Vnieto Project Ambulatory Care Online Topic Discussion

Running Head: AMBULATORY CARE ONLINE TOPIC DISCUSSIONS
Pharmacy Students Retention of Knowledge Following Web-based Topic Discussions as Part of

an Advanced Pharmacy Practice Experience in Ambulatory Care:
An Outline of Web-based Topic Discussions
Veronica M. Nieto
Texas A&M University Health Science Center College of Medicine
AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Abstract
Knowledge retention problems often result in clinical application and practice issues among
fourth year pharmacy students. The objective of this project is to outline the content of a webbased learning module series and lay the foundation for module development for use in an
ambulatory care Advanced Pharmacy Practice Experience (APPE). This web-based topic
discussion series will focus on five core disease states commonly managed by clinical
pharmacists in the outpatient setting (i.e. anticoagulation, asthma/chronic obstructive pulmonary
disease [COPD], diabetes, hypertension, hyperlipidemia). The modules will accompany an
APPE rotation in ambulatory care pharmacy in an attempt to enhance pharmacy student
knowledge, retention of information, and to aid in providing efficient patient care.
Keywords: ambulatory care, advance pharmacy practice experience (APPE), online modules,
web-based learning

Advanced pharmacy practice experiences (APPEs) are designed to provide opportunities
for practical application of material learned during the didactic phase of the pharmacy
curriculum. Students often attend these advanced practice experiences having forgotten some of
the basics of pharmacology and therapeutics which makes it difficulty to participate effectively
in direct patient care. Despite students successful completion of progress examinations
throughout the didactic curriculum, documentation of clinical knowledge retention has proven to
be challenging in pharmacy education (Szilagyi, 2008). Students often perform well on
classroom examinations; yet forget information shortly thereafter. This calls to question how
educators can best enhance student learning and knowledge retention as they progress into the
pharmacy profession.
Formative assessments are widely used in the pharmacy curriculum to evaluate students
knowledge during professional years 1 3 prior to beginning advance practice experiences. A
review of the pharmacy education literature reveals that progress examinations take many forms
during the initial years of pharmacy school (Kelley, Beatty, Legg, & McAuley, 2008; Meszaros
et al., 2009; Plaza, 2007; Szilagyi, 2008). Limited information, however, is available on the use
of learning techniques and assessment strategies employed during fourth year pharmacy
rotations.
The objective of this project is to outline the content of a web-based learning module
series and lay the foundation for module development for use during an ambulatory care APPE
rotation. Modules to be developed will focus on core disease states commonly managed by
clinical pharmacists in the outpatient setting and include anticoagulation, asthma/chronic
obstructive pulmonary disease (COPD), diabetes, hypertension, and hyperlipidemia. This webbased learning module series is an attempt to enhance pharmacy students knowledge retention of

commonly encountered disease states through the use of a multimedia-centered, active learning
environment. The modules will be designed to encourage experiential learning as students set
priorities, establish drug therapies, and assist in managing disease states. The goal of this series
is to promote the transfer of knowledge of pharmacology and therapeutics from the classroom to
the provision of patient care.
Standard teaching approaches in experiential education are complicated by geography
and diversity among clinical sites and preceptors (Harris et al., 2016). The American College of
Clinical Pharmacy (ACCP) calls for knowledge assessments to be objective and based on
predefined content areas during experiential education. The organization also encourages
standardized assessments to ensure students are assessed in a similar fashion, regardless of the
experiential site (Haase, Smythe, Orlando, Resman-Targoff, & Smith, 2008). These modules will
assist in defining core knowledge areas for ambulatory care APPEs and provide an effective and
efficient mechanism for sites to deliver standard content and provide objective assessments of
student knowledge in the core areas.
The Accreditation Council for Pharmacy Education (ACPE) Standards 2016 outlines
educational outcomes deemed essential to the contemporary practice of pharmacy. Standard 24
specifically calls for the institution of higher education to develop and implement a plan to assess
attainment of educational outcomes to ensure that graduates are prepared to enter practice
(Accreditation Council for Pharmacy Education, 2015). This project will provide a novel way to
address the standards and provide documentation of achievement of key artifacts to the
accrediting agency, the institution, and other stakeholders.

In order to be effective, instruction must be based upon proven methods and techniques
(Usova & Casteen, 1986). Perception of personal value in a learning task and clear illustration of
the relationship between the lesson and performance captivates students attention. Learning
must be performed, and students should be directed to participate in such activities. Many
students today, belonging to the millennial generation, are more acclimated to learning in
technology-enhanced environments (Benedict, Schonder, & McGee, 2013) and prefer a variety
of active learning methods, less lecture, use of multimedia, and collaborating with peers (Bart,
2011). By placing these modules online, students will have the ability to access the content
throughout the educational experience and apply their knowledge to patient care during the
rotation.
Given the primary objective of this project is to outline the content of a web-based
learning module series, much of the determination of its success will take place well after the
series creation and initiation into the ambulatory care APPE curriculum. Demonstration of
knowledge improvement and expansion will be seen through an increase in students scores on
post-rotation exams, benchmark exams, and possibly, domain specific areas on the national
licensure exams. Students satisfaction of the learning experience will be assessed through an
online survey, following the rotation experience, addressing the students perception of the webbased modules, their functionality, and the overall educational experience. As this modular
creation is the first step in addressing the problem (knowledge retention of pharmacology and
therapeutics and its effect on the provision of patient care), information obtained following
incorporation of these modules into the curriculum will add to the current body of pharmacy
education literature. Results may likely spark further interest in this type of hybrid, web-based
experiential learning environment to be utilized not only in other areas of pharmacy education,

but potentially medicine, nursing, and other health professions as well.
Literature Review
Three studies in pharmacy education have evaluated the use of web-based learning
modules prior to or during APPEs on learning facilitation (Flowers, Vanderbrush, K, & West,
2010; Isaacs, Walton, & Nisly, 2015; Morris & Knoderer, 2011). Flowers et al. (2010) evaluated
the effectiveness of web-based vignettes on student learning outcomes of complex drug
administration. Students were randomly assigned to a study group, those with access to view the
vignettes, or to a control group. A 12-item questionnaire was administered to all students at
orientation and on the last day of the rotation to evaluate their knowledge of counseling patients
on the use of inhalers and ear and eye drops. Students in the intervention group scored higher on
their post-intervention assessment while the control group did not show improvement in
counseling knowledge (p < 0.001). Morris and Knoderer (2011) sought to assess the
effectiveness of web-based training (WBT) modules on students ability to learn and provide
pharmaceutical care to children during a pediatric APPE. Four WBT modules, along with preand post-assessments, were developed to reinforce and/or supplement material presented in the
didactic curriculum. Significant improvements in post module assessments scores occurred in
three of the four modules. More recently Isaacs and colleagues (2015) implemented a web-based
learning module series to evaluate baseline knowledge of commonly encountered disease states
while on general medicine APPEs. The authors note significant improvement in post assessment
scores overall and for each module.
Additionally, medical education literature demonstrates the utilization and incorporation
of web-based instruction to clinical experiences as a means to supplement and enhance students
confidence in their knowledge and skills (Kumar, Hata, Bayman, & Krishnan, 2013; Rebel et al.,

2011). Kumar et al. (2013) showed improvement in knowledge and understanding of the basic
elements of critical care through implementation of a learner-centered, hybrid, web-based critical
care curriculum provided along side a medical rotation in the surgical intensive care unit (SICU).
The authors demonstrated a 19% improvement on the post-rotation exam scores over the course
of seven semesters (p< 0.0001 and 95% CI: 16.8 21.5). Rebel and colleagues (2011)
demonstrated improvement in transfusion medicine-related knowledge following the
development and implementation of a new, online curriculum in transfusion medicine for
anesthesiology residents. A significant increase of 25 14% of correctly answered questions
was observed (pre-test 50 13%, post-test 74 8%, p < 0.05) on the written examination scores
for students participating in the rotation (n = 9).
Despite the limited number of studies present in medical and pharmaceutical academic
literature, several authors have reported the benefits of incorporating web-based instruction,
either prior to or during, the educational experience (Flowers et al., 2010; Isaacs et al., 2015;
Morris & Knoderer, 2011; Reuhter, Lindsey, Graham, & Garavalia, 2012; Salter, Karia,
Sanfilippo, & Clifford, 2014; Seybert & Kane-Gill, 2011). Isaacs et al. (2015) and Morris and
Knoderer (2011) argue that the use of web-based instruction to review previously taught
curricular content not only optimizes APPE education time, but also allows for incorporation of
these topics into advance topic discussions leading to a higher level of comprehension and
potentially enhancing patient care. Others propose that adjunctive online learning allows for
standardization of educational content that can easily be updated as new guidelines, standards of
practice, and therapies become available. Online modules also allow for real time feedback for
both teachers and learners and the objective assessment of knowledge and performance (Salter et
al., 2014; Seybert & Kane-Gill, 2011). Reuhter and colleagues (2012) believe that because

students are able to receive immediate feedback after completing modular built in assessments
that students are able to reflect on their learning and determine if further review of the material is
necessary. This near immediate feedback may also help preceptors determine if supplementary
reading, instruction, or additional practice is warranted to help students succeed.
Although not evident in the literature, one could argue that the time required to develop
these online modules, from inception, to production, to publication, and later assessment, may
deter many from embarking on such a task. Additionally, the manpower needed to develop,
publish, and maintain these modules may be viewed as obstacles by some. This may be why,
despite the reported benefits, this type of instruction is not more commonly utilized.
Pinchevsky-Font and Dunbar (2015) report several challenges in online teaching. These
challenges include multi-generational cohorts, varying degrees of comfort with technology, fast
paced technological advances, varying learning styles, and conflicting life demands.
In moving forward, it is important to reflect on best practices reported in the literature to
ensure project success. Given todays millennial generation, with higher expectations for
incorporation of computer-aided technologies in education, best practice likely involves teaching
mechanisms which address and accommodate multiple dimensions of learning styles (Romanelli,
Bird, & Ryan, 2009). Effective online instruction requires an understanding of the learners
needs, technological knowledge required to be successful in a different learning environment,
and effective communication in the absence of face-to-face qualities of traditional instruction.
Instructors responsibilities include organizing instructional tools and materials clearly, making
the content relevant, and clearly stating expectations and objectives (Pinchevsky-Font & Dunbar,
2015).
While evidence in pharmacy and medical education demonstrates knowledge retention is

achieved during clinical rotations supplemented by web-based training (Flowers et al., 2010;
Isaacs et al., 2015; Kumar et al., 2013; Morris & Knoderer, 2011; Rebel et al., 2011), the
evaluation of the use of web-based training to improve learning and knowledge retention in the
ambulatory care arena of pharmacy is not well documented (Harris et al., 2016). This project
will help to answer the following question: Does the incorporation of web-based training
modules affect fourth year pharmacy students knowledge retention of primary care disease
states and facilitate their ability to provide pharmaceutical care during a 6-week APPE in
ambulatory care medicine?
Educational Theory
Historically education centered on the transfer of information from the content expert to
the student. Teachers directed the learning process as students responded to environmental
stimuli and reinforcement. Behaviorists, such as Thorndike, Pavlov, and Skinner, claimed that
observable behavior indicated whether or not the learner had in fact learned something while
internal processing of information was of little to no interest (Ally, 2008; Cooper, 1993; Fosnot
& Perry, 1996). If students could objectively pass an exam, competency could be claimed and
the teacher could move to the next subject. However, despite claimed competency, noticeable
gaps in pharmacy students knowledge leads to issues once students are called upon to apply
their knowledge to clinical practice (Flowers et al., 2010; Isaacs et al., 2015; Morris & Knoderer,
2011).
Later development of the cognitive and constructivism theories shifted the
responsibilities of learning from the instructor to the student. The cognitive theory focuses on
the internal processes of the mind: memory, motivation, and reflection. While prior knowledge
influences knowledge construction, understanding is gained through experiences. Constructivist

theorists also claim that students learn by observation, processing, and interpretation, and then
personalize the information into knowledge. Students learn best when they can contextualize
what they have learned for immediate use (Cooper, 1993; Matsuoka, 2004). These two existing
theories encourage deeper processing through active learning and allow students to develop selfawareness of their knowledge through self-reflection.
The Adult Learning Theory, as proposed by Malcolm Knowles in 1968, suggests adult
learners seek practical information. Adult learners are more concerned with what information or
skill they need to know or perform in order to be successful in meeting the task at hand
(Merriam, 2001; Pappas, 2013). Merriam (2001) summarizes five assumptions underlying adult
learning and provides a description of the adult learner as someone who possesses the following:
1) an independent self-concept, able to direct their own learning, 2) collection of life experiences
that serve as a learning resource, 3) learning needs related to changing social roles, 4) interest in
immediate application of knowledge, and 5) internal motivation.
While the importance of reflection in higher education is widely recognized and selfreflection is commonly embedded into assessment requirements, students often do not receive
the necessary scaffolding or clear expectations to articulate well developed reflections and learn
from prior experiences (Colbert et al., 2015; Ryan & Ryan, 2013). Metacognition, which allows
individuals to self-assess and regulate cognitive processes related to learning and performance,
has received little attention in the pharmacy education literature. By developing metacognitive
skills, students can monitor their own knowledge, make a plan to fill in gaps, and evaluate new
learning. Students should be able to monitor what they know and what they do not know in
order to improve performance (Garrett, Alma, Gardner, & Born, 2007; Schneider, Castleberry,
Vuk, & Stowe, 2014). For many students, the focus of the initial three years of pharmacy school
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has been to survive and advance. Pass this exam and move on to studying for the next exam.
This only perpetuates the problem of students inability to recall key concepts of disease state
management at the clinical level.
By producing web-based topic discussions, students can access the learning material at
anytime; location and distance are not an issue. Students can access these resources in their own
time and can contextualize learning in real time. This is of benefit to the adult learner who learns
best when the information is relevant and immediately applicable (Merriam, 2001; Pappas,
2013). From an instructors point of view, materials can be updated quickly, and learners
instantly able to see the change (Ally, 2008). This is important as disease state guidelines and
standards of practice change overtime and new studies in medicine are published frequently.
Lastly, online learning environments facilitate real-time feedback, self-reflection, and allow
instructors to direct students to appropriate information based on their individual needs (Ally,
2008).
Contrarily, Hirumi (2002) argues that students may become dissatisfied if they perceive
online interaction as meaningless busywork, and instructors have expressed concern that it takes
more time and effort to manage the communication that occurs during an online course. Hirumi
further argues that often times the expertise necessary to generate desired online modules might
not be available on staff and would require funds to outsource their development. One could
argue that it takes longer to develop and implement online learning modules than to prepare for a
didactic instructional session.
While the modules are designed for individualized assessment, reflection, scaffolding,
and metacognition, as pharmacy students become more confident in their application of the
materials, this will enhance student interactions with other members of an interprofessional team
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and encourage collaboration. Progression through these modules and application of knowledge
through pharmacist interventions will also help to further define the roles and responsibilities of
the pharmacist. Lastly, while not the initial intent of the project, portions of these online
modules could be disseminated and accessed by nursing and medical students as a resource
available for their respective primary care rotations. Dissemination and use to students in other
health care professions could further enhance the learning experience given preview of the same
baseline information.
Educational Framework
Hirumi (2002) proposed a framework of interaction in online learning that will guide the
development and implementation the web-based topic discussions. The framework consists of
three levels: 1) learner-self interactions, 2) learner-human and learner-non-human interactions,
and 3) learner-instruction interactions (Hirumi, 2002).
At the lowest level of interaction, the students take time to access and sense the available
information. Once students access the online materials, there must be learner- content interaction
to process the information. Learners navigate through the content to access the components of
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the lesson, which could take the form of pre-learning, learning, and post-learning activities. It is
during the learner-content interaction that learners process the information to transform it from
short-term to long-term memory. The higher the level of processing, the more associations are
made in long-term memory, which results in higher-levels of learning.
As learners work through the content, they will find the need for learner support, which
could take the form of learner-to-learner, learner-to-instructor, instructor-to-learner, and learnerto-expert interactions (Ally, 2008). There should be strategies to promote learner-context
interaction to allow learners to apply what they learn in real life so that they can contextualize
the information. Learner-context interaction allows learners to develop personal knowledge and
construct personal meaning from the information, an interaction essential to the self-directed,
adult learner (Merriam, 2001).
As part of The Standards (Accreditation Council for Pharmacy Education, 2015)
previously mentioned, ACPE has established key elements that all accredited Doctor of
Pharmacy programs must meet in order to be in compliance with the aforementioned standards
and receive accreditation. As examples:
Key Element 4.1: Self-awareness the graduate is able to examine and reflect on personal
knowledge, skills, abilities, beliefs, biases, motivation, and emotions that could enhance or
limit personal and professional growth.

Key Element 10.12: teaching and learning methods the curriculum is delivered via
teaching/learning methods that actively engage learners, promote student responsibility for
self-directed learning.
To provide evidence of achievement of the standards and key elements, colleges and schools
must provide outcomes data and documentation. Development and implementation of these
online learning modules for use during an ambulatory care APPE, would allow the college to
13

demonstrate compliance with the standards through the provision of outcome data from
assessments summarizing students overall achievement of relevant APPE learning objectives
and self-awareness. Additionally these modules will allow for documentation of a process by
which students are guided to develop a commitment to self-directed lifelong learning. Lastly,
this project will serve as documentation of an instructional method used to actively engage
learners, integrate and reinforce content across the curriculum, stimulate higher-order thinking,
problem solving, and clinical-reasoning skills.
Procedures and Methods
In order to promote the vertical transfer of pharmacology and therapeutics from the
classroom to the provision of patient care, the ambulatory care web-based learning module series
will guide pharmacy students through a review of commonly encountered disease states in the
ambulatory care setting. The modules will focus on the areas of anticoagulation, asthma/COPD,
diabetes, hypertension, and hyperlipidemia. Pharmacists participation in primary care clinics has
been shown to be cost-effective and to improve health outcomes in these core disease states
(American Society of Health-System Pharmacists, 1999; Carter et al., 2008; Cone, Brown, &
Stambaug, 2008; Devine et al., 2009; Kislan, Bernstein, Fearrington, & Ives, 2016; Pett & Nye,
2016; Zhong, Ni, Cui, & Liu, 2014). This is why these disease states have been selected for this
web-based module series.
Pharmacists interventions in these core disease states have resulted in decreased blood
pressure, hemoglobin A1c, cholesterol, and risk factors for coronary heart disease. Medication
education and disease management by pharmacists not only improves surrogate endpoints, but
also reduces adverse events related to comorbidities associated with common chronic diseases
(American Society of Health-System Pharmacists, 1999; Chisholm-Burns et al., 2010; Isetts et
14

al., 2008; Kislan et al., 2016; Tan, Stewart, Elliott, & George, 2014). Given the progression of
clinical pharmacy practice, it is imperative for pharmacy students to be up to date with current
literature, research, and standards of practice in order to provide optimal medication therapy to
their patients. These modules may provide a solution to this issue of knowledge gaps that affect
clinical application and practice when students begin their clinical rotations.
Ambulatory care-specific, web-based modules will be developed for completion by
APPE students during a required six-week pharmacy rotation. Five web-based modules, along
with pre- and post-assessments and a student satisfaction survey, will be developed by
ambulatory care faculty members from Texas A&M Rangel College of Pharmacy (RCOP). These
modules will reinforce and/or supplement adult, ambulatory care -focused material initially
introduced during the didactic pharmacy curriculum.
The web-based modules will focus on disease state and drug knowledge relevant to five
core diseases commonly seen in ambulatory care: anticoagulation, asthma/ COPD, diabetes,
hypertension, and hyperlipidemia. Each module will have module specific objectives, pre- and
post assessments, and sections related to disease state pathophysiology, guidelines, medications,
and exercises for students to work through clinical application of the learned material. The intent
is for each disease state module to take students approximately two hours to complete. Modules
will be broken up in to smaller sections, and of shorter duration, to allow students easy access to
the specific areas of the disease state management.
Students will be required to complete pre-and post-assessments for each module. The preand post-assessments will contain the same 10-12 multiple-choice questions in a randomized
sequence, and assessments will be scored on a scale of 0-100%. Students will receive a score
upon completion of each pre-assessment, however no feedback on the correct answers to the
15

questions will be provided until the initial post-assessment attempt. Should a student score
100% on the pre-assessment, the respective online module will be available and encouraged for
review, but not required. Students will have up to three opportunities to successfully complete
the post-assessment with a passing score of 80% or greater. The order of completion and the
time between assessment completion and review of the module material are intentionally not
prescribed. This will allow for introspective reflection on behalf of the adult learner to focus on
the area(s) of most need.
Upon completion of the web-based modules and the ambulatory care learning experience,
students should be able to demonstrate content knowledge mastery in the areas of basic disease
pathophysiology, diagnostic studies, monitoring parameters, non-pharmacologic and
pharmacologic treatment, and clinical application of pharmacotherapy. When the online modules
are completed, all students assigned to Texas A&M - RCOP ambulatory care faculty members
APPEs will be assigned the web-based modules during the respective rotation.
At the completion of the rotation, students will be encouraged to complete an online
satisfaction survey of the learning experience. Students will answer questions pertaining to their
perception of the web-based modules, their functionality, utility and accessibility of the
information for use during the experiential rotation. Web-based modules and assessments will be
administered via the universitys web-based learning management system (i.e., Blackboard
Learning System, Blackboard, Washington, DC). The post-rotation survey will be administered
through Qualtrics (Qualtrics, LLC, Provo, UT), and the survey link will be distributed to the
students during the final week of the rotation.
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The planning process, initial exercises, and activities leading to the final project are
outlined in the table below. Significant contributors are also included. Task 3 will serve as the
deliverable for this current project.
Projected Major Tasks, Exercises and Activities
Task 1: Define the Plan
1.1 Determine rationale, goals and objectives for the project
1.2 Review and refine the project plan with faculty mentor, office of
experiential education, and ambulatory care faculty
1.3 Discuss and negotiate project budget with Office of Experiential
Education (OEE) and Office of Instructional Design and Support
Services
1.4 Develop an outline of the proposed timeline for completion of
the project
Task 2: Conduct Review of Research-Based Theory & Practice
2.1 Conduct a systematic review of learning techniques and
assessment strategies employed during fourth year pharmacy
rotations
2.2 Review and select an educational theory to guide the project
2.3 Review existing instruments used for online learning in
pharmacy education
2.4 Summarize findings regarding the primary focus of the project
2.5 Present summary of findings to involved stakeholders
*Task 3: Develop ambulatory care web-based learning modules
3.1 Determine core disease states for areas of clinical focus
3.2 Establish learning objectives for each disease state module
3.3 Select content material utilizing current pharmacy resources,
disease state review articles, organizational guidelines, and
standards of care
3.4 Develop patient cases to be integrated into each module for
knowledge application practice
3.5 Develop pre- and post-assessment questions for each module
Task 4: Develop sample coursework and field trials
4.1 Create five web-based learning modules
4.2 Pilot web-based learning modules to students nearing
completion of the PharmD program to review and assess the
learning tool
4.3 Create and pilot an evaluation tool to collect qualitative data
about the web based modules
4.4. Analyze pilot data and determine necessary changes
4.5 Share results with involved parties
4.6 Revise instruments and surveys as needed based on
measurements and feedback (complete the PDSA cycle)
Significant
Contributors
VN, CW, GF, ED,
ambulatory care
faculty
VN, CW, RB, CD, GF,

ambulatory care
faculty
VN
VN, GF, ED,

ambulatory care
faculty, fourth year
pharmacy students
17
Projected Major Tasks, Exercises and Activities

Task 5: Integration of web-based modules in the curriculum
5.1 Implement online web-based disease state modules into
ambulatory care APPEs for one complete academic year
5.2 Collect and analyze data for all participating preceptors and
students
5.3. Write a report summarizing descriptive statistics, pre- and postassessment results, and student perceptions of the new learning
technique
5.4 Disseminate results to professional audiences (e.g peerreviewed journals, professional conferences)
5.5 Conduct meeting with ambulatory care faculty and other
stakeholders to determine whether outcomes are successful and plan
for continuation including modifications
Significant
Contributors
VN, GF, and APPE
ambulatory care
faculty
VN = Veronica Nieto, Pharm.D.1; CW = Courtney West, Ph.D.2; RB = Regina Bentley, RN, EdD, CNE3; CD =
Charles Douglas, PhD.4, GF= Gary Frech, MBA, MS, RPh5; ED = Elaine Demps, Ph.D6; Ambulatory Care Faculty7
1.
2.
3.
4.
5.
6.
7.
DepartmentofVeteransAffairs,SamRayburnMedicalCenter,Bonham,TX
DepartmentofInternalMedicine,TexasA&MUniversityCollegeofMedicine,Bryan,TX
DepartmentofAcademicAffairs,TexasA&MUniversityCollegeofMedicine,Bryan,TX
DepartmentofPharmaceuticalSciences,TexasA&MRangelCollegeofPharmacy,Kingsville,TX
OfficeofExperientialEducation,TexasA&MRangelCollegeofPharmacy,Kingsville,TX
OfficeofInstructionalDesignandSupportServices,TexasA&MRangelCollegeofPharmacy,Kingsville,TX
DepartmentofPharmacyPractice,TexasA&MRangelCollegeofPharmacy;AmbulatoryCareFacultyare
presentlylocatedinCollegeStation,CorpusChristi,Houston,RoundRock,andTemple,Texas
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Project Deliverable
Outline of Web-based Topic Discussions for an Advanced Pharmacy Practice Experience (APPE) in
Adult Ambulatory Care Medicine
The objective of this project is to outline the content of a web-based learning module series for
use during an ambulatory care APPE rotation. The goal of this series is to promote the vertical transfer of
pharmacology and therapeutics from the classroom to patient care during the students final year of
pharmacy school. This web-based learning module series is an attempt to enhance pharmacy students
knowledge retention of commonly encountered disease states in the ambulatory care setting through the
use of a multimedia-centered, active learning environment. These modules will assist in providing an
effective and efficient mechanism for sites to deliver standard content, and provide objective assessments
of student knowledge in the core areas of anticoagulation, asthma/COPD, diabetes, hypertension, and
hyperlipidemia.
To be effective, instruction must be based upon proven methods and techniques (Usova &
Casteen, 1986). Many students today are more acclimated to learning in technology-enhanced
environments (Benedict et al., 2013). They prefer a variety of active learning methods, less lecture, use
of multimedia, and collaborating with peers (Bart, 2011).
Few studies in pharmacy education have evaluated the use of web-based learning modules prior
to or during APPEs on learning facilitation (Flowers et al., 2010; Isaacs et al., 2015; Morris & Knoderer,
2011). Each one demonstrates that the groups receiving the intervention, preview of online modules, score
higher on the post-intervention assessments than students in the control groups. Medical education
literature also demonstrates the benefit of web-based instruction in addition to clinical experiences as a
means to supplement and enhance students confidence in their knowledge and skills (Kumar et al., 2013;
Rebel et al., 2011).
Isaacs et al. (2015) and Morris and Knoderer (2011) argue that the use of web-based instruction to
review previously taught curricular content not only optimizes APPE education time, but also allows for
incorporation of these topics into advanced topic discussions leading to a higher level of comprehension
19

and potentially enhancing patient care. Online modules allow for real time feed back for both teachers and
learners and provide an objective assessment of knowledge and performance (Salter et al., 2014; Seybert
& Kane-Gill, 2011). Given immediate feedback, students are able to reflect on their learning and
determine if further review of the material is necessary (Reuhter et al., 2012).
Module Series Objectives:
Demonstrate knowledge and comprehension of pharmacotherapy of core primary care disease

states
Areas of focus include: pathophysiology, diagnosis and diagnostic studies, clinical

laboratory monitoring, and non-pharmacologic and pharmacologic treatment modalities
Apply therapeutic management strategies, national clinical guidelines and clinical trial data to
make clinical decisions in simple and complex patients
Develop treatment plans for core primary care disease states given case-based scenarios
Content of Module Outlines

The following module outlines include: learning objectives, content outlines, suggested exercises
and guideline references for the five core disease states commonly encountered in the delivery of patient
care in the ambulatory care setting.
Module 1: Anticoagulation
Objectives:
1) Identify risk factors and signs and symptoms of deep vein thrombosis (DVT) and
pulmonary embolism (PE)
2) Calculate the CHA2DS2-VASc score to determine the risk of a thromboembolic event in
a non-anticoagulated patient with non-valvular atrial fibrillation
3) Review the clotting cascade and identify targets of anticoagulation therapies along the
intrinsic and extrinsic pathways
4) Identify risk factors for bleeding complications and strategies for minimizing the risk of
bleeding with oral anticoagulant agents
a. HEMORR2HAGES, ATRIA, HAS-BLED scoring systems
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5) Select and interpret laboratory tests to monitor anticoagulation agents commonly used in
the outpatient setting
6) Manage a patient with an elevated international normalized ration (INR) with or without
bleeding
7) Identify warfarin drug-drug and drug-food interactions
8) Formulate an appropriate treatment plan for a patient receiving oral anticoagulation
therapy in the outpatient setting
a. Goals of therapy, medications, monitoring, and follow-up
9) Develop a therapeutic plan for perioperative management of anticoagulation therapy for a
patient undergoing a medical procedure requiring interruption of therapy
Content outline:
Section 1: Anticoagulation module pre-assessment

Section 2: Pathophysiology review
2.1 Platelet activation
2.2 Clotting cascade
Section 3: Review of pertinent Chest Guidelines
3.1 Executive summary (Guyatt, Akl, Crowther, Gutterman, & Schuunemann, 2012)
3.2 Oral anticoagulant therapy (Ageno et al., 2012)
3.3 New antithrombotic drugs (Weitz, Eikelboom, & Samama, 2012)
3.4 Perioperative management of antithrombotic therapy (Douketis et al., 2012)
3.5 Antithrombotic therapy for venous thromboembolism (Kearon et al., 2012)
3.6 Antithrombotic therapy for atrial fibrillation (Guyatt et al., 2012; You et al., 2012)
Section 4: Medications (mechanism of action, starting doses, maximum doses, side effects,
monitoring parameters, counseling points, and place in therapy)
4.1 Oral anticoagulants
4.1.1 Vitamin K antagonist
4.1.2 Direct thrombin inhibitor
4.1.3 Factor Xa inhibitors
4.2 Injectable anticoagulants
4.2.1 Low Molecular Weight Heparin
Section 5: Clinical application unlocking clinical simulations*
Section 6: Anticoagulation module post-assessment
Section 7: Helpful links and additional resources
* Suggested exercises (self-assessments and clinical simulations):
Match location of drug therapy to steps in the clotting cascade

Match the appropriate monitoring parameters to medications used for anticoagulation in
the outpatient setting
21
Calculate the bleeding risk using the HAS-BLED scoring system for a patient with atrial
fibrillation on warfarin
Calculate a CHA2DS2-VASc score to determine if a patient with atrial fibrillation
requires anticoagulation therapy

Select appropriate monitoring parameters for patients on warfarin
Select appropriate monitoring parameters for patients on enoxaparin
Upon review of a patient case:

Adjust weekly warfarin dosage based upon supra- or sub-therapeutic INR and
patient specific factors

Identify warfarin food/drug interactions and the effects on INR
Develop an appropriate treatment plan for a patient receiving warfarin and
enoxaparin prior to and after planned colonoscopy
Module 2: Asthma/Chronic Obstructive Pulmonary Disease (COPD)

Objectives:
1) Compare and contrast pathogenesis, clinical presentation, diagnosis, and staging of

asthma and COPD
2) Define spirometric measurements used in diagnosis and assessment of asthma/COPD
3) Review current guidelines for asthma and COPD
4) Identify drug classes of inhaled and systemic medications utilized in the management of
asthma/COPD in the outpatient setting
5) Review counseling points for inhalation devices commonly used in asthma/COPD
6)
7)
8)
9)
management
a. Metered dose inhalers (MDI) with or without a valved-holding chamber (VHC)
b. Dry-power inhalers (DPI)
c. Soft mist inhalers
d. Nebulized solutions
List a stepwise approach for managing asthma in an adult patient
Counsel a patient on the appropriate management of exercise induced asthma
Review recommended vaccination requirements for adult patients with asthma/COPD
Design a therapeutic plan for the management of a patient with COPD in the ambulatory
care setting
22

Content outline:
Section 1: Asthma/COPD module pre-assessment

2.1 Airway inflammation, airway obstruction, and airway hyper-responsiveness
Section 3: Review staging of asthma/COPD and recommend drug classes for each stage
3.1 Staging of asthma (intermittent vs. persistent (mild, moderate, severe)
3.2 Staging classifications of COPD (grades A-D)
Section 4: Review of current Guidelines
4.1 National Heart, Lung, and Blood Institute (NHLBI) (National Heart Lung and Blood
Institute, 2007)
4.2 Global Initiative for Chronic Obstructive Lung Disease (GOLD) (Global Initiative for
Chronic Obstructive Lung Disease, 2016)
5.1 Quick-relief medications:
5.1.1 Short-acting beta-agonists (SABAs)
5.1.2 Short-acting anticholinergics
5.2 Long-term control medications
5.2.1 Inhaled corticosteroids (ICS)
5.2.2 Long-acting beta-agonists (LABAs)
5.2.3 Long-acting anticholinergics
5.3 Alternative medications
5.3.1 Leukotriene modifiers
5.3.2 Cromolyn
5.3.3 Theophylline
5.3.4 Immunomodulators
5.3.5 Phosphodiesterase 4-inhibitor (PDE-4i)
5.3.6 Oral corticosteroids
Section 7: Asthma/COPD module post-assessment
Match distinguishing characteristics (clinical presentation, spirometry results, and stages)
to the respective disease state (asthma/COPD)

Classify asthma severity based on impairment due to asthma and future risk for negative
outcomes
23
Match spirometric measurements with the appropriate definition

Categorize asthma/COPD medications into their respective drug classes
Appropriately stage an asthmatic patient and provide recommendation for initial
therapy
Develop an asthma action plan providing spirometric parameters and medication
instructions for a patient to follow in times of worsening asthmatic symptoms

Identify the appropriate COPD grade based on a patients symptoms, frequency of
exacerbations, and FEV1 and make recommendation for pharmacotherapy

Develop a monitoring plan to assess effectiveness and adverse effects of
pharmacotherapy for COPD

Identify potential errors in inhalation technique depending on the type of inhaler
prescribed
Provide recommendation for vaccinations for an adult patient with asthma
Provide recommendation for initiation of corticosteroids and/or antibiotics for a
patient with a COPD exacerbation
Module 3: Diabetes
Objectives:
1)
2)
3)
4)
5)
Outline the pathogenesis of Type 2 Diabetes and targets for drug therapy
Compare and contrast current diabetes treatment guidelines
List screening and diagnostic criteria for diabetes
Differentiate between signs and symptoms of hypo- and hyper-glycemia
Identify appropriate screening criteria (including timelines) for microvascular and
macrovascular diabetic complications

6) Review therapeutic goals for blood glucose, blood pressure, and lipids for a patient with
diabetes
7) Provide education on glucometer use and insulin administration technique
8) Review nonpharmacologic recommendations (carbohydrate counting, physical activity,
immunizations)
9) Outline the steps to perform a diabetic foot exam
10) Compare and contrast oral and injectable agents used in treating diabetes
11) Outline the appropriate management of a hypoglycemic event in the outpatient setting
24

12) Design a therapeutic plan for the management of Type 2 Diabetes in the ambulatory care
setting
Content outline:
Section 1: Diabetes module pre-assessment

2.1 Impaired insulin secretion
2.2 Insulin resistance
2.3 Impaired glucagon secretion
2.4 Metabolic syndrome
2.5 Incretin effect
Section 3: Diagnostic and screening criteria for diabetes and microvascular and macrovascular
complications
Section 4: Review of current guidelines
4.1 American Diabetes Association (ADA) (American Diabetes Association, 2016;
Inzucchi et al., 2015)
4.2 American Association of Clinical Endocrinologists (AACE), American College of
Endocrinology (ACE) (Garber et al., 2016; Handelsman et al., 2015)
5.1 Oral medications
5.1.1 Sulfonylureas
5.1.2 Biguanides
5.1.3 Glitinides
5.1.4 Thiazolidinediones (TZD)
5.1.5 Alpha-glucosidase inhibitors (AGI)
5.1.6 Dipeptidyl peptidase-4 (DPP4) inhibitors
5.1.7 Sodium-glucose transporter 2 (SGLT2) inhibitors
5.1.8 Other (dopamine receptor agonist, bile acid sequestrant)
5.2 Injectable medications
5.2.1 GLP-1 agonists
5.2.2 Amylin analogue
5.2.3 Insulin (rapid, short, intermediate, long-acting & mixed preparations)
Section 6: Goals of therapy
6.1: Individualized glycemic goals (HgbA1c, fasting, and 2-hr post prandial)
6.2: Blood pressure goals
6.3: Lipid goals
Section 8: Diabetes module post-assessment
25

Match diabetes drug classes with their respective site of action

Categorize presenting symptoms as symptoms of hypo- or hyperglycemia
Fill in the blank with mechanism of action (preset list of actions)
Select the appropriate diagnostic or screening mechanism for diabetes and its
complications
Classify oral hypoglycemic medications according to their adverse effects
Classify insulin products according to their onset, peak, and duration of action
Upon review of a patient case
Identify appropriate goals of therapy for a 50-y/o T2DM patient without
complications
Identify appropriate goals of therapy for a 75-y/o T2DM with multiple major
comorbidities and microvascular complications

Provide education on glucometer use and frequency of testing blood sugars
Provide recommendations for a patient on oral hypoglycemic agents with
uncontrolled blood glucose

Provide recommendations for a patient on oral hypoglycemic agents with
hypoglycemia
Develop a plan for initiating insulin therapy for a patient with symptomatic
hyperglycemia and an elevated HgbA1c

Counsel a patient on the use of an insulin pen device and insulin administration
Provide recommendations for a patient on insulin with uncontrolled blood glucose
Provide recommendations for a patient on insulin with hypoglycemic episodes
Hypoglycemic simulation; outline recommended steps to treat and manage a
hypoglycemic episode (15-15 rule)

Diabetic foot exam simulation (select the appropriate areas)
Module 4: Hypertension
Objectives:
1) Outline the pathogenesis of hypertension and targets for antihypertensive therapy

2) Compare and contrast current hypertension treatment guidelines
3) Identify barriers to successful management of hypertension
26

4) Demonstrate appropriate blood pressure monitoring technique using sphygmomanometer
and stethoscope
5) Review lifestyle modifications
a) Weight loss, tobacco cessation, caffeine reduction, Dietary Approaches to Stop
Hypertension (DASH) Diet
6) Review antihypertensive therapeutic drug classes and respective drugs
a) Mechanism of action, adverse effects, dosing strategies, monitoring parameters, major
counseling points, contraindications, drug-drug interactions
7) Select the appropriate antihypertensive medication based on comorbid conditions,
medication characteristics, and goals of therapy
8) Develop a therapeutic plan for the management of a patient with hypertension in the
ambulatory care setting
a) Goals of therapy, medications, monitoring, follow-up
9) Differentiate between hypertensive urgency and emergency and develop a therapeutic
plan for the management of a hypertensive urgency in the outpatient setting
Content outline:
Section 1: Hypertension module pre-assessment

2.1 Humoral mechanism (renin-angiotensin-aldosterone system [RAAS])
2.2 Neuronal regulation (sympathetic nervous system [SNS])
2.3 Endothelial dysfunction
Section 3: Taking a blood pressure in the ambulatory care setting
Section 4: Review of current hypertension guidelines
4.1 The eighth Joint National Committee (JNC 8) (James et al., 2014)
4.2 European Society of Hypertension (ESH) and the European Society of Cardiology
(ESC) (Mancia et al., 2013)
4.3 American Heart Association (AHA), American College of Cardiology (ACC) and
American Society of Hypertension (ASH) (Rosendorff et al., 2010)
5.1 Diuretics
5.1.1 Thiazides
5.1.2 Loops
5.1.3 Potassium-sparing
5.2 Beta-blockers
5.2.1 Cardioselective
27

5.2.2 Nonselective
5.2.3 Mixed alpha and beta-blocker
5.3 Calcium Channel Blockers (CCB)
5.3.1 Non-dihydropyridine CCB
5.3.2 Dihydropyridines
5.4 Angiotensin Converting Enzyme Inhibitors (ACEi)
5.5 Angiotensin Receptor Blockers (ARB)
5.6 Direct Renin Inhibitors (DRI)
5.7 Central alpha-2 agonists
5.8 Alpha-1 blockers
5.9 Direct vasodilators
Section 6: Goals of therapy and compelling indications
Section 8: Hypertension module post-assessment
Outline a diagram of the RAAS system and identify sites of pharmacologic action of
available therapies
Match goals of therapy for patients with hypertension based on underlying comorbidities
and age
Blood pressure assessment simulation: obtain blood pressure reading using
sphygmomanometer and stethoscope

Match available blood pressure medications with their respective drug classes
Fill in the blank, mechanism of action, of select antihypertensive agents
Differentiate between presenting signs/symptoms for patients with hypertensive urgency
or hypertensive emergency
Establish a step wise plan for a patient to self-monitor blood pressure
Counsel a patient on lifestyle modifications to assist with blood pressure control
Recommend an appropriate antihypertensive regimen based on patient specific
factors for a patient with elevated blood pressures

Provide recommendations for pharmacological changes to an antihypertensive
regimen for a patient experiencing adverse effects to therapy

Recommend appropriate treatment options and monitoring parameters for a
patient experiencing a hypertensive urgency in the outpatient setting
28

Module 5: Hyperlipidemia
Objectives:
1) List the major lipoproteins and described their role in lipoprotein metabolism and the
development of atherosclerosis
2) Identify the statin-benefit groups and intensity of statin therapy according to the
American College of Cardiology (ACC)/American Heart Association (AHA)
3) Review current guidelines for the management of hyperlipidemia
4) Identify the key components of the atherosclerotic cardiovascular disease (ASCVD) risk
calculation and potential limitations to this risk assessment tool
5) Determine a patients atherosclerotic cardiovascular disease risk and corresponding
treatment goals according to the National Lipid Association (NLA)
6) Recommend appropriate therapeutic lifestyle changes (TLC) and pharmacotherapy
interventions for patients with hyperlipidemia
7) Design a monitoring plan to assess effectiveness and adverse effects of pharmacotherapy
for hyperlipidemia
Content outline:
Section 1: Hyperlipidemia module pre-assessment

2.1 Lipoprotein metabolism
2.2 Development of atherosclerosis
Section 3: Review of hyperlipidemia guidelines
3.1 ACC/AHA (Goff et al., 2013; Stone et al., 2013)
3.2 NLA (Jacobson, Ito, et al., 2015; Jacobson, Maki, et al., 2015)
4.1 Statins
4.2 Fibric acid derivatives
4.3 Bile acid sequestrants
4.4 Cholesterol absorption inhibitors
4.5 Omega-3-acid ethyl esters (fish oil)
4.6 Nicotinic acid
Section 6: Hyperlipidemia module post-assessment
29
List the steps of the development of atherosclerotic plaque

List major lipoproteins in descending size and ascending density
Identify the four major statin benefit groups
Match the statin benefit groups with the appropriate patient profile
Categorize statin doses according to low, moderate, or high-intensity statins
Select the appropriate statin intensity given patient specific parameters
Develop a therapeutic plan for the management of patient with elevated
triglycerides
Develop a therapeutic plan for the management of hyperlipidemia in a patient
with intolerance to multiple statin therapies

Outline a monitoring plan for a patient experiencing adverse effects to lipid
lowering therapies
Provide education on therapeutic lifestyle changes
Next Steps & Future Implications
The next steps involve selection of content material from current pharmacy resources,
disease state review articles, organizational guidelines, and standards of care. Patient cases, selfassessments, and pre- and post-module assessments also need to be developed to address
modular learning objectives. The selected learning materials can then be placed into a blueprint
for use as a reference to develop the course. Five interactive self-paced learning modules will be
created for the five aforementioned disease states. Ambulatory care faculty and invited
ambulatory care preceptors will review the blueprints. Their primary role will be to determine if
both modular and disease state objectives are met and to provide feedback with regard to
corrections, revisions, or clarifications necessary.
Once created, the online modules will be piloted to students nearing completion of the
PharmD program to review and assess the learning tool. Initial assessment will look at the
feasibility, accessibility, ease of use, and students perception of improved understanding of
pharmaceutical care in the ambulatory care setting. The resultant pilot data will provide
30

information with regards to necessary changes that need to be made to the online modular
content prior to its implementation in the ambulatory care APPE curriculum.
Prior to implementation into the curriculum, separate assessments should be developed to
assess pharmacy students and preceptors perceptions of the utility of the online modular content
as a supplement to the advanced practice experience. These assessment tools will be used to aid
in data collection. Collected data will be analyzed and developed into a written report
summarizing the findings of the pre- and post-assessment results and student and preceptor
perceptions of the new learning technique. Results will be disseminated to professional
audiences of medical educators through posters, platform presentations, and journal articles with
the intent to expand this type of teaching modality to other areas of pharmacy education and
other health professions clinical experiences.
31

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Vnieto Project Ambulatory Care Online Topic Discussion

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Running Head: AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Pharmacy Students Retention of Knowledge Following Web-based Topic Discussions as Part of

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

limit personal and professional growth.

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

VN, CW, RB, CD, GF,

VN, GF, ED,

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Projected Major Tasks, Exercises and Activities

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Demonstrate knowledge and comprehension of pharmacotherapy of core primary care disease

Areas of focus include: pathophysiology, diagnosis and diagnostic studies, clinical

Content of Module Outlines

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Section 1: Anticoagulation module pre-assessment

Match location of drug therapy to steps in the clotting cascade

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

requires anticoagulation therapy

Upon review of a patient case:

patient specific factors

Module 2: Asthma/Chronic Obstructive Pulmonary Disease (COPD)

1) Compare and contrast pathogenesis, clinical presentation, diagnosis, and staging of

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Section 1: Asthma/COPD module pre-assessment

Match distinguishing characteristics (clinical presentation, spirometry results, and stages)

to the respective disease state (asthma/COPD)

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Match spirometric measurements with the appropriate definition

instructions for a patient to follow in times of worsening asthmatic symptoms

exacerbations, and FEV1 and make recommendation for pharmacotherapy

pharmacotherapy for COPD

macrovascular diabetic complications

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Section 1: Diabetes module pre-assessment

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Match diabetes drug classes with their respective site of action

comorbidities and microvascular complications

uncontrolled blood glucose

hyperglycemia and an elevated HgbA1c

hypoglycemic episode (15-15 rule)

1) Outline the pathogenesis of hypertension and targets for antihypertensive therapy

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

Section 1: Hypertension module pre-assessment

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS

sphygmomanometer and stethoscope

factors for a patient with elevated blood pressures

regimen for a patient experiencing adverse effects to therapy

AMBULATORY CARE ONLINE TOPIC DISCUSSIONS