Advancing the role of the pharmacy technician: A ... · PDF fileREVIEW Advancing the role of the pharmacy ... both the technician and the pharmacy. Data sources: A literature search

Journal of the American Pharmacists Association 58 (2018) 94e108

SCIENCE AND PRACTICE

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Journal of the American Pharmacists Association

journal homepage: www.japha.org

REVIEW

Advancing the role of the pharmacy technician:A systematic review

Ashlee N. Mattingly*, T. Joseph Mattingly II

a r t i c l e i n f o

Article history:Received 26 June 2017Accepted 29 October 2017

Disclosure: The authors declare no conflicts of interesin any product or service mentioned in the article(pending or received), employment, gifts, stock holdraria, consultancies, expert testimony, patents, and rand members of their immediate families.* Correspondence: Ashlee N. Mattingly, PharmD

Maryland School of Pharmacy, 20 North Pine Street,MD 21201.

E-mail address: [email protected] (A.

https://doi.org/10.1016/j.japh.2017.10.0151544-3191/© 2018 American Pharmacists Associat

a b s t r a c t

Objectives: To summarize the findings of a literature search on advancing the role of pharmacytechnicians, including the types of training identified and the potential costs and benefits toboth the technician and the pharmacy.Data sources: A literature search of Scopus, Embase, and Medline was conducted on January11, 2017.Study selection: Original research, research reports, case studies, or association reports wereincluded for review. Articles were considered to be relevant based on identification of anadvanced pharmacy technician role or addressing additional training/education for technicianfunctions.Data extraction: A standard data extraction formwas used to collect study authors, article title,year published, journal title, study design, brief description of methods, primary outcomemeasures, advanced technician roles identified, additional education or training addressed,and additional costs and benefits identified in each article.Results: A total of 33 articles were included for full review and data extraction. Study designvaried, with 17 (52%) quantitative, 1 (3%) qualitative, 5 (15%) mixed-method, and 10 (30%) casestudy designs. Seventeen (52%) of the studies included were published after 2006. Themechanism of training was primarily through supervised on-the-job training, allowingtechnicians to assume administrative-based positions that facilitated a pharmacist-led clinicalservice, with either the pharmacist or the pharmacy receiving the greatest benefits.Conclusion: Although the literature supports technicians performing advanced roles in thepharmacy, resulting in either improved patient outcomes or opportunities for pharmacists toengage in additional clinical services, the benefits to the technician were primarily indirect,such as an increase in job satisfaction or a more desirable work schedule. If a technician is totake on additional roles that require completion of a formalized training or educational pro-gram, benefits that are more tangible may help to inspire technicians to pursue these roles.

© 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

1,2
Both the American Society of Health-System Pharmacists(ASHP) and the American Pharmacists Association (APhA)have supported the standardization of education, training, andcertification requirements for entry-level pharmacy techni-cians, including completion of a training program accreditedby ASHP and the Accreditation Council for Pharmacy Educa-tion and national certification through the Pharmacy
ts or financial interests. This includes grantsings or options, hono-oyalties for all authors

, BCPS, University ofRoom S449, Baltimore,

N. Mattingly).

ion®. Published by Elsevier I

Technician Certification Board (PTCB). The ASHP statementfurther delineates among the competencies of an entry-leveltechnician and acknowledges that with additional training,technicians can take on advanced roles.1 These advanced rolesinclude “tech-check-tech,” purchasing or fiscal management,supervisory positions, assistance with medication history,medication therapy management, immunizations, qualityimprovement, hazardous drug handling, patient assistanceprograms, education and training, community outreach, druguse evaluation, adverse drug event monitoring, industry, andinformatics.1 ASHP states that there may be additionalopportunities for advanced roles not included in this list.However, training components to prepare technicians forthese roles is yet to be defined.

In 2010, ASHP held the Pharmacy Practice Model Initiative(PPMI) with the goal to “advance the health and well-being of

nc. All rights reserved.

Delta:1_given name

Delta:1_surname

mailto:[email protected]

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https://doi.org/10.1016/j.japh.2017.10.015



Key Points

Background:

� After completing an advanced training program, few

national pharmacy organizations have clear and

supportive policies on the use of pharmacy techni-

cians in novel positions both inside and outside of

the pharmacy.

� The costs and benefits of advancing the pharmacy

technician are not defined.

Findings:

� Thirty-three articles were included that evaluated the

use of pharmacy technicians in an advanced role and

identified the training required and subsequent costs

and benefits obtained from using technicians in this

role.

� The mechanism of training was primarily through

supervised on-the-job training, allowing technicians

to assume administrative-based positions that facil-

itated a pharmacist-led clinical service, with either

the pharmacist or the pharmacy receiving the great-

est benefits.

Advancing the role of the pharmacy technician


patients by developing and disseminating a futuristic practicemodel that supports the most effective use of pharmacists asdirect patient care providers.”3 Participants in the PPMI agreedthat “pharmacy technicians could be used more extensively tofree pharmacists from drug distribution activities.”3 To suc-cessfully implement and maintain these new services, atten-tion has been focused on the advancement of technicians andhow they can offset the dispensing responsibilities of phar-macists and assist in the facilitation of these services. As aresult of the PPMI, in 2013 the PTCB set new requirements tobe implemented in 2020 that would require all technicianswishing to obtain certification to complete a training programaccredited by the Pharmacy Technician Accreditation Com-mission before being eligible for the examination.4 Theimplementation of this requirement was suspended in 2017,citing the need for additional research and deliberation.5

Although there is support from national organizations forthe advancement of technicians, the primary focus remainson creating an environment that allows pharmacists topractice at the top of their licenses. The realization that therole of the technician must evolve for this to happen appearsto be an afterthought. The ASHP and APhA statements definethe role of the technician in terms of an “aid to the phar-macist in providing optimal patient care”1 or “assisting thepharmacist with the delivery of patient care.”2 With techni-cians defined as support staff and the advocacy for theiradvancement merely to facilitate the progression of the roleof the pharmacist, the question remains as to who is thebeneficiary from the advancement of technicians. If addi-tional training is needed to prepare technicians for advancedroles, the scope and cost of this training as well as the ben-efits gained from advancing the role of the technicianmust bedefined.

Objective

The objective of this literature searchwas to summarize thefindings of advancing the role of pharmacy technicians,including the types of training identified and the potentialcosts and benefits to both the technician and the pharmacy.

Methods

Search strategy

A literature search was conducted using Scopus, Embase,and Medline, including any date through January 11, 2017. Thesearch included a combination of “pharmacy technician” OR“pharmacy technologist” AND “education” OR “training.” Thesearch was limited to peer-reviewed articles and reviewspublished in English. Search results from each database wereexported to Microsoft Excel, merged, and sorted for removal ofduplicate citations.

Study selection

Original research, research reports, case studies, and asso-ciation reports were included for review. Viewpoints or com-mentary papers were excluded. Articles were considered to berelevant based on identification of an advanced pharmacytechnician role or addressing additional training/education fortechnician functions. Initial screening of all abstracts and titleswas conducted independently by both authors to determinewhether to include or exclude based on selection criteria.During the abstract and title screening phase, an a priori levelof agreement on inclusion/exclusion was set at 80%. Allscreening disagreements were reconciled through discussionbefore moving to full-text review. Full-text articles wereassessed for inclusion, and reasons were documented for allexcluded papers.

Data extraction

A standard data extraction form was used to collect studyauthors, article title, year published, journal title, study design,brief description of methods, primary outcome measures,advanced technician roles identified, additional education ortraining addressed, and additional cost and benefits identifiedin each article regardless of economic perspective used. Studydesign was operationalized as a categoric variable, and eacharticle was determined to be either a quantitative, qualitative,mixed-methods, or case study.

Results

A total of 785 records were identified through databasesearches, resulting in a total of 549 unique articles after du-plicates were removed (Figure 1). Agreement was reachedindependently for 507 out of 549 articles (92%) concerninginclusion/exclusion based on abstract and title screening.Disagreements were discussed until full agreement wasreached, resulting in 27 (55%) of the 42 articles added to full-text review. During abstract screening, 347 (63%) of the arti-cles were excluded owing to lack of relevance to pharmacy

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Figure 1. Summary of literature screening and selection (PRISMA 2009 flow diagram).

A.N. Mattingly, T.J. Mattingly II / Journal of the American Pharmacists Association 58 (2018) 94e108


technicians, being commentary only, or failure to identify anadvanced role or added education/training for technicians.

Of the 202 articles remaining, an additional 169 (84%) wereexcluded during full-text review owing to lack of relevance toadvanced pharmacy technicians or technician education/training (86/167) or being commentary only (83/169). A totalof 33 articles were included for full review and data extraction.Study design varied, with 17 (52%) quantitative, 1 (3%) quali-tative, 5 (15%) mixed-method, and 10 (30%) case study de-signs.6-38 Seventeen (52%) of the studies included werepublished after 2006. Thirty-two (97%) of the articles includedwere published in journals with a primary audience of phar-macy practitioners, with the only nonpharmacy journal beingthe British Journal of Cancer.

Various advanced roles for pharmacy technicians identifiedthrough the review include increased administrative, clinical,dispensing, or leadership responsibilities. Nineteen articles(58%) identified administrative roles, 15 (45%) identified clin-ical roles, 12 (36%) identified dispensing roles, and 3 (9%)identified leadership roles. Sixteen articles (48%) identifiedmore than 1 advanced role, with 4 (25%) identifying admin-istrative, clinical, and dispensing roles, 7 (44%) identifyingadministrative and clinical roles, 2 (13%) identifying adminis-trative and dispensing roles, 2 (13%) identifying administrativeand leadership roles, and 1 (6%) identifying administrative,dispensing, and leadership roles.

Six training mechanisms were identified. Of these, 3 werebaseline qualifications that a technician must have to beconsidered for the role. Nine articles (27%) required certifica-tion, 8 (24%) required a minimum amount of work experience,

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and 10 (30%) required previous training. The remaining 3training mechanisms included informal on-the-job trainingled by the pharmacists or other technicians, formal techniciantraining programs by and apart from the employer, and test-based certification to demonstrate competency after educa-tion. Twenty (61%) required a formal training program, 19(58%) required an informal on-the-job training program, and12 (36%) required test-based certification. The majority of thearticles, 21 (64%), required a combination of trainingmechanisms.

Both direct and indirect costs and benefits were identifiedin 27 articles (82%). Direct and indirect costs included the timefor both the technician and the educator to complete thetraining (2 [7%]), supplies included in the training (4 [15%]),and the cost to cover routine operations in the pharmacyduring the training when appropriate (2 [7%]). Indirect bene-fits to the organization of advancing technician roles and re-sponsibilities were identified as cost savings through potentialelimination of pharmacist positions (4 [15%]), increase in po-tential revenue through expanded clinical services (9 [33%])and improved efficiency (9 [33%]), improved patient adher-ence (3 [11%]), and improved satisfaction from other de-partments (2 [7%]) and patients (7 [26%]) in pharmacy services.Direct and indirect benefits to the pharmacist and technicianwere identified throughout, such as increases in technicianwages (7 [26%]), improved job satisfaction for technicians (6[22%]) and pharmacists (2 [7%]), a stronger career ladder fortechnicians (3 [11%]), and an increase in confidence of thetechnician in their knowledge and ability to perform aparticular skill (4 [15%]; Table 1).

Table 1Qualitative data extracted from all included studies

Author(s) Year Design Objective(s) andoutcome(s)

Advanced roles Additional education Costs/benefits identified

Schafheutle EI, Jee SD,Willis SC

2017 Mixed methods Fitness for purpose oftech education andtraining in U.K.

Pharmacy technician inGreat Britain

2 years' workexperience in eithercommunity or hospital;knowledge-based andcompetency-basedqualifications

Higher salary fortechnicians aftertraining; higher salaryfor technicians inhospital compared withcommunity

Bailey JE, Surbhi S, BellPC, Jones AM, et al.

2016 Case study Describe the design,implementation, andexperience usingtechnicians to improvetransitions of care

Assist in medicationreview and obtainingaccurate admissionmedlist in hospital; reinforcemedication-relatededucation; identifypotential social barriersto discharge; developspecific plans forpatients to obtaindischarge medswithin 24 hours ofdischarge; schedulehome visits and makereminder calls; performmedicationreconciliation andidentify potential DTPs;provide follow-updocumentation topharmacist; contactpharmacist foremergencies; conduct2nd home visit; makesupport sessionreminder calls and helparrange transportation;attend support sessionsand encourage patientparticipation; scheduleCMR visits andreminder calls; assistMedicaid patients inmaximizing drug plancoverage; assistphysicians in obtainingprior authorization;help patients identifyand use least expensivepharmacy

Certified;healthsysteme

specific training: healthsystem personnel;program-specifictraining (didactic andinteractive): faculty andstaff and programpharmacists; patientcommunication andmotivationalinterviewing;medication historytraining; appropriatedrug disposal practices;basic diseasemanagement (signs/symptoms of adversedrug events andworsening condition);safety planning trainingfor home visits; formalonline assessments;follow-up discussionand role playing toassess knowledge,understanding, andskills; on-the-jobtraining: programpharmacists

Allow techs to performat the top of theirlicense; positive trendsin all key processmeasures over time;positive trend in homevisit completion rateafter discharge; highhome visit completionrate; positive trend inphone follow-upcompletion rate;identify potential DTPsat home visits for 84.9%of patients; coordinatedtargeted MTM bypharmacists for 104patients; positive trendin number of targetedMTM contacts;coordinated outpatientCMRs for 33% ofpatients; positive trendin number of outpatientCMRs conducted bypharmacist; positivetrend in number ofparticipants scheduledfor support sessions

Evans JL, Gladd EM,Gonzalez AC, TranamS, et al.

2016 Case study Describe the creation ofa clinical pharmacytechnician

Manage pharmacists'schedule (appointmenttemplate, scheduling,managingcancellations); manageconsultations (reviewreferral, determiningpriority, schedulingappointment); gathermetric data andgenerate reports;communicate clinicalpharmacyannouncements;coordinate clinicalpharmacist peer reviewprocess; contactpatients via phone toprovide educationabout propermedicationadministration, storage

4 months (on-the-jobsupervision, interactivemock patient scenarios,and written exams);certified; orientation toclinical pharmacyservices; creation ofclinical pharmacistschedules; appropriateconsultation reviewand appointmentscheduling; method forprioritizing patientcare; triage or transferof care (pharmacist orprovider issue); basicfamiliarity with diseasestates managed bypharmacist; review ofhigh-risk meds;appropriate patientcommunication skills;

Improved efficiencyand productivity ofpharmacist andincrease in volume ofpatient care providedby pharmacy team;initial 3 months (only 1tech): pharmacist coulddevoteanadditional10e15 hours each monthto clinical services,increase in number ofpharmacist-completedencounters (240e290)per month, completedan average of 90 phoneencounters eachmonthto provide education topatients; with additionof 2nd tech: offset 104.3hours of pharmacisttime, patients were

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Table 1 (continued )



and disposal, and chartreview of Rx dispensinghistory anddocumentation inmedical record;communicate withother health careproviders to coordinatepharmacy care andnotify of completedconsults; assist withdrug informationinquiries; prepareeducational materialsfor patients and healthcare providers; assistwith data collection

EHR documentation;data collection andreporting; competencyassessment

contacted within 48hours of receivingreferral to scheduleappointment, increasefrom 41% of referralsresulting in completedpatient encounter to56%, decrease from 22.6days average tocomplete encounter to10.3 days, completed anaverage of 193 phoneencounters each monthto provide education

Gilbert EM,Gerzenshtein L

2016 Case study Describe the servicesoffered and the rolesof the pharmacist,students, andtechnicians

Developed the role of“patient care advocate”for pharmacytechnicians; help toovercome insuranceand payment barriers;“own” a disease state;monthly refill calls;adherence remindercalls

Certified; on-the-jobtraining for navigatingthe patient's healthrecord; filling out andproviding clinicalinformation on priorauthorization forms;collaborating withspecialty pharmacistson insurance appealsubmissions; finddisease-specific patientcopay assistance;“become familiar withtherapies associatedwith treating thesespecific disease states”

In 18 months, patientcare advocatesobtained >$700,000 inpatient assistance;provide “seamless flowof medicationmanagement services”

Justis L, Crain J,Marchetti ML,Hohmeier KC

2016 Quantitative Effect of pharmacytechnicians on industrystandard adherenceperformance measures(Star ratings)

Role in cognitivepharmaceuticalservices, includingMTM and adherencecoaching; support tasks

Classroom training forthe 3 MTM platformsused; web-basedtraining activities forthese platforms; hands-on in-store training

56% of sites improved indiabetes PDC (originallyonly 7/16 had a 4-starscore); 100% of sitesachieved a 5-star scorefor cholesterol(originally 14/16 were5-star, other 2 were 4-star); 100% of sites hada 5-star score for RASAmeasure (originally 16/16 were 5-star); 56% ofsites improved in score

Shireman TI,Svarstad BL

2016 Quantitative Effectiveness andsustainability of aprotocol usingpharmacists,technicians, and noveltools for adherence andBP control inuncontrolledhypertensive patients

Calling and remindingpatients; printing Rxprofiles; setting uptable and chairs; usingan automatic monitorto measure BPs;administering patientself-report tools

8 hours of training (1 hself-study, 7 h jointworkshop); assist thepharmacists in makingand confirmingappointments; settingup a semiprivate BPcounseling station;measuring BPs;collecting previsit toolscompleted by patients

30 minutes of tech timeper completed visit at$13.01/h; 95.4 minutesper patient of tech timeover 6 months; $104.80per patient forpharmacist, tech, andtools used; $22.2 ± 16.3per 1 mm Hg decreasein SBP; $60 ± 228.4 per1 mm Hg decrease inDBP; $665.2 ± 265.2 tohelp 1 more patientachieve BP control;$463.3 ± 110.7 to help 1more patient achievegood refill adherence;decrease in SBP andDBP compared withcontrol; increase inpercentage of patientsachieving BP control;increase in percentage



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of patients achievinggood refill adherence;decrease in time ofpharmacist-patientencounter comparedwith previous studies

Houle SKD, RosenthalMM, Tsuyuki RT

2014 Case study Description of 2successfulimplementations ofprogressive technicianfacilitation ofpharmacist’s patientcare activities in thecommunity

Admin duties:appointmentscheduling;transcribing care notesinto reports forcommunication toother healthprofessionals; drawingup injections for fluclinics or travelmedicineconsultations;completing amedication history;identifying patients forpharmacistconsultation; collatingdispensing records andlab results beforerounds; checking Rxprepared by othertechs; in-storemarketing of vaccineservices; phone high-risk patients to bookvaccine appointments;coordinate onsiteclinics with retirementhomes; inventory,billing, anddocumentation

Regulated pharmacytechnician; selecteddue to experience,conscientiousness, andwillingness to expandrole; mutual trustbetween pharmacistand tech led toexpansion of roles

Greater professionalsatisfaction; greaterpharmacy efficiencywith reducedduplication of effort;pharmacist could focusmore time on activitiesrequiring clinicalexpertise; greatercapacity for billableservices

Svarstad BL, KotchenJM, Shireman TI,Brown RL, et al.

2013 Quantitative Refill adherence ratesand changes in systolicand diastolic BP andproportion of patientsachieving BP <140/90mm Hg

Calling and remindingpatients; printing Rxprofiles; setting uptable and chairs; usingan automatic monitorto measure BPs;administering patientself-report tools

8 hours of training (1 hself-study, 7 h jointworkshop); assist thepharmacists in makingand confirmingappointments; settingup a semiprivate BPcounseling station;measuring BPs;collecting previsit toolscompleted by patients

Increase in refilladherence rate duringintervention; decreasein SBP and DBP, andincrease in BP controlduring intervention;increase in refilladherence rate afterintervention; lower SBPand greater SBPreduction afterintervention; patientshad higher level ofadherence monitoringand support by theirpharmacists

Reed M, Thomley S,Ludwig B, Rough S

2011 Case study Describe a tech-check-tech program createdand implemented at anacademic medicalcenter

A technician role calleda “Validated PharmacistAssistant” to performchecking functions,commonly “tech-check-tech”

6 months' experienceor PTCB; in-house self-learning packet (mustscore�90% on awrittenexam coveringmaterial); practicaltraining withpharmacist oversight(must complete �24hours of practicaltraining); validation:must attain �99.8%accuracy rate for �2500consecutive doseschecked during �5separate audits over �5

Pharmacist stillperforms a final checkon 10% of doses; 90% ofpharmacists agreedthat they had moretime for patient careactivities and reduceddrug distributionworkload; 82% ofpharmacists agreedthat the programimproved their overalljob satisfaction;reduction in time spentchecking cart fill from 6hours 5 minutes per




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separate days; errorsintroduced at <0.2% (<5out of every 2500doses)

day to 20 minutes perday

Pattin AJ, Powers MF,Lengel AJ

2011 Quantitative Describe a trainingprogram for pharmacytechnicians about theirrole in theMTMprocess

Nonclinical role in MTMprocess; identifyeligible patients;schedule appointments

2-hour live session:Powerpointpresentations; reviewof an MTM manual(instructions on how tolog into differentsoftware systems);schedule patientappointments; performother functions; pre-and post-survey

Increase in number oftechs who thought theycould perform MTMservices aftercompleting the trainingprogram (statisticallysignificant); increase innumber of techs whothought that MTMservices are importantfor customers (notstatistically significant);increase in number oftechs who stronglyagreed that technicianscan help pharmacistsperform MTM services(statisticallysignificant); techsexcused from work andpaid hourly rate toattend training

McKee J, ZimmermanM 2011 Quantitative Development andimplementation oftech-check-tech

Advanced PracticePharmacy Technician tocheck unit dosesprepared by othertechnicians (“tech-check-tech”)

Certified with 1 year'sequivalent experiencein unit dose filling;didactic training (self-learning packet);competencyassessment (100%accuracy rate for eachannual audit; audit:500 line items in thecart fill and 100 lineitems in the automationrefill process)

Pharmacist time saved,allowing for moreclinical services to beimplemented;elimination of a 0.5 FTEpharmacist position;savings of $83,576 ofpharmacist salary;increase incompensation fortechnician (5%);increased jobsatisfaction; peerrecognition; takingownership of expandedroles

Friesner DL, Scott DM 2010 Quantitative Identify aspects oftechnicians'experience, training,practice setting, andlocation that influenceroles

Compounding oralmedications;compounding topicalmedications; preparing3rd-party billing; refillrequests; obtainingmedication history;ordering stock; takingnew prescriptions overthe phone; counselingpatients on OTCmedications

Certified; 1-yeartraining program(technical degree); 2-year training program(associate degree);Pharmacist-AssistedTechnician Self-Instruction Module

Certified techs morelikely to compoundtopical medications;certified techs morelikely to request refillauthorizations

van den Bemt PMLA,van den Broek S, vanNunen AK, HarbersJBM, et al.

2009 Quantitative Frequency ofmedication and allergydiscrepancies beforeand afterimplementation ofmedicationreconciliation

Medication history;medicationreconciliation; allergyhistory; prepare arecommendation onantithrombotic foranesthesiologist;delivery of reconciledmedication list,allergies, and advice onantithrombotic toanesthesiologist

Communication skills;definitions of allergicreactions; generalpharmacotherapy;pharmacotherapy ofanticoagulants

Decrease in patientswith �1 medicationdiscrepancies

Mark SM, Saenz R,Yourich BE, Weber RJ

2008 Qualitative Overview of how therole of a technician canbe incorporated into

Order entry; clinicaldata collection; profilereviews; medicationreconciliation; deliver

Certified; training in �4of the 6 existingpharmacy departmentareas; acceptable

Decrease in turn-around time; increasednursing satisfactionscores with pharmacy



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the pharmaceuticalcare process

meds to nurse;establish relationshipswith nurses; answerphone calls frompatient care providers;resolve missingmedication doses;discharge medicationcounselingpreparation;medication driprounds; emergency/code support; follow-up on chartingomissions; narcoticsurveillance and use ofdispensing cabinets;drug use andcompliance reporting;adverse drug reactionand error surveillance

customer serviceratings on previousevaluations; orderentry; 2 weeks of unit-based training: 1 weekwith technician(customer servicetraining program;observationalcomponent oftechnician interactionwith nurses); 1 weekwith pharmacist

Scott DM, Halvorson D 2007 Quantitative Evaluation of thewages, benefits, andresponsibilities ofpharmacy technicians

Pharmacy technician inNorth Dakota

Certified; 1-yeartraining program(technical degree); 2-year training program(associate degree);Pharmacist-AssistedTechnician Self-Instruction Module(PATSIM)

Grandfatheredtechnicians had thehighest hourly ratefollowed by 1-yeargraduates, 2-yeargraduates, and PATSIMgraduates;grandfatheredtechnicians had thehighest gross salaryfollowed by 1-year,PATSIM, and 2-yeargraduates; higherhourly rate for certifiedtechnicians

Read H, Ladds S, RhodesB, Brown D,Portlock J

2007 Quantitative Assessment of patientunderstanding ofsupport medications:baseline and secondmeasurement

Drug history; druginteractions; whethersupplies of supportmedications wererequired

Accredited medicinesmanagement course(private study; studydays; competence inwork-based activities ina written portfolio;OSCE); directed studyon patient counseling,chemotherapyregimens for breastcancer, supportmedications,identification of sideeffects, druginteractions, writtenexamination,assessment ofcounseling skillsthrough in-practiceobservation

Decrease in patientswith chemotherapydelays; decrease inpatients experiencingchemotherapy dosereductions; decrease insupport medicationsrequired; decrease inpharmacy time todispense; decrease inmean cost of itemssupplied to patients;decrease in techniciantime; cost of trainingprogram; decrease inpharmacy time perpatient resolving Rxissues; patients ratedtheir level ofunderstanding ofsupport medicationshigher

Rose D, Evans SW,Williams R

2005 Case study Describe theimplementation of atechnician dischargetranscribing service

Technician responsiblefor transcribingdischarge prescriptions

3 years' post-qualificationexperience; MTO2grade or above;qualified accreditedchecking technician;qualified medicinesmanagementtechnician; academictutorial (read 2standard operation

Save doctor hours;decrease in turn-around time; fewererrors than whendoctors wrote theorders




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procedures; signindicating theyunderstand process;read and understandthe Trust’s safeprescribing procedure);supervised transcribing(transcribe 100 itemsand assessed: can make1 minor but no majorerrors); auditedregularly

Hilaire ML, Powers MF,Kit MJ

2004 Quantitative Develop a structuredtraining module fortechnicians to enhancetraining for technicalaspects of BG meters

Providing technicalassistance with BGmeters

3-hour live trainingsession (technicalaspects of BG meters;informationcomponent; hands-onexperience); pre-training survey; post-training survey;provided a manual as areference

Techs were paid fortime in training;confident they couldhelp with technicalquestions; improvedknowledge regardingmeters

Zillich AJ, Aquilino ML,Farris KB

2004 Quantitative Knowledge andattitudes of techniciansbefore and afterattending a smokingcessation program

Promotion of smokingcessation interventions

2-hour course (tobacco-related health statistics;nicotine dependence;stages of behavioralchange model;available smokingcessationpharmacotherapies;clinical practiceguidelines); pre-training survey; post-training survey

Improved knowledgeregarding smokingcessation; increasedconfidence to discusssmoking cessation;increased perception ofhow smoking cessationcounseling would affectabstinence

Burnett D, Dooley MJ,Wall D

2003 Case study Develop technicianinvolvement in themanufacture of cell-based therapies for thetreatment of cancer

Qualified cell-processingtechnologists

Aseptic chemotherapypreparationexperience; didacticeducation; formaltraining (production ofantibody-primedautologousmacrophage-activatedkiller cells; didacticsessions (5 days);supervised activities;recognizing specificcells; washing andculturing cells; additionof stimulating drugs toactivate cells);validation:demonstratecompetence incompliance to standardoperating procedures(gowning, washing,gloving, aseptictechnique)

Increased workload forpharmacists andtechnicians while techsattended training;expansion of service toallow hiring ofadditional tech;advanced knowledgeand skills; developmentof a 6-tier paystructure; additionalsalary

Hobson J 2003 Case study Describe theimplementation of ananticoagulant servicetechnician

Anticoagulant servicetechnician: accuratelyinterpret INR results;calculate doseadjustments; counselpatients about theiranticoagulant; answerpatient queries; assistin the recall of patientswho fail to attend;assist in service audits

In-house teachingpacks, 6 hours/pack(hemostasis;pulmonary embolism;pharmacology and druginteractions; cardiacconditions; deepvenous thrombosis;thrombophilia);reading list; list of tasksand activities; 2-hourtutorial after each pack;

Job satisfaction;patients haveadditional time withpharmacy staff; saved~25 hours ofpharmacist time perweek



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formal assessment:role-playing test,shadow staff in clinicsetting, competence(had to dose 50consecutive patients)

Ambrose PJ, Saya FG,Lovett LT, Tan S, et al.

2002 Quantitative Accuracy of trainedtechnicians checkingunit dose medicationcassettes

Trained technicians tocheck unit dosemedication cassettesfilled by othertechnicians (“tech-check-tech”)

6 months' experiencefilling unit dosemedication cassettes;didactic training(lectures on unit doseprocess, properpackaging andrepackagingtechniques, medicationsafety, basicpharmaceuticalcalculations, writtenexam [had to achieve�80%]); practicaltraining (observing apharmacist checkingcassettes; hands-onexperience); auditedfor 3500 doses: had tohave �99.8% accuracyrate, monthly audits of�500 doses

Save pharmacist time;pharmacists reportincrease in jobsatisfaction

Leversha A, Ahlgren KL,Gray MJ

2001 Mixed methods Impact on patient careand pharmacy staff

Identify patientsadmitted in past 24hours; obtain aphotocopy of drugtherapy chart;interview patient aboutmedication supplies;inform patient ofpharmacy dischargeprocedure; take drugtherapy chart andpatient’s medications topharmacy forverification; record onpharmacy computerthat patient'smedication is stored inpharmacy; ensuresupply of medicationsrequired in ward;complete referral formsfor patients withquestions forpharmacist

Training session toidentify issues relatedto their encounter withpatients andinformation to provideto patient abouthospital pharmacy’srole

Address admissionmedication issuespromptly; ensure thattech referrals werefollowed up on day ofrequest; increase innumber of patientsseen by pharmacy staffwithin 24 hours ofadmission; decrease inmedications that areneeded to be suppliedon discharge; costsavings of $1.22 perpatient on dischargemedications;pharmacists able toaddress clinical issuesquicker; dischargemedications processedmore efficiently;increase in technicianjob satisfaction

Koch KE, Weeks A 1998 Case study Justification for andimpact of 2 clinicaltechnicians

Clinical technician:collect lab data, screenpatients, trackoutcomes; clinicaladministrativeassistant: secretarialservices, manageadministrative portionsof clinical pharmacyprojects

Hospital techniciantraining program (6months); basic trainingin pharmacy math,pharmacology, overallexplanation of eachclinical program andtech’s role; readingmaterials; made roundswith pharmacists;competenceassessment

Improved workschedule; expandedresponsibilities; salaryincrease: 9%; savepharmacist time: extra8 hours of clinical timeeach day, 1e2 hours ofdocumentation;improved trackingenhancing themeasurement of thepharmacists' time andimpact

Ness JE, Sullivan SD,Stergachis A

1994 Quantitative Error rates and types oferrors

Trained technicians tocheck unit dosemedication drawersfilled by other

Certification þ 1 yearinpatient experience,completion of a trainingprogram (general skills

Implied costs ofadditional training;benefits of replacing




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technicians (“tech-check-tech”)

exam, introductorysession on study,comprehensive sessionsupported by a trainingmanual, generalintrodution to unit dosedistribution systems,exam coveringmaterial, minimumaccuracy in checking)

verificationpharmacists with techs

Raehl CL, Pitterle ME,Bond CA

1992 Mixed methods Clinical pharmacyservices' relationship tothe use of technicians

Filling unit dose carts;filling orders for floorstock; managingcontrol drug inventorywere listed as higherfunction roles

6 states required somein-service training; 5states required highschool graduation; 4states required 3months of on-the-jobtraining; 3 statesrequired techs to meetinstitutionalrequirements

Increased use ofpharmacy technicianswas associated withincreased involvementby pharmacists inpatient-specific clinicalpharmacy services;association betweenhigher technician useand higher techniciansalaries

Spooner SH, BrittonME,Erskine LM,Verschoor BA, et al.

1991 Mixed methods Evaluation of supportand process forexpanding tech roles

Expanded dispensing;checking unit-dosecarts; front counterscheduling; totalparenteral nutritionorder entry; expandeddecentralized roles:filling prescriptions,compounding,dispensing andinventorying narcotics,front counterscheduling,manufacturing ofcentral venousnutrition, peripheralvenous nutrition, large-volume sterilesolutions, analgesicsyringes; schedulingmanufacture of large-volume sterilesolutions; packagingand dispensing dyes forradiology;management roles

Technicians traintechnicians; entry-leveltraining tied to corecompetencies; certaintechnician jobs wouldrequire a higher level ofcompetency withtraining; job rotation

Reassigning technicaltasks (savings of$237.60/day if switchtasks from pharmaciststo technicians; savingsof 23.76 h/day if switchtasks from pharmaciststo technicians); cost oftechnician turnover of$1500/technician(savings of $1166.67 oftraining costs/mo);addition of 712.8 h/moof pharmacist time;improved jobsatisfaction; cost ofimplementing wouldbe 4.16 additionaltechnician FTEs; cost totrain, supervise, andcoordinate techfunctions

Phillips CS, Ryan MR,Roberts KB

1988 Quantitative Current roles, futureroles, preference oftraining and techrecognition

Supportive activitiesmore frequentlydelegated thandispensing

Self-studycorrespondenceprogram; communitycollege based; formalin-house training;college of pharmacyebased program; formaltraining at anotherpharmacy; informalon-the-job training

Implied delegation ofadditional activities totechnicians to savepharmacist time; preferformal in-housetraining programs 1stfollowed by programsat colleges of pharmacy

Fillmore AD, SchneiderPJ, Bourret JA,Caswell RJ

1986 Quantitative Cost to train Drug administration 9-week trainingprogram: 4 phases

$12,277 for phase 1training; $16,903 forphase 2 training;$20,382 for phase 3training; $33,900 forphase 4 training; $1783cost for personalacquisition; $5683 costper trainee

Mahoney CD, GallinaJN, Jeffrey LP

1982 Case study Descriptive Liaison betweenpharmacy supervisorand supportivepersonnel; determining

600 hours' on-the-jobtraining; classroominstruction in allaspects of pharmacy

Creation of a careerladder; recognition ofperformance; increasedsalary; increased



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priorities forestablished productionprocedures; trainingand continuingeducation programs fortrainees andtechnicians

clinical services;advanced trainingprogram for specializedand more sophisticatedassignments;continuing educationprograms

stability in position;increased jobsatisfaction

Hoffmann RP 1982 Quantitative Tech utilization,training, roles, jobrequirements, salaries

Different “levels oftechnicians”

Different jobqualificationrequirements; differentlevels of on-the-jobtraining; typing abilityand high schoolgraduation mostcommon qualification;high preference forproper phoneetiquette; passage of amath quiz; knowledgeof medication terms;background in math;hospital pharmacyexperience

Highest salary for chieftechnician, lowest fordata entry

Jeffrey LP, Mahoney CD 1975 Quantitative Descriptive Supervision of othersupportive personnel;coordinate workassignments for othertechnicians; training ofstaff

Formal on-the-jobtraining program (15 �40-hour weeks)

Career ladder;increased salary;recognition

Miller DE, Kendall RW,Hynniman CE, et al.

1972 Mixed methods Interest in expandedrole and job satisfaction

Maintenance and repairof patient careequipment;maintaining operatingroom's supply;“purchase, preparation,and distribution ofimplants”

Mostly 1-on-1 trainingpersonalized based onindividual support staffand scope of the newrole to support thepharmacy operation;authors recommendthe individualizedtraining over formaltraining

Indirect benefits ofcareer advancement orupward mobility

Abbreviations used: BG, blood glucose; BP, blood pressure; CMR, comprehensive medical review; DBP, diastolic blood pressure; DTP, drug therapy problem; FTE,full-time equivalence; MTM, medication therapy management; MTO2, medical technical officer grade 2; OSCE, observed structured clinical examination; OTC,over-the-counter; PDC, patient-delivered care; PTCB, Pharmacy Technician Certification Board; RASA, renin angiotensin system antagonists; SBP, systolic bloodpressure.



Discussion

Roles

The role of the pharmacy technicianwas typically limited toone that does not require professional judgment, and this issupported by the ASHP statement identifying that advancedtechnicians are able to assist in the delivery of clinical services.The roles identified in the literature are consistent with tech-nicians performing administrative positions, such asmanagingpatient appointments7,8,11-13,15,26 and pharmacy consulta-tions,8,29 administering patient self-report tools,11,13 andbilling and documentation of vaccine administration.12 Thereis also support for using technicians to collect a comprehensivemedication history7,12,17,18,21,28 and to collect clinical dataneeded to appropriately dose and monitor medica-tions,8,12,19,29 but this information is reported to the pharma-cist who then evaluates and makes a clinical recommendationto the health care team. Although this may be seen asadvancement from the traditional dispensing roles, if the aim

of pharmacy service is to provide patient care and optimizemedication delivery, organizations should consider whetherthey are underutilizing technicians who are capable of per-forming more patient care activities.

Three articles identified roles in positions that require pro-fessional judgment. Read et al. discussed the use of a pharmacytechnicianeled outpatient breast cancer clinic,21 and Hobsonused technicians to dose warfarin in an outpatient anti-coagulation clinic26; both studieswereperformed in theUnitedKingdom and reported favorable patient outcomes. The thirdstudy, conducted in a preoperative screening clinic in theNetherlands, used technicians to perform medication recon-ciliation and to prepare a recommendation for the anesthesi-ologist regarding discontinuance of any antithrombotic beforesurgery.18 These studies support using technicians in clinicalpositions beyonddata collection andmayhelp to conceptualizeadditional advancement opportunities in the United States.

The literature also identified roles in which techniciansused their experience to perform positions outside of thepharmacy. For example, Burnett et al. identified the use of

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pharmacy technicians with experience in chemotherapypreparation as cell-processing technologists in the manufac-ture of cell-based therapies for the treatment of cancer,25 andFillmore et al. evaluated their use as drug-administrationtechnicians.34 Technicians can also serve a role in assistingpatients with insurance and cost barriers.7,9 Navigating thehealth care system can be an overwhelming and confusingtask for patients. Technicians engaging in the navigation ofthese complexities can assist patients in obtaining medica-tions that they otherwise would not have been able to receive.Gilbert and Gerzenshtein found that by integrating pharmacytechnicians in an outpatient infectious disease clinic, theywere able to assist patients in obtaining more than $700,000from patient assistance programs.9

One area that appeared to be lacking in the literature wasthe use of pharmacy technicians in managerial or supervisoryroles. The ASHP position statement supports the use of tech-nicians in this capacity, but only 3 articles reviewed identifiedusing technicians in a management role,32,35,37 all of whichwere published before 2000. Those articles primarily usedtechnicians to supervise other support staff35,37 and to trainnew technicians32,27; none of the articles reviewed usedtechnicians in formalized managerial or decision-making po-sitions. The 2016 Law Review released by the National Asso-ciation of Boards of Pharmacy identified that only 8 statesrequire that at least 1 pharmacy technician serve as a memberof the board of pharmacy,39 limiting the impact they can haveon the evolution of their role or the practice of pharmacy.

Training

Several articles identified that adequately trained phar-macy technicians can be used in a more extensive capacity, butwhat constitutes adequate training is still undecided. Incontrast to the training requirements outlined by ASHP1 andAPhA,2 common prerequisites for consideration for a positionincluded certification7-9,14,16,17,19,20,30 and a minimum amountof previous work experience.12,14,16,17,20,22,27,30 Five of thearticles12,21,22,26,30 required technicians to have completed aformal educational program; however, 3 of thosearticles21,22,26 were based in the United Kingdom, and1 article12 involved technicians in Alberta and BritishColumbia, Canada. Only 1 article30 published in the UnitedStates required technicians to have completed a board ofpharmacyeapproved training program to be considered forthe advanced role. None of the articles required technicians tocomplete an accredited technician training program.

In 1988, Phillips et al. surveyed pharmacists-in-charge inboth community and institutional pharmacies in Tennesseeand found that formal on-the-job training programs were thepreferred method of training.33 Although the content of eachprogram differed according to the varying knowledgeand skills required to perform the specialized roles, the resultsof that research were consistent with the results of severalother studies, in which technicians were trained via anin-house didactic component,7,10,11,13-16,18,21-27,29,30,34,35,37

supervised on-the-job training,6-10,14,18,19,21,22,25-27,29,33-37 anda competency-based examination.6-8,14,16,21,22,25-27,29,30

Although on-the-job training may be adequate in somecases, it is difficult to replicate and reproduce to ensure thatknowledge and skills are transferable outside of the

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organization. Training provided by employers may focus onthe needs of the organization and are potentially less likely toconsider career enhancement as a primary outcome for thetechnician. In addition, practitioners providing the trainingmay lack skills as educators, limiting the effectiveness ofknowledge transfer.

Cost/benefit

Several costs to either the pharmacy department or theindividual technician must be weighed against the potentialbenefits of advancing the role of the technician. One such costis the training program.21,30,32,34 Depending on the complexityof the new role, the training required and the subsequent costwill vary. Fillmore et al. identified in 1986 that the cost to thepharmacy department to train 1 pharmacy technician toperform a drug administration role would be $5683,34 andRead et al. in 2007 reported a training cost of £1955 to preparea technician to lead an outpatient clinic for breast cancer pa-tients.21 Few articles evaluated the full costs of advancedtechnician training or whether the technician should beresponsible for a proportion of the costs.

Scott and Halverson in 2007 evaluated the salaries ofpharmacy technicians in North Dakota and compared the levelof training with the reported salary. They found that grand-fathered technicians with no formal training reported thehighest salaries at $13.11/hour compared with technicianswho completed either a 1-year certificate program or a 2-yearAssociate in Applied Science degree. Marginal increases ($0.10to $0.30/hour) were associated with each level of training ifthe technician became certified. These results imply that workexperience and tenure with an employer have the greatestimpact on salary, not the level of formalized trainingcompleted.20

The APhA statement encourages the development ofcompensation models that promote sustainable career oppor-tunities.2 However, the trend appeared to focus on benefitsresulting froman increase inpharmacist time8,12,14,16,19,26-30,32,33

resulting in an expansion of services,25,29 greater pharmacyefficiency,7,8,11,12,19,21,22,28,29 and improved patient out-comes.7,11,13,18,22,28 An increase in salary was identified in only7 of the articles reviewed,6,16,25,29,35-37 and only 2 articlesmonetized the increase, 1 with a 5%16 and the other a 9%29

increase. Nonmonetary benefits were identified, such as anincrease in job satisfaction,12,16,26,28,32,35 a more desirable workschedule,29 and increasing the knowledge base of techni-cians.15,23,29 These incentivesmayoffer additionalmotivation forcurrent technicians to learn and grow but may not be a strongincentive to recruit the best employees into the field or tosupport a longer career planwith a stable financial trajectory.

Consideration for technician advancement could follow thepath of other allied health technologists and technicians. Forexample, dietetic technicians must either complete anaccredited program or obtain a bachelor degree and pass anational credentialing examination.40 Technicians are thenable to obtain additional certifications to allow them toadvance their career. Another example is dental hygienists.According to the American Dental Association, dental hy-gienists are required to obtain an associate degree from anaccredited program, pass a licensing examination, and receivea license from their individual state board. Hygienists then



have the opportunity to further their education by obtainingbachelor and master degrees,41 and in 2005 the AmericanDental Hygienists' Association recommended the creation of adoctorate in dental hygiene to further advance the profes-sion.42 These and other allied health professions provide apotential outline for a path forward to advance the role of thepharmacy technician.

Limitations

One limitation of the present study is the differing titlesthat have been or are currently used for pharmacy technicians.The titles “pharmacy technician” and “pharmacy technolo-gist,” which are commonly used today, were included assearch terms; however, older titles such as “pharmacy assis-tant” or “pharmacy supportive personnel” were not includedin the search. In addition, the search was limited to publishedliterature, excluding potential results found in “gray”literature.

The abundance of papers reporting on-the-job training asthe primary mode of knowledge transfer to teach advancedroles creates a potential for information bias. Supervised on-the-job training may have significant variation in its imple-mentation, limiting the ability to compare across sites orreproduce in different settings. Some on-the-job training maybe inadequate to prepare technicians for an advanced role, butwith limited information published by authors about thespecifics of the training, we were forced to categorize in 1group with the potential for significant heterogeneity ofexposure. Because we were not attempting a meta-analysiswith this review, we thought that inclusion would providevalue of a descriptive nature. Additional information bias mayderive from categorizing costs and benefits where multiplestakeholders exist. For example, costs or benefits may beexperienced by both the pharmacy and the individual tech-nician. This limited our ability to perform any economicanalysis of the findings.

Another limitation of this study is the differing state re-quirements for an entry-level position. The aim of this studywas not to determine the requirements of each state tobecome a technician; however, this could affect the level oftraining or education of a technician involved in the studies,which may have affected his or her ability or the comfortlevel of the pharmacist with allowing the technician to takeon a certain role. In addition, the differing state laws andregulations may limit the roles that a pharmacy technician islegally allowed to perform. Obtaining board approval tostudy a technician's performance in a certain position mayhave hindered the evaluation of certain roles. In addition tointerstate differences, there are also intercountry differencesthat may affect the advancement opportunities oftechnicians.

Conclusion

Although the literature supports that technicians arecapable of performing advanced roles in the pharmacy,resulting in either improved patient outcomes or opportu-nities for pharmacists to engage in additional clinical services,

the benefits to the technician were primarily indirect, such asan increase in job satisfaction or a more desirable workschedule. If a technician is to take on additional roles thatrequire completion of a formalized training or educationalprogram, benefits that are more tangible may help to inspiremore technicians to pursue these roles.

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Ashlee N. Mattingly, PharmD, BCPS, Pharmacist and PharmTechX Coordinator,School of Pharmacy, University of Maryland, Baltimore, MD

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