The VAriety of a VA Internship

What is the advantage of a VA internship? I would have to say the variety of experience. The last few weeks has given me opportunities to work on several new projects.

Administration

During the fall semester of P3 year we took a class called Managing Medication Systems. Part of the class focused on root cause analysis (RCA) and failure mode and effects analysis (FMEA). At the time the information didn’t seem that applicable to what I would be doing as a pharmacist, but last week I actually attended a root cause analysis meeting. We discussed a real problem, what caused it, and then proceeded to come up with short term and long term solutions. Sometimes all the lectures in the world can’t substitute for an actual experience.

Medication Safety

I have also been working on updating the high-alert medication safe practice guidelines. These guidelines were created to standardize the information on the use of high-alert drugs like bivalirudin, potassium, cyclosporine, and dobutamine within the Ann Arbor VA. The skills I learned in evidence based medicine have really paid off as I have searched through a bunch of references pulling out the most important clinical information. Along with the updates I am creating a Drug Bulletin flyer to be distributed throughout the hospital to inform physicians, pharmacists, and nurses of the purpose of the safe practice guidelines.

Drug Information

For the past few weeks I have been contacting drug information centers trying to find if a list of core clinical pharmacy references exist. I am helping put together a drug information rotation for the incoming residents. I get a first hand view of what goes into preparing a rotation. It has given me new respect for preceptors and the extra effort they put in to take on students and residents.

In the upcoming weeks I will be stepping away from the administrative/drug information side of pharmacy and getting into the ambulatory care setting. I will be sure to keep you posted.

Intern in the ‘ship part 3

I finally got to work drop-off! I have actually have done this before in first semester pharmacy class last year. Drop-off is either laid back or crazy busy. You can be typing a prescription, having a person waiting in line, and a person asking about insurance on the phone. My knowledge and ability to read sig codes from class has made the drop-off easier for me but it is still hard to keep up the pace. It just takes time in any job to be at proper work speed. I am learning how to enter in insurance cards in the system then run them through the system with a new prescription. It is kind of strange in the sense that it is all through the computer system and formularies. If the bill comes back 25 dollars and the customer usually pays 10 dollars then we cannot do anything about it. It is in the control of the insurance company. Many customers do not get that concept. We do not have any magic button to change the price.

Now customers can be clueless and frustrating at times, but we do have some great customers. This one parent has a child who has many prescriptions fill throughout the month. The pharmacist knows this person very well because how often they come to the pharmacy. This parent is always upbeat and understanding when there is a wait or a re-billing for a prescription. Other people like her always say along the lines of “I am here enough not to get mad over the small stuff.” These people make the job enjoyable and give confidence in one’s work. We can do our job and deliver customers medication in a pleasant matter which is otherwise an unpleasant topic: understanding and taking drugs.

What happens if you have to fill a prescription on a holiday say Memorial Day? Do not Fear! The pharmacist is here…and his pharmacy intern. Yes my pharmacy was open on Memorial Day and Yes I work that day and Yes people came in to drop off and pick up their prescriptions. It was actually quite busy in the morning with left over prescriptions and plenty of people calling to ask if we were open to pick up their medication. As the afternoon hit, the day became slower. I got to learn how to return medication to the stock shelves when customers decide not to pick up and pay for their prescription. It was not hard to learn, but I was surprise how many prescriptions people want filled but don’t pick them up. As the late afternoon came upon us, business was at a crawl which I prefer to be at a busier pace. My pharmacist showed me a website where I can receive current drug information. It gives information about new drugs on the market and good counseling points on many of the medications in the pharmacy. Yes, I worked on Memorial Day but as I said to a customer: At least it is air conditioned!

The ABC's of Managed Care - D, E, and F

Hello again everyone! Now that monsoon season is almost over in Ann Arbor, I'm ready to take off my poncho (just kidding, I don't actually wear a poncho) and start writing again. Last time we kicked it old school with A, B, and C of our tour through managed care. Bet you can guess what's coming next..

D: Dynamic - Managed care is a dynamic environment. Why you ask? Let's just take a quick look at a couple of snippets from the FDA's Press Announcements just this month:

• May 23, 2011 - FDA approves Incivek for hepatitis C
• May 20, 2011 - FDA approves Sutent for rare type of pancreatic cancer
• May 20, 2011 - FDA approves new HIV treatment
• May 13, 2011 - FDA approves Victrelis for Hepatitis C
• May 06, 2011 - FDA approves new treatment for rare type of pancreatic cancer (This is not the same drug as on May 20th!)
• May 02, 2011 - FDA approves new treatment for Type 2 diabetes

This doesn't even take into consideration the surprising number of new drug formulations that are constantly being approved. Each of these newly approved drugs and formulations has to be reviewed carefully and decisions must be made as to their place in therapy. Clearly, managed care organizations like Blue Care Network (BCN) have their hands full adapting to the ever-changing world of pharmacy.

E: Evidence-based medicine - One of the exciting things about managed care is that you are making decisions not just for one individual patient, but for an entire population of patients. This is where evidence-based medicine (EBM) comes into play. With so much on the line, clinical pharmacists at BCN have to delve deep into the literature to find the best evidence to support their clinical decisions. Some of the questions the clinical pharmacists have charged me with investigating have been pretty tough so far:

• What is the correct dose and interval for IVIG in the treatment of relapsing-remitting multiple sclerosis (RRMS) exacerbations?
• Should alemtuzumab (Campath) be used in MS? Or should the patient try fingolimod (Gilenya) first? Or natalizumab (Tysabri)?
• What evidence is there for IVIG in urticarial vasculitis? (We could only find less than 10 case studies in the literature of this!)

I never thought I would say this, but that EBM class we all dreaded P1 year is truly paying off. Thank you Dean Welage; we will miss you greatly!

F: Fun - You can't have a career in pharmacy without a little phun! I can honestly say that I've had a fantastic time so far at my internship at BCN. The atmosphere there is truly unique. The dress is casual. The coffee is flowing. And each computer is equipped with an instant messenging feature to allow quick, fun communication between co-workers. It's a pretty tight-knit group at BCN, and the fun atmosphere seems to cultivate a culture of hard-work, efficiency, and teamwork. In the words of arguably the most entertaining boss in the world, Michael Scott: "What is the single most important thing for a company? Is it the building? Is it the stock? Is it the turnover? It's the people. The people." Well said, Mr. Scott. It is the people at BCN who make it such a great place to work.

Well, that's it for this week's adventures in managed care.

Your homework for next week: be dynamic, have fun, and uh... don't forget your EBM.

Investigational Drug Service aka IDS

Hello everyone! My name is Meenakshi and I am an incoming P3. I've worked as a University of Michigan Health System Intern in the Investigational Drug Service (IDS) through last summer and during the school year. So a basic question I am asked is, what is IDS!? Here's a summary... IDS is a designated section of the Department of Pharmacy Services within the University of Michigan Health System that handles the experimental drugs used for patients enrolled in clinical trials. IDS is responsible for the pharmacy-related tasks of both hematology/oncology and non-hematology/oncology studies. This includes drug accountability (both paper and electronic systems), meticulous records, proper storage and disposal of drug and compounding. The pharmacists, in addition to verifying every drug order or prescription, have many responsibilities. These include drafting and verifying dispensing guidelines, amendments and opening study procedures. Also, they are active in several committees and task forces including the Institutional Review Board (IRB). There is never a routine day in IDS and the work that is accomplished here is critical for patients and for data that the FDA will analyze when deciding to approve drugs for approved indications.

Entering my second summer is pretty exciting with new innovative projects including helping to design and pilot a new Advanced Pharmacy Practice Experience or APPE aka a P4 rotation experience! We have recently crossed the mark of currently handling 400 active investigational drug trials! This is an accomplishment for clinical trials research and for our dedicated team of pharmacists, technicians and interns. This summer, we've welcomed Julie Zhu as the P2 intern and throughout the year, we have been working with the P4 students who are on rotation. With the experience of both technical and professional aspects of IDS operations, I've been able to help train while working on my daily to-do lists, including audit preparation. What I love about IDS and this internship is the variety of responsibilities and projects, that all play an important role in the process of the pharmacy-focused part of a clinical trial with investigational agents. Stay tuned for updates!

Commonwealth Care Alliance: A Comprehensive Prepaid Accountable Care Organization for Medicaid and Dual Beneficiaries with Complex Care Needs

... Phew! Say that 10 times fast!!

Hello! My name is Anna Polk, and I am a soon-to-be P4! I am spending my summer in Boston (please see photo of how stunningly beautiful Boston is in the spring) working at the Commonwealth Care Alliance, henceforth referred to as CCA. This is a small (around 3200 members) not-for-profit managed care organization that mainly covers dually eligible (Medicare/Medicaid) seniors throughout Massachusetts. I started earlier this month and have been working on several projects since arriving. More on those later, but first I want to tell you all about CCA and the work that they do. Before arriving I was excited to learn more about the world of managed care and was happy to be doing so in a not-for-profit so I would have a leg to stand on when people with managed-care-misconceptions accused me of being one of the bad guys! Once I arrived, however, and began learning more about the organization, I have become incredibly proud to be associated with such an innovative team. I really hadn’t begun to grasp the scope of the care they provide until I attended orientation this past Tuesday. Our CEO, Bob Master started off the day talking about the mission and the culture of the organization.

They don’t think of themselves as a managed care company, but rather a health-care delivery system. They employ their own group of primary care providers, nurse practitioners, registered nurses, social workers, physical therapists- the list goes on and on! They use a team based, multidisciplinary, coordinated approach to care, in an effort to keep patients functioning independently in their homes for as long as possible. Through this approach, they have been successful in reducing the hospitalization rate of their members nearly in half!

The field workers are granted the autonomy to make decisions for their patient’s care. For example: they don’t have to wait for a patient to develop bed sores before authorizing a specialized mattress for them- if their team feels it is in the best interest for the patient, then they can have it. If you are dying to know more, here is an article about CCA from WBUR (Boston’s NPR News Station.)

I took a few courses at the public health school in my first year of pharmacy school, and it has been so exciting seeing how the theories I learned about there are actually being put into action to improve care for this specialized group of patients. I am working on several projects here and can’t wait to tell you all about them.... stay tuned!

The Michigan Difference

Hello everyone, my name is Adam Loyson and I am currently a pharmacy student at the University of Michigan entering my second year. For the summer, I am interning at the University of Michigan Hospital in multiple in-patient settings. While some of you might have read an earlier post given by Kari Horn who also works at the hospital, I will be providing you a different perspective outside of Mott Children’s Hospital where she is currently working.

With that said, I have started my training this past week by working in the central pharmacy department compounding medications. Particularly, I am involved with the mixing of various pharmaceutical compounds with different intravenous bases to create IVs for patients. While it is possible to make IVs in the satellite pharmacies located on each floor of the UofM hospital, most of the extensive and large batch production takes place inside the central pharmacy department located in the lower floor.

To make these intravenous medications for patients, I work in a area called the “Clean Room”. This area is considered very sterile and has a limit of less than 100 particles per square foot. Now that is clean! In order to enter the room, I am required to scrub with soap up to my elbows and gown up by wearing shoe covers, a medical mouth covering, a hair net, a full gown, and sterile surgical gloves with an application of sanitizer. Once in the clean room, there are five chemical compounding hoods that circulate the air in order to purify it. Four hoods are designated as regular pharmaceutical compounding while one is labeled for the production of chemotherapy drugs and is located in a separate room with even further sterilization requirements. Once gowned and ready to go in front of one of the hoods, I am required to sanitize my entire work area with isopropyl alcohol and keep documentation of such cleanings. I have learned that keeping documentation of cleaning, procedures used and inventory is very important quality control and in the case that hospital is investigated by the Joint Commission, which is the institutional body that accredits the hospital and is necessary for the acceptance Medicare patient insurance.

So let the fun begin! At designated times during the day, a batch of labels containing drug names and strengths are printed out. At that time, the labels are passed through into the hood and I am then able to start compounding the required medications. Attention to details is critical here as selection of the correct drug, the dosage strength, correct volume, correct procedure, and aseptic technique are all important. A sample scenario for compounding an IV medication would follow the following steps:

1. Selection of the correct pharmaceutical: Medication location in the clean room can vary based on chemical stability. Chemicals that are unstable at room temperature are kept in a fridge while chemicals that are sensitive to light are prevented from degrading by keeping them in opaque packaging. Finding the correct medication and strength that you need as designated on the hospital label is vital.

2. Dilution to the correct concentration: Most medications are supplied in the powder form for stability reasoning. In order for the drug to be added to the liquid IV base, it is diluted using saline solution, static water, or bacteriostatic water.

3. Drug Injection of the correct dose into an IV base: After dilution, a specific volume of the solubilized drug is drawn by syringe and injected into a base in an IV bag such as dextrose or sodium chloride. Selection of the IV base is dependent on each individual patient case and their disease state.

4. Compounding accuracy and delivery: Once the IV bag is finished and labeled, it is marked with a hang-by date and time, expiration date and time, as well as any special storage instructions for the nursing staff. The IV is then provided to a pharmacist along with the original drug container and syringe noting volume drawn to check for compounding accuracy. After it is verified, the IV drug is then ready for delivery to one of the multiple medication stock areas on each hospital floor called Omnicells that are kept under digitalized pass codes. This is where I get my exercise!

In summary, I had a blast this past week. If you are like me and enjoy doing labs in chemistry, compounding pharmaceuticals and creating individualized IVs for patients can be a rewarding experience. It gives me an excellent opportunity to familiarize myself with the drug names that are used by the hospital, special considerations for each medication, and a chance to brush up on my compounding bench skills. While this particular experience is specific to within the hospital's central department of pharmacy, I will be sharing my experience of working in one of the floor satellite pharmacies next week. Stay tuned as you have a great summer!

What I'm working on

The advantages of using a wiki(pedia) for documentation...

Speed: Wikis are minimalist web pages containing mostly plain text (usually). They load quickly.
Search: Users can perform site-wide searches, which is akin to sifting through multiple Word documents in one shot, quickly, and without having to open them.
Structure: Wikis are made up of directories, which can contain children directories that contain grandchildren directories. Upon demand, the wiki can generate a genealogy tree for easy navigation.
Archiving: Everything--modifications, old versions, new versions, users who made the changes, timestamps--is documented. It's possible to revert to an older version with a single click regardless of the damage done to the current version (unless the page itself is deleted, perhaps, in which case its history is probably also deleted).
Collaboration: Users can be individually authorized for viewing, editing, and moderating different sections of the wiki. Editing a page is not unlike editing a Word document--the interface is simple and intuitive for basic tasks.
Feedback: Polls, ratings, notifications, and other extensions are available on demand.

These are points I might have to present to the pharmacy department sometime this summer. We currently use a document library to keep track of department guidelines and procedures. It's a web directory that authorized pharmacists upload Word documents and pdf files to. The library worked well and fit very nicely into our existing web interface, but, as the directory got larger, the loading time got longer. Dr. Stevenson, Director of Pharmacy, brought up wikis during a manager meeting. It was a good idea, so I began my research. We started out with three potential platforms: MediaWiki (open source), SharePoint (Microsoft), and Confluence (Atlassian, an Australian software company you probably haven't heard of). Within MCIT-Rx, we decided that MediaWiki was too rough, the user interface too hostile for non-technical audiences. So it was SharePoint or Confluence. Even though the hospital had a tight relationship with Microsoft, we didn't choose SharePoint because it was unnecessarily complicated. (SharePoint came as a package in which the wiki was only one small component.) And we were left with Confluence.

As wonderful as Confluence is, there are drawbacks. There is no way to integrate it seamlessly into the internal pharmacy website so, for pharmacists, getting to the wiki will require an extra log-in step. Also, we don't have our own Confluence. The Medical School does. Technically, we will be using their service. While they are very friendly people, it's still inconvenient for us because we don't have control over the backbone. That becomes an issue during downtimes, etc.

Those are my research. Ultimately, whether a wiki is worth pursuing will be determined by the pharmacy department.

Intro to EC Pharmacy

Hello everyone! My name is Katrina, and I am an incoming P3 student currently interning at Royal Oak Beaumont Hospital. I've been a pharmacy intern there for a year, working alternating weekends during school and full-time in the summer. As a pharmacy intern at Beaumont, there are several practice areas where I been trained to work, namely in the central inpatient pharmacy, satellite pharmacies (general and pediatrics), IV clean room, and in the emergency center (EC).

During the summer, I am frequently scheduled to work in the EC. Working in this setting as an intern is definitely an interesting experience in the unexpected- no day is the same. Royal Oak Beaumont has a Level I Trauma center, which translates into receiving a variety of critical patients from around Michigan in addition to local cases.

Typical daily tasks include: refilling the EMS boxes and bike packs, restocking the pharmacy, filling and delivering doses to 1 of the 8 areas of the EC, and crediting unused patient medications. Compounding IVs quickly and accurately in the EC is essential, especially for medications like TPA and amiodarone. All of the EC pharmacists that supervise my work are truly knowledgable, and are more than happy to both teach and test me on drug information and dosing while I work.

When the EC pharmacist is paged to attend the trauma bay, I usually get to tag along and help out with whatever case presenting. Most often, pharmacist involvement in traumas features intubation sequences and the provision of syringes for cardiac arrest codes. For example, during a code, the EC pharmacist is responsible for providing the nursing staff and physicians with specific medications at defined intervals of time, all depending on the patient's status. At the discretion of the EC pharmacist, interns are permitted to draw up doses on the spot for the traumas, which are immediately used after verification by the pharmacist. The pressure can be on when those around you are depending on a syringe in a few moments!

Overall, it has been rewarding to be able to experience this different side of inpatient pharmacy as a student, and I look forward to more times in the EC!

The VAluable lessons of my VA Internship

Hello everybody. My name is Matt Wolf, an incoming P4. This summer I am working at the VA Ann Arbor Hospital. My official government title is Student Pharmacy Tech (VALOR). The VALOR program offers an opportunity for pharmacy students to develop competencies in pharmacy practice settings such as inpatient and outpatient pharmacy. It also provides exposure to management practices and clinical pharmacy services, such as anticoagulation, critical care, and discharge counseling. I spend most of my time working with Dr. Greg Schepers, the Residency Program Director.

I have been at the VA for a little over a week and they have been keeping me very busy. I have had opportunities to report adverse drug events to the FDA, update the residency recruitment poster for the ASHP Midyear Clinical Meeting, and draft standard operating procedures. I am also in the process of developing an informational website for potential pharmacy residents.

It is going to be a great summer filled with exciting opportunities. Having the chance to take care of veterans is a truly rewarding experience. They have sacrificed so much for us and this is a chance to give back to them. I look forward to keeping you all posted on the VAluable lessons I learn this summer at the VA.

Allegiance Health

My name is Kristen Tedders and I am a proud member of the COP Class of 2012, also known as a P4-elect (with the current P4 class still not graduated, I think it’s only fair to think of myself with this title). I am returning to Allegiance Health, a hospital in Jackson, MI (formerly known as Foote Hospital) for my second summer in a row. After working in the IV room and OR pharmacy satellite last year, I am currently being trained in the Emergency Room pharmacy.

Working down here can either be incredibly hectic or pretty laid back, you never know what the day will bring. The pharmacist and technician (or in my case, intern) will service the ER by making IVs throughout the shift as they are needed for the patient and delivering them and medications directly to the room (as most are needed STAT). They must also be prepared for emergency angios, strokes, codes, and a number of other situations that can happen at any time. Along with these inpatient services, I also deal with outpatient ER patients and their prescriptions. Throughout my 8-hour afternoon shift, we can fill anywhere from 20-60 prescriptions. While this may not seem like much, patients always seem to come in bulks of 5-10 at a time, so that when you are filling prescriptions for one, there is always a line behind them. Add to this the constant need for IVs to be made and delivered, things can easily get pretty busy!

Throughout the last 4 days I have been training (with the aid of a very knowledgeable technician!) and everything has been pretty laid back. I will soon be working my own, with a pharmacist also in the pharmacy with me, in a couple days and I am fully expecting to experience my first wildedly busy day when I am all on my own. Not to worry though, just remember: the needs of patients in the ER come first. Don’t be afraid to politely tell those waiting for prescriptions to be filled that it may be a little bit of a wait if there is a lot going on! And always remember, remaining calm under high stress situations will make things go by much smoother.

Hello from Singapore!

My name is Grace Chen and I'm an incoming P4. I'm currently working in Singapore at the National Healthcare Group Polyclinics (NHG) in Choa Chu Kang (CCK).

These polyclinics are government subsidized clinics where patients get treated for minor acute ailments and chronic conditions. Physician offices, labs, nursing stations, pharmacy are all located in one 3-story building. Because it's subsidized (read: cheap), our pharmacy serves 700-800 patients in a DAY alone. Needless to say, it's super busy every day.

Here are my observations so far on working in Singapore:

Technician role. at NHG, there's this advanced version of the tech-check-tech system. In fact it's more like tech-check-tech-check-tech-check-tech, and then it gets to the patient....without a pharmacist check. Technicians here can do every step of the process and are usually the ones doing the patient counseling before giving the meds to patients.

Pharmacist role. Definitely not as developed as in the United States. Because pharmacists do not have to be the final check in the dispensing progress, they help out with filling, typing, or dispensing whenever it's busy. There are, however, "pharmacy only medicines" (e.g. famotidine) that only pharmacists can dispense, so a pharmacist duty include triaging patients who ask for those medications.

Pharmacists also run anti-coagulation and hypertension/diabetes/lipid clinics but it's still in a nascent stage and the demand for pharmacist interventions is low. Pharmacists have no prescribing rights, so for every warfarin dosing change the pharmacist must first call the patient's doctor to get approval. This gets very inconvenient when the patient is sitting next to you and the doctor cannot be reached.

Languages. People here are so incredibly fluent in multiple languages and dialects. Bilingual (usually English and Chinese) is the norm, but someone like my pharmacy manager can effortlessly switch between English, Mandarin, Cantonese, Hokkien, and Malay. I'm currently learning to do inhaler and warfarin counseling in Cantonese, my goal is to do one anti-coagulation clinic session entirely in Chinese. Haha we'll see about that....

Work ethics. I am constantly amazed by how hard everyone works. At NHG pharmacies, the average work week is 42 hours (which means working on Saturdays!). The staff stay late and some are on their feet constantly but they rarely complain (contrary to my work experience in the US!)

The picture I have above is of the staff practicing their dance for "Family Day," a corporate-sponsored team-building day. It's definitely fun working with these people!

Anyways, today I have the day off because it's Vesak Day (Buddha's birthday)...so I'm off to the Singapore zoo and night safari!

Intern in the ‘ship part 2

One word: busy. Retail is busy at least at my store. I did expect to be busy, but it is always different when you are actually in the flow of work. I have been doing pick-up, production, and drive thru for my first couple of days. I am starting to learn how to work the computer system for looking up customer’s information and refill requests. There is a ton of little things customers want like knowing when their next refill is to wanting to pick up a prescription with new insurance which takes time to enter and process. The pharmacist and techs have been great to work with. They help me out whenever I have trouble and they love making the work day enjoyable. One day I actually knocked over some food on the floor but the pharmacist wasn’t too mad. He actually helped me clean it up when he got a moment of freedom.

One thing I have not mastered yet is insurance problems. Once we get prescriptions we type them into the computer and run it through the insurance system. The system will shoot back a response with a green or red light. We like seeing GREEN lights. When a red light pops up, we have to see why it is rejected to see if we can adjust anything to make it work. The more experience technicians are quick with the computer system and can determine if anything can be done. No one wants to be the person who says to the customer “your insurance did not cover this prescription.” Even though we do not control the payment, people still vent. Luckily, I haven’t experienced someone blowing up on me. Most people are annoyed but sensible. Next week, I will be working the drop off station and some new experiences!

AmCare at the VA

Hello, all,
My name is Garret Smith an incoming P4 student and I am an intern at the VA Medical Center in Battle Creek Michigan. The Medical Center has around 235 inpatient beds most of which are filled with psychiatric patients as well as substance abuse and post traumatic stress disorder patients. Being a Veteran's Affairs hospital the patient population is fairly limited, however it is a population that is needing and deserving of our services.
This summer I will be working with the clinical team in the pharmacist-run ambulatory care clinics. The clinical pharmacists at the VA are in a fairly unique position in that they have prescriptive authority for their patients! Clinics are offered in anticoagulation, hypertension, dyslipidemia, and diabetes. If a veteran has one or more of the aforementioned conditions their physician can refer them to our clinic where we the pharmacists are in charge of all their medications related to those conditions.
Using this team approach much of the patient load is shifted off of the primary care physician and patient care is greatly improved since we can see patients much more frequently than 3 to 6 month wait to see the doc.
Today was my first day, so stay tuned for more info on our clinics as I delve deeper into the VA system!
-Garret

"You probably don't know what you don't know."

One of the pharmacists expressed this quote to my fellow interns and I at orientation, and after my first week in in-patient pharmacy I have a feeling this will be the theme of my summer!

Hello Readers! My name is Kari Horn and I am a P2 at the University of Michigan College of Pharmacy. My internship this summer is right here in Ann Arbor at the University of Michigan Hospital in the In-Patient Pharmacy. Specifically, I will be working in the C.S. Mott Children's Hospital. I hope to give readers a unique insight into the world of hospital pharmacy from the perspective of a pharmacy student.

After a very relaxing week off after final exams, we officially started our internship Monday May 9. The time off was nice, but I actually found myself getting bored with the abundant amount of free time I had, so I was definitely excited to get back to Ann Arbor and start my new position.

Our group of new interns started on Monday with a Michigan Traditions and Values (MTV) Orientation for all new Health Systems employees. It was nice to interact with employees in other areas of the UM Health System, and we learned a lot about the mission, values, and policies to abide by at the hospital. One idea that was stressed in this orientation is doing our best to assist patients and their families. If we see someone who looks lost or confused, we should go out of our way to help them find where they are going. This becomes critical in a hospital system the size of Michigans. Our group of interns determined that in the first few days we might be the ones needing help navigating!

Tuesday and Wednesday, the group of interns went through department-specific orientation with pharmacy services. These days were filled with lots of introductions and information. One thing that our group was very excited about was being about to wear scrubs. I've attached a picture of me and a fellow intern/P2 Erin Dukarski in our new scrubs and pharmacist intern badges.

Thursday and Friday, our group of new interns split up to train in our respective areas. Mine was being the "runner" in Mott Children's Hospital. Mott is connected to University Hospital (as is the Cardiovascular Center and the Cancer Center), so it was easy to find and get acclimated to. The day shift starts promptly at 7am with many tasks to get done right away. The runner first checks the messages. Messages are sent from the different floors to the pharmacy to order IV's and other medications. The runner checks these and relays them to the rest of the pharmacy to fill the order and get it out to the patient. Then, we quickly go on a "run". This happens at the beginning of every hour. "Runs" consist of taking all of the medications to the floors (NICU, 7, 6, 5) and getting them to the proper place. Depending on the floor, the medications might go to different places. One thing I am still in awe of are the giant Omnicells in each of the units. Omnicells are Medication Dispensing Systems that hold a variety of medications. Controlled medications are always kept in Omnicells, and depending on the floor other medications are placed in here too. The Omnicells require a password to unlock and keep a very careful inventory of medications, so there are no mix ups or lost medications. This is critical to reduce medication errors and lost inventory. If medications are not delivered to Omnicells, they might go to patient bins in the medication rooms on the floors, or in the refridgerator if needed.

With the help of my trainer, I quickly developed a system for each run to make the process more efficient. One thing I really enjoy is because we do a run every hour, we get to see the familiar faces of the other healthcare professionals and patients and families.

In between runs, we fill prescriptions that come into the pharmacy. Being a children's hospital, Mott has a lot of unique dosing and dosage forms. The dosage of a diuretic will be infinitely smaller for a neonate than the dosage for a regular 150 pound adult. Many of the doses are also drawn up from oral bulk solutions, so I got to put my compounding skills to the test and make some solutions! I also found out that taste is a factor, so flavoring is also routinely added to oral solutions.

One thing that is very apparent is you are always busy when working in the hospital pharmacy. There was never a time when I had nothing to do! I really enjoy the fast-paced atmosphere of the pharmacy. Before I knew it, my shift was over and it was time to go home. I also really enjoy the fellow technicians and pharmacists working in Mott, which makes coming to work fun.

I learned so much from my first few days of training, and I am excited to continue on Monday. Stay tuned for more updates!

The ABC's of Managed Care

Hello everyone! My name is Bernie Marini, and I am an incoming P4 who will be doing an internship in managed care this summer at Blue Care Network (BCN). Yesterday was actually my first day, and it was definitely a change of pace from working retail. Managed care is a new world for me, and every day I am surprised by how attractive a career in Managed care might be. Since I (and you, maybe) are new to managed care, we'll start with the ABC's. Prepare to be Kindergartner-ized (I'm an author of a blog now, so I can make up words):

A: Acronyms - Managed care is FULL of acronyms. It's like learning a new language. At first, during meetings, I was pretty lost - terms like ERISA, ECRI, HEDIS, MAC, CFI, PREFALT, PCOT, AGL, FAIR, FACETS, and NCQA just flew over my head. It's made for a difficult start, but I'm starting to get the hang of it. I now know that PREFALT letters are those that are sent to providers when a PA is denied, letting them know what the preferred alternatives are. If I'm feeling ambitious, I might make a glossary for future interns by the end of the year.

B: Boring? Not so much. Every day is completely different. There are a lot of meetings in managed care, but they vary greatly from day to day. Today I attended my first webinar on a successful safety initiative in the Philadelphia area known as the Partnership for Patient Care. I had another meeting about compounding fraud, and another one discussing branching logic built for certain medication prior authorizations (more on this later...). I also am being assigned a different project just about every single day. I'm currently working on several short informational stories and brochures regarding COPD guidelines for both providers and patients, to improve compliance with NCQA guidelines. Next I'll be working on a presentation for the members of the Chrysler Automotive group on their medication use within the health plan compared to all other BCN members.

C: Clinical - One cool part about this internship is that I have my very own cubicle, and I get to work right next to the clinical pharmacists there....wait... whaaaat? Clinical Pharmacists? In managed care? That's right, BCN employs many clinical pharmacists, and much of the work done at BCN is very clinically based. The pharmacists have to create the branching logic for prior authorizations and other formulary rules regarding medication selection by members of the HMO. For example, let's take the hypothetical example where a doctor writes a prescription for tizanidine (Zanaflex), a muscle relaxant. Because of safety concerns with tizanidine, this would require a prior authorization, and the form that the doctors fill out asking questions such as "has the patient tried cyclobenzaprine (Flexeril)? (Y/N)..." is created by clinical pharmacists. The answers to these questions determine whether or not the prior authorization is approved. These safety and efficacy decisions concerning formulary rules and prior authorizations are one of the the many responsibilities of clinical pharmacists at BCN.

I think that's enough ABC's for today. Stay tuned for more adventures in managed care!

Next week: D, E, and F - get excited.

-Bernie

Abbott Laboratories

Hello World. This is Eric Zhao (incoming P4) checking into the Summer Experiences blog. I'll be interning at Abbott Laboratories in the Regulatory Affairs Department this summer, and I'll do my best to give you a taste of what the pharmaceutical industry has to offer.

Quick Note: Due to Abbott's new social media policies, I have to wait for clearance before I begin posting any details, so stay tuned.

Abbott: A Promise For Life
Abbott Park, IL

-Eric Zhao

Hello. My name is Jennifer. I'm a P2. My internship this summer is right here in Ann Arbor. I work with the Pharmacy Group in Clinical Systems Management in Medical Center Information Technology at the University of Michigan Health System--for short, MCIT-Rx. I have been part of the team since last May. There are seven of us. I'm the only student and everyone else is a full-time employee. They are Pete, Rob, Todd, Robin, Russ, and Rick, our boss and the only licensed pharmacist. We are situated in the heart of the Pharmacy Department in the University Hospital, down on level B2. Scroll to the bottom of this post for some photos. These IT folks are quite photogenic.

IT folks are also team players. Our agenda is always full and we constantly juggle multiple projects. Pete is our expert for WORx, the inpatient pharmacy management system. Robin and Russ support Omnicells, dispensing machines scattered throughout the hospital that nurses use for easy medication retrieval. Todd is our web developer and database man. Rob works with the Robot, an automated drug packing machine, and QS1, the outpatient pharmacy management system. Rick, our leader and ambassador to pharmacy management and MCIT, oversees our projects. Me? I dabble in a little bit of everything. I support IT support. It's important to point out that these are merely some of the roles each person takes on. We do much more to support our pharmacy and there are overlaps in our duties. For example, someone has to be "on call" 24/7, and the full-time members of our team (everyone except I) take turns to be that popular person. At one point last semester, I wanted to volunteer for this role once summer comes around, just to experience that wonderful feeling of being wanted by nurses, pharmacists, hospital staff, etc., during all hours of day and night. But, now that school's over, I think I'm actually reconsidering. Not sure why...

So, there you go. The first installment of six (a sextet!), documenting my experience with MCIT this summer. The photos I mentioned earlier aren't ready yet, but I'll post this anyway. ¡Happy Cinco de Mayo! Stay tuned for photos of my team, coming next week.

[edit 5/9] Here are the photos.