Challenges of Oncology Pharmacy Practice in the Community Setting. Part 3
Michele Woods, PharmD, BCOP
Illinois Cancer Center, Peoria
When you are ready to start designing your oncology clinic, you need to consider some of the "soft" requirements of clinic setup as well as the equipment issues discussed in Part 2 of this series (September/October 2009). In this category, I would include computer/phone needs, references, the formulary, and your Pharmacy and Therapeutics (P&T) committee.
Computer/phone needs
Data and phone lines often need to be requested early in the planning process, so you need to decide what your computer needs are as early as possible. Will you work from a desktop or laptop computer? What are the data requirements of your automated dispensing system? Does your refrigerator monitoring system require a dedicated phone line? You may need to request these things (and keep requesting them) at the beginning.
References
References are another important part of the pharmacy that are often left to chance. While the clinic is being planned, start a list of preferred references and check for updated versions. Determine whether you will use print or online versions. This decision might be made based on personal preference or overall cost. Ease of use might be another factor, if multiple personnel will be using the reference or if the reference will be needed at multiple sites. Mobility is also a factor. Consider a PDA/smartphone with loaded references if you will be very mobile.
The formulary
There are many good reasons to have a written formulary in an outpatient clinic. You will use it every time you develop or update systems in the clinic. This would include when switching wholesalers, implementing automated dispensing systems, adopting electronic medical records, and designing preprinted chemotherapy order sheets, just to name a few. A written formulary also comes in handy when developing guidelines for dose rounding, high/low limits, and compatibility/stability charts. In our clinic, I have also posted the written formulary on our intranet as a means of communication with our clinical and financial staff. The formulary answers many frequently asked questions, including those about brand/generic names, manufacturers, single-dose versus multipledose vials, and vial size availability. It also makes staff aware of what we keep in stock and what requires notice for ordering (Table).
Regarding treatment drugs, we make few formulary decisions in the classic sense. Mainly, we choose whether to keep a drug in stock or order when needed based on utilization. Keeping inventory of low-volume drugs to a minimum reduces waste. Making vial size information readily available to staff facilitates dose rounding. The supportive care aspect of treatment offers more opportunities for traditional formulary management. More agents in a class, for example, antiemetics, allows for selection between clinical equivalents based on cost. Posting your formulary can keep everyone informed of the current choices.
The P&T committee
Depending on the size of your practice, you may benefit from starting a P&T committee. Even smaller practices may be able to standardize their clinical services using a clinical committee of some kind. Either way, pharmacists should take an active role in obtaining physician agreement for standardization and guideline development. For the sake of simplicity, I will refer to this process as the P&T committee.
Ideally, the clinical pharmacist should coordinate the P&T committee. To get started, choose a physician champion who is the most likely to be both sympathetic to stand ardization and (if possible) inspire buy-in from other physicians. The physician champion can help determine how to choose other physician members and how they will rotate through the committee. Next, interested nonphysician members should be invited. These members will vary depending on the practice, but may include midlevel practitioners, a clinical nurse specialist or nurse educator, and financial counselors/business office staff (voting or nonvoting). It is also important to decide how decisions will be implemented and enforced.
The next step is the preparation of the agenda. The pharmacist/coordinator prepares each meeting’s agenda by soliciting topics from committee members and other physicians. Topics may also be suggested by other members of the clinical staff. I often present new drug information at this time, make formulary reviews, or clarify confusing drug policies. If I have students, they present drug utilization reviews or interesting drug information questions that may change practice. Agendas should be sent out about 3 to 4 days before each meeting, and should include a standard format of objective, summary, and references, so that committee members can prepare for meetings.
Conclusion
Setting up or remodeling an oncology clinic in the community practice setting presents many challenges. The articles in this series have discussed selection of equipment, software needs, and organizational issues to be considered. Careful planning and coordination with other members of the healthcare team are essential to maintaining a safe, efficient oncology clinic and providing high-quality care for patients.
