R.Ph.s chafe under systems that time their dispensing

As reimbursements for drugs keep falling, chains must fill more prescriptions-and apply even more pressure on their pharmacists to dispense quickly-to make up for their loss. But pharmacists claim this is leading to more drug errors.

The practice of timing pharmacists on how quickly they fill prescriptions is increasingly being called into question. One national chain, for instance, uses a red light on their pharmacists' computer screens to warn them if they are falling behind in their dispensing.

"My main concern is with the impact on staffing and the profession," commented Charles L. Duhon, R.Ph., a community pharmacist who practices in Oklahoma. "You feel like the guy behind the hotdog stand. It is all money, money, money, as fast as you can."

Kaiser Permanente has had a standard of filling each new prescription within 15 minutes for more than six years, noted Steven Gray, Pharm.D., J.D., who heads professional affairs for the HMO's pharmacy operations. "The service standard is for the entire pharmacy operation," he explained. "Eighty percent of prescriptions should be filled within 15 minutes."

The goal, Gray said, is not to single out pharmacists who do not meet the standard, but rather to focus on how the pharmacy can be improved to produce efficiently. "If a pharmacy starts to fall below standard, we send in a pharmacy improvement team [PIT]," he explained. The team works with management and staff to see what the problem is. Based on PIT recommendations, Kaiser may hire additional staff for the pharmacy or change procedures to meet the pharmacy standard.

Kaiser said its 15-minute rule came out of surveys of pharmacy patients. "We find a correlation between member satisfaction and the waiting time," Gray reported.

Kaiser maintains that automated refills and training are key ingredients for meeting the service standard. The vast majority of refills are handled at centralized robotic fill centers. Furthermore, with e-prescribing, prescriptions are often started before patients even enter the pharmacy. The Kaiser HMO model with the physicians and pharmacy under the same roof also helps to increase efficiency and reduce the time pharmacists spend on the phone. "In my opinion it is the most forward-looking pharmacy group in the nation, ahead of most everyone," said one current Kaiser pharmacist who asked not to be identified.

"It is such an efficient organization. On a typical day, you'd work behind the counter dispensing medications for an hour then consult for an hour," the Kaiser pharmacist explained. "It's not like a factory assembly line." Still, he went on to note that pharmacists are judged daily based on their speed.

It is that judging that causes concern for many observers and raises questions about the value of such time-based service standards. And while many observers agreed that Kaiser is respected for its efficiency, similar workplace standards that exist at several large chain pharmacies are troubling. "We are concerned about prescription errors and the impact on consumers," insisted Fred S. Mayer, R.Ph., M.P.H., president, Pharmacists Planning Service Inc. (PPSI), a pharmacy-related consumer advocacy group. "If you believe the studies, pharmacists should not be filling more than 180 prescriptions per shift."

Some drugs, especially those with black box warnings, may need extra time, Mayer argued, and timers place an undue pressure on pharmacists to focus more on time than on patient safety. While he admitted that Kaiser Permanente's pharmacy operations may be able to handle the volume, he worries that at other chain pharmacies, the same safeguards and quality control mechanisms may not be as stringent.

In all likelihood, this debate over the efficacy, safety, and professional impact of timed service standards will only continue as the practice spreads. "What we need to do," Duhon demanded, "is get together to change the system."