review their drug list, find out the potential drug-drug interaction and have good performance on managing the anticoagulant, you gain the trust from physicians and nurse. And you will build out your own accountability and credibility. Then, if they have any question on managing anticoagulant, they will counsel you. Once you move on to that stage, you can start your communication with the physicians. You can tell the physician that I am setting up an anticoagulation clinics and ambulatory care.
So, if you have any patient who take the anticoagulant, you can consider to referral those patients to us because you already have the trust from the physician. The physicians will be very glad to referral their patients to you. So, after you communicate with the doctor, and the physician is very glad to referral their patients to you. Then, you have to prepare the invitation cards or brochure to the physicians or nurse. The invitation cards need 3 components. One is you have to mention the location and referral instruction in the invitation card. If the doctor does not know the location of your clinics and your clinic is very far away from the doctor’s clinics.
Then, it is almost impossible to get the referral from the physicians, because the physician cannot tell the patient the location of your clinics and that is almost impossible to get the referral. So, in this case, invitation cards include the location of an anticoagulation clinics and referral instruction. We use electronic referral system, So, we need to tell the doctor our clinical code, which is 1G2. So, once you provide this information, the doctor can referral their patient to you through our system. The second component of the invitation cards is the physician note. You have to remind the physicians what they should make a note on their medication records.
In the AC example, the patient use warfarin, the physicians need to write down the target INR range in the medication records so that the pharmacists, and the physicians and patients will have the same target and on the same page then we can work on the anticoagulant management on the same page. Another case is if the patient is using note, the doctors have to make note on the medication records the reason the doctor referral the patient to our clinics. For example, the doctor need the pharmacists to do the medication review to find out the potential drug-drug interaction. The physicians need to make the medical record so that everyone can be in the same page.
The third part on the invitation cards is the service detail and workflow. In anticoagulation clinics, this is the reminder for the physician. Because if the physician want to referral the patient to your clinics, they will have a brief introduction of your clinics. It may tell the patient that you are using anticoagulant. So, I want the pharmacists to do the pharmacy education for this drug. And it will give you a better idea of your own condition. So, in the invitation cards, you need to list your service detail and it will help the physician to referral the patient to your clinics. Once you get the support from physician, and you got the patient. Then you need laboratory support.
Before you get the laboratory support, there is 3 part you need to be serious consider. One is laboratory turnaround time. You need to know the lab data you want is urgent or routine. If a routine data, you have to know that in your laboratory, you do it once a week or once a day. If it is a once a week examination, then you need to tell your patient you have to come back one week before the appointment to get the blood test done. If the turnaround time is one day, then the patients have to go to the laboratory one day before the appointment time.
So, if you need the lab data very urgent, then you need to counsel the laboratory staff, and to see the number of your patient need to be tested and if it is increase the workflow in the laboratory. If it is a need to hire another technician to do the tests or not. The second thing you have to consider if you want to use point-of service machine or you just want to rely on the central laboratory. If you are working in a hospital, you don’t have to worry about that. But, if you are working in local pharmacy store, then you have to seriously consider about apply a point-of service machine.
However, if you use a point-of service machine, you need to have budget to buy machine supplies and you need to do the control and calibration routinely by yourself. And the third part is the data presentation. Because if you rely on the central laboratory in your hospital, usually, you don’t have to worry about the data records and data presentation. But, if you use the point-of service machine, and you have to make your own record by your own, and the data presentation will become an issue for your medical record. So, in Taipei Veterans General Hospital, we have a very powerful support from our laboratory. Because all samples will be processed and uploaded in two hour.
So, in our case, our patients just come to our hospital on the same day, and they will go to the blood test first, then they have some relax in the coach room. Maybe they go to have a breakfast, then they can come to our clinics during their appointment time. And, they will have their lab data done. And, this is the data presentation in our hospital. All the data will be clustered together and categorized in SMAC data or CBC data. And, you can choose the duration that you want to see in the past 3 months or in the past one year or in the past two years.
And all the data is listed by time and you can see it is organized very well. So, our laboratory support is very powerful.

Setting up the pharmacist clinic requires support from other sectors and disciplines. Ms Wung will explain the necessary cooperative relationships to establish.

Key concepts

Support from local institutions:

  • Physician/nurse

  • Laboratory

  • Information technology

  • Clerical/business support

An example of anticoagulation clinics:

The target patient group comes from 3 departments, atrial fibrillation patients from the cardiology department, patients with valve replacements from the cardiovascular surgery department, and patients with cardioembolic stroke from stroke and the neurovascular center.

TVGH pharmacists form a cooperative relationship with physicians and nurses so that physicians are more comfortable referring patients to pharmacist clinics.

Invitation cards or brochures are necessary for referrals. It must contain information about the location of anticoagulation clinics and the physician note, which informs physicians about the patient’s medication record. Lastly, a brief introduction of the services offered at the clinic.

There are 3 important things to consider for laboratory support. The first would be laboratory turnaround time. How often do they perform the tests you require? How urgently do you need this data? Second, should the clinic invest in a point-of-service clinic? Is there enough budget, manpower, etc. to invest in one? Lastly, how is the data recorded and presented?

Share and learn:

  • Besides laboratories in hospitals, where else can pharmacist clinics get laboratory support?

  • Do pharmacist clinics in your country rely solely on physician referrals?

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Good Pharmacy Practice: Introduction to Clinical Pharmacy Services

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