Pilot Evaluation of Pharmacists’ and Pharmacy Technicians’ Knowledge and Understanding of a Medication Synchronization Program

Abstract

Background: Medication synchronization (MS) improves adherence by allowing patients to pick up all medications at the same time. Pharmacy staff need training to utilize a MS program effectively. Objective: Evaluate the impact of a video tutorial with decreased extraneous and intrinsic load on pharmacists’ and pharmacy technicians’ knowledge and understanding of a MS program. Study Method: Participants completed a prequestionnaire to assess knowledge and understanding of the MS process. They then watched a step-by-step video tutorial and were reassessed by a postquestionnaire 2 weeks later. Study participants included pharmacists and pharmacy technicians employed at 1 of 2 pharmacies in 1 regional division of a large community-based chain pharmacy. Participants were eligible if they were registered and in good standing with the Kansas Board of Pharmacy and employed for greater than 30 days since July 1, 2018. Results: Twenty participants were included in the final analysis. The median age was 36 years, 14 (70%) were female, 13 (65%) were pharmacy technicians, and each study site had equal representation. Most participants, 15 (75%), had previously completed the standard MS training. There was a significant improvement in number of correct responses after the intervention with a prequestionnaire score of 61.3% to postquestionnaire score of 70% (P=.002). Significant improvement in knowledge was seen in participants who completed the previous training as well as first-time learners of the MS process. Conclusion: Optimizing training on MS processes by decreasing extraneous and intrinsic load improved the pharmacy team’s knowledge and understanding of the MS process.

Keywords

community pharmacy service inservice training pharmacists pharmacy technicians instructional film and video

Background

Prescription medication nonadherence is an issue that negatively affects health outcomes and increases health care costs.^1,2 Medication nonadherence accounts for approximately $100 to $300 billion in avoidable hospitalizations in the United States yearly.^3-5 Common barriers to medication adherence may include forgetting to take medications, obtain refills, financial restraints, impaired cognition, decision to omit 1 or more doses or modify treatment, and lack of inclusion in treatment decisions.^4,6 There have been many devices implemented to improve medication adherence such as pill-boxes, alarms, and phone application reminders. However, not all low-cost devices are suitable for every individual as adherence concerns is a multifaceted problem.⁷

Another method aimed at improving medication adherence is medication synchronization (MS), a program which has been implemented in pharmacies across the nation and has gained popularity in the past several years.⁸ Medication synchronization is a program that aligns a patient’s prescription medications, so they can all be picked up at 1 time (e.g., once per month) by working with prescribers, insurance organizations, and the patient. The synchronization process can be performed by a remote off-site centralized call center or locally by the pharmacy team. Patients enrolled in the MS program receive phone calls to verify their prescription refills instead of calling the pharmacy to refill their own medications as part of the standard workflow process. For locations utilizing the MS remote center model, the call center would handle contacting the patient for prescription refills, insurance processing, and identify the sync date.

Studies have shown that patients benefit from MS by decreased visits to the pharmacy, increased medication adherence, and increased customer satisfaction.^9-14 A systematic review performed by Nguyen and colleagues included 5 observational studies that demonstrated improved adherence in patients enrolled in MS vs control.¹⁵ Pharmacies also benefit from MS through an increased efficiency and a decreased number of phone calls leading to a streamlined pharmacy workflow.¹⁶

There have been several studies that depict the various designs for implementing MS.^3,9,16 One retrospective cohort analysis compared the effects of 3 different MS designs on medication adherence and medication use outcomes, including 2 types of call centers and 1 model where MS was done by pharmacy staff. The authors found that all 3 MS designs increased the number of fills after enrollment.⁹ Another study developed a systematic and iterative process to review publicly available medication synchronization-related documents. Their objective was to develop a common language for the MS process allowing for consistency in implementation and operation of these programs among community-based pharmacies.¹⁷ A challenge with common language for the MS process is in part due to proprietary concerns. While there are many studies that focus on the implementation and design of MS programs, a search for studies that address the most effective method for training pharmacy team members to use MS programs produced no literature.

There are many ways to design workplace training for health care professionals and it is essential to take into consideration the health care setting. Cognitive load theory (CLT) suggests that learning can occur when the working memory needed to learn is reduced and extraneous distractors are minimized.¹⁸ Health care workplaces are one of the most complex environments, which may create cognitive overload for health care professionals learning new tasks and processes while performing their job responsibilities and caring for patients.¹⁹ CLT includes 3 main components: extraneous load, intrinsic load, and germane load. Extraneous load relates to cognitive processes that are not essential to the learning process such as environmental distractions or requiring the learner to search for information due to poor instructional design. Intrinsic load is in reference to the complexity of what is being learned. Germane load, in turn, refers to the process of building long-term memory.

Working memory is the rate-limiting step for learning new processes and has a limited capacity to process new information. CLT suggests that in learning environments there is an extraneous load, which includes external distractors such as phone calls or questions from patients that occur while an individual is attempting to complete the learning task, and an intrinsic load, the cognitive demands of the learning task itself.¹⁸ While extraneous and intrinsic loads should be minimized, germane load, or the development of schema for the long-term memory, should be increased to promote knowledge retention.²⁰ The purpose of this study was to fill a gap in the literature by creating a new educational intervention to increase pharmacists’ and pharmacy technicians’ knowledge and understanding of an MS program.

Study Method

This was a pre/postquestionnaire quantitative and qualitative study completed at 2 community-based pharmacies within 1 regional division of a large community-based chain pharmacy. Participants were eligible to partake in the study if they were a pharmacist or pharmacy technician employed at 1 of the 2 study sites, registered and in good standing with the Kansas State Board of Pharmacy, and employed by the community-based pharmacy for greater than 30 days since July 1, 2018. Pharmacy A and B contained 10 study participants each. The pharmacy managers of pharmacy A and B assisted with recruitment and consent with their respective pharmacy. Participants had the option to withdraw from the survey process and no risks were identified.

The pharmacy staff needed to be able to enroll patients and answer questions on the MS program, even if they were not initiating all the synchronization steps. In addition, the pharmacy staff would need to troubleshoot issues as they came up such as early refills and partial fills. With enrollment fluctuations, there was a perceived lack of understanding among the pharmacy team with the remote off-site centralized call center model of the MS program the regional division had implemented. The original MS training provided to the pharmacist included a 30-page standard operating procedure packet without visual aids. To improve pharmacy team knowledge, the pharmacy organization revised and implemented a new training process. A new step-by-step video tutorial on the MS process was provided immediately following completion of the prequestionnaire. The new video was a 12-minute step-by-step tutorial created by the primary investigator and addressed important concepts such as eligible and targeted patients, benefits of the program, frequently asked questions, and troubleshooting for insurance issues. The 12-minute length of the video is an appropriate amount of time for pharmacy staff to be absent from the pharmacy without disrupting workflow. Most importantly, it provided a streamlined step-by-step visual navigation through the entire MS portal with graphics and animations identifying important navigation windows, resources, links, and how to manage a patient synchronization order. The participants completed the same questionnaire 2 weeks later. This timeframe allowed for the participants to apply the information learned within the workflow and assess for retention from the new step-by-step video. The study period was from November 13, 2018 to December 18, 2018. The primary outcome was change in participant knowledge of the MS program. Secondary outcomes evaluated change in pharmacists’ and pharmacy technicians’ perceived understanding, comfort, and satisfaction with the MS program.

All data were collected anonymously using Google Forms (Google; Mountain View, CA). Study participants created a unique identifier code to match their baseline and postintervention responses. Once a participant was deemed eligible to participate, the primary investigator administered the baseline questionnaire individually to each participant at a specific workstation within each pharmacy’s office over a period of 1 week. The questionnaire collected demographic data including gender, age, primary store location, hours worked per week, role at the pharmacy, and years worked in current role. The questionnaire also asked if the participant had completed the required standard MS training (the training that took place prior to the new video) as there was no formal documentation to verify if a pharmacy team member had read it. There were 11 multiple choice questions that assessed the participant’s knowledge of the MS program. The questions focused on essential concepts of the MS program and identified if the participant knew how to access the MS portal and complete daily tasks. There were ten 5-point Likert scale questions that assessed participants’ perceived understanding, comfort, and satisfaction with the MS program. Two open-ended items were included for participants to report issues/concerns and opportunities for improvement of the MS program.

The participants then watched the new step-by-step video tutorial created by the primary author through an online link provided at the end of their baseline questionnaire. Each participant was given dedicated time in a distraction-free environment, the pharmacy’s office, to complete the questionnaire and watch the video tutorial. The primary investigator was able to monitor and record that each participant completed the questionnaire and intervention. The participants were re-evaluated 2 weeks later with the same questionnaire.

For the primary outcome, a McNemar test was used to compare the baseline and postintervention questionnaire responses. A Wilcoxon signed-rank test was utilized to compare the baseline and postintervention comfort and satisfaction responses. Medians were utilized due to the small sample size and participant demographics were assessed through descriptive statistics. Analyses were performed using SPSS version 25 (IBM; Armonk, NY) and an a-priori alpha level of .05 was used to determine statistical significance. Qualitative comments were analyzed for emerging themes. This study was deemed exempt from the University of Kansas Medical Center Investigational Review Board.

Results

There were a total of 20 participants in the study. Participants were a median age of 36 years, 14 (70%) participants were female, 13 (65%) participants were pharmacy technicians, and each study site had equal representation (Table 1). Most participants, 15 (75%), had completed the required standard MS training prior to participating in this study. All study participants completed the pre and postquestionnaires and watched the step-by-step video tutorial. The primary outcome revealed a statistically significant increase in the number of correct responses between the baseline (61.3%) and postintervention (70%) questionnaires (median 7 vs 8 questions correct, respectively, P=.002) (Table 2). Even among the staff who completed the prior training, there was a noted statistical difference upon completion of the new training (median 6 versus 8 questions correct, respectively, P=.007). The data also showed that the intervention improved pharmacists’ and pharmacy technicians’ understanding, comfort, and satisfaction with the program. Eight out of the ten questions that assessed change in understanding, comfort, and satisfaction demonstrated statistical significance (Table 3).

Table 1.

Baseline Demographics (n = 20).

Demographic	n (%)
Gender
Female	14 (70)^a
Male	4 (20)^a
Prefer not to answer	2 (10)^a
Age, years	36 (27.50-49.75)^b
Primary pharmacy
Pharmacy A	10 (50)^a
Pharmacy B	10 (50)^a
Hours worker per week	40 (34.25-40.00)^b
Role
Pharmacist	7 (35)^a
Pharmacy technician	13 (65)^a
Years worked in current role	5.00 (2.25-10.75)^b
Completed initial MS training
Yes	15 (75)^a
No	5 (25)^a

^an (%).

^bMedian (Interquartile Range).

Table 2.

Participants’ Change in Knowledge of the MS Program (n = 20)^a.

Question	Prequestionnaire correct answer n (%)	Postquestionnaire correct answer n (%)	P-value^b
1. Which is a requirement for enrollment in the MS program?	17 (85)	19 (95)	.500
2. The call center is staffed by whom?	12 (60)	18 (90)	.031
3. Which homepage tab houses the MS communication request, enrollment forms, and store portal?	12 (60)	14 (70)	.625
4. Which education link should be chosen to submit a MS referral for a patient?	12 (60)	14 (70)	.625
5. Which education link should be chosen to access pharmacist connect?	10 (50)	12 (60)	.625
6. What does pharmacist connect give access to?	20 (100)	20 (100)	1.000^c
7. How often should a pharmacist or pharmacy technician review sync orders?	12 (60)	12 (60)	1.000
8. When should patients pick up their synced medications (select all that apply)?	7 (35)	10 (50)	.250
9. What time should patients pick up their medications on the sync date to ensure all medications are ready?	16 (80)	18 (90)	.625
10. When are enrollment visits performed (CMR, patient signature, documentation)?	16 (80)	15 (75)	1.000
11. An enrollment visit must be completed and documented in the patient record within how many days?	1 (5)	8 (40)	.016
Overall questionnaire score, median (IQR)	7 (5-8.75)	8 (5.25-9)	.002^d

^aMcNemar test.

^bBinomial distribution used.

^cStatistical analyses could not be performed.

^dWilcoxon Signed-Ranked Test.

Table 3.

Participants’ Change in Understanding, Satisfaction, and Comfort (n = 20)^a.

Question	Prequestionnaire^b,c	Postquestionnaire^b,c	P-value
1. I understand the benefits of the MS program	4.00 (3.25–4.00)	4.00 (4.00–5.00)	.070
2. I am satisfied with the level of MS program training I have received thus far	2.00 (1.00–3.00)	3.00 (2.25–4.00)	.001
3. I know where to access MS resources if necessary	3.00 (1.00–3.00)	4.00 (3.00–4.00)	<.001
4. I understand where to locate MS call center information such as telephone number and days and hours of operation	3.00 (1.25–3.75)	4.00 (4.00–5.00)	<.001
5. I do not understand the call center model for the MS program	3.00 (2.00–4.00)	2.00 (1.25–3.00)	.045
6. I understand how to prepare MS enrollment forms	2.00 (1.00–4.00)	3.00 (2.25–4.75)	.003
7. I do not understand how to access patient sync orders by sync date	2.50 (1.25–4.75)	3.00 (1.00–3.00)	.231
8. I feel comfortable troubleshooting any issues with patient sync orders	2.00 (1.25–3.00)	3.00 (2.25–4.00)	.002
9. Overall, I can manage the entire MS process from start to finish	2.00 (1.00–3.00)	3.00 (2.00–4.00)	<.001
10. I Am satisfied with the MS program process	1.00 (1.00–2.00)	2.50 (2.00–3.00)	<.001

^aWilcoxon Signed-Ranked Test.

^bLikert Scale Response (5 = Strongly Agree, 4 = Somewhat Agree, 3 = Neutral, 2 = Somewhat Disagree, 1 = Strongly Disagree).

^cMedian (Interquartile Range).

Participants were able to provide additional comments through open-ended questions within the pre and postquestionnaires (Table 4). When questioned regarding the issues with the current MS process, the most common themes from the prequestionnaire included patient frustration (7/20, 35%) and that the current MS process is not effective (e.g., process takes too long, medications are forgotten, patients get a stockpile of medications, process is still being developed) (7/20, 35%). Additional themes included issues with the call center model, lack of adequate staff training, and communication issues. When participants were asked how the MS process could be improved, common themes included better communication (7/20, 35%), better staff training (5/20, 25%), and better education of patients (3/20, 15%). On the postquestionnaire, participants were asked what they felt was valuable about the new MS tutorial. The most common responses included improved knowledge (8/20, 40%), the high quality of the training video (5/20, 25%), and the step-by-step training video increased knowledge of navigating the MS portal (5/20, 25%). Finally, participants were asked what else they would have liked for the tutorial to address. One of the most common themes was that participants were satisfied with the training and no additional information was needed in the tutorial (5/20, 25%). However, participants would have liked more information on the call center (5/20, 25%), how to troubleshoot when problems arise (2/20, 10%), and 1 participant identified that it would be helpful to have a hands-on component to the tutorial.

Table 4.

Conventional Content Analysis.

Themes	Frequency of occurrence N (%)
Prequestionnaire: What issues/concerns do you have with the MS program process?
Current process could be optimized (e.g., process takes too long, meds are forgotten, get a stockpile of meds, process still being developed/improved)	12 (60)
Patient frustration	7 (35)
Issues with call center	4 (20)
Lack of training	3 (15)
Communication issues	3 (15)
Prequestionnaire: How do you believe the MS program process can be improved?
Better communication	7 (35)
Better staff training	5 (25)
Better education of patients	3 (15)
Postquestionnaire: What did you find valuable about the MS training video?
Improved knowledge/understanding	8 (40)
Good quality (e.g., thorough, presented well)	5 (25)
Navigating the site/portal (e.g., identifying the location of resources/forms)	5 (25)
Postquestionnaire: What else would you have liked for the MS training video to address?
Nothing	5 (25)
More information on call center	5 (25)

Discussion

To the authors’ knowledge, this is the first study to examine how the design of an educational intervention impacted pharmacy team knowledge and understanding of an MS program. While 75% of participants had completed the initial training of the 30-page written manual, there was a statistically significant increase in program knowledge after completing the intervention which provided step-by-step instruction in a video tutorial in a quiet environment.

Extraneous load is important when designing new workplace training for health care professionals. Training manuals are 1 form of standardized training that are commonly used in the workplace.¹⁸ Manuals, such as the original 30-page written training without visual references, require learners to search for information to help solve problems, and may be used when a question or issue arises rather than to learn the process. This means the manual is used within the work environment, thereby increasing extraneous load. The increased extraneous cognitive load can decrease the effectiveness of learning which was seen in the original training model. Conversely, the redesigned training provided dedicated work time to complete the tutorial and it was completed in a quiet room, which reduced the extraneous cognitive load by decreasing distractions.

Intrinsic load is another essential factor to consider. Methods to decrease intrinsic load and increase effectiveness of training include reducing the complexity of the training material and increasing participant buy-in, specifically the original 30-page training manual versus the 12-minute step-by-step video tutorial. The intrinsic load of a step-by-step tutorial is lower than a manual by facilitating novice and expert learners and reducing the complexity of learning.¹⁸ According to Debue and van de Leemput, intrinsic load is defined by the number of components that the learner must process.²⁰ The step-by-step nature of the video tutorial reduced intrinsic load by presenting information to the learner in a way that decreased the number of new pieces of information introduced to the learner during the training. The emerging themes analysis of the postquestionnaire demonstrated the reduced complexity of the new training with comments from both novice and expert learners stating the tutorial was “straight forward and to the point.”

It is also important to recognize the significance of getting participant buy-in as it is crucial to reduce intrinsic load. When participants are intrinsically motivated by the environment they are in, they have a greater ability to devote cognitive resources to learning.²⁰ Therefore, it could be theorized, when intrinsic cognitive load is too high, participants of a training program are less engaged and potentially avoid the training. The initial MS training was mandatory; however, there was no dedicated work time or method to determine if the pharmacy team member had read the MS training manual, which may have increased intrinsic load and decreased participant buy-in. In contrast, providing dedicated time to complete the new tutorial decreased intrinsic load and participant buy-in theoretically was improved, thus leading to improved learning. Our results demonstrated that redesigning the MS training process can improve participants overall knowledge and understanding of the MS program. Qualitative themes extrapolated from this study further support the idea that a lower intrinsic load with the updated MS program training led to more effective training of staff members, as supported by the improved knowledge scores. The ease of a step-by-step tutorial that encompasses the most important concepts vs navigating through a lengthy training manual may have improved the participants’ willingness to learn the MS program.

Germane load is the only cognitive load which improves learning when increased. Debue and van de Leemput found a lower germane load occurred when participants reviewed a multimedia news article with animation compared to text with pictures or text alone.²⁰ They hypothesized the animation distracted from the news content resulting in lower retention. Manuals which are often text heavy with static images do not promote the germane load, limiting retention. Our study, however, incorporated the animation with the learning content, which improved knowledge, possibly due to greater attention being given to the animation, as was seen by Debue and van de Leemput. In our study, the animation-enhanced learning, possibly through increased germane load because it complemented the content, while in the Debue and van de Leemput study, the animation drew attention away from the content. Optimizing training and providing concise, clear instructions for all program entities theoretically will lead to program success through better understanding.²⁰ This is directly evidenced by the trend seen in the results in allowing the participants to watch the video tutorial uninterrupted in a separate environment from the rest of the pharmacy.

Future research should continue to assess varying methods of training to optimize program outcomes and how to target various learning styles with step-by-step tutorials or manuals in a conducive manner that encourages learning and retainment. Due to proprietary development, the step-by-step 12-minute video would not be applicable to other organizations, however, the basis of presenting the information in a condensed easy to follow step-by-step video tutorial in place of a written manual would.

Limitations

Data were collected at 2 pharmacy locations with a small sample size of twenty participants, which limits generalizability. The community-based pharmacies differ in their volume of prescriptions, number of pharmacists and pharmacy technicians working daily, and patient populations. Introducing more study sites and participants could potentially provide more robust data. Pharmacies could then be grouped and analyzed depending on their prescription fill volume to further explain why written manuals may not work best in a busy pharmacy. The study questionnaire is not a validated survey. Due to the pre/postquestionnaire design, study participants may have identified what concepts were important prior to watching the video tutorial therefore introducing recall bias.

Conclusion

This study demonstrates that training is a key component of satisfaction in understanding the program and revealed minimizing extraneous and intrinsic load and optimizing germane load improved the pharmacy team’s knowledge of, understanding, comfort, and satisfaction with the MS process by utilizing different teaching styles. This emphasizes the importance of optimized training on medication synchronization processes in any pharmacy setting.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Amy D. Robertson

Bradley J. Newell

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